Factors influencing antimicrobial stewardship implementation in healthcare facilities in four countries of Southeast Asia: a mixed-methods study (2022-23).

Background: Antimicrobial stewardship (AMS) implementation is highly context dependent. This mixed-methods study aimed to assess contextual factors associated with AMS implementation at national, facility, and healthcare-provider levels in four countries. Methods: We used a sequential mixed-methods approach, with a combination of quantitative surveys, qualitative interviews and focus group discussions (FGDs) using the World Health Organisation's National AMS assessment tools at national, healthcare-facility, and provider levels in Indonesia, Nepal, Thailand, and Viet Nam between 2022 and 2023. Facility-level implementation was evaluated using the U.S. Centers for Disease Control and Prevention's Global Antibiotic Stewardship Evaluation Tool (G-ASET) in 16 hospitals across these countries. We included stakeholders and healthcare personnel involved in AMS implementation at the national and hospital levels. Findings: All four countries had national AMS policies, and two incorporated financing mechanisms into national action plans. Main areas for further improvement were the development of stewardship guidelines for primary care and community settings; stronger linkages across related sectors and programmes; expanded professional training; strengthened regulatory enforcement; systematic performance tracking; and better data use for feedback and decision-making. Among the 16 hospitals, the mean G-ASET score was 241/335 (72%), highest in tracking, monitoring and reporting [56/75 (75%)] and lowest in training and education [17/25 (66%)], and the scores varied by hospital type and size. Although all hospitals had initiated AMS activities, implementation was often partial, with gaps in data-informed treatment guidelines, staff training, and resources. Interpretation: National guidelines on treatment and stewardship initiatives are crucial and trainings for healthcare personnel need to be strengthened for facility-level AMS implementation. Enhancing inter-programme coordination and support for small-size hospitals and primary care settings in Asia will be essential to advance AMS implementation. Funding: Supported by the U.S. Centers for Disease Control and Prevention.