. 2025 Feb 25;20(1):12.

doi: 10.1186/s13012-024-01413-4.

Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

Duncan Wagstaff¹, John Amuasi^{2

3

4}, Sumaiya Arfin^{5

6

7}, Diptesh Aryal⁸, Mohd Basri Mat Nor⁹, Joseph Bonney^{10

4}, Arjen Dondorp^{7

11

12}, David Dongelmans^{13

14}, Layoni Dullawe¹⁵, Fathima Fazla¹⁵, Aniruddha Ghose¹⁶, Eva Hanciles^{17

18}, Rashan Haniffa^{7

15

19}, Madiha Hashmi²⁰, Adam Hewitt Smith^{21

22}, Bharath Kumar²³, Yen Lam Minh²⁴, Ramani Moonesinghe²⁵, Luigi Pisani⁷, Cornelius Sendagire^{26

27}, Mohd Shahnaz Hasan⁹, Maryam Shamal Ghalib²⁸, Moses Siaw Frimpong²⁹, Otavio Ranzani^{30

31}, Menbeu Sultan³², David Thomson³³, Swagata Tripathy^{19

34}, Louise Thwaites²⁴, Rabiul Alam Md Erfan Uddin¹⁶, Mohd Zulfakar Mazlan³⁵, Wangari Waweru-Siika³⁶, Abigail Beane^{7

15

19}

Affiliations

¹ Centre for Preoperative Medicine, University College London, London, UK. d.wagstaff@ucl.ac.uk.
² Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
³ Department of Implementation Research, Bernhard Nocht Institute of Tropical Medicine, Hamburg, Germany.
⁴ Global Health and Infectious Disease Research Group, KCCR, KNUST, Kumasi, Ghana.
⁵ The George Institute for Global Health, New Delhi, India.
⁶ Amsterdam Public Health (APH), Amsterdam University Medical Centre(UMC), Amsterdam, The Netherlands.
⁷ Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
⁸ Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal.
⁹ Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia.
¹⁰ Emergency Medicine Department, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
¹¹ Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
¹² Nuffield Department of Medicine, University of Oxford, Oxford, UK.
¹³ National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.
¹⁴ Department of Intensive Care Medicine, UMC, University of Amsterdam, Amsterdam, The Netherlands.
¹⁵ Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka.
¹⁶ Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh.
¹⁷ Connaught Hospital, Freetown, Sierra Leone.
¹⁸ Ministry of Health and Sanitation, Freetown, Sierra Leone.
¹⁹ Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK.
²⁰ Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan.
²¹ Faculty of Health Sciences, Busitema University, Mbale, Uganda.
²² William Harvey Research Institute, Queen Mary University of London, London, UK.
²³ Department of Critical Care Medicine, Apollo Hospitals Educational and Research Foundation, Chennai, India.
²⁴ Clinical Research Unit, Oxford University, University of Oxford, Ho Chi Minh City, Vietnam.
²⁵ Centre for Preoperative Medicine, University College London, London, UK.
²⁶ D'Or Institute for Research and Education, Sao Paulo, Brazil.
²⁷ Uganda Heart Institute, University of Makerere, Makerere, Uganda.
²⁸ General Surgery, Wazir Akbar Khan Hospital, Kabul, Afghanistan.
²⁹ Department of Anaesthesiology and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
³⁰ Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain.
³¹ Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
³² Department of Emergency Medicine and Critical Care, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
³³ Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa.
³⁴ AII India Institute of Medical Sciences, New Delhi, India.
³⁵ Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia.
³⁶ Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya.

PMID: 40001051
PMCID: PMC11863957
DOI: 10.1186/s13012-024-01413-4

Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

Duncan Wagstaff et al. Implement Sci. 2025.

. 2025 Feb 25;20(1):12.

doi: 10.1186/s13012-024-01413-4.

Authors

Affiliations

¹ Centre for Preoperative Medicine, University College London, London, UK. d.wagstaff@ucl.ac.uk.
² Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.
³ Department of Implementation Research, Bernhard Nocht Institute of Tropical Medicine, Hamburg, Germany.
⁴ Global Health and Infectious Disease Research Group, KCCR, KNUST, Kumasi, Ghana.
⁵ The George Institute for Global Health, New Delhi, India.
⁶ Amsterdam Public Health (APH), Amsterdam University Medical Centre(UMC), Amsterdam, The Netherlands.
⁷ Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand.
⁸ Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal.
⁹ Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia.
¹⁰ Emergency Medicine Department, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
¹¹ Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
¹² Nuffield Department of Medicine, University of Oxford, Oxford, UK.
¹³ National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.
¹⁴ Department of Intensive Care Medicine, UMC, University of Amsterdam, Amsterdam, The Netherlands.
¹⁵ Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka.
¹⁶ Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh.
¹⁷ Connaught Hospital, Freetown, Sierra Leone.
¹⁸ Ministry of Health and Sanitation, Freetown, Sierra Leone.
¹⁹ Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK.
²⁰ Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan.
²¹ Faculty of Health Sciences, Busitema University, Mbale, Uganda.
²² William Harvey Research Institute, Queen Mary University of London, London, UK.
²³ Department of Critical Care Medicine, Apollo Hospitals Educational and Research Foundation, Chennai, India.
²⁴ Clinical Research Unit, Oxford University, University of Oxford, Ho Chi Minh City, Vietnam.
²⁵ Centre for Preoperative Medicine, University College London, London, UK.
²⁶ D'Or Institute for Research and Education, Sao Paulo, Brazil.
²⁷ Uganda Heart Institute, University of Makerere, Makerere, Uganda.
²⁸ General Surgery, Wazir Akbar Khan Hospital, Kabul, Afghanistan.
²⁹ Department of Anaesthesiology and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.
³⁰ Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain.
³¹ Pulmonary Division, Heart Institute, Faculty of Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
³² Department of Emergency Medicine and Critical Care, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.
³³ Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa.
³⁴ AII India Institute of Medical Sciences, New Delhi, India.
³⁵ Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia.
³⁶ Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya.

