Supporting antimicrobial stewardship in Ghana: evaluation of the impact of training on knowledge and attitudes of healthcare professionals in two hospitals

An Assessment of the Current Level of Implementation of the Core Elements of Antimicrobial Stewardship Programs in Public Hospitals in Ghana

Introduction: Antimicrobial resistance (AMR) is becoming a threat to global public health. Antimicrobial stewardship (AMS) program (ASP) is one of the 5 strategic areas in the Ghana National Action Plan to fight this menace. Assessment of the core elements of ASP in a hospital setting has been identified as a pragmatic way of identifying the barriers and facilitators for its effective implementation. Method: The World Health Organization's toolkit for assessment of the 7 core elements of ASP in hospitals in low and middle income countries was used for this situational analysis of public hospitals in 2 regions of Ghana. The core elements included leadership commitment, accountability and responsibility, pharmacy expertize, AMS actions and interventions, education and training, and periodic monitoring and surveillance. Data collected using a checklist were imported into STATA version 14 for descriptive and bivariate analyses. Results: 15 public hospitals were assessed with the toolkit. Most of them were primary health care facilities (n = 12, 80.0%), had bed capacities between 100 and 199 beds, less than 50 medical doctors (n = 12, 80.0%), less than 5 pharmacists (n = 10, 66.7%), and between 100 and 199 nurses. Performances in 4 out of the 7 core elements were most deficient and they included leadership commitment, pharmacy expertize, AMS actions (interventions) implemented, monitoring and surveillance of antibiotic use, and bacteria resistance rates. Pharmacist-led ASPs were also found to be associated with their formal training on AMS. Key barriers identified included lack of skilled human resources, lack of available time for AMS-related duties and poor laboratory infrastructure. Conclusion: There was sub-optimal performance for almost all the core elements of ASP in the public hospitals in Ghana hampered mostly by lack of skilled human and financial resources. Pharmacists must be empowered through formal training and certificate programs in infectious disease management and AMS principles and strategies to enhance their contribution toward ASPs in hospitals. The results from this study should encourage nationwide assessment of ASPs across hospital settings in Ghana to better evaluate the level of their implementation and address potential barriers to guide AMS policies and ASP strategy development toward the fight against AMR.

Knowledge, awareness and practices of healthcare workers regarding antimicrobial use, resistance and stewardship in Zambia: a multi-facility cross-sectional study

Background

Antimicrobial resistance (AMR) poses a threat to public health globally. Despite its consequences, there is little information about the knowledge, awareness, and practices towards AMR among healthcare workers (HCWs). Therefore, this study assessed the knowledge, awareness and practices regarding antimicrobial use (AMU), AMR and antimicrobial stewardship (AMS) among HCWs who are involved in the implementation of AMS activities across eight hospitals in Zambia.

Methods

A cross-sectional study was conducted among 64 HCWs from October to December 2023 using a semi-structured questionnaire. Data were analysed using IBM SPSS version 25.0.

Results

Of the 64 HCWs, 59.4% were females, 60.9% were aged between 25 and 34 years, 37.5% were nurses, 18.7% were pharmacists, 17.2% were medical doctors and only one was a microbiologist. Overall, 75% of the HCWs had good knowledge, 84% were highly aware and 84% had good practices regarding AMU, AMR and AMS. Most of the HCWs (90.6%) responded that they had a multidisciplinary AMS team at their hospitals and were implementing the use of the WHO AWaRe classification of antibiotics.

Conclusion

This study found good knowledge levels, high awareness and good practices regarding AMU, AMR and AMS among HCWs who were involved in the implementation of AMS activities in hospitals in Zambia. Additionally, most hospitals have been conducting AMS training and implementing the use of the WHO AWaRe classification of antibiotics. However, there is still a need to address some identified gaps in AMU and AMR through the strengthening of AMS activities in hospitals.

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications

Background

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia.

Methods

A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool.

Results

Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List.

