Bentham's Principle of Reinforcement

Bentham's principle of reinforcement tells that to make a donkey into work one has to put a carrot in front of it as well as jab with a stick from behind. That works as the carrot acts as reward for forward progress while stick ensures that progress is dynamic and unidirectional. Unfortunately, when putting antimicrobial stewardship into practice, despite theoretical soundness and expected fluency, either we behave as donkeys or collide with some of them.

Thinking from the other end of the table, one person performs his duties religiously and he will do it more efficiently if he knows what he does is right to do.

However, situations of non-performances do arise by own reluctance or by external functionalities where a punishment might improve personal attributes or expose the functional hindrance. Basically medical service is nothing but behavioural science at a large. Only reward will not drive our inherent resilience neither continuous punishments would improve the work flow. It is imperative to keep in mind that punishment would be effective in behaviour modulation if an individual switches on to a desirable alternative behaviour.

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In case it is not, then the original behaviour is going to reappear as soon as the punitive period is suspended. So, actually the punishment works best at the time of actual performance of an undesirable behaviour. Human nature is difficult and punishment may be utilized as reward for an undesirable behaviour; care has to be cautioned there to have the positive effect of motivation. There are many ways to implement antimicrobial stewardship in hospitals and healthcare sectors.

Majority focuses upon formulary restriction and pre-authorization of antimicrobials. However, in a given clinical situation such things might cause inconvenience to the grass-root healthcare providers and may cause restraint which may be disastrous at moments.

Schuts EC et al (2016) performed a systematic review and meta-analysis on hospital antimicrobial stewardship objectives to see whether they have any effect on clinical outcomes, adverse events, costs and bacterial resistance rates. After studying 145 studies they found that guideline-based empirical therapy, de-escalation, IV-to-PO switch, therapeutic drug monitoring, use of restricted antibiotics and bedside consultation showed statistical significant benefits for one or more of the four outcomes. Guideline-based empirical therapy was associated with a relative risk reduction for mortality of 35% (relative risk 0·65, 95% CI 0·54-0·80, p).