Challenges in Implementing Antimicrobial Stewardship Programmes at Secondary Level Hospitals in India: An Exploratory Study

Dental antibiotic policies, stewardship, and implementation in India: A policy document analysis

OBJECTIVES

Dental antibiotic stewardship is crucial in low- and middle-income countries where the burden of antimicrobial resistance (AMR) is high and antibiotic misuse is common. Given that India is the most populous country, the largest antibiotic consumer and has a large dental prescriber population, this study investigated the extent to which current Indian policy and practice for dental antibiotic prescribing and stewardship aligns with the global policy and best practice.

METHODS

The READ approach was used to identify and extract data and synthesize the findings. Policy documents on dental antimicrobial stewardship were identified using a systematic search strategy involving nine medical and grey literature databases (Medline, Global Health, Web of Science, Cochrane, CINAHL, Eldis, Global Index Medicus, Proquest and Opengrey), targeted websites (government organizations and dental regulatory bodies) and contact with experts. Framework analysis was used to code extracted data into themes related to dental antimicrobial stewardship.

RESULTS

Of the 3039 records screened, 25 documents were included in the final analysis. The analysis showed a lack of guidelines or toolkits for appropriate antibiotic prescribing in dentistry in India. The treatment guidelines for antimicrobial use in common syndromes published by the Indian Council of Medical Research had no section or content for dental practitioners. Furthermore, the undergraduate dental curriculum developed by the Dental Council of India (DCI), included little content on appropriate antibiotic prescribing and no mention of AMR or stewardship. There were no educational resources either for dental practitioners or patients in the documents.

CONCLUSION

This document analysis showed that there was little or no mention of dental antibiotic prescribing guidelines in key policy documents such as the National Action Plan on AMR. In addition, contradictory and subjective information provided in some policy documents could encourage dentists and other health professionals such as general practitioners to prescribe antibiotics for common dental conditions for which they are contra-indicated. There is an urgent need to develop relevant guidelines and include these in Indian policy documents on AMR particularly the National Action Plan on AMR.

Assessment of challenges and opportunities in antibiotic stewardship program implementation in Northwest Ethiopia

Background

Indiscriminate use of antibiotics leads to antibiotic resistance (AMR) and results in mortality, morbidity, and financial burden. Antibiotic stewardship programs (ASPs) with education can resolve a number of barriers recognized in the implementation of successful ASPs. The aim of this study was to assess health professionals' perceptions and status of ASPs in hospitals in 2022.

Methods

A cross-sectional study was conducted from September 1, 2022 to October 30, 2022. A total of 181 health professionals were included, and a self-administered questionnaire was used to collect data. The status of hospitals was assessed using a checklist. The data were analyzed using SPSS version 23, and descriptive statistics and Chi-square tests (X2) at a P-value of <0.05 were used.

Results

Of the 181 respondents, 163 (90.1 %), and 161 (89.0 %) believed that AMR is a significant problem in Ethiopia and globally, respectively. Easy access to antibiotics 155 (85.6 %), and inappropriate use 137 (75.7 %) were perceived as key contributors to AMR. Antibiotics were believed to be prescribed/dispensed without laboratory results 86 (47.5 %), and antibiotic susceptibility patterns were not considered to guide empiric therapy 81 (44.8 %). ASP was believed to reduce the duration of hospital stays and associated costs 137 (75.7 %), and improve the quality of patient care 133 (73.5 %), whereas 151 (83.4 %), 143 (79 %), and 142 (78.5 %) suggested education, institutional guidelines, and prospective audits with feedback interventions to combat AMR in their hospitals, respectively. There were significant differences in perception among professionals based on professional category and attempts by hospitals to implement ASPs. Although ASPs were not functioning according to standard, there have been attempts to implement it in three hospitals. The issue of ASP had never been heard in general hospitals. Currently, it is feasible to implement ASPs in four hospitals.

Conclusion

The status of ASP in hospitals was very poor. Despite a lack of prior knowledge on ASPs, most respondents do have a positive perception of AMR and the implementation of ASPs. Pharmacist-led prospective audits and feedback with education and institutional guidelines for empiric antibiotic use can be better implemented in hospitals. Involvement of representatives from infection prevention and control, and collaboration among hospitals in ASP implementation will help establish a strong ASP in the area.

Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review

BACKGROUND

Antimicrobial stewardship programs (ASPs) are pivotal components of the World Health Organization's Global Action Plan to combat antimicrobial resistance (AMR). ASPs advocate rational antibiotic usage to enhance patient-centered outcomes. However, existing evidence on ASPs and their determinants is largely limited to well-equipped hospitals in high-income nations.

OBJECTIVE

This scoping review aimed to examine the current state of hospital-based ASPs in low- and middle-income countries (LMICs), shedding light on barriers, facilitators, prescribers' perceptions and practices, and the impact of ASP interventions.

DESIGN

Scoping review on ASP.

METHODS

Adhering to PRISMA guidelines, we conducted electronic database searches on PubMed, Scopus, and Google Scholar, covering ASP articles published between January 2015 and October 2023. Our review focused on four key domains: barriers to ASP implementation, facilitators for establishing ASP, ASP perceptions and practices of prescribers, and the impact of ASP interventions. Three reviewers separately retrieved relevant data from the included citations using EndNote 21.0.

