272 research outputs found
A mixed-methods study of antibiotics use and prescribing dynamics in Indonesian hospitals: implications for antimicrobial stewardship
No full textAntimicrobial resistance (AMR) is an accelerating public health problem, with antimicrobial agents, including their inappropriate use, being one of the key drivers. In Indonesian hospitals, there is a fragmented picture of antibiotic use and of the drivers of prescribing patterns. This thesis aimed to fill this knowledge gap by assessing patterns and quality indicators of antibiotic prescribing for hospitalised patients, mapping their drivers and dynamics, and exploring the factors influencing the implementation of antimicrobial stewardship (AMS) programmes.
Using an explanatory sequential mixed-method approach, data collection was conducted in six hospitals in Jakarta, between March 2019 and October 2020.
A quantitative survey found high proportions of hospitalised patients receiving systemic antibiotics, that guideline compliance was poor, use of blood cultures was low, and that prolonged surgical prophylaxis was common.
The qualitative findings revealed multidimensional social-cultural factors influenced antibiotic prescribing, such as disjunctions between drivers of AMR and day-to-day clinical practice, antibiotic prescribing as risk aversion vis-à-vis concerns of poor clinical outcomes, the ‘pull’ of conformity to normative, suboptimal group prescribing practices, and suboptimal operations of microbiology and surgical facilities. Effective AMS programme implementation was challenged by ineffective resourcing and institutional buy-in, cost-prohibitive culture testing, entangled hospital priorities to generate profits, and a non-collegial communication approach to AMS execution.
Three identified areas of improvement are addressing hierarchical cultural norms in the medical profession, encouraging ownership of the AMR problem and solution among all stakeholders, and developing sustainable context-specific AMS strategies. Based on the complex adaptive system (CAS) concept, I formulated four recommendations: 1) identifying the agents of influence; 2) evaluating the problem using a CAS lens; 3) developing health system resilience; and 4) identifying leverage points.
In conclusion, this thesis contributed to the development of a conceptual framework showing how multilevel and multidimensional social-cultural factors interact to influence antibiotic prescribing and AMS implementation
Global knowledge gaps on antimicrobial resistance in the human health sector: A scoping review
No full textABSTRACT: Objectives: To identify and summarize existing global knowledge gaps on antimicrobial resistance (AMR) in human health, focusing on the World Health Organization (WHO) bacterial priority pathogens, Mycobacterium tuberculosis, and selected fungi. Methods: We conducted a scoping review of gray and peer-reviewed literature, published in English from January 2012 through December 2021, that reported on the prevention, diagnosis, treatment, and care of drug-resistant infections. We extracted relevant knowledge gaps and, through an iterative process, consolidated those into thematic research questions. Results: Of 8409 publications screened, 1156 were included, including 225 (19.5%) from low- and middle-income countries. A total of 2340 knowledge gaps were extracted, in the following areas: antimicrobial research and development, AMR burden and drivers, resistant tuberculosis, antimicrobial stewardship, diagnostics, infection prevention and control, antimicrobial consumption and use data, immunization, sexually transmitted infections, AMR awareness and education, policies and regulations, fungi, water sanitation and hygiene, and foodborne diseases. The knowledge gaps were consolidated into 177 research questions, including 78 (44.1%) specifically relevant to low- and middle-income countries and 65 (36.7%) targeting vulnerable populations. Conclusion: This scoping review presents the most comprehensive compilation of AMR-related knowledge gaps to date, informing a priority-setting exercise to develop the WHO Global AMR Research Agenda for the human health sector
Drug-resistant HIV-1 in sub-Saharan Africa: clinical and public health studies
No full textThe past decade has witnessed an unparalleled expansion of access to antiretroviral treatment for people living with HIV/AIDS in sub-Saharan Africa. This historic public health achievement has saved the lives and improved the well-being of millions of people. Concern has been raised about rising drug-resistant HIV in resource-limited countries as a potential threat to the worldwide control of HIV/AIDS. To this end, the PharmAccess African Studies to Evaluate Resistance (PASER) network was established in Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe in 2006. This thesis presents the results of landmark research on the epidemiology, diagnostic strategies, clinical management and public health implications related to emerging HIV drug resistance in sub-Saharan Africa
What the WHO's list of essential diagnostics means for clinical microbiology laboratories and antimicrobial stewardship practice worldwide
No full textNext-generation sequencing and HIV drug resistance surveillance
No full textCirculating drug-resistant HIV-1 variants in antiretroviral-naive populations are on the rise in regions where access to antiretroviral therapy (ART) has recently been scaled up, particularly in low-income and middleincome countries (LMICs).1,2 This increase threatens the success of national ART programmes and the achievability of the UNAIDS 90-90-90 treatment goals for AIDS.
