Impact of Global Health Partnerships – Nigeria and UK

The Antimicrobial Stewardship Partnership programme  has been running since 2018 and extended to the CMUL/UK FPH in 2021. Previous  Commonwealth Partnerships for Antimicrobial Stewardship Forum (CwPAMS) grants have focused on improving Antimicrobial Stewardship (AMS), developing pharmacy expertise and capacity, and supporting IPC initiatives. The new phase of the programme builds on the successes of the partnerships to date by encouraging sustainability through the development of in-country centres of excellence and sharing of best practices.

I was hosted by Professor Oyin Oduyebo. It is worthy to note that Tropical Health and Education Trust (THET) now called Global Health Partnerships and the Commonwealth Pharmacists Association (CPA) hold the Department of Health and Social Care’s Fleming grant funds as part of the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) 2 programme. One of these grants is the Sustaining Antimicrobial Stewardship, which is held  by UK Faculty of Public Health (FPH), and the College of Medicine of the University of Lagos (CMUL), with the delivery site as the Lagos University Teaching Hospital working in partnership with other organisations such as the National Orthopaedic Hospital, Igbobi, Lagos (NOHIL).

Proposed Project Outcomes:

• Advocacy performed to NOHL management to prioritise AMS
• AMS committee is initiated in NOHIL
• NOHIL AMS teams and healthcare professionals are trained
• “Prospective audit with intervention and feedback” is performed consistently in LUTH
• Antibiotic consumption data calculations consistently reported in LUTH

Noteworthy is the fact that the discovery of antimicrobials effectively cured many life-threatening diseases and in the latter half of the 20th century many new effective antimicrobials were discovered and developed. However, the pace of discovery and development has slowed. Increasing antimicrobial resistance is causing global and local concerns which appear to coincide with the increasing epidemics of hospital-acquired infections (HAI). As such, there is urgent need for increased education and change in clinical practice regarding antimicrobial resistance among the public and healthcare professionals.
Modified from Source: Lagos University Teaching Hospital (LUTH) Lagos, Nigeria Antibiotic policy and guidelines December 2021, LUTH antimicrobial stewardship committee

During my visit to the Medical Microbiology department at LUTH on 6 November 2024, I also met with other members of the LUTH team, namely:

• Dr Philip Oshun, medica microbiology and representative on the AMS
• Mrs Joke Okusanya, Infection Prevention Control Nurse
• Vivian Chuka-Ebene, Pharmacist, ensuring buy into the programme and ensure consistent antibiotic consumption data
• Dr Muyiwa Rotimi, Director, Intensive Care Unit

The programme has adopted a Multidisciplinary approach and shifted what was initially seen as a standalone individual research project to an institutional programme aimed at improving patient outcomes.

It is worthy to note that the ongoing programme at LUTH has had aims, phrases and challenges as listed below:

CwPAMS 1.5  Identified the Following Gaps

• Inadequate Manpower
• Resistance of staff to change
• Loss of staff (High staff turnover)
• Underutilization of the Medical microbiology laboratory e.g. antibiotic decisions made on definitive diagnosis in very few patients and empirical in the arge majority of cases.
• Identified knowledge gaps and research

The second phase aim is to embed learning, share knowledge and skills with National Orthopaedic Hospital, Igbobi, Lagos.

Other Aims Include:

• Advocacy
• Priortising AMS
• Training health care professionals
• Continuous learning given the staff turnover as a teaching hospital
• Identified gaps such as the use of Electronic Medical Records (EMR) to embed and sustain learning

