Assessment of Appropriateness of Antimicrobial Therapy in Resource-Constrained Settings: Development and Piloting of a Novel Tool—AmRAT

Abstract

Inappropriate antimicrobial prescribing is considered to be the leading cause of high burden of antimicrobial resistance (AMR) in resource-constrained lower- and middle-income countries. Under its global action plan, the World Health Organization has envisaged tackling the AMR threat through promotion of rational antibiotic use among prescribers. Given the lack of consensus definitions and other associated challenges, we sought to devise and validate an Antimicrobial Rationality Assessment Tool—AmRAT—for standardizing the assessment of appropriateness of antimicrobial prescribing. A consensus algorithm was developed by a multidisciplinary team consisting of intensivists, internal medicine practitioners, clinical pharmacologists, and infectious disease experts. The tool was piloted by 10 raters belonging to three groups of antimicrobial stewardship (AMS) personnel: Master of Pharmacology (M.Sc.) (n = 3, group A), Doctor of Medicine (MD) residents (n = 3, group B), and DM residents in clinical pharmacology (n = 4, group C) using retrospective patient data from 30 audit and feedback forms collected as part of an existing AMS program. Percentage agreement and the kappa (κ) coefficients were used to measure inter-rater agreements amongst themselves and with expert opinion. Sensitivity and specificity estimates were analyzed comparing their assessments against the gold standard. For the overall assessment of rationality, the mean percent agreement with experts was 76.7% for group A, 68.9% for group B, and 77.5% for group C. The kappa values indicated moderate agreement for all raters in group A (κ 0.47–0.57), and fair to moderate in group B (κ 0.22–0.46) as well as group C (κ 0.37–0.60). Sensitivity and specificity for the same were 80% and 68.6%, respectively. Though evaluated by raters with diverse educational background and variable AMS experience in this pilot study, our tool demonstrated high percent agreement and good sensitivity and specificity, assuring confidence in its utility for assessing appropriateness of antimicrobial prescriptions in resource-constrained healthcare environments.

Gaps in data collection for sex and gender must be addressed in point prevalence surveys on antibiotic use

“…There is a dearth information on antimicrobial consumption and use especially in low-and middle-income countries (World Health Organization, 2018;World Health Organization, 2022). Standardized monitoring of antimicrobial use (AMU) underpins the effective implementation and success of AMS interventions in combatting AMR ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). Point prevalence survey tools, are standardized surveillance tools to collect information from medical records of hospitalized patients ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016; European Centre of Disease Control and Prevention (ECDC), 2016-2017World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022).…”

“…Standardized monitoring of antimicrobial use (AMU) underpins the effective implementation and success of AMS interventions in combatting AMR ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). Point prevalence survey tools, are standardized surveillance tools to collect information from medical records of hospitalized patients ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016; European Centre of Disease Control and Prevention (ECDC), 2016-2017World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). The antimicrobial information collected include, but are not limited to, the substance name, dosage, route of administration, indication and category of patients by specialty and healthcare facility ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022).…”

“…Point prevalence survey tools, are standardized surveillance tools to collect information from medical records of hospitalized patients ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016; European Centre of Disease Control and Prevention (ECDC), 2016-2017World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). The antimicrobial information collected include, but are not limited to, the substance name, dosage, route of administration, indication and category of patients by specialty and healthcare facility ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). The overall aim of the tools is to support policymakers and practitioners to improve AMU as a part of an AMS program ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2018;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022;World Health Organization, 2022).…”

“…The antimicrobial information collected include, but are not limited to, the substance name, dosage, route of administration, indication and category of patients by specialty and healthcare facility ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). The overall aim of the tools is to support policymakers and practitioners to improve AMU as a part of an AMS program ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2018;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022;World Health Organization, 2022). These data are used to raise awareness of AMU in hospitals, build the capacity of healthcare staff in monitoring and evaluation and to identify problems of antimicrobial prescribing and use ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022).…”

“…The overall aim of the tools is to support policymakers and practitioners to improve AMU as a part of an AMS program ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006; Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2018;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022;World Health Organization, 2022). These data are used to raise awareness of AMU in hospitals, build the capacity of healthcare staff in monitoring and evaluation and to identify problems of antimicrobial prescribing and use ( , ; Samverkan mot Antibiotikaresistens (STRAMA), 2006;Seaton et al, 2007;Versporten et al, 2016;European Centre of Disease Control andPrevention (ECDC), 2016-2017;World Health Organization, 2019;Kakkar et al, 2021;European Antimicrobial Resistance Surveillance System (EARSS), 2022). By doing so, it is then possible to set up priorities to address any gaps in AMS.…”