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Year : 2019  |  Volume : 37  |  Issue : 3  |  Page : 309--317

Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda

Mathur Purva1, Guleria Randeep2, Malhotra Rajesh3, C Misra Mahesh4, Gupta Sunil5, Kumar Subodh6, Sagar Sushma6, Wig Naveet6, Garg Pramod7, Kapil Arti8, Khurana Surbhi1, Katoch Omika1, Katyal Sonal1, Sahu Manoj9, Chakrabarti Arunaloke10, Ray Pallab10, Biswal Manisha10, Taneja Neelam10, Rupali Priscilla11, K Subaramani12, Jacob Ebor13, Balaji Veeraraghavan14, Rodrigues Camilla15, Nag Vijayalakshmi16, Tak Vibhor16, Singh Kuldeep17, K Bhatia Pradeep18, Gupta Neeraj19, Khera Daisy17, Venkatesh Vimala20, Mukhopadhyay Chiranjay21, KE Vandana21, Varma Muralidhar22, Deotale Vijayshri23, Attal Ruchita23, Padmaja Kanne24, Sudhaharan Sukanya24, Wattal Chand25, Goel Neeraj26, Bhattacharya Sanjay27, Sen Sourav28, Tadepalli Karuna29, Saigal Saurabh30, Bijayini Behera29, Singh Sanjeev31, MA Thirunarayan32, Nath Reema33, Saikia Lahri34, Ray Raja35, J Raj Hirak35, Baveja Sujata36, D'Souza Desma36, Chandy Mammen37, Mukherjee Sudipta38, K Roy Manas39, Goel Gaurav40, Tripathy Swagata41, Misra Satyajeet41, Dey Anupam42, S Mishra Tushar43, A Fomda Bashir44, Bashir Gulnaz44, Nazir Shaista44, Devi Sulochana45, R Devi Khuraijam45, C Singh Langpoklakpam46, Das Padma47, Bhargava Anudita47, Gaikwad Ujjwala47, Khandelwal Neeta48, Vaghela Geeta48, Sukharamwala Tanvi48, Jain Shristi49, Verma Prachi50, Lamba Mamta51, Bhattacharyya Prithwis52, C Phukan Anil53, Lyngdoh Clarissa53, Gaind Rajni5, Saksena Rushika5, Kapoor Lata40, Ohri Vinod40, Walia Kamini40,  
1 Department of Laboratory Medicine, JPNATC, All India Institute of Medical Sciences, Kolkata, West Bengal, India
2 Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, Kolkata, West Bengal, India
3 Department of Orthopedics, All India Institute of Medical Sciences, Kolkata, West Bengal, India
4 Department of Surgery, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India
5 Department of Microbiology, Safdarjung Hospital and VMMC, Delhi, India
6 Department of Surgical Disciplines, All India Institute of Medical Sciences, Kolkata, West Bengal, India
7 Department of Gastroenterolog, All India Institute of Medical Sciences, Kolkata, West Bengal, India
8 Department of Microbiology, All India Institute of Medical Sciences, Kolkata, West Bengal, India
9 Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Kolkata, West Bengal, India
10 Department of Medical Microbiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
11 Department of Infectious Diseases, Christian Medical College and Hospital, Vellore, India
12 Department of Surgery, Christian Medical College and Hospital, Vellore, India
13 Department of Pediatrics, Christian Medical College and Hospital, Vellore, India
14 Department of Clinical Microbiology, Christian Medical College and Hospital, Vellore, India
15 Department of Microbiology, P. D. Hinduja Hospital and Medical Research Center, Mumbai, Maharashtra, India
16 Department of Microbiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
17 Department of Paediatrics, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
18 Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
19 Department of Neonatology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
20 Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India
21 Department of Microbiology, Kasturba Medical College, Manipal, Karnataka, India
22 Department of Medicine, Kasturba Medical College, Manipal, Karnataka, India
23 Department of Microbiology, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
24 Department of Microbiology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
25 Department of Clinical Microbiology and Immunology, Sir Ganga Ram Hospital, Kolkata, West Bengal, India
26 Department of Microbiology, Sir Ganga Ram Hospital, Kolkata, West Bengal, India
27 Department of Microbiology, Tata Medical Centre, Kolkata, West Bengal, India
28 Department of Microbiology, Armed Forces Medical College, Pune, Maharashtra, India
29 Department of AIIMS, Bhopal, Madhya Prades, India
30 Department of Trauma and Emergency, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
31 Department of Infection Control, Amrita School of Medicine, Kochi, Kerala, India
32 Department of Microbiology, Apollo Hospital, Chennai, Tamil Nadu, India
33 Department of Microbiology, Assam Medical College, Gwahati, Assam, India
34 Department of Microbiology, Guahati Medical College, Gwahati, Assam, India
35 Department of Microbiology, Institute of Post-Graduate Medical Education and Research, and Seth Sukhlal Karnani Memorial Hospital, Kolkata, West Bengal, India
36 Department of Microbiology, Lokmanya Tilak Municipal General Hospital, Mumbai, Maharashtra, India
37 Department of Haematology, Tata Medical Center, Kolkata, West Bengal, India
38 Department of Critical Care Medicine, Tata Medical Center, Kolkata, West Bengal, India
39 Department of Surgical Oncology, Tata Medical Center, Kolkata, West Bengal, India
40 Department of Microbiology, Tata Medical Center, Kolkata, West Bengal, India
41 Department of Anaesthesiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
42 Department of Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
43 Department of General Surgery, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
44 Department of Microbiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
45 Department of Microbiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
46 Department of Anaesthesiology, Regional Institute of Medical Sciences, Imphal, Manipur, India
47 Department of Microbiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
48 Department of Microbiology, Government Medical College, Surat, Gujarat, India
49 Department of Critical Care and Respiratory Medicine, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India
50 Department of Anaesthesiology and Critical Care, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India
51 Department of Microbiology, Mahatma Gandhi University of Medical Sciences and Technology, Jaipur, Rajasthan, India
52 Department of Anaesthesiology and IC, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India
53 Department of Microbiology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, Meghalaya, India