Conclusions

There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.

Antimicrobial stewardship capacity and antibiotic utilisation practices in the Cape Coast Teaching Hospital, Ghana: A point prevalence survey study

INTRODUCTION

Antimicrobial resistance (AMR) is a global threat that necessitates coordinated strategies to improve antibiotic prescribing and reduce AMR. A key activity is ascertaining current prescribing patterns in hospitals to identify targets for quality improvement programmes.

METHODS

The World Health Organisation point prevalence survey methodology was used to assess antibiotic prescribing in the Cape Coast Teaching Hospital. All core variables identified by the methodology were recorded.

RESULTS

A total of 78.8% (82/104) patients were prescribed at least one antibiotic, with the majority from adult surgical wards (52.14%). Significantly longer hospital stays were associated with patients who underwent surgery (p = 0.0423). "Access" antibiotics dominated total prescriptions (63.8%, 132/207) with ceftriaxone, cefuroxime, and ciprofloxacin being the most prescribed "Watch" antibiotics. The most common indications were for medical prophylaxis (59.8%, 49/82) and surgical prophylaxis (46.3%, 38/82). Over one-third of surgical prophylaxis (34.2%, 13/38) indications extended beyond one day. There was moderate documentation of reasons for antibiotic treatment in patient notes (65.9%, 54/82), and targeted therapy after samples were taken for antimicrobial susceptibility testing (41.7%, 10/24). Guideline compliance was low (25%) where available.

CONCLUSIONS

There was high use of antibiotics within the hospital which needs addressing. Identified quality targets include developing surgical prophylaxis guidelines, reviewing "Watch" antibiotic prescribing, and assessing antibiotic durations for patients on two or more antibiotics. Organizational-level deficiencies were also identified that need addressing to help instigate ASPs. These can be addressed by developing local prescribing protocols and antibiotic stewardship policies in this hospital and wider in Ghana and across Africa.

Antimicrobial stewardship: knowledge, attitudes and practices regarding antimicrobial use and resistance among non-healthcare students at the University of Zambia

Background

Antimicrobial resistance (AMR) poses a significant threat to the world and could become humanity's next major challenge. This study assessed non-healthcare students' knowledge, attitude and practices (KAP) towards antimicrobial use (AMU) and AMR at the University of Zambia.

Methods

This cross-sectional study was conducted among 443 non-healthcare students from August to October 2022 using a structured questionnaire. Data analysis was done using IBM SPSS version 24.0.

Results

Of the 433 participants, 55.2%, 63.5% and 45% had moderate KAP scores regarding AMU and AMR. The prevalence of self-medication with antibiotics was 76.7%. Male participants were less likely to have good knowledge (OR = 0.524, 95% CI: 0.347-0.792) and positive attitudes (OR = 0.585, 95% CI: 0.364-0.940) towards AMU and AMR compared with females. Students who were studying Engineering and Mining were more likely to have good knowledge of AMR (OR = 1.891, 95% CI: 1.197-2.987) compared with those in Social Sciences. Those who were in their fourth and fifth years were more likely to have positive attitudes towards AMU and AMR (OR = 1.851, 95% CI: 1.147-2.986) compared with those who were in the first, second and third years. Finally, students who practised self-medication were less likely to have good self-reported practice towards AMR (OR = 0.442, 95% CI: 0.278-0.702) compared with those who did not.

Conclusions

This study demonstrated that non-healthcare students had moderate KAP regarding AMU and AMR. All university students should be provided with education about AMU and AMR through free short courses, seminars, workshops, and AMR and antimicrobial stewardship awareness campaigns.

