Title : Impact of clinical engagement program on antimicrobial stewardship and use in Pakistan: A multicenter prospective point prevalence survey
Abstract:
Background/Objectives:
Antimicrobial resistance (AMR) is a growing global health crisis, particularly in low- and middle-income countries (LMICs) like Pakistan, where excessive and inappropriate antibiotic use contributes to rising resistance. Hospital-based AMR surveillance and stewardship programs are critical for improving antibiotic prescribing practices, reducing resistance, and enhancing patient outcomes. However, there remains a gap in assessing the effectiveness of targeted interventions. The study aimed to assess the impact of clinical engagement interventions on antimicrobial prescribing patterns and infection control practices. We hypothesized that structured training programs and active clinical mentorship would lead to appropriate antibiotic prescribing, and reduced unnecessary antimicrobial use.
Methods:
A multi-center, prospective study was conducted across five tertiary care hospitals in Pakistan between 2021 and 2023 under the Fleming Fund Country Grant. Three periodic Point Prevalence Surveys (PPS) were conducted to evaluate antibiotic prescription patterns, and adherence to stewardship guidelines. Key interventions included antimicrobial stewardship training sessions, supportive supervision during clinical rounds, advocacy meetings with hospital management, and the development of local antibiotic guidelines. Data on antibiotic use, prescription as per WHO’s AWaRe classification, and antibiotic usage for different indication were collected and analyzed in SPSS using one way ANOVA.
Results:
Antimicrobial prescription rates remained high, with 80% of patients surveyed receiving antibiotics at the end of the survey. Most of the prescribed antibiotics belonged to watch group followed by access, not recommended and reserve group respectively, though there was a notable reduction in the use of reserve-category antibiotics. The proportion of empirical antibiotic prescriptions remained high (95.08%). Antibiotics were mostly prescribed for surgical prophylaxis (SP), followed by community acquired infections (CAI), medical prophylaxis (MP) and hospital acquired infections (HAI). Ceftriaxone was the most prescribed antibiotic followed by metronidazole and meropenem. Antibiotic prescription was highest in age group <13 years, followed by those aged >50 and 13-30 years respectively. An increase in culture testing rates (37.37%, p-value <0.0001) was observed, indicating better diagnostic stewardship. Significant improvements were observed in compliance with local antimicrobial guidelines, increasing from 0.1% at baseline to 7.6% at endline (p-value <0.0001).
Conclusions:
Improvements in guideline compliance and culture testing indicate progress. However, despite stewardship interventions, antibiotic prescription rates remained high, likely due to the limited study duration, inconsistent intervention uptake, and entrenched prescribing habits. Strengthening antimicrobial stewardship, enhancing surveillance infrastructure, and integrating decision-support tools are essential for sustainable improvements in antibiotic use and AMR control.
Keywords:
Antimicrobial Use, Clinical engagement program, antimicrobial stewardship, WHO AWaRe framework, Point Prevalence Survey, Prescription Practices.
