Improving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone

Abstract

There is global concern over increasing antibiotic resistance rates due to poor antimicrobial stewardship, particularly in low-income and middle-income countries where there are limited diagnostic facilities, fewer doctors per capita and inadequate control over the production and sale of antibiotics. This quality improvement project was designed to improve the antimicrobial prescriptions practices of paramedical staff in the outpatient department of a rural district general hospital in Masanga, Sierra Leone, West Africa.At baseline, 57 of 66 (86%) of patients were prescribed at least one antimicrobial. On further review of 243 prescriptions for 128 patients, only 161 (66%) antimicrobials were deemed appropriate for the named diagnosis when compared with international guidelines or senior medical opinion, and 86 (35%) prescriptions had the correct drug, dose and course-length.A full, empirical antimicrobial guideline was written and introduced to local staff via a number of different methods, including: one-to-one feedback, announcements in general meetings and printed copies placed in each outpatient room. After the first cycle, the choice of appropriate antimicrobial had improved to 85% and the correct drug, dose and course-length to 53%. Unfortunately, 2 months after the second cycle, coinciding with the departure of the international internal medical physician, the rates had degraded to 65% and 43%, respectively.This study shows that implementing an empirical antimicrobial guideline can be effective at improving appropriate antibiotic prescription but that other measures are required for sustainable change. It is suggested that projects designed to change practice in low-resource countries should include national staff from the outset to improve longer term sustainability.

Improving inpatient provider-initiated HIV testing and counseling in Sierra Leone

“…These findings are consistent with studies showing that the use of QI methods and the QIC approach can empower health facility teams to identify and address process and management barriers to attaining high quality health services [19,20,23,27]. Contexts in which national guidelines and standards exist and quality challenges can be addressed at the facility level are optimal settings for QI interventions, which have been used successfully to address other quality challenges in Sierra Leone [28,29,30]. To our knowledge, this is the only study of QIC methodology to improve inpatient PITC coverage, but other PITC implementation projects report similar challenges, such as non-standardized workflows, suboptimal staffing and test kit shortages [10,11,31].…”

“…The four QI learning sessions were well-attended, with an average of 50 participants attending each of the quarterly meetings. The initial training increased participant knowledge, as shown by improved performance on a multiple-choice test, from a median of 41% (29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(46)(47) at the pretest to 73% (60-85) at the post-test (p < 0.0001). ICAP and MoHS provided twice-monthly supportive supervision, making a total of 188 site visits to the ten sites between October 2017 and August 2018.…”

Advocacy for Increased International Efforts for Antimicrobial Stewardship Actions in Low-and Middle-Income Countries on Behalf of Alliance for the Prudent Use of Antimicrobials (APUA), Under the Auspices of the International Society of Antimicrobial Chemotherapy (ISAC)

“…Five years after the launch of WHO global action plan, many who have worked in the field have the feeling that, although progress have been achieved ( 12 , 39 , 40 ), with remarkable success stories ( 41 – 43 ), the actions undertaken to optimize the use of antimicrobial agents do not match the challenges of emerging antimicrobial resistance in most countries ( 23 ). In addition, the durability of progress achieved in AMS requires sustained efforts, otherwise the benefits may be rapidly lost ( 30 , 43 ). In line with the WHO global action plan, there are various initiatives led by professional societies or non-governmental bodies, aimed at reducing the emergence of antimicrobial resistance through international collaborations over the last decades.…”

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

“…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.…”