A Multicenter Cross-Sectional Survey of Knowledge, Attitude, and Practices of Healthcare Professionals towards Antimicrobial Stewardship in Ghana: Findings and Implications

Antimicrobial stewardship (AMS) programs are part of the key activities that contribute to reducing antimicrobial resistance (AMR). Good knowledge, attitudes, and practices (KAP) among healthcare professionals (HCPs) are essential to improving future antimicrobial use and reducing AMR, which is a priority in Ghana. A multicenter cross-sectional survey was conducted in six public hospitals in Ghana among key HCPs to assess their level of KAP towards AMS using a validated self-administered electronic questionnaire. Data analyses included descriptive and inferential statistics using STATA version 14. Overall, 339 out of 355 HCPs responded to the questionnaire, giving a response rate of 95.5%. Most responders were nurses (n = 256, 78.2%), followed by medical doctors (n = 45, 13.3%). The study recorded both poor knowledge (8.9%) and practice levels (35.4%), as well as a good attitude (78.8%) towards AMS. Ongoing exposure to AMS structured training, exposure to continuous professional development training on AMS in the previous year, and the number of years of working experience were predictors of the HCPs' level of knowledge (aOR = 3.02 C.I = 1.12-8.11), attitude (aOR = 0.37 C.I = 0.20-0.69) and practice (aOR = 2.09 C.I =1.09-3.99), respectively. Consequently, concentrated efforts must be made to address current low levels of knowledge and poor practices regarding AMS among HCPs in Ghana as part of ongoing strategies in the National Action Plan to reduce AMR.

Evaluation of Healthcare Students' Knowledge on Antibiotic Use, Antimicrobial Resistance and Antimicrobial Stewardship Programs and Associated Factors in a Tertiary University in Ghana: Findings and Implications

Antimicrobial resistance (AMR) is a major public health problem globally, and Ghana is no exception. Good knowledge regarding antibiotic use, AMR, and the concept of antimicrobial stewardship (AMS) is critical among healthcare students to curb rising AMR rates in the future. Consequently, a need to ascertain this. A cross-sectional survey was undertaken among fifth-year pharmacy, medical students and fourth (final)-year nursing and physician assistantship students at the University of Health and Allied Sciences in Ghana to assess their knowledge on antibiotic use, AMR and AMS using a web-based self-administered structured questionnaire. Descriptive statistics, Fishers’ exact test, and multiple logistic regression analyses were performed. A total of 160 healthcare students were interviewed, of which 56.3% (n = 90) were male and 58.8% (n = 94) were in their fourth year of study. Good knowledge of antibiotic use, AMR, and AMS was associated with the study course (p = 0.001) and the number of years of study (p < 0.001). Overall, there were differences in the level of knowledge of antibiotics among the different healthcare students and their years of study. Efforts must now be made to enhance the curricula to ensure an improved and uniform transfer of knowledge of antibiotics, AMR, and AMS among the different healthcare students to sustain the fight against AMR in Ghana given growing concerns.

Appropriateness of surgical antimicrobial prophylaxis in a teaching hospital in Ghana: findings and implications

Background

Surgical site infections (SSIs) are among the most common infections seen in hospitalized patients in low- and middle-income countries (LMICs), accounting for up to 60% of hospital-acquired infections. Surgical antimicrobial prophylaxis (SAP) has shown to be an effective intervention for reducing SSIs and their impact. There are concerns of inappropriate use of SAP in Ghana and therefore our audit in this teaching hospital.

Methods

A retrospective cross sectional clinical audit of medical records of patients undergoing surgery over a 5 month duration from January to May 2021 in Ho Teaching Hospital. A data collection form was designed to collect key information including the age and gender of patients, type and duration of surgery, choice and duration of SAP. The collected data was assessed for the proportion of SAP compliance with Ghana Standard Treatment Guidelines (STGs) and any association with various patient, surgical wound and drug characteristics.

Results

Of the 597 medical records assessed, the mean age of patients was 35.6 ± 12.2 years with 86.8% (n = 518) female. Overall SAP compliance with the STG was 2.5% (n = 15). SAP compliance due to appropriate choice of antimicrobials was 67.0% (n = 400) and duration at 8.7% (n = 52). SAP compliance was predicted by duration of SAP (P < 0.000) and postoperative hospitalization duration (P = 0.005).