Correspondence Address:
Dr. Walia Kamini
Indian Council of Medical Research, New Delhi
India

Abstract

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs. Subjects and Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis. Results and Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.

How to cite this article:
Purva M, Randeep G, Rajesh M, Mahesh C M, Sunil G, Subodh K, Sushma S, Naveet W, Pramod G, Arti K, Surbhi K, Omika K, Sonal K, Manoj S, Arunaloke C, Pallab R, Manisha B, Neelam T, Priscilla R, Subaramani K, Ebor J, Veeraraghavan B, Camilla R, Vijayalakshmi N, Vibhor T, Kuldeep S, Pradeep K B, Neeraj G, Daisy K, Vimala V, Chiranjay M, Vandana K E, Muralidhar V, Vijayshri D, Ruchita A, Kanne P, Sukanya S, Chand W, Neeraj G, Sanjay B, Sourav S, Karuna T, Saurabh S, Behera B, Sanjeev S, Thirunarayan M A, Reema N, Lahri S, Raja R, Hirak J R, Sujata B, Desma D, Mammen C, Sudipta M, Manas K R, Gaurav G, Swagata T, Satyajeet M, Anupam D, Tushar S M, Bashir A F, Gulnaz B, Shaista N, Sulochana D, Khuraijam R D, Langpoklakpam C S, Padma D, Anudita B, Ujjwala G, Neeta K, Geeta V, Tanvi S, Shristi J, Prachi V, Mamta L, Prithwis B, Anil C P, Clarissa L, Rajni G, Rushika S, Lata K, Vinod O, Kamini W. Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda.Indian J Med Microbiol 2019;37:309-317

