Sustained Reduction in Third-generation Cephalosporin Usage in Adult Inpatients Following Introduction of an Antimicrobial Stewardship Program in a Large, Urban Hospital in Malawi

Abstract

Background Third-generation cephalosporins (3GC) remain the first-choice empiric antibiotic for severe infection in many sub-Saharan African hospitals. In Malawi, the limited availability of alternatives means that strategies to prevent the spread of 3GC resistance are imperative; however, suitable approaches to antimicrobial stewardship (AMS) in low-income settings are not well studied. Methods We introduced an AMS intervention to Queen Elizabeth Central Hospital in Blantyre. The intervention consisted of a prescribing application for smartphones and regular point-prevalence surveys with prescriber feedback. We evaluate the effects of the intervention on 3GC usage and on the cost of providing antibiotics. Using a thematic analysis of semi-structured interviews and participant observations, we additionally evaluate the acceptability of the stewardship program. Results The proportion of antibiotic prescriptions for a 3GC reduced from 193/241 (80.1%) to 177/330 (53.6%; percentage decrease, 26.5%; 95% confidence interval, 18.7–34.1) with no change in the case-fatality rate. The cost analysis estimated an annual savings of US$15 000. Qualitative research revealed trust in the guideline and found that its accessibility through smartphones helpful to guide clinical decisions. Operational health-system barriers and hierarchal clinical relationships lead to continued reliance on 3GC. Conclusions We report the successful introduction of an antimicrobial stewardship approach in Malawi. By focusing on pragmatic interventions and simple aims, we demonstrate the feasibility, acceptability, and cost savings of a stewardship program where resources are limited. In doing so, we provide a suitable starting point for expansions of AMS interventions in this and other low-income settings.

Improving Access to Antimicrobial Prescribing Guidelines in 4 African Countries: Development and Pilot Implementation of an App and Cross-Sectional Assessment of Attitudes and Behaviour Survey of Healthcare Workers and Patients

“…It would also be important to incorporate regular reminders about the app into the implementation strategy. A recently published study by Lester et al [ 29 ] highlighted that implementing a locally appropriate, pragmatic antibiotic guideline through an app, supported by a simple educational strategy of weekly ‘reminders’, led to a significant reduction in third generation cephalosporin usage as well as an increase in the proportion of 48-h antibiotic reviews.…”

Healthcare-associated infections and antimicrobial use in surgical wards of a large urban central hospital in Blantyre, Malawi: a point prevalence survey

“…In Malawi, lack of alternatives has been reported as a reason for preventing the broad use of 3GCs in most hospitals [ 39 ]. An antimicrobial stewardship program implemented in adult medical wards at QECH was effective in reducing the use of 3GCs [ 40 ]. Such a program should be extended to other departments for promoting the rational use of antibiotics as inappropriate use of 3GCs may facilitate the emergence of multi-drug resistant pathogens.…”

Revised hospital antibiotic formulary reduces antimicrobial consumption and promotes a shift towards narrow‐spectrum antibiotic usage

“…However, reports regarding efforts to reduce antibiotic usage have mainly focused on interventions for in-hospital prescriptions and injectables. [5][6][7][8][9][15][16][17][18][19]24,25 In addition, no reports are examining the effects of interventions on outpatient prescriptions. This is the first report to evaluate the effects of a revised antibiotic formulary on both in-and out-hospital prescriptions to the best of our knowledge.…”

“…Fujibayashi et al reported that revising clinical pathways effectively reduced antibiotic consumption and shortened the antibiotic administration period without increasing the incidence of surgical site infections. 10 Preauthorization and prospective audit and feedback [5][6][7][8][9]24,25 the usage of oral cephalosporins, macrolides and fluoroquinolones to the 50% target. In the future, it is thought that these combined efforts will be necessary at our hospital as well.…”

“…4 The Japanese government's AMR action plan aims to tackle this and set a target to "reduce the use of oral cephalosporins, quinolones, and macrolides per day per 1,000 inhabitants in 2020 by 50% from the level in 2013". 2 Previous reports have proposed preauthorization, [5][6][7] prospective audit and feedback [6][7][8][9] and revising clinical pathways 10 as methods to reduce antibiotic consumption. Most Japanese hospitals have pharmaceutical affairs committees that select and purchase pharmaceuticals based on the hospital's regulations.…”