Standardizing Antimicrobial Use in a Resource-Limited Pediatric Surgical Unit in Botswana
Alemayehu Ginbo Bedada1, Mazvita Rankin2, Andrew P Steenhoff2,3,4,5
1Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana.
Insights
Clinical pathways significantly improved appropriate antimicrobial use in pediatric surgical patients in Botswana. Ongoing stewardship education is key to sustaining these gains against antimicrobial resistance.
Area of Science:
- Public Health
- Infectious Diseases
- Pediatric Surgery
Background:
- Antimicrobial resistance is a critical issue in low- and middle-income countries.
- Princess Marina Hospital (PMH) in Botswana reported inappropriate antimicrobial use in 100% of pediatric surgical patients.
- This highlights an urgent need for interventions to optimize antimicrobial prescribing practices.
Purpose of the Study:
- To implement and evaluate a quality improvement initiative aimed at enhancing antimicrobial use in pediatric surgical patients.
- To standardize antimicrobial prescribing through the development and implementation of clinical pathways (CPs).
- To assess the impact of CPs on appropriate antimicrobial utilization based on World Health Organization (WHO) guidelines.
Main Methods:
- Developed clinical pathways (CPs) for common surgical diagnoses, incorporating WHO Access, Watch, and Reserve (AWaRe) guidelines.
- Distributed CP booklets to healthcare providers at PMH's pediatric surgical ward.
- Conducted prospective antimicrobial use audits over one year (3 months pre-implementation, 9 months post-implementation).
Main Results:
- Appropriate antimicrobial use significantly improved across multiple surgical subspecialties (e.g., pediatrics, orthopedics, neurosurgery, ENT) post-CP implementation (P < .001).
- Improvements were observed across all provider categories (medical officers, interns, specialists) and experience levels.
- The WHO Access group constituted 72.4% and the Watch group 27.6% of prescribed antibiotic courses.
Conclusions:
- Clinical pathway implementation led to a significant increase in appropriate antimicrobial use in pediatric surgical patients.
- Sustained improvement requires expanding CPs and reinforcing antimicrobial stewardship education.
- This initiative offers a scalable model for combating antimicrobial resistance in resource-limited settings.
Background:
Antimicrobial resistance is rampant in low- and middle-income countries. Recent data from Princess Marina Hospital (PMH), Botswana, revealed that 100% of pediatric surgical unit patients received antimicrobials inappropriately.
Methods:
We implemented a quality improvement initiative to improve antimicrobial use in children admitted to PMH's pediatric surgical ward. With key stakeholders, we developed clinical pathways (CPs) to standardize antimicrobial use across common surgical diagnoses. A CP booklet, informed by the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) guideline, was distributed to prescribers. We conducted weekly prospective antimicrobial use audits over 1 year, from 3 months pre-CP implementation to 9 months post-CP implementation.
Results:
A total of 1099 pediatric surgical patients were admitted and 374 (34.0%) required antimicrobials. The WHO Access group accounted for 360 antibiotic courses (72.4%) and the Watch group for 137 (27.6%), a total of 497. Overall, appropriate antimicrobial use improved significantly (pediatric surgery, 33 [50.8%] vs 99 [93.4%]; orthopedics, 3 [10.3%] vs 26 [89.7%]; neurosurgery, 5 [27.8%] vs 13 [72.2%]; and ear, nose, and throat, 4 [33.3%] vs 19 [95.0%]; each P < .001) in the postimplementation period except for maxillofacial-dental patients (1 [25.0%] vs 3 [75.0%]; P = .264). Improvements were observed across provider categories and years of experience: medical officers (28 [42.4%] vs 38 [91.0%]), interns (7 [33.3%] vs 20 [87.0%]), and specialists (11 [26.2%] vs 64 [97.0%]); years of experience: <2 years (9 [32.1%] vs 22 [91.7%]), 2-5 years (3 [25.0%] vs 50 [92.6%]), and >5 years (34 [38.2%] vs 154 [92.2%]) (P < .001 for each).
Conclusions:
Appropriate antimicrobial use improved post-CP implementation. Expanding CPs with ongoing antimicrobial stewardship education will ensure sustained improvement.
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