2.1 Where to start: hospital facility-level AMS structures

AMS can be introduced or progressed in individual healthcare facilities by building on existing capabilities and resources using a stepwise approach. The starting point is to assess the current situation. Usually healthcare settings have pharmaceutical and therapeutic committees – often referred to as drugs and therapeutics committees (DTCs) – that oversee the use of all drugs used at the institution. These already existing committees could initiate the AMS programme.

The WHO has produced a toolkit, Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries (WHO, 2019) as a practical guide for setting up AMS structures at national, regional and healthcare facility levels. The elements of each programme are stratified into core and advanced (which require more facilities) and the exact nature of each programme will depend on the situation and the resources available.

The first step is to assess any AMS strategies already in place, and consider additional strategies that can be easily implemented. Areas for assessment could include:

• the availability of data on antimicrobial consumption
• whether prescription audits are routinely performed
• whether there is appropriate training for healthcare staff available at the facility.

The assessment can then be used to allocate human and financial resources to AMS and set up sustainable governance structures. These should be multi-disciplinary but may depend on existing structures and resources: for example, the AMS committee could be stand-alone or embedded in another existing committee such as the DTC.

Sample terms of reference for AMS structures, including for a hospital-level AMS committee, are set out in the WHO toolkit (WHO, 2019).

The membership of such a committee, which is set out in Annex II of the WHO toolkit in more detail, is likely to include:

• the administrator of the healthcare facility (chair)
• a director of medical services (vice chair)
• a clinical lead, physician or microbiologist
• a physician or pharmacist to act as secretary
• directors of other departments
• a patient safety and clinical manager
• representatives from nursing, pharmacology, microbiology and the different wards
• representatives from other relevant committees (e.g. DTCs) if the AMS committee is not embedded in one of these
• other members co-opted as necessary.

Regardless of whether or not the AMS committee is separate or a sub-committee of the larger DTC, there should be collaboration between the AMS committee and those overseeing IPC programmes and diagnostic stewardship programmes (DSPs), where these are in place. DSPs are systems and interventions designed to promote evidence-based utilisation of diagnostic tests, focusing on the role of the laboratory in clinical decision-making. DSPs and AMS have distinct roles but may be overseen by one committee.

The AMS committee should produce regular activity reports on the implementation of the AMS programme, both for their own healthcare facility management and for dissemination to regional/national structures. These reports should include data on AMU, resistance patterns for key pathogens and interventions implemented by the AMS team. The AMS committee is also responsible for ensuring that up-to-date standard treatment guidelines and ongoing training are available to all staff.