Findings from the Programme

• Variable antimicrobial prescribing practices with some examples of good practice
• Quality indicators for prescribing such as reasons for prescribing, duration of the medication and prescribing date were not consistently found in notes
• The National Orthopedic Hospital has an established EMR system, so you could see reasons for prescribing approximately 99% of the time. This compares to LUTH which isn’t as advanced in the use of EMR resulting in 40% of cohort having recorded reasons for prescribing or duration/review dates
• LUTH Antibiotic policy based on AWaRe classification will be facilitated with EMR:
  • ACCESS – can be prescribed by all doctors including house officers
  • WATCH – can be prescribed only by prescribers at the level of consultants or senior registrars in line with the approved antibiotic guidelines of the department. They can be prescribed by medical officers in strategic areas in line with antibiotic guidelines if they possess membership or have passed the Part 1 fellowship examinations of the either of the Post-Graduate Medical Colleges.
  • RESERVE – should not be stocked by the hospital pharmacy but procured as required for patients by the pharmacy in accordance with hospital protocol.
• An enabled EMR if modified will support compliance and enable audit, monitoring and evaluation.
• Antibiotic policy supported by protocols

Thus

A modified EMR with enabled software requiring funding of approx.10k USD will enable systematic tracking and monitoring outcomes. It would also ensure the systematic embedding of practice as well as monitoring and evaluation.  This will also address the limitations of being able to have comparable AMS outcome data such as:

• Mortality rates of patients that died from infection
• Infection rates patients that died from MRSA
• Rates of multidrug resistant infections caused by extended spectrum Beta lactamase (ESBL) producing organisms
• Prevalence and mortality rates of infections caused by Carbapenem resistant organisms
• Prolonged hospital stay

Process measures have shown how stewardship efforts have impacted prescribing practices at LUTH. Education and awareness have impacted the antibiotic prescribing rates reducing from it from 80.6% in the adult wards and 89.7% in the pediatric wards in 2015, to 67.0% and 59.2 % in 2017 respectively.

Education supported by dissemination of evidence gathered made possible by the CwPAMS 1.5 & 2 Projects continued to make a positive difference in prescribing practices at the hospital.

Other Benefits of the Project

Research dissemination via stake holders meetings

• Online training events open to all, supporting other public and private hospitals and open to professional bodies, animal healthcare professionals and environmental health professionals.

Patient Awareness and Education

• Conducting education and awareness to patients in wards and clinics on use of antibiotics and the dangers of fake drugs. The program also highlights the rationale for patients consenting to appropriate antimicrobial tests as recommended by the attending physician given the funding implications to patients. The programme would like to extend awareness beyond patients at LUTH to wider public awareness. However, the costs of doing this e.g.  radio/TV 200k naira for 30mins noting this should be a week so approx. 200k US dollars for a weeklong mass awareness using different media platforms.

Global accreditation

• The program has enabled LUTH to secure Global Antimicrobial Stewardship Accreditation Scheme (GAMSAS), one of the first centres in the world to be accredited via the scheme, which is run by the British Society for Antimicrobial Chemotherapy (BSAC). This received national attention

https://bsac.org.uk/bsac-gamsas-accredited-hospital-receives-national-attention-in-nigeria/

Future activities

• Behavior change workshops November 27 & 28, 2024
• Research Dissemination December 2024
• Pursue full EMR Utilisation for AMS in the ICU & Outpatients for reporting at monthly Antimicrobial Stewardship Committee meetings
• World Antimicrobial resistance Awareness Week (WAAW) in November 2024
  • Special Hospital grand round for WAAW
  • Full report of the trends in Resistance rates versus antibiotic consumption rates
• Final Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (GPPS) & advocacy to hospital management

My Personal Reflections

I was very impressed with the ongoing programme. More importantly, the outcomes for patients, the enthusiasm of the staff have made making an impactful difference. Funding of the EMR software as a tool to systematically embed best practice AMS and moving the education and awareness to wider public on the use of antibiotics is something that I would advocate for and recommend.

Also, as a member of the Diaspora and a Trustee at Global Health Partnership, it is great to see impactful transformational links with colleagues in Nigeria and the Diaspora. The partnership model championed by Global Health Partnership to build capacity and support organisations in different countries worldwide to be trail-blazers, as evidenced by this programme, is to be commended and supported by key donors and funders.