Combating the complex global challenge of antimicrobial resistance: what can Antimicrobial Stewardship contribute?

Abstract Introduction Antimicrobial resistance is a global health problem, especially in developing countries. Antimicrobial Stewardship Programmes (AMS) have been shown to be effective at reducing antimicrobial resistance and hospital patient stays. Health information technology (HIT) can support Outpatient Parenteral Antimicrobial Therapy (OPAT) through more accurate diagnosis and management of infectious diseases. Aim To evaluate the knowledge and attitude of Egyptian healthcare professionals towards the application of HIT to optimize OPAT. Methods Healthcare professionals who worked in either private or public sectors of Egyptian healthcare system were emailed and asked if they would be willing to complete an electronic questionnaire (using google forms). One reminder was sent by email each week for two weeks (two in total) from the first invitation. The survey was laid out in four sections. The first section included specific details about the healthcare professional’s current employment and role, the second related to HIT services available in their organisations, the third covered their training in HIT and antimicrobial stewardship programmes, and the fourth included their use of HIT to optimize OPAT. Ethical approval was obtained from National Heart Institute, Egypt. Descriptive analysis was carried out for all the variables. One-way ANOVA testing at level of significance P-value <0.05, was used to compare numerical variables. SPSS version 26 was used for statistical analysis. Results Three hundred and eighty-five healthcare professionals were invited to respond to the questionnaire. (The response rate was 75.34% (290)). Of these, 152 (52.6%) were pharmacists, 134 (46.4%) physicians, and 3 (1%) nurses, and many participants (30.8%) had between 6 to 10 years of experience working in either outpatient or in-patient units. Only 15.2% of respondents mentioned that they have access to OPAT in their organizations, 51.2% did not have the service, while 33.6% responded that they did not know if the service was available. However, 27.3% had a training on ASP and 18.3% had a training on HIT. Mean scores for both knowledge (14.31±5.49) and attitude (14.67±2.53) were significantly higher in professionals who had received training in HIT (p = 0.003 & 0.006 respectively). However, scores for attitude were better than scores for knowledge. Conclusions In developing countries, HIT applications in OPAT are still in their infancy with only a few organisations adopting them. Egyptian healthcare professionals showed positive attitudes towards HIT use, especially when their knowledge was improved through training. Two strengths of this study include our high response rate and the wide breadth of different healthcare professionals who responded from both private and public healthcare settings. However, being a questionnaire, some questions were left unanswered and some respondents may not have been aware of their reasons for a particular answer. That said, this study has important implications for practice, with more awareness amongst healthcare professionals required on the availability of HIT services in their hospitals and how further training may be needed on the applications of HIT in optimizing OPAT.

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Assessing Knowledge and Perception Regarding Antimicrobial Stewardship and Antimicrobial Resistance in University Students of Pakistan: Findings and Implications

Antibiotics ◽

10.3390/antibiotics10070866 ◽

2021 ◽

Vol 10 (7) ◽

pp. 866

Author(s):

Iltaf Hussain ◽

Nisa Yousaf ◽

Sana Haider ◽

Pervisha Jalil ◽

Muhammad Usman Saleem ◽

...

Keyword(s):

Antimicrobial Resistance ◽

University Students ◽

Antimicrobial Stewardship ◽

Antibiotic Use ◽

Cross Sectional Study ◽

Dosing Regimen ◽

Student Knowledge ◽

Chi Square ◽

Cross Sectional ◽

Self Administered Questionnaire

The irrational use of antimicrobials has enormously contributed to antimicrobial resistance (AMR) globally and especially in the developing world. To assess the knowledge and perception regarding AMR and antimicrobial stewardship (AMS), a descriptive cross-sectional study was carried out in university students enrolled in pharmacy, veterinary, and biology programs by using an online self-administered questionnaire. The Chi-square and Fisher exact tests (where applicable) were performed to assess the association of the demographics with the students’ knowledge and perception regarding AMR and AMS. A total of 496 students completed the questionnaire, among which, 85.7% of the participants were familiar with the term AMR and 79.4% of the participants correctly identified a poorly designed dosing regimen as a contributing factor towards AMR. The majority of participants (57.9%) were familiar with the term AMS and 86.5% were aware of the aim of AMS. The participants showed good knowledge regarding AMR and AMS, but to further improve student knowledge and perception of AMS and AMR, it is suggested that dedicated modules on antibiotic use and AMS should be incorporated into the curricula of these undergraduate and postgraduate programs.

