Current status and future direction of antimicrobial stewardship programs and antibiotic prescribing in primary care hospitals in Zambia

Abstract

Background: Antimicrobial Stewardship Programs (ASPs) intended to optimize antibiotic use will be more effective if informed by the current status and patterns of antibiotic utilisation. In Zambia's primary healthcare (PHC) settings, data on ASPs and antibiotic utilisation were inadequate to guide improvements. As a first step, this study assessed antibiotic prescribing and ASP core elements among PHC first-level hospitals (FLHs) in Zambia.

Methods: A point prevalence survey was conducted at the five FLHs in Lusaka using the Global-PPS^® protocol. Hospital ASP core elements evaluated included hospital leadership commitment, accountability, pharmacy expertise, action, tracking, reporting, and education.

Results: Antibiotic use prevalence was 79.8% (146/183). A total of 220 antibiotic prescription encounters were recorded among inpatients, with ceftriaxone (J01DD04, Watch) being the most (50.0%) prescribed. Over 90.0% (202) of the antibiotic prescriptions targeted suspected community-acquired infections, but only 36.8% (81) were compliant with national treatment guidelines. ASP core element implementation was 36.0% (16.2/45), with only two hospitals achieving over 50.0%. The most deficient core elements were accountability, action, tracking, and reporting.

Conclusions: ASP implementation in Zambia's FLHs providing PHC was sub-optimal, with high antibiotic prescribing rates, frequent use of broad-spectrum Watch group antibiotics, and low compliance with national treatment guidelines. As key ways forward, ASPs in Zambia's PHC require strengthening by adapting the WHO AWaRe recommendations and improving accountability, actions, tracking, and reporting antibiotic use to improve stewardship practice and reduce AMR.

Figure 1.

Average usage of antibiotic subgroups (by ATC4 code) across categories. This plot reveals the proportional use of each antibiotic subgroup, allowing us to compare their usage across the different categories. Across the hospitals, the third-generation cephalosporins (J01DD) accounted for over 50% average usage.

Figure 2.

Common diagnoses treated with antibiotics across the FLHs surveyed. This chart displays the various frequent diagnoses by anatomical site for which antibiotics were prescribed for treatment across the hospitals. From the chart, we can see that Pneumonia, a lower respiratory tract infection, was the most common diagnosis, indicating a significant need for antibiotic treatment in these cases. Other notable diagnoses included SST infections and Sepsis, which also showed considerable prescription counts. CVS, Cardiovascular system infections; CNS, Central nervous system infections; GIT, Gastrointestinal tract infections; OBGY, Obstetrics & Gynaecology infections; SST, Skin & soft tissue infections; *Other, non-defined diagnosis groups, including Ear, Nose and Throat infections, Bone and Joint infections, Bronchitis, Tuberculosis, Malaria, and other prophylaxes.

Figure 3.

Hospital ASP core element scores and performance heatmap in the self-assessment across the FLHs. This figure displays performance scores among the 5 FLHs’ self-assessments in ASP core elements, which included hospital commitment, accountability, pharmacy expertise, actions taken to improve antibiotic use, tracking of antibiotic use and outcomes, reporting practices, and education initiatives. The heatmap analysis of the data revealed the strengths and weaknesses of ASPs across different hospitals.