RESULTS

Among the 7016 articles searched, 84 met the inclusion criteria, representing 34 LMICs. Notably, 58% (49/84) of these studies were published after 2020. Barriers to ASP implementation, including human-resources shortage, lack of microbiology laboratory support, absence of leadership, and limited governmental support, were reported by 26% (22/84) of the studies. Facilitators for hospital ASP implementation identified in five publications included the availability of antibiotic guidelines, ASP protocol, dedicated multidisciplinary ASP committee, and prompt laboratory support. The majority of the research (63%, 53/84) explored the impacts of ASP intervention on clinical, microbiological, and economic aspects. Key outcomes included increased antibiotic prescription appropriateness, reduced antimicrobial consumption, shorter hospital stays, decreased mortality rate, and reduced antibiotic therapy cost.

CONCLUSIONS

The published data underscores the imperative need for widespread antimicrobial stewardship in LMIC hospital settings. Substantial ASP success can be achieved through increasing human resources, context-specific interventions, the development of accessible antibiotic usage guidelines, and heightened awareness via training and education.

Improving Antimicrobial Resistance Awareness Among Medical Students in India: The Sensitization of Medical Students on Antimicrobial Resistance (SOS-AMR) Study

OBJECTIVES

To evaluate the impact of an online educational intervention on improving knowledge of antimicrobial resistance (AMR) and stewardship among final-year medical students in Chennai, India.

METHODS

This was a prospective 'before-after' study conducted across 5 medical colleges in Chennai, India. Participants who were final-year (fourth year) undergraduate medical students were administered a pretest to evaluate baseline knowledge. Students were then provided access to online educational material comprising 20 short lectures. Lectures were delivered by content experts and covered a range of topics which included basics of microbiology, fundamental concepts in AMR and stewardship, diagnosis and management of common infections, basics of antimicrobial pharmacokinetics and pharmacodynamics, and vaccination. Students were required to take a posttest at the end of these modules. Primary outcome was improvement in test scores from pretest baseline which was analyzed using a t test. A 30% improvement in the mean scores from baseline was predefined as a measure of success.

RESULTS

A total of 599 students participated from 5 medical colleges among whom 339 (56.6%) were female participants; 542 (90.4%) students completed the posttest. Mean pretest score was 11.6 (maximum possible score of 25) (SD: 4.3) and the mean posttest score was 14.0 (SD: 4.6). Comparing pre and posttest scores, there was an improvement of 2.4 marks (20%) from the baseline (95% confidence interval: 1.9, 2.9) (P < .001). Improvement in scores was similar for male and female participants.

CONCLUSIONS

In this before-after study evaluating the impact of an educational intervention on AMR among final-year medical students, there was an improvement in knowledge; however, the extent of improvement did not meet the predefined metric of success.

Impact of Antimicrobial Stewardship on Reducing Antimicrobial Resistance

Antimicrobial resistance has become a serious global issue, posing a significant threat to public health and healthcare professionals. Since the advent of penicillin, many antibiotics have lost their effectiveness in combating microbes simply due to inappropriate, irrational, unnecessary, and unrestricted use. The ineffectiveness of an increasing number of antibiotics necessitates the utilization of more potent antimicrobial agents for combatting uncomplicated infections. In response to the escalating prevalence of multidrug-resistant pathogens and the imperative to curtail the demand for novel antibiotics, the Antimicrobial Stewardship Program was conceived and implemented. This initiative is characterized by a lead physician, ideally possessing expertise in infectious diseases, alongside a pharmacist serving as a secondary leader and a microbiologist with defined responsibilities to achieve several objectives. These objectives include reducing indiscriminate usage of antimicrobial agents, promoting selective antimicrobial utilization based on culture results, de-escalating therapy from broad-spectrum to targeted antimicrobial agents, and transitioning from parenteral to oral administration when feasible. These objectives are pursued through a combination of pre-prescription and post-prescription strategies. While the Antimicrobial Stewardship Program is widely established in developed nations, a pressing need exists for its more comprehensive implementation in less developed regions. This review aims to examine the strategies used in antimicrobial stewardship programs to evaluate their effectiveness in preventing the development of multidrug-resistant organisms (MDROs) based on existing research studies. Under the Antimicrobial Stewardship Program, education of healthcare professionals and continuous disposal of information about antimicrobial resistance have helped to restrict the emergence of multidrug-resistant organisms.

Antimicrobial Stewardship and Pandemic Preparedness: Harnessing Lessons Learned to Advance Our Mission

Antimicrobial stewardship programs (ASPs) demonstrated poise and resilience in assisting with COVID-19 efforts across the globe, harnessing expertise in diagnostic stewardship, therapeutics, protocol development, and use of technology to rapidly expand their scope through strategic collaborations, dissemination of content expertise, and numerous contributions to the body of knowledge on COVID-19. Lessons learned from pandemic response should be used to advance the mission of ASPs and secure a "seat at the table" as health systems continue to expand and adapt to future public health crises.

Efficacy of telemedicine-based antimicrobial stewardship program to combat antimicrobial resistance: A systematic review and meta-analysis

INTRODUCTION

Antimicrobial resistance (AMR) is a major public health threat. Improving antimicrobial use is the main strategy against AMR, but it is challenging to implement especially in low-resource settings. Thus, this review aims to explore the efficacy of telehealth-based antimicrobial stewardship programs (ASP), which is more accessible.

