Strengthening antimicrobial stewardship in public health facilities in Malawi through a participatory epidemiology approach.

Background: In healthcare settings, antimicrobial resistance (AMR) is largely driven by excessive use of antibiotics. Empirical prescription largely remains common due to fragile healthcare systems characterized by lack of appropriate diagnostic services. Despite limited data on the epidemiology and the burden of AMR due to the scarcity of routine microbiology facilities, it is evident that Malawi shares a heavy burden of AMR. Effectively implemented antimicrobial stewardship programmes have demonstrated successes in minimizing inappropriate antibiotic usage, and curbing the burden of AMR. However, there are limited data on how antimicrobial stewardship teams can effectively deliver their roles in hospital settings in resource limited settings, including in Malawi. Methods: Malawi's Antimicrobial Resistance National Coordinating Centre (AMRCC) in collaboration with Clinical Research Education and Management Services (CREAMS) conducted participatory workshops with hospital-based antimicrobial stewardship committees aimed at establishing drivers of resistance and antibiotic overuse in hospitals from the perspective of the committees, and co-design facility-friendly intervention against AMR. The workshops consisted of participatory discussion, sorting and design thinking exercises, utilizing principles of implementation research. All the interviews were recorded, transcribed and thematically analysed, revealing key drivers for antibiotic overuse and resistance in hospital settings. Data were analysed using thematic content analysis. Results: Key drivers of AMR included limited antibiotic formulary access, poor cross-sectoral coordination challenges between healthcare, veterinary services, government agencies and private facilities, and culturally specific barriers. The participants recommended regular training for healthcare workers on AMR and infection prevention and control (IPC), widespread dissemination of AMR findings, public awareness, introducing electronic monitoring systems and the enforcement of antibiotic restriction policies as the best measures for improving rational antimicrobial use and controlling the spread of AMR. Conclusions: Our findings underscore the complexity of the drivers for antibiotic overuse and resistance in hospital settings, as well as the need for more participatory approaches in tackling the complex challenge of AMR. The findings also signify the importance of a bottom-up approach in designing a solution for promoting antimicrobial stewardship and controlling resistance in hospital and community settings. Participatory approaches blended with principles of implementation research will help to identify contextual challenges, and help to design solutions that are people-centred, context-specific and largely accepted by all involved stakeholders.