Antimicrobial stewardship: Attitudes and practices of healthcare providers in selected health facilities in Uganda.

Isaac Magulu Kimbowa,Cecilia Stålsby Lundborg,Joan Kalyango,Mary Nakafeero,Celestino Obua,Jaran Eriksen,Moses Ocan,Elena Ambrosino

doi:10.1371/journal.pone.0262993

Abstract

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda's national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers' AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47-0.92, P < 0.016), having a bachelor's degree (aOR: 1.81, 95% CI: 1.24-2.63, P < 0.002) or master's (aOR: 2.06, 95% CI: 1.13-3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region's health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34-0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

Highlights

Antimicrobial resistance (AMR) is a global public health threat caused by the misuse of antibacterial agents in human, animal, and environmental sectors [1,2]
Antimicrobial stewardship (AMS) Practices Use of standard treatment guidelines Avoid unnecessary broad spectrum antibacterial use Documenting antibacterial use in patient care Pre-surgical single-dose antibacterial administration Complying with culture and susceptibility results Antimicrobial prescription audit and review Antibacterial time-out Patient education on antibacterial use Existence of antibacterial use best practices Assessment of antibacterial use Measurement of antibacterial use outcomes Use of hospital antibacterial audit data antimicrobial stewardship (AMS) practice scores reported as means and standard deviation (SD)) in each of the professional groups
While the Ministry of Health in Uganda is in the implementation stages of the National Action Plans (NAPs) on AMR, which places AMS as a critical priority, the high AMS attitude in our study suggests that health facilities could have adopted AMS programmes with strategies that improve healthcare providers’ attitudes prior to the Ministry of Health policy intervention

Summary

Introduction

Antimicrobial resistance (AMR) is a global public health threat caused by the misuse of antibacterial agents in human, animal, and environmental sectors [1,2]. National, and professional organisations, including the World Health Organization (WHO), have called for the establishment of antimicrobial stewardship as a strategy to promote optimal antibacterial use in the human, veterinary, and agricultural sectors in order to reduce the transmission and development of antimicrobial resistance (AMR) [6,7,8]. Antimicrobial stewardship (AMS) is a set of synchronised interventions that optimise antibacterial use to generate the best clinical outcome, increase patient safety, and reduce the risk of AMR development [9,10,11]. Adopting AMS interventions in health facilities is critical in supporting healthcare providers with tools and systems in optimising antibacterial use, reducing the transmission and colonisation of multidrug-resistant bacteria, and lowering the incidence of antimicrobial-related adverse events [12]. Previous studies have shown that the adoption of AMS activities is dependent on the healthcare providers’ attitudes and practices, which were affected either by the top-down approach of government policy implementation or bottom-up participation of healthcare providers in policy development [8,16]

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Discussion

Conclusion