METHODS

Registered to PROSPERO and following PRISMA guidelines, literature search was performed in databases including PubMed, Scopus, Cochrane, Science Direct, EBSCOhost, EMBASE, and Google Scholar, searching for studies implementing telehealth ASP. Critical appraisal of studies was performed using Newcastle-Ottawa Scale for Cohort Studies (NOS), Cochrane Risk-of-Bias tool (RoB) 2.0, and Risk Of Bias In Non-randomised Studies-of Interventions (ROBINS-I). We utilized inverse variance, random effects model to obtain the pooled odds ratio (OR) and mean difference (MD) estimates, as well as sensitivity and subgroup analysis.

RESULTS AND DISCUSSION

The search yielded 14 studies. Telehealth-based ASP was associated with better adherence to guidelines (pooled OR: 2.78 [95%CI:1.29-5.99], p = 0.009; I2 = 93%), within which streamlining yielded better odds (pooled OR: 30.54 [95%CI:10.42-89.52], p < 0.001) more than the compliance with policy subgroup (pooled OR: 1.60 [95%CI:1.02-2.51], p = 0.04). The odds of antimicrobial prescription rate reduced significantly (pooled OR: 0.60 [95%CI:0.42-0.85], p = 0.005; I2 = 94%), especially for the lower respiratory infection subgroup (pooled OR: 0.37 [95%CI:0.28-0.49], p < 0.001). Days of therapy decreased (pooled MD: -47.12 [95%CI: -85.78- -8.46], p = 0.02; I2 = 100%), with the greatest effect in acute care settings (pooled MD: -97.73 [95%CI:-147.48-47.97], p = 0.0001). Mortality did not change significantly (pooled OR: 1.20 [95%CI:0.69-2.10], p = 0.52; I2 = 63%).

CONCLUSION

Telehealth-based ASP was proven beneficial to increase adherence to guideline and reduce prescription rates, without significantly affecting patient clinical outcome. After further studies, we recommend more widespread use of telemedicine to combat AMR.

Antibiotic Prophylaxis in Surgery: Current Insights and Future Directions for Surgical Site Infection Prevention

Surgical site infections (SSIs) remain a significant concern in the field of surgery, contributing to patient morbidity, prolonged hospital stays, and increased healthcare costs. Antibiotic prophylaxis, the administration of antibiotics before surgery, has been a cornerstone in preventing SSIs for decades. This review explores the current state of antibiotic prophylaxis in surgery, offering insights into its effectiveness, challenges, and emerging trends. In this comprehensive analysis, we delve into the historical development of antibiotic prophylaxis, examining its evolution from early practices to modern guidelines. We explore the various classes of antibiotics commonly used, their dosing regimens, and the importance of timing in optimizing prophylactic interventions. Additionally, we investigate the role of patient-specific factors, such as comorbidities and allergies, in tailoring antibiotic prophylaxis to individual needs. While antibiotic prophylaxis has undeniably reduced the incidence of SSIs, concerns about antimicrobial resistance and adverse effects necessitate a reevaluation of current practices. This review presents a critical assessment of the challenges posed by the overuse and misuse of antibiotics in surgery and highlights the urgent need for judicious antibiotic stewardship. Moreover, the future of antibiotic prophylaxis holds promise with the emergence of innovative strategies such as antimicrobial coatings, probiotics, and immunomodulatory agents. We discuss these novel approaches and their potential to enhance SSI prevention while minimizing antibiotic-related risks. In conclusion, antibiotic prophylaxis in surgery has been instrumental in reducing SSIs, but its continued effectiveness requires a multifaceted approach. By addressing current challenges, promoting antibiotic stewardship, and embracing innovative strategies, we can advance the field of SSI prevention and improve patient outcomes in the years to come. This review provides valuable insights and direction for clinicians, researchers, and policymakers as they navigate the evolving landscape of surgical prophylaxis.

Nanobiotics and the One Health Approach: Boosting the Fight against Antimicrobial Resistance at the Nanoscale

Antimicrobial resistance (AMR) is a growing public health concern worldwide, and it poses a significant threat to human, animal, and environmental health. The overuse and misuse of antibiotics have contributed significantly and others factors including gene mutation, bacteria living in biofilms, and enzymatic degradation/hydrolyses help in the emergence and spread of AMR, which may lead to significant economic consequences such as reduced productivity and increased health care costs. Nanotechnology offers a promising platform for addressing this challenge. Nanoparticles have unique properties that make them highly effective in combating bacterial infections by inhibiting the growth and survival of multi-drug-resistant bacteria in three areas of health: human, animal, and environmental. To conduct an economic evaluation of surveillance in this context, it is crucial to obtain an understanding of the connections to be addressed by several nations by implementing national action policies based on the One Health strategy. This review provides an overview of the progress made thus far and presents potential future directions to optimize the impact of nanobiotics on AMR.

Establishing an effective antimicrobial stewardship program at four secondary-care hospitals in India using a hub-and-spoke model

Background

The high burden of antimicrobial resistance in India necessitates the urgent implementation of antimicrobial stewardship programs (ASPs) in all healthcare settings in India. Most ASPs are based at tertiary-care centers, with sparse data available regarding the effectiveness of an ASP in a low-resource primary/secondary-care setting.

Methods

We adopted a hub-and-spoke model to implement ASPs in 4 low-resource, secondary-care healthcare settings. The study included 3 phases measuring antimicrobial consumption data. In the baseline phase, we measured days on antimicrobial therapy (DOTs) with no feedback provided. This was followed by the implementation of a customized intervention package. In the postintervention phase, prospective review and feedback were offered by a trained physician or ASP pharmacist, and days of therapy (DOT) were measured.

