Applying the Multimodal Improvement Strategy framework to understand current gaps in the use of antibiograms in hospitals caring for children with cancer in the Eastern Mediterranean and African regions
Authors: Khedr Reham , Sherif Maazin , Mhmoud Amal Hosni , Bayoumi Ahmed Kamal , Safdar Dilnasheen , Deribessa Solomie , Kayange Neema , Madney Yousif , Gaber Mervat , Abdelhakim Mohamed , Masalalipu Boniface , Ziegenhorn Whitney , Homsi Maysam R , Caniza Miguela A 
Published: October 2024

Abstract

Background
Empiric use of antibiotics in sick children guided by local antimicrobial susceptibilities (AMS) increases initial therapy effectiveness. Antibiograms (ABG) are cumulative AMS based on results of isolates susceptible to antimicrobial agents routinely tested in an institution over a specific time period. Although ABG use can enhance healthcare quality, for optimum quality healthcare the World Health Organization (WHO) recommends the use of frameworks such as the multimodal improvement strategy (MMIS). We used the MMIS framework to analyze the literature and understand gaps in using ABG in low- and middle-income countries (LMIC). The 5 WHO MMIS components are: system change, training and education, monitoring and feedback, reminders and communication, and a culture of safety, summarized as “build it, teach it, check it, sell it, and live it”. By combining elements of a scoping methodology with the MMIS framework, we reviewed the literature surrounding ABG and report the results here.

Methods
We assembled a 24-member working group (WG) interested in improving infection care and prevention (ICP) in their institutions in the Eastern Mediterranean and African regions. The WG members (physicians, pharmacists, and microbiologists) met virtually twice monthly from March to October 2023. We searched PubMed using essential keywords such as antibiogram, antibiotic, antimicrobial, antibacterial, isolate, and sensitivity test, and supporting keywords such as misuse, resistance, adherence, guideline, susceptibility, development, improvement, stewardship, low-income, middle-income and LMIC. Any identified additional papers were screened for relevance. We grouped the literature according to the five components of the MMIS framework focusing on information on the ABG tool, training in ABG, the outcomes of its use, promotion of its use, and elevation of its importance institutionally. The WG members reviewed literature assigned to each of the five MMIS components, and presented oral reports of main points, gaps, and how to fill the gaps according to a rubric encompassing relevance assessment, methodological evaluation, content evaluation and recommendations.

