Strengthening antimicrobial stewardship and infection prevention and control in secondary and mid-level hospitals in...

Small and mid-level hospitals constitute the backbone of healthcare delivery for much of India's population, yet inadequate capacity to implement infection prevention and control (IPC) and antimicrobial stewardship (AMS) programmes limits their ability to address antimicrobial resistance (AMR). This study evaluated a structured mentorship model that harnessed the expertise of tertiary care hospitals to strengthen IPC and AMS capacity in secondary and mid-level healthcare facilities.

A multicentre pre-post intervention study was conducted across 88 secondary and mid-level tertiary care hospitals in India mentored by 11 tertiary care hospitals between 2021 and 2023. A structured mentorship-based intervention focusing on IPC and AMS strengthening was implemented. Quantitative outcomes were analyzed using McNemar's test for paired binary variables, while qualitative findings from mentor feedback, site visits, and follow-up interactions were analyzed using thematic analysis and presented through a fishbone framework. A p value < 0.05 was considered statistically significant.

Overall, the mentee hospitals showed substantial improvements in IPC and AMS indicators following the intervention. Among the 30 secondary hospitals, IPC implementation increased from 30% (9/30) to 83% (25/30), while AMS implementation increased from 6.7% (2/30) to 60% (18/30). Laboratory practices also improved, with greater standardization of antibiogram reporting and the development of hospital-specific antibiotic policies in three hospitals. Institutional capacity was further strengthened through the recruitment of full-time microbiologists and clinical pharmacists. Qualitative assessments identified persistent staff shortages, inadequate infrastructure, and variable adherence to IPC and AMS protocols as the principal barriers to successful implementation.

Engaging small and mid-level hospitals in AMR containment is essential to achieving a comprehensive national response. Our findings suggest that a structured mentorship model leveraging expertise of tertiary hospitals is a feasible approach to strengthening IPC and AMS practices in smaller healthcare facilities. However, these findings should be interpreted in light of the pre-post study design and the potential influence of the COVID-19 pandemic and the Hawthorne effect. Tertiary centers with established IPC and AMS expertise can serve as regional resource and training hubs to support neighbouring secondary and mid-level hospitals. Sustained engagement, standardized laboratory practices, investment in skilled human resources, and stronger monitoring and evaluation systems will be critical to ensure consistent implementation, long-term sustainability, and measurable improvements in AMR containment and measurable impact.