Results

In the baseline phase, 1,459 patients from all 4 sites were enrolled; 1,233 patients were enrolled in the postintervention phase. Both groups had comparable baseline characteristics. The key outcome, DOT per 1,000 patient days, was 1,952.63 in the baseline phase and significantly lower in the post-intervention period, at 1,483.06 (P = .001). Usage of quinolone, macrolide, cephalosporin, clindamycin, and nitroimidazole significantly decreased in the postintervention phase. Also, the rate of antibiotic de-escalation was significantly higher in the postintervention phase than the baseline phase (44% vs 12.5%; P < .0001), which suggests a definite trend toward judicious use of antibiotics. In the postintervention phase, 79.9% of antibiotic use was justified. Overall, the recommendations given by the ASP team were fully followed in 946 cases (77.7%), partially followed in 59 cases (4.8%), and not followed in 137 cases (35.7%). No adverse events were noted.

Conclusion

Our hub-and-spoke model of ASP was successful in implementing ASPs in secondary-care hospitals in India, which are urgently needed.

The effectiveness of an antimicrobial stewardship program in an Australian rural hospital

OBJECTIVE

The aim of this study was to investigate the type, indication and duration of restricted antibiotics prescribed to inpatients who had undergone antimicrobial stewardship (AMS) review by the infectious diseases specialist and to assess the effectiveness of the AMS program in a rural hospital.

DESIGN

This was an observational retrospective study.

SETTING

The study was conducted at a rural referral hospital in NSW.

PARTICIPANTS

Inpatients from the medical, surgical and intensive care units were included.

MAIN OUTCOME MEASURES

The main outcome measure was the type, indication and average duration of restricted antibiotics that were reviewed in the AMS rounds. The rate of adherence to AMS advice and the rate of step-down of antibiotics after AMS advice were other outcome measures. Data on participant characteristics were also collected.

RESULTS

The most commonly prescribed restricted antibiotic in medicine and surgery was amoxicillin-clavulanic acid (28%), followed by ceftriaxone (15%) and piperacillin-tazobactam (10%), with the most common indication being intra-abdominal infection (37%). In intensive care, ceftriaxone (16.7%) and piperacillin-tazobactam (16.7%) were most prescribed, and the most common indication was community-acquired pneumonia (24.5%). The adherence rate to AMS advice was 86% in medicine and surgery and 83% in intensive care. AMS rounds managed to cease or step down antibiotics 60% of the time.

CONCLUSION

The AMS program in a rural hospital was effective with an overall AMS advice adherence rate of 84.5% which measures well against tertiary-level centres. Continued AMS and advocacy of such programs in rural regions are fundamental to optimising patient outcomes in the rural community.

Antimicrobial Consumption from 2017 to 2021 in East Trinidad and Tobago: A Study in the English-Speaking Caribbean

An antimicrobial consumption (AMC) study was performed in Trinidad and Tobago at the Eastern Regional Health Authority (ERHA). A retrospective, cross-sectional survey was conducted from 1 November 2021 to 30 March 2022. Dosage and package types of amoxicillin, azithromycin, co-amoxiclav, cefuroxime, ciprofloxacin, levofloxacin, moxifloxacin, nitrofurantoin and co-trimoxazole were investigated. Consumption was measured using the World Health Organization’s Antimicrobial Resistance and Consumption Surveillance System methodology version 1.0, as defined daily doses (DDD) per 1000 population per day (DID). They were also analyzed using the ‘Access’, ‘Watch’ and ‘Reserve’ classifications. In the ERHA, AMC ranged from 6.9 DID to 4.6 DID. With regards to intravenous formulations, the ‘Watch’ group displayed increased consumption, from 0.160 DID in 2017 to 0.238 DID in 2019, followed by a subsequent drop in consumption with the onset of the COVID-19 pandemic. Oral co-amoxiclav, oral cefuroxime, oral azithromycin and oral co-trimoxazole were the most highly consumed antibiotics. The hospital started off as the higher consumer of antibiotics, but this changed to the community. The consumption of ‘Watch’ group antibiotics increased from 2017 to 2021, with a drop in consumption of ‘Access’ antibiotics and at the onset of COVID-19. Consumption of oral azithromycin was higher in 2021 than 2020.

Perspectives on Antibiotic Stewardship Programs among Health Care Providers at Two University Hospitals in Egypt

The perspectives of healthcare professionals on antibiotic stewardship programs (ASPs) should be explored. Any antibiotic stewardship strategy must be individualized based on patient needs, prescription habits, and local resources. The current study aimed to explore the perspectives of healthcare providers on antibiotics stewardship and their awareness of these perspectives. Furthermore, potential barriers to the application of ASPs should be identified and addressed. This exploratory cross-sectional study utilized a qualitative method to evaluate critical care physicians, pediatricians, and clinical pharmacists (n = 43). The mean age of the physicians was 32 ± 1.5 years. Among them, approximately two-thirds (66%) were women. A thematic content analysis was performed to examine the responses of the participants and to prioritize the recommendations for and barriers to the implementation of ASPs from the perspective of healthcare providers. According to the interviewees, the primary obstacles include lack of time in implementation and monitoring and lack of awareness of the need for ASPs. All respondents recommended the implementation of supervised and continuous trainings. In conclusion, the abovementioned barriers must be adequately addressed to facilitate the implementation of ASPs.