A thirty-four-marker spectral flow cytometry panel for deep immunophenotyping to characterize activation, cytotoxic and metabolic features of unconventional and conventional T cells in human peripheral blood
No full textThis data is part of a manuscript describing the development and validation of a spectral flow cytometry panel
Antimicrobial-resistant infections, and diagnostic and antimicrobial stewardship practices in inpatients in Indonesia
No full textAntimicrobial-resistant (AMR) bacterial infection is a global threat to public health. Low and middle-income countries (LMICs), including Indonesia, is the hot spot of AMR infection. Understanding AMR situation, clinical diagnostic practices, and antimicrobial use practices in Indonesia could contribute to inform opportunities for intervention; including diagnostic stewardship programme and antimicrobial stewardship program (ASP). The objectives of my studies are to improve understanding of the epidemiology of AMR infections, clinical diagnostic practices and antibiotic use practices in Indonesian national referral hospital, and the current state of nation-wide ASP implementation in Indonesian hospitals before and during the COVID-19 pandemic.
Using routine microbiology and hospital admission databases of the Indonesian national referral hospital from 1 January 2019 to 31 December 2020, I evaluated proportion and incidence rate of AMR-bloodstream infections (BSIs), and blood culture utilization rate. I observed that in the Indonesian national referral hospital, the proportion of resistance for each bacterial pathogen was not different between COVID-19 and non-COVID-19 cases. The observed incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization.
I developed clinical diagnostic and antibiotic use practice parameters to monitor and evaluate hospital diagnostic and antimicrobial stewardship practices in resource-limited settings. Using data from routine microbiology, hospital admissions, and antimicrobial dispensing databases of the Indonesian national referral hospital spanning from 1 January 2019 to 31 December 2020, I assessed clinical diagnostic practices and antibiotic use practices. Specifically, I used Fine and Grey sub-distribution hazard models to evaluate the time to mortality, time to blood culture sampling, and time to discontinuation of parenteral antibiotics, while accounting for competing risks for each outcome. I showed that the proportion of timely blood culture is low, and duration of parenteral antibiotics is long in both COVID-19 and non-COVID-19 patients.
I conducted the first nationwide assessment of the current state of hospital ASP implementation across all 34 provinces of Indonesia and estimated the impact of COVID-19 on ASPs at the sub-national level. Applying a mixed-method approach with an explanatory sequential design, I contextualized combined quantitative and qualitative data. Initially, ordinal regression models were used to estimate associations between ASP implementation scores and explanatory variables at both the hospital and district levels. Subsequently, practical thematic analysis was employed to delve deeper into the barriers and enablers of ASP implementation. By integrating the enablers and barriers identified from quantitative and qualitative findings using the System Engineering Initiative for Patient Safety (SEIPS) framework, I formulated recommended future actions.
This thesis describes works which generated data, provided evidence, and developed parameters of measuring hospital AMR infections, blood culture utilization, diagnostic practices, antibiotic use practices, and ASP implementation in Indonesia
A qualitative study of barriers to antimicrobial stewardship in Indonesian hospitals: governance, competing interests, cost, and structural vulnerability
No full textBACKGROUND: Antimicrobial resistance (AMR) is one of the leading global public health threats of the 21st Century. Antimicrobial stewardship (AMS) programmes have been shown to improve antibiotic use and clinical outcomes in high-income settings, but context-specific evidence is lacking on the value and effectiveness of current AMS programmes in low-resource settings. This study sought to explore context-specific underlying barriers to AMS implementation in Indonesian hospitals with a focus on governance practices and structural vulnerabilities. METHODS: We conducted semi-structured interviews with physicians, surgeons, clinical microbiologists, pharmacists, AMS team leaders, hospital managers, medical students, and national AMR stakeholders, and performed a thematic analysis. RESULTS: Based on 51 interviews conducted between January and October 2020, four main barriers to AMS implementation were evident in the participants' experiences: (1) Ineffective resourcing and institutional buy-in regarding mandatory AMS under hospital accreditation; (2) Entangled priorities to generate profits and interprofessional relationships between doctors and hospital managers or AMS leaders; (3) Cost-prohibitive bacterial culture testing and thresholds of national health insurance coverage; (4) Unreliable infrastructures, including microbiology laboratory and surgical facilities, ensuring high antibiotic usage to cover structural vulnerabilities. CONCLUSIONS: Limited progress will be made with implementing AMS in Indonesian hospitals, and in settings with similar structural features, without addressing concerns around governance, competing interests, cost and structural vulnerabilities
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