Abstract
BackgroundAntimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Antimicrobial stewardship programmes are being implemented in health systems globally, primarily in hospitals, to address the growing threat of antimicrobial resistance. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. This narrative review aims to identify in rural and remote primary health care settings the (1) correlation of antimicrobial resistance with antibiotic prescribing and volume of antibiotic use, (2) appropriateness of antimicrobial prescribing, (3) risk factors associated with inappropriate use/prescribing of antibiotics, and (4) effective antimicrobial stewardship strategies.MethodsThe international literature was searched for English only articles between 2000 and 2020 using specified keywords. Seven electronic databases were searched: Scopus, Cochrane, Embase, CINAHL, PubMed, Ovid Medline and Ovid Emcare. Publication screening and analysis were conducted using Joanna Briggs Institute systematic review tools.ResultsFifty-one eligible articles were identified. Inappropriate and excessive antimicrobial prescribing and use directly led to increases in antimicrobial resistance. Increasing rurality of practice is associated with disproportionally higher rates of inappropriate prescribing compared to those in metropolitan areas. Physician knowledge, attitude and behaviour play important roles in mediating antimicrobial prescribing, with strong intrinsic and extrinsic influences including patient factors. Antimicrobial stewardship strategies in rural and remote primary health care settings focus on health care provider and patient education, clinician support systems, utility of antimicrobial resistance surveillance, and policy changes. Results of these interventions were generally positive with decreased antimicrobial resistance rates and improved appropriateness of antimicrobial prescribing.ConclusionsInappropriate prescribing and excessive use of antimicrobials are an important contributor to the increasing resistance towards antimicrobial agents particularly in rural and remote primary health care. Antimicrobial stewardship programmes in the form of education, clinical support, surveillance, and policies have been mostly successful in reducing prescribing rates and inappropriate prescriptions. The narrative review highlighted the need for longer interventions to assess changes in antimicrobial resistance rates. The review also identified a lack of differentiation between rural and remote contexts and Indigenous health was inadequately addressed. Future research should have a greater focus on effective interventional components and patient perspectives.
Highlights
Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health
Antimicrobial stewardship (AMS) programmes combat the rise of antimicrobial resistance (AMR) through evidence-based multicomponent strategies, including AMR surveillance, education, and guidance to encourage judicious antimicrobial use, to improve health outcomes [7, 8]
There are four objectives of this review: to describe the correlation of AMR with antibiotic prescribing and/or volume of antibiotic use; describe the appropriateness of antimicrobial prescribing in rural and remote primary health care (PHC); identify risk factors associated with inappropriate use/prescribing of antibiotics; and describe effective AMS strategies in rural and remote PHC settings
Summary
Antimicrobial resistance is an emerging problem worldwide and poses a significant threat to human health. Despite the significance of primary health care services in providing health care to communities, antimicrobial stewardship programmes are not well established in this sector, especially in rural and remote settings. Antimicrobial resistance is a global health concern that contributes to patient morbidity and mortality and increases the cost of health care [2]. It has been recognised as one of the most significant health challenges of the present and future, generating global and national responses [3–6]. The implementation of AMS programmes in primary health care (PHC) settings is less well established due in part to additional challenges, including shortages of healthcare professionals and less access to therapeutic tools [10, 11]. There is a gap in the understanding of how AMS programmes best work in PHC settings, in the rural and remote context
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