Challenges Faced by Health Facilities in Implementing Antimicrobial Stewardship Program: A Narrative Review

  • Shikha Yadav Master of Public Health, Department of Preventive and Social Medicine, JIPMER Puducherry, India.
  • Mayank Sharma Master of Public Health, Department of Preventive and Social Medicine, JIPMER Puducherry, India.
  • Kavita Rajesh Epidemiology Division, National Centre for Disease Control, New Delhi, India.
  • Priyanka Khuda Epidemiology Division, National Centre for Disease Control, New Delhi, India.
  • Shailja Anand Epidemiology Division, National Centre for Disease Control, New Delhi, India.
  • Vibhor Dudhraj Epidemiology Division, National Centre for Disease Control, New Delhi, India.
  • Suneet Kaur Epidemiology Division, National Centre for Disease Control, New Delhi, India.
  • Arti Bahl Epidemiology Division, National Centre for Disease Control, New Delhi, India
  • Sujeet Kumar Singh National Centre for Disease Control, New Delhi, India.
Keywords: Antimicrobial Resistance, “Drug Resistance, Microbial,” Infection Control, Antimicrobial Stewardship, Delivery of Health Care

Abstract

Background: Antimicrobial Resistance (AMR) has become a significant world-wide health problem. Antimicrobial use though necessary, overusing/misusing can have detrimental long-term effects. Managing AMR involves a lot of challenges, therefore appropriate strategies must be developed to overcome them.

Methods: We conducted a comprehensive search using web‑based search engines employing a combination of search terms. The search yielded 404 papers between 2000 and 2021. We took up Forty-four papers fulfilling the inclusion-exclusion criteria for review.

Results: The challenges identified from studies in implementing the Antimicrobial Stewardship Program (AMSP) include the administration’s lack of knowledge, a deficit of resources, staff turnover, resistance to change, delay in Culture and Drug Sensitivity Testing (CDST), inadequate training, patient expectations, and insufficient Electronic Medical Records (EMR).

Conclusion: Antimicrobial resistance is a growing public health concern that all stakeholders must address. Improvements in antimicrobial consumption reporting and locally tailored guidelines can help to ensure successful implementation.

How to cite this article:
Yadav S, Sharma M, Rajesh K, Khuda P, Anand S, Dudhraj V, Kaur S, Bahl A, Singh SK. Challenges Faced by Health Facilities in Implementing Antimicrobial Stewardship Program: A Narrative Review. Epidem Int. 2022;7(4):27-36.

DOI: https://doi.org/10.24321/2455.7048.202218

References

Hutchings MI, Truman AW, Wilkinson B. Antibiotics: past, present and future. Current Opinion in

Microbiology. 2019;1;51:72-80.

AMR Review Paper - Tackling a crisis for the healthand wealth of nations_1.pdf [Internet]. [cited 2022

Aug 1]. Available from: https://amr-review.org/sites/default/files/AMR%20Review%20Paper%20-%20

Tackling%20a%20crisis%20for%20the%20health%20and%20wealth%20of%20nations_1.pdf

The-State-of-the-Worlds-Antibiotics-in-2021.pdf [Internet]. [cited 2022 Jul 15]. Available from: https://

cddep.org/wp-content/uploads/2021/02/The-Stateof-the-Worlds-Antibiotics-in-2021.pdf

Antimicrobial resistance [Internet]. [cited 2022 Jul 14]. Available from: https://www.who.int/news-room/

fact-sheets/detail/antimicrobial-resistance 5. CDC. What Exactly is Antibiotic Resistance? [Internet].

Centers for Disease Control and Prevention. 2022 [cited 2022 Jul 14]. Available from: https://www.cdc.

gov/drugresistance/about.html

Sharma A. National Action Plan on Antimicrobial Resistance. 57.

9789289054980-eng.pdf [Internet]. [cited 2022 Jul 28]. Available from: https://apps.who.int/iris/bitstream/ha

ndle/10665/340709/9789289054980-eng.pdf

World Health Organization. Antimicrobial stewardship programmes in health-care facilities in low- and

middle-income countries: a WHO practical toolkit [Internet]. World Health Organization; 2019 [cited

Jul 14];71. Available from: https://apps.who.int/iris/handle/10665/329404

Baraka MA, Alsultan H, Alsalman T, Alaithan H, Islam MdA, Alasseri AA. Health care providers’ perceptions

regarding Antimicrobial Stewardship Programs (AMS) implementation-facilitators and challenges: a crosssectional study in the Eastern province of Saudi Arabia. Ann Clin Microbiol Antimicrob. 2019;24;18:26.

Sayegh N, Hallit S, Hallit R, Saleh N, Zeidan RK. Physicians’ attitudes on the implementation of an antimicrobial stewardship program in Lebanese hospitals. Pharm Pract (Granada). 2021;19(1):2192.

