Assessing the impact of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) on hospital antimicrobial stewardship programmes: results of a worldwide survey

The Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) provides a methodology to support hospitals worldwide in collecting antimicrobial use data. We aim to evaluate the impact of the Global-PPS on local antimicrobial stewardship (AMS) programmes and assess health care professionals’ educational needs and barriers for implementing AMS. A cross-sectional survey was disseminated within the Global-PPS network. The target audience consisted of hospital healthcare workers, involved in local surveillance of antimicrobial consumption and resistance. This included contacts from hospitals that already participated in the Global-PPS or were planning to do so. The survey contained 24 questions that addressed the hospital’s AMS activities, experiences conducting the PPS, as well as the learning needs and barriers for implementing AMS. A total of 248 hospitals from 74 countries participated in the survey, of which 192 had already conducted the PPS at least once. The survey response rate was estimated at 25%. In 96.9% of these 192 hospitals, Global-PPS participation had led to the identification of problems related to antimicrobial prescribing. In 69.3% at least one of the hospital’s AMS components was initiated as a result of Global-PPS findings. The level of AMS implementation varied across regions. Up to 43.1% of all hospitals had a formal antimicrobial stewardship strategy, ranging from 10.8% in Africa to 60.9% in Northern America. Learning needs of hospitals in high-income countries and in low-and middle-income countries were largely similar and included general topics (e.g. ‘optimising antibiotic treatment’), but also PPS-related topics (e.g. ‘translating PPS results into meaningful interventions’). The main barriers to implementing AMS programmes were a lack of time (52.7%), knowledge on good prescribing practices (42.0%), and dedicated funding (39.9%). Hospitals in LMIC more often reported unavailability of prescribing guidelines, insufficient laboratory capacity and suboptimal use of the available laboratory services. Although we observed substantial variation in the level of AMS implementation across regions, the Global-PPS has been very useful in informing stewardship activities in many participating hospitals. More is still to be gained in guiding hospitals to integrate the PPS throughout AMS activities, building on existing structures and processes.


Background
Optimising the use of antimicrobial agents is a key element in the global response to the antimicrobial resistance (AMR) crisis [1]. The principles of antimicrobial stewardship (AMS) are increasingly being adopted, at organisational and national levels [2,3]. Hospital AMS interventions have been shown to increase appropriate use of antibiotics, reduce treatment costs, resistance rates and healthcare-associated infections, and improve patient outcomes [4,5]. Many hospitals worldwide are in different stages of implementing AMS activities. However, in low-and middle-income countries (LMIC) this has proven to be challenging due to a high infectious disease burden, limited access to certain antibiotics, unregulated use of antibiotics in the community and a lack of diagnostic capacity to guide clinical decision-making [6][7][8][9][10][11]. These hospitals are faced with an urgent need to set up locally-adapted, sustainable and scalable interventions to contain the problem of AMR. This requires robust, yet feasible, methods for monitoring antimicrobial use and resistance as these are among the cornerstones to a successful implementation and evaluation of antimicrobial stewardship programmes [9,12,13]. Point prevalence surveys (PPS) are commonly used within stewardship programmes to assess the quality of antimicrobial prescribing at ward-and institutional level and to inform local stewardship activities [14][15][16]. The Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS), developed at the University of Antwerp, Belgium, provides a standardised method for assessing hospital antimicrobial prescribing, and supports participating hospitals in electronic data entry, validation and reporting of results [17]. Launched worldwide in 2015, repeated in 2017, and available on a fourmonthly basis since 2018, the Global-PPS had been used in more than 700 different hospitals from over 70 different countries worldwide at the end of 2018, including many in LMIC [18]. While many of these hospitals have successfully gathered antimicrobial use data through the Global-PPS, it remains to be investigated how they are using these findings to inform contextualised stewardship activities. This paper reports the results of a crosssectional survey sent out to hospitals in the Global-PPS network and aims to: (I) evaluate experiences from hospitals participating in the Global-PPS and assess its role in informing hospital AMS programmes, (II) identify barriers to implementing AMS in different resource settings, (III) explore the learning needs of healthcare workers involved in stewardship worldwide in terms of AMS and using the PPS to support hospital AMS programmes.