How to cite this URL:
Purva M, Randeep G, Rajesh M, Mahesh C M, Sunil G, Subodh K, Sushma S, Naveet W, Pramod G, Arti K, Surbhi K, Omika K, Sonal K, Manoj S, Arunaloke C, Pallab R, Manisha B, Neelam T, Priscilla R, Subaramani K, Ebor J, Veeraraghavan B, Camilla R, Vijayalakshmi N, Vibhor T, Kuldeep S, Pradeep K B, Neeraj G, Daisy K, Vimala V, Chiranjay M, Vandana K E, Muralidhar V, Vijayshri D, Ruchita A, Kanne P, Sukanya S, Chand W, Neeraj G, Sanjay B, Sourav S, Karuna T, Saurabh S, Behera B, Sanjeev S, Thirunarayan M A, Reema N, Lahri S, Raja R, Hirak J R, Sujata B, Desma D, Mammen C, Sudipta M, Manas K R, Gaurav G, Swagata T, Satyajeet M, Anupam D, Tushar S M, Bashir A F, Gulnaz B, Shaista N, Sulochana D, Khuraijam R D, Langpoklakpam C S, Padma D, Anudita B, Ujjwala G, Neeta K, Geeta V, Tanvi S, Shristi J, Prachi V, Mamta L, Prithwis B, Anil C P, Clarissa L, Rajni G, Rushika S, Lata K, Vinod O, Kamini W. Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda. Indian J Med Microbiol [serial online] 2019 [cited 2020 Apr 1 ];37:309-317
Available from: http://www.ijmm.org/text.asp?2019/37/3/309/277071

Full Text



 Introduction



Antimicrobial resistance (AMR) is a global health emergency and patient safety challenge. As pathogens are multiplying their armamentarium of AMR genes, patient outcomes are becoming dependent on the efficiency of healthcare facilities (HCFs) to control infections and optimise antimicrobial use.[1],[2],[3] Patients infected with resistant organisms are at higher risk to have adverse outcomes, prolonged hospital stays and deaths.[4] Overuse/misuse of antimicrobials is the most important contributor to the spread of AMR in hospitals and communities;[5],[6],[7],[8] almost 20%–50% of antimicrobial administrations in hospitals may be unnecessary/inappropriate.[9],[10],[11],[12] AMR has huge economic consequences; the USA alone adds $20 billion in excess of direct healthcare costs.[1],[13] Antimicrobial stewardship (AMS) is a key component to curtail the spread of AMR across institutions and nations. Institutions can learn from each other, and the lessons learnt can be used to implement national policies. AMS aims to escalate and sustain the rational use of antimicrobials to achieve optimum clinical outcomes and ensures the cost-effectiveness of treatment, keeping unintended consequences of antimicrobial use such as toxicity and promotion of AMR to a minimum.[14],[15]

The Global Health Security Agenda (GHSA) was launched in 2014 to help create a world safe and secure from the threats of infectious diseases (IDs).[16],[17] The Ministry of Health and Family Welfare (MoHFW), Government of India, in partnership with the Centers for Disease Control and Prevention (CDC), is working to build the nation's capacity to prevent, detect and respond to IDs/other public health threats.[16],[17] The Indian healthcare system is a conglomeration of public and private HCFs catering to a population of over 1.2 billion people. Life-saving treatments and equipment often take precedence over infection control/AMS activities in many poorly funded Indian hospitals. This unique amassment of diverse socioeconomically, culturally, politically and administratively controlled HCFs in India makes implementation of policies a big challenge.

The Indian Council of Medical Research (ICMR) had launched the AMR Surveillance and Research Network in 2013 to facilitate a customised stewardship programme for India.[18] The All India Institute of Medical Sciences (AIIMS), New Delhi, is collaborating with the ICMR and CDC, under the aegis of the GHSA to build capacities for surveillance and prevention of hospital-acquired infections (HAIs).[19] A total of twenty hospitals across India, with more than eighty ICUs, have been enrolled in this network since October, 2015. We assessed the baseline existing AMS practices across this network to identify the gaps and scopes for interventions in order to develop a uniform AMS programme (AMSP) in India. This article reports the findings of this baseline assessment.

