The CLIMIDSON Manual for Antimicrobial Stewardship Programmes in Nigerian Health Care Facilities

Antimicrobial stewardship (AMS) remains a cornerstone of efforts aimed at improving antimicrobial-related patient safety. It slows the  development and spread of antimicrobial resistance (AMR), while helping clinicians to improve clinical outcomes and minimise harm by  improving antimicrobial prescribing. AMS programmes (ASPs) are driven through various processes and people. An AMS structure  comprises the core elements that should be in place to support the ASP including the AMS team, treatment guidelines, and surveillance of AMR and antimicrobial use (AMU). This manual aims to provide a practical guide to health care facilities in Nigeria and other low-and- middle-income countries, for establishing, implementing and sustaining ASPs, and is structured into 14 sections. Section 1 introduces the  subject matter and gives background information on the current situation of AMS in Nigeria. It describes the efforts of the National  Antimicrobial Stewardship Working Group (NASWOG), an arm of the Clinical Microbiology and Infectious Diseases Society of Nigeria  (CLIMIDSON), in identifying the AMR issues in health care facilities in the country and providing evidence-based recommendations for  ASPs. Section 2 describes the goals of AMS and core elements which must be in place for successful and sustainable ASPs. Section 3  presents how a health care facility could start an ASP depending on the size, highlighting the important role of point prevalence survey  (PPS) in obtaining baseline data on AMU and prescribing practice in health care facilities, which is useful in developing an action plan.  Although management support is key for a successful ASP, the governance of the programme rests with the AMS committee, which  composition and size will depend on the level of health care facility. Section 4 describes AMS strategies, which include the core and  supplemental strategies. Every hospital should aspire to do at least a core strategy, although it may be convenient to start with other  stewardship activities and supplemental strategies. Section 5 describes the antibiotic policy and guidelines, which provide the framework  for all AMS activities, and is an effective means of changing behaviour in antimicrobial prescribing. The guidelines should be written by a  multidisciplinary team and due consideration must be given to the local antibiotic susceptibility data and the common infectious disease  syndromes in the facility or region. Dissemination of the policy and guidelines should be given wide publicity. At the primary health care  facilities, where there may be no doctors to prescribe, “standing orders” are used to guide antibiotic prescribing. Section 6 describes the  critical importance of stakeholder engagement to a successful ASP. If stakeholders are more informed about AMR issues and ASP, they are better able to positively support the programme. AMS stakeholders will differ from facility to facility but generally include health care  facility management, clinicians, pharmacists, nurses, infection prevention and control (IPC) practitioners, clinical microbiologists, other relevant laboratory staff, and patients. The importance of education and training to the successful implementation of AMS is presented in  section 7. Health care facilities should provide induction and in-service training to all staff on AMS and IPC. Training objectives should  be clear and targets of education and training should include AMS committee and team(s), clinicians, pharmacists, nurses and other  health care staff, patients and caregivers, and advocacy and community campaigns. Sections 8 and 9 explain how monitoring and  evaluation (M&E) of ASP, and feedback to stakeholders are conducted. Monitoring and evaluation are critical to identifying the impact of  intervention measures and opportunities for improvement. This involves the evaluation of the structures, processes and outcomes of  ASPs. Sections 10 and 11 delved into the roles of clinical microbiology laboratory support for AMS, and diagnostic stewardship as well as  information and communication technology (ICT) in ASPs. The clinical microbiology laboratory should provide quality antibiotic  susceptibility testing data, and standard antibiograms periodically to the AMS committee. Sections 12, 13 and 14 enumerated the core  elements of outpatient ASP, institutional mentoring in AMS, and system building approach to sustainability of ASP. The recommendations  for outpatient AMS in this document apply to either stand-alone clinics and casualties or those located in secondary or  tertiary hospitals.