Inappropriate use of antibiotics has become a serious threat to public health.Taking antibiotics for the wrong reasons or incorrectly causes bacteria to become resistant to antibiotic treatments. So when you do need antibiotics in the future they may no longer work.
Keeping antibiotics effective is everyone’s responsibility. In accordance with the WHO recommendations The National Campaign For The Proper Use Of Antibiotic was conducted to raise awareness and initiate action to eliminate the inappropriate use of antibiotics.
WHO 3rd Global Patient Safety Challenge enhanced having antimicrobial stewardship to decrease the prevalence of antimicrobial resistant organisms.
Antimicrobial stewardship (antimicrobial management programs) is an activity that includes appropriate selection, dosing, route, frequency and duration of the therapy. The primary goal of this stewardship is to optimize clinical outcome while minimizing unwanted consequences of antimicrobial such as emergence of resistance and toxicity.
The campaign was under support of Undersecretary Assistant For Public Health Affairs and it targeted the physicians, other health care providers, pharmacists and the general public . It was conducted in all governmental hospitals starting from March, 2009.
Vision
Rational use of antibiotics in Kuwait Health care settings by 2014.
Mission
Promote appropriate antibiotic usage for patients in Kuwait Health care settings through awareness, education and adoption of best practices.
There was a full coverage for the activities of the campaign by the media in the form of reports in the Newspapers , Television programs on (kuwait-Al Rai- AL Watan channeles), Radio programmes ( Kuwait-Quraan kareemm) ,large electronic displays (LED) advertisment in Salmiyah and advertisments on City bus.
Phase1
The campaign was launched March 19th , 2009 in the Islamic Medical Centre under the Patronage of his excellency the Minister of Health with attendence of Undersecretary of Ministery of Health and Assisstant Undersecretary for Support Service and representatives from doctors in different specialities.
A committee was formulated to be responsible for conducting the campaign chaired by the of director of the Infection Control Directorate, and membership of infection control doctors, microbiologist, infectious disease consultant and biostatisticians
Members of the committee were divided into 5 subcommittee
- Budget committee.
- Scientific committee.
- Information and awareness committee.
- Statistical analysis of data committee.
- Audit for the adherence to the local antibiotic policies in the hospitals committee.
Action Plan for the campaign
Stage I
- Approval of audit protocol by the Ethical Committee for Medical Researchers in Ministry of Health ,Kuwait .
- Formulation of sheet for auditing the adherence to the local antibiotic policies in the selected governmental hospitals.
- Training for the infection control doctors on filling the audit sheet.
- Designing of the campaign logo and posters .
- Designing a website on the Internet for the activities and events of the campaign.
- Conducting a pilot study in similar circumstances of the main study for one week on the selected hospitals.
- Auditing for the compliance to the local antibiotic policy in the selected hospitals.
- Statistical analysis for the audit and results preparation.
Stage II
- Campaign launching ( including lectures showing results of the audit).
- Sendindg short messages (SMS) to doctors in collaboration with Kuwait Medical Association.
- Coordination with the media to cover the activities of the campaign.
- Activities of the campaign in all governmental hospitals
- Lectures by the infection control doctors to different departments to illustrate the audit results ,get a feed back and elucidate recommendations.
- Distribution of brochures, posters,booklets and National antibiotic policy handbook by infection control team in the hospitals to healthcare workers and public
- Questionnaire filled by the visitors ,patient relatives to measure their awareness about proper use of antibiotics.
- Gifts with campaign logo were distributed to hospital staffs and to the visitors and patient relatives
- Some of the campaign activities were conducted in one of the most popular shopping mall in Kuwait(Avenues) for public awareness to the campaign activities .It included
- Personal interviews by the infection control doctors with the public to deliver the key messages of the campaign.
- Filling the Questionnaire to measure the public knowledge about the proper use of antibiotics
- Distribuation of the campaign educational materials.
- Distribution of gifts
Audit of the compliance to local antibiotic policy
• The aim was to audit doctors’ adherence to hospital antibiotic guidelines before and after the introduction of educational interventions of the campaign.
