Perspective of Pakistani Physicians towards Hospital Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.

Knowledge and attitude of healthcare prescribers and pharmacists toward antimicrobial stewardship program and the barriers for its implementation

BACKGROUND

Antimicrobial stewardship (ASP) is considered a key prevention strategy in addressing the worldwide concern of accelerating antimicrobial resistance. Limited research is available regarding healthcare providers' knowledge and attitude toward antimicrobial stewardship and the barriers for its implementation.

METHODS

The present cross-sectional study was conducted on pharmacists and healthcare prescribers (HCPs) in different hospital sites across Jordan. A validated survey was used to evaluate HCPs and pharmacists' knowledge, and attitudes towards ASP and the barriers for its implementation. Logistic and linear regression were conducted to identify the factors associated with knowledge and attitude toward ASP, respectively.

RESULTS

A total of 603 participants, 69 (11.4%) pharmacists and 534 (88.6%) HCPs completed the study questionnaire, with a response rate of 80.4%. The overall mean knowledge about ASP was 7.16 out of 10, ranging from 0 to 10 (SD 2.22). Being a pharmacist and increased awareness/familiarity about ASP were associated with improved ASP knowledge. The overall average attitude score was = 3.8 ± 0.49 (range: 1.8-4.8). Results revealed that being a pharmacist and improved knowledge were associated with improved attitude toward ASP. Lack of specialized staff with expertise in ASP and lack of access to education and training programs were the major barriers hinder ASP implementation.

CONCLUSION

Despite the reasonable knowledge and the positive attitude toward the ASP, several barriers were reported, particularly by the pharmacists. Therefore, promoting the presence of adequately skilled healthcare personnel, creating easily accessible online courses, and establishing a comprehensive database of ASP resources are all suggested approaches to improve the application of ASP in healthcare settings.

Perceptions of antibiotic stewardship programmes and determinants of antibiotic prescribing patterns among physicians in tertiary hospitals in Bangladesh: implications for future policy and practice

BACKGROUND

The concerning growth of antimicrobial resistance (AMR) renders common infections life-threatening due to irrational antibiotic use and a lack of effective antimicrobial stewardship programmes (ASPs).

AIM

To investigate the awareness, perceptions and practices of physicians regarding ASPs, AMR and antibiotic prescribing in tertiary care hospitals in Bangladesh.

METHODS

This hospital-based cross-sectional survey was conducted in 11 tertiary care hospitals across Bangladesh between September 2020 and January 2021. A semi-structured questionnaire was administered through face-to-face interviews for data collection. Descriptive and multi-variate analyses were performed using STATA Version 13.

RESULTS

In total, 559 physicians were enrolled in this survey. Overall, 40.6% [95% confidence interval (CI) 36.5-44.8] of physicians reported being aware of ASPs, and this figure was higher in public hospitals compared with private hospitals (43.8% vs 27.1%). None of the study hospitals had any ASP initiatives. More than half (55.1%) of the participants were willing to receive feedback from an ASP on their antibiotic selection. Only 30.9% of respondents stated that they wait for the findings of microbiological tests before prescribing antibiotics, although challenges included empiric use of broad-spectrum antibiotics, delayed laboratory results and the existence of drug-resistant patients. In contrast, physicians aware of ASPs were 33% (adjusted odds ratio 0.67, 95% CI 0.45-0.98; P=0.033) less likely to wait for laboratory results before prescribing antibiotics. However, 42.5% of physicians considered patient affordability of purchasing antibiotics when prescribing.

CONCLUSIONS

Physicians' fundamental knowledge of ASPs and rational antibiotic prescription were found to fall short of the standard. Context-specific and integrated ASP activities, availability and use of guidelines, and improved laboratory facilities are required to battle AMR in Bangladesh.

Impact of a pharmacist-led educational intervention on knowledge, attitude, and practice toward the rational use of antibiotics among healthcare workers in a secondary care hospital in Punjab, Pakistan

Introduction: Growing antimicrobial resistance (AMR) and decreasing efficacy of the available antimicrobials have become a significant public health concern. The antimicrobial stewardship program (ASP) ensures the appropriate use of antimicrobials and mitigates resistance prevalence through various interventions. One of the core components of the ASP is to educate healthcare workers (HWs). Therefore, this study aims to identify the impact of a pharmacist-led educational intervention targeting knowledge, attitude, and practices regarding rational antibiotic use among healthcare professionals in a secondary care hospital in Punjab. Methods: This is a single-center, questionnaire-based, pre-post interventional study conducted over a six-month time period. Data analysis was conducted using SPSS version 26. Results: Regarding the pre-interventional knowledge, attitude, and practice (KAP) score of the respondents, 90.3% had a good knowledge score, 81.5% had a positive attitude, and 72.3% of HWs (excluding doctors) had a good practice score. Additionally, 74.6% of the doctors had a good practice score. After educational intervention, there was a significant improvement in the knowledge, attitude, and practice of the respondent HWs (p-value <0.001). Furthermore, males have higher knowledge scores compared to females in the pre- and post-intervention stages (p-value <0.05), and doctors differ from nurses regarding knowledge scores in both pre- and post-intervention stages. Conclusion: Considering educational programs as the backbone of the ASP, it is imperative to sustain efforts in the ongoing educational programs of HWs to foster high awareness and adherence to the ASP among HWs.

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.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.

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.

Understanding of Final Year Medical, Pharmacy and Nursing Students in Pakistan towards Antibiotic Use, Antimicrobial Resistance and Stewardship: Findings and Implications

Antimicrobial resistance (AMR) is a leading public health threat, which is exacerbated by the high and inappropriate use of antibiotics. Consequently, there is a need to evaluate knowledge regarding antibiotic use, AMR and the readiness to implement antimicrobial stewardship programs (ASPs) among final year medical, pharmacy and nursing students in Pakistan. This reflects the high and increasing rates of AMR in the country, and students as future healthcare professionals (HCPs). A cross-sectional study was conducted among 1251 final year students from 23 public and private educational institutions in Punjab. The majority of the surveyed participants possessed good knowledge of antibiotic use, AMR and the potential causes of AMR. The most common sources of the information on antibiotics were smartphones (69.9%), peers (35.9%) and medical textbooks (30.6%). However, most surveyed participants were not fully prepared to participate in ASPs. They knew, though, how to reduce AMR by educating HCPs about appropriate prescribing, implementing ASPs and improving laboratory facilities. There was a significant association between antibiotic knowledge and causes of AMR with sex, family income and student type (p < 0.05). Being a student at a public sector university (OR = 4.809; CI = 3.261−7.094; p < 0.001) and age (OR = 0.524, CI = 0.327−0.842; p < 0.008) were among the key factors impacting students’ training on ASPs. Educational curricula must be improved to include more information about appropriate antibiotic use and ASPs, along with sufficient training, workshops and clinical rotations in the final year, to fully equip students by graduation.

