Development of Antimicrobial Stewardship Programmes in Low and Middle-Income Countries: A Mixed-Methods Study in Nigerian Hospitals

Abstract

Antimicrobial resistance (AMR) is a major concern facing global health today, with the greatest impact in developing countries where the burden of infectious diseases is much higher. The inappropriate prescribing and use of antibiotics are contributory factors to increasing antibiotic resistance. Antimicrobial stewardship programmes (AMS) are implemented to optimise use and promote behavioural change in the use of antimicrobials. AMS programmes have been widely employed and proven to improve antibiotic use in many high-income settings. However, strategies to contain antimicrobial resistance have yet to be successfully implemented in low-resource settings. A recent toolkit for AMS in low- and middle-income countries by the World Health Organisation (WHO) recognizes the importance of local context in the development of AMS programmes. This study employed a bottom-up approach to identify important local determinants of antimicrobial prescribing practices in a low-middle income setting, to inform the development of a local AMS programme. Analysis of prescribing practices and interviews with prescribers highlighted priorities for AMS, which include increasing awareness of antibiotic resistance, development and maintenance of guidelines for antibiotic use, monitoring and surveillance of antibiotic use, ensuring the quality of low-cost generic medicines, and improved laboratory services. The application of an established theoretical model for behaviour change guided the development of specific proposals for AMS. Finally, in a consultation with stakeholders, the feasibility of the plan was explored along with strategies for its implementation. This project provides an example of the design, and proposal for implementation of an AMS plan to improve antibiotic use in hospitals in low-middle income settings.

Antimicrobial Stewardship: Fighting Antimicrobial Resistance and Protecting Global Public Health

“…Though AMS programs have proven to improve antibiotic use in developed countries, AMS strategies to contain AMR are unsuccessfully executed in developing countries 56 which has led to an urgency to establish, implement and evaluate effective AMS programs 57–59 in these territories. To tackle this emergency, in 2016, the WHO and the United Nations General Assembly ratified the implementation of AMS programs globally and at the institutional-level.…”

Prevalence of Multi-Resistant Microorganisms and Antibiotic Stewardship among Hospitalized Patients Living in Residential Care Homes in Spain: A Cross-Sectional Study

“…The inappropriate use of antimicrobial drugs has become one of the main causes of increased AMDR worldwide [2]. Therefore, current strategies to combat AMDR are primarily focused on antimicrobial stewardship [3][4][5]. Moreover, according to the One Health perspective, AMDR can occur for different reasons, including human, animal or environmental factors [6,7].…”

Antibiotic prescription practices and attitudes towards the use of antimicrobials among veterinarians in the City of Tshwane, South Africa

“…An Australian study by Hardefeldt et al (2018a) also reported that cost was as an important factor in the decision regarding antimicrobial prescription indicating that cost of the antimicrobial is an important consideration regardless of the geographical location. However, the cost and affordability of medications is especially important in low-income settings where prescribers often choose cheaper alternatives ( Kpokiri, Taylor & Smith, 2020 ).…”

“…It is therefore evident that there is a need to educate veterinarians on the importance of use of antibiogram before making antibacterial treatment decisions. However, it is worth pointing out that in low- and middle-income countries (LMIC) there is usually lack of laboratories to perform the necessary tests and access is an important limiting factor ( Petti et al, 2006 ; Kpokiri, Taylor & Smith, 2020 ). Therefore, improvement of access to laboratory facilities in such situations would play an important role in the fight against AMR.…”

“…Therefore, improvement of access to laboratory facilities in such situations would play an important role in the fight against AMR. Since reliable diagnostic testing is severely limited in sub-Saharan Africa, making laboratory testing more available to guide clinical decisions and judicious use of antibiotics needs to be a priority ( Petti et al, 2006 ; Kpokiri, Taylor & Smith, 2020 ). Suffice it to say that addressing the problem of AMR will require: (a) ensuring availability of diagnostic testing, (b) providing education to healthcare and veterinary professions as well as the general public, (c) development/improvement of regulations and audit on production, distribution and dispensing of drugs, (d) improving interaction between policy makers, academia, medical/veterinary professionals and civil society and (e) designing and studying easy and scalable interventions ( Cox et al, 2017 ).…”