Prevalence of methicillin-resistant Staphylococcus aureus carriage among healthcare workers in South Asia in non-outbreak settings: A systematic review and meta-analysis

BACKGROUND

This study aimed to estimate the pooled prevalence and sub-group-specific prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) carrier rate among Healthcare Workers (HCWs) in South Asia.

METHODOLOGY

We considered prospective and cross-sectional studies published in the English language with participants ≥50 by searching different electronic databases to locate the relevant articles that reported the epidemiology of MRSA. The participants were healthy South Asian nationality HCWs (asymptomatic for any infectious disease) of any age and gender with a definitive diagnosis of MRSA carriage. The result was synthesized for the pooled prevalence of MRSA carriers among HCWs using 95% confidence interval (CI) with DerSimonian and Laird random-effects models.

RESULTS

The pooled prevalence of MRSA carriage among HCWs was 9.23% (95%CI; 6.50%, 12.35%) with a range from 0.67% to 36.06%. The prevalence in India, Nepal, Pakistan, Sri Lanka, and Bangladesh was 5.65% (95%CI; 3.65%, 8.03%), 8.83% (95%CI; 6.77%, 11.11%), 17.20% (95%CI; 10.70%, 24.85%), 22.56% (95%CI; 4.93%, 47.83%), and 4.93% (95%CI; 1.88%, 9.20%) respectively. The pooled prevalence of MRSA carriage among nurses and doctors was 8.90% (95%CI; 6.00%, 12.24%) and 6.53% (95%CI; 3.63%, 10.06%) respectively.

CONCLUSION

The findings from our study suggests that if the propagation of MRSA continues, then it can lead to a situation of an outbreak. Hence, proper preventive measures are to be adopted to prevent this outbreak.

Opportunities, associations, and impact of early intravenous to oral antimicrobial switch for hospitalized patients in Ethiopia

Objective:

Short intravenous antimicrobial therapy for 2–3 days followed by its per oral comparable antimicrobial course is a crucial part of the antimicrobial stewardship program. However, nothing is known about this practice in Ethiopian hospitals. Therefore, this study assessed the proportion, associations, and outcomes of early intravenous to per oral antimicrobial switch for patients who were admitted to the three wards of Ambo University Referral Hospital.

Method:

A hospital-based prospective cohort pilot study was conducted. During the 3-month period, 117 patients met initial inclusion criteria and were followed until Day 3 of intravenous antimicrobial. Of these, 92 (78.6%) subsequently met criteria for early intravenous to per oral switch and are the cohort investigated in this study. Written informed consent was sought from participants and/or parents or guardian for ages 15–17 years. Logistic regression models and independent t-tests were done with a significance of p ⩽ 0.05.

Results:

Out of 92 study participants, early intravenous to per oral antimicrobial switch was done only for 36 (39.1%). The only independent predictors for lack of early intravenous to per oral antimicrobials switch were poly-pharmacy (adjusted odds ratio = 3.4 at 95% confidence interval, 1.036–11.16; p = 0.044). There was a significant difference in terms of mean length of hospital stay (8.80 ± 3.57 versus 3.17 ± 0.74; p < 0.0001), in-hospital complication rate (95% versus 5%; p < 0.0001), and the mean cost of healthcare in Ethiopian Birrs (652.29 ± 403.29 versus 126.67 ± 29.47; p < 0.0001) between the comparator/early intravenous to per oral not switched and early switched group, respectively.

Conclusion:

The proportion of early intravenous to per oral antimicrobial switch was unsatisfactory. There was a significant difference between the intervention and comparator groups in terms of length of hospital stay, in-hospital complications, and extra cost. Therefore, implementation of interventions that improve the practice of early intravenous to per oral switch is needed urgently.

Strengthening antimicrobial stewardship activities in secondary and primary public healthcare facilities in India: Insights from a qualitative study with stakeholders

PURPOSE

Examining the existing federal and state policies in place that could strengthen antimicrobial stewardship (AMS) activities in district and sub-district hospitals in India.

METHODS

In-depth interviews were conducted with national and state level policy makers and various stakeholders at a district hospital. For national level, officials from the National Health Systems Resource Centre (NHSRC) were approached. The state of Haryana was selected and officials from Haryana State Health Systems Resource Centre (HSHRC), a state-level counterpart of the NHSRC, along with officials from the Health Department and relevant stakeholders from one of the district hospitals of the Haryana state were selected as participants. The recorded interviews were transcribed verbatim and thematic analysis was done.

RESULTS

Several measurable elements within the existing policies such as National Quality Assurance Program (NQAP) and Kayakalp program, could be leveraged to strengthen AMS activities in district and sub-district hospitals, were identified. These cover aspects such as infection control, standard treatment guidelines (STGs), prescription auditing, essential medicine list (EML), availability of antimicrobials and incentives for meeting quality standards. Revising the EML based on WHO AWaRe classification, incorporating the STGs for common clinical infections from the WHO AWaRe antibiotic book and Indian Council of Medical Research (ICMR), program mandated requirements for dedicated staff/standards for AMS activities and antimicrobial-specific prescription audits as per WHO AMS tool-kit and ICMR AMS guidelines are identified as opportunities for strengthening AMS activities. Further, hindrances in executing existing policies were also identified such as shortage of human resources, reluctance to follow STGs, and limited availability of diagnostic microbiology laboratory services.

CONCLUSION

Implementing NQAS and Kayakalp program in public healthcare facilities are identified as existing well working key programs that aid in improving AMS activities with incorporation of WHO and ICMR recommended practices.

