Opportunities and barriers to implementing antibiotic stewardship in low and middle-income countries: Lessons from a mixed-methods study in a tertiary care hospital in Ethiopia

Abstract

BackgroundGlobal action plans to tackle antimicrobial resistance (AMR) include implementation of antimicrobial stewardship (AMS), but few studies have directly addressed the challenges faced by low and middle-income countries (LMICs). Our aim was to explore healthcare providers’ knowledge and perceptions on AMR, and barriers/facilitators to successful implementation of a pharmacist-led AMS intervention in a referral hospital in Ethiopia.MethodsTikur Anbessa Specialized Hospital (TASH) is an 800-bed tertiary center in Addis Ababa, and the site of an ongoing 4-year study on AMR. Between May and July 2017, using a mixed approach of quantitative and qualitative methods, we performed a cross-sectional survey of pharmacists and physicians using a pre-tested questionnaire and semi-structured interviews of purposively selected respondents until thematic saturation. We analyzed differences in proportions of agreement between physicians and pharmacists using χ2 and fisher exact tests. Qualitative data was analyzed thematically.FindingsA total of 406 survey respondents (358 physicians, 48 pharmacists), and 35 key informants (21 physicians and 14 pharmacists) were enrolled. The majority of survey respondents (>90%) strongly agreed with statements regarding the global scope of AMR, the need for stewardship, surveillance and education, but their perceptions on factors contributing to AMR and their knowledge of institutional resistance profiles for common bacteria were less uniform. Close to 60% stated that a significant proportion of S. aureus infections were caused by methicillin-resistant strains (an incorrect statement), while only 48% thought a large proportion of gram-negative infections were caused by cephalosporin-resistant strains (a true statement). Differences were noted between physicians and pharmacists: more pharmacists agreed with statements on links between use of broad-spectrum antibiotics and AMR (p<0.022), but physicians were more aware that lack of diagnostic tests led to antibiotic overuse (p<0.01). More than cost, fear of treatment failure and of retribution from senior physicians were major drivers of antibiotic prescription behavior particularly among junior physicians. All respondents identified high turnover of pharmacists, poor communication between the laboratory, pharmacists and clinicians as potential challenges; but the existing hierarchical culture and academic setting were touted as opportunities to implement AMS in Ethiopia.ConclusionsThis knowledge and perceptions survey identified specific educational priorities and implementation strategies for AMS in our setting. This is likely also true in other LMICs, where expertise and infrastructure may be lacking.

Challenges in Implementing Antimicrobial Stewardship Programmes at Secondary Level Hospitals in India: An Exploratory Study

“…Lack of a uniform national policy strictly enforceable in all healthcare facilities may affect the prescribing patterns of doctors. The patchy implementation efforts make it difficult for campaigners to convince doctors about rational prescribing of antibiotics and prescription autonomy (15). The rampant use of antibiotics without prescriptions is also affecting the prescription autonomy of the physicians (16).…”

Impact of a Multifaceted Pharmacist-Led Intervention on Antimicrobial Stewardship in a Gastroenterology Ward: A Segmented Regression Analysis

“…The decision to prescribe an antibiotic is influenced by many factors, and professionals play an important role (van der Meer and Grol, 2007). Studies found that physicians feared treatment failure and, therefore, routinely prescribed broad-spectrum antibiotics for surgical prophylaxis.as well as frequently switched and used combinations (Livorsi et al, 2015;Gebretekle et al, 2018). Moreover, these habits were not easily changed (Furst et al, 2015), whereby multifaceted interventions with activities at a variety of levels were the most successful in reducing antibiotic prescriptions (Arnold and Straus, 2005;van der Meer and Grol, 2007).…”

Half of Prescribed Antibiotics Are Not Needed: A Pharmacist-Led Antimicrobial Stewardship Intervention and Clinical Outcomes in a Referral Hospital in Ethiopia

“…Studies conducted in LMICs have shown that models of stewardship using non-specialized health care providers such as clinical pharmacists can lead to reductions in antimicrobial consumption (11)(12)(13). However, clinical pharmacists play a predominantly dispensing role in most LRS hospitals and hardly ever interact with physician members of the treating teams-remaining unknown entities in terms of potential contribution to clinical decision-making (14). Physicians and other professionals frequently raise concerns regarding the applicability of antimicrobial stewardship particularly for tertiary care hospitals where patients are at significant risk of hospitalassociated multi-drug resistant infections.…”