Pharmaceutical Services Strategies

Antimicrobial Stewardship
Continuous Quality Improvement

Drug and Therapeutics Committees
Preservice Curriculum Reform
Medicine Use Evaluation

Antimicrobial Stewardship

Antimicrobial stewardship and complementary infection control and surveillance programs are considered key strategies to contain antimicrobial resistance (AMR). Comprehensive antimicrobial stewardship programs have consistently demonstrated success in reducing inappropriate antimicrobial use by as much as 36% in hospitals.[1] These strategies help to preserve the efficacy and future use of antimicrobials, reduce adverse drug events, lower health care costs, and ultimately contribute to improved patient outcomes.

Key components of an antimicrobial stewardship program include standard prescribing guidelines and clinical pathways, antimicrobial use evaluations, audit and feedback of prescriptions, formulary management, provision and use of local susceptibility data, control of pharmaceutical promotional activities, and appropriate education and training for hospital staff and the public.

The USAID-funded SIAPS program worked to improve the rational and appropriate use of antimicrobials through the use of antimicrobial stewardship approaches in low- and middle-income countries.

Key SIAPS activities contributing to antimicrobial stewardship included:

  • Local advocacy and coalition building for antimicrobial stewardship programs
  • Development and implementation of standard treatment guidelines and formularies
  • Antimicrobial use evaluations
  • Support for the development of an antimicrobial stewardship strategy and stewardship committees
  • Pre-service curriculum reform to include rational medicine use and AMR
  • Journalist trainings and publication of antimicrobial stewardship materials for media
  • Collaboration with professional associations to promote antimicrobial stewardship
  • Measurement of early warning indicators for HIV drug resistance

To help stakeholders and local partners achieve these activities, SIAPS developed materials, guidance documents, and how-to manuals to support the implementation of antimicrobial stewardship programs, including:

Continuous Quality Improvement

The continuous quality improvement (CQI) concept in program management is an iterative or cyclical approach that includes elements of self-reflection on processes or feedback; identification and elimination of inefficient processes; and quality improvement through small-scale, incremental changes. CQI has the potential to improve systems of patient care and outcomes by using existing resources, making the rationale for applying it in countries with limited resources compelling.

SIAPS and its predecessor programs—Strengthening Pharmaceutical Systems, Rational Pharmaceutical Management (RPM), and RPM Plus—used the CQI approach to help countries strengthen pharmaceutical management in their health facilities to improve the health of their people. SIAPS adapted the CQI approach in a program called monitoring-training-planning (MTP) to make it suitable for the audience and setting in each country. SIAPS collaborated with in-country stakeholders in Afghanistan, China, Ethiopia, Kenya, Liberia, Malawi, Mozambique, Rwanda, South Africa, South Sudan, Tanzania, and Uganda to train health care workers on how to use MTP to better manage pharmaceuticals. The program also helped countries in Africa and Latin America improve hospital infection control practices by using infection control self-assessments and CQI. More recently, SIAPS helped three public hospitals in Jordan develop a system for improving antibiotic prophylaxis in cesarean sections using the CQI approach.

Drug and Therapeutics Committees

Supporting Drug and Therapeutics Committees (DTCs), which evaluate clinical use of drugs, develop policies for managing drug use and administration, and manage the formulary system, is a proven strategy that contributes to effective, safe, and cost-effective use of medicines in a health facility. However, many developing country institutions lack functioning DTCs or face challenges in managing them effectively. 15-272

SIAPS focused on DTCs as a core strategy to improve medicine use and contain AMR—primarily by collaborating with in-country partners, including ministries of health and hospitals, to establish, revitalize, or improve the efficiency of DTCs. This strategy included training DTC members and providing technical assistance to members to plan, implement, and monitor improvement activities.

SIAPS established local cadres of DTC master trainers in a country to build local capacity and sustain DTC scale-up. The program also helped DTCs conduct studies to identify medicine use problems and use the results to find appropriate and cost-saving solutions. Committees received support to develop and maintain standard treatment guidelines and formularies, provide medicine information to health care providers and patients, and carry out pharmacovigilance activities.

Effective DTCs help improve medicine availability, promote rational use and medicine safety, and contain AMR within their institutions.


Preservice Curriculum Reform

Preservice Curriculum Final_Page_01Preservice curriculum reform is a cost-effective and sustainable intervention that leads to broader health system strengthening. It provides students with a critical foundation of knowledge and skills and develops their competency to practice in the real world. Effective preservice training reduces the need for future large-scale and expensive in-service trainings.

Proper preservice exposure to some key pharmaceutical management topics, such as rational medicine use (RMU), antimicrobial resistance (AMR), pharmacovigilance, pharmaceutical care, and supply chain, is critical for practice competency in various health-related fields, especially pharmacy, nursing, medicine, and public health. But curricula in resource-constrained countries often do not adequately address such topics. SIAPS and its predecessor programs provided technical assistance to Afghanistan, Ethiopia, Kenya, Liberia, Namibia, Rwanda, South Africa, Swaziland, Vietnam, and Zambia to reform their preservice training courses.

SIAPS developed a guidance document entitled Revising Preservice Curriculum to Incorporate Rational Medicine Use Topics: A Guide. The document describes a step-wise process to add RMU components to preservice training curricula, including tools and templates. It also provides examples of curriculum reforms carried out in resource-constrained countries to include RMU, AMR, and pharmacovigilance topics. Click here to read the guide.


Medicine Use Evaluation

Medicine use evaluation (MUE), or drug utilization review, is a method for reviewing and improving how medicines are used, including the prescribing, dispensing, and administering processes. It is a structured and ongoing process that compares actual medicines use to established criteria or standards and can detect inappropriate or costly medicine use, identify suitable interventions, and measure the effect of implemented solutions. Applying a continuous quality improvement (CQI) approach complements and enhances the MUE process.

SIAPS worked to build the capacity of in-country stakeholders to design and implement MUE programs. For example, SIAPS supported the implementation of MUE exercises at three hospitals in Jordan using complementary CQI methods to improve prophylactic antibiotic use during cesarean sections. The interventions led to improved use of correct antibiotics administered at the correct time and increased cost-savings. SIAPS also supported local stakeholders in Kenya to design and conduct MUEs for tuberculosis medicines.

An initial review of medicine use can identify specific problem areas that can then be addressed through focused MUE programs. For example, SIAPS published a hands-on tool—How to Investigate Antimicrobial Use in Hospitals: Selected Indicatorsto help carry out an initial investigation for antimicrobials, a commonly misused class of medicines.

Available in English, Spanish, and French, the manual defines 17 indicators to objectively measure antimicrobial management and use and provides detailed instructions on how to carry out the assessment. This tool can help drug and therapeutics committees, physicians, pharmacists, managers, and researchers better monitor and assess antimicrobial use in their facilities, enhancing the rational use of medicines and, ultimately leading to better patient outcomes.

[1] Dellit et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of AmericaGuidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 2007; 44:159–77