Impact of Infection Control on Prevalence of Surgical Site Infections in a Large Tertiary Care Hospital in Haiphong City

Few point prevalence surveys (PPS) have been conducted in Vietnam on Surgical Site Infections (SSI) or antimicrobial use in surgery. The objective of this study was to evaluate the PPSs of SSI before and after implementation of antibiotic stewardship programs (ASP) and infection control (IC) in a Vietnamese tertiary care hospital. ASP and IC practices were implemented in operating rooms and the orthopedic department, including antibiotic training, skin preparation, hand hygiene, gloves and sterile instruments, and SSIs risk factors. A PPS of SSIs and antimicrobial use was performed in January 2016 according to methods from the Centers for Disease Control and Prevention, before ASP and IC, and in December 2019. Information recorded included surgical data, antibiotic prophylaxis, microorganisms, and SSI risk factors. Skin preparation compliance assessed preoperative washing and antisepsis. SSI prevalence was 7.8% in 2016 versus 5.4% in 2019 (p = 0.7). The use of prophylactic antibiotics decreased from 2016 to 2019. A third-generation cephalosporin was prescribed more than 48 h after surgery for most patients. Skin preparation compliance increased from 54.4% to 70.5% between assessments. The decreased SSI, although non-statistically significant, warrants continuing this program. Vietnamese hospitals must provide comprehensive IC education to healthcare workers to address the prevention of SSI and establish IC policies.

Gaps in antimicrobial stewardship programmes in Asia: a survey of 10 countries

OBJECTIVES

To determine antimicrobial stewardship (AMS) programme practices in Asian secondary- and tertiary-care hospitals.

METHODS

AMS programme team members within 349 hospitals from 10 countries (Cambodia, India, Indonesia, Japan, Malaysia, Pakistan, the Philippines, Taiwan, Thailand and Vietnam) completed a questionnaire via a web-based survey link. The survey contained questions as to whether 12 core components deemed essential for AMS programmes were implemented.

RESULTS

Overall, 47 (13.5%) hospitals fulfilled all core AMS programme components. There was a mean positive response rate (PRR) of 85.6% for the responding countries in relation to a formal hospital leadership statement of support for AMS activities, but this was not matched by budgeted financial support for AMS activities (mean PRR 57.1%). Mean PRRs were ≥80.0% for the core AMS team comprising a physician or other leader responsible for AMS activities, a pharmacist and infection control and microbiology personnel. Most hospitals had access to a timely and reliable microbiology service (mean PRR 90.4%). Facility-specific antibiotic treatment guidelines for common infections (mean PRR 78.7%) were in place more often than pre-authorization and/or prospective audit and feedback systems (mean PRR 66.5%). In terms of AMS monitoring and reporting, PRRs of monitoring specific antibiotic use, regularly publishing AMS outcome measures, and the existence of a hospital antibiogram were 75.1%, 64.4% and 77.9%, respectively.

CONCLUSIONS

Most hospitals participating in this survey did not have AMS programmes fulfilling the requirements for gold standard AMS programmes in hospital settings. Urgent action is required to address AMS funding and resourcing deficits.

WHO Point Prevalence Survey to Describe the Use of Antimicrobials at a Tertiary Care Center in Pakistan: A Situation Analysis for Establishing an Antimicrobial Stewardship Program

Antimicrobial stewardship is a systematic approach for promoting and monitoring responsible antimicrobial use globally. We conducted a prospective point prevalence survey of antimicrobial utilization among hospitalized adult patients during September 2021. The survey instrument was adapted from the WHO methodology for point prevalence surveys, and it was conducted at The Indus Hospital and Health Network, Karachi. Among the 300 admitted patients, 55% were males and the mean age was 44 (±18) years. At least 67% of the patients received one antimicrobial agent and the most common indication was surgical prophylaxis (40%). The most frequently used were antibacterial agents (97%) among all antimicrobials. Amoxicillin/Clavulanic acid and Ceftriaxone were the most frequently used antibacterial agents, i.e., 14% each. At least 56% of the antibacterial agents were amenable to antimicrobial stewardship when reviewed by infectious disease (ID) experts. Reasons for stewardship were: antibacterial not indicated (n = 39, 17.0%), unjustified prolonged duration of antibacterial (n = 32, 13.9%), extended surgical prophylaxis (n = 60, 26.2%), non-compliance to surgical prophylaxis guidelines (n = 30, 13.1%), and antibacterial not needed on discharge (n = 27, 11.7%). Median days of therapy (DOT) per agent was 3 days (IQR 2–4), while median DOT per patient was 2 days (IQR 1–4). These data have described the pattern of antimicrobial utilization in our institute. We found a higher prevalence of antimicrobial use overall as compared to the global figures, but similar to other low- and middle-income countries. Two important areas identified were the use of antimicrobials on discharge and extended surgical prophylaxis. As a result of these data, our institutional guidelines were updated, and surgical teams were educated. A post-intervention survey will help us to further determine the impact. We strongly recommend PPS at all major tertiary care hospitals in Pakistan for estimating antimicrobial utilization and identifying areas for stewardship interventions.

The impact of COVID-19 on antimicrobial stewardship programme implementation in hospitals - an exploration informed by the Consolidated Framework for Implementation Research

Introduction and objectives

The disruption of antimicrobial stewardship programmes (ASPs) caused by coronavirus disease 2019 (COVID-19) has been recognized but not explored in depth. This study used a theoretical, qualitative approach to understand the impact of COVID-19 on ASP implementation in hospitals.

