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Low Income *
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| Gebretekle et al., Ethiopia, 2020 [176] |
1109 individual patients took part (707 during the intervention and 402 in the post-intervention periods) Principally Education as an intervention. This included: Intervention—weekly audit meetings and immediate (verbal and written) feedback sessions regarding antibiotic prescriptions of admitted patients on 4 wards This built on recently developed institutional guidelines and training sessions with relevant clinicians on ASPs and guidelines Aim: auditing of antibiotic prescriptions post intervention However, no feedback initiatives to remind physicians
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Most commonly prescribed antibiotics were ceftriaxone, cefepime, meropenem, metronidazole and vancomycin 96% of the recommendations made by the AMS team were accepted Once the intervention ceased, total antimicrobial use increased by 51.6% and the mean duration of treatment increased by 4.1 days/patient respectively Mean hospital stay and crude mortality decreased during the intervention; however, increased significantly after the intervention
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| Alabi et al., Liberia, 2022 [134] |
Intervention: education and engineering involving a collation of three activities:
QIs included prescribing of correct antibiotics (incorporating completeness of microbiological diagnostics) as well as dosages and duration QIs were assessed in a case series after AMS ward rounds and fed back to key personnel 620 patients overall—310 pre intervention and 310 post intervention Aim: Assess the impact of AMS programs with improving antibiotic prescribing
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Improvements were seen in all QIs:
Adherence to local guidelines improved from 34.5% (107/310) to 61.0% (189/310) (p < 0.0005) Correct dosing improved from 15.2% (47/310) to 36.5% (113/310) (p < 0.0005) Optimal duration of antibiotic use improved from 13.2% (41/310) to 31.0% (96/310) (p < 0.0005) Proportion of patients receiving ceftriaxone reduced from 51.3% (159/310) to 14.2% (44/310) (p < 0.0005). Following the ASP, 79.7% (247/310) of patients had samples sent for microbiological analysis
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| Lester et al., Malawi, 2020 [193] |
Intervention: education and engineering involving guidelines, posters and the application of smartphones to help with clinical decision making as well as regular PPS studies combined with prescriber feedback 503 patients were involved—203 pre implementation, 200 in the implementation phase and 100 patients post implementation Aim: Reduce extensive prescribing of third-generation cephalosporins within the hospital and associated costs with no adverse impact on mortality—especially with high rates of HIV among in-patients in the hospital (approximately 61% across the surveys)
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The proportion of prescriptions for an IV 3rd-generation cephalosporin fell from 80.1% (193/241) of all prescriptions in the first survey to 53.6% (177/330) by the last survey The median length of a ceftriaxone course was reduced from 5 to 4 days aided by an increase in the number of clinician reviews of prescriptions at 48 h—increasing from 22.4% (54/241) at the start to 73.3% (242/330) by the final antibiotic survey Overall annual savings from the 3 wards was estimated at USD 15,000 with no change in mortality or median length of hospital stay
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| Suliman et al., Sudan, 2020 [188] |
Intervention—principally education. Activities included:
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○
Verbal contact by clinical pharmacists with all consultants and registrars involved with performing emergency caesarean sections (ECSs) separately about agreed updated guidelines for the use of prophylactic antibiotics in ECS to prevent SSIs
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○
Brochures giving details about proposed changes in prophylactic antibiotic recommendations for patients undergoing ECS
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○
These included no longer administering metronidazole (IV before cord clamping and on discharge) and oral amoxicillin-clavulanic acid on discharge
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○
Subsequent auditing and feedback of the findings
Overall, 195 participants were included, 94 participants before and 101 participants after the intervention Aim: To improve the rational use of prophylactic antibiotics among patients undergoing a cesarean section and to assess the impact of clinical pharmacist intervention on subsequent antibiotic utilization/ adherence to guidelines and possible cost-savings
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The hospital protocol was fully followed so no patient subsequently received either metronidazole (IV or oral) or oral amoxicillin-clavulanic acid on discharge following the ASP intervention Cost saving of 31% on antibiotics administered to prevent SSIs post ASP No patient in the revised administration group developed any symptoms or signs of SSI (at days 15 and 30 post discharge)
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| Gentilotti et al., Tanzania, 2020 [160] |
Intervention: principally Education. Activities included formal and on-job training including seminars on infection prevention and control/ evidence-based education on antimicrobial resistance and good antimicrobial prescribing practice Prior to this—antibiotics were typically prescribed post-operatively (98.2%) and for 8–10 days when given 1377 women undergoing caesarean sections were enrolled, 664 in the pre-intervention phase and 713 in the post-intervention phase Aim: Enhance appropriate antibiotic prescribing to prevent SSIs for patients undergoing caesarean sections
