Table 1.

Hospital activities to improve antimicrobial use.

Activity	Role with Improving Antimicrobial Prescribing
IPC committees	Can be a core component of enhancing antimicrobial use within hospitals through instigating pertinent quality improvement programs [189], with minimum requirements for IPCs established by the WHO and others [190,191] Studies have shown that IPCs can reduce AMR in key hospital wards [191] However, there can be issues with lack of resources and identity as well as negative staff attitudes [187]
PPS studies	PPs studies are important to gain an understanding of current antimicrobial use in hospitals and potential programs for quality improvement initiatives [105,168,193,194] PPS studies help determine the extent of HAIs within LMICs [104], with typically a higher rate of HAIs among LMICs at 5.7–19.1% of patients versus 5.7–7.5% in high-income countries [104,195,196]—although rates up to 28% to 45.8% have been recorded among hospitals in sub-Saharan African countries [104,197,198] This is a key issues as HAIs are associated with appreciable morbidity, mortality and costs [104,131,199,200], with higher prevalence rates of HAIs in LMICs due to a number of factors including poorly enforced ward environmental sanitation practices, lack of monitoring of adherence to IPC guidelines and concerns with facilities [104,201] Key concerns with PPS studies include the extent of documentation of the rationale for the choice of antimicrobial(s), whether the rationale is in line with local/national recommendations, whether culture and sensitivity testing (CST) is being routinely undertaken, the extent of switching from intravenous (IV) to oral use, the timing and duration of administration of antibiotics to prevent SSIs and adherence to local or national guidance—increasingly seen as a key quality indicator [88,168,169,171,202] Specific data collection forms have been designed for Africa recognizing the additional burden of HIV, TB, malaria and malnutrition [88,203], with APPs developed to accelerate data collection and analysis [204,205]
ASPs	Seen as a core element especially within hospitals to improve future antibiotic prescribing (Section 3.1.1) Publications including from the Commonwealth Partnership for Antimicrobial Stewardship and practical toolkits from the WHO and others can assist with implementation [171,206,207,208,209,210,211] However, ASPs can take time to implement in LMICs in view of ongoing cultures and resources [97]: ○ In Tanzania, one year after the instigation of the NAP, 35.9% of respondents had instigated some form of ASP in their hospital; however, hospital antibiotic policy documents were only available in 15.4% of facilities [76]. Encouragingly, IPC committees were now present in the majority of hospitals surveyed ○ In Vietnam, by the end of 2018, ASPs had been initiated in 47% of its hospitals, but actual implementation has been slow [212,213]