Abstract:
Background: Antimicrobial resistance has been named as one of the top ten threats to public health in the world.
Hospital-based antimicrobial stewardship programs (ASPs) can help reduce antimicrobial resistance. The purpose of
this study was to determine perceived barriers to the development and implementation of ASPs in tertiary care cent-
ers in three low- and middle-income countries (LMICs).
Methods: Interviews were conducted with 45 physicians at tertiary care hospitals in Sri Lanka (n = 22), Kenya (12),
and Tanzania (11). Interviews assessed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescrib-
ing practices, access to diagnostics that inform antimicrobial use, receptiveness to ASPs, and perceived barriers to
implementing ASPs. Two independent reviewers coded the interviews using principles of applied thematic analysis,
and comparisons of themes were made across the three sites.
Results: Barriers to improving antimicrobial prescribing included prohibitively expensive antimicrobials, limited
antimicrobial availability, resistance to changing current practices regarding antimicrobial prescribing, and limited
diagnostic capabilities. The most frequent of these barriers in all three locations was limited drug availability. Many
physicians in all three sites had not heard of ASPs before the interviews. Improved education was a suggested compo-
nent of ASPs at all three sites. The creation of guidelines was also recommended, without prompting, by interviewees
at all three sites. Although most participants felt microbiological results were helpful in tailoring antibiotic courses,
some expressed distrust of laboratory culture results. Biomarkers like erythrocyte sedimentation rate and c-reactive
protein were not felt to be specific enough to guide antimicrobial therapy. Despite limited or no prior knowledge of
ASPs, most interviewees were receptive to implementing protocols that would include documentation and consulta-
tion with ASPs regarding antimicrobial prescribing Conclusions: Our study highlighted several important barriers to implementing ASPs that were shared between
three tertiary care centers in LMICs. Improving drug availability, enhancing availability of and trust in microbiologic
data, creating local guidelines, and providing education to physicians regarding antimicrobial prescribing are impor-
tant steps that could be taken by ASPs in these facilities.