Alghamdi S, Atef-Shebl N, Aslanpour Z, Berrou I. Barriers to implementing antimicrobial stewardship

programmes in three Saudi hospitals: Evidence from a qualitative study. J Glob Antimicrob Resist.

;18:284-90.

Nassar H, Abu-Farha R, Barakat M, Alefishat E. Antimicrobial Stewardship from Health Professionals’

Perspective: Awareness, Barriers, and Level of Implementation of the Program. Antibiotics [Internet].

;11(1). Available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85123255694&doi=10.

%2fantibiotics11010099&partnerID=40&md5=dced17fd355f3cc0f13da009d52e3767

Gebretekle GB, Haile Mariam D, Abebe W, Amogne W, Tenna A, Fenta TG. Opportunities and barriers to

implementing antibiotic stewardship in low and middleincome countries: Lessons from a mixed-methods

study in a tertiary care hospital in Ethiopia. PLoS One. 2018;20;13(12):e0208447.

Chen AW, Khumra S, Eaton V, Kong DC. Snapshot of Barriers to and Indicators for Antimicrobial Stewardship

in Australian Hospitals. Journal of Pharmacy Practice and Research. 2011;41(1):37-41.

Elligsen M, Walker SAN, Simor A, Daneman N. Prospective Audit and Feedback of Antimicrobial

Stewardship in Critical Care: Program Implementation, Experience, and Challenges. Can J Hosp Pharm.

;65(1):31-6.

Black EK, MacDonald L, Neville HL, Abbass K, Slayter K, Johnston L. Health Care Providers’ Perceptions

of Antimicrobial Use and Stewardship at Acute Care Hospitals in Nova Scotia. Can J Hosp Pharm.

;72(4):263-70.

Ji W, Hayat K, Ye D, McIver DJ, Yan K, Kadirhaz M. Antimicrobial Stewardship Programs in Northwest

China: A Cross-Sectional Survey of Perceptions, Involvement, and Perceived Barriers Among Hospital

Pharmacists. Frontiers in Pharmacology [Internet]. 2021 [cited 2022 Aug 6];12. Available from: https://www.

frontiersin.org/articles/10.3389/fphar.2021.616503

Baubie K, Shaughnessy C, Kostiuk L, Joseph MV, Safdar N, Singh SK. Evaluating antibiotic stewardship in a

tertiary care hospital in Kerala, India: a qualitative interview study. BMJ Open. 2019;1;9(5):e026193.

Nampoothiri V, Sudhir AS, Joseph MV, Mohamed Z, Menon V, Charani E, et al. Mapping the Implementation

of a Clinical Pharmacist-Driven Antimicrobial Stewardship Programme at a Tertiary Care Centre in

South India. Antibiotics (Basel). 2021;23;10(2):220.

Bhattacharya S, Joy VM, Goel G, Nath SR, Santosh S, George K. Antimicrobial stewardship programme -

from policies to practices: A survey of antimicrobial stewardship programme practices from 25 centres in

India. Journal of The Academy of Clinical Microbiologists. 2019;1;21(1):4.

Howard P, Pulcini C, Levy Hara G, West RM, Gould IM, Harbarth S, et al. An international cross-sectional

survey of antimicrobial stewardship programmes in hospitals. J Antimicrob Chemother. 2015;70(4):1245-

Perozziello A, Routelous C, Charani E, Truel A, Birgand G, Yazdanpanah Y, et al. Experiences and perspectives

of implementing antimicrobial stewardship in five French hospitals: a qualitative study. Int J Antimicrob

Agents. 2018;51(6):829-35.

Limato R, Broom A, Nelwan EJ, Hamers RL. A qualitative study of barriers to antimicrobial stewardship in

Indonesian hospitals: governance, competing interests, cost, and structural vulnerability. AntimicrobialResistance & Infection Control. 2022;14;11(1):85.

Wong LH, Tay E, Heng ST, Guo H, Kwa ALH, Ng TM. Hospital Pharmacists and Antimicrobial Stewardship:

A Qualitative Analysis. Antibiotics (Basel). 2021;24;10(12):1441.

Lai WM, Islahudin FH, Ambaras Khan R, Chong WW. Pharmacists’ Perspectives of Their Roles in

Antimicrobial Stewardship: A Qualitative Study among Hospital Pharmacists in Malaysia. Antibiotics (Basel).

;9;11(2):219.

Livorsi DJ, Stewart Steffensmeier KR, Perencevich EN, Goetz MB, Schacht Reisinger H. Antibiotic stewardship

implementation at hospitals without on-site infectious disease specialists: A qualitative study. Infect Control

Hosp Epidemiol. 2022 May;43(5):576-81.

