166. Barriers to implementing antimicrobial stewardship programs in low- or middle-income country settings: findings from a multi-site qualitative study

Robert J Rolfe, Jr, MD DTMH, Charles M Kwobah, MBChB, MMed, Florida Muro, MD, PhD, Anushka S Ruwanpathirana, MBBS, Furaha Lyamuya, MD, Champica K Bodinayake, MBBS MD, Ajith Nagahawatte, MBBS MD, Dammalage Lasanthi Bhagya Piyasiri, MBBS, DipRCPath, MD, Tianchen Sheng, MSc, John W Bollinger, MS, Chi Zhang, Richard H Drew, PharmD, MS, Peter S Kussin, MD, Deverick J Anderson, MD, MPH, Christopher W Woods, MD, MPH, Melissa H Watt, PhD, Blandina T Mmbaga, MD, Mmed, PhD, L Gayani Tillekeratne, MD, MSc
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Antimicrobial resistance has been named as one of the top ten threats to health in the world. The World Health Organization has endorsed the implementation of hosptial-based antimicrobial stewardship programs (ASPs) to reduce antimicrobial resistance. We conducted a qualitative study to determine perceived barriers to the development and implementation of ASPs in low- and middle-income countries (LMICs).


We conducted 46 interviews with medical doctors at tertiary care hospitals in Sri Lanka (22 doctors), Kenya (12), and Tanzania (12). Interviews assessed knowledge and receptiveness to ASPs and barriers to implementing ASP protocols. Interviews were conducted in English, audio recorded, and transcribed. The interviews discussed knowledge of antimicrobial resistance and ASPs, current antimicrobial prescribing practices, access to diagnostics, receptiveness to ASPs, and perceived barriers to implementing ASPs. Data analysis followed procedures of applied thematic analysis, and used NVivo software. A codebook included structural themes based on the interview questions and emerging inductive themes. Two independent reviewers coded the interviews, and the coding was combined and reviewed for consensus. Themes were synthesized, with comparisons made across the three sites.


Medical doctors from all three sites discussed multiple barriers to improving antimicrobial prescribing: prohibitively expensive antimicrobials, limited antimicrobial availability, resistance to change current practices regarding antimicrobial prescribing, and limited diagnostic data. The most frequent of these barriers discussed in all three locations was limited drug availability, mentioned by 12/22 physicians in Sri Lanka, 5/12 in Tanzania and 8/12 in Kenya. Improved education was a suggested component of ASPs in all three sites: 7/22 in Sri Lanka, 6/12 in Tanzania, and 6/12 in Kenya.


The study highlighted several important issues in determining the next steps for the implementation of ASPs in these LMIC hospitals. Improving drug availability and improving education to change physicians’ antimicrobial prescribing practices are important targets that could be addressed by ASPs in these facilities.