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Pre-incision antibiotic prophylaxis was administered in significantly more cases post the educational intervention (p < 0.001) The extent of antibiotics administered post-operatively to prevent SSIs was also appreciably lower post intervention (p < 0.001) The timing of prophylaxis was adequate only in 28% of cases in the post intervention group, but this did not seem to affect SSI prevalence rates The total number of SSIs decreased from 48% pre-intervention to 17% post intervention (p < 0.001)
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| Ashiru-Oredope et al., 2022 [135] |
Intervention: Principally Education and Engineering. Activities included developing a checklist of 54 items across 8 sections to identify current AMS activities surrounding key areas (highlighted in Box 1) across 19 participating hospitals with the number of inpatient beds ranging from 100 to 2000 (average 536) Educational initiatives undertaken to improve AMS capabilities within the hospitals, which included guideline development and promotion Post-intervention monitoring to record improvements in AMS activities to improve future antimicrobial prescribing
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Improvements in AMS activities recorded across all hospitals (overall 79% improvement in AMS activities)—before this program only 3 hospital sites had a formal AMS structure Increased multidisciplinary membership of AMS teams including an increasing number of nurses and pharmacists to assist with future sustainability of AMS activities New guidelines, policies, posters developed/ implemented across participating hospitals to improve future antimicrobial prescribing Increased awareness of the WHO AWaRe classification of antimicrobials across most participating hospitals (79%)
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| Ngonzi et al., Uganda, 2021 [197] |
Intervention: Principally Education and Engineering regarding the World Health Organization’s checklist of activities to reduce SSIs in patients undergoing caesarean sections Educational interventions combined with daily audits and feedback 678 patients’ charts were reviewed (200 in the pre-intervention phase, 230 in the intervention phase and 248 in the post-intervention phase). Aim: reduction in SSIs among patients undergoing caesarean sections in the hospital
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The use of the WHO’s checklist for SSIs increased from 7% (13/200) pre-intervention to 92% (211/230) in the intervention phase (p < 0.001) Subsequently, fell to 77% ((191/248) post-intervention (p < 0.001) Prescribing of antibiotics rose from 18% (36/200) of patients pre-intervention to 90% (208/230) in the intervention phase (p < 0.001); subsequently, reduced to 84% (208/248) post-intervention phase (p < 0.001) The documented SSI rate fell from 15% pre-intervention phase to 7% in the intervention phase (p = 0.02)
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Low-Middle Income *
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| Aitken et al., Kenya, 2013 [152] |
Intervention: Education and Engineering to develop, implement and monitor a policy within the hospital to improve post-operative prescribing of antibiotics among patients undergoing surgical operations Aim: Improve antibiotic prescribing for SAP and reduce costs
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Appreciable improvement in reducing extensive post-operative prescribing of antibiotics to 40% (18/45) of operations within the first week and just 10% (5/50) by week 6 following the policy implementation (p < 0.0001) Overall, net reduction in the costs for IV antibiotics and associated consumables used to prevent SSIs at approximately, USD 2.50/operation
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| Amdany et al., Kenya, 2014 [181] |
Intervention: Principally an educational initiative to enhance the use of oral vs. IV metronidazole including education, audit and feedback. Aim: Increase the use of oral vs. IV metronidazole
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| Ntumba et al., Kenya, 2015 [194] |
Intervention: Education and Engineering to improve the use of antibiotics in to prevent SSIs including reducing the number of patients prescribed antibiotics post-operatively. Activities included:
Local adaptation of published guidelines Creation and tools for advocacy, training, and leadership around appropriate antibiotic use to prevent SSIs
406 patients pre-intervention, 353 post-intervention Aim: Improve antimicrobial use of SAP and reduce SSI rates
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Patients receiving antibiotics post-operatively decreased from 50% to 26% Alongside this, crude SSI rates significantly decreased from 9.3% to 5% of patients
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| Ayieko et al., Kenya, 2019 [187] |
Intervention—education and engineering involving two groups, with both groups receiving a half-day training on the new Kenyan pneumonia guidelines, with physicians in all hospitals supplied with updated protocol booklets including specific pneumonia algorithms. All hospitals also received continued network support The two groups were:
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(i)
standard feedback with regular auditing and bimonthly feedback of general paediatric care and
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(ii)
enhanced feedback group—Regular auditing of agreed indicators of pneumonia care, with monthly feedback using specific feedback sheets
Overall 2299 childhood pneumonia admissions, 1087 within the hospitals randomized to enhanced feedback and 1212 to standard feedback Aim: Examined whether providing enhanced audit and feedback might accelerate adoption of new pneumonia guidelines