Setting and participants
Since 2015 the Global-PPS supports hospitals in gathering antimicrobial prescribing data on inpatient wards using the methodology of a point prevalence survey [17,19]. These data include basic antimicrobial prescription data as well as a set of quality indicators for prescribing. After electronic data entry and validation, a real-time, personalised feedback report in pdf-format presents the hospitals' PPS results in a series of graphs and tables. The Global-PPS resources are available at no cost and participation is voluntary and open to all hospitals worldwide. The Global-PPS methodology has been described in detail elsewhere [19]. In addition to collecting baseline antimicrobial prescribing data, hospitals can follow up on their stewardship interventions using repeated point prevalence surveys. Within the activities of the Global-PPS project, a self-administered, cross-sectional survey on antimicrobial stewardship was disseminated in the Global-PPS network. The respondents of the survey were local healthcare professionals, involved in surveillance of antimicrobial consumption and resistance, who had already conducted the Global-PPS in their hospital or were planning to do so.

Survey development
A first set of questions addressed the structure and components of hospital AMS programmes before and after participation in the Global-PPS. These questions were developed based on surveys in existing literature and published standards and core elements for hospital AMS programmes [10,12,[20][21][22][23]. In a second series of questions, focused on the Global-PPS automated feedback function, respondents were asked to comment on the comprehensiveness and usefulness of the report and to list the most important findings identified from this report in their respective institutions. The specific terminology used in these questions was adapted to the terminology used in the feedback report. Finally, the questionnaire also addressed barriers to implementation of AMS and specific learning needs of local stewardship teams on the topic of AMS. The respondents planning to conduct their first PPS were asked to only complete the questions on AMS activities, barriers and learning needs, as the Global-PPS-specific questions did not apply to them. The questionnaire was pilot-tested and reviewed for content and comprehensiveness by Global-PPS participants and experts in the field of AMS from different countries. The final version of the questionnaire contained a total of 24 questions and was translated into Arabic, Russian, French and Spanish (the full questionnaire is available in Additional file 1). We used Qualtrics (Provo, Utah, USA) to programme the electronic questionnaire and question logic was applied to reduce the time needed to complete the questionnaire and improve the survey completion rate.

Data collection
The link to the online questionnaire was sent out by e-mail to the entire Global-PPS network. This included focal persons at individual hospital level as well as contacts responsible for a network of hospitals and country coordinators. Respondents working in multiple hospitals were asked to fill out one survey for the hospital which they considered most representative of their daily practice and to share the survey with their contacts working in other hospitals. We asked respondents to complete only one survey per hospital but did not restrict duplicate entries. Respondents had the option to fill in the survey through a personal invitation over email or through an anonymous survey link. Answers from respondents using the personal invitation were kept strictly confidential and were de-identified before data analysis. Responses were collected between February 2019 and May 2019 and reminders were sent 4 weeks, 9 weeks and 13 weeks after the initial invitation.

Data analysis
Partially completed responses were only included if at least the question on hospital AMS components was answered. During data cleaning, free-text answers to multiple choice questions with an 'Other, please specify response' were re-categorised into one of the listed response options where applicable. Duplicate entries at institutional level were amalgamated into one response. As the survey was disseminated within national and regional networks, the final number of hospitals receiving the survey could not be identified, and therefore it was impossible to calculate an exact response rate. A response rate was therefore approximated based on the number of hospitals that had participated in the Global-PPS by the time the survey had closed. The hospitals stating that they did not yet conduct the Global-PPS were not included in this estimation. During data analysis, countries were grouped according to the 2019 World Bank income classification [24]. Categorical variables were analysed descriptively and results were presented as frequencies and percentages. As not all respondents replied to all survey questions, denominators are reported for every question separately. The differences between high-income countries and low-and middle-income countries for the AMS learning needs and barriers for implementation were evaluated using the Pearson's chi-squared test or Fisher's exact test as appropriate. Significance levels were corrected for multiple comparisons. Statistical analyses were performed using R version 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria) with RStudio (RStudio, PBC, Boston, MA, USA).

General results
By the end of the survey period, a total of 297 respondents had returned the questionnaire. Up to 23 records did not contain any information on hospital AMS structures and were excluded from the analyses. Another 26 duplicate records at institutional level had to be amalgamated. This finally resulted in 248 records to be included in the analyses. Of all hospitals returning the questionnaire, 77.4% (192/248) had participated at least once in the Global-PPS at the time of the survey. As a total of 765 hospitals had collected data for the Global-PPS at that time, the approximate response rate was estimated at 25% (192/765).
Survey respondents consisted primarily of infectious diseases specialists (22.6%), pharmacists (20.1%), medical microbiologists (16.4%), clinicians (15.3%), and infection prevention and control (IPC) specialists (12.4%). The 248 included hospitals were from 74 different countries ( Fig. 1 Table 1 Hospital characteristics *Tertiary hospital: clinical services are highly differentiated by function. Provides regional services and regularly takes referrals from other (primary and secondary) hospitals. Secondary hospital: clinical services are highly differentiated by function. Takes some referrals from other (primary) hospitals. Primary care institution: has only few medical specialties. Only limited laboratory services are available. Infectious diseases specialised hospital and paediatric hospital: single clinical specialty, possibly with sub-specialties. Highly specialised staff and technical equipment [25]. **Inpatient beds: accommodate hospitalized patients who stay in the hospital for a minimum of one night We subsequently asked hospitals which educational activities on AMS would support them in continuing their stewardship efforts, and 76.3% (177/232) replied that they would benefit from face-to-face training sessions from stewardship champions. Up to 73.3% (170/232) considered case-based learning useful, and over half of the hospitals (57.8%; 134/232) stated that they would like to engage in joint research activities on the implementation of AMS. From a list of potential topics for learning activities, hospitals were asked to identify the topics they considered most useful (Table 3). These topics were largely similar for hospitals in high-income countries and those in low-and middleincome countries.

