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Harun MGD, Sumon SA, Hasan I, Akther FM, Islam MS, Anwar MMU. Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review. Antimicrob Resist Infect Control 2024; 13:8. [PMID: 38263235 PMCID: PMC10804809 DOI: 10.1186/s13756-024-01369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/15/2024] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
- Md Golam Dostogir Harun
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh.
| | - Shariful Amin Sumon
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Istiaque Hasan
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
| | - Fairoze Masuda Akther
- Infectious Diseases Division, icddr, b, 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212, Bangladesh
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Wade T, Roberts N, Ban JW, Waweru-Siika W, Winston H, Williams V, Heneghan CJ, Onakpoya IJ. Utility of healthcare-worker-targeted antimicrobial stewardship interventions in hospitals of low- and lower-middle-income countries: a scoping review of systematic reviews. J Hosp Infect 2023; 131:43-53. [PMID: 36130626 DOI: 10.1016/j.jhin.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Antimicrobial stewardship (AMS) initiatives in hospitals often include the implementation of clustered intervention components to improve the surveillance and targeting of antibiotics. However, impacts of the individual components of AMS interventions are not well known, especially in low- and lower-middle-income countries (LLMICs). OBJECTIVE A scoping review was conducted to summarize evidence from systematic reviews (SRs) on the impact of common hospital-implemented healthcare-worker-targeted components of AMS interventions that may be appropriate for LLMICs. METHODS Major databases were searched systematically for SRs of AMS interventions that were evaluated in hospitals. For SRs to be eligible, they had to report on at least one intervention that could be categorized according to the Effective Practice and Organisation of Care taxonomy. Clinical and process outcomes were considered. Primary studies from LLMICs were consulted for additional information. RESULTS Eighteen SRs of the evaluation of intervention components met the inclusion criteria. The evidence shows that audit and feedback, and clinical practice guidelines improved several clinical and process outcomes in hospitals. An unintended consequence of interventions was an increase in the use of antibiotics. There was a cumulative total of 547 unique studies, but only 2% (N=12) were conducted in hospitals in LLMICs. Two studies in LLMICs reported that guidelines and educational meetings were effective in hospitals. CONCLUSION Evidence from high- and upper-middle-income countries suggests that audit and feedback, and clinical practice guidelines have the potential to improve various clinical and process outcomes in hospitals. The lack of evidence in LLMIC settings prevents firm conclusions from being drawn, and highlights the need for further research.
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Affiliation(s)
- T Wade
- Department for Continuing Education, University of Oxford, Oxford, UK.
| | - N Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - J-W Ban
- Section of Evidence-Based Practice, Western Norway University of Applied Sciences, Bergen, Norway
| | - W Waweru-Siika
- Section of Evidence-Based Practice, Western Norway University of Applied Sciences, Bergen, Norway
| | - H Winston
- Department of Family Medicine, University of Pittsburgh Medical Center, McKeesport, PA, USA
| | - V Williams
- School of Nursing, Nipissing University, North Bay, Ontario, Canada
| | - C J Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - I J Onakpoya
- Department for Continuing Education, University of Oxford, Oxford, UK
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Borde K, Medisetty MK, Muppala BS, Reddy AB, Nosina S, Dass MS, Prashanthi A, Billuri P, Mathai D. Impact of an Antimicrobial Stewardship Intervention on Usage of Antibiotics in Coronavirus Disease-2019 at a Tertiary Care Teaching Hospital in India. IJID REGIONS 2022; 3:15-20. [PMID: 35720136 PMCID: PMC8820141 DOI: 10.1016/j.ijregi.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/31/2022] [Accepted: 02/03/2022] [Indexed: 11/19/2022]
Abstract
High empirical usage of beta-lactams and macrolides seen in COVID 19 patients. Interrupted time series analysis showed significant reduction in antibiotic usage. 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.