 Subjects and Methods



The AIIMS–ICMR–CDC network includes twenty hospitals across different states of India [Figure 1]. These hospitals are a mix of public/private/missionary/army hospitals, catering to a diverse category of patient populations. The tool used for this assessment was adapted from the CDC's checklist for Core Elements of Hospital AMSP.[20] The tool was modified and validated by a team of experts from the ICMR/AIIMS/CDC and investigators from the twenty hospitals.{Figure 1}

[Table 1] shows the questions incorporated in the tool. The tool was given to all the sites, to be self-administered and filled by the senior investigator. The filled questionnaire was sent via E-mail/hard copies to the central team of the AIIMS, to be entered onto the software. The software gave a score of 1 for a reply of 'yes' and 0 for 'no'. The cumulative score for each question was generated as average percentage of 'yes'. Some sites did not provide response to a question; these non-responses were excluded from the percentage calculations. The percentages represented the degree of reported implementation of AMSP activities amongst all sites that completed the assessment. As each of the broadheads had several subheading questions, the average percentage of affirmatives for each subheading was combined to give the network average compliance to the broader heads. For example, in the broad category, 'Key Support for AMSP', there were nine questions; each of these generated a score of 1 or 0. The average score of 'yes' in these nine components was generated as a score for this major component for a hospital. The score was then compiled for each hospital to generate the network average for that component by the database. The scores generated by the database were used for analysis. Although most of the responses were elicited from all the twenty centres, wherever the response was lacking, the denominators have been mentioned in the results below.{Table 1}

The study was approved by all the participating institutes' ethical committees and by the Indian Health Ministry's Scientific Committee.

 Results



A total of twenty hospitals participated in this assessment; 12 were public sector (government aided/army); six were private sector and two were missionary hospitals (these two were considered private hospitals in data analysis). Nineteen of the 20 (95%) were multispeciality hospitals and one was a cancer hospital. Their bed strength varied from 183 to 3860 beds. The monthly average outpatient footfall ranged from 2000 to 2,24,000 patients. The average monthly discharges numbered from 210 to 84,590.

Leadership support

The hospitals were found to have a highly variable leadership support (none to 100%) across the network, with private hospitals faring better than government. Thirteen of the twenty hospitals (65%) had a written statement from the facility administrator supporting AMS; only five (25%) received a budgeted financial support for AMSP.

Accountability

The network average for the presence of a system of accountability was 53%. Only 10 (50%) hospitals had a person directly responsible for coordination of AMSP and 11 (55%) had an AMSP review committee, which met at least once in 6 months. Of the 11 hospitals who held a stewardship meeting, ten communicated the minutes to all stakeholders.

Key support for antimicrobial stewardship programmes

The average score for this component was 58% (varying from 0% to 100%). Eight (40%) hospitals had clinical pharmacist/pharmacy staff participating in AMSP, 10 out of 18 respondents (56%) had support of clinical pharmacologist, 10 of 19 respondents (53%) had support of ID physician, 15 (75%) had involvement of infection control team/focal person, 8 (40%) had support from quality improvement staff, 15 (75%) had a microbiologist's involvement, 8 (40%) had involvement of information technology (IT) department and 70% each (14 hospitals) had clinical departmental heads and hospital administration staffs support in the AMSP.

Policies to support optional antibiotic use

With an network average of 59%, 13 (65%) hospitals had policies requiring prescribers to record dose/duration for antibiotic prescriptions, 10 (50%) had policies requiring documentation of indication for prescription, 12 (60%) had policies requiring sample cultures before antibiotic prescription and 12 out of 19 respondents (63%) had policies for prescribing generic antibiotics. The average score for policies for antibiotic procurement was 79%; 16 of 19 respondents (84%) required pharmacies to maintain antibiotic formulary and 14 of 19 respondents (74%) had policies to avoid the procurement of unnecessary/duplicative antibiotic combinations.

Broad interventions to improve antibiotic use

A low average of 33% was found in this component; 9 (45%) hospitals had processes for reviewing the appropriateness of all empiric antibiotics 48 h after initial orders; 6 (30%) needed approval by senior physicians/ID specialists for prescribing last-resort antimicrobials and 5 (25%) had policies to conduct audits with feedback.