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Where to from here? Identifying and prioritising future directions for addressing drug-resistant infection in Australia

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00953-4 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Gregory Merlo ◽

Minyon Avent ◽

Trent Yarwood ◽

Bonnie Smith ◽

Mieke van Driel ◽

...

Keyword(s):

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

Infection Prevention ◽

Implementation Strategies ◽

Antibiotic Use ◽

Future Directions ◽

World Cafe ◽

Resistant Infection ◽

Using Data ◽

Patient Stories

Abstract Background The Australian National Antimicrobial Resistance Strategy calls for a collaborative effort to change practices that have contributed to the development of drug-resistance and for implementation of new initiatives to reduce antibiotic use. Methods A facilitated workshop was undertaken at the 2019 National Australian Antimicrobial Resistance Forum to explore the complexity of antimicrobial stewardship (AMS) implementation in Australia and prioritise future action. Participants engaged in rotating rounds of discussion using a world café format addressing six topics relating to AMS implementation. Once all tables had discussed all themes the discussion concluded and notes were summarised. The documents were independently openly coded by two researchers to identify elements relating to the implementation of antimicrobial stewardship. Results There were 39 participants in the facilitated discussions, including pharmacists, infectious disease physicians, infection prevention nurses, and others. Participants discussed strategies they had found successful, including having a regular presence in clinical areas, adapting messaging and implementation strategies for different disciplines, maintaining positivity, and being patient-focused. Many of the recommendations for the next step involved being patient focussed and outcomesdriven. This involves linking data to practice, using patient stories, using data to celebrate wins and creating incentives. Discussion Recommendations from the workshop should be included in priority setting for the implementation of AMS initiatives across Australia.

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A case of neck abscess caused by rare hypervirulent Klebsiella pneumoniae, capsular type K20 and sequence type 420

Annals of Clinical Microbiology and Antimicrobials ◽

10.1186/s12941-021-00453-8 ◽

2021 ◽

Vol 20 (1) ◽

Author(s):

John Alexander McHardy ◽

Vathshalan Selvaganeshapillai ◽

Priya Khanna ◽

Ashley Michael Whittington ◽

Jane Turton ◽

...

Keyword(s):

Public Health ◽

Case Report ◽

Antimicrobial Resistance ◽

Klebsiella Pneumoniae ◽

East Asia ◽

South East Asia ◽

Neck Abscess ◽

Global Challenge ◽

Life Threatening ◽

The Uk

Abstract Background This case report describes a neck abscess caused by a strain of Hypervirulent Klebsiella pneumoniae in a middle aged man with diabetes without a history of travel to East and South East Asia. This case report is of notable significance as Hypervirulent Klebsiella pneumoniae neck abscesses are rarely seen in the UK and are very infrequently documented in individuals who have not first travelled to the high prevalence areas of East and South East Asia. Case presentation This case report describes a 53 year old diabetic man who contracted a Hypervirulent Klebsiella pneumoniae neck abscess which led to the development of sepsis. Klebsiella pneumoniae was cultured from blood cultures and fluid aspirated from the abscess grew the pathogen with same antimicrobial susceptibility. Hypervirulence was demonstrated after the samples were analysed, at the Antimicrobial Resistance and Healthcare Associated Infections Reference Unit Public Health England Colindale, and found to contain the K20 (rmp)A and rmpA2 virulence genes. Discussion Hypervirulent Klebsiella pneumoniae is a Gram-negative, encapsulated, non-motile bacillus notable for its ability to metastatically spread and cause potentially life threatening infections in otherwise healthy adults, but especially in those with diabetes. Genes responsible for the production of hyperviscous mucoid polysaccharide capsules and siderophores, such as those isolated in this case, enable the bacteria to more efficiently evade the hosts immune system and disseminate and invade surrounding and distant tissues. Data from Public Health England shows Hypervirulent Klebsiella pneumoniae are rare in the UK. A review of current literature also showed Hypervirulent Klebsiella pneumoniae almost exclusively occur in those who have traveled to East and South East Asia. Conclusions This case reported a rare Hypervirulent Klebsiella pneumoniae neck abscess outside of, and without travel to, East and South East Asia. This raises concerns about future, potentially life threatening, Hypervirulent Klebsiella pneumoniae infections becoming more widespread without the need for endemic travel. This concern is further exacerbated by the growing global challenge of antimicrobial resistance.