Hayat K, Rosenthal M, Gillani AH, Zhai P, Aziz MM, Ji W. Perspective of Pakistani Physicians towards Hospital

Antimicrobial Stewardship Programs: A Multisite Exploratory Qualitative Study. Int J Environ Res Public

Health. 2019;16(9):1565.

Frost HM, Andersen LM, Fleming-Dutra KE, Norlin C, Czaja CA. Sustaining outpatient antimicrobial

stewardship: Do we need to think further outside the box? Infect Control Hosp Epidemiol. 2020;41(3):382-4.

Mathew P, Ranjalkar J, Chandy SJ. Challenges in Implementing Antimicrobial Stewardship Programmes

at Secondary Level Hospitals in India: An Exploratory Study. Front Public Health. 2020;8:493904.

Verma M, Shafiq N, Tripathy JP, Nagaraja SB, Kathirvel S, Chouhan DK. Antimicrobial stewardship programme

in a trauma centre of a tertiary care hospital in North India: Effects and implementation challenges. J Glob

Antimicrob Resist. 2019;17:283-90.

Setiawan E, Cotta MO, Abdul-Aziz MH, Sosilya H, Widjanarko D, Wardhani DK. Indonesian healthcare

providers’ perceptions and attitude on antimicrobial resistance, prescription and stewardship programs.

Future Microbiol. 2022;17:363-75.

Mauffrey V, Kivits J, Pulcini C, Boivin JM. Perception of acceptable antibiotic stewardship strategies in

outpatient settings. Med Mal Infect. 2016;46(6):285-93.

Park S, Kang JE, Choi HJ, Kim CJ, Chung EK, Kim SA. Antimicrobial Stewardship Programs in Community

Health Systems Perceived by Physicians and Pharmacists: A Qualitative Study with Gap Analysis.

Antibiotics (Basel). 2019;5;8(4):252.

Rizvi T, Thompson A, Williams M, Zaidi STR. Validation and Implementation of a National Survey to Assess

Antimicrobial Stewardship Awareness, Practices and Perceptions amongst Community Pharmacists of

Australia. Journal of Global Antimicrobial Resistance [Internet]. 2019 [cited 2022 Jul 27]; Available from:

https://eprints.utas.edu.au/32040/

Howell CK, Jacob J, Mok S. Remote Antimicrobial Stewardship: A Solution for Meeting The Joint

Commission Stewardship Standard? Hosp Pharm. 2019;54(1):51-6.

Jeffs L, McIsaac W, Zahradnik M, Senthinathan A, Dresser L, McIntyre M, et al. Barriers and facilitators

to the uptake of an antimicrobial stewardship program in primary care: A qualitative study. PLoS One.

;5;15(3):e0223822.

Mbugua SM, Njoroge G, Kijogi C, Kamita M, Kimani R, Mwaura P. Exploring perspectives on antimicrobial

stewardship: a qualitative study of health managers in Kenya. Global Health Research and Policy.

;17;5(1):49.

Skodvin B, Aase K, Charani E, Holmes A, Smith I. An antimicrobial stewardship program initiative: a

qualitative study on prescribing practices among hospital doctors. Antimicrob Resist Infect Control.

;4:24.

Abubakar U. Practices and Perception of Nigerian Community Pharmacists towards Antimicrobial

Stewardship Program. International Journal of Pharmacy and Pharmaceutical Sciences. 2020;1;37-42.

Singh S, Menon VP, Mohamed ZU, Kumar VA, Nampoothiri V, Sudhir S. Implementation and Impact

of an Antimicrobial Stewardship Program at a Tertiary Care Center in South India. Open Forum Infect Dis.

;6(4):ofy290.

Badar V, Parulekar VV, Garate P. Study of knowledge, attitude and practice amongst medical professionals

about antimicrobial stewardship in a tertiary care teaching hospital in India: a questionnaire-based study.

International Journal of Basic & Clinical Pharmacology. 2018;22;7(3):511-7.

Singh S, Charani E, Wattal C, Arora A, Jenkins A, Nathwani D. The State of Education and Training

for Antimicrobial Stewardship Programs in Indian Hospitals-A Qualitative and Quantitative Assessment.

Antibiotics (Basel). 2019;30;8(1):E11.

Saleh D, Abu-Farha R, Mukattash TL, Barakat M, Alefishat E. Views of Community Pharmacists on Antimicrobial Resistance and Antimicrobial Stewardship in Jordan: A Qualitative Study. Antibiotics (Basel). 2021;3;10(4):384.

Emberger J, Tassone D, Stevens MP, Markley JD. The Current State of Antimicrobial Stewardship: Challenges,

Successes, and Future Directions. Curr Infect Dis Rep. 2018;29;20(9):31.

Broom A, Gibson A. Optimising Antibiotic Usage in Hospitals: A Qualitative Study of the Perspectives

of Hospital Managers. Journal of Hospital Infection. 2016;1;94.

