Exploring perspectives on antimicrobial stewardship: a qualitative study of health managers in Kenya
Authors: Mbugua Samuel MUNGAI , Njoroge George , Kijogi Caroline , Kamita Moses , Kimani Rachel , Mwaura Peter , Waiganjo-Aidi Bibianne Wanja , Gitaka Jesse 
Published: September 2020

Abstract
Background: Antimicrobial resistance is a significant public health concern with the establishment of antimicrobial stewardship in hospitals being obligatory now more than ever. The perspectives and insights of health managers on antimicrobial stewardship (AMS), the complementary health services and building blocks are imperative towards implementation of robust antimicrobial stewardship programs. This study aimed to understand the perspectives of hospital managers to AMS and identify areas of management engagement and addressing potential blockades to change.Methods: A cross-sectional, qualitative, multicenter study was conducted in three hospitals in Kenya. Key-informant, face-to-face interviews with hospital health managers were carried out on their perspectives on antimicrobial stewardship. Qualitative data was captured using audio tapes and field notes, transcribed and managed using NVivo 12 software. An iterative process was used to develop the thematic framework and updated in two rounds of iteration analysis. Analysis charts for each emergent theme were developed and categorized across all participants.Results: Perspectives on antimicrobial stewardship are described in five thematic categories; Importance of antimicrobial stewardship and the role of medicines and therapeutics committee, availability of an antimicrobial formulary and usage surveillance systems, laboratory competency and recommendations for infection prevention and management, educational resources and communications channels available, building blocks and low-lying fruits for Antimicrobial Stewardship Committees. The role of stewardship collaboration in diagnosis and antimicrobial prescription was alluded to with managers indicating a growing rise in occurrence of antimicrobial resistance. There was no contextualized, hospital specific antimicrobial formulary based on the local antibiograms in any of the hospitals. Lack of adequate laboratory competency was a major deficit with most hospitals lacking culture and sensitivity testing services. Staff training and communication channels were available in varying capacity across the three hospitals. Building blocks identified include medicines and therapeutics committee, education, and training platforms (Continuous Medical Education and Continuous Professional Development activities) and hospital leadership commitment towards antimicrobial stewardship.Conclusions: The practice of antimicrobial stewardship is not implemented and well developed in the sampled healthcare facilities as demonstrated by lack of core AMS complementary health services. However, the health managers are aware of the fundamental importance of antimicrobial stewardship programs and the vast benefits of implementation and institutionalization of AMS to the hospital and its clients alike. The findings underpin the importance of understanding and incorporating the perspectives of health managers on the existing contextual mechanisms that can be leveraged on to establish robust Antimicrobial Stewardship programs in the fight against antimicrobial resistance.