Conclusions

SAP compliance rate was suboptimal, principally due to a longer duration of prescription. Quality improvement measures such as education of front-line staff on guideline compliance, coupled with clinical audit and regular updates, are urgently needed to combat inappropriate prescribing and rising resistance rates.

Prevalence of bacterial coinfection and patterns of antibiotics prescribing in patients with COVID-19: A systematic review and meta-analysis

Background

Evidence around prevalence of bacterial coinfection and pattern of antibiotic use in COVID-19 is controversial although high prevalence rates of bacterial coinfection have been reported in previous similar global viral respiratory pandemics. Early data on the prevalence of antibiotic prescribing in COVID-19 indicates conflicting low and high prevalence of antibiotic prescribing which challenges antimicrobial stewardship programmes and increases risk of antimicrobial resistance (AMR).

Aim

To determine current prevalence of bacterial coinfection and antibiotic prescribing in COVID-19 patients.

Data source

OVID MEDLINE, OVID EMBASE, Cochrane and MedRxiv between January 2020 and June 2021.

Study eligibility

English language studies of laboratory-confirmed COVID-19 patients which reported (a) prevalence of bacterial coinfection and/or (b) prevalence of antibiotic prescribing with no restrictions to study designs or healthcare setting.

Participants

Adults (aged ≥ 18 years) with RT-PCR confirmed diagnosis of COVID-19, regardless of study setting.

Methods

Systematic review and meta-analysis. Proportion (prevalence) data was pooled using random effects meta-analysis approach; and stratified based on region and study design.

Results

A total of 1058 studies were screened, of which 22, hospital-based studies were eligible, compromising 76,176 of COVID-19 patients. Pooled estimates for the prevalence of bacterial co-infection and antibiotic use were 5.62% (95% CI 2.26–10.31) and 61.77% (CI 50.95–70.90), respectively. Sub-group analysis by region demonstrated that bacterial co-infection was more prevalent in North American studies (7.89%, 95% CI 3.30–14.18).

Conclusion

Prevalence of bacterial coinfection in COVID-19 is low, yet prevalence of antibiotic prescribing is high, indicating the need for targeted COVID-19 antimicrobial stewardship initiatives to reduce the global threat of AMR.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

Evaluation of antibiotic prescribing for ambulatory patients seeking primary dental care services in a public hospital in Ghana: a clinical audit study

Background

One in 10 of all antibiotic prescriptions globally are for dental conditions with 80% of them being inappropriate, making it a potential driver of antimicrobial resistance.

Objectives

To evaluate the appropriateness of antibiotic use among ambulatory patients seeking dental care services in a public hospital in Ghana.

Methods

A retrospective clinical audit was conducted by extracting the medical records of all patients seeking dental care at the ambulatory care clinic of Keta Municipal Hospital (KMH) from January 2020 to December 2020 using the hospital’s electronic database. Descriptive statistics, bivariate and multivariate analysis were performed on the data collected.

Results

Overall, 1433 patient medical records were extracted from the database within the study period. The mean age of the patients identified was 39.9 years with almost two-thirds being female. The majority (91.1%, n = 1306) of them were attended to by a dental nurse. In total, 88.6% (n = 1269) of the patients received antibiotics and 87.5% (n = 1254) of antibiotics prescribed were non-compliant with Ghana Standard Treatment Guidelines. Three-quarters of the dental conditions were managed with dual antibiotics comprising amoxicillin and metronidazole. Antibiotic prescription was associated with age, gender, type of prescriber and type of dental condition diagnosed.

Conclusions

There is a high usage of antibiotics for dental conditions managed at the outpatient section of the hospital and most are inappropriate. Development of local guidelines supported by education of dental clinicians on empirical use of antibiotics is a suitable target for the antimicrobial stewardship team to address in KMH.

