The Economic Outcome of Antimicrobial Stewardship in a Hospital Setting: the Case of Gertrude’s Childrens’ Hospital

Abstract

Background The Centre for Disease Control and Prevention has strongly advocated for the planning and implementation of antimicrobial stewardship (AMS) programs in a bid to fight antimicrobial resistance (AMR). The World Health Organization has included antimicrobial resistance (AMR) in the list of top ten public health concerns. It leads to increased cost of treatment, prolonged hospital stays, treatment failure and at times death. Implementing AMS programs requires allocation of significant financial resources and therefore it is important for stakeholders to understand the economic and financial impact of these initiatives. Although various authors have conducted studies on the economic impact of AMS in hospitals, not much has been done in the Kenyan context. Objectives The main objective of the study was to investigate the economic outcome of implementing antimicrobial stewardship interventions at Gertrude’s Children Hospital (GCH). Methodology A mixed method study involving collection of both qualitative and quantitative data was carried out for the period between 2015-2022. Five AMS committee members were interviewed and responses were validated by review of AMS meeting minutes, periodic AMS reports and hospital guidelines on use of antibiotics. Purposive sampling was done, where the Chief Pharmacist identified the participants who met the inclusion criteria. The economic outcome of the AMS program was assessed through review of retrospective pre-post data on antibiotics consumption and the cost attached. Data was extracted from the electronic medical record software used at the hospital. A comparison of antibiotic use before and after implementation of AMS program was done to assess changes in consumption and cost. The pre-phase was 2015-2018 while

post-phase was 2019-2022. Qualitative data was analyzed by content analysis while quantitative data was analyzed using STATA version 13.0 software. Alpha was set at 0.05. Results AMS interventions implemented at GCH include structural, restrictive and persuasive strategies. Structural strategies implemented at GCH include digitization through an electronic medical records (EMR) software, antibiograms, pro-calcitonin testing, rapid diagnostic testing of respiratory viruses as well as penicillin allergy testing. No decision support software was in place to help in rational antibiotic prescribing. Restrictive strategies included restriction of antibiotic prescribed particularly for surgical prophylaxis and a pre-authorization policy for all reserve antibiotics. Education of hospital staff on AMR and AMS principles was also a key strategy for Gertrude’s children’s hospital. Implementation of these strategies was done at estimated total annual cost of $84,229. This figure includes $5,200 in capital costs and $79,029 in recurrent costs. This annual recurrent cost included a figure of $58,896 incurred in form of full-time equivalent salaries (FTE). There was an overall 25.4% decrease in consumption of selected antibiotics between the pre-AMS phase (2015-2018) to post-phase (2019-2022), from 137.8 Defined Daily Doses (DDDs) to 112.4 DDDs. Consumption of imipenem/cilastatin (-81%), meropenem (-54.7%), from 9.05 DDDs to 4.09 DDDs and vancomycin (-54.4%), from 1.85 DDDs to 0.84 DDDs. However, increased consumption was seen with cefotaxime (44%) and clindamycin (22%) injections. The number of patients exposed to the study antibiotics reduced from 39143 (pre-AMS) to 37425 (post-AMS).In terms of cost, Antimicrobial Shillings per patient Day (AMSD) decreased by 9.3% in the first year (2018) and by 33.3% in 2019, there was a very slight increase in 2020 (0.5%). Antibiotic Shillings Per patient Day (ABSD) then increased in 2021 by 4.2%. 2022 saw a drop by 29.2% in 2022.

Conclusion AMS program implementation at Gertrude’s Children’s Hospital was associated with a decreased consumption and expenditure on target antibiotics. This finding should serve to encourage the implementation of such a program across all level 4, 5 and 6 hospitals in Kenya as it promotes rational use of antimicrobial agents while saving costs for the hospital.