Nurses’ Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study

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Abstract

Purpose

Antimicrobial resistance (AMR) is leading to greater therapeutic cost, length of hospital stays, adverse events, morbidity and mortality. Hospital-based antimicrobial stewardship programs (ASPs) engaging physicians, pharmacists, microbiologists and nurses are considered as effective way to ensure appropriate use of antimicrobial agents. The aims of our study were to assess nurses’ perception, involvement, confidence and barriers towards hospital-based ASPs, and use the findings to provide future guidance.

Methods

A web-based, cross-sectional study was conducted among the nurses serving at eleven hospitals of Punjab province of Pakistan during a period of two months (December 2021-January 2022). Data were collected using a validated self-administered questionnaire. All data were analyzed using SPSS version 22.

Results

A total of 583 nurses participated in the study (response rate = 77.7%). All the participants were female staff nurses and 86% had a minimum of 3 years of working experience. The overall median score on the perception towards ASPs among the nurses was 18 (IQR: 16, 19) on a 0 to 20 scale whereas median score on the involvement in ASPs was 18 (IQR: 15, 37) on a 0 to 64 scale. Median perception and involvement score were statistically significantly differed by age (p < 0.001) and years of experience (p < 0.001). The overall median score on the confidence to perform ASP activities was 22 (IQR: 14, 24) on a 0 to 28 scale. Lack of knowledge, insufficient support from administration, and heavy workload were found to be the common barriers to perform ASP.

Conclusion

Our study concluded that Pakistani nurses have positive perception but limited involvement in ASPs. Moreover, they are confident to perform ASP besides many barriers.

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Most cited references 48

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Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis

(2022)

Summary Background Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen–drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with bacterial AMR for 23 pathogens and 88 pathogen–drug combinations in 204 countries and territories in 2019. We obtained data from systematic literature reviews, hospital systems, surveillance systems, and other sources, covering 471 million individual records or isolates and 7585 study-location-years. We used predictive statistical modelling to produce estimates of AMR burden for all locations, including for locations with no data. Our approach can be divided into five broad components: number of deaths where infection played a role, proportion of infectious deaths attributable to a given infectious syndrome, proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antibiotic of interest, and the excess risk of death or duration of an infection associated with this resistance. Using these components, we estimated disease burden based on two counterfactuals: deaths attributable to AMR (based on an alternative scenario in which all drug-resistant infections were replaced by drug-susceptible infections), and deaths associated with AMR (based on an alternative scenario in which all drug-resistant infections were replaced by no infection). We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. We present final estimates aggregated to the global and regional level. Findings On the basis of our predictive statistical models, there were an estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9–35·3), and lowest in Australasia, at 6·5 deaths (4·3–9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000–1 270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019. One pathogen–drug combination, meticillin-resistant S aureus, caused more than 100 000 deaths attributable to AMR in 2019, while six more each caused 50 000–100 000 deaths: multidrug-resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporin-resistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae, and third-generation cephalosporin-resistant K pneumoniae. Interpretation To our knowledge, this study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.

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Antibiotic stewardship in low- and middle-income countries: the same but different?

G Levy Hara, J.A. Cox, E Vlieghe … (2017)

Antibiotic resistance (ABR) is a quickly worsening problem worldwide, also in low- and middle-income countries (LMICs). Appropriate antibiotic use in humans and animals, i.e. antibiotic stewardship (ABS), is one of the cornerstones of the World Health Organization's global action plan for ABR. Many LMICs are in the process of developing stewardship programs.

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Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000–15: an analysis of pharmaceutical sales data

Eili Klein, Maja Milkowska-Shibata, Katie Tseng … (2020)

The WHO Access, Watch, and Reserve (AWaRe) antibiotic classification framework aims to balance appropriate access to antibiotics and stewardship. We aimed to identify how patterns of antibiotic consumption in each of the AWaRe categories changed across countries over 15 years.

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Author and article information

Journal

Journal ID (nlm-ta): J Multidiscip Healthc

Journal ID (iso-abbrev): J Multidiscip Healthc

Journal ID (publisher-id): jmdh

Title: Journal of Multidisciplinary Healthcare

Publisher: Dove

ISSN (Electronic): 1178-2390

Publication date (Electronic): 04 November 2022

Publication date Collection: 2022

Volume: 15

Pages: 2553-2562

Affiliations

[1 ]Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia , Penang, Malaysia

[2 ]Department of Pharmacy Services, District Headquarter (DHQ) Hospital , Pakpattan 54700, Pakistan

[3 ]Department of Medicine, Faisalabad Medical University , Faisalabad 38000, Pakistan

[4 ]Department of Medicine, Rawalpindi Medical University , Rawalpindi 46000, Pakistan

[5 ]Institute of Pharmacy, Faculty of Pharmaceutical and Allied Health Sciences, Lahore College for Women University , Lahore, Pakistan

[6 ]Institute of Pharmaceutical Sciences, University of Veterinary and Animal Sciences , Lahore, Pakistan

[7 ]Lahore School of Nursing, The University of Lahore , Lahore, Pakistan

[8 ]Clinical Pharmacy Program, College of Pharmacy, Al Ain Campus, Al Ain University , Al Ain, Abu Dhabi, United Arab Emirates

[9 ]Clinical Pharmacy Department, College of Pharmacy, Al-Azhar University , Nasr city, Cairo, Egypt

[10 ]Imam Abdulrahman Bin Faisal University , Dammam, Kingdom of Saudi Arabia

[11 ]Department of Pharmacy Services, District Headquarter Hospital , Okara South City, Pakistan

[12 ]Department of Pharmacy Services, District Headquarter Hospital , Chakwal, Pakistan

[13 ]Department of Pharmacy Services, District Headquarter Hospital , Kasur, Pakistan

[14 ]School of Pharmacy, Sefako Makgatho Health Sciences University , Ga-Rankuwa, South Africa

[15 ]Centre of Medical and Bio-allied Health Sciences Research, Ajman University , Ajman, United Arab Emirates

[16 ]Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde , Glasgow, UK

[17 ]Faculty of Pharmacy & Health Sciences, University of Balochistan , Quetta, Pakistan

[18 ]SMART Afghan International Trainings and Consultancy , Kabul, Afghanistan

Author notes

Correspondence: Mohammad Bashaar, SMART Afghan International Trainings and Consultancy , Shahri Naw, Hospital Street No. 1, Kabul, Afghanistan, Tel +93788233865, Email dr.mbashaar@gmail.com

Author information

Muhammad Salman http://orcid.org/0000-0002-4366-1461

Khezar Hayat http://orcid.org/0000-0001-7984-1870

Mohamed A Baraka http://orcid.org/0000-0002-7645-2420

Fahad Saleem http://orcid.org/0000-0001-8100-8992

Mohammad Bashaar http://orcid.org/0000-0002-7502-482X

Article

Publisher ID: 376664

DOI: 10.2147/JMDH.S376664

PMC ID: 9642086

SO-VID: 558c409a-9b0d-45a2-b30d-ac0a6676df7b

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This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

History

Date received : 08 July 2022

Date accepted : 18 October 2022

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Nurses’ Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study

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Abstract

Purpose

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Results

Conclusion

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Point-Of-Care Testing for AMR

Most cited references 48

Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis

Antibiotic stewardship in low- and middle-income countries: the same but different?

Assessment of WHO antibiotic consumption and access targets in 76 countries, 2000–15: an analysis of pharmaceutical sales data

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