Management of Children Admitted to Hospitals across Bangladesh with Suspected or Confirmed COVID-19 and the Implications for the Future: A Nationwide Cross-Sectional Study

There is an increasing focus on researching children admitted to hospital with new variants of COVID-19, combined with concerns with hyperinflammatory syndromes and the overuse of antimicrobials. Paediatric guidelines have been produced in Bangladesh to improve their care. Consequently, the objective is to document the management of children with COVID-19 among 24 hospitals in Bangladesh. Key outcome measures included the percentage prescribed different antimicrobials, adherence to paediatric guidelines and mortality rates using purposely developed report forms. The majority of 146 admitted children were aged 5 years or under (62.3%) and were boys (58.9%). Reasons for admission included fever, respiratory distress and coughing; 86.3% were prescribed antibiotics, typically parenterally, on the WHO ‘Watch’ list, and empirically (98.4%). There were no differences in antibiotic use whether hospitals followed paediatric guidance or not. There was no prescribing of antimalarials and limited prescribing of antivirals (5.5% of children) and antiparasitic medicines (0.7%). The majority of children (92.5%) made a full recovery. It was encouraging to see the low hospitalisation rates and limited use of antimalarials, antivirals and antiparasitic medicines. However, the high empiric use of antibiotics, alongside limited switching to oral formulations, is a concern that can be addressed by instigating the appropriate programmes.

Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction

Antimicrobial resistance (AMR) is a growing problem worldwide, including South Africa, where an AMR National Strategy Framework was implemented to instigate antimicrobial stewardship programmes (ASPs) and improve antimicrobial prescribing across sectors. To address the need to assess progress, a sequential mixed methodology with an explanatory research design was employed. In Phase 1, a self-administered questionnaire was completed by healthcare professionals (HCPs) from 26 public sector healthcare facilities across South Africa to assess compliance with the Framework. The results were explored in Phase 2 through 10 focus group discussions and two in-depth interviews, including 83 participants. Emerging themes indicated that public healthcare facilities across South Africa are facing many challenges, especially at entry level primary healthcare (PHC) facilities, where antimicrobial stewardship activities and ASPs are not yet fully implemented. Improved diagnostics and surveillance data are a major shortcoming at these facilities. Continuous education for HCPs is deficient, especially for the majority of prescribers at PHC level and health campaigns are nearly non-existent. Involvement and visibility of management at certain facilities is a serious shortfall. Consequently, it is important to call attention to the challenges faced with improving antimicrobial prescribing across countries and address these to reduce AMR, especially in PHC facilities, being the first point of access to healthcare for the vast majority of patients in developing countries.

Practical Pharmacist-Led Interventions to Improve Antimicrobial Stewardship in Ghana, Tanzania, Uganda and Zambia

The World Health Organisation (WHO) and others have identified, as a priority, the need to improve antimicrobial stewardship (AMS) interventions as part of the effort to tackle antimicrobial resistance (AMR). An international health partnership model, the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme, was established between selected countries in Africa (Ghana, Tanzania, Zambia and Uganda) and the UK to support AMS. This was funded by UK aid under the Fleming Fund and managed by the Commonwealth Pharmacists Association (CPA) and Tropical Health and Education Trust (THET). The primary aims were to develop local AMS teams and generate antimicrobial consumption surveillance data, quality improvement initiatives, infection prevention and control (IPC) and education/training to reduce AMR. Education and training were key components in achieving this, with pharmacists taking a lead role in developing and leading AMS interventions. Pharmacist-led interventions in Ghana improved access to national antimicrobial prescribing guidelines via the CwPAMS mobile app and improved compliance with policy from 18% to 70% initially for patients with pneumonia in one outpatient clinic. Capacity development on AMS and IPC were achieved in both Tanzania and Zambia, and a train-the-trainer model on the local production of alcohol hand rub in Uganda and Zambia. The model of pharmacy health partnerships has been identified as a model with great potential to be used in other low and middle income countries (LMICs) to support tackling AMR.