Prescription-specific interventions to improve antibiotic use

A varying availability was found with regard to antibiotic prescription policies, with the general average for parameters to be 52%. Written policies on changes from intravenous (IV) to oral therapy were available in 10 (50%) hospitals; 14 (70%) had written guidelines for dose adjustments in organ dysfunction; 9 (45%) had policies of dose adjustments based on pharmacokinetics/pharmacodynamics; 10 (50%) had written policies to provide feedbacks in case of unnecessary duplicative treatments and 9 (45%) had written policies for time-sensitive stop orders for specified antibiotics.

Diagnosis and infection-specific interventions to improve antibiotic use

The average score for guideline availability for hospitalised patients was 72%; treatment guidelines were available for community-acquired pneumonia (CAP) in 15 (75%), healthcare-associated pneumonia in 16 (80%), catheter-associated urinary tract infection (UTI) in 14 (70%), healthcare-associated-UTI in 15 (75%), skin- and soft-tissue infections (SSTIs) in 14 (70%), surgical prophylaxis in 16 (80%), acute gastrointestinal infections in 13 (65%), meningitis in 14 of 19 respondents (74%), neonatal sepsis in 14 of 19 respondents (74%), clinical sepsis in 14 of 18 respondents (78%) and intrapartum and postpartum infections in 10 of 19 respondents (53%).

For outpatients, the network average for availability of guidelines was 48%; 10 (50%) hospitals had guidelines for upper respiratory tract infections/CAP/SSTIs/acute gastroenteritis, 9 of 19 respondents (47%) had guidelines available for sexually transmitted infection and 8 of 19 respondents (42%) had guidelines for antenatal/intrapartum/postpartum infections.

Process measures

With a network average of 40%, 8 (40%) facilities had processes to monitor adherence to the dose/duration/clinical indication for inpatient antibiotic prescription, 11 (55%) facilities routinely monitored adherence to hospital-specific empiric treatment for at least one HAI, 12 (60%) hospitals monitored whether cultures were sent before starting empiric treatment for inpatient infections and 14 (70%) had systems to monitor culture result-based adjustments of antibiotics for inpatient infections.

For outpatients, only six (30%) hospitals had processes to monitor duration/dose, four (20%) had monitored the documentation of clinical indication of antibiotic prescription, seven (35%) monitored empiric treatment recommendations for at least one common outpatient infection and five (25%) and seven (35%), respectively, had processes for monitoring the practice of sending cultures and adjusting antibiotics based on culture results.

Antibiotic use and outcome measures

In order to assess how the AMR data were being utilised, 49% of the facilities had some processes to document outcomes, 15 (75%) tracked the infections caused by AMR pathogens and 16 (80%) produced a cumulative antibiogram for at least one common infection. Only five (25%) monitored antibiotic use by the counts of antibiotics administered per day (days of therapy [DOT]), seven (35%) monitored by the number of grams of antibiotics used (defined daily dose [DDD]) and six (30%) by overall purchasing cost of antibiotics consumed.

Reporting information to staff on antibiotic use and resistance

A system for any form of reporting information to staff was present on an average in 53% of participating facilities. The AMS programme shared unit-/department-specific reports on antibiotic use with prescribes in 10 (50%) participating hospitals; 14 (70%) had a current antibiogram for common infections disseminated to prescribers in the past year. In 10 (50%) facilities, the prescribes routinely received direct personalised communications on mechanisms to improve antibiotic prescribing, and 8 of the 19 respondents (42%) had practices for issuing warnings to prescribers regarding clinically significant interactions between prescribed antibiotics and other medications.

Education

The cumulative score for education was 40%; 12 (60%) hospitals provided orientation to prescribes for facility-specific antibiotic policies and 6 (30%) facilities had a refresher training or unit-/department-specific trainings on antibiotic policies.

