The WHO methodology for point prevalence surveys on antibiotics use in hospitals should be improved: Lessons from pilot studies in four Mexican hospitals

Healthcare-associated infections and antimicrobial use at a major referral hospital in Papua New Guinea: a point prevalence survey

Background

Healthcare-associated infections (HAI) and antimicrobial use (AMU) are drivers for antimicrobial resistance, and robust data are required to inform interventions and track changes. We aimed to estimate the prevalence of HAI and AMU at Port Moresby General Hospital (PMGH), the largest hospital in Papua New Guinea.

Methods

We did a point prevalence survey (PPS) on HAI and AMU at PMGH in May 2023 using the European Centre for Disease Prevention and Control (ECDC) PPS protocol. We included all critical care patients and randomly sampled half of the patients in other acute-care wards. We calculated weighted HAI and AMU prevalence estimates to account for this sampling strategy. Weighted HAI estimates were also calculated for an expanded definition that included physician diagnosis.

Findings

Of 361 patients surveyed in 18 wards, the ECDC protocol identified 28 HAIs in 26 patients, resulting in a weighted HAI prevalence of 6.7% (95% CI: 4.6, 9.8). Surgical site infections (9/28, 32%) were the most common HAI. When adding physician diagnosis to the ECDC definitions, more skin and soft tissue, respiratory, and bloodstream HAIs were detected, and the weighted HAI prevalence was 12.4% (95% CI: 9.4, 16.3). The prevalence of AMU was 66.5% (95%CI: 61.3, 71.2), and 73.2% (263/359) of antibiotics were from the World Health Organization Access group.

Interpretation

This is the first reported hospital PPS of HAI and AMU in Papua New Guinea. These results can be used to prioritise interventions, and as a baseline against which future point prevalence surveys can be compared.

Funding

Australian Government Department of Foreign Affairs and Trade and Therapeutic Guidelines Limited Australia.

READ-ing antimicrobial stewardship in the Caribbean: a tri-nation document review

Objective

To explore the antimicrobial stewardship policy landscape in three English-speaking Caribbean countries (Barbados, Guyana, and Saint Lucia) and examine the key enablers and challenges to the design and implementation of formal antimicrobial stewardship programs.

Methods

A document analysis that searched for existing policy, communications, and contributions on antimicrobial stewardship from these three countries, adapting the READ (Ready materials; Extract data; Analyze data; Distill findings) approach, a systematic procedure for health policy document review.

Results

The search strategy identified 726 initial records. Of those, 15 (2%) met the inclusion criteria. The analysis included official policy documents (n = 3), scholarly works/reviews (n = 3), advocacy documents (n = 2), news articles (n = 4), and confidential reports (n = 3) from the three countries.

Conclusions

Critical matters such as cross-programmatic coordination, the significance of individual action, and the need for bidirectional knowledge discourse are prominent in optimizing antimicrobial stewardship adaptation in these countries. CARICOM regional coordination has positively impacted the integration of infection prevention and control with antimicrobial stewardship across this knowledge network.

Reporting on antibiotic use patterns using the WHO Access, Watch, Reserve classification in the Caribbean

Objective

To assess antibiotic use in three hospitals in three Caribbean countries based on data from 2013 and 2018 using the World Health Organization Essential Medicines List "Access, Watch, Reserve" (AWaRe) classification.

Methods

A retrospective observational study, which analyzed the World Health Organization Point Prevalence Survey data from three hospitals in three Caribbean countries, to examine proportional AWaRe group antibiotic use for the top ten inpatient indications. The Access-to-Watch ratio was calculated, and the top three antibiotics prescribed in each hospital were determined.

Results

The final data set included 376 prescriptions for the top ten indications in 766 inpatients. The hospital antibiotic use point prevalence for Hospital 1 was 35.6%, Hospital 2 was 48.6%, and Hospital 3 was 47.1%. The Access-to-Watch ratio for the top ten indications was 2.45, 1.36, and 1.72 in the three hospitals. Access group prevalence was 71.0% in Hospital 1, 57.6% in Hospital 2, and 63.2% in Hospital 3. There were no Reserve antibiotics prescribed in any of the institutions. The most common indication for Watch prescription was skin and soft tissue infections in Hospital 1 and pneumonia in Hospital 2 and 3.

Conclusions

This study draws urgent attention to evidence of a high proportion of Watch antibiotic prescribing and lack of Reserve group antibiotics in three Caribbean countries. This research provides data that may inform national formulary and antimicrobial stewardship policy-making across the settings analyzed and the wider region.