Exploring Knowledge of Antibiotic Use, Resistance, and Stewardship Programs among Pharmacy Technicians Serving in Ambulatory Care Settings in Pakistan and the Implications

Antimicrobial resistance (AMR) is a leading global health threat, increasing morbidity, mortality, and costs, with excessive and irrational use of antimicrobials contributing to the development of AMR. Consequently, the aims of this study were to evaluate the understanding of antibiotic use, AMR, and antimicrobial stewardship programs (ASPs) among pharmacy technicians serving in ambulatory healthcare settings in Pakistan. A cross-sectional survey was conducted among pharmacy technicians serving in 144 ambulatory care settings in seven districts of Punjab province using a validated questionnaire. Overall, 376 technicians completed the survey (85.8% response rate). The majority were men (89.1%), aged 25−35 years (45.1%), serving in emergency departments (43.9%) and filling 31−60 prescriptions per day (37.5%). Most (79.5%) knew that antibiotics were one of the most frequently prescribed drug classes, while 59.8% believed antibiotics for common colds did not speed up recovery. Inadequate duration (59.6%) and inadequate dosages (57.7%) of antibiotic therapy were reported as the leading causes of AMR. Terms including ‘superbugs’, ‘multidrug resistance’, and ‘extensively drug resistance’ were known to 42.0%, 25.3%, and 20.7% of participants, respectively; however, <10% knew about ASPs, including their core elements and purpose. Our study revealed that pharmacy technicians have adequate awareness of antibiotic use but are currently unaware of AMR and ASPs, which is a concern.

Antimicrobial Resistance Rates and Surveillance in Sub-Saharan Africa: Where Are We Now?

Introduction

Although antimicrobials have traditionally been used to treat infections and improve health outcomes, resistance to commonly used antimicrobials has posed a major challenge. An estimated 700,000 deaths occur globally every year as a result of infections caused by antimicrobial-resistant pathogens. Antimicrobial resistance (AMR) also contributes directly to the decline in the global economy. In 2019, sub-Saharan Africa (SSA) had the highest mortality rate (23.5 deaths per 100,000) attributable to AMR compared to other regions.

Methods

We searched PubMed for articles relevant to AMR in pathogens in the WHO-GLASS list and in other infections of local importance in SSA. In this review, we focused on AMR rates and surveillance of AMR for these priority pathogens and some of the most encountered pathogens of public health significance. In addition, we reviewed the implementation of national action plans to mitigate against AMR in countries in SSA.

Results and Discussion

The SSA region is disproportionately affected by AMR, in part owing to the prevailing high levels of poverty, which result in a high burden of infectious diseases, poor regulation of antimicrobial use, and a lack of alternatives to ineffective antimicrobials. The global action plan as a strategy for prevention and combating AMR has been adopted by most countries, but fewer countries are able to fully implement country-specific action plans, and several challenges exist in many settings.

Conclusion

A concerted One Health approach will be required to ramp up implementation of action plans in the region. In addition to AMR surveillance, effective implementation of infection prevention and control, water, sanitation, and hygiene, and antimicrobial stewardship programs will be key cost-effective strategies in helping to tackle AMR.

Views of Pharmacists and Government Representatives Toward the Pilot Chief Pharmacist System in Chinese Hospitals: A Multicenter Exploratory Qualitative Study

Background

In China, the pharmacy departments of most hospitals have changed their main focus from drug procurement and distribution to providing pharmaceutical care services. Various regions of China have successively implemented the pilot Chief Pharmacist System (CPS) to help improve pharmaceutical care services and rational drug use in hospitals. This study was designed to explore the perspectives of pharmacists and government officials on CPS, including the advantages and barriers to the successful implementation of CPS.

Methods

A qualitative study, based on semi-structured interviews, was conducted from October 1, 2018 to March 1, 2019. The interview data were gathered from 18 pharmacy staff and government representatives working in five distinct regions of China using purposive sampling. A thematic analysis approach and NVivo version 12 Plus was utilized to code and analysis of all interviews.

Results

Five broad themes were identified: the role of the chief pharmacist; their attitudes toward the CPS; the advantages and results of the CPS; the barriers toward CPS; and their suggestions toward CPS. Most of the participants believed that the chief pharmacist played a vital role in a hospital. Under CPS, the hospital pharmacy department pays more attention to prescription review, medication monitoring, and pharmaceutical consultation. However, an insufficient number of pharmacy personnel, unclear authority, and inadequate salaries were the main barriers to the implementation of the CPS.

Conclusion

The attitudes of most of the participants were found to be positive toward CPS in China. The CPS can enhance the prestige of the hospital pharmacy department, improve the quality of hospital pharmaceutical care services, and promote rational drug use. Nevertheless, certain barriers highlighted in this study should be addressed promptly.

Effectiveness of Community Pharmacy Diabetes and Hypertension Care Program: An Unexplored Opportunity for Community Pharmacists in Pakistan

Background: The effective management of patients diagnosed with both Diabetes as well as Hypertension is linked with administration of efficacious pharmacological therapy as well as improvement in adherence through counseling and other strategies. Being a part of primary healthcare team, community pharmacists can effectively provide patient care for chronic disease management. The objective of the study was to evaluate the impact of pharmacist counseling on blood pressure and blood glucose control among patients having both hypertension and diabetes attending community pharmacies in Pakistan. Method: A randomized, controlled, single-blind, pre-post-intervention study design was used. The respondents included patients diagnosed with diabetes mellitus (Type I or II) and hypertension visiting community pharmacies to purchase their regular medicine. A simple random sampling technique using the lottery method was used to select community pharmacies in groups A (intervention, n = 4) and group B (control, n = 4). The total number of patients was 40 in each group, while estimating a dropout rate of 25%. The patients in the intervention group received special counseling. Blood pressure and blood glucose were checked after every 15 days for 6 months. Prevalidated tools such as the hypertension knowledge level scale, the diabetes knowledge questionnaire 24, and a brief medication questionnaire was used. Data were coded and analyzed using SPSS 21. Wilcoxon test (p < 0.05) was used to compare pre-post intervention knowledge regarding the disease, while the Mann-Whitney test (p < 0.05) was used to find differences in medication adherence among control and intervention groups. Results: A significant improvement in mean knowledge scores of patients with diabetes (16.02 ±2.93 vs. 19.97 ±2.66) and hypertension (15.60 ±3.33 vs. 18.35 ±2.31) in the intervention group receiving counseling for 6 months than control group (p < 0.05) was noted. Furthermore, the fasting blood glucose levels (8.25 ±1.45) and systolic BP (130.10 ±6.89) were significantly controlled after 6 months in the intervention group. Conclusion: The current study results concluded that community pharmacists' counselling has a positive impact on blood glucose and blood pressure management among patients suffering with both diabetes and hypertension.

