2.2 AMS in primary healthcare systems

This course focuses primarily on AMS in hospitals, but AMS is also very important in primary healthcare (PHC) systems, such as a family doctor, pharmacist or local clinic. The most important elements of AMS in PHC are as follows:

  • Commitment: A commitment from all healthcare team members to prescribe antimicrobials appropriately and engage in AMS. This approach is critical for improving antimicrobial prescribing.
  • Policy and practice: Use evidence-based diagnostic criteria and treatment recommendations for patient management.
  • Tracking and reporting: This is called ‘audit and feedback’. It can guide changes in practice and can be used to assess progress in improving antimicrobial prescribing.
  • Education and expertise: Education on appropriate AMU can involve patients and clinicians. Educating patients and family can improve health literacy and enhance efforts to improve AMU. Education for clinicians and clinic staff can reinforce appropriate antimicrobial prescribing and improve the quality of care.
(Adapted from Sanchez et al., 2016; Bitton et al., 2019; Park, 2019)

In high-income countries AMS in PHC settings may use an integrated database system, which includes information technology support to pharmacists for processing prescriptions, and preparing and dispensing medication. This approach is recommended based on the evidence from a US study (Sanchez et al., 2016).

However, this integrated technology is unlikely to be available in LMICs, so a stepwise approach could begin by setting up a regional or local AMS committee, comprising representatives from medical, pharmacy and laboratory staff. Because of the weakness of many LMIC PHC systems, improved funding and commitment at all levels, and education about AMR, are key to improving AMS.

Educating the general population about AMR and correct AMU is important at a national or regional level, because general awareness of this problem is poor: patients’ demands for antimicrobials often result in inappropriate prescriptions being made, and over-the-counter purchases of antimicrobials is also common. Healthcare workers should also be provided with specific information and training to improve their awareness, which can be poor in situations where they are under-resourced and under pressure.

People in geographically remote locations, or in areas where there are too few healthcare workers, may consult untrained health assistants. Therefore, education about the issues is essential: radio, television and other media may be used most effectively. Approaches such as healthcare workers explaining AMR and correct AMU to the patient while providing the prescription can also improve general awareness (Rijal et al., 2021).

Activity 3: Improving AMS in your setting

Timing: Allow about 10 minutes

If you work in a hospital or PHC setting, think about:

  • how you might improve communication and involvement of relevant professionals
  • other measures you could take to improve AMS.
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Discussion

Some of the things that you will have thought of will be specific to your setting. You may also have considered the following:

  • Enhancing the involvement of pharmacists by regular meetings or teleconferences, and developing integrated databases if the computer facilities are available.
  • Ensuring timely updates on local AMR susceptibility data by enhancing the communication between the laboratory or clinical microbiologist, pharmacists, and prescribers.
  • Implementing a review of the local facility prescribing practice based on local known resistance patterns, carried out by representative pharmacists, medical and laboratory staff.
  • Using regular audit and feedback to provide up-to-date prescribing guidelines, and disseminating these effectively (either electronically or as posters).
  • Regular in-service training for medical staff, with input from clinical microbiology and pharmacy staff.
  • Using posters and media to improve the awareness of patients and local people of the importance of appropriate AMU.
  • Using leaflets to explain AMR and correct AMU to patients at the point of prescription.
  • Arranging training on AMR for all staff at your PHC facility, either in person or using online courses.
  • Nominating one person at your PHC facility to undertake more extensive training relevant to AMS; they can become a local expert who can educate others.

2.1 Where to start: hospital facility-level AMS structures

3 Behavioural change