• Study design: It was a retrospective descriptive study of compliance to local antibiotic policy in Governmental Kuwait hospitals .
• Prior to the audit , a pilot study was conducted .
• Study setting: Out of six general governmental hospitals, four hospitals were randomly selected ( Al Sabah-Al Amiri- Mubarak Al Kabeer and Al Farwania) .
• Out of thirteen specialized governmental hospitals, five hospitals were randomly selected (Ibn Sina- Al Babtein-Hamed Al Essa - Al Bahar and Maternity).
• Selection of patients’ files was random from 2007 hospital discharges of
the corresponding hospitals using Kuwait Ministry of Health data base.
• Decision of the total number of files selected from each hospital was
proportional to its discharge.
• Total of 3000 hospital patient files were selected , If any selected file was missing, it was traced till the end of the audit period.
• Data Collection
• For all selected files, antibiotic therapy of the last condition required antibiotics were collected. Compliance of the antibiotic data to the hospital antibiotic policy was judged in relation to hospital guidelines issued at the corresponding hospital regarding the choice of antibiotic treatment, dose, route, frequency, duration, indication for antibiotic therapy.
Results
• It was found that 25 % of the prescribed antibiotics was not indicated. 52.8% of antimicrobial were appropriate chice for the condition. Only 30.4% of all reviewed files were adhernt to all parameters of antibiotic prescription according to the hospital policy.
Conclusions
• Antibiotics were prescribed in 49.8% of the reviewed files.
• Some policies were not reviewed & updated .
• Policies were deficient in specifying Indication for antibiotic therapy (10.1%) Dose (12.7% ), Route (11.7%) , Frequency (13.2%) and Duration (19%) .
• Certain conditions requiring antibiotics were not mentioned in the local policies (11.2% )
Recommendations
• Adherence to the local antibiotic policy needs to be promoted.
• review & update of the policy are required periodically with regular monitoring of the adherence to the policy .
• Continuous Education to the doctors is vital.
Phase2
It started with very enlightening motivating CME accredited workshop. It consisted of lectures by different interested specialities in the field: Infection prevention and control, infectious diseases, microbiology, surgery, primary care and pharmacy.The workshop started by publicizing the result of the second audit of physician adherence to the local antibiotic policy. In addition, the workshop browsed between antibiotics use in primary care, in surgery and antibiotic utilization: pharmacy perspective. It focused on antibiotics resistance and overuse, abuse and misuse of antibiotic prescriptions. Furthermore, the results of enormous survey that was conducted among doctors and public's to obtain their knowledge, perception and behavior were publicized .
There was a full coverage for the activities of the campaign by the media in the form of reports in the Newspapers , Television programs and Radio programmes. Large electronic displays advertisment was placed in most of primary health care centres, TV channels and all Kuwait co-operative socities.
There after, the activies of the campagin were conducted in all governmental hospitals afterwards which include:
Audit on adherence to antibiotic policy in Kuwait governmental hospitals (2nd audit)
Aim was to audit doctors’ adherence to hospital antibiotic guidelines after the introduction of educational interventions in the first phase of campaign
(March 2009). This was achieved by finding out if the antibiotics were correctly prescribed in accordance with the standards given in the local antibiotic policy.
Study design: Multicenter descriptive retrospective medical records review. Study Setting: Four general governmental hospitals (Al Sabah- Al Amiri-Mubarak Al Kabeer and Al Farwania). And five specialized hospitals (Ibn Sina- Al Babtein -Hamed Al Essa - Al Bahar and Maternity) they were randomly chosen.
Result
Phase3
The 3rd phase of campaign was launched in the infection control directorate on 14th November 2012 with a valuable workshop focusing on antimicrobial resistance and proper use of antimicrobials. It targeted all healthcare personell (HCP) of all specialities in the private sector.
The activies of the campagin started in all Kuwait governmental hospitals and primary healthcare centres in the same day.
There was a full coverage for the activities of the campaign by the media in the form of reports in the Newspapers , Television programs, Radio programmes , educational video flashes on closed circuits in hospitals, primary healthcare centres and cooperative markets.