Understanding of Future Prescribers About Antimicrobial Resistance and Their Preparedness Towards Antimicrobial Stewardship Activities in Pakistan: Findings and Implications

Background: Insufficient antimicrobial-related training for physicians during their undergraduate education could have a negative impact on their prescribing. Unlike previous studies, this study not only explored the understanding and perception of Pakistani medical students about antibiotics and resistance, but also their preparedness towards antimicrobial stewardship programs.

Methods: An online cross-sectional study was undertaken with final-year medical students using a validated questionnaire from January 2021 to May 2021. Descriptive and inference statistics were applied for data analysis.

Results: Of 411 students, only 6.3% had undergone antimicrobial resistance (AMR) training. 16.1% of students believed that antibiotics are effective for viral ailments. More than half of the students agreed that AMR is a major healthcare problem in Pakistan (65.9%). Most students viewed poor infection control practices (66.9%), the use of too many broad-spectrum antibiotics (68.4%) for a longer duration (62.8%) with inadequate doses (67.9%) as the causes of AMR. The student’s preparation was insufficient in interpreting microbiological and pathological results (26.3%), selecting the correct antibiotics (22.1%), and awareness of the antibiotic spectrum (20.9%). The median preparedness score showed significant differences with sex (p = 0.049), age (p < 0.001), institute type (p = 0.014), and family income (p = 0.006).

Conclusion: Pakistani medical students showed adequate understanding of antibiotics, but lacked preparedness for several components of ASPs, including interpretation of microbiological results and spectrum of antibiotics. More steps need to be taken to prepare medical students for AMR and stewardship initiatives adequately.

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.

Perception, Attitude, and Confidence of Physicians About Antimicrobial Resistance and Antimicrobial Prescribing Among COVID-19 Patients: A Cross-Sectional Study From Punjab, Pakistan

Background: Patients with coronavirus disease 2019 (COVID-19) could experience multiple coinfections, and judicial antimicrobials, including antibiotics, is paramount to treat these coinfections. This study evaluated physicians' perception, attitude, and confidence about antimicrobial resistance (AMR) and antimicrobial prescribing in patients with COVID-19. Methods: A self-administered and validated online questionnaire comprised of six sections was disseminated among physicians working in public sector hospitals in Punjab, Pakistan, using the convenience sampling method from April to May 2021. The study also assessed the validity and reliability of the study questionnaire using exploratory factor analysis and Cronbach's alpha. In addition, the descriptive and inferential statistics present survey results. Results: A total of 387 physicians participated in this study. The study showed that the questionnaire demonstrated good internal consistency (Cronbach's alpha = 0.77). Most physicians (n = 221, 57.1%) believed that AMR is a considerable problem in Pakistan. Less than a quarter of respondents (n = 91, 23.5%) consulted with local antibiotic resistance data to prescribe antibiotics in COVID-19 patients. However, the respondents were confident to select a suitable antibiotic (n = 229, 59.2%). More than three-quarters of the respondents believed that advice from a senior colleague (n = 336, 86.8%), infectious disease (ID) physician (n = 315, 81.4%), and implementing antimicrobial stewardship programs (ASPs) could facilitate appropriate prescribing of antibiotics in COVID-19 patients. Multivariate logistic regression revealed that physicians with more than 10 years of experience had higher odds of consulting local guidelines for antibiotic therapy (OR, 4.71 95% CI: 1.62-13.73, p = 0.004) than physicians with less than 5 years of experience. Similar trends were found for consulting national guidelines and local resistance data to select an empiric antibiotic therapy. Conclusion: AMR-related awareness was optimal among physicians. Only a few physicians looked up local antibiotic resistance data before prescribing antibiotics to COVID-19 patients empirically. The significant approaches advised by physicians to reduce AMR risk among COVID-19 patients were the implementation of ASPs combined with advice from ID physicians.

Cancer Care in Pakistan: A Descriptive Case Study

In this descriptive case study, we aimed to understand the experiences of cancer diagnosis, treatment, and palliative care in Pakistan. The case was limited to a hospital for cancer and hospice care in Karachi, Pakistan. Data collection included interviews with patients who had a cancer diagnosis, family members, healthcare providers, and unstructured observations. Two themes of suffering and late diagnosis were developed to describe the experiences of people with cancer. Suffering occurred as a result of poverty, social ideas about cancer, and physical suffering. Late diagnosis happened because of cultural ideas about health, low health literacy, and healthcare challenges, although both themes are interconnected. The findings illuminate three key pathways that will improve cancer diagnosis and palliative care in Pakistan: specifically, the need to (a) educate healthcare providers about cancer and palliative care, (b) eradicate corruption in healthcare, and (c) develop policies for universal access to health.

Exploring Undergraduate Pharmacy Students Perspectives Towards Antibiotics Use, Antibiotic Resistance, and Antibiotic Stewardship Programs Along With the Pharmacy Teachers' Perspectives: A Mixed-Methods Study From Pakistan

Background: Antibiotic resistance (ABR) is one of the major issues around the globe. Timely education and awareness of pharmacy students regarding the appropriate use of antibiotics, ABR, and antimicrobial stewardships are required.

Methods: The present study was first conducted in 12 (public and private sector) universities among undergraduate pharmacy students (UGPS) (n = 414) irrespective of their study year through a validated questionnaire, and the insights of pharmacy teachers were taken through in-depth semi-structured interviews in the second phase. For the quantitative data, different statistical methods were used, and data were presented in tabulated form, whereas inductive thematic interpretation was used to categorize themes and derive conclusions from qualitative evidence.

Results: The majority of the students were males (n = 223, 54%) with the mean age group 19–23 years, and 20 faculty members were interviewed with a mean duration of 15 min. Students have good knowledge about antibiotics use and the majority purchased antibiotics through prescription (n = 277, 66.9%) during the last month and strongly agreed to stop unnecessary household storage (n = 183 44.2%). Most of the students have heard the terminologies related to antimicrobial resistance through social media while unaware (n = 104, 25.1%) of a Pakistan national action plan against AMR (antimicrobial resistance). Overall, respondents have a somewhat good understanding of the ABR. Regular use of antibiotics without consultation of a physician can lead to ABR and some wrong answers were observed (162, 39.1%; p > 0.05). The majority of the students (n = 198, 47.8%) and teachers believe that the current pharmacy syllabus must be swiftly updated with the new subjects related to ABR and AMS (antimicrobial stewardship) in Pakistan. The UGPS have emphasized (n = 220, 53.1%; Median = 1, IQR = 2) establishing a link between academia and hospitals. The ABR issue has been highlighted by pharmacy faculty members, who have urged students to take practical efforts toward ABR and AMS knowledge.