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A road-map for addressing antimicrobial resistance in low- and middle-income countries: lessons learnt from the public private participation and co-designed antimicrobial stewardship programme in the State of Kerala, India

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-020-00873-9 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Sanjeev Singh ◽

Esmita Charani ◽

Sarada Devi ◽

Anuj Sharma ◽

Fabia Edathadathil ◽

...

Keyword(s):

Public Health ◽

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

Infection Prevention ◽

The State ◽

Action Plans ◽

Public And Private ◽

Middle Income ◽

Middle Income Countries ◽

Public Health Threat

Abstract Background The global concern over antimicrobial resistance (AMR) is gathering pace. Low- and middle-income countries (LMICs) are at the epicentre of this growing public health threat and governmental and healthcare organizations are at different stages of implementing action plans to tackle AMR. The South Indian state of Kerala was one of the first in India to implement strategies and prioritize activities to address this public health threat. Strategies Through a committed and collaborative effort from all healthcare related disciplines and its professional societies from both public and private sector, the Kerala Public Private Partnership (PPP) has been able to deliver a state-wide strategy to tackle AMR A multilevel strategic leadership model and a multilevel implementation approach that included developing state-wide antibiotic clinical guidelines, a revision of post-graduate and undergraduate medical curriculum, and a training program covering all general practitioners within the state the PPP proved to be a successful model for ensuring state-wide implementation of an AMR action plan. Collaborative work of multi-professional groups ensured co-design and development of disease based clinical treatment guidelines and state-wide infection prevention policy. Knowledge exchange though international and national platforms in the form of workshops for sharing of best practices is critical to success. Capacity building at both public and private institutions included addressing practical and local solutions to the barriers e.g. good antibiotic prescription practices from primary to tertiary care facility and infection prevention at all levels. Conclusion Through 7 years of stakeholder engagement, lobbying with government, and driving change through co-development and implementation, the PPP successfully delivered an antimicrobial stewardship plan across the state. The roadmap for the implementation of the Kerala PPP strategic AMR plan can provide learning for other states and countries aiming to implement action plans for AMR.

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Antimicrobial stewardship in rural and remote primary health care: a narrative review

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00964-1 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Jun Wern Yau ◽

Sze Mun Thor ◽

Danny Tsai ◽

Tobias Speare ◽

Chris Rissel

Keyword(s):

Health Care ◽

Primary Health Care ◽

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

Inappropriate Prescribing ◽

Narrative Review ◽

Rural And Remote ◽

Antimicrobial Prescribing ◽

Primary Health ◽

Resistance Rates

Abstract Background Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies. Methods The international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools. Results Fifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing. Conclusions Inappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.

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Efforts to Identify and Combat Antimicrobial Resistance in Uganda: A Systematic Review

Tropical Medicine and Infectious Disease ◽

10.3390/tropicalmed6020086 ◽

2021 ◽

Vol 6 (2) ◽

pp. 86

Author(s):

Mark Tefero Kivumbi ◽

Claire J. Standley

Keyword(s):

