Background

Antimicrobial stewardship (AMS) is an important strategy to control antimicrobial resistance (AMR). Resources are available to provide guidance for the design and implementation of AMS programmes. However, these may have limited applicability in resource-limited settings, including those in Asia.

Context-specific matters for Health Care Facility (HCF)-level AMS implementation are not yet captured in the current HCF tools of the World Health Organization (WHO). Understanding implementation needs and practices within the Asian context and being able to monitor progress over time is key to assisting local healthcare facilities with improving antimicrobial use.

A context-specific assessment tool that is practical and responsive to the local conditions is needed to support institutions to start and maintain AMS programmes in Asia. This assessment tool will be complementary to the WHO tools on the national and HCF levels to provide support for hospitals in assessing their AMS status and improving the programme implementation.

Aims

1. To develop, test and validate a context-specific assessment tool of AMS programs in conjunction with the US CDC team and global partners, building from the available guidance documents and experience
2. To explore the current state of AMS implementation (the core elements, policy and practices, interventions, evaluation metrics) using an established WHO tool (national level) and the new assessment tool (hospital level) in four countries of different income status in Asia
3. To understand the existing AMS resources at the national and hospital level, support from the government (including health ministry and departments), level of training, processes and factors influencing AMS activities and interventions and perceived needs for implementation at the study hospitals in four countries
4. To determine perceived successes/ failures of AMS interventions across the hospital networks in the four countries

Outputs to Date:

Development of the assessment tools:

Developed, tested and validated two assessment tools at Wilson Medical Center (USA) and Friendship Hospital (Vietnam):

• Self-assessment for the AMS team in HCF (CORE): with 68 items, it covers five main domains, including leadership commitment and accountability; resources; education and training; antibiotic stewardship actions; and antibiotic use tracking, monitoring, and reporting.
• Knowledge, Attitude, and Perception (KAP) survey: 41 items for healthcare workers on AMS and antibiotic prescribing practices.

Implementation of the assessment tools:

• At National level:
  We evaluated the national AMS implementation status in terms of core elements in four Asian countries using the WHO National Assessment Tool on AMS Implementation. The overall state of AMS implementation at the national level of the four countries is shown in the figure below.

  

• At Healthcare facilities level:
  We evaluated the current state of AMS implementation at 16 Asian hospitals in Indonesia, Nepal, Thailand, and Vietnam using two new assessment tools. In total, 108 in-depth interviews were conducted with members of the AMS committees or those designated by the hospital leader as the ones in charge of responding to the particular AMS domains to complete all items in the CORE assessment tool for 16 hospitals. The figure below displays key findings for each domain by hospital in our network.

  

   

  Additionally, the KAP survey tool was used to collect information on knowledge, attitudes, and perceptions of AMS programs and the practice of antibiotic prescribing from health workers. Two hundred ninety-one doctors, pharmacists, microbiologists, and nurses completed and submitted their ratings in the KAP survey from 16 hospitals in the four countries.

Workshops:

On October 26, 2022, the research team hosted a virtual kick-off meeting with 102 attendees from a number of meeting rooms, joining each hospital partner and relevant stakeholders to launch the implementation phase of the project.

A national workshop on AMS implementation in Vietnam was organized on August 30, 2023, with the participation of representatives from different key stakeholders to discuss and receive feedback on the WHO’s tool at the national level and national assessment results.

At the regional workshop in Bangkok, Thailand, on September 13–14, 2023, all investigators’ team members and representatives from local partners from four countries shared the findings of the assessment and discussed the next steps to improve the assessment tools, their applicability, and approaches for improving antibiotic prescribing practices in healthcare facilities in Asia.

Reports

• National assessment report on antimicrobial stewardship implementation in Indonesia, Nepal, Thailand, and Vietnam
• Hospital assessment report on antimicrobial stewardship implementation for each hospital in the network in four countries: Indonesia, Nepal, Thailand, and Vietnam