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Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review
Eko Setiawan1,2, Mohd-Hafiz Abdul-Aziz1, Jason A Roberts1,3,4
1University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, Australia.
Abstract:
The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.
Insights
Antimicrobial resistance (AMR) is a major challenge in low- and middle-income countries (LMICs). Hospital antimicrobial stewardship programs (ASPs) show positive outcomes, but prescribing behavior is influenced by factors like awareness and hierarchy.
Area of Science:
- Infectious Diseases
- Public Health
- Health Services Research
Background:
- Antimicrobial resistance (AMR) poses a significant global health threat, particularly in low- and middle-income countries (LMICs).
- Effective antimicrobial stewardship programs (ASPs) are crucial for combating AMR, yet their implementation and impact in LMICs require further understanding.
- Prescribing behaviors are complex and influenced by various individual and systemic factors.
Purpose of the Study:
- To describe hospital-based ASP activities in LMICs.
- To report on methods used to measure the impact of ASPs in these settings.
- To explore factors influencing antimicrobial prescribing behavior within LMICs.
Main Methods:
- A scoping review of PubMed was conducted from database inception until April 2021.
- The Capability-Opportunity-Motivation-Behavior (COMB) framework was utilized to analyze factors influencing prescribing.
- Studies predominantly focused on tertiary and university-affiliated hospitals.
Main Results:
- The primary ASP activities reported were audits of antimicrobial prescriptions with feedback and restrictive strategies.
- Total antimicrobial consumption was the most common metric for assessing ASP impact.
- Positive clinical and microbiological outcomes were noted, though primarily from non-randomized trials.
- Key behavioral influences included limited local AMR awareness, perceived low consequences of overprescription, and hierarchical influences among prescribers.
Conclusions:
- LMICs should incorporate antimicrobial appropriateness assessments to better evaluate ASP impact.
- Enhancing access to microbiology/diagnostic facilities and appointing senior prescribers as ASP champions can improve stewardship.
- Addressing prescriber motivation and awareness is vital for optimizing antimicrobial prescribing behavior in LMICs.
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