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Published on: August 30, 2018
Sustained Reduction in Third-generation Cephalosporin Usage in Adult Inpatients Following Introduction of an
Rebecca Lester1,2, Kate Haigh1,2, Alasdair Wood3
1Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi.
Background:
Third-generation cephalosporins (3GC) remain the first-choice empiric antibiotic for severe infection in many sub-Saharan African hospitals. In Malawi, the limited availability of alternatives means that strategies to prevent the spread of 3GC resistance are imperative; however, suitable approaches to antimicrobial stewardship (AMS) in low-income settings are not well studied.
Methods:
We introduced an AMS intervention to Queen Elizabeth Central Hospital in Blantyre. The intervention consisted of a prescribing application for smartphones and regular point-prevalence surveys with prescriber feedback. We evaluate the effects of the intervention on 3GC usage and on the cost of providing antibiotics. Using a thematic analysis of semi-structured interviews and participant observations, we additionally evaluate the acceptability of the stewardship program.
Results:
The proportion of antibiotic prescriptions for a 3GC reduced from 193/241 (80.1%) to 177/330 (53.6%; percentage decrease, 26.5%; 95% confidence interval, 18.7-34.1) with no change in the case-fatality rate. The cost analysis estimated an annual savings of US$15 000. Qualitative research revealed trust in the guideline and found that its accessibility through smartphones helpful to guide clinical decisions. Operational health-system barriers and hierarchal clinical relationships lead to continued reliance on 3GC.
Conclusions:
We report the successful introduction of an antimicrobial stewardship approach in Malawi. By focusing on pragmatic interventions and simple aims, we demonstrate the feasibility, acceptability, and cost savings of a stewardship program where resources are limited. In doing so, we provide a suitable starting point for expansions of AMS interventions in this and other low-income settings.
Insights
Implementing antimicrobial stewardship (AMS) in Malawi reduced third-generation cephalosporin (3GC) use by 26.5% without impacting patient survival. This study highlights the feasibility and cost-effectiveness of AMS in resource-limited settings.
Area of Science:
- Infectious Diseases
- Global Health
- Health Systems Research
Background:
- Third-generation cephalosporins (3GC) are crucial for severe infections in sub-Saharan Africa.
- Limited alternatives necessitate strategies to combat 3GC resistance in Malawi.
- Antimicrobial stewardship (AMS) approaches in low-income settings require further investigation.
Purpose of the Study:
- To introduce and evaluate an AMS intervention at Queen Elizabeth Central Hospital, Malawi.
- To assess the impact of the intervention on 3GC usage and antibiotic costs.
- To determine the acceptability of the AMS program through qualitative methods.
Main Methods:
- Implementation of a smartphone-based prescribing application and point-prevalence surveys.
- Regular prescriber feedback integrated into the AMS intervention.
- Thematic analysis of interviews and participant observation for qualitative assessment.
Main Results:
- 3GC prescriptions decreased from 80.1% to 53.6%, a 26.5% reduction.
- No significant change in case-fatality rates observed.
- Estimated annual cost savings of US$15,000; qualitative data indicated trust in guidelines but identified barriers to full adoption.
Conclusions:
- Successful introduction of an AMS program in a resource-limited Malawian hospital.
- Demonstrated feasibility, acceptability, and cost savings of pragmatic AMS interventions.
- Provides a model for expanding AMS programs in similar low-income settings.
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