At the institutional level, hospitals are a key focal point for intervention. In hospital settings, seriously ill patients present, often requiring immediate treatment with broad-spectrum antibiotics before a diagnosis of bacterial infection or drug resistance testing can be completed. Bacterial infections may affect any organ in the human body–e.g., lungs (pneumonia), kidneys and bladder (urinary tract infection), or bloodstream (sepsis). The testing for bacterial infection and whether the infection is resistant to first-line antibiotics used for treatment depends on the hospital having reliable laboratory facilities. Antibiotics used in the hospital setting, unlike most outpatient treatment, may be administered parenterally or intravenously instead of being taken orally. If a bacterial infection is resistant to first-line antibiotics, an alternative or second-line antibiotic regimen may be used. Antibiotics may be used in combination to cover the range of potential infections until a laboratory diagnosis is made.
Challenges can include stockouts of second-line antibiotics to treat drug-resistant infections, unaffordability of antibiotic treatments, the lack of appropriate local treatment guidelines, the lack of adequate microbiology facilities, the failure to provide lab-based, audit-and-feedback to guide clinicians, and difficulties in implementing infection and control procedures such as hand hygiene. Complicating this situation, fewer than two-thirds of hospitals providing surgical care in nineteen LMICs had a reliable source of water.
Various strategies are used to improve hospital antimicrobial stewardship: preauthorization of antibiotic use, formulary restriction, audit and feedback. [Chung GW, Wu JE, Yeo CL, Chan D, Hsu LY. Antimicrobial stewardship: A review of prospective audit and feedback systems and an objective evaluation of outcomes. Virulence 2013; 4(2):151-157. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654615/pdf/viru-4-151.pdf]
The impact of antimicrobial stewardship programs in hospitals might be measured by changes in the use of these drugs and savings in costs, resistance patterns and the incidence of antibiotic-related adverse effects (e.g., Clostridium difficile infection), and hospital length of stay, readmission rates and mortality. [Akpan MR, Ahmad R, Shebl NA, Ashiru-Oredope D. A Review of Quality Measures for Assessing the Impact of Antimicrobial Stewardship Programs in Hospitals. Antibiotics 2016; 5(5):1-16. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4810407/pdf/antibiotics-05-00005.pdf ]
Both enablement approaches (defined as “increasing means/reducing barriers to increase capability or opportunity”) and restriction (defined as “using rules to reduce the opportunity to engage in the target behavior) were found to increase compliance with antibiotic policies in hospitals. [Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database of Systematic Reviews 2017;(2):CD003543 doi.org/10.1002/14651858.CD003543.pub4]
At the same time, the WHO Essential Medicines List recently classified antibiotics according to how widely available or restricted such drugs should be, taking into account the risk of drug resistance. This classification system, called AWaRe, has three categories: Access, Watch and Reserve. Antibiotics in the Access category should be available to all patients in need in all facilities. Watch antibiotics pose a higher risk of resistance and should only be prescribed for specific instances. Reserve antibiotics should only be used as a last-resort when all other treatments fail. How best might one implement this approach in low-resourced settings?
Opportunities for Innovation
–What role might telehealth play in improving antimicrobial stewardship where local infectious disease consultation may not be available?
–How might the strategic use of treatment guidelines and of locally generated antibiograms improve hospital stewardship of antibiotics in resource-limited settings? [Hindler JF, Stelling J. Analysis and Presentation of Cumulative Antibiograms: A New Consensus Guideline from the Clinical and Laboratory Standards Institute. CID 2007;44: 867-873. Available at: https://academic.oup.com/cid/article/44/6/867/364325 ]
–Could innovative financing approaches or cost savings from antimicrobial stewardship programs enable insurers or hospitals to invest in these efforts? [Oberjé, E. J. M., Tanke, M. A. C., & Jeurissen, P. P. T. (2017). Antimicrobial Stewardship Initiatives Throughout Europe: Proven Value for Money. Infect Dis Rep, 9(1), 6800.]
–Are there ways to encourage best practices across a network of hospitals? [The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement 2003; 1-20.]
–How can hospital accreditation support the adoption of antimicrobial stewardship practices?