Impact of guidelines implementation for the rational use of prophylactic antibiotics in elective cesarean sections at Elqutainah Teaching Hospital

Pharmacist roles in antimicrobial stewardship: a qualitative study from India, South Africa and the United Kingdom

Objective

To explore pharmacist roles in antimicrobial stewardship (AMS) in India, South Africa (SA), United Kingdom (UK) and the factors that contribute to their participation in the programme in these countries.

Methods

Data were collected between April 2019 and March 2022 through semi-structured interviews with key AMS stakeholders from India (Kerala); SA (Western Cape province) and the UK (England). Interviews were conducted face to face or via Zoom and Skype platforms, audio recordings were transcribed verbatim and thematically analysed using a grounded theory approach aided by NVivo 12 software.

Results

We interviewed 38 key AMS stakeholders (pharmacists and doctors). India and the UK have dedicated AMS pharmacists (Doctor of Pharmacy and Master of Pharmacy graduates with opportunities for additional post-graduate qualifications respectively). Pharmacists in the UK lead AMS programmes, while in India, predominantly in the private sector, pharmacists drive AMS in collaboration with clinicians. In SA, pharmacists (Bachelor of Pharmacy graduates) participate in AMS out of their own commitment in addition to their pharmacy responsibilities. Private sector pharmacists drive AMS while public sector pharmacists participate in clinician-led AMS programmes. Current pharmacy curricula do not provide adequate training in AMS, and this limitation shapes pharmacist roles and acceptance in AMS among clinicians in India and SA. Support of mentors (doctors/senior pharmacists) and self-motivated learning are key factors for effective pharmacist involvement in AMS.

Conclusions

A contextually developed, standardized and accessible AMS training programme along with pharmacy curricula modification to include AMS, may facilitate prominent pharmacist roles in AMS.

Bacterial co-infections, secondary infections and antimicrobial use among hospitalized COVID-19 patients in the sixth wave in Pakistan: findings and implications

INTRODUCTION

Previous studies in Pakistan have shown considerable over prescribing of antibiotics in patients hospitalized with COVID-19 despite very low prevalence of bacterial infections. Irrational use of antibiotics will worsen antimicrobial resistance (AMR).

METHODS

Retrospective analysis of medical records of patients in the COVID-19 wards of three tertiary care hospitals to assess antibiotic use during the sixth COVID-19 wave.

RESULTS

A total of 284 patients were included, most were male (66.9%), aged 30-50 years (50.7%) with diabetes mellitus the most common comorbidity. The most common symptoms at presentation were cough (47.9%) and arthralgia-myalgia (41.5%). Around 3% were asymptomatic, 34.9% had mild, 30.3% moderate, and 23.6% had severe disease, with 8.1% critical. Chest X-ray abnormalities were seen in 43.3% of patients and 37% had elevated white cell counts, with 35.2% having elevated C-reactive protein levels. Around 91% COVID-19 patients were prescribed antibiotics during their hospital stay, with only a few with proven bacterial co-infections or secondary bacterial infections. Most antibiotics were from the 'Watch' category (90.8%) followed by the 'Reserve' category (4.8%), similar to previous COVID-19 waves.

CONCLUSION

There continued to be excessive antibiotics use among hospitalized COVID-19 patients in Pakistan. Urgent measures are needed to address inappropriate prescribing including greater prescribing of Access antibiotics where pertinent.

Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future

There are serious concerns with rising antimicrobial resistance (AMR) across countries increasing morbidity, mortality and costs. These concerns have resulted in a plethora of initiatives globally and nationally including national action plans (NAPs) to reduce AMR. Africa is no exception, especially with the highest rates of AMR globally. Key activities in NAPs include gaining a greater understanding of current antimicrobial utilization patterns through point prevalence surveys (PPS) and subsequently instigating antimicrobial stewardship programs (ASPs). Consequently, there is a need to comprehensively document current utilization patterns among hospitals across Africa coupled with ASP studies. In total, 33 PPS studies ranging from single up to 18 hospitals were documented from a narrative review with typically over 50% of in-patients prescribed antimicrobials, up to 97.6% in Nigeria. The penicillins, ceftriaxone and metronidazole, were the most prescribed antibiotics. Appreciable extended prescribing of antibiotics up to 6 days or more post-operatively was seen across Africa to prevent surgical site infections. At least 19 ASPs have been instigated across Africa in recent years to improve future prescribing utilizing a range of prescribing indicators. The various findings resulted in a range of suggested activities that key stakeholders, including governments and healthcare professionals, should undertake in the short, medium and long term to improve future antimicrobial prescribing and reduce AMR across Africa.

Impact of Antimicrobial Stewardship Interventions to Improve Antibiotic Prescribing for Hospital Inpatients in Africa: A Systematic Review and Meta-analysis

BACKGROUND

Antimicrobial stewardship (AMS) interventions to improve antibiotic use are being implemented in Africa, but their impact is not fully known.

AIM

To estimate the effectiveness of interventions to improve antibiotic prescribing for hospital inpatients.

