Introduction
Antimicrobial Resistance (AMR) is the ability of microorganisms to evade effects of drugs that could otherwise inhibit their growth or kill them. Factors that have led to the growing resistance problem include increased consumption of antimicrobial drugs, both by humans and animals, and improper prescribing of antimicrobial therapy by clinicians. In Nyeri County, there were similar problems of improper use of antimicrobials drugs, where the facilities struggled with initial prescription of broad- spectrum antibiotics that are unnecessary instead of targeted therapy based on clinical symptoms and likely organisms for the infections, and not guided by any treatment guidelines. Clinicians would prescribe antibiotics for infections due to a myriad of other causes of infections like viruses and fungi and not bacteria. These problems were brought about by inadequate mentorship of the clinicians by their seniors, patient pressure for antibiotic prescriptions, inadequate laboratory investigation, complacency of health-workers and the fact that most antibiotics have wide therapeutic index meaning they have low toxicity potential thus could be prescribed without fear of causing adverse drug reactions to the patients.
The resulting outcomes were that patients would develop antimicrobial resistance specifically to antibiotics. They would be treated severally for one infection without being cured. This resulted in the use of higher classes of antibiotics that are more expensive and more toxic; this notwithstanding, the other direct costs of previous treatments and indirect costs of visiting the hospitals several times and mental anguish on the patients. The hospitals also would incur high costs because of continual purchases of medication and administration due to costs associated with repeated visits since the patient queues would perennially be very long necessitating more staff to attend to them.
This also resulted in an alarming spread of multi- and pan-resistant bacteria (also known as “superbugs”) that cause infections that are not treatable with existing antibiotics, and this would be seen in outpatient but was worse in the inpatient setting. For example, urinary tract infections affecting patients with catheters due to bladder outlet obstruction and general population presenting with urinary symptoms that had been treated with injectable ceftriaxone and higher order fluoroquinolones (class of antibiotics approved to treat or prevent certain bacterial infections) were not responding after several cycles of therapy. Pharyngitis affecting pediatrics and adults that would normally be treated with oral amoxicillin was being treated with ceftriaxone injections. Reproductive tract infections affecting mostly sexually active adults were initially being treated with 5-day courses of cefixime or injectable ceftriaxone instead of cefixime stat or doxycycline with azithromycin and metronidazole. The overuse of ceftriaxone was also very common in both inpatient and outpatient. This indiscriminate use would result in this drug not working for other infections that it is meant for; for example, hospital acquired pneumonia or bacterial meningitis; many cases of which then required ceftazidime.
Activities Undertaken to Implement the Medicines and Therapeutics Committees as Response to the Safe Use of Antimicrobials
The activities were in line with those of antimicrobial stewardship programme adapted from the World Health Organisation (WHO). Driven by the passion to address Antimicrobial Resistance, preserve lifesaving antimicrobials and most importantly provide quality health care, the County Executive Member (CECM) for Health was very instrumental in bringing on board implementing partners USAID through the Medicines, Technologies, and Pharmaceutical Services (MTaPs) programme. The CECM had worked at the national level where she had gathered experience in antimicrobial stewardship and was cascading the same to the county level.
Through the CECM’s leadership, level 4 and 5 health facilities in the whole County revived their Medicines and Therapeutics Committees (MTCs). A Medicines and Therapeutics Committee is a multidisciplinary committee responsible for overseeing policies and procedures related to all aspects of medication use. It evaluates the clinical use of medicines, formulates policies for managing medicines use and administration.It also has broad responsibilities in determining which medicines will be available in the hospital and how they will be used. MTCs membership in Nyeri County facilities were reviewed comprising of: the hospital consultants, pharmacist specialists, clinical officers, nurse manager, commodity nurse and the laboratory in charges. In October 2019, all the MTCs of all the level 4 and 5 hospitals were trained on MTC core mandate and the need to be working through simple but very impactful action plans. A 3-day training on antimicrobial resistance was done, that included; in principle, its definition and evolution, guidelines for managing common infections, antibiotic allergies and strategies of implementing antimicrobial stewardship programmes. All facility MTCs thereafter developed standard action plans with the following activities: setting up antimicrobial stewardship (AMS) committees, reducing prescriptions with antibiotics in them and carrying out periodic antibiotic audits of the same, formally appointing members of the MTC through formal appointment letters, giving the MTC their terms of reference and seeking administration support for MTC activities. MTCs held meetings to think through the operationalisation and after the meetings, the MTCs gave feedback to their administrators and were able to get support for their activities. By December 2019, the formal appointment letters and terms of reference had been issued to all the MTC members. This brought in alotof motivation and commitment by MTC members. The AMS committees were also constituted as sub-committees of the MTCs with members drawn from MTC. In January 2020, through the support of the County Government, workshops were carried out in the level 4 and 5 hospitals targeting all cadres. This activity started with two separate one-day trainings where 40 health workers in each of the hospitals were trained on basics of antimicrobial resistance, protocols for managing common infections i.e., pharyngitis, urinary tract infections, surgical site infections, community and hospital acquired pneumonia, skin infections and allergies to antimicrobials. In Karatina those trained were as follows: twelve (12) registered clinical officers; six (6) medical lab technologists; twelve (12) nurses; four (4) pharmaceutical technologists; four (4) nutritionists and two (2) medical officers. They were also trained on Access, Watch and Reserve (AWaRe) categorization of antibiotics.
