An ASP implementation in district hospitals in Sarawak without clinical specialist: A 4 years data on antibiotic consumption post implementation

Abstract

Background: Antimicrobial resistance (AMR) is a global health threat. Prompt and co-ordinated actions are needed, thus Antimicrobial Stewardship Program (ASP) need to be implemented in any health-care institution. Methods and materials: A state-wide surveillance on injectable antibiotic consumption was performed in district hospitals without clinical specialist in Sarawak, Borneo Island since 2012. The antibiotics under surveillance were amoxicillin-clavulanate, ampicillin-sulbactam, ciprofloxacin, third-generation cephalosporins, cefepime, piperacillin-tazobactam, vancomycin, aminoglycosides and carbapenems. Antibiotic consumption was measured in Defined Daily Dose (DDD) per 1000 patient-days. A front-end ASP approach through state-wide formulary restriction and pre-authorization on the aforementioned antibiotics was implemented in February 2014. Results: There was an immediate impact, which was seen as early as in year 2014 itself. Mean total injectable antibiotic consumption was reduced by 15.6%, from 140.07 to 118.17 in the year 2013 and 2014 respectively. From 2015 to 2018, the average mean total antibiotic consumption was 121.76, albeit a small inter-year fluctuation of less than 15% and represented a small 3% (121.76 vs. 118.17) increase from year 2014. Analysis of individual antibiotics pre and post implementation (2013 vs. 2014) showed greatest reduction for vancomycin (88.2%) followed by piperacillin-tazobactam (75.4%), ciprofloxacin (70.7%), aminoglycosides (67.7%), cefuroxime (23.8%) and third-generation cephalosporins (18.3%). However, amoxycillin-clavulanate which needed pre-authorization only if used beyond 5 days duration showed a 6% increase in consumption from the year 2014 to 2015. There was an increase in cefuroxime consumption by 7.7% (2015 vs. 2016) and 16.5% (2016 vs. 2017) respectively, as well as third-generation cephalosporin by 9.6% (2015 vs. 2016). During this period, there was disruption in amoxicillin-clavulanate supply. The consumption of other antibiotics remained stable. There were no vancomycin and carbapenems consumption from year 2015 and 2017 onwards respectively. Conclusion: Our result showed that formulary restriction and pre-authorization method can be implemented to immediately control the usage of broad spectrum antibiotics in such setting and it was sustainable. However, it did not effectively bring down the overall antibiotic consumption, suggesting that we need to look at strategies that influence prescriber's decision to start antibiotics.