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Affiliation(s)
- Kalyani Borde
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Mahender Kumar Medisetty
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
- Corresponding author: Mahender Kumar Medisetty (Ph No: 9000538043), Address: Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad – 500033.
| | - Baby Shalini Muppala
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Aishwarya B Reddy
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Sireesha Nosina
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Manick S. Dass
- Department of Microbiology, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - A. Prashanthi
- Infection control nurse, Nursing Department, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Pushpanjali Billuri
- Infection control nurse, Nursing Department, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
| | - Dilip Mathai
- Department of General Medicine, Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Road No. 92, Film Nagar, Jubilee Hills, Hyderabad, 500033
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Setiawan E, Abdul-Aziz MH, Roberts JA, Cotta MO. Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review. Microb Drug Resist 2022; 28:566-584. [PMID: 35333607 DOI: 10.1089/mdr.2021.0363] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Eko Setiawan
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Clinical and Community Pharmacy; and Center for Medicines Information and Pharmaceutical Care (CMIPC), Faculty of Pharmacy, University of Surabaya, Surabaya, Indonesia
| | - Mohd-Hafiz Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Menino Osbert Cotta
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Foxlee ND, Townell N, Heney C, McIver L, Lau CL. Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review. Trop Med Infect Dis 2021; 6:tropicalmed6030166. [PMID: 34564550 PMCID: PMC8482147 DOI: 10.3390/tropicalmed6030166] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 01/09/2023] Open
Abstract
Containing antimicrobial resistance and reducing high levels of antibiotic consumption in low- and lower middle-income countries are a major challenge. Clinical guidelines targeting antibiotic prescribing can reduce consumption, however, the degrees to which clinical guidelines are adopted and adhered to are challenging for developers, policy makers and users. The aim of this study was to review the strategies used for implementing and promoting antibiotic guideline adherence in low- and lower middle-income countries. A review of published literature was conducted using PubMed, Cochrane Library, SCOPUS and the information systems of the World Health Organization and the Australian National University according to PRISMA guidelines and our PROSPERO protocol. The strategies were grouped into five broad categories based on the Cochrane Effective Practice and Organization of Care taxonomy. The 33 selected studies, representing 16 countries varied widely in design, setting, disease focus, methods, intervention components, outcomes and effects. The majority of interventions were multifaceted and resulted in a positive direction of effect. The nature of the interventions and study variability made it impossible to tease out which strategies had the greatest impact on improving CG compliance. Audit and feedback coupled with either workshops and/or focus group discussions were the most frequently used intervention components. All the reported strategies are established practices used in antimicrobial stewardship programs in high-income countries. We recommend interrupted time series studies be used as an alternative design to pre- and post-intervention studies, information about the clinical guidelines be made more transparent, and prescriber confidence be investigated.
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Affiliation(s)
- Nicola D. Foxlee
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, ACT 2600, Australia;
- Correspondence: ; Tel.: +61-7-435-549-071
| | - Nicola Townell
- Infectious Disease Department, Sunshine Coast University Hospital, Birtinya, QLD 4575, Australia;
| | - Claire Heney
- Pathology Queensland, Central Microbiology, Brisbane, QLD 4006, Australia;
| | - Lachlan McIver
- Rocketship Pacific Ltd., Port Melbourne, Melbourne, VIC 3207, Australia;
| | - Colleen L. Lau
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, ACT 2600, Australia;
- School of Public Health, University of Queensland, Herston, QLD 4006, Australia
