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Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems.

ABSTRACT: World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is fraught with several challenges. The key limiting factors include lack of clear political commitment, inadequate funding, overcrowded healthcare systems, lax legal and regulatory frameworks, non-uniform access to diagnostics, absence of electronic health record systems, limited knowledge and awareness especially with existence of multiple systems of medicines, issues with access to quality assured medicines, in-house pharmacies, and shortage of trained manpower. Since these implementation-impeding issues may differ considerably from those experienced in developed economies, intervention efforts in low- and middle-income countries (LMICs) need to address the context and focus on the root causes prevailing locally. In this article, we review the evidence highlighting the magnitude of these challenges and suggest feasible models with effective application. We also share the evidence from our center where we have contextualized the core elements to resource constrained settings. These domains include delivering prospective audit and feedback, prescriber education, development of evidence-based and implementable guidelines, and optimization of surgical antibiotic prophylaxis. However, there is a tremendous need for scaling up, extending outreach and honing these models while at the same time, addressing the existing strategic challenges that curtail the full potential of global antimicrobial stewardship.

SUBMITTER: Kakkar AK

PROVIDER: S-EPMC7198767 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems.

Kakkar Ashish Kumar AK Shafiq Nusrat N Singh Gurpreet G Ray Pallab P Gautam Vikas V Agarwal Ritesh R Muralidharan Jayashree J Arora Pankaj P

Frontiers in public health 20200428

World Health Organization (WHO) has identified antimicrobial resistance as one of the top 10 threats to public health. The agency has formulated a global action plan to tackle antimicrobial resistance by reducing incidence of infectious diseases, increasing knowledge and awareness and promoting rational use of antimicrobials amongst other measures. While the core elements of successful antimicrobial stewardship (AMS) programs are much publicized, there application in resource limited settings is ...[more]

PMID: 32411647

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Project description:BackgroundInformation about the feasibility, barriers and facilitators of antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) has been scant. Exploring the prevailing perceptions and attitudes of key healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance and AMS in the RACF setting is imperative to guide AMS interventions.MethodsSemi-structured interviews and focus groups were conducted with key RACF healthcare providers until saturation of themes occurred. Participants were recruited using purposive and snowball sampling. The framework approach was applied for data analysis.ResultsA total of 40 nurses, 15 general practitioners (GPs) and 6 pharmacists from 12 RACFs were recruited. Five major themes emerged; perceptions of current antibiotic prescribing behaviour, perceptions of antibiotic resistance, attitude towards and understanding of AMS, perceived barriers to and facilitators of AMS implementation, and feasible AMS interventions. A higher proportion of GPs and pharmacists compared with nurses felt there was over-prescribing of antibiotics in the RACF setting. Antibiotic resistance was generally perceived as an issue for infection control rather than impacting clinical decisions. All key stakeholders were supportive of AMS implementation in RACFs; however, they recognized barriers related to workload and logistical issues. A range of practical AMS interventions were identified, with nursing-based education, aged-care specific antibiotic guidelines and regular antibiotic surveillance deemed most useful and feasible.ConclusionsAreas of antibiotic over-prescribing have been identified from different healthcare providers' perspectives. However, concern about the clinical impact of antibiotic resistance was generally lacking. Importantly, information gathered about feasibility, barriers and facilitators of various AMS interventions will provide important insights to guide development of AMS programs in the RACF setting.

Project description:Background:Antibiotics are the most common medicines prescribed to children in hospitals and the community, with a high proportion of potentially inappropriate use. Antibiotic misuse increases the risk of toxicity, raises healthcare costs, and selection of resistance. The primary aim of this systematic review is to summarize the current state of evidence of the implementation and outcomes of pediatric antimicrobial stewardship programs (ASPs) globally. Methods:MEDLINE, Embase and Cochrane Library databases were systematically searched to identify studies reporting on ASP in children aged 0-18?years and conducted in outpatient or in-hospital settings. Three investigators independently reviewed identified articles for inclusion and extracted relevant data. Results:Of the 41,916 studies screened, 113 were eligible for inclusion in this study. Most of the studies originated in the USA (52.2%), while a minority were conducted in Europe (24.7%) or Asia (17.7%). Seventy-four (65.5%) studies used a before-and-after design, and sixteen (14.1%) were randomized trials. The majority (81.4%) described in-hospital ASPs with half of interventions in mixed pediatric wards and ten (8.8%) in emergency departments. Only sixteen (14.1%) studies focused on the costs of ASPs. Almost all the studies (79.6%) showed a significant reduction in inappropriate prescriptions. Compliance after ASP implementation increased. Sixteen of the included studies quantified cost savings related to the intervention with most of the decreases due to lower rates of drug administration. Seven studies showed an increased susceptibility of the bacteria analysed with a decrease in extended spectrum beta-lactamase producers E. coli and K. pneumoniae; a reduction in the rate of P. aeruginosa carbapenem resistance subsequent to an observed reduction in the rate of antimicrobial days of therapy; and, in two studies set in outpatient setting, an increase in erythromycin-sensitive S. pyogenes following a reduction in the use of macrolides. Conclusions:Pediatric ASPs have a significant impact on the reduction of targeted and empiric antibiotic use, healthcare costs, and antimicrobial resistance in both inpatient and outpatient settings. Pediatric ASPs are now widely implemented in the USA, but considerable further adaptation is required to facilitate their uptake in Europe, Asia, Latin America and Africa.

Project description:BACKGROUND AND OBJECTIVES:Infections caused by multidrug-resistant organisms and Clostridium difficile are associated with substantial morbidity and mortality as well as excess costs. Antimicrobial exposure is the leading cause for these infections. Approximately 30% of antimicrobial doses administered in outpatient hemodialysis facilities are considered unnecessary. Implementing an antimicrobial stewardship program in outpatient hemodialysis facilities aimed at improving prescribing practices would have important clinical and economic benefits. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We developed a decision analytic model of antimicrobial use on the clinical and economic consequences of implementing a nationwide antimicrobial stewardship program in outpatient dialysis facilities. The main outcomes were total antimicrobial use, infections caused by multidrug-resistant organisms and C. difficile, infection-related mortality, and total costs. The analysis considered all patients on outpatient hemodialysis in the United States. The value of implementing antimicrobial stewardship programs, assuming a 20% decrease in unnecessary antimicrobial doses, was calculated as the incremental differences in clinical end points and cost outcomes. Event probabilities, antimicrobial regimens, and health care costs were informed by publicly available sources. RESULTS:On a national level, implementation of antimicrobial stewardship programs was predicted to result in 2182 fewer infections caused by multidrug-resistant organisms and C. difficile (4.8% reduction), 629 fewer infection-related deaths (4.6% reduction), and a cost savings of $106,893,517 (5.0% reduction) per year. The model was most sensitive to clinical parameters as opposed to antimicrobial costs. CONCLUSIONS:The model suggests that implementation of antimicrobial stewardship programs in outpatient dialysis facilities would result in substantial reductions in infections caused by multidrug-resistant organisms and C. difficile, infection-related deaths, and costs.

Dataset Information

Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems.

Publications

Antimicrobial Stewardship Programs in Resource Constrained Environments: Understanding and Addressing the Need of the Systems.

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