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Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries-A qualitative study.

  • Charani, Esmita1
  • Smith, Ingrid2
  • Skodvin, Brita3
  • Perozziello, Anne4
  • Lucet, Jean-Christophe4, 5
  • Lescure, François-Xavier4, 5
  • Birgand, Gabriel1
  • Poda, Armel6
  • Ahmad, Raheelah1
  • Singh, Sanjeev7
  • Holmes, Alison Helen1
  • 1 NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, United Kingdom. , (United Kingdom)
  • 2 Department of Essential medicines and Health Products, World health Organization, Geneva, Switzerland. , (Switzerland)
  • 3 Norwegian advisory unit for Antibiotic use in Hospitals, Haukeland University Hospital, Bergen, Norway. , (Norway)
  • 4 Assistance Publique-Hôpitaux de Paris (AP-HP), Bichat-Claude Bernard Hospital, Infection Control Unit, Paris, France. , (France)
  • 5 IAME, UMR 1137, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France. , (France)
  • 6 School of Medicine, University Hospital Souro Sanou, University of Bobo Dioulasso, Bobo Dioulasso, Burkina Faso. , (Burkina Faso)
  • 7 Department of Medicine, Amrita Institute of Medical Sciences, Amrita University, Kerala, India. , (India)
Published Article
Public Library of Science
Publication Date
Jan 01, 2019
DOI: 10.1371/journal.pone.0209847
PMID: 30650099


Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings.

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