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Mugada V, Mahato V, Andhavaram D, Vajhala SM. Evaluation of Prescribing Patterns of Antibiotics Using Selected Indicators for Antimicrobial Use in Hospitals and the Access, Watch, Reserve (AWaRe) Classification by the World Health Organization. Turk J Pharm Sci 2021; 18:282-288. [PMID: 34157817 DOI: 10.4274/tjps.galenos.2020.11456] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objectives Antibiotic resistance poses a significant threat to the world, and irrational use of antibiotics is a major contributing factor. Evaluation of antimicrobial use is underway with the help of indicators and the World Health Organization (WHO) classification of antibiotics into Access, Watch, and Reserve (AWaRe) categories. We aimed to evaluate the prescribing pattern of antibiotics using the AWaRe classification by the WHO and selected indicators for antimicrobial use in hospitals. Materials and Methods A total of 1.000 prescriptions were analyzed during the study for antibiotic prescribing patterns. Antibiotic consumption was calculated using defined daily dose (DDD) methodology. The prescribing pattern was evaluated using the WHO classification of antibiotics into the categories AWaRe and using selected indicators (hospital and prescribing) for antimicrobial use in hospitals. Results A total of 1.128 antibiotics were prescribed during the study. The 19-44 age group was prescribed a high number of antibiotics (n=510). Females were prescribed a high number of antibiotics compared with males (n=602). Azithromycin was the most commonly consumed antibiotic (14.97 DDD/1000/day). Four antibiotics from the Access category and five from the Watch category were prescribed in the study. The Watch category of antibiotics were consumed in a high number. There were no standard treatment guidelines in the hospital. In all, 98.0% of antibiotics were consistent with the hospital formulary and prescribed under generic names. The average number of antibiotics prescribed per patient was 1.12. The average duration of antimicrobial treatment was 5.24 days. The percentage of patients prescribed antimicrobials for pneumonia in accordance with treatment guidelines was 13.28%. Conclusion Irrational use of antibiotics exists in hospitals. There is a need to maintain standard treatment guidelines in the hospital because it prevents irrational use of antibiotics.
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Affiliation(s)
- Vinodkumar Mugada
- Vignan Institute of Pharmaceutical Technology, Department of Pharmacy Practice, Andhra Pradesh, India
| | - Varsha Mahato
- Vignan Institute of Pharmaceutical Technology, Department of Pharmacy Practice, Andhra Pradesh, India
| | - Damayanthi Andhavaram
- Vignan Institute of Pharmaceutical Technology, Department of Pharmacy Practice, Andhra Pradesh, India
| | - Sairam Mouli Vajhala
- Vignan Institute of Pharmaceutical Technology, Department of Pharmacy Practice, Andhra Pradesh, India
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Chandela R, Jade D, Mohan S, Sharma R, Sugumar S. Identification of Therapeutic Drug Target of Stenotrophomonas maltophilia Through Subtractive Genomic Approach and in-silico Screening Based on 2D Similarity Filtration and Molecular Dynamic Simulation. Comb Chem High Throughput Screen 2021; 25:123-138. [DOI: 10.2174/1871520620666201123094330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 01/21/2020] [Accepted: 01/30/2020] [Indexed: 11/22/2022]
Abstract
Background:
Stenotrophomonas maltophilia is a multi-drug resistant, gram-negative
bacterium that causes opportunistic infections and is associated with high morbidity and mortality
in severely immunocompromised individuals.
Aim:
The study aimed to find out the drug target and a novel inhibitor for Stenotrophomonas
maltophilia.
Objectives:
The current study focused on identifying specific drug targets by subtractive genomes
analysis to determine the novel inhibitor for the specified target protein by virtual screening,
molecular docking, and molecular simulation approach.
Materials and Methods:
In this study, we performed a subtractive genomics approach to identify
the novel drug target for S.maltophilia. After obtaining the specific target, the next step was to
identify inhibitors that include calculating 2D similarity search, molecular docking, and molecular
simulation for drug development for S.maltophilia.
Results:
With an efficient subtractive genomic approach, five unique targets as the impressive therapeutics founded out of
4386 protein genes. In which UDP-D-acetylmuramic (murF) was the most remarkable target. Further virtual screening,
docking, and dynamics resulted in the identification of seven novel inhibitors.
Conclusion:
Further, in vitro and in vivo bioassay of the identified novel inhibitors could facilitate effective drug use against
S.maltophilia.
