Victoria Rutter

Background/Objectives: Antimicrobial resistance (AMR) poses a global threat, exacerbated by the overuse and misuse of antimicrobials. This study evaluated antimicrobial use and prescribing patterns among inpatients in three tertiary hospitals in Nepal. Methods: A cross-sectional point prevalence survey of the inpatient module of the standardized Global-PPS methodology was conducted across three tertiary hospitals in Nepal during the 2022 Global-PPS Period 2 (P2) survey, carried out between May and August 2022. Data were collected via a paper-based form (University of Antwerp;) and analyzed descriptively. Antimicrobial use was defined as the proportion of inpatients receiving at least one systemic antimicrobial on the day of the survey. Results: Of 379 patients eligible for the study, 233 (61.5%) received at least one antimicrobial, with the highest prevalence observed in adult and neonatal intensive care units (ICUs). Out of 371 antibiotic prescriptions, third-generation cephalosporins (30.2%) and carbapenems (8.1%) were the most frequently prescribed, and 61.0% of overall antibiotics belonged to the Watch group of WHO AWaRe classification. Surgical prophylaxis often exceeded recommended durations, with 91.5% of prophylactic antibiotics prescribed for more than one day. Empirical therapy dominated 56.33% of all prescriptions, with targeted therapy limited to 4.04%. Conclusions: The high overall prevalence of antimicrobial use, the reliance on empirical therapy, and over-reliance on Watch-group antibiotics and Unclassified AWaRe antibiotics highlights the urgent need for robust antimicrobial stewardship programs in Nepal.

Background: Antimicrobial resistance is a growing global health challenge, particularly in low- and middle-income countries where antimicrobial stewardship (AMS) implementation and leadership capacity remain limited. Pharmacists play a central role in AMS but often lack access to structured leadership development. To address this gap, the Commonwealth Pharmacists Association developed the UK–Africa Leadership Fellowship in Antimicrobial Stewardship (UK-ALF-A), a 12-month bidirectional leadership development programme combining online learning modules, live webinars, peer-learning sessions, dual mentorship from UK- and Africa-based mentors, and workplace-based AMS continuous quality improvement projects. UK-ALF-A was designed to strengthen leadership capability among pharmacists in the United Kingdom and sub-Saharan Africa. Methods: This study evaluated changes in leadership capability among pharmacists participating in the programme and explored how fellows applied these capabilities within AMS-related practice. A mixed-methods evaluation was conducted with 40 fellows (20 UK, 20 Africa), using pre- and post-programme self-assessments and 360-degree colleague feedback based on the International Pharmaceutical Federation Global Advanced Development Framework (FIP GADF), alongside post-fellowship surveys and semi-structured interviews. Results: The proportion of fellows self-assessing at the highest competency level increased from 10% pre-programme to 39% post-programme, with corresponding increases in colleague feedback ratings from 17% to 49%. Qualitative data from open-ended survey responses and semi-structured interviews suggested improvements in leadership confidence, communication, and ability to influence AMS practice. Fellows reported leading prescribing improvements and multidisciplinary engagement, often without formal authority, with greater relative gains observed among Africa-based participants. Conclusions: UK-ALF-A was associated with enhanced leadership capability and contributions to AMS practice, alongside reported changes in individual and organisational practices that support broader health system strengthening, highlighting its value as a workforce development model.

Introduction: The hub-and-spoke model (HSM) offers a methodological and hierarchical project management framework for efficient healthcare service delivery. The Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme supports the development and implementation of antimicrobial stewardship (AMS) interventions to optimise the use of antimicrobials across eight African countries: Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia. Currently the second phase of the programme (CwPAMS 2.0) is being implemented, between March 2023 and March 2025, in which six countries are adopting the HSM to deliver AMS interventions. The aim of this study was to design a hybrid II monitoring, evaluation and learning (MEL) framework to assess the implementation and effectiveness of the HSM in delivering and adapting AMS interventions. Methods: A mixed-methods Hybrid II Implementation trial design was used to develop the MEL framework, guided by the Theory of Change, Socio-Ecological Theory, and Normalisation Process Theory and in alignment with the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Data collection will be continuous and longitudinal (pre-, mid- and post-implementation). The evaluation framework has been designed to study implementation evaluation at three ecological levels: programme, partnership, and individual site level. Data collection will encompass mixed methodologies and include non-participant observations, formal and informal feedback (from individual key stakeholders and groups), knowledge tools and surveys, scored evaluations, pre-and post-assessments, semi-structured interviews, focus groups, and data collected during formal and informal meetings. This approach will facilitate continuous data collection for evaluation and help study the utilisation and adaptation of AMS interventions. Discussion: This study provides a protocol for developing and utilising an MEL framework to study the application of the HSM in delivering AMS interventions. Developing an evaluation framework requires meticulous planning and a robust implementation and evaluation protocol to ensure methodological rigour, transparency, and effective resource management throughout the project lifecycle. Despite comprehensive consideration of developing progress and programmatic indicators and measures across all domains, the study acknowledges limitations in definitively attributing causality to individual AMS interventions due to their complexity and varied implementation contexts.