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

One Health ◽

Antifungal Resistance ◽

Future Research ◽

Middle Income ◽

Pubmed Database ◽

The Status ◽

Antimalarial Resistance ◽

Ongoing Surveillance

The global burden of antimicrobial resistance is on the rise, resulting in higher morbidity and mortality in our communities. The spread of antimicrobial resistance in the environment and development of resistant microbes is a challenge to the control of antimicrobial resistance. Approaches, such as antimicrobial stewardship programmes and enhanced surveillance, have been devised to curb its spread. However, particularly in lower- and middle-income countries, the overall extent of antimicrobial resistance and knowledge on ongoing surveillance, stewardship or investigation efforts, are often poorly understood. This study aimed to look at the efforts that have been undertaken to detect and combat antimicrobial resistance in Uganda as a means of establishing an overview of the situation, to help inform future decisions. We conducted a systematic literature review of the PubMed database to assess these efforts. A search combining keywords associated with antimicrobial resistance were used to find relevant studies between 1995 and 2020 on surveillance of antimicrobial resistance in Uganda, and susceptibility of microbes to different drugs. The search yielded 430 records, 163 of which met the inclusion criteria for analysis. The studies were categorized according to country and region, the type of antimicrobial resistance, context of the study, study design and outcome of the study. We observed that antibacterial resistance and antimalarial resistance had the most published studies while antiviral and antifungal resistance were represented by very few studies each. Most studies were conducted in humans and hospital settings, with few in veterinary and One Health contexts, and only one that included environmental sampling. The majority of studies have focused on surveillance, susceptibility testing or resistance genes; none of our included papers had a policy or stewardship focus. The results from our work can inform public health policy on antimicrobial stewardship as it contributes to understanding the status of antimicrobial resistance surveillance in Uganda, and can also help to guide future research efforts. Notably, a One Health approach needs to be followed with respect to surveillance of antimicrobial resistance to better understand the mechanisms of resistance transfer across the human-animal–environment interface, including additional investigation in antiviral and antifungal resistance.

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Technologies to address antimicrobial resistance

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1717160115 ◽

2018 ◽

Vol 115 (51) ◽

pp. 12887-12895 ◽

Cited By ~ 47

Author(s):

Stephen J. Baker ◽

David J. Payne ◽

Rino Rappuoli ◽

Ennio De Gregorio

Keyword(s):

Antimicrobial Resistance ◽

Bacterial Infections ◽

Membrane Vesicles ◽

Multidrug Resistant ◽

Outer Membrane Vesicles ◽

Resistant Bacteria ◽

Multiple Stakeholders ◽

Global Challenge ◽

Life Threatening ◽

Bacterial Outer Membrane

Bacterial infections have been traditionally controlled by antibiotics and vaccines, and these approaches have greatly improved health and longevity. However, multiple stakeholders are declaring that the lack of new interventions is putting our ability to prevent and treat bacterial infections at risk. Vaccine and antibiotic approaches still have the potential to address this threat. Innovative vaccine technologies, such as reverse vaccinology, novel adjuvants, and rationally designed bacterial outer membrane vesicles, together with progress in polysaccharide conjugation and antigen design, have the potential to boost the development of vaccines targeting several classes of multidrug-resistant bacteria. Furthermore, new approaches to deliver small-molecule antibacterials into bacteria, such as hijacking active uptake pathways and potentiator approaches, along with a focus on alternative modalities, such as targeting host factors, blocking bacterial virulence factors, monoclonal antibodies, and microbiome interventions, all have potential. Both vaccines and antibacterial approaches are needed to tackle the global challenge of antimicrobial resistance (AMR), and both areas have the underpinning science to address this need. However, a concerted research agenda and rethinking of the value society puts on interventions that save lives, by preventing or treating life-threatening bacterial infections, are needed to bring these ideas to fruition.

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How can multi-professional education support better stewardship?

Infectious Disease Reports ◽

10.4081/idr.2017.6917 ◽

2017 ◽

Vol 9 (1) ◽

Cited By ~ 1

Author(s):

Nuno Rocha-Pereira ◽

Enrique Castro Sanchez ◽

Dilip Nathwani

Keyword(s):

Antimicrobial Resistance ◽

Antimicrobial Stewardship ◽

Professional Education ◽

Healthcare Workers ◽

Education For All ◽

Research Gaps ◽

Efficient Strategy ◽

Adequate Education ◽

Education Support

Antimicrobial stewardship is widely accepted as an efficient strategy to combat the growing threat of antimicrobial resistance. Education is one of the cornerstones of successful antimicrobial stewardship programs. There is also general agreement that antimicrobial stewardship is a team effort that must involve the whole continuum of healthcare workers. Providing adequate education for all different professionals although challenging is deemed crucial to achieve good results. This paper reviews the different strategies available to educate the multiple healthcare workers, discusses how education can improve antimicrobial stewardship programs and outlines some of the challenges faced and research gaps that need to be addressed in order to improve education in this field.

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