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Affiliation(s)
- Rahul Chandela
- Department of Genetic Engineering, SRM Institute of Science and Technology, Kattankulathur - 603203, Chennai, Tamil Nadu,India
| | - Dhananjay Jade
- Laboratory of Molecular Biology and Genetic Engineering, School of Biotechnology, Jawaharlal Nehru University, New Delhi, 110067,India
| | - Surender Mohan
- Laboratory of Molecular Biology and Genetic Engineering, School of Biotechnology, Jawaharlal Nehru University, New Delhi, 110067,India
| | - Ridhi Sharma
- Department of Genetic Engineering, SRM Institute of Science and Technology, Kattankulathur - 603203, Chennai, Tamil Nadu,India
| | - Shobana Sugumar
- Department of Genetic Engineering, SRM Institute of Science and Technology, Kattankulathur - 603203, Chennai, Tamil Nadu,India
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Wali A, Ishtiaq A, Rahim A, Iftikhar S. The Impact of Evidence-Based Transformation on Healthcare Practices at a Teaching Hospital. Cureus 2020; 12:e11744. [PMID: 33403174 PMCID: PMC7773286 DOI: 10.7759/cureus.11744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objective In this study, we aimed to compare the frequency of anemia, blood transfusions, and the use of antimicrobial therapy (AMT) before the implementation of standard protocols in obstetrics and gynecology with the data after one year of implementation at a teaching hospital. Methods In this retrospective observational study, the pre-intervention data (group A) were compared to the data after the implementation of standard protocols (group B). Data were retrieved from hospital electronic medical records and were entered and analyzed on SPSS Statistics version 24 (IBM, Armonk, NY). Results In obstetrics (n=829), anemia was observed in 43.1% vs. 26.8% (p<0.001) and transfusion rate in 5.4% vs. 0.6% (p<0.001) in the groups A and B respectively. In vaginal deliveries (VD), the use of AMT for >24 hours was 98% in group A vs. 9% in group B, and in cesarean deliveries (CD), it was 100% in group A vs. 54.5% in group B (p<0.001). The cost of AMT decreased by 78.4% in VD and by 51.1% in CD. In gynecology (n=221), the prevalence of anemia was 22.6% in group A vs. 17.9% in group B (p=NS). In minor procedures, the use of AMT for >24 hours was 76.7% vs. 8.4% (p<0.001), and in major procedures, it was 86.5% vs. 38% (p<0.001) between the two groups. The cost of AMT decreased by 79.5% in minor procedures and 26.4% in major procedures. Conclusion The implementation of quality standards can bring about significant improvements in clinical outcomes in a short period of time.
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Affiliation(s)
- Aisha Wali
- Obstetrics and Gynecology, The Indus Hospital, Karachi, PAK
| | | | - Anum Rahim
- Epidemiology and Public Health, The Indus Hospital, Karachi, PAK
| | - Sundus Iftikhar
- Statistics, Indus Hospital Research Center, The Indus Hospital, Karachi, PAK
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Bediako-Bowan AAA, Kurtzhals JAL, Mølbak K, Labi AK, Owusu E, Newman MJ. High rates of multi-drug resistant gram-negative organisms associated with surgical site infections in a teaching hospital in Ghana. BMC Infect Dis 2020; 20:890. [PMID: 33238903 PMCID: PMC7689982 DOI: 10.1186/s12879-020-05631-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There is limited data to guide the prevention and management of surgical site infections (SSI) in low- and middle-income countries. We prospectively studied aetiological agents associated with SSI and their corresponding antibiotic susceptibility patterns in a tertiary hospital in Ghana. METHODS As part of a cohort study carried out at the surgical department of the Korle Bu Teaching Hospital (KBTH) from July 2017 to April 2019, wound swabs were collected from patients diagnosed with SSI. Isolates cultured from the wound swabs were identified by MALDI TOF and susceptibility testing was conducted according to EUCAST 2020 guidelines. Clinical data were monitored prospectively. RESULTS Of 4577 patients, 438 developed an SSI and 352 microbial isolates were cultured. Isolates were predominantly Gram negative (286, 81%), a pattern seen for all kinds of surgery and all wound classes. The most common species included Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Staphylococcus aureus and Acinetobacter baumannii. The majority of organisms were multi-drug resistant including 86% of E. coli, 52% of A. baumannii and 86% of K. pneumoniae; and 65% (17/26) of the cefotaxime-resistant K. pneumoniae were extended spectrum β-lactamase producing. One of 139 E. coli, 15 of 49 P. aeruginosa, and 6 of 23 A. baumannii were meropenem resistant, but no clonal pattern was found. There was a 1% (5/428) prevalence of methicillin-resistant S. aureus. CONCLUSIONS The predominance of Gram-negative organisms and the high level of multi-drug resistance indicate a need to re-evaluate antibiotic prophylaxis and treatment protocols in surgical practice in low- and middle-income countries.
