Antimicrobial stewardship programs in health facilities: A behavioral science approach
Background
The rising threat of AMR calls for a strong and structured Antimicrobial Stewardship (AMS) to regulate antimicrobial use. India is at the epicentre of the AMR crisis with the problem being compounded by a complex interplay of factors such as rapid industrial and pharmaceutical development, policy infrastructure, rationing/ purchasing of health care and diverse economic and social dynamics. With multiple factors at play, AMR becomes a social problem too, demanding a strong AMS infrastructure. Effective leadership, accountability and efficient tracking mechanisms can be key to boosting stewardship success.
About the Study
The study aims to understand antibiotic prescribing and dispensing practices in health facilities across India and to assess the barriers and enablers with an aim to promote behavioural change regarding these practices.
Methodology
The study used an explorative qualitative design wherein besides the extensive literature review, semi-structured interviews with various stakeholders were also conducted. Through the extensive literature review and expert interviews initially, important components of the study were outlined such as hospital classification, AMS components relevant to LMICs, factors affecting AMS, identifying relevant stakeholders to interview and creating interview guides. The interview guides were then tested to ensure they were built to cover comprehensive information.
Thereafter, these interview guides were used to conduct interviews with clinicians, nurses, microbiologists, clinical pharmacists and administrators from several hospitals of various sizes in 11 locations across India.
Outcome
Some key insights relating to hospital staff behaviour were identified that can influence prescribing practices throughout the continuum of care across hospitals of all sizes.
- Engaging prescribers in antimicrobial therapy reviews. This will facilitate first hand education for them and empower them to make more informed prescriptions while preserving their autonomy as prescribers.
- Robust AMS system in place with a dedicated internal/ external AMS champion can ensure better vigilance and communication between prescribers and other stakeholders.
- Education of all concerned stakeholders to align their understanding and actions on antimicrobials
- Implementation of a ‘Four Moments Framework’ can be a way forward. Pauses structured around four key moments in the prescribing and treatment cycle can be a game changer. Moment 1 corresponds to the assessment for prescription- whether or not the prescription is truly required. Moment 2 will be obtaining culture data prior to antibiotic treatment to gauge the efficacy of the treatment while Moment 3 is de-escalation wherein the prescriber can be nudged by pharmacists/ nurses to revise the treatment decision- from IV to oral, need for continuity of the regimen, dosage within a few days of start. Moment 4 will deal with treatment duration, with focus on shortening the duration as much as is optimal.