Conclusion: The UGPS knowledge related to ABR and AMS must be updated. Students at the undergraduate level must get training in order to encourage the sensible use of antibiotics. Courses on ABR and AMS should be included in present pharmacy curricula.

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications

Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.

Assessment of Adherence to the Core Elements of Hospital Antibiotic Stewardship Programs: A Survey of the Tertiary Care Hospitals in Punjab, Pakistan

Background: To restrain antibiotic resistance, the Centers for Disease Control and Prevention (CDC), United States of America, urges all hospital settings to implement the Core Elements of Hospital Antibiotic Stewardship Programs (CEHASP). However, the concept of hospital-based antibiotic stewardship programs is relatively new in Low- and Middle-Income Countries. Aim: To appraise the adherence of the tertiary care hospitals to seven CEHASPs. Design and Setting: A cross-sectional study in the tertiary care hospitals in Punjab, Pakistan. Method: CEHASP assessment tool, (a checklist) was used to collect data from the eligible hospitals based on purposive sampling. The check list had 19 statements to cover seven CEHASPs: Hospital Leadership Commitment, Accountability, Pharmacy Expertise, Action (Implement Interventions to Improve Antibiotic Use), Tracking Antibiotic Use and Outcomes, Reporting Antibiotic Use and Outcomes, and Education. For each statement, a response of "YES", "NO" or "Under Process" constituted a score of 2, 0 and 1, respectively, where the higher the scores the better the adherence. Categorical variables were described through descriptive statistics, while independent t-test computed group differences. Result: A total of 68 hospitals (n = 33 public, n = 35 private) participated with a response rate of 79.1%. No hospital demonstrated "Perfect" adherence. Roughly half private (48.6%) and more than half public (54.5%) sector hospitals were "Poor" in adherence. Based on the mean score, there was no significant difference between the private and the public hospitals in terms of comparison of individual core elements. The two most neglected core elements emerged as top priority area were: Reporting Antibiotic Use and Outcomes and Tracking Antibiotic Use and Outcomes.Conclusion: The current response of Pakistan to implement hospital-based antibiotic stewardship programs is inadequate. This study points out significant gaps of practice both in public and private tertiary care hospitals. A majority of the core elements of antibiotic stewardship are either absent or "Under Process". The deficiency/priority areas mentioned require immediate attention of the concerned stakeholders in Pakistan.

Antibiotic use among hospitalized children with lower respiratory tract infections: a multicenter, retrospective study from Punjab, Pakistan

BACKGROUND

Lower respiratory tract infection (LRTI) is one of the triggering factors toward death in children below the age of five years necessitating appropriate antibiotic selection. This study aimed to evaluate antibiotic use among hospitalized children (≤5 years age) with LRTIs.

METHODS

A retrospective study was conducted in seven health facilities of the central region of Punjab province of Pakistan. The medical records of hospitalized children ≤5 years diagnosed with LRTI were thoroughly evaluated to get information on demographics, clinical characteristics, and details of prescribed antibiotics. The appropriateness of antibiotics was assessed according to guidelines of the British National Formulary due to a lack of indigenous standard treatment guidelines.

RESULTS

The medical records of 5926 children were searched with the majority (70.9%) diagnosed with community-acquired pneumonia (CAP) followed by acute bronchitis (14.1%). Ceftriaxone plus ampicillin and ceftriaxone plus ampicillin plus amikacin were prescribed to 39% and 11.7% study population, respectively. One-fourth of children were prescribed the wrong dose, and more than half were encountered with the incorrect route of antibiotic administration. Alarmingly, 90.2% of antibiotic prescriptions were inappropriate in our findings.

CONCLUSIONS

Current surveillance study revealed a worrying degree of antibiotic misuse among hospitalized LRTI children aged ≤5 years.

Prevalence and risk factors associated with multi-drug resistant organisms (MDRO) carriage among pediatric patients at the time of admission in a tertiary care hospital of a developing country. A cross-sectional study

Background

The rise of Multidrug-resistant organisms (MDROs) poses a considerable burden on the healthcare systems, particularly in low-middle income countries like Pakistan. There is a scarcity of data on the carriage of MDRO particularly in the pediatrics population therefore, we aimed to determine MDRO carriage in pediatric patients at the time of admission to a tertiary care hospital in Karachi, Pakistan, and to identify the risk factors associated with it.

Methods

A cross-sectional study conducted at the pediatric department of Aga Khan University Hospital (AKUH) from May to September 2019 on 347 children aged 1–18 years. For identification of MDRO (i.e., Extended Spectrum Beta-Lactamase (ESBL) producers, Carbapenem Resistant Enterobacteriaceae (CRE), Vancomycin Resistant Enterococci (VRE), Methicillin Resistant Staphylococcus aureus (MRSA), Multidrug-resistant (MDR) Acinetobacter species and MDR Pseudomonas aeruginosa), nasal swabs and rectal swabs or stool samples were cultured on specific media within 72 h of hospitalization. Data was collected on a predesigned structured questionnaire on demographics, prior use of antibiotics for > 48 h in the last 6 months, history of vaccination in last 6 months, exposure to health care facility regardless of the time of exposure, ICU stay for > 72 h, and about the prior use of medical devices (urinary catheter, central venous lines etc.) in last 1 year. Statistical analysis was performed by Standard statistical software.

Results

Out of 347 participants, 237 (68.3%) were found to be MDRO carriers. Forty nine nasal swabs from 346 children (14.2%) showed growth of MRSA. The majority of the stool/rectal swabs (n = 222 of 322; 69%) collected were positive for MDRO. The most isolated species were ESBL Escherichia coli 174/222 (78.3%) followed by ESBL Enterobacter species 37/222 (16.7%) and ESBL Klebsiella pneumoniae 35/222 (15.8%). On univariate analysis, none of the risk factors showed statistically significant association with MDRO carriage.

Conclusion

Overall, a high prevalence of MDRO carriage was identified among admitted pediatric patients. Implementation of systematic screening may help to identify true burden of MDROs carriage in the health care settings.

