Applying Implementation Science to Improve Antimicrobial Stewardship: Why is it Important?

Antimicrobial resistance (AMR) is a significant threat to global health. At least 700, 000 deaths occur yearly as result of AMR. Antimicrobial stewardship (AMS) is one of the key strategies that has been proposed by the World Health Organization (WHO) Global Action Plan on AMR to solve the problem of the inappropriate use of antimicrobials, and hence tackle AMR.

Antimicrobial stewardship is the optimisation of the use of antimicrobials with the sole aim of improving patients’ health outcomes and reducing AMR, while avoiding unnecessary treatment costs. AMS has evolved over the years and is more developed in high-income countries (HICs) compared to low- and middle-income countries (LMICs). The reasons for the differences in the development and implementation of AMS across the different country income classifications are diverse. LMICs have lesser resources to implement AMS compared to HICs. Also, in many LMICs there are weak or no regulations to prevent the sale of antimicrobials over-the-counter, i.e. without a prescription. It is important to highlight that even in HICs,  a challenge to sustaining the effect of AMS interventions in the long-term persist. This is as a result of contextual and cultural differences that arise from setting to setting.

An updated Cochrane review that included 221 studies which evaluated interventions to improve antibiotic prescribing in acute-care hospitals, showed that AMS interventions are clinically effective. AMS interventions such as audit and feedback, education, and reminders, are effective in reducing antibiotic consumption, reducing the duration of antibiotic therapy and improving the appropriateness of antibiotic therapy. They also lead to reduced lengths of hospital stay, without any likely increases in mortality. The review authors concluded by highlighting key gaps in the evidence. These gaps include, absence of research that investigates the barriers and facilitators to implementing AMS in different settings, and the design of AMS interventions without a behavioural approach and a theoretical underpinning.

So, while AMS interventions are known to be clinically effective, there is insufficient information on how to best implement them in different healthcare settings. There is also the struggle to embed AMS interventions within healthcare settings (which are typically known to be complex). Healthcare settings are complex environments with various interacting and conflicting factors, and contextual and cultural differences. Hence, to successfully implement healthcare interventions different approaches than have been applied in the past need to be employed. These approaches should include considerations of the theoretical basis of, and the social aspect of intervention implementation. Stakeholder engagement in the implementation process also needs to be considered.

Herein lies the application of Implementation Science, a newly emerging field with great prospects for improving the implementation of healthcare interventions. Implementation Science involves employing theories, models and frameworks in order to arrive at the best possible way to embed interventions within healthcare settings. It has been reported that it takes an average of 17 years for 14% of healthcare evidence to be translated into practice. Research conducted with an Implementation Science lens helps to bridge that wide gap⁠—“the know-do gap”⁠— between evidence and implementation.

The Way Forward

In order to improve AMS we need to apply Implementation Science principles. Implementation research in AMS should seek to understand how effective it is to implement AMS interventions, alongside investigating clinical effectiveness of these interventions. This will allow more effective application and scale up of AMS interventions in healthcare settings. Evaluating implementation outcomes will guide in depth exploration of the factors that influence implementation and will enable investigation of the social influences on the implementation of AMS.

Particularly, in low resource settings in LMICs, implementation research will reveal key barriers and facilitators to the implementation of AMS interventions in these unique settings. This will guide the design of tailor-made, theoretically underpinned interventions and successful evaluation of these interventions.

The world is faced with dwindling investments in the development of new antibiotics. Also, there are suboptimal infection prevention and control practices in many countries. To tackle the global health problem of AMR, implementation research to improve AMS needs to be prioritised. There needs to be a focus on implementing AMS interventions that are tailored to each unique health care setting. These refined AMS interventions would potentially stand the test of time. Improved AMS and other concerted efforts to tackle AMR would mean that the impending projected 10 million yearly deaths due to AMR by 2050 can be avoided.

About the author:

AypdejiAyodeji Matuluko is a PhD Candidate at Glasgow Caledonian University, United Kingdom where she is conducting research in antimicrobial stewardship. She is the Chairperson of Projects on the Young Pharmacists Group of International Pharmaceutical Federation (FIP-YPG) Steering Committee for the year 2020. Ayodeji was a participant in the 2nd Global Alliance for Chronic Diseases (GACD) Implementation Science Research Training School in Bangkok, Thailand in November 2019.She tweets at  @AyodejiMatuluko

Competing interests:

I have read and understood the BMJ policy on declaration of interests and declare I have no conflicts of interests.

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