Evaluation of a Hospital-Based Post-Prescription Review and Feedback Pilot in Kathmandu, Nepal

Joshi, Rajesh; Zervos, Marcus J.; Kaljee, Linda; Shrestha, Basudha; Maki, Gina; Prentiss, Tyler; Bajracharya, Deepak; Karki, K. B.; Joshi, Nilesh; Man, Shankar

doi:10.4269/ajtmh.18-0724

Cited by 12 publications

(14 citation statements)

References 12 publications

(11 reference statements)

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“…Seven studies commented on the adaptability of an intervention that refers to the degree to which interventions were tailored to the local needs [ 37 – 40 , 52 , 54 , 56 ]. Specifically, interventions that were designed to be embedded into routine practice, adapted to the local capacities and priorities, and delivered jointly by local and international teams were more likely to be accepted by target populations.…”

Section: Resultsmentioning

confidence: 99%

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Tannous

Haldane

et al. 2022

Implementation Sci

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Background Behavior change interventions that aim to improve rational antibiotic use in prescribers and users have been widely conducted in both high- and LMICs. However, currently, no review has systematically examined challenges unique to LMICs and offered insights into the underlying contextual factors that influence these interventions. We adopted an implementation research perspective to systematically synthesize the implementation barriers and facilitators in LMICs. Methods We conducted literature searches in five electronic databases and identified studies that involved the implementation of behavior change interventions to improve appropriate antibiotic use in prescribers and users in LMICs and reported implementation barriers and facilitators. Behavior change interventions were defined using the behavior change wheel, and the coding and synthesis of barriers and facilitators were guided by the Consolidated Framework for Implementation Research (CFIR). Results We identified 52 eligible studies, with the majority targeting prescribers practicing at tertiary facilities (N=39, 75%). The most commonly reported factors influencing implementation were found in the inner setting domain of the CFIR framework, particularly related to constraints in resources and the infrastructure of the facilities where interventions were implemented. Barriers related to the external policy environment (e.g., lack of national initiatives and policies on antibiotic use), and individual characteristics of target populations (e.g., reluctance to change prescribing behaviors) were also common, as well as facilitators related to intervention characteristics (e.g., embedding interventions in routine practice) and process (e.g., stakeholder engagement). We also provided insights into the interrelationships between these factors and the underlying causes contributing to the implementation challenges in LMICs. Conclusion We presented a comprehensive overview of the barriers and facilitators of implementing behavior change interventions to promote rational antibiotic use in LMICs. Our findings suggest that facilitating the implementation of interventions to improve rational antibiotic use needs comprehensive efforts to address challenges at policy, organizational, and implementation levels. Specific strategies include (1) strengthening political commitment to prompt mobilization of domestic resources and formulation of a sustainable national strategy on AMR, (2) improving the infrastructure of health facilities that allow prescribers to make evidence-based clinical decisions, and (3) engaging local stakeholders to improve their buy-in and facilitate contextualizing interventions. Trial registration PROSPERO: CRD42021252715.

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Section: Resultsmentioning

confidence: 99%

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Tannous

Haldane

et al. 2022

Implementation Sci

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“…The studies were conducted in 16 countries: Afghanistan (1) [ 30 ], Bangladesh (4) [ 31 , 32 , 33 , 34 ], Egypt (1) [ 35 ], Ethiopia (1) [ 36 ], India (7) [ 37 , 38 , 39 , 40 , 41 , 42 , 43 ], Indonesia (2) [ 44 , 45 ], Kenya (3) [ 46 , 47 , 48 ], Lao PDR (2) [ 49 , 50 ], Nepal (2) [ 51 , 52 ], Pakistan (1) [ 53 ], Serra Leone (1) [ 54 ], Sri Lanka (1) [ 55 ], Sudan (1) [ 56 ], Tanzania (2) [ 57 , 58 ], Vietnam (3) [ 59 , 60 , 61 ] and Zimbabwe (1) [ 62 ]. More than two thirds (68%; n = 23) of the studies were conducted in hospital settings, 26% ( n = 9) in community health clinics or rural health centres and 6% ( n = 2) were drawn from both hospital and community.…”

Section: Resultsmentioning

confidence: 99%

“…In a study in Nepal seven physician champions, one for each department, were specially trained to conduct the intervention in their departments. Their tasks included audit and feedback; modify/de-escalate/stop treatment according to the CG; attend all staff training; and keep a log of all associated activities [51]. In an Egyptian study, senior surgeons were nominated as champions to audit prescriptions in patient charts and give one-to-one feedback about the prescription plan with the prescriber when needed [35].…”

Section: Organisational Strategiesmentioning

confidence: 99%

Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review

et al. 2021

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Containing antimicrobial resistance and reducing high levels of antibiotic consumption in low- and lower middle-income countries are a major challenge. Clinical guidelines targeting antibiotic prescribing can reduce consumption, however, the degrees to which clinical guidelines are adopted and adhered to are challenging for developers, policy makers and users. The aim of this study was to review the strategies used for implementing and promoting antibiotic guideline adherence in low- and lower middle-income countries. A review of published literature was conducted using PubMed, Cochrane Library, SCOPUS and the information systems of the World Health Organization and the Australian National University according to PRISMA guidelines and our PROSPERO protocol. The strategies were grouped into five broad categories based on the Cochrane Effective Practice and Organization of Care taxonomy. The 33 selected studies, representing 16 countries varied widely in design, setting, disease focus, methods, intervention components, outcomes and effects. The majority of interventions were multifaceted and resulted in a positive direction of effect. The nature of the interventions and study variability made it impossible to tease out which strategies had the greatest impact on improving CG compliance. Audit and feedback coupled with either workshops and/or focus group discussions were the most frequently used intervention components. All the reported strategies are established practices used in antimicrobial stewardship programs in high-income countries. We recommend interrupted time series studies be used as an alternative design to pre- and post-intervention studies, information about the clinical guidelines be made more transparent, and prescriber confidence be investigated.

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“…In many LMIC, there are inadequate numbers of infectious disease specialists, and therefore a key element of the adapted PPRF program in Nepal includes training “physician champions” in AMR and AMS. More details about the adaptation of the PPRF intervention for use in Nepal is described in detail elsewhere [ 5 ]. Variations for the current study included revisions to the antibiotic prescribing guidebook to include information on wound and burn care and a training-of-trainers approach, whereby the AMR “physician champions” were both trained in the PPRF program and provided with information and tools to train other healthcare providers within their wards.…”

Section: Methodsmentioning

confidence: 99%

“…PPRF programs have been shown to be effective in U.S. hospitals, and on the basis of four studies reviewed by Dijck et al, there was a decrease in antibiotic days noted with audit and feedback in LMIC [ 4 ]. In addition, comparison of baseline and post-intervention data of a PPRF program in medical, obstetrics and gynecology, and general surgery wards at Kathmandu Model Hospital indicated decreased days of therapy per 1000 patient-days for courses of aminoglycoside and cephalosporin, increased justified use of antibiotics, de-escalation, and rational use of antibiotics [ 5 ].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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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.

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Evaluation of a Hospital-Based Post-Prescription Review and Feedback Pilot in Kathmandu, Nepal

Cited by 12 publications

References 12 publications

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

Strategies Used for Implementing and Promoting Adherence to Antibiotic Guidelines in Low- and Lower-Middle-Income Countries: A Systematic Review

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

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