Antimicrobial Stewardship Programs in Northwest China: A Cross-Sectional Survey of Perceptions, Involvement, and Perceived Barriers Among Hospital Pharmacists

Background: Antimicrobial stewardship (AMS) is a key prevention strategy in addressing the global concern of increasing antimicrobial resistance (AMR). Pharmacists are one of the integral members of AMS hospital teams around the world. Toward reducing AMR, a major strategy in China is to improve the capacity and participation of pharmacists in the AMS framework. However, little is known about how hospital pharmacists perceive their position and participation in AMS work, and the barriers to this work in China, especially in the Northwest region. Methods: Region this work describes a cross-sectional, anonymous, online survey study. Hospital pharmacists from five provinces/autonomous regions in northwest China were invited to participate in June and July 2020. Participants completed the survey by using WeChat, a popular social application in China. We purposefully distributed the questionnaire link and QR code to hospital pharmacists through the hospital antimicrobial resistance surveillance network, hospital antimicrobial consumption surveillance network, provincial and city pharmaceutical associations, and hospital pharmacist WeChat groups. Results: Out of 1032 respondents, 93.1% believed that AMS programs promote the judicial prescribing of antimicrobials, 95.5% strongly agreed that AMS could reduce the widespread use of antimicrobials, and 92.3% believed that AMS could improve medical services. Pharmacists were most likely to be involved in AMS through reviewing prescriptions of antimicrobials, intervening in inappropriate prescriptions, and providing feedback on antimicrobial prescriptions and medical orders. Barriers to participating in AMS included workload (59.5% of respondents), ineffective communication between pharmacists and doctors (57.7%), and inadequate knowledge of AMS (47.0%). Differences in responses were found between the five surveyed provinces. A significant association was found between median involvement scores and gender, age, education, level of superiority, experience, and type of hospital (p < 0.05). Conclusion: Pharmacists perceived that AMS programs are important, but that their involvement in related activities is limited in all provinces. Further studies and strategies should consider how to overcome the identified barriers to optimize the participation of pharmacists in AMS programs.

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices

BACKGROUND

The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices.

METHODS

In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data.

RESULTS

The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics.

CONCLUSION

This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.

Fecal Microbiome and Resistome Profiling of Healthy and Diseased Pakistani Individuals Using Next-Generation Sequencing

In this paper, we aimed to characterize the fecal microbiome and its resistomes of healthy and diseased subjects infected with multidrug-resistant Escherichia coli using next-generation sequencing (NGS). After initial screening, 26 stools samples belonging to healthy (n = 13) and diseased subjects (n = 13) were selected and subjected to NGS. A total of 23 and 42 antibiotic-resistant genes (ARGs) conferring resistance to 6 and 9 classes of antibiotics were identified in the resistomes of healthy and diseased subjects, respectively. Bacteroidetes were found to be the major phylum in both healthy and diseased subjects; however, Proteobacteria was predominantly present in the diseased subjects only. Microbial dysbiosis and predominance of various ARGs in the resistome of diseased subjects reflect the excessive usage of antibiotics in Pakistan and warrants immediate attention to regulate the use of various antimicrobials.

Knowledge, Attitude, and Practice on Antibiotics and Its Resistance: A Two-Phase Mixed-Methods Online Study among Pakistani Community Pharmacists to Promote Rational Antibiotic Use

Antibiotic resistance (ABR) is an emerging global threat to public health. Substantial evidence has indicated that community pharmacists (CPs) can play a critical role in managing the ever-increasing threat of antibiotic resistance. This study aimed to determine the knowledge, attitude, and practices of CPs (n = 180) towards antibiotics and antibiotic resistance as well as to improve the rational use of antibiotics. A two-phase mixed-methods (quantitative and qualitative) online study was conducted in Pakistan from August 2019 to March 2020 by using validated questionnaires and semi-structured interview data. Different statistical methods were used to tabulate the quantitative data, whereas inductive thematic analysis was conducted to categorize themes from the qualitative data and to draw conclusions. Approximately 64.4% of the CPs were male (mean: 29–33 years old). Overall, CPs had good knowledge of and were familiar with multidrug-resistant organisms and their roles in ABR (65.6%, median = 1, and IQR = 1), although their knowledge was poor in differentiating some antibiotic groups with their respective ABR patterns (31.1%, median = 1, and IQR = 1). Most CPs have a positive attitude towards antibiotics, with most (90.0%) identifying ABR as a critical issue in public health (median = 1 and IQR = 0). Overall, CPs’ practices towards antibiotics were somewhat acceptable, where they leaned towards educating patients about the rational use of antibiotics (52.8%, median = 1, and IQR = 1). The two main themes discovered (antibiotics and counseling of patients) were related to self-medication, while educational intervention is the main subtheme. ABR is multifactorial, with subthemes related to budget, time constraints, incompetent staff, the absence of CPs, the lack of training, and the enforcement of laws and regulations being the needs of the hour in Pakistan. Effective antibiotic stewardship programs, patient education, and awareness campaigns about antibiotics and ABR along with training of the CPs are important factors that have to be addressed in a timely manner.

Understanding of Pharmacy Students towards Antibiotic Use, Antibiotic Resistance and Antibiotic Stewardship Programs: A Cross-Sectional Study from Punjab, Pakistan

Antibiotic resistance (ABR) is a significant issue for public health globally. An adequate understanding of ABR and the approaches used to tackle ABR, including antibiotic stewardship programs, are vital. This study aimed to get an insight into antibiotic use, ABR, and antibiotic stewardship programs among pharmacy students of Punjab, Pakistan. This multicenter study was undertaken among final (fifth) year undergraduate pharmacy students of 7 universities of Punjab, Pakistan. A paper-based self-administered questionnaire comprising 48-items was utilized for data collection. Descriptive and inferential statistics were employed for data analysis. This study included a total of 296 respondents with a response rate of 85.8%. Most of the students had an average understanding of antibiotic use (59.8%), ABR (42.6%), ABR mechanisms (48.0%), and factors of ABR (51.7%). Only 21.6% of students have heard about antibiotic stewardship programs. More than half of the students believed that educating and training healthcare professionals (53.4%) and medical students (57.8%) about the prescribing and judicial usage of antibiotics could reduce the ABR burden. The awareness of most of the pharmacy students about certain aspects of antibiotic use, ABR, and stewardship programs was suboptimal.

National standard treatment guidelines: their impact on medicine use indicators in a resource-limited setting

Objectives

Standard treatment guidelines improve patient care outcomes. Few studies assess the impact of standard treatment guidelines on population-level medicine use indicators in resource limited settings in sub-Saharan Africa, where the burden of disease is greatest. The objective of this study was to determine the immediate and long-term impact of the national standard treatment guidelines on medicine use indicators at the population-level in Namibia.

Methods

An interrupted time-series modeling of the impact of national standard treatment guidelines implemented in Namibia in 2011, on population-level medicine use indicators. Antibiotic, generic and polypharmacy prescribing indicators were abstracted from the national Pharmaceutical Information System, over an eight-year period, 2007– 2015. This generated 15-quarterly time points. The impact was estimated by changes in trends of the indicators, immediately and after the intervention using R-software. The immediate impact was reflected by level change while long term impact was determined by trends/quarterly change after standard treatment guideline implementation.