Methods

Semi-structured online interviews, informed by the Consolidated Framework for Implementation Research (CFIR), were conducted with ASP team members and non-members in hospitals. Participants were recruited via purposeful and snowball sampling with interviews video recorded, transcribed and analysed independently by two researchers based on mapping against CFIR constructs.

Results

Thirty-one interviews were conducted across 11 hospitals. The following themes were identified: (i) increased complexity of ASP implementation and changes in prescribing behaviour influenced by COVID-19; (ii) adaptations, networking and cosmopolitanism to enhance integration of COVID-19 management into ASP services; and (iii) adaptations and networking to support continuity of the ASP implementation process. A disruption to pre-pandemic ASP activities was reported, with complexity of COVID-19 overwhelming the healthcare system. ASP team members and services showed an ability to adapt and repurpose roles to respond to the pandemic. Interventions included developing national guidelines for treatment of patients with COVID-19 and contributing to guideline management and monitoring. A gradual restoration of ASP activities was perceived. Technological adaptations and enhancements in networking were reported as positive impacts of the pandemic.

Conclusion

Despite the initial disruption of ASP implementation caused by the pandemic, successful adaptation and evolution of ASP services reflects the high value and adaptability of ASP implementation in hospitals in the United Arab Emirates.

Impact of an Antimicrobial Stewardship Intervention on Usage of Antibiotics in Coronavirus Disease-2019 at a Tertiary Care Teaching Hospital in India

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High empirical usage of beta-lactams and macrolides seen in COVID 19 patients.

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Interrupted time series analysis showed significant reduction in antibiotic usage.

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Stewardship interventions in resource-limited areas can garner positive outcomes.

Background

There was evidence that antibiotic usage increased in hospitalized COVID-19 patients during the early days of the pandemic.

Objective

We assessed the impact of stewardship interventions on antibiotic usage in these patients.

Methods

We designed a quasi-experimental study using an interrupted time series. Patients were stratified according to the severity category of the illness – mild and moderate-to-severe (O2 saturation ≥94% and <93% respectively). Baseline antibiotic usage data was collected in the pre-intervention phase. Intervention was given in the form of focus group discussion (FGD) and followed up with feedback-audit during the post-intervention phase. Primary outcome was the change in days of therapy (DOT) per 1000 patient-days.

Results

361 adult patients were recruited in both phases during July to December, 2020. In the post-intervention phase, DOT per 1000 patient-days reduced from 589 to 523 (P=0.013) and from 843 to 585 (P <0.0001) in mild and moderate-to-severe categories, respectively. De-escalations at 48 hours increased significantly from 21% to 41% (P=0.0079) and from 31% to 62% (P=0.0006), respectively. No difference in mortality was observed.

Conclusion

We found high usage of empirical antibiotics in adult patients hospitalized with COVID-19. FGD and feedback audits can successfully reduce antibiotic overuse in these patients.

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Background

Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs.

Methods

We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR).

Results

We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs.

Conclusion

We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions.

Trial registration

PROSPERO: CRD42021252715.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01209-4.

Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review

The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.

Antimicrobial Stewardship from Health Professionals' Perspective: Awareness, Barriers, and Level of Implementation of the Program

This study aimed to evaluate health professionals' perceptions regarding the level of implementation of the Antimicrobials Stewardship (AMS) programs in Jordanian tertiary hospitals and to assess the perceived barriers to its implementation. During this cross-sectional study, a total of 157 healthcare providers agreed to participate (response rate 96.3%). Participants were asked to complete an electronic survey after meeting them at their working sites. Only 43.9% of the healthcare providers (n = 69) reported having an AMS committee in their hospital settings. The results suggested that private hospitals have significantly better AMS implementation compared to public hospitals among four areas (p ≤ 0.05). Moreover, the results showed that the most widely available strategies to implement AMS were infectious disease/microbiology advice (n = 112, 71.3%), and treatment guidelines (n = 111, 70.7%). Additionally, the study revealed that the main barrier to AMS implementation was the lack of information technology support (n = 125, 79.6%). These findings could draw managers' attention to the importance of AMS and support the health care provider's practice of AMS in Jordanian tertiary hospitals by making the right decisions and the required modifications regarding the strategies needed for the implementation of AMS programs.

A Systematic Review of Pharmacist-Led Antimicrobial Stewardship Programs in Sub-Saharan Africa

BACKGROUND

The misuse of antibiotics contributes significantly to antimicrobial resistance (AMR). Higher treatment costs, longer hospital stays, and clinical failure can all result from AMR. According to projections, Africa and Asia will bear the heaviest burden of AMR-related mortalities in the coming years. Antimicrobial stewardship (AMS) programmes are therefore critical in mitigating the effects of AMR. Pharmacists may play an important role in such programmes, as seen in Europe and North America, but the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals are unknown. The purpose of this systematic review was to assess the impact, challenges, and opportunities of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan African hospitals.

METHODS

The Joanna Briggs Institute (JBI) guidelines were used to search for peer-reviewed pharmacist-led studies based in hospitals in Sub-Saharan Africa that were published in English between January 2015 and January 2021. The PubMed, Embase, and Ovid databases were used.

