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

Abstract

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.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

“…However, the findings that the availability of guidelines increased empiric prescribing of antibiotics is a concern. This is because we have seen that GPs in other studies who use guidelines are less likely to prescribe antibiotics empirically; however, guidelines must be easy to use, available and regularly referenced rather than sitting on shelves to achieve this [ 57 , 67 , 115 , 119 , 120 , 121 ]. These may be key factors here, and we will be exploring this further in future studies.…”

“…Consumption of antibiotics based on agreed metrics, e.g., total number of Defined Daily Doses (DDDs), number of DDDs per patient encounters or per patient days, DDDs per 1000 inhabitants per day [ 57 , 58 , 59 ]…”

“…Correct antibiotic, correct dose, correct duration of course prescribed and correct route of administration [ 46 , 57 , 60 , 61 ]…”

“…Agreed adherence rates to robust national guidelines including those for ARIs [ 46 , 57 , 61 , 67 , 68 , 69 , 70 ]…”

Ongoing Efforts to Improve Antimicrobial Utilization in Hospitals among African Countries and Implications for the Future

“…Robust guidelines: Need to be developed/ updated/disseminated for the management of key infectious diseases within hospitals among African countries, recognizing that active dissemination and communication of guidelines, as well as trust in those developing guidelines and their content, combined with their ease of use, are key to enhancing subsequent adherence rates [ 185 , 208 , 209 , 210 , 211 , 212 ]. This should include encouraging greater prescribing of ‘Access’ antibiotics where indicated [ 56 , 58 ], aided by the development of specific Apps to monitor the progress of ASPs and their impact on subsequent prescribing [ 135 ].…”