Point prevalence survey to assess antibiotic prescribing pattern among hospitalized patients in a county referral hospital in Kenya

Antibiotic resistance causes higher morbidity and mortality and higher healthcare costs. One of the factors influencing the emergence of antibiotic resistance is the inappropriate use of antibiotics. Clinical practitioners' incorrect prescription patterns and a disregard for antibiotic usage recommendations are the leading causes of this resistance. This study examined the antibiotic prescription patterns among hospitalized patients at the Kiambu Level 5 hospital (KL5) to find potential for hospital quality improvement. This study was conducted in July 2021, and all patients hospitalized on the study day were included. The information was extracted from patient medical records using a World Health Organization Point Prevalence Survey (PPS) instrument. Anonymized data was gathered, entered, and then SPSS version 26 was used for analysis. Among the 308 surveyed patients, 191 (62%) received antibiotic medication, and 60.1% of the total were female. The pediatric ward, which had an antibiotic prescription rate of 94.1%, had the highest rate of antibiotic usage, followed by the medical ward (69.2%) and gynecological ward (65.6%). Over 40% of antibiotic prescriptions had a prophylactic medical indication. Penicillin G was the most prescribed antibiotic for community-acquired infections (32.2%), followed by 3rd generation cephalosporins (27.6%) and aminoglycosides (17.2%). Based on the AWaRe classification, 57% of the prescribed antibiotics were in the Access class while 42% were in the Watch class. Incomplete site of indication, lack of a method of administration, and length of administration are some of the conformities that were missing in the medical records. This study shows that antibiotic prescription rates are high, particularly for young patients, and there is a higher risk of antibiotic misuse. The data makes a compelling justification for using antibiotic stewardship practices in Kenyan hospitals.

Antimicrobial stewardship in Latin America: Past, present, and future

Implementation of antimicrobial stewardship programs (ASPs) in well-resourced countries has been associated with reductions in antibiotic-resistant infections and improved patient outcomes. Several guidance documents providing recommendations on how to structure antimicrobial stewardship activities at the national and hospital level in resource-limited settings have been published. However, few hospitals in Latin America report having a structure or resources needed for a successful ASP. Given the alarming increases in antimicrobial resistance in Latin America, better understanding of barriers to promote implementation of effective ASPs is urgently needed. We have summarized past and present antimicrobial stewardship activities in Latin American hospitals, and we describe key elements needed in future efforts to strengthen antimicrobial stewardship in the region.

Point prevalence survey of antibiotic use in hospitals in Latin American countries

BACKGROUND

Point prevalence surveys (PPSs) on antibiotic use are useful for understanding different aspects related to prescription patterns in hospitals.

METHODS

An adaptation of the WHO methodology for a PPS on antibiotic use was applied. Hospital wards were divided into medical (MED), surgical (SUR), ICUs, gynaecology and obstetrics (GO), high-risk (HR) and mixed wards (MIX). A web application (RedCap©) through a mobile device was used for data collection.

RESULTS

Between December 2018 and August 2019, 5444 patients in 33 hospitals in five countries were included (10 hospitals in Cuba, 7 in Paraguay, 6 in El Salvador, 5 in Mexico and 5 in Peru). Of these patients, 54.6% received at least one antibiotic, with variations between and within hospitals and countries. Antibiotics were more frequently used in ICUs (67.2%), SUR (64.5%) and MED wards (54.2%), with 51.2% of antibiotics prescribed for community-acquired infections (CAIs), 22.9% for healthcare-associated infections (HAIs), 11.1% for surgical prophylaxis and 6.1% for unknown reasons. Adherence to guidelines was observed in 68.6% of cases (72.8% for CAIs, 72.4% for HAIs and 44.3% for prophylaxis). Third-generation cephalosporins were the class of antibiotics most frequently used (26.8%), followed by carbapenems (10.3%) and fluoroquinolones (8%). Targeted treatments were achieved in 17.3% of cases.

CONCLUSIONS

Antibiotic use was generally higher than that published in other studies. There is an urgent need to promote and strengthen the antimicrobial stewardship programmes in Latin America.

Point Prevalence Survey of Antimicrobial Use in Four Tertiary Care Hospitals in Mexico

PURPOSE

To describe the antimicrobial use in four tertiary care hospitals in Mexico.

PATIENTS AND METHODS

Point prevalence surveys (PPSs) were conducted on medical records of hospitalized patients with prescribed antimicrobials (AMs) in four tertiary care hospitals in Mexico in 2019. Prevalence estimates and descriptive statistics were used to present the collected data on antimicrobial prescribing and microbiological studies.

RESULTS

The prevalence of patients with prescribed AMs among the hospitals ranged from 47.1% to 91.3%. Antibiotics for systemic use (J01s) were the most prescribed (84.6%, [95% CI: 81.5-87.3]), mainly extended-spectrum J01s: third-generation cephalosporins 19.8% [95% CI: 16.8-23.1], and carbapenems 17.0% [95% CI: 14.2-20.2]. Antibiotic treatments were largely empirical, with no planned duration or review dates. The ceftriaxone use was excessive and prolonged. No formal reference guidelines for antimicrobial prescribing were available in the hospitals. Multidrug-resistant Escherichia coli and ESKAPE pathogens were identified in all hospitals.

CONCLUSION

This study describes the extensive use of antimicrobials and broad-spectrum antibiotics for systemic use in Mexican hospitals, along with the presence of resistant pathogens to the antibiotics frequently used in the hospitals surveyed.