PMID: 40001051
PMCID: PMC11863957
DOI: 10.1186/s13012-024-01413-4

Erratum in

Correction: Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study.
Wagstaff D, Amuasi J, Arfin S, Aryal D, Nor MBM, Bonney J, Dondorp A, Dongelmans D, Dullawe L, Fazla F, Ghose A, Hanciles E, Haniffa R, Hashmi M, Smith AH, Kumar B, Minh YL, Moonesinghe R, Pisani L, Sendagire C, Hasan MS, Ghalib MS, Frimpong MS, Ranzani O, Sultan M, Thomson D, Tripathy S, Thwaites L, Uddin RAME, Mazlan MZ, Waweru-Siika W, Beane A. Wagstaff D, et al. Implement Sci. 2025 Mar 31;20(1):15. doi: 10.1186/s13012-025-01425-8. Implement Sci. 2025. PMID: 40165313 Free PMC article. No abstract available.

Abstract

Background: Approximately half of all antimicrobial prescriptions in intensive care units (ICUs) may be inappropriate, including those prescribed when not needed, in unnecessary combinations or for longer durations than needed. Inappropriate prescribing is costly, exposes patients to unnecessary side-effects and drives population-level antimicrobial resistance, the prevalence and consequences of which are greatest in low- and middle-income countries. However, the implementation of interventions to improve the appropriateness of antimicrobial prescribing has been variable and requires further study.

Methods: We propose a type III hybrid implementation/effectiveness interventional cohort trial in 35 ICUs in up to 11 low- and middle- income countries. The study intervention is a structured review of antimicrobial prescriptions as recommended by the World Health Organisation. Strategies to support stakeholder-led implementation include development of local protocols, registry-enabled audit and feedback, and education. Evaluation of implementation, and the determinants of its success, is informed by the RE-AIM framework and the Consolidated Framework for Implementation Research respectively. The primary outcome is a composite measure of fidelity, reach and adoption. Secondary outcomes describe the effectiveness of the intervention on improving antimicrobial prescribing. Qualitative interviews will assess relevant implementation acceptability, adaptations and maintenance. A baseline survey will investigate ICU-level antimicrobial stewardship structures and processes.

Discussion: This study addresses global policy priorities by supporting implementation research of antimicrobial stewardship, and strengthening associated healthcare professional competencies. It does this in a setting where improvement is sorely needed: low- and middle- income country ICUs. The study will also describe the influence of pre-existing antimicrobial stewardship structures and processes on implementation and improve understanding about the efficacy of strategies to overcome barriers to implementation in these settings.

Trial registration: This study protocol has been registered with ClinicalTrials.gov (ref NCT06666738) on 31 Oct 2004. https://clinicaltrials.gov/study/NCT06666738?term=NCT06666738&rank=1 .

Keywords: Antimicrobial Resistance; Antimicrobial Stewardship; Audit & Feedback; Critical Care; Implementation; Intensive Care; Low- and Middle- Income Countries; Quality Improvement.

PubMed Disclaimer

Conflict of interest statement

Ethics approval and consent to participate: See ‘Ethical considerations’ section. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.

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References

1. Kaki, et al. Impact of antimicrobial stewardship in critical care: A systematic review. J Antimicrob Chemother. 2011;66(6):1223–30. 10.1093/jac/dkr137. - PubMed
1. Organization, “Antimicrobial resistance : accelerating national and global responses,” 2024;3:3–8.
1. Murray, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. Lancet. 2022;399(10325):629–55. 10.1016/S0140-6736(21)02724-0. - PMC - PubMed
1. O’Neill, “Tackling drug-resistant infections globally: Final report and recommendations,” 2016. 10.4103/2045-080x.186181.
1. Chiotos, et al. Antibiotic stewardship in the intensive care unit: Challenges and opportunities. Infect Control Hosp Epidemiol. 2019;40(6):693–8. 10.1017/ice.2019.74. - PubMed

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Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

Affiliations

Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

Authors

Affiliations

Erratum in

Abstract

Conflict of interest statement

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