Other activities undertaken include:
- In November 2019, all the health facilities and the department of agriculture and fisheries commemorated the World Antimicrobial Awareness week with talks and posters in the hospitals, at the cattle dips and within chiefs barazas respectively.
- on 4th august 2020 the Aware categorization was adapted for all facilities and a memo was sent out to sensitize all clinicians in Outpatient Department (OPD) on AWaRe categorization emphasizing on reducing prescription of watch and reserve antibiotics.
- Following review, memos were also sent out for all clinicians in the hospital stopping the use of ceftriaxone injection in the outpatient. In the outpatient department only patients reviewed by Registered Clinical Officers (RCOs) with post basic qualifications were required to prescribe this as initial doses for complicated Sexually Transmitted Infections (STIs) not responding to first line drugs and for 3-days for infections like pharyngitis and URTIs not responding to access category medications.
- A whole month follow-up with one-on-one encounters with the clinicians in Outpatient department was done. Clinician feedback and sensitization to those who might not have seen the memo when they prescribed watch antibiotics without following the memo advice was also done.
- The pharmacy staff were all sensitized on the above to ensure the measures were adhered to during dispensing; four (4) pharmaceutical technologists, two (2) pharmacists and four (4) other support staff were also sensitized.
- A County Antimicrobial Stewardship Interagency Committee (CASIC) comprising members of human health, animal, plant and marine health was revamped to tackle AMR from the ONE health approach.
- A CASIC strategizing meeting was held on 18th August 2020 to review county progress with the health, agricultural and fisheries sectors; The CASIC strategizing meeting carried out some important activities that included.
o Radio programme in the local stations to educate on AMR
o Development of a CASIC action plan
o Sensitization to farmers in cattle dips and chief barazas on use of antibiotics
o That the regional veterinary laboratory to be sharing culture and sensitivity data to veterinary clinicians
- Antibiotic audits were done for October 2019, January 2020, and July 2020 as per the guidelines provided to assess the level of antibiotic use in the outpatient department. For the inpatient department there were planned point prevalence surveys though these are yet to be done.
- Carbonated prescriptions were reviewed with the hope of improving accountability in clinicians and to enhance antibiotic audits
- In September 2020 the AMS committees sensitized inpatient staff in all the departments on AWaRe categories, restriction of watch and reserve antibiotics to only medical officers and consultant prescription; the staff sensitized were:
o Surgery department: two (2) consultants; two (2) Medical officers, interns, six (6) Clinical officer interns.
o Pediatrics department: one (1) consultant, two (2) Medical officers interns, one (1) Medical officer, five (5) Clinical officer interns.
o Obstetrics and Gynecology department; one (1) Medical officer, two (2) Medical officer Interns, three (3) Clinical officer Interns.
o In internal medicine department: one (1) Medical officer, two (2) Medical officer Interns, six (6) Clinical officer interns and seven (7) nursing Heads of Departments.
§ In September 2020, the inpatient staff were sensitized on pre-authorization forms that were to be filled by only medical officer and consultants for watch and reserve antibiotics.
§ Clinical pharmacists who were part of the medical teams of the major ward rounds in medical and pediatric wards advised on antibiotic choices.