Key findings

Data points from 522 Pharmaceutical Information System reports from 38 health facilities were included. The eight-year period estimates were, 2.9 ± 0.1 medicines prescribed per outpatient, 48.1 ± 2.5% of prescriptions had an antibiotic and 74.0 ± 4.2% of medicines were prescribed by generic name. Of the 13 regions, 61.3% and 53.8% had a decline in the average medicines per prescription and prescriptions with antibiotics respectively, as well as 53.8% of the regions had an increase in prescribing of generic medicines immediately after implementation of the standard treatment guidelines. Thereafter, quarterly trends in the three indicators did not significantly improve after the intervention at national and in all regions, except for generic prescribing in Oshikoto region, 4.5% (95% CI: 2.6 – 6.3%, P &lt; 0.001).

Conclusion

Whilst national standard treatment guidelines immediately improved medicine use indicators, it is discouraging that the improvement over time was marginal across regions and was not sustained at the national level. Robust point of care interventions is needed for sustained and effective implementation of standard treatment guidelines.

Exploring perspectives on antimicrobial stewardship: a qualitative study of health managers in Kenya

BACKGROUND

Antimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being increasingly obligatory. Perspectives and insights of health managers on antimicrobial stewardship (AMS), complementary health services and building blocks are imperative towards implementation of robust AMS programs. This study aimed to understand perspectives of hospital managers on AMS and identify areas of management engagement while addressing potential blockades to change.

METHODS

A cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant interviews on perspectives on AMS were administered to hospital managers. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants.

RESULTS

Perspectives on AMS are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There lacked contextualized, hospital specific antimicrobial formulary and adequate laboratory competency. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment.

CONCLUSIONS

The practice of antimicrobial stewardship is not implemented and well developed as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to hospitals and their clients. The findings underpin the importance of understanding and incorporating perspectives of health managers on existing contextual mechanisms that can be leveraged on to establish robust AMS programs in the fight against antimicrobial resistance.

Adherence to the Core Elements of Outpatient Antibiotic Stewardship: A Cross-Sectional Survey in the Tertiary Care Hospitals of Punjab, Pakistan

BACKGROUND

There is a growing global interest in hospital-based antibiotic stewardship programs (ASPs). Centers for Disease Control and Prevention (CDC) recommends clinicians and facilities in outpatient department (OPD) to adhere to a set of stewardship activities called the Core Elements of Outpatient Antibiotic Stewardship (CEOAS). CEOAS includes 4 core elements for OPD facilities and clinicians each, ie, commitment, action, tracking and reporting, and education and expertise.

AIM

The aim of this study was to evaluate the adherence of OPDs in tertiary care hospitals to CEOAS.

DESIGN AND SETTING

A cross-sectional study in the hospitals in Punjab, Pakistan.

METHODS

Study was reported as per STROBE guidelines. Data were collected from hospitals based on purposive sampling on the CEOAS framwork. On a summative scale, positive response to each core element worthed a score and higher the score better the adherence. Descriptive statistics was used for categorical variables while independent t-test computed group differences.

RESULTS

Fifty-three tertiary care hospitals (n=22 public, n=31 private) participated (response rate=86.9%). No hospital reported "perfect" adherence. Overall, facilities and clinicians in OPDs were moderately adherent. Subgroup analysis indicated that hospitals in public and private were poorly (4.9) and moderately (6.0) adherent to CEOAS respectively, however, private clinicians scored significantly higher in action, and tracking and reporting. Tracking and reporting of antibiotics and education of patients and clinicians emerged as top deficiency areas in facilities and clinicians respectively.

CONCLUSION

Significant gaps exist in the adherence to CEOAS. The deficiency areas highlighted in the study should be given priority in future policy shift.

Knowledge, attitude, and practices of community pharmacy staff toward antimicrobial stewardship programs: a cross-sectional study from Northeastern China

BACKGROUND

Antimicrobial resistance is one of the most significant challenges of the twenty-first century, and the illegal sale of antimicrobial drugs at community pharmacies is a driver of antimicrobial resistance. This study explores the knowledge, attitudes, and practices (KAP) of pharmacy staff toward antimicrobial stewardship programs (ASPs).

METHODS

We conducted a descriptive cross-sectional study among community pharmacy staff in Northeastern China, from April 1 to 31 May 2019, using a self-administered KAP questionnaire comprising 20 items. The data analysis was carried out by employing Mann-Whitney and Kruskal-Wallis tests.

RESULTS

A response rate of 98.5% (394/400) was obtained. The majority of participants (94.9%) demonstrated a good understanding of antimicrobial use, but they lacked an adequate understanding of ASPs. Nearly half of the participants (40.6%) reported that they sold antimicrobials to patients without a prescription. Education level, age, occupation, and experience were all significantly associated (P < 0.05) with participants' median ASPs scores. Besides, the presence of a licensed pharmacist (OR 46.327, 95% CI 2.443-878.451, P = 0.011) was the main factor associated with the pharmacy staff's understanding of antimicrobial use policies.

CONCLUSIONS

The participants' knowledge of antimicrobials was good, and their attitudes regarding ASPs were positive, but their practices regarding ASPs were poor.

Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries: Progress and Challenges in Eight South Asian and Southeast Asian Countries

Antimicrobial resistance (AMR) is a serious global health threat and is predicted to cause significant health and economic impacts, particularly in low- and middle-income countries (LMICs). AMR surveillance is critical in LMICs due to high burden of bacterial infections; however, conducting AMR surveillance in resource-limited settings is constrained by poorly functioning health systems, scarce financial resources, and lack of skilled personnel. In 2015, the United Nations World Health Assembly endorsed the World Health Organization's Global Action Plan to tackle AMR; thus, several countries are striving to improve their AMR surveillance capacity, including making significant investments and establishing and expanding surveillance networks. Initial data generated from AMR surveillance networks in LMICs suggest the high prevalence of resistance, but these data exhibit several shortcomings, such as a lack of representativeness, lack of standardized laboratory practices, and underutilization of microbiology services. Despite significant progress, AMR surveillance networks in LMICs face several challenges in expansion and sustainability due to limited financial resources and technical capacity. This review summarizes the existing health infrastructure affecting the establishment of AMR surveillance programs, the burden of bacterial infections demonstrating the need for AMR surveillance, and current progress and challenges in AMR surveillance efforts in eight South and Southeast Asian countries.

