Situational analysis of antimicrobial stewardship program (ASP) among public and private tertiary care hospitals in Karachi : a qualitative case study

Date of Award


Document Type


Degree Name

Master of Science in Health Policy & Management (MSc Health Policy & Mgmt)


Community Health Sciences


Antimicrobial Resistance arises as a substantial threat to the "Global Health" sanctuary. Unbefitting use of antimicrobials is linked to the growth and spread of drug-resistant microorganisms and is associated with increased mortality, morbidity, length of hospital stay (LOS) and healthcare expenditure. Despite being a natural phenomenon it is promulgated by misuse of antimicrobial medicines, inexistent or inadequate programs for infection prevention and control, weak laboratory capacities, poor quality and counterfeit drugs, ineffective surveillance and regulations for the use of antimicrobial medicines. "Antimicrobial Stewardship" is the umbrella term for an evidence-based knowledge, translation strategy containing comprehensive quality enhancement activities for optimal use of antimicrobials, improvise patient's clinical outcomes, reduces the progress of antimicrobial resistance and hospital acquired infections such as clostridium difficile and reduce healthcare expenditures. There is scarcity of available literature about antimicrobial stewardship within Pakistan and not much is known about ASP development and implementation. The study aims to assess the current status of implementation of ASP and to identify the barriers and facilitators faced by hospital leadership for its implementation among public and private tertiary care hospitals of Karachi, Pakistan. Moreover, the study also aims to identify the challenges faced by Provincial and National Key Stakeholders for formulation, implementation and monitoring of ASP. Methods: The study employed an exploratory case study design because there is scant knowledge about the development and implementation of the ASP at the organizational level in Karachi and at provincial and national level. For this study, data was collected from 3 public and 4 private tertiary care hospitals in city of Karachi. Twenty Eight in-depth interviews were conducted from the higher and middle management which included Chief Executive Officer, Chief Medical Officer, Medical Superintendent and departmental heads of internal medicine, general surgery and paediatric respectively. Purposive sampling was done to include higher and middle managers whereas the infectious diseases consultant, infectious diseases/clinical pharmacist and clinical microbiologist were interviewed throUgh snow ball sampling methodology at the public and private tertiary care hospitals. Moreover, two key informant interviews were conducted consisting one each from provincial and national stakeholders, again sampling was done purposively. The findings of in-depth and key informant interviews were analyzed via computer-assisted analysis software NVivo. Themes were generated out of the nodes and sub-nodes of the collected data. Information was triangulated between the higher and middle managers and amongst the provincial and federal stakeholders. Results: In this study we found that more than two thirds (n=7, 71%) of tertiary care hospitals in Karachi do not have structured ASP which includes major public sector hospitals (n=3, 43%) and half of private sector hospitals (n=4, 29%). The biggest barrier faced by hospital leadership for the implementation of ASP were related to lack of funding, lack of expertise such as infectious diseases physicians and infectious diseases pharmacist, inadequate information technology resources, non-compliance with infection control and prevention practices, lack of extra benefits and support and prescriber opposition. However, the facilitators were related to acceptance and existence of ASP, dealing of physician antagonism, multidisciplinary team, steward's empowerment and institutional surveillance and reporting mechanism. Moreover, the institutes where ASP is not formulated the resultant emerging themes were; inadequate institutional/hospital based initiatives for antimicrobial control and management, departmental based initiatives for antimicrobial control/management and rationalize use of antimicrobials, improvising means for the formulation and development of ASP and barriers for the formulation of ASP. Moreover, the key findings of the challenges faced by provincial and national key stakeholders for formulation, implementation and monitoring of ASP were related to knowledge and skills, laboratory, accountability, human assets, financial, measures and medications. The three biggest challenges highlighted by provincial and national stakeholder were lack of national policy on surveillance of antimicrobial resistance, weak understanding and limited awareness regarding AMR and ASP, and dearth of expertise. Both stakeholders emphasized that there is a need to establish a coherent vision for antimicrobial stewardship at federal level that need to be executed countrywide. Conclusion: The study identifies the serious dearth of ASP in one of the major city of the country. There are serious barriers and challenges in public sector hospitals as compared to the private sector hospitals. The provincial and federal stakeholders identify AMR as a major public health challenge for the Pakistan. The study even highlights the importance of engaging health ministry in implementing ASP policies at each and all healthcare institutes of the country.

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