Antibiotic stewardship interventions in hospitals in low-and middle-income countries: a systematic review

Abstract

ObjectiveTo review the effectiveness of antibiotic stewardship interventions in hospitals in low- and middle-income countries.MethodsWe searched MEDLINE®, Embase®, Cochrane Central Register of Controlled Trials and regional indexes for studies of interventions to improve appropriate prescribing and use of antibiotics for hospitalized patients in low- and middle-income countries. We included controlled trials, controlled before-and-after studies and interrupted time-series studies published up to December 2017. We report prescribing, clinical and microbiological outcomes using a narrative approach.FindingsWe screened 7342 original titles and abstracts, assessed 241 full-text articles and included 27 studies from 2 low-income and 11 middle-income countries. We found a medium (11 studies) or high risk (13 studies) of bias. Generally, all types of interventions (structural, persuasive and enabling) and intervention bundles were reported to improve prescribing and clinical outcomes. However, the studied interventions and reported outcomes varied widely. The most frequent intervention was procalcitonin-guided antibiotic treatment (8 of 27 studies, all randomized controlled trials). The intervention was associated with a relative risk for patients receiving antibiotics ranging between 0.40 and 0.87.ConclusionThe majority of studies reported a positive effect of hospital antibiotic stewardship interventions. However, we cannot draw general conclusions about the effectiveness of such interventions in low- and middle-income countries because of low study quality, heterogeneity of interventions and outcomes, and under-representation of certain settings. To strengthen the evidence base, action needs to be taken to address these shortcomings.

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

“…Studies conducted in high-income countries have shown how antibiotic stewardship programmes can improve antibiotic prescribing in hospital settings, but these interventions have been poorly employed in LMICs [22] with only limited guidance regarding how this might be operationalized, in these settings [23]. The WHO practical toolkit for implementing AMS in LMICs provides guidance regarding strategies and procedures, also highlights the importance of exploring local context, priorities, and opportunities in the development of AMS programmes in LMICs [1].…”

“…Earlier AMS strategies to improve antibiotics use in LMICs include institutional policies, restrictions, and controlled usage using antibiotic charts [22,24]. A systematic review found that antibiotics stewardship programmes in LMICs had some positive impact on antibiotics use however studying the local context and adapting interventions will have more beneficial outcomes [23].…”

Pulling Together to Beat Superbugs Knowledge and Implementation Gaps in Addressing Antimicrobial Resistance

“…Key barriers to effective AMS include a lack of effective strategies to implement AMS, particularly in the LMIC setting; poor response from governments to engage in AMS; lack of coordination of AMS across different sectors and specialties (Tiong et al 2016); and economic viability (Ibrahim et al 2018). A recent systematic review (Van Dijck et al 2018) of AMS in LMIC settings concluded that most of the AMS interventions had a positive effect. However, general conclusions about their effectiveness could not be made, probably due to context-specific variables in certain settings.…”

Antibiotics prescreption pattern and resistance profile of common isolates at Soba university hospital in Khartoum, Sudan, a retrospective cross sectional study

“…Although the majority of antibiotic usage is within the community; increased antibiotic usage per patient, resistant pathogens, and infections due to resistant organisms are all concentrated more within hospital-settings (17,18) Studies showed that antibiotic stewardship interventions in hospitals help to increase compliance with the local guidelines of prescriptions, and the clinical outcomes for patients (19)(20)(21). However, before organizing and implementing an antimicrobial stewardship program, information about prescription patterns and the situation of antimicrobial resistance need to be acquired (22).…”