Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-Saharan Africa: A Co-Creation Consensus Approach

Abstract

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

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

“…At least 20 ASPs have been successfully instigated across Africa in recent years (between 2013 and 2022) to improve antimicrobial prescribing, with checklists and guidance now being developed for sub-Saharan Africa and beyond to help with their development and implementation [ 135 , 139 , 198 ]. Box 1 contains key areas for hospitals to concentrate on when seeking to introduce sustainable programs to improve future antimicrobial use in hospitals.…”

“…Robust guidelines: Need to be developed/ updated/disseminated for the management of key infectious diseases within hospitals among African countries, recognizing that active dissemination and communication of guidelines, as well as trust in those developing guidelines and their content, combined with their ease of use, are key to enhancing subsequent adherence rates [ 185 , 208 , 209 , 210 , 211 , 212 ]. This should include encouraging greater prescribing of ‘Access’ antibiotics where indicated [ 56 , 58 ], aided by the development of specific Apps to monitor the progress of ASPs and their impact on subsequent prescribing [ 135 ].…”

“…Monitoring prescribing: Monitoring against current guidelines and NAPs, enhanced by auditing, academic detailing and use of electronic record systems [ 208 , 211 ]. In addition, groups such as the Commonwealth Pharmacists developing and testing specific applications to assist with prescribing and ASPs [ 81 , 135 , 213 ]. AMS teams have a key role here along with Drug and Therapeutic Committees in hospitals [ 214 , 215 ].…”

“…Multidisciplinary work: Work with Governments, health authorities and other key national organisations to develop (where pertinent) national/local evidence-based guidelines for important infectious diseases in hospitals, which are regularly updated and easily accessible increasingly through simple, easy to use applications and other systems [ 135 , 185 ]. This builds on current Pan-African initiatives [ 50 , 51 , 224 ].…”

“…However, there can be concerns instigating ASPs, with issues of resources, manpower, and knowledge among key stakeholders especially among low- and middle-income countries (LMICs) including African countries ( Box S1—Supplementary Material ) [ 128 , 129 , 130 , 131 ]. This though is also starting to change among African countries as well as among other LMICs [ 111 , 132 , 133 , 134 , 135 , 136 , 137 ]. We are likely to see more ASPs being instigated across Africa and beyond as part of NAPs to reduce AMR, enhanced by the availability of toolkits from the WHO and others [ 67 , 70 , 132 , 137 , 138 , 139 , 140 ].…”