METHODS

Systematically searched for studies from PubMed, Embase, African Journals online and Google scholar from January 2010 to July 2022. Studies were included if they reported the impact of AMS interventions on outcomes of interest for hospital inpatients in Africa. Risk of bias was evaluated using the Cochrane Effective Practice and Organization of Care guidelines and the National Heart, Lung and Blood Institute tool. Findings were summarized in tables and meta-analyses were performed using random-effects models.

FINDINGS

Twenty-eight studies were included, 89% being uncontrolled before and after studies. Most interventions employed were multifaceted and found to be effective, evidenced by increased compliance, reduction in antibiotic utilization and cost, and slight reduction or no difference in mortality and length of hospital stay (LOS). Meta-analysis generated a relative risk of 0.82 (95% CI: 0.70∼0.97) for mortality, and a standard mean difference of -0.30 (95% CI: -0.41∼-0.19) for LOS. Generally, a decrease in resistance to most microorganisms was observed. Despite an increase in the number of AMS studies conducted in Africa, the studies lack in most quality design features for AMS studies.

CONCLUSION

Antimicrobial stewardship interventions are likely to be effective, however efforts are still required to align the study design with the quality design features required for validity and to inform practice.

Discharge instructions given to women following delivery by cesarean section in Sub-Saharan Africa: A scoping review

OBJECTIVE

A scoping review of discharge instructions for women undergoing cesarean section (c-section) in sub-Saharan Africa (SSA).

METHOD

Studies were identified from PubMed, Globus Index Medicus, NiPAD, EMBASE, and EBSCO databases. Eligible papers included research based in a SSA country, published in English or French, and containing information on discharge instructions addressing general postnatal care, wound care, planning of future births, or postpartum depression targeted for women delivering by c-section. For analysis, we used the PRISMA guidelines for scoping reviews followed by a narrative synthesis. We assessed quality of evidence using the GRADE system.

RESULTS

We identified 78 eligible studies; 5 papers directly studied discharge protocols and 73 included information on discharge instructions in the context of a different study objective. 37 studies addressed wound care, with recommendations to return to a health facility for dressing changes and wound checks between 3 days to 6 weeks. 16 studies recommended antibiotic use at discharge, with 5 specifying a particular antibiotic. 19 studies provided recommendations around contraception and family planning, with 6 highlighting intrauterine device placement immediately after birth or 6-weeks postpartum and 6 studies discussing the importance of counselling services. Only 5 studies provided recommendations for the evaluation and management of postpartum depression in c-section patients; these studies screened for depression at 4-8 weeks postpartum and highlighted connections between c-section delivery and the loss of self-esteem as well as connections between emergency c-section delivery and psychiatric morbidity.

CONCLUSION

Few studies in SSA directly examine discharge protocols and instructions for women following c-section. Those available demonstrate wide variation in recommendations. Research is needed to develop structured evidence-based instructions with clear timelines for women. These instructions should account for financial burden, access to resources, and education of patients and communities.

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.

Is It Necessary to Perform a Routine Antibiotic Prophylaxis before an Elective Surgery of Cesarean Section?

INTRODUCTION: According to the data by World Health Organization, the broad and often insufficiently substantiated prescription of antibiotics, including for prophylactic purposes, has led to the growth of antibiotic-resistant microflora, which is a dangerous and intractable problem of modern medicine. Despite the undoubted benefits of antibiotics in the management of wound infection and endometritis after cesarean section, the routine prophylactic administration of antibacterial drugs can not only carry the risk of growth of resistant nosocomial microflora, but also have doubtful effects on the health of a newborn. PURPOSE OF THE STUDY: The purpose of the study was to justify the possibility of carrying out elective cesarean section operations without routine antibiotic prophylaxis. MATERIALS AND METHODS: An analysis of 333 cases of elective cesarean section operations carried out in the obstetric department in the period from 2017 to 2019 was performed. Routine antibiotic prophylaxis before surgery was not prescribed in 118 healthy patients with an uncomplicated history and a smooth course of the gestational process. The remaining 215 women received a single intravenous injection of 1 g of cefazolin sodium intraoperatively, after extraction of the fetus. A comparative analysis of the clinical groups was carried out according to the following criteria: vaginal microbiocenosis before surgical delivery, duration, and features of the operation, clinical blood count on days 1 and 5 of the post-operative period, condition of postoperative sutures, the presence of discharge from the wound, signs of infectious complications from the uterus or other organs, uterine involution rate, duration of hospital stay before and after surgery, follow-up history for 1 month after discharge from the maternity ward. The data obtained were subjected to statistical processing. RESULTS: We have found no significant differences in the course and number of complications in the postpartum period in the compared clinical groups. The statistically significant transient leukocytosis observed on the 1st day of the postoperative period in patients who did not undergo antibiotic prophylaxis before the surgery seems to be associated with a more pronounced adaptive reaction and was not combined with any clinical symptoms of development of infection. CONCLUSION: No relationship has been identified between the routine prescription of antibiotics before or during an elective cesarean section and the risk of developing infectious complications in the post-operative period. Antibiotic prophylaxis before surgery should be carried out differentially, taking into account the history and features of the course of this pregnancy.