Barriers to implementing AMS
Globally, the main barriers to implementing hospital AMS programmes were a lack of time to work on AMS activities (52.7%; 128/243), a lack of knowledge on good prescribing practices (42.0%; 102/243), and a lack of dedicated funding for the AMS programme (39.9%; 97/243). Although there was a certain degree of similarity in the barriers identified in high-income countries and low-and middle-income countries, significant differences could be observed for certain barriers (Table 4). Hospitals in low-and middle-income countries were more often confronted with unavailability of prescribing guidelines (35.6% vs. 7.5%; p < 0.001), insufficient laboratory capacity (35.0% vs. 12.5%; p < 0.001) and suboptimal use of the available laboratory services (21.5% vs. 2.5%; p < 0.001). In high-income countries, a lack of information technology to support antimicrobial prescribing was more frequently identified as a barrier, compared to low-and middleincome countries (46.3% vs. 22.1%; p < 0.001).

Global-PPS experiences
Since the first Global-PPS in 2015, many hospitals worldwide have collected PPS data on antimicrobial use, however, little is known on the AMS structures and activities in these hospitals and on the impact of Global-PPS on hospital AMS programmes. The results from a survey    10:138 in 248 hospitals from 74 countries show that the Global-PPS has been very useful in informing and evaluating stewardship activities in many of the participating hospitals. In nearly all of the hospitals that had collected PPS data, participation in the PPS resulted in the identification of targets for AMS programmes, and up to 69.3% stated that at least one of the AMS components or interventions in their institution was driven by Global-PPS findings. One-third of the hospitals conducted at least one follow-up PPS, the majority of which observed improvements in one or more of the indicators evaluated by the PPS. This process of repeated measurements, combined with effective communication of the results to prescribers, contributes to a system of continuous selfmonitoring and feedback, a behaviour change strategy essential to the sustainability of the AMS programme [5,26]. Although several studies have successfully used point prevalence surveys to assess the impact of hospital AMS activities [27][28][29][30][31], there is still a need for guidance in performing AMS studies with a robust yet more complex design, such as controlled interrupted time-series [6,32].

AMS structures and interventions
Substantial regional variations were observed in the percentage of hospitals with a formal AMS programme, and in the level of implementation of different components for stewardship. As such, access to local, evidence-based prescribing guidelines ranged from 31.6% in African hospitals to 95.8% in Northern American hospitals. The authors from a worldwide survey on AMS structures, conducted in 2012, reported overall higher results for the existence of treatment guidelines for nearly all regions [10]. However, as our study specifically assessed the presence of local, evidence-based guidelines, this could suggest that in some hospitals guidelines may not be adapted to the local situation. In LMIC's specifically, development of antibiotic prescribing guidelines is often constrained by limited expertise with the rigorous methods needed to develop guidelines and by a lack of locally-relevant, high-quality evidence to inform guideline development. [9,33,34]. The presence of organisational structures, such as AMS committees and hands-on AMS teams, was particularly high in Northern America, where hospitals typically have AMS programmes with a strong focus on accountability and well-established roles for physicians and pharmacists specialised in infectious diseases, both in the AMS committees and in the day-to-day, operational AMS teams [10,35,36]. In settings where these resources are not readily available, a possible approach could be to train non-clinically trained staff members, such as pharmacists, to take the lead on implementing hospital AMS activities and coordinating a multidisciplinary AMS team [37,38].
Education on AMS was mostly targeted at clinicians, although many hospitals also provided education for nurses and pharmacists. The percentage of hospitals educating nurses on AMS was particularly high in our study, and exceeded the percentage of hospitals providing education to pharmacists across all continents. This is in contrast with an international inventory of AMS training programmes performed in 2018, in which AMS training was less likely to be aimed at nurses, compared to other groups of healthcare workers [39].
Our findings suggest that many hospitals were in the process of planning the development of an institutional AMS strategy early 2019, at the time of the survey. It remains to be investigated, however, how the COVID-19 pandemic has impacted the successful development and roll-out of these activities. While the pandemic has led to a disruption of health services worldwide, hospital infectious disease and microbiology teams have been confronted with a shift in priorities, a re-allocation of resources and a reduction of AMS activities [40,41]. Moreover, in settings where dedicated AMS resources are already scarce, the disruptive impact on hospital AMS activities is expected to be even higher [42].

