Antimicrobial stewardship programs in primary and secondary care settings in India: current challenges, facilitators, perceptions, and impact - a scoping review.

introductionAntimicrobial stewardship programs (AMSP) is a major initiative of World Health Organization Global Action Plan (WHO-GAP) to address antimicrobial resistance (AMR). The program aims to promote the rational use of antibiotics to help improve patient outcomes. Existing evidence on AMSPs and their activities is largely restricted to the resource intense settings in India thereby impacting sustainability and adaptation of initiatives within rural/remote region.

aimsThe review focus on the current state of AMSP practices in the Indian primary and secondary care settings, identifying the challenges, enablers, perceptions and practice of physicians, and the impact of current AMSP interventions.

methodsWe conducted electronic database searches on PubMed, Scopus, and EMBASE, in adherence to the PRISMA-ScR guidelines. Our review identifies four key domains such as barriers to AMSP establishment, facilitators for establishing AMSP, AMSP perceptions and practices among the prescribers, and the impact of AMSP interventions.

resultsAmong the 4739 articles searched, five studies met the inclusion criteria, in the primary and secondary care clinical settings in India. We focused on articles published after the 2015 post WHO GAP implementation. Barriers to AMSP implementation, including access to the healthcare system, poor regulatory implementation, poor knowledge and awareness about antibiotic regulations and AMR, and lack of awareness in all the studies. Facilitators identified for hospital AMSP implementation include, use of staff engagement, audit feedback and discussion, administrative representation, documentation, interactive sessions and education. Only one study could explore the impacts of AMSP intervention on both clinical and microbiological outcomes. The major outcomes included more appropriate antibiotic prescriptions, reduced consumption of antimicrobials, reduced hospital stays and decrease in mortality rate.

conclusionThe existing evidence based on adaptation and implementation of AMSP is sparse. This study highlights the urgent need for widespread AMSP in the resource-constraint settings of India. Multipronged approach is crucial to encompass skilled human resources, implement facility-specific interventions, develop accessible guidelines for antibiotic use, providing economic support and increasing awareness through capacity-building programs, and can attain effective establishment of AMSPs.