News and Opinions  –  2020

4 key reflections from engaging hospitals in India for antibiotic stewardship

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Next month experts will gather in Bangkok at a WHO-organized meeting - this to discuss the roll-out of WHO’s new toolkit on Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. In context of this ReAct takes the opportunity to share its reflections from a ReAct-led stewardship project in rural secondary level hospitals in India.


Photo: ReAct Asia Pacific.

In India, secondary level hospitals play a critical role in providing healthcare services to the community, but few actively implement any antibiotic stewardship measures. Full-scale antibiotic stewardship programs require many resources and are often not feasible in this setting.

About the project

In 2018, ReAct engaged and assisted a number of Indian hospitals to initiate work on antibiotic stewardship. Participating staff were primarily general physicians, pharmacists and microbiologists. Educational sessions in combination with interactive discussions and decision-making among participants, followed by hands-on work, were used to sensitize professionals working at the hospitals towards stewardship. Here we share four reflections from the process.

Philip Mathew, ReAct Asia Pacific.

Dr. Philip Mathew, React Asia Pacific, one of the organizers of the project says:

“It was encouraging to see the enthusiasm and willingness to do something among the participants. You have to remember that these facilities are facing many challenges. There are no staff fully trained in infectious diseases, no in-house capacity to culture bacteria and do susceptibility testing, and they often have only few doctors working for them.”

Four key takeaways

1. Inspire exchange and engagement with a workshop format.

A workshop was organized together with the Infectious Diseases Training and Research Centre at the Christian Medical College (CMC) in Vellore, India. Stewardship experts from CMC Vellore and ReAct led educational sessions on the benefits of antibiotic stewardship programs in optimizing antibiotic use and containing resistance. Participants in turn presented the existing facilities and spoke about challenges they were facing in their workplace.

The workshop discussion forum worked well and is a fairly low-cost way to provide training and inspire exchanges and engagement.

2. Ensure active ownership with a participatory process

At the workshop, common strategies for stewardship were presented together with the level of evidence and their overall pros and cons. The participants then decided which interventions to implement in their own hospital in consultation with the experts through a discussion and voting process. Participants then returned to their hospitals to try and implement the decided upon measures. ReAct maintained a support function throughout the implementation phase.

The open and participatory process provided an environment for participants to discuss challenges and together with experts decide feasible interventions to implement without imposing views and suggesting best practices. This was appreciated and ensured active ownership.

Three short interviews – Antimicrobial Stewardship in rural India. By ReAct Asia Pacific. Please note that the interviewed persons are not linked to the stewardship project described here.

3. External support helps to get started

Although knowledgeable about the problem of antibiotic resistance and willingness to do something, many participants expressed they did not know where to start. Many secondary centers would likely benefit from external support that allows a step wise scaling up of stewardship.

4. Identify and support champions to initiate action locally

In this project, junior doctors, microbiologists and pharmacists came together to discuss barriers and possibilities to stewardship in secondary level care settings. Although faced with many barriers, they were enthusiastic and able to initiate actions in their hospitals.

Identifying and supporting champions within hospitals is central for success.

Jaya Ranjalkar, ReAct Asia Pacific.

Jaya Ranjalkar, co-lead of the project, says:

“I think this project has been positive in terms of raising the profile of antibiotic resistance and sensitizing staff in the participating hospitals towards stewardship. Several hospitals were able to implement some stewardship measures. One hospital was able to introduce new guidelines for common conditions and another even had formed an antibiotic stewardship committee. We are now summarizing all the qualitative and quantitative data from the project that we are hoping to publish officially.”

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