Background: The hub-and-spoke model (HSM) offers a framework for efficient healthcare service delivery. This scoping review seeks to explore the implementation and effectiveness of the HSM in antimicrobial stewardship (AMS) programmes. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guideline was followed. A systematic search was conducted in four electronic databases (PubMed, Medline, Cochrane Library, and Google Scholar) from inception until January 2024. Studies where the HSM was used for delivering any AMS activity, intervention, or action, were included. No study-specific filters were applied and all populations, study designs, and health settings were included. Data screening and selection were achieved using Rayyan. Three authors independently screened studies, with conflicts resolved by a fourth author. Data were narratively synthesised. Standard appraisal tools were impractical; however, critical evaluation of data collection and outcome reporting was ensured. Results: Out of 1438 articles, three were included in the scoping review. The primary interventions utilising the HSM in AMS involved reducing antibiotic misuse, training healthcare professionals, case-based learning, establishing AMS programmes, developing antibiograms, and formulating policies or guidelines pertinent to AMS. The studies demonstrated significant clinical improvements in AMS. Clinical outcomes from the studies include a significant reduction in antimicrobial usage and improved antibiotic management, with a notable decrease in days on antimicrobial therapy and increased antibiotic de-escalation. Key facilitators for AMS programme success were tailored education, collaborative learning, strong leadership, strategic practices, and data-driven decisions. Key barriers were leadership challenges, change resistance, knowledge gaps, inadequate data systems, resource limitations, and technological constraints. Conclusions: The review identified a literature gap in HSM use in AMS programmes. Further studies are needed to assess HSM’s effectiveness, feasibility, and cost-effectiveness in AMS contexts.

Background: The hub-and-spoke model (HSM), offers a framework for efficient healthcare service delivery. This scoping review seeks to establish the implementation and effectiveness of the HSM in Antimicrobial Stewardship (AMS) programs. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guideline was followed. A systematic search was conducted in four electronic databases (PubMed, Medline, Cochrane library and Google scholar) from inception until January 2024. Studies where the HSM was used for delivering any AMS activity, intervention or action, were included. No study specific filters were applied and all populations, study designs and health settings were included. Data screening and selection was achieved using Rayyan. Three authors independently screened studies, with conflicts resolved by a fourth author. Data were narratively synthesized. Standard appraisal tools were impractical; however, critically evaluation of data collection and outcome reporting was ensured. Results: Out of 1,438 articles, three were included in the scoping review. The primary interventions utilising the HSM in AMS involved reducing antibiotic misuse, training healthcare professionals, case-based learning, establishing AMS programs, developing antibiograms, and formulating policies or guidelines pertinent to AMS. The studies demonstrated significant clinical improvements in AMS. Clinical outcomes from the studies include a significant reduction in antimicrobial usage and improved antibiotic management, with a notable decrease in days on antimicrobial therapy and increased antibiotic de-escalation. Key facilitators for AMS program success: tailored education, collaborative learning, strong leadership, strategic practices, and data-driven decisions. Key barriers: leadership challenges, change resistance, knowledge gaps, inadequate data systems, resource limitations, and technological constraints. Conclusion: The review identified a literature gap in HSM use for AMS programs. Further studies are needed to assess HSM's effectiveness, feasibility, and cost-effectiveness in AMS contexts.

Background: It is essential to ensure that medication dispensing; a vital step in the treatment process takes place in an environment with a strong safety culture. The objectives of this study were to measure the safety culture and to assess the effectiveness of an educational intervention to improve safety culture, as perceived by dispensing pharmacists of a state sector teaching hospital of a resource limited country.Methods: An interviewer administered questionnaire, developed in-house based on published literature, was initially administered to all dispensing pharmacists of the study hospital. Two weeks later, participants attended an educational workshop on safety culture. The same questionnaire was administered one month after the workshop to assess the six domains of safety culture. The mean composite scores (MCSs) and average positive response rate (PRR) of each domain were compared before and after the intervention (5% significance level).Results: Except for the domains of environment factors and documentation, other domains (human factor, communication, supervision along with reactions and responses to mistakes) obtained a PRR of more than 50%. A statistically significant difference (p>0.05) between the MCSs or PRRs of any domain was not observed after the intervention. However, results indicated an improvement in the knowledge of safety culture among pharmacists as the total number of “don’t know” responses reduced (p=0.019) after the intervention.Conclusion: The present study implies that factors such as documentation and working environment needs to be improved to establish a sound safety culture. Additionally, educational interventions alone may have a limited effect in enhancing a safety culture in the dispensing process.

To support efforts towards addressing the increasingly growing global burden of antimicrobial resistance (AMR), a diverse and multicountry team of stakeholders developed a board and online game on antimicrobial stewardship (AMS). The game aims to create awareness and develop knoweledge of healthcare teams at all levels. Reports from initial players reflect that the game is an innovative, engaging and inclusive education resource on AMR and AMS. The game continues to be promoted for continued and wider usage across the globe.

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa, as well as to implement the checklist in health institutions in four African countries. The AMS checklist tool was developed using a modified Delphi approach to achieve local expert consensus on the items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, Ghana and the UK were invited to review, score and comment on items from a published global AMS checklist. Following their feedback, 8 items were rephrased, and 25 new items were added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites. The final tool comprised 54 items. Across the 14 sites, the completed checklists consistently showed improvements for all the AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). The elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing the quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions. Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist, which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. This study extends the existing AMS materials for low- and middle-income countries and provides empirical evidence for successful use in practice.

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents have increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR and AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists’ and other healthcare professionals’ curricula for pre-service and in-service training.

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents has increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR & AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists’ and other healthcare professionals' curricula for pre-service and in-service training.