Capacity and Capability

Antimicrobial stewardship is a bundle of integrated interventions designed to optimise the use of antimicrobials and contribute to slowing the spread of antimicrobial resistance. While infectious-disease-trained physicians, with clinical pharmacists, are often considered the leaders of antimicrobial stewardship programs, clinical microbiologists and the laboratory can play a key role in these programmes.

In order to improve laboratory capacity and capability we must first establish some of the challenges. This paper lists some of the key barriers and facilitators to implementation of AMS programmes in high resource settings, the four points below are made in reference to barriers for the laboratory:

• Inadequate supply of laboratory provisions
• Lack of knowledge of results
• Lack of standards
• Lack of facilities and trained staff

When looking at challenging AMS in low resource settings, common laboratory capacity and capability challenges can include all of the above as well as the following:

• Lack of automated instruments and systems
• Patient data can be recorded in many different forms causing challenges when performing retrospective analysis
• Paper-based record keeping is common
• Media, antimicrobials, disk potencies can fail to be in concordance with guidelines (EUCAST and/or CLSI)
• Substantial imbalance between the capacities of the laboratories even in the same city
• Whether standards are not being followed or the standards are outdated
• When reagents are not stored accordingly, internal or external control studies are not being performed

In the previous step, examples of AMS interventions were discussed in this paper and were categorised depending on their stewardship activity level; essential, achievable and aspirational. For low resource laboratories completing all of these may be difficult, however, focussing on the essential interventions and adapting them to the setting is an ideal way of addressing AMS.

Within a high resource healthcare settings strategies like this this may work but in a low resource setting your options may be limited. An example of a laboratory strengthening an AMS programme in these circumstances is listed below. A feasible laboratory strengthening intervention yielding a sustainable clinical bacteriology sector to support antimicrobial stewardship in a large referral hospital in Ethiopia, ran serval interventions with positive results:

• Development of key standard operating procedures (SOP)
• Adaptation of analytic-phase processes for this setting
• Training and supervision of laboratory staff
• Implementation of a practical quality systems approach

Please read the article for full details of their implementation strategies

The results showed a marked increase in laboratory utilisation.

The laboratory began supporting antimicrobial stewardship by generating regularly updated cumulative antibiograms and WHONET software was implemented in the laboratory with support from EPHI, in order to link data between institutional testing and national AMR surveillance. As a result, the laboratory has contributed a significant portion of the carbapenem-resistance data submitted by EPHI in the last 2 years as part of the Global Antimicrobial Surveillance System (GLASS). Overall, there was observed that downstream laboratory-supported outputs created further demand for laboratory services.

Let us know in the comments section below:

• What surprised you the most in this step?

• Is there something here that you could implement in your own health care setting?