Challenges and opportunities for antimicrobial stewardship in resource-rich and resource-limited countries

ABSTRACT

Introduction: Inappropriate prescription practices, patient and provider knowledge and attitudes, variable availability of diagnostic and surveillance systems, and the unrestricted use of antimicrobials in animals and plants are contributory factors to the global crisis of antimicrobial resistance (AMR).

Areas covered: Notwithstanding that interventions to revert AMR should be tailored to the socio-politico-economic landscape, there is a global consensus for the implementation and enhancement of antimicrobial stewardship strategies. Yet the implementation of Antimicrobial Stewardship Programs (ASPs) remains relatively limited within healthcare settings and faces complex challenges in resource-limited countries. The current review summarizes the limitations of current ASPs, translation challenges in resource-limited countries, and potential solutions.

Expert opinion: Suboptimal ASP implementation in hospitals is multifactorial. Restriction of antimicrobial use should be informed by risk-benefit analyses, including the potential for substitute prescribing, and displacement of selection pressures. Thresholds in population use of antibiotics above which AMR increases may provide quantitative targets for ASPs. Horizontal and vertical collaborations involving policymakers and the general public are of paramount importance. While impactful prescribing changes require sustained engagement of the public and health-care professionals, we warn against over-estimating the benefits of behavioral interventions. We advocate for population-level stewardship interventions in addition to investment in structural factors that will aid ASP implementation.

KEYWORDS:

• Antimicrobial resistance
• antimicrobial stewardship
• One Health
• resource-limited countries
• tiered national-level model

Article highlights

• ASPs remain a critical tool in the reversal of AMR within hospital and community settings.

• ‘Back-end’ strategies are more widely practiced as persuasive and educational initiatives, but ‘front-end’ strategies and restriction may be more effective.

• Improved diagnostics and surveillance provide opportunities for ensuring empirical and prophylactic therapies are appropriate, and for early rationalization or de-escalation.

• Aggregate prescribing and AMR data can be used to identify the thresholds in population use of specific antimicrobials above which clinical burdens from AMR pathogens increase. This may provide quantitative targets for ASPs and serve as a practical alternative to total restriction of antimicrobials, which is not always feasible or desirable.

• There is evidence suggesting that the indiscriminate use of biocides increases AMR. ASPs should be broadened to include the use of biocides.

• ASPs should be informed by a ‘One Health’ approach that integrates AMR research relating to human and veterinary health as well as agriculture and the environment.

• A tiered approach, ensuring vertical and horizontal coordination amongst all stakeholders, is key to the implementation of ASPs.

• Economic development is one of the prime determinants of AMR burden and the likely capacity to implement ASPs. International cooperation, technology sharing, and greater investment in AMR research in low- and middle-income countries is needed to adapt ASPs to socio-political, public health and economic challenges, recognizing both the importance of improving access and limiting excess.

• Diffusion of lower cost and point-of-care diagnostics and IT for surveillance, health system strengthening, reductions in out-of-pocket health-care expenditures, and reducing burdens of infectious disease or associated risk-factors provide opportunities for ASPs in low- and middle-income countries.

• Behavioral interventions, such as enablement and restriction in particular, are promising tools to modify prescribing trends.

Acknowledgments

The authors thank Dr Timothy Lawes for his critical review and input to the manuscript.

Declaration of interest

The authors have declared the following conflicts of interest: IMG receives consultancy and lecture fees from Merck Sharp & Dohme, AstraZeneca, Bayer, Pfizer, Basilea; IMG receives also consultancy fees from Achaogen and Gilead as well as lecture fees from Sanofi, Norma Hellas, Xellia.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.