Atif M, Asghar S, Mushtaq I, Malik I. Community pharmacists as antibiotic stewards: A qualitative studyexploring the current status of Antibiotic Stewardship Program in Bahawalpur, Pakistan. Journal of Infection

and Public Health. 2020;1;13(1):118-24.

Kakkar AK, Shafiq N, Singh G, Ray P, Gautam V, Agarwal R. Antimicrobial Stewardship Programs in

Resource Constrained Environments: Understanding and Addressing the Need of the Systems. Front Public

Health. 2020;28;8:140.

Rolfe R. Barriers to implementing antimicrobial stewardship programs in three low- and middle-income

country tertiary care settings: findings from a multisite qualitative study | Antimicrobial Resistance &

Infection Control | Full Text [Internet]. [cited 2022 Aug 8]. Available from: https://aricjournal.biomedcentral.

com/articles/10.1186/s13756-021-00929-4

Alghamdi S, Berrou I, Bajnaid E, Aslanpour Z, Haseeb A, Hammad MA, et al. Antimicrobial Stewardship Program Implementation in a Saudi Medical City: An Exploratory Case Study. Antibiotics (Basel). 2021;9;10(3):280.

Gautham M, Spicer N, Chatterjee S, Goodman C. What are the challenges for antibiotic stewardship at the

community level? An analysis of the drivers of antibiotic provision by informal healthcare providers in rural

India. Soc Sci Med. 2021;275:113813.

Takamatsu A, Yao K, Murakami S, Tagashira Y, Hasegawa S, Honda H. Barriers to Adherence to Antimicrobial

Stewardship Postprescription Review and Feedback For Broad-Spectrum Antimicrobial Agents: A Nested Case-

Control Study. Open Forum Infect Dis. 2020;17;7(8):of aa298.

Ravi N, Laha A, Hmar L, Chatterjee S, Goswami J, Goel G. Exploring the Prescribing Behaviours and the Mind

of Antibiotic Prescribers are Critical for a Successful Antibiotic Stewardship Programme: Results of a

Survey from Eastern India. Indian Journal of Medical Microbiology. 2017;1;35.

Wilcock M. Antimicrobial stewardship and the hospital nurse and midwife: how do they perceive their role?

| European Journal of Hospital Pharmacy [Internet]. [cited 2022 Aug 8]. Available from: https://ejhp.bmj.

com/content/26/2/89

Niwa T, Shinoda Y, Suzuki A, Ohmori T, Yasuda M, Ohta H. Outcome measurement of extensive implementation of antimicrobial stewardship in patients receiving intravenous antibiotics in a Japanese university hospital. Int J Clin Pract. 2012;66(10):999-1008.

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;15;4(2):151-7.

Kakkar M, Walia K, Vong S, Chatterjee P, Sharma A. Antibiotic resistance and its containment in India. BMJ.

;5;358:j2687.

Burgess LH, Miller K, Cooper M, Moody J, Englebright J, Septimus E. Phased implementation of an antimicrobial stewardship program for a large community hospital system. Am J Infect Control. 2019;47(1):69-73.

Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and

issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect

Dis. 2020;19;7:2049936120933187.

The Core Elements of Hospital Antibiotic Stewardship Programs. 40.

Magedanz L, Silliprandi EM, dos Santos RP. Impact of the pharmacist on a multidisciplinary team in

an antimicrobial stewardship program: a quasiexperimental study. Int J Clin Pharm. 2012;34(2):290-4.

Lee KR, Bagga B, Arnold SR. Reduction of Broad-Spectrum Antimicrobial Use in a Tertiary Children’s

Hospital Post Antimicrobial Stewardship Program Guideline Implementation. Pediatr Crit Care Med.

;17(3):187-93.

Seto WH, Ching TY, Kou M, Chiang SC, Lauder IJ, Kumana CR. Hospital antibiotic prescribing was successfully

modified by “immediate concurrent feedback.†Br J Clin Pharmacol. 1996;41(3):229-34.

Dyar OJ, Pagani L, Pulcini C. Strategies and challenges of antimicrobial stewardship in long-term care facilities. Clin Microbiol Infect. 2015;21(1):10-9.

Jawhari B, Keenan L, Zakus D, Ludwick D, Isaac A, Saleh A. Barriers and facilitators to Electronic Medical Record (EMR) use in an urban slum. International Journal of Medical Informatics. 2016;1;94:246-54.

Leung E, Weil DE, Raviglione M, Nakatani H, World Health Organization World Health Day Antimicrobial

Resistance Technical Working Group. The WHO policy package to combat antimicrobial resistance. Bull World

Health Organ. 2011;1;89(5):390-2.

Fridkin SK, Srinivasan A. Implementing a strategy for monitoring inpatient antimicrobial use among hospitals

in the United States. Clin Infect Dis. 2014;58(3):401-6.

Published
2023-04-11