Barriers to implementing AMS
As demonstrated in earlier studies [10,[43][44][45][46][47], organisational factors such as a lack of financial and human resources remain important barriers to the implementation of AMS. This could explain why only one-third of hospitals had conducted a follow-up PPS at the time of the survey, as incorporating the PPS throughout the hospital's AMS activities requires a dedicated and sustainable investment of time and resources. Hospitals in LMIC were more often confronted with unavailability of prescribing guidelines, insufficient laboratory capacity and suboptimal use of the available laboratory services. Indeed, in addition to strengthening the microbiological laboratory capacity in LMIC, efforts should be directed at promoting diagnostic stewardship and improving the communication interface between clinicians and laboratory services [48,49]. Many hospitals also reported a lack of knowledge on good prescribing practices and a lack of cooperation from prescribers as key barriers to a successful AMS programme. The importance of social and contextual factors determining antimicrobial prescribing behaviour is increasingly being acknowledged. In recent years, qualitative studies have explored some of the drivers behind hospital prescribing practices, such as medical hierarchies and social norms [31,47,50,51], the dynamic between immediate, individual patient care and long-term impact on AMR [31,52] and clinical uncertainty [51,53]. Since many of these barriers and driving factors are context-dependent, identifying barriers and strategies to overcome them on a local level should allow hospitals to tailor AMS interventions more precisely and thereby maximise the sustainability of these interventions [54].

Limitations
The current study had a number of important limitations; first, as the survey was distributed within national and local networks, it was impossible to define the exact response rate and the degree of non-response. However, several strategies to maximise response rates were used, such as involving participants in design and pilot-testing of the survey and sending out reminders at regular intervals. An approximate response rate was estimated at 25%, by identifying the number of hospitals that had collected Global-PPS data at the time the survey was closed, however, the hospitals that stated that they did not yet conduct the Global-PPS were excluded from this estimation. Second, hospitals were not sampled and were therefore entirely self-selecting, which could contribute to selection bias. Third, hospitals in the Global-PPS network (i.e. hospitals that have conducted the PPS or are planning to do so) may have more mature AMS systems compared to other hospitals that are not involved in any kind of stewardship activities. In addition, the majority of hospitals were tertiary hospitals from high-and middle-income countries. As such, primary health services in more rural settings and hospitals in low-income countries were underrepresented in the current survey. Investigating the feasibility and relevance of the Global-PPS in these settings is an important area for further research. Next, results on AMS at regional levels are not generalizable to the entire region, as some regions (e.g. Oceania) are clearly under-represented. Furthermore, regional results may be biased towards countries with a large number of responses such as Canada in Northern America (18/24 hospitals) and Nigeria in Africa (18/38 responses). The survey was self-administered and therefore it was impossible to assess the correct interpretation of the survey questions and the accuracy of the responses. Finally, for the multiple choice questions, there was no choice randomization, which might have introduced a certain bias towards the first answer options.

Conclusions
This study shows substantial variation in hospital AMS programmes and barriers to implementation of AMS across regions and income levels globally. These gaps are likely even larger worldwide than the differences observed here, as the majority of the hospitals participating in the survey were those institutions with time and resources to engage in surveillance activities, highlighting the need for a contextualized approach to antimicrobial resistance in hospitals around the world.
The current study sheds a light on how participation in the Global-PPS can contribute to hospital AMS activities, both in high-income settings and in LMIC. Providing all participating hospitals with a personalised feedback report, the Global-PPS allows local teams to identify targets for antimicrobial stewardship without the need to invest time and resources in complex data analyses. More is still to be gained in guiding hospitals to integrate the PPS throughout AMS activities building on what is already existing, support them in broadly and effectively communicating the PPS results to obtain much-needed buy-in from prescribers, hospital management and other healthcare workers involved in stewardship, and to empower local champions to take the lead on AMS in their hospital. The results presented here will inform the further development of a set of dedicated educational resources, targeting Global-PPS participants worldwide and focused on translating PPS-findings into locally-tailored AMS interventions thus contributing to a sustained response to AMR in participating hospitals.