Insights from ReAct Asia Pacific project on antibiotic stewardship in secondary level hospitals in India

2019-05-22

Healthcare facilities managed by Faith Based Organizations are vital in delivering good quality healthcare to the vast rural hinterland of Asia and Africa. In the absence of a robust primary healthcare system, secondary level hospitals often serve as the most important healthcare provider for the rural population. Implementing antibiotic stewardship in secondary level hospitals in countries like India, presents its own challenges. ReAct Asia Pacific took up the challenge to pilot antibiotic stewardship programmes in secondary level institutions managed by Faith Based Organisations - this resulted in 8 major insights.

3 short interviews – Antimicrobial Stewardship in rural India. By ReAct Asia Pacific.

Healthcare facilities managed by Faith Based Organizations (FBOs) are vital in delivering good quality healthcare to the vast rural hinterland of Asia and Africa. They have assisted the respective governments in ensuring that healthcare services reach the most under-served areas of the country. In some developing countries, the contribution of FBOs to the overall healthcare delivery reaches as high as 50%.

Most of these institutions function through a not-for-profit model; and is financed by donations and grants. Most of these donations used to come from the developed countries of Europe and North America; but the changing funding landscape is affecting the flow of money and the sustainability of these institutions. Also, governments in many developing countries now does not hold a favourable view of institutions managed by Faith Based Organizations. Even in the midst of difficulties, these healthcare facilities do a yeomen service to the society and the people they serve.

ReAct Asia Pacific pilots stewardship programmes in secondary level institutions

ReAct Asia Pacific took up the challenge to pilot antibiotic stewardship programmes in secondary level institutions, which are managed by Faith Based Organisations.

Initially a total of 9 hospitals were identified through the networks of Christian Medical Association of India, Church of South India and Catholic Health Association of India. Two representatives from each hospital were called for a capacity building workshop at Vellore, India, at the start of the project. We tried to get a medical officer and a pharmacist from each centre, but it was not possible at all instances due to staffing constraints at the hospitals.

The capacity building workshop was organized in association with the department of infectious diseases at CMC Vellore; and dealt with various aspects of antibiotic stewardship. The workshop discussed the feasibility of each intervention in secondary hospital settings and tried to form a consensus on the interventions which are sustainable.

Finally, it was decided to implement one intervention each for outpatient and inpatient settings. A protocol based management for upper respiratory tract infection was selected as the intervention among outpatients and antibiotic de-escalation was the intervention for inpatients.

The representatives went back and sensitized their colleagues about the stewardship interventions. We collected baseline data through these representatives; and looked at the rate of antibiotic prescriptions and type of antibiotics used. Follow-up was done for a total of 6 months; and compliance to the stewardship interventions were evaluated. The group was called for an evaluation workshop and their experiences were discussed. A qualitative study was done using in-depth interviews to understand the various challenges faced by them in implementing antibiotic stewardship, the successes and the perceived sustainability of the initiatives.

Project improvs understanding about antibiotic use in secondary hospitals in India

The project was instrumental in improving the understanding about antibiotic use in secondary level hospitals in India. Macrolides were the most commonly used antibiotics in outpatient setting and third generation cephalosporins were used maximally among inpatients. The success of the stewardship interventions was moderate at best; and this can be attributed to multiple systemic factors.

Insights from the project

Some of the insights obtained from the whole project are given below:

• The lack of diagnostic support is one of the major challenges for implementing antibiotic stewardship measures in secondary care settings. Having referral diagnostic facilities representing geographical facilities would be of help.
• Lack of physicians/clinical pharmacists training in infectious diseases makes implementation of classical antibiotic stewardship measures such as prospective audit and feedback difficult. However, in these settings, a senior physician with interest could take the lead for a few components of stewardship.
• There is a need to create champions within the hospital setting. Antibiotic Stewardship is a long process that requires a team effort. If the process is initiated and led by a person who is well-respected among all the relevant stakeholders in the hospital, the probability of AMS succeeding is much higher.
• In hierarchical societies and structures, there is a need to convince the leaders and prescribers about the necessity of Antibiotic Stewardship in order to ensure the success of the implementation efforts in the short term.
• Many smaller hospitals do not stock many expensive antibiotics due to financial issues. Many facilities do not have Carbapenems or Polymyxins in their pharmacy. If a patient requires the same, he/she is referred to a tertiary care centre. This functions as a type of formulary restriction but also raises the issue of access.
• In many cases, prescribers attribute antibiotic misuse to patient pressure. ‘Pressure’ is mostly perceived and the demand for antibiotics is rarely verbalized by patients. There is a need to educate both patients and prescribers about antibiotic use consequences and as well as prescriber strategies to educate the patient.
• Some of the hospitals were in the process of accreditation mainly due to requirements of insurance coverage. Though the robustness of Antibiotic Stewardship for such reasons tends to be suboptimal, it helps to create the structures essential for implementation at a later stage.
• Antibiotic stewardship implementation in hospitals with well functional infection control committees is easier. Services of a hospital infection control nurse complements the functions of the stewardship team. Therefore the establishment of a hospital infection control team should precede AMS rollout especially in the LMIC contexts.

Absence of robust primary healthcare system

In the absence of a robust primary healthcare system, secondary level hospitals often serve as the most important healthcare provider for the rural population. In many regional settings, the politicians and the administrators are still not convinced about investing in primary care and therefore there is a state of perennial neglect of primary health initiatives. Secondary level institutions are often promoted as a panacea for all health problems in the community; and this effectively destroys any rudimentary referral systems which are in place.

In countries like India, secondary level hospitals handle a large number of patients and are bursting at its seams. They are usually understaffed and under-resourced; and this brings down the quality of healthcare delivery. Healthcare Associated Infection (HAI) rates tend to be very high and infection control mechanisms are often deficient. Secondary healthcare facilities managed by FBOs often handle a huge patient load, that too under severe capacity constraints. Increasing their capacity to improve hygiene, reduce HAIs and rationalize antibiotic prescriptions form a very important aspect of any country level antibiotic stewardship programmes.

Challenging to implement antibiotic stewardship

Implementing antibiotic stewardship in secondary level hospitals in countries like India, presents its own challenges. The resource constraints, lack of trained personnel and the huge work load makes it difficult to convince the hospital administrators about the need for stewardship programmes. Also, most of the existing antibiotic stewardship models are based on tertiary care institutions which are well resourced. The adaption of stewardship processes to secondary level settings require pilot projects which can help us identify the best approach to be taken. Also, it is very important to document the various challenges faced by these institutions during the process of implementation.