Pediatric Antimicrobial Stewardship Programs: Current Perspectives

With the rapid growth of the field of pediatric antimicrobial stewardship, there has been a marked increase in the establishment of programs dedicated to this specialty. Shared objectives of all pediatric antimicrobial stewardship programs (ASPs) include optimization of antibiotic use and improvement in clinical outcomes for children, while certain core operational strategies and metrics used to measure program effectiveness are typically utilized by pediatric ASPs. Antimicrobial stewardship is the responsibility of every individual who prescribes, dispenses, and administers antibiotics to children, and pediatric ASP principles are rooted in collaboration and cooperation. Pediatric ASPs are uniquely suited to meet the needs of the local populations they serve and the environments within which they practice while also fostering an awareness of the interconnected global nature of pediatric stewardship. As such, pediatric ASPs are well positioned to confront the evolving challenges of antimicrobial overuse and resistance.

Knowledge and Beliefs of Health Care Professionals Towards Antimicrobial Resistance in Hiwot Fana Specialized University Hospital, in Harar, Ethiopia

BACKGROUND

Antimicrobial resistance (AMR) results in treatment failure and spread of the infection, which will cause prolonged illness, increased mortality, and financial burdens. Some factors that are responsible for inappropriate use of antimicrobials include lack of expertise by health care professionals and problems in diagnosis.

OBJECTIVE

To assess the knowledge and belief related to AMR among health care professionals in HFSUH in Harar, Ethiopia.

METHODOLOGY

A cross-sectional study was conducted on 153 physicians, nurses, and pharmacists from HFSUH, which were selected using stratified sampling with proportional allocation. Data were collected from March 1 to March 30, 2017, and were analyzed using the Statistical Package for Social Sciences (SPSS 20.0).

RESULTS

Only 132 participants were willing to participate from the 153 health care providers; of whom, 35 (26.5%) were physicians, 86 (65.2%) were nurses, and 11 (8.3%) were pharmacists. MRSA was mentioned as the prominent resistant bacteria by 74.3% of the physician, 59.3% of the nurses, and 63.6% of the pharmacists. The majority consider the overuse of antibiotics, poor infection control, sub-standard antibiotic, and patients' poor adherence as factors for AMR. AMR was considered a problem worldwide, country, and hospital level. Forty percent of the physicians, 32.6% of the nurses, and 63.6% of the pharmacists consider the patient influence on the prescriber as the cause; whereas, 31.4% of the physician, 48.8% nurses, and 36.4% of the pharmacists consider the failure of previous treatment as the major cause of unnecessary antimicrobial prescription.

CONCLUSION

The information the health care professionals have about the different resistant bacteria, on the different factors that cause unnecessary antibiotic prescription and on how to use susceptibility testing is low. All professionals should take regular AMR training and select antibiotics based on tests and minimize the risk of AMR.

Knowledge, attitude and practices among consumers toward antibiotics use and antibiotic resistance in Swat, Khyber-Pakhtunkhwa, Pakistan

Objective: Inappropriate use of antibiotics is one of the main causes of antibiotic resistance around the globe. The present study was aimed to assess the knowledge, attitude, and practices toward antibiotics and antibiotic resistance among consumers. Methods: A cross-sectional study was conducted from April 2019 to September 2019. The participants visiting community pharmacies to buy the antibiotics were approached by data collectors. The descriptive analysis, Kruskal Wallis, and Mann-Whitney statistical tests were used for data analysis through SPSS. Results: 399 participants at three pharmacies with male (n = 352, 88.2%), age (years) group between 34 to 41(n = 138, 34.6%), uneducated (n = 128, 32.1%), and higher education (n = 76, 19.0%) level of the participants were noted. Poor to moderate knowledge were observed; participants were unaware of the risk and misuse of antibiotics at all three pharmacies. By some means, a positive attitude noted, but the storage of antibiotics at home (Median = 2, IQR = 2) was preferred to use when needed. Most of the respondents didn't follow the actual dosage regimen as prescribed (n = 266, 66.7%, p < 0.05). Conclusion: A lack of knowledge and malpractices toward antibiotics use among consumers were observed. Education and awareness of the public about antibiotic resistance is the need of the hour.

Knowledge, Attitude, and Practices of Antibiotics and Antibiotic Resistance Among Chinese Pharmacy Customers: A Multicenter Survey Study

BACKGROUND

Resistance to antibiotics is one of the major global health challenges. An adequate understanding of the public regarding rational antibiotic use is a prerequisite to limit progression in antibiotic resistance. This study aimed to investigate the knowledge, attitude, and practices (KAP) of antibiotics and antibiotic resistance among customers visiting community pharmacies.

METHODS

This study was undertaken in three capital cities in China during March 2019 and July 2019 by using a questionnaire of 28 items. The questionnaire had four parts, including sociodemographic characteristics, KAP about antibiotics, and antibiotic resistance. A systematic random sampling approach was used to recruit the participants. Kruskal-Wallis and Mann-Whitney tests were carried out for data analysis.

RESULTS

The response rate was 66.7% (1800/2700). Out of the total, only 9.7% of the customers had good knowledge about antibiotics. Nearly half of the participants were unable to differentiate between antibiotics, and anti-inflammatory drugs (n = 820, 45.6%, Median = 2, IQR = 1). Most of the customers were of the view that the use of over the counter antibiotics in pregnant women is unsafe (n = 1307, 72.6%, Median = 2, IQR = 0). Almost half of the participants disagreed that costly antibiotics are more effective and have fewer side effects (n = 897, 49.9%, Median = 3, IQR = 1). Only 22.3% of participants said that they always finish the course of antibiotic treatment (n = 401, 22.3%, Median = 3, IQR = 1).

CONCLUSION

The knowledge of Chinese pharmacy consumers was inadequate, and a lack of good attitudes and practices in certain aspects of antibiotic use was observed. Educational interventions are needed to increase public knowledge of antibiotics.

Antimicrobial point prevalence surveys in two Ghanaian hospitals: opportunities for antimicrobial stewardship

BACKGROUND

Improved knowledge regarding antimicrobial use in Ghana is needed to reduce antimicrobial resistance (AMR). This includes point prevalence studies (PPSs) in hospitals. Objectives were to: (i) provide baseline data in two hospitals [Keta Municipal Hospital (KMH) and Ghana Police Hospital (GPH)] and identify priorities for improvement; (ii) assess the feasibility of conducting PPSs; and (iii) compare results with other studies.

METHODS

Standard PPS design using the Global PPS paper forms, subsequently transferred to their template. Training undertaken by the Scottish team. Quality indicators included: rationale for use; stop/review dates; and guideline compliance.

RESULTS

Prevalence of antibiotic use was 65.0% in GPH and 82.0% in KMH. Penicillins and other β-lactam antibiotics were the most frequently prescribed in both hospitals, with third-generation cephalosporins mainly used in GPH. Antibiotic treatment was mainly empirical and commonly administered intravenously, duration was generally short with timely oral switching and infections were mainly community acquired. Encouragingly, there was good documentation of the indications for antibiotic use in both hospitals and 50.0%-66.7% guideline compliance (although for many indications no guideline existed). In addition, almost all prescribed antibiotics had stop dates and there were no missed doses. The duration of use for surgical prophylaxis was generally more than 1 day (69.0% in GPH and 77.0% in KMH).

