Antimicrobial Stewardship and Infection Prevention and Control in Low- and Middle-income Countries: Current Status and Best Practices.

Abstract

The history of infection prevention and control (IPC) dates back at least 2500 years, with recommendations for large rooms with adequate ventilation to help reduce the spread of infections in hospitals dating back to 500 BCE.1 Scientific study of how to prevent infection in hospitals began in the mid-18th century, predating the discovery of bacteria. Sir John Pringle noted the importance of poor ventilation and overcrowding, whereas Florence Nightingale, after her experience in the Balkans, promoted cleanliness and hospital reform.2 Penicillin, the first antibiotic, was discovered in 1928 by Alexander Fleming and naturally occurring penicillinases in 1940, preceding its introduction for therapy. Sulfonamides, the first broadly effective antimicrobial agents, were introduced in 1937, with resistance reported already in the late 1930s.3 Since then, the rapid rise of antibiotic resistance has outpaced antibiotic development and use.4 Also, most new antibiotics focus on adult populations. Although well documented in high-income settings, resistance data are scanty in more poorly resourced settings. Reasons include poor laboratory capacity, lack of health information systems and insufficient resources for many sick patients.5 Given these issues, it is very possible that antibiotic resistance, especially multi-drug resistance, is even more common in less-resourced countries. Antimicrobial stewardship (AMS), a means for preserving antimicrobial effectiveness through judicious use, first appeared in the medical literature in 1999, with a logarithmic increase in PubMed citations from 2010.6 AMS, by limiting antimicrobial consumption through responsible use, and IPC measures, by preventing the spread of resistant organisms in healthcare settings, are interlinked essential activities in which healthcare providers have some control. While both complementary programs are gaining more attention, especially after the World Health Organization adopted a global action plan to combat antimicrobial resistance in 2015, implementation in resource-limited settings, especially for children, is difficult. Most guidance, although highly relevant, is designed for well-resourced settings. In many less resourced settings, clinicians often face overcrowded wards and clinics, insufficient space and personnel, insufficient laboratory back-up and long turn-around times for results. There are too few dedicated infection control practitioners, often without adequate career tracks for professional advancement. Most importantly, there are many critically ill children requiring intervention. However, the core principles are universal. Background to Supplement In 2017, at its 10th conference in Shenzhen, China, the World Society of Pediatric Infectious Diseases (WSPID) launched its declaration on combatting antimicrobial resistance.7 Key emphases were that children, including neonates, require special consideration for both AMS and IPC programs. The 5 key components are illustrated in Table 1. In December 2019, a WSPID working group met at its 11th World Conference in Manilla, the Philippines, to plan a series of articles on AMS and IPC reflecting their status in less resourced settings and to offer practical guidance. This supplement, the outcome of much work and collaboration, focuses on what we, as doctors, can do in healthcare settings. In addition, we add our voices to advocate for limiting easy antibiotic availability without medical prescriptions in many countries, lack of microbiology diagnostic resources and antimicrobial abuse in agriculture. Table 1. - Key Components of the WSPID Declaration on Combatting Antimicrobial Resistance in Children, 2017 1. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training 2. Strengthen knowledge base through surveillance and research 3. Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures 4. Optimize the use of antimicrobial medicines in human and animal health 5. Develop the economic case for sustainable investment, considering the needs of all countries and increase investment in new medicines (including vaccines), diagnostic tools and other interventions Content of Supplement Led by Penelope Bryant for AMS and Susan Coffin for IPC, the supplement begins with reporting on a widely circulated questionnaire representing a situational analysis of these programs from 135 respondents in 39 low- and middle-income and 27 high-income settings. The responses highlight resource scarcity and an enormous need for ongoing education which WSPID is committed to tackling through its educational program. This was followed by systematic reviews on the status of AMS and IPC programs in resource-limited healthcare settings and practical case studies by colleagues from Africa, Asia and Latin America. Both systematic reviews highlight the importance of bundled interventions, already shown in many studies from high-resource settings to be effective, but with limited evidence to support these or other practices in resource-limited settings. This is an area with a huge research agenda. The case studies present narratives from the real world that are often not obvious in data-driven research publications but are well recognized by hard-pressed clinicians. The vignettes illustrate almost insurmountable problems, most of which were addressed through teamwork, motivation and innovation. CONCLUSIONS Ongoing education and international collaboration are essential components necessary to minimize antimicrobial resistance and maintain the efficacy of interventions. Many interventions, such as meticulous handwashing and avoiding unnecessary antibiotic use, are relatively simple concepts, but not always that easy either to implement or monitor. We hope that this supplement will complement ongoing activities to promote safe healthcare settings for children to survive and thrive. WSPID’s CALL TO ACTION In developing and reflecting upon the content of this supplement, we propose a modified antimicrobial resistance declaration that is more child focused, with emphasis on what we must do for pediatric populations in hospitals and clinics. While we strongly support broader initiatives such as developing new medications and interventions and improving sanitation in communities, we must focus on our core responsibility: improving childhood outcomes (Table 2). Table 2. - Modified WSPID Declaration for Combatting Antimicrobial Resistance 1. Support and advocate for pediatric antimicrobial stewardship and infection prevention and control programs globally through mentorship, discussion groups, webinars and focused training on appropriate research. 2. Encourage and develop multiple education initiatives to improve the understanding and practice of optimal antibiotic prescribing by all those involved in giving antibiotics to children. 3. Assist with developing appropriate metrics and monitoring methods of deficiencies in care impacting on AMR and IPC outcomes for hospitalized neonates and children globally. 4. Assist with developing appropriate metrics and quality indicators of good prescribing for children in primary healthcare and hospital settings, using the WHO AWaRe system. 5. Assist with developing simple metrics and quality indicators for hospital-acquired infections, including clinical and health economic outcomes. AWaRe – Access, Watch and Reserve (https://adoptaware.org – updated 2019, accessed 27 July 2021). ACKNOWLEDGMENTS AMR working group: Mike Sharland – Chair (UK), Mark Cotton – Co-Chair (South Africa), Ramesh Agarwal (India), Daniela Pavez (Chile), Penelope Bryant (Australia), Susan Coffin (USA), Mohammad Issack (Mauritius), Shamim Qazi (Switzerland), Ilan Youngster (Israel), Mehreen Arshad and Celina Hanson (USA), Devika Dixit (Canada), Tinsae Alemayehu (Ethiopia), Mei Zeng (China) AMR portal development group: Anna Markowich (Italy), Danilo Buonsenso (Italy), Joycelyn Dame (Ghana), Kevin Meesters (Belgium), Olha Shvaratska (Ukraine), Sofia Benou (Greece), Tinsae Alemayehu (Ethiopia) Kenes support: Evelyn Zuberbuhler and Hester Lanting.