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An improvement was seen in the enhanced feedback group regarding the correct classification and treatment of pneumonia after each round of enhanced feedback However, the performance declined in the standard feedback arm over time, which was attributable to consistently poor performances among four out of the six participating facilities
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Allegranzi et al., Kenya, Uganda, Zambia,
and Zimbabwe, 2018 [195] |
Intervention: Education and Engineering to improve antibiotic prescribing for the prevention of SSIs Activities included: Five planned visits to each participating hospital among four African countries during the study period—supported by a range of educational tools Local teams identified key areas of concern with preventing SSIs; subsequently monitoring an agreed range of indicators (six pre-identified ones including skin preparation and optimal timing of prophylaxis) Subsequent launch of pertinent tools and agreed indicators alongside monitoring/feedback to improve future prescribing Aim: Improve antibiotic prescribing for the prevention of SSIs
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Appropriate use of antibiotics to prevent SSIs improved from 12.8% (205/1604) at baseline to 39.1% (714/1827) in the follow-up phase (p < 0.0001) among the studied hospitals Concurrently, the cumulative incidence of SSIs decreased from a baseline of 8.0% (129/1604) to 3.8% (70/1827) post intervention (p < 0.0001)
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| Abubakar et al., Nigeria, 2019 [200] |
Intervention: Principally education and engineering Activities included:
The development and dissemination of an agreed protocol—agreed before its adoption to enhance subsequent adoption rates Educational meetings held with key clinicians to enhance the uptake of agreed protocols combined with wall mounted posters Alongside this, regular audit and feedback meetings using the baseline data to try and improve future antibiotic prescribing
There were 226 and 238 surgical procedures in the pre- and post-intervention periods respectively Aim: To improve antibiotic prescribing by reducing the extent of extended prophylaxis to prevent SSIs.
|
Patients in the post-intervention period were 5.6 times more likely to receive antibiotics within 60 min before the incision to prevent SSIs vs. pre-intervention (p < 0.001) The prescribing of 3rd-generation cephalosporins for SAP was reduced from 29.2% in the pre-intervention period to 20.6% in the post-intervention period (p = 0.032). The rate of redundant antibiotic prescriptions was reduced by 19.1%—from 70.8% in the pre-intervention period to 51.7% in the post-intervention period The mean cost of SAP among patients was reduced by USD 4.2 (p < 0.001) after the interventions
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|
Upper-Middle Income *
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| Messina et al., South Africa, 2015 [177] |
Intervention: Education and Engineering with pharmacists conducting daily AMS rounds in ICUs and ICU step-down wards among 33 private hospitals in South Africa to evaluate hang-time compliance among patients A total of 32,985 patients who received day 1 IV antibiotics were assessed for hang-time compliance Hang-time compliance was seen as patients receiving appropriate antimicrobials within an hour following the prescription Aim: To evaluate the change in compliance with administering antimicrobials within an hour of the prescription after implementation of a national antibiotic stewardship pharmacist-driven hang-time process improvement protocol
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Overall hang-time compliance improved from 41.2% (164/398) pre-intervention to 78.4% (480/612) post-intervention (p < 0.0001) Post-intervention was analysed at week 60 among participating hospitals (p < 0.0001)
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| Brink et al., South Africa, 2016 [174] |
Intervention: Principally Education. Activities involved: Initial training sessions with key stakeholders in each hospital among a total of 47 hospitals discussing the five process measures that would subsequently be audited by pharmacists in each hospital were provided through face-to-face regional learning sessions Subsequently, each pharmacist was required to undertake audits of the five measures in their hospitals The five measures included: (a) Cultures not performed before starting empiric treatment; (b) prolonged treatment (7 and 14 days); (c) more than 4 antibiotics prescribed concurrently; (d) concurrent double or EUR redundant antibiotic coverage 16,662 patients on antibiotics were reviewed during the 104 weeks of standardized measurement, with 7934 interventions by pharmacists recorded for the five targeted measures Aim: Improve antibiotic prescribing including increasing culture and sensitivity testing and reducing prolonged administration
|
Combined reduction in mean antibiotic prescribing in defined daily doses/ 100 patient days—down from 101.38 to 83.04 (p < 0.0001) Reductions across participating hospitals in the number of cultures not performed before starting empiric treatment or prolonged antibiotic treatment (7 and 14 days) Reductions also in the prescribing of more than 4 antibiotics prescribed concurrently, and the prescribing of concurrent double or redundant antibiotic coverage among participating hospitals
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| Boyles et al., South Africa, 2017 [175] |
Aim: To improve future antibiotic use in the hospital |
Total antibiotic consumption fell from 1046 defined daily doses/1000 patient days (pre-intervention) to 868 (first 2 years of the intervention—remaining at similar levels for the next 2 years). Improvements driven by reductions in IV antibiotic use, particularly ceftriaxone Laboratory testing increased over the same period Cost savings on antibiotics (inflation adjusted) were ZAR3.2 million over 4 years No significant change in mortality or 30-day readmission rates over the 4 years
