Establishing an effective antimicrobial stewardship program at four secondary-care hospitals in India using a hub-and-spoke model

Abstract

Background: The high burden of antimicrobial resistance in India necessitates the urgent implementation of antimicrobial stewardship programs (ASPs) in all healthcare settings in India. Most ASPs are based at tertiary-care centers, with sparse data available regarding the effectiveness of an ASP in a low-resource primary/secondary-care setting. Methods: We adopted a hub-and-spoke model to implement ASPs in 4 low-resource, secondary-care healthcare settings. The study included 3 phases measuring antimicrobial consumption data. In the baseline phase, we measured days on antimicrobial therapy (DOTs) with no feedback provided. This was followed by the implementation of a customized intervention package. In the postintervention phase, prospective review and feedback were offered by a trained physician or ASP pharmacist, and days of therapy (DOT) were measured. Results: In the baseline phase, 1,459 patients from all 4 sites were enrolled; 1,233 patients were enrolled in the postintervention phase. Both groups had comparable baseline characteristics. The key outcome, DOT per 1,000 patient days, was 1,952.63 in the baseline phase and significantly lower in the post-intervention period, at 1,483.06 (P = .001). Usage of quinolone, macrolide, cephalosporin, clindamycin, and nitroimidazole significantly decreased in the postintervention phase. Also, the rate of antibiotic de-escalation was significantly higher in the postintervention phase than the baseline phase (44% vs 12.5%; P < .0001), which suggests a definite trend toward judicious use of antibiotics. In the postintervention phase, 79.9% of antibiotic use was justified. Overall, the recommendations given by the ASP team were fully followed in 946 cases (77.7%), partially followed in 59 cases (4.8%), and not followed in 137 cases (35.7%). No adverse events were noted. Conclusion: Our hub-and-spoke model of ASP was successful in implementing ASPs in secondary-care hospitals in India, which are urgently needed.

Barriers, facilitators, perceptions and impact of interventions in implementing antimicrobial stewardship programs in hospitals of low-middle and middle countries: a scoping review

“…To assess the impact of ASP interventions, 24 studies (45%, 24/53) assessed clinical or patient-centered outcomes [ 62 – 64 , 66 , 67 , 69 , 73 – 75 , 77 , 79 – 81 , 86 – 88 , 97 , 100 – 104 , 106 – 108 ]. Metrics used to evaluate the intervention included length of stay in hospital (LOS) in specific units (e.g., ICU) [ 46 , 62 , 68 , 69 , 73 , 74 , 76 , 77 , 81 , 86 , 88 , 96 , 101 – 103 ], hospital mortality [ 62 , 76 , 77 , 80 , 86 , 100 – 102 , 106 ], rehospitalization [ 77 , 81 , 83 , 86 , 104 ], hospital-acquired infections [ 63 , 64 , 67 , 81 , 97 , 107 , 109 ], and device-associated infections [ 64 ]. ASPs brought about positive clinical outcomes in hospital inpatients in most cases.…”

“…ASPs brought about positive clinical outcomes in hospital inpatients in most cases. Microbiological outcomes to assess the impact of ASP were reported in 42% (22/53) of studies [ 63 , 65 , 66 , 71 , 76 , 79 , 81 – 85 , 87 – 89 , 100 , 101 , 109 , 110 ], including a decrease in the prevalence of multi-drug resistance bacterial strains like Acinetobacter spp , Methicillin-Resistant Staphylococcus aureus (MRSA) , Vancomycin-Resistant Enterococcus [VRE], increase in the antibiotic susceptibility of bacterial strains such as Pseudomonas aeruginosa, E. coli [ 71 , 81 , 82 , 85 ]. Studies also documented a reduction in the incidence of bacterial infections such as Clostridioides difficile infections and Candidemia [ 75 , 77 ], and a decrease in pan-drug resistant isolates [ 65 , 71 , 77 , 85 ].…”