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Affiliation(s)
- Antoinette A A Bediako-Bowan
- Department of Surgery, University of Ghana Medical School, University of Ghana, P. O. Box 4356, Accra, Ghana.
- Department of Surgery, Korle Bu Teaching Hospital, Accra, Ghana.
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark.
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark.
| | - Jørgen A L Kurtzhals
- Centre for Medical Parasitology at Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
| | - Kåre Mølbak
- Department of Veterinary and Animal Science, University of Copenhagen, Copenhagen, Denmark
- Division of Infectious Disease Preparedness, Statens Serum Institut, Copenhagen, Denmark
| | - Appiah-Korang Labi
- Centre for Medical Parasitology at Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital (Rigshospitalet), Copenhagen, Denmark
- Department of Microbiology, Korle-Bu Teaching Hospital, P.O. Box 77, Accra, Ghana
| | - Enid Owusu
- Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Science, University of Ghana, Legon, Accra, Ghana
| | - Mercy J Newman
- Department of Medical Microbiology, University of Ghana Medical School, University of Ghana, Accra, Ghana
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Bahl A, Sahni A, Martolia R, Jain S, Singh S. Implementation of antimicrobial stewardship activities in India. INDIAN JOURNAL OF MEDICAL SPECIALITIES 2020. [DOI: 10.4103/injms.injms_118_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Van Dijck C, Vlieghe E, Cox JA. Antibiotic stewardship interventions in hospitals in low-and middle-income countries: a systematic review. Bull World Health Organ 2018; 96:266-280. [PMID: 29695883 PMCID: PMC5872012 DOI: 10.2471/blt.17.203448] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/26/2017] [Accepted: 01/08/2018] [Indexed: 12/25/2022] Open
Abstract
Objective To review the effectiveness of antibiotic stewardship interventions in hospitals in low- and middle-income countries. Methods We searched MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials and regional indexes for studies of interventions to improve appropriate prescribing and use of antibiotics for hospitalized patients in low- and middle-income countries. We included controlled trials, controlled before-and-after studies and interrupted time-series studies published up to December 2017. We report prescribing, clinical and microbiological outcomes using a narrative approach. Findings We screened 7342 original titles and abstracts, assessed 241 full-text articles and included 27 studies from 2 low-income and 11 middle-income countries. We found a medium (11 studies) or high risk (13 studies) of bias. Generally, all types of interventions (structural, persuasive and enabling) and intervention bundles were reported to improve prescribing and clinical outcomes. However, the studied interventions and reported outcomes varied widely. The most frequent intervention was procalcitonin-guided antibiotic treatment (8 of 27 studies, all randomized controlled trials). The intervention was associated with a relative risk for patients receiving antibiotics ranging between 0.40 and 0.87. Conclusion The majority of studies reported a positive effect of hospital antibiotic stewardship interventions. However, we cannot draw general conclusions about the effectiveness of such interventions in low- and middle-income countries because of low study quality, heterogeneity of interventions and outcomes, and under-representation of certain settings. To strengthen the evidence base, action needs to be taken to address these shortcomings.
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Affiliation(s)
- Christophe Van Dijck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium
| | - Erika Vlieghe
- Unit of Internal Medicine and Infectious Diseases, University Hospital Antwerp, Antwerp, Belgium
| | - Janneke Arnoldine Cox
- Unit of Tropical Laboratory Medicine, Institute of Tropical Medicine, Antwerp, Belgium
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