WHO Point Prevalence Survey to Describe the Use of Antimicrobials at a Tertiary Care Center in Pakistan: A Situation Analysis for Establishing an Antimicrobial Stewardship Program

Abstract

Antimicrobial stewardship is a systematic approach for promoting and monitoring responsible antimicrobial use globally. We conducted a prospective point prevalence survey of antimicrobial utilization among hospitalized adult patients during September 2021. The survey instrument was adapted from the WHO methodology for point prevalence surveys, and it was conducted at The Indus Hospital and Health Network, Karachi. Among the 300 admitted patients, 55% were males and the mean age was 44 (±18) years. At least 67% of the patients received one antimicrobial agent and the most common indication was surgical prophylaxis (40%). The most frequently used were antibacterial agents (97%) among all antimicrobials. Amoxicillin/Clavulanic acid and Ceftriaxone were the most frequently used antibacterial agents, i.e., 14% each. At least 56% of the antibacterial agents were amenable to antimicrobial stewardship when reviewed by infectious disease (ID) experts. Reasons for stewardship were: antibacterial not indicated (n = 39, 17.0%), unjustified prolonged duration of antibacterial (n = 32, 13.9%), extended surgical prophylaxis (n = 60, 26.2%), non-compliance to surgical prophylaxis guidelines (n = 30, 13.1%), and antibacterial not needed on discharge (n = 27, 11.7%). Median days of therapy (DOT) per agent was 3 days (IQR 2–4), while median DOT per patient was 2 days (IQR 1–4). These data have described the pattern of antimicrobial utilization in our institute. We found a higher prevalence of antimicrobial use overall as compared to the global figures, but similar to other low- and middle-income countries. Two important areas identified were the use of antimicrobials on discharge and extended surgical prophylaxis. As a result of these data, our institutional guidelines were updated, and surgical teams were educated. A post-intervention survey will help us to further determine the impact. We strongly recommend PPS at all major tertiary care hospitals in Pakistan for estimating antimicrobial utilization and identifying areas for stewardship interventions.

Antibiotic Susceptibility Surveillance in the Punjab Province of Pakistan: Findings and Implications

“…This includes Pakistan, where there are appreciable concerns with the current surveillance to fully document AMR patterns across the country, which is currently exacerbated by a lack of requests in hospitals for culture and sensitivity testing; however, progress is being made [ 6 , 41 , 43 , 44 , 45 ]. This is illustrated by very high rates of prescribing of antibiotics in Pakistan among patients admitted to hospitals with COVID-19 during the first five waves at 89.7% of patients, with ‘Watch’ antibiotics being prescribed on 93.4% of occasions adding to AMR [ 46 ]. This was despite only a limited number of patients in these tertiary care/teaching hospitals having proven bacterial co-infections (1.14% of admitted patients) or secondary infections (3.14% of patients) [ 46 ].…”

“…This is illustrated by very high rates of prescribing of antibiotics in Pakistan among patients admitted to hospitals with COVID-19 during the first five waves at 89.7% of patients, with ‘Watch’ antibiotics being prescribed on 93.4% of occasions adding to AMR [ 46 ]. This was despite only a limited number of patients in these tertiary care/teaching hospitals having proven bacterial co-infections (1.14% of admitted patients) or secondary infections (3.14% of patients) [ 46 ]. This endorses the need for accurate diagnostic and sensitivity data, even among tertiary hospitals in Pakistan, to improve future antibiotic prescribing and reduce AMR.…”

“…This is a concern as the susceptibility patterns of microbes should be increasingly monitored among primary, secondary and tertiary hospitals as well as nationally within LMICs to improve empiric prescribing. This is important given concerns with rising AMR rates in Pakistan, as well as high rates of antimicrobial prescribing among hospitals in Pakistan, often without culture and sensitivity testing [ 43 , 44 , 46 , 48 , 49 , 50 ], as well as the current absence of national prescribing guidance.…”

Antibiotic use among hospitalised patients in Sierra Leone: a national point prevalence survey using the WHO survey methodology

“…Antimicrobial resistance (AMR) is a public health threat that will undo the gains made in modern medicine and public health 1–3. AMR could potentially result in an economic loss of more than 5% of the gross domestic product in low-income and middle-income countries and more than 10 million deaths annually by 2050 4.…”

“…Antimicrobial resistance (AMR) is a public health threat that will undo the gains made in modern medicine and public health. [1][2][3] AMR could potentially result in an economic loss of more than 5% of the gross domestic product in low-income and middle-income countries and more than 10 million deaths annually by 2050. 4 If the necessary steps and proven effective public health interventions are not implemented, the world might be heading towards a post-antibiotic era where these priceless medical tools will be rendered ineffective.…”