Evaluation of an Antimicrobial Stewardship Program for Wound and Burn Care in Three Hospitals in Nepal

Abstract

Antimicrobial stewardship (AMS) programs can decrease non-optimal use of antibiotics in hospital settings. There are limited data on AMS programs in burn and chronic wound centers in low- and middle-income countries (LMIC). A post-prescription review and feedback (PPRF) program was implemented in three hospitals in Nepal with a focus on wound and burn care. A total of 241 baseline and 236 post-intervention patient chart data were collected from three hospitals. There was a significant decrease in utilizing days of therapy per 1000 patient days (DOT/1000 PD) of penicillin (p = 0.02), aminoglycoside (p < 0.001), and cephalosporin (p = 0.04). Increases in DOT/1000 PD at post-intervention were significant for metronidazole (p < 0.001), quinolone (p = 0.01), and other antibiotics (p < 0.001). Changes in use of antibiotics varied across hospitals, e.g., cephalosporin use decreased significantly at Kirtipur Hospital (p < 0.001) and Pokhara Academy of Health Sciences (p = 0.02), but not at Kathmandu Model Hospital (p = 0.59). An independent review conducted by infectious disease specialists at the Henry Ford Health System revealed significant changes in antibiotic prescribing practices both overall and by hospital. There was a decrease in mean number of intravenous antibiotic days between baseline (10.1 (SD 8.8)) and post-intervention (8.8 (SD 6.5)) (t = 3.56; p < 0.001), but no difference for oral antibiotics. Compared to baseline, over the 6-month post-intervention period, we found an increase in justified use of antibiotics (p < 0.001), de-escalation (p < 0.001), accurate documentation (p < 0.001), and adherence to the study antibiotic prescribing guidelines at 72 h (p < 0.001) and after diagnoses (p < 0.001). The evaluation data presented provide evidence that PPRF training and program implementation can contribute to hospital-based antibiotic stewardship for wound and burn care in Nepal.

Chronic wound isolates and their minimum inhibitory concentrations against third generation cephalosporins at a tertiary hospital in Uganda

“…Lower rates of bacterial resistance to ceftriaxone could be as a result of pre-authorization of ceftriaxone prescription and regular clinical audits/ward rounds led by experienced surgeons in the surgical ward of MRRH which greatly limits indiscriminate use of antibiotics, particularly ceftriaxone. In comparison, ceftriaxone resistance has been reported to be increasing in Nepal due to high incidence of irrational prescription of ceftriaxone and limited antibiotic stewardship practices across a number of health facilities in Nepal 34 , 35 . This finding is useful for monitoring the effectiveness of ceftriaxone 1 g (Epicephin) in patients with Klebsiella spp.…”

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

“…The majority of studies (63%, 53/84) measured the impact of ASP interventions, which is displayed in five categories in Table 5 . The impact of ASP interventions on the appropriateness of antibiotic prescriptions administered was reported in (43%, 23/53) of studies [ 33 , 34 , 39 , 46 , 62 – 80 ]. Metrics used to measure appropriate prescriptions included dose adjustment or dose optimization [ 46 , 63 , 64 ], antibiotic de-escalation [ 62 , 63 , 68 , 74 , 80 , 81 ], and timing and duration of antibiotic prophylaxis [ 67 , 70 , 76 ].…”

Antimicrobial Stewardship in Wound Care

“…Some examples of improvements included a reduction in surgical site infections compared with standard surgical dressings, 12 a shorter duration of antimicrobial use in infected pressure injuries compared with standard care, 13 and equal rates of bacterial infection elimination from wound beds compared with therapy with topical mupirocin 14 . Nauriyal et al 15 looked at the effects of postprescription review and feedback on patients requiring burn and wound care in Nepal. They reported a significant decrease in mean days of IV antibiotic use and changes in antibiotic-prescribing practices over the 6-month postintervention period.…”

“…They reported a significant decrease in mean days of IV antibiotic use and changes in antibiotic-prescribing practices over the 6-month postintervention period. Additional improvements included increases in justified use of antibiotics, de-escalation, accurate documentation, and adherence to local prescribing guidelines 15 . Limitations identified in this study included the increased workload on physicians due to the need for manual data entry and associated data entry inconsistencies attributable to time constraints.…”

“…Additional improvements included increases in justified use of antibiotics, de-escalation, accurate documentation, and adherence to local prescribing guidelines. 15 Limitations identified in this study included the increased workload on physicians due to the need for manual data entry and associated data entry inconsistencies attributable to time constraints. This illustrates another potential barrier for AMS programs: these programs require a significant time commitment from healthcare workers to function well.…”