The responses were also compared between public and private sector hospitals. [Table 2] shows the difference in core capacities between public and private sector hospitals. In general, private sector hospitals had a higher score for most of the components.{Table 2}

 Discussion



AMS is a key strategy in local/national programmes to tackle AMR and monitor the effectiveness of those programmes. Many hospitals are now relying on last-resort antimicrobials such as colistin, due to the escalating rates of carbapenem-resistant Enterobacteriaceae.[21],[22]

In a unique initiative under the GHSA, HAI surveillance is being implemented in India in a phased manner in twenty centres, coupled with the strengthening of infection prevention/control and characterisation of AMR in HAIs. Considering the urgency to implement AMSP in Indian hospitals, this self-assessment of baseline practices gave us important information which will help us in strengthening institutional capacity for developing/implementing AMSP. The ICMR had previously conducted one survey in 2013 which looked at the following components: general information, AMSP, HIC, AMR data analysis, antimicrobial agent (AMA) usage, AMSP strategies, AMA prescription guidelines, AMA usage audit and feedback, etc., This survey builds on the ICMR survey as it aims to capture the additional information including leadership support, accountability, key support for AMSP, policies to support optional antibiotic use, broad interventions to improve antibiotic use, prescription-specific interventions to improve antibiotic use, diagnosis and infection-specific interventions to improve antibiotic use, process measures, antibiotic use and outcome measures, reporting information to staff on antibiotic use and resistance, as well as education.

All hospitals responded to the assessment tool. The study showed that although hospitals had a written statement supporting antibiotic stewardship, there was a dearth of financial support for stewardship activities. Lack of resources is not limited to middle- and low-income countries alone as shown in a recent survey across the NHS trust in England.[23] A few studies have found economic benefits of implementing even simple measures such as antibiotic checklists as AMS intervention.[24] The recent release of standard treatment guidelines by the ICMR, based on Indian-AMR data, will encourage implementation of a more uniform policy of antimicrobial prescription in Indian hospitals.[25] Hospitals in India need to devote personnel/funds specifically for AMSP.

Almost half of the participating hospitals lacked a system for reviewing the AMSP, a gap which can be easily filled by local administration. We also observed that in most hospitals, there was a lack of personnel from pharmacology/pharmacy/ID/IT in the AMS programmes. Empowering them would strengthen the policies for the judicious use of antimicrobials. The felt-need for the incorporation of pharmacists in AMSP is being now documented for low-resource countries.[14] In a recent survey of AMS activities in Swiss hospitals, it was found that ID physicians, microbiologists and pharmacists were available on-site in 49/63 (79%), 27/63 (43%) and 25/63 (40%) of hospitals, respectively, with none of these resources available in 10/63 (16%) of hospitals.[26] Although IT infrastructure has seen an explosive expansion in Asia, its usage in health sector has not seen a similar growth, which remains a barrier to comprehensive HAI/AMR surveillance and AMSP.[27] It is encouraging to note that the WHO, Regional Office for South-East Asia, has offered to support international partners to translate recommendations on IT development into actions and leverage partnerships.[27]

This study also brings to light the need to have clear written policies to order specimen cultures before prescription of antimicrobials. Empiric treatments not supported by culture data are often constitute a broad spectrum. AMS programmes in many hospitals are now moving towards rapid blood culture identification based on nucleic acid technology, coupled with stewardship-based education on interpretation.[28],[29] An encouraging finding is the high proportion of hospitals having pharmacies that maintain antibiotic formulary and most have some form of formulary restriction.

An identified area with a clear scope for improvement is the general lack of intervention to improve antibiotic use, especially higher-generation ones. In two large-scale surveys on AMSP, restrictions on the use of broad-spectrum antimicrobial drugs were present in only 84% worldwide and 30% of hospitals in Victoria. The same was found to be existing in 29% of hospitals in a Swiss survey. Evaluation of antimicrobial use was conducted less frequently in Swiss hospitals (52%) as compared to 80% of the 667 hospitals in the worldwide survey and 47% of hospitals in Victoria.[5],[30]

Hospitals can easily implement simple policies such as prior approval by a senior physician for last-resort antimicrobials. These are low-investment activities which can be incorporated as routine quality improvement procedure in all hospitals. We also need to develop manuals/guidelines on dose/duration and policies for switching from IV to oral antibiotics. Simple steps such as time-sensitive stop orders for higher-generation antibiotics, the average score of which was 45%, would go a long way in limiting the use of these last-resort agents.