Objective of 3rd phase
- Because changes in antimicrobial prescribing patterns will necessitate changes in doctors’ behavior, the 2nd and 3rd phase objective was targeting doctors’ behavior, a better understanding of these underlying factors will permit the development of a more effective intervention.To study the doctors and public’ knowledge, perception and behavior towards antibiotic resistance and use, a cross-sectional survey was performed.
- the campaign in 3rd phase has focused on the private sector particularly because of the widespread misuse in antimicrobial use.
The campaign activities:
- The campaign was launched in the infection control directorate on 14th November 2012.
- An informative workshop focused on the rising of antimicrobial resistance and the proper use of antimicrobials was conducted.
- The workshop targeted all doctors in all specialties in private sector.
- The workshop gained CME points.
- The program included several lectures by infection control doctors.
- Lectures by the infection control doctors to different departments to illustrate the audit result, provide feedback and elucidate recommendations.
- Distribution of brochures, posters, booklets and National antibiotic policy handbook by infection control team in the hospitals to healthcare workers and public.
- Presentation of educational video flashes emphesizing the importance of antimicrobial jugious use in all closed circuits in hospitals, primary healthcare centers and cooperative markets.
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HCP questionnaire was performed to measure their awareness about proper use of antibiotics.
- Gifts with campaign logo were distributed to hospital staffs and to the visitors and patient relatives.
- Personal interviews by the infection control doctors with the public to deliver the key messages of the campaign.
- Public questionnaire to measure the public knowledge about the proper use of antibiotics was carried out.
Conclusion
- Doctors had good knowledge but suboptimal antibiotic prescribing behavior.
- No significant difference in prescribing practices between doctors in hospitals and PHC.
- Majority of doctors perceive that there is an antibiotic resistance problem in Kuwait mainly as a result of misuse by the public, and over-prescription by the doctors themselves.
- The main drive for excessive antibiotic prescribing are: lack of time to perform the required investigation, fear of complication and antibiotic resistance concerns.
- The older the age and the higher knowledge the better the behavior.
- In the doctors’ opinion, non-adherence to the policy could be mainly attributed to non-availability or poor distribution of the policy, neglect of reading the policy, being incomplete or not updated and interrupted supply of some antibiotics.
- Compared to 2011 significant improvement in knowledge & behavior was observed.
- Out of the listed reasons for non adherence to antibiotic policy, significant decline was observed among more than 70% of items.
- knowledge score were significantly higher in hospitals compared to PHC. However, behavioral score showed no significant difference, where comparable figures was observed in most of behavioral questions.
- PHC showed significantly higher % of the listed reasons (compared to hospitals) related to non adherence to antibiotic policy.
- Still the lowest knowledge area was related to types of resistant organisms & isolation precautions.
- Behaviors related to prescription of antibiotics due to fear of complications, no enough time for investigations, diagnostic uncertainty and use of antibiotics for patients’ satisfaction (specially in PHC) are still prevailing .
Recommenadtions:
- Abx prescribing during viral illnesses like colds and flu should be avoided by the doctors.
- Antibiotic policy should always be the first reference to antibiotic prescribing.
- Update, availability, and proper distribution of the policy, beside ensuring uninterrupted supply of policy-cited antibiotics would enhance adherence to the policy.
- Antibiotic policy should be readily accessible to all working physicians in all health care settings (hospitals & PHC).
- Improving antibiotic prescribing by in-facility approved restrictive measures and computer-assisted decisions.
- Behaviors related to fears of complications, no enough time for investigations, diagnostic uncertainty and use of antibiotics for patients’ satisfaction should be remodeled .
- The reasons behind non adherence to antibiotic (specially policy as unawareness or unavailability of policy) should be highlighted & discussed with hospital management.
- The Campaign related activities should continue in all health care settings through:
- Periodical meetings of antibiotic committees in hospitals.
- Workshops and lectures
- Public information on antibiotic use should be raised. Certain concept about the role of antibiotics particularly during colds and flu should be changed using promotional and mass media campaigns.