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| Brink et al., South Africa, 2017 [189] |
Intervention: Education and Engineering to reduce inappropriate prescribing of antibiotics to prevent SSIs. Key activities (driven by hospital pharmacists) included:
Testing and revising the developed guidelines and toolkits at pilot sites prior to their launch at regional training and institutional workshops Obtaining consensus and endorsement from key professionals within each hospital—enhanced by adapting and modifying guidelines where appropriate (building on current knowledge within each participating hospital including current SSI rates) Choosing at least one or more surgical procedures to audit—including recording pre-intervention practices and trends to demonstrate improvements Measuring compliance to agreed measures over a 4-week period and giving feedback
24,206 surgical cases were reviewed during the 70 weeks of standard measurements Aim: Implement a model utilizing existing resources in order to improve antimicrobial use for SAP in line with current guidelines among 34 hospitals in South Africa
|
Significant improvement in compliance with all process measures (composite compliance—choice, dosage, timely administration and duration) from 66.8% to 83.3% (95% CI 80.8–85.8) SSI rate decreased by 19.7% from a mean group rate of 2.46 pre-intervention to 1.97 post-intervention (p = 0.0029) Timely administration of antibiotics increased to 56.4% of surgical patients (p < 0.0001)—representing a 62.4% increase Antibiotic choice consistent with the guidelines increased to 95.9% of patients and the duration of prophylaxis was now appropriate among 93.9% of patients
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| Junaid et al., South Africa, 2018 [192] |
Intervention: Principally education in a single hospital over 3 years Key activities included:
Weekly dedicated AMS ward rounds A dedicated prescription chart with key issues including dose, frequency, duration, route of administration and possible de-escalation Audit tools for pharmacy, IPC and ward rounds, with regular multi-professional patient reviews A hospital-wide education program incorporating current principles of AMS, posters and e-training modules Infection prevention and control program monitoring
Aim: Describe the development of an institutional ASP over a 3-year period in a single hospital and its impact to provide future guidance
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Dosing considerations completed on patient’s charts improved for weight and eGFR; however, allergy entries decreased leading to additional training Education on sending of cultures prior to antibiotic commencement resulted in increased awareness of HCPs need to improve future prescribing Staff members reported increased knowledge on AMS principles following the various ASP activities
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| van den Bergh et al., South Africa, 2020 [184] |
Intervention: Principally education to improve compliance to agreed guidelines for CAP. Activities included:
A CAP bundle was developed which incorporated seven process measures, which included admission criteria, antibiotic choices, dose and length, as well as three outcome measures including length of hospital stay and mortality, which pharmacists subsequently used to audit compliance to the bundle and provide feedback Training sessions were conducted on the CAP guidelines and implementing ASPs within hospitals across South Africa. Following each learning session, a checklist of essential activities and deadlines was provided to each attending pharmacist Baseline data were collected to identify areas for improvement In a four-week period following the learning sessions, pharmacists subsequently applied the learnt ideas to improve compliance to the CAP guidelines and ways to give feedback to address identified gaps to further improve future compliance
Overall, 3117 patients were reviewed of which 2464 were included in the final analysis—1247 patients at baseline that were compared to 1217 post intervention. Aim: To improve compliance to agreed guidelines for CAP to improve future care of patients
|
2464 patients from 39 hospitals were included with the ASP showing positive results: CAP bundle compliance improved from 47.8% to 53.6% (p < 0.0001) Diagnostic stewardship compliance improved from 49.1% to 54.6% (p < 0.0001) Improved compliance with process measures was significant for 5 of the 7 components, which included choice and dose of antibiotics prescribed as well as IV to oral switching However, there was no significant difference in mortality or median length of stay pre- and post-intervention
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| Bashar et al., South Africa, 2021 [173] |
Intervention: Education and Engineering involving regular ASP ward rounds on two surgical wards During the ward rounds—each condition was discussed especially concerning antibiotic selection and laboratory investigations In addition, potential switching from intravenous to oral agents, dose optimisation and any dose adjustments in patients with renal and hepatic impairment 476 patients were involved—264 at baseline vs 212 in ASP phase Aim: Demonstrate a reduction in antibiotic usage (measured by the volume of antibiotic consumption following the ASP)—as a result improve overall antibiotic prescribing
|
Reduction in the volume of antibiotic consumption from 739.30 DDDs/1000 to 564.93 DDDs/1000 patient days following the ASP Reduction in inappropriate antibiotic use from 35% to 26% of patients An overall increase in culture targeted therapy Reduction in antibiotic administration for more than one day post operatively to prevent SSIs (from 7.3% to 6.6%) Small (non-significant reduction) in total antibiotics administered IV (from 89.4% to 84.2%) alongside an increase in appropriate IV administration from 56.9% to 60.8%
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