RESULTS

Education and training, audits and feedback, protocol development, and ward rounds were identified as primary components of pharmacist-led antimicrobial stewardship interventions in Sub-Saharan Africa. The pharmacist-led antimicrobial interventions improved adherence to guidelines and reduced inappropriate prescribing, but were hampered by a lack of laboratory and technological support, limited stewardship time, poor documentation, and a lack of guidelines and policies. Funding, mentorship, guidelines, accountability, continuous monitoring, feedback, multidisciplinary engagements, and collaborations were identified as critical in the implementation of pharmacist-led antimicrobial stewardship programmes.

CONCLUSIONS

These findings suggest that pharmacists in Sub-Saharan African hospitals can successfully lead antimicrobial stewardship programmes but their implementation is limited by lack of mentorship, accountability, continuous monitoring, feedback, collaborations, and poor funding.

Assessing feasibility of establishing antimicrobial stewardship programmes in two provincial-level hospitals in Vietnam: an implementation research study

OBJECTIVES

To investigate the feasibility of establishing hospital-based antimicrobial stewardship (AMS) programmes comprising action-planning, educational interventions and data feedback in two provincial-level hospitals in Viet Nam.

DESIGN AND SETTING

This was an implementation research using participatory action process and existing resources from the Duke Antimicrobial Stewardship Outreach Network with local adjustments. A national stakeholder meeting and Strengths-Weaknesses-Opportunities-Threats (SWOT) analysis were conducted to identify gaps and potential interventions.

PARTICIPANTS

Hospital AMS staff implemented activities throughout the study phases. Routinely collected patient data were analysed to support planning, implementation and evaluation.

INTERVENTIONS

Hospitals were considered as a complex adaptive system and leveraged their unique characteristics and interconnections to develop 1-year plans containing core interventions (data use, educational training, prospective audit with feedback (PAF) and evaluations).

OUTCOME MEASURES

We assessed feasibility using outputs from stakeholder meeting, SWOT analysis, baseline data, planning process and implementation.

RESULTS

The stakeholder meeting identified three gaps for AMS at national level: supportive policies, AMS training and core competencies and collaboration. At the hospitals, AMS programmes took 1 year for planning due to lack of hospital-specific procedures and relevant staff competencies. Baseline data (January-December 2019) showed variations in antibiotic consumption: 951 days of therapy (DOT) per 1000 days present in the control and 496 in the intervention wards in hospital 1, and 737 and 714 in hospital 2, respectively. During 1-year implementation, clinical pharmacists audited 1890 antibiotic prescriptions in hospital 1 (June 2020-May 2021) and 1628 in hospital 2 (July 2020-July 2021), and will continue PAF in their daily work.

CONCLUSION

Our data confirmed the need to contextualise AMS programmes in low-income and middle-income countries (LMICs) and demonstrated the usefulness of implementation research design in assessing programme feasibility. Developing staff competencies, using local data to stimulate actions and integrating programme activities in routine hospital work are key to success in LMICs.

Barriers to implementing antimicrobial stewardship programs in three low- and middle-income country tertiary care settings: findings from a multi-site qualitative study

BACKGROUND

Antimicrobial resistance has been named as one of the top ten threats to public health in the world. Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care centers in three low- and middle-income countries (LMICs).

METHODS

Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12), and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis, and comparisons of themes were made across the three sites.

RESULTS

Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested component of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses, some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of ASPs, most interviewees were receptive to implementing protocols that would include documentation and consultation with ASPs regarding antimicrobial prescribing.

CONCLUSIONS

Our study highlighted several important barriers to implementing ASPs that were shared between three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are important steps that could be taken by ASPs in these facilities.

Feasibility of De-Escalation Implementation for Positive Blood Cultures in Patients With Sepsis: A Prospective Cohort Study

Purpose: The aim of the present study was to determine whether de-escalation guided by blood cultures for patients with a diagnosis of sepsis, severe sepsis or septic shock reduces mortality, and antimicrobial drug resistance (ADR).

Methods: A prospective, single-center, cohort study was conducted with adults admitted to the ICU with a diagnosis of sepsis, severe sepsis, or septic shock at a public hospital in Sorocaba, State of São Paulo, Brazil, from January 2013 to December 2013. We excluded patients who had negative blood cultures. Patients who had replaced the initial empirical broad-spectrum antibiotic therapy (EAT) by the antibiotic therapy guided by blood cultures were compared with those who continued receiving EAT. The outcome included mortality and antimicrobial drug resistance. We used the Cox regression (proportional hazards regression) and the Poisson regression to analyze the association between antibiotic therapy guided by blood cultures (ATGBC) and outcomes. The statistical adjustment in all models included the following variables: sex, age, APACHE II (Acute Physiology And Chronic Health Evaluation II) score and SOFA (Sequential Organ Failure Assessment) score.

Results: Among the 686 patients who were admitted to the intensive care unit, 91 were included in this study. The mean age of the patients was 52.7 years (standard deviation = 18.5 years) and 70.3% were male. EAT was replaced by ATGBC in 33 patients (36.3%) while 58 patients (63.7%) continued receiving EAT. Overall hospital mortality decreased from 56.9% in patients who received EAT to 48.5% in patients who received ATGBC [Hazard ratio- HR 0.44 (95% CI 0.24–0.82), p = 0.009]. There was no association between ATGBC and ADR [HR 0.90 (95% CI 0.78 – 1.03) p = 0.15].

Conclusions: Although the early and appropriate empirical EAT is undoubtedly an important factor prognostic, ATGBC can reduce the mortality in these patients.