CONCLUSIONS

These two hospitals were the first in Ghana to use the Global PPS system. We found the PPS was feasible, relatively rapid and achieved with limited training. Targets for improvement identified included reduction of broad-spectrum antibiotics and duration of treatment.

Perspective of Key Healthcare Professionals on Antimicrobial Resistance and Stewardship Programs: A Multicenter Cross-Sectional Study From Pakistan

Background: Antimicrobial resistance (AMR) is an increasing global threat, and hospital-based antimicrobial stewardship programs (ASPs) are one of the effective approaches to tackle AMR globally. This study was intended to determine the attitude of key healthcare professionals (HCPs), including physicians, nurses, and hospital pharmacists, towards AMR and hospital ASPs.

Methods: A cross-sectional study design was used to collect data from HCPs employed in public teaching hospitals of Punjab, Pakistan, from January 2019 to March 2019. A cluster-stratified sampling method was applied. Descriptive statistics, Mann Whitney and Kruskal Wallis tests were used for analysis.

Results: A response rate of 81.3% (881/1083) for the surveys was obtained. The majority of the physicians (247/410, 60.2%) perceived AMR to be a serious problem in Pakistani hospitals (p < 0.001). Most of the HCPs considered improving antimicrobial prescribing (580/881, 65.8%; p < 0.001) accompanied by the introduction of prospective audit with feedback (301/881, 75.8%; p < 0.001), formulary restriction (227/881, 57.2%; p = 0.004) and regular educational activities (300/881, 75.6%; p = 0.015) as effective ASP methods to implement hospital ASPs in Pakistan. A significant association was found between median AMR and ASP scores with age, years of experience, and types of HCPs (p < 0.05).

Conclusions: The attitude of most of the HCPs was observed to be positive towards hospital-based ASPs regardless of their poor awareness about ASPs. The important strategies, including prospective audit with feedback and regular educational sessions proposed by HCPs, will support the initiation and development of local ASPs for Pakistani hospitals.

Perspective of community pharmacists about community-based antimicrobial stewardship programs. A multicenter cross-sectional study from China

Background: Antimicrobial stewardship programs (ASPs) are commonly used worldwide to tackle antimicrobial resistance. The current study aimed to investigate the perspective of pharmacists on community-based ASPs in China.Methods: A multicenter cross-sectional study was conducted in the capital cities of three different provinces of China between March 2019 and July 2019. A systematic random sampling method was used to recruit respondents.Results: A response rate of 87.4% (416/476) was obtained. A large number of respondents (n = 308, 74.0%) believed that ASPs are vital to improving patient care (Median = 4, IQR = 2). Approximately one-third of the respondents (n = 142, 34.1%) always ask patients about their knowledge related to antimicrobials (Median = 4, IQR = 2). Additionally, a considerable number of respondents (n = 127, 30.5%) always, or often (n = 117, 28.1%) collaborated with other healthcare professionals (Median = 4, IQR = 2). Age, gender, and experience were observed to have a significant association (p < 0.05) with median scores of knowledge about antibiotics, perceptions, and practices on ASPs.Conclusions: The perceptions of pharmacists regarding ASPs were positive. However, gaps in knowledge about some aspects of antibiotics and participation in ASPs were found. The development of regional community-based ASPs is urgently required.

Attitude of clinicians towards hospital-based antimicrobial stewardship programs: a multicenter cross-sectional study from Punjab, Pakistan

Background: Antimicrobial resistance (AMR) is a major threat to global health and antimicrobial stewardship programs (ASPs) are useful to limit the momentum of AMR. This study was intended to determine the attitudes of clinicians about AMR, ASP strategies, and their readiness to participate in ASPs. Methods: A cross-sectional survey was carried out among clinicians working in teaching hospitals of Punjab between August and November 2018. A multistage sampling method was used. Descriptive statistics and Kruskal-Wallis tests were employed for data analysis. Results: A response rate of 77.9% (670 ⁄ 859) was achieved. Most of the physicians (n = 302, 71.7%) compared to surgeons (n = 134, 70.9%) and anesthetists (n = 25, 41.7%) considered AMR as a serious health problem in Pakistani hospitals (p < 0.001). Clinicians were agreed that hospital audit and feedback (n = 434, 64.8%), restriction of certain antibiotics (n = 424, 63.3%), readily accessible microbiological data (n = 453, 67.6%), and regular educational sessions (n = 496, 74.0%) are imperative approaches to implement ASPs. Median ASP and AMR scores were significantly associated with age, experience, and types of clinicians (p < 0.05). Conclusions: Despite poor previous knowledge of ASPs, all clinicians showed a positive attitude towards hospital ASPs. Several approaches suggested by clinicians will be helpful to implement hospital ASPs in Pakistan.

Snapshot of antimicrobial stewardship programs in the hospitals of Pakistan: findings and implications

Objective

We are unaware of the extent of antimicrobial stewardship programs (ASPs) among hospitals in Pakistan, which is a concern given the population size, high use of antibiotics across sectors and increasing antimicrobial resistance (AMR) rates. Consequently, we sought to address this by undertaking a comprehensive survey.

Method

In this cross-sectional observational study in Punjab, an instrument of the measure was developed based on health care facility characteristics and ASPs after an extensive literature review. The questionnaire was circulated by mail or through drop off surveys to medical superintendents or directors/heads of pharmacy departments of hospitals.

Results

Out of 254, a total of 137 hospitals fully completed the questionnaire - 11 primary, 65 secondary, 46 tertiary and 15 specialized hospitals. The use of antimicrobial prescribing guidelines (68.7%), provision of infectious diseases consultation services (66.4%), clinical pharmacy service (65.7%), use of drug and therapeutics committees to approve antimicrobial prescribing (65.5%), regular audit by doctors on antimicrobial prescribing (54.1%) and use of a restricted formulary for antimicrobial (50.4%) were the most common ASPs. However, most of these activities were only somewhat or moderately successful. Whereas, electronic antimicrobial prescribing approval systems (15.3%), using a sticker to notify prescribers regarding the need to obtain approval for the antimicrobial prescribed (16.1%) and participation in the national antimicrobial utilization surveillance program (19.7%) were only seen in a few hospitals.

Conclusion

Study inferred that there are inadequate ASPs in the hospitals of Pakistan. A multidisciplinary approach, clinical leadership and availability of motivated and trained individuals are essential elements for the success of future ASPs.