We observed that most hospitals had treatment guidelines for the common infections for use in hospitalised patients, but the same was lacking for outpatient-based treatment. The ICMR's ongoing project encourages hospitals to create their own antibiograms and have treatment guidelines based on antibiograms. The bulk of antimicrobial usage occurs for community-acquired infections, where antibiotics are rampantly used for simple respiratory/diarrhoeal infections. According to one report, at least 15% of emergency department visits result in antibiotic use, with poor compliance to evidence-based guidelines.[31],[32],[33],[34]

The current network also needs to strengthen the process measures for AMSP. The only monitoring process with more than 50% availability was collection of cultures before treatment and adjustment of antibiotics based on culture reports. There is a need to augment monitoring of documentation of dose/duration/clinical indications.

As most AMS programmes in our country are largely driven by microbiology/ID people, it was encouraging to find that most hospitals tracked the rates of AMR infections and generated cumulative antibiograms, which is shared with individual departments. However, there is a need to incorporate some monitoring mechanism for antibiotic consumption such as DOT or DDD. The programme also needs to incorporate mechanisms for direct communication to the treating physician regarding the improvement of antibiotic prescription and drug interactions.

All programmes need to sustain through continuous education. Globally, education on AMS is provided in the majority of hospitals.[35] Although many facilities had some form of orientation training, there was a serious lack of refresher training or tailored education to individual departments. Institutions need to develop their own training modules in order to continue the orientation of healthcare personnel towards judicious antimicrobial usage.

In contrast to the developed countries,[35] in India, AMS strategies were most frequently implemented in private hospitals as compared to university hospitals. A primary reason of this may be the compulsory accreditations, which the private hospitals strive for and the huge sizes/diverse administrative controls that the public hospitals in India have. This was also previously highlighted by Walia et al. in 2015.[18] There was a statistically significant difference in leadership support, broad interventions to restrict the use of higher-generation antibiotics, outcome measurements by counts of antibiotics and educational interventions between public and private sector hospitals.

It is clear that considerable gaps exist in most hospitals with regard to the implementation of an AMS programme. However, the current ICMR–AIIMS–CDC initiative is providing us a unique opportunity to fill these gaps, aided with good-quality data being generated through HAI-AMR surveillance. Such data-driven programmes would hopefully be sustained through continuous collaboration with the Ministry of Health and Family Welfare and allied agencies. The findings of this survey would help the Indian government to identify and fund priority areas for AMR containment. In a large survey of AMS programmes in US acute care hospitals, it was observed that only 39% reported having met all the seven core elements, with larger hospitals being more compliant.[35]

Our survey has several lacunae. First, this represents a very small sample of hospitals and therefore, the information cannot be generalised to the entire Indian healthcare system. Second, this was a self-administered tool; therefore, data validation could not be ascertained. Although the tool was very objective, there may have been differing interpretations to a question, which we could not ascertain.

 Conclusion



AMS programmes can be established in any type of health facility. The development of national AMS programme will aid in advancing stewardship activities, which can be incorporated in the national action plan with the scope of allowing local flexibility. However, the most important determinant of a successful AMS programme in India will be the hospital leadership support.

Acknowledgement

We thank Kayla Laserson, Aditya Sharma, Paul Malpiedi, Neil Gupta, Siromany Valan, Padmini Srikantiah, Daniel VanderEnde, Anoop Velayudhan, and Rajeev Sharma (U.S. Centers for Disease Control and Prevention) for their assistance with this study. We acknowledge the support of the Global Health Security Agenda (GHSA) cell of the Ministry of Health and Family Welfare and the Directorate General of Health Services for this work. The participation and support of all the staff working in this project and the Microbiology staff at JPNATC is acknowledged.

Financial support and sponsorship

This work was supported by the US Centers for Disease Control and Prevention Global Health Security Agenda cooperative agreement 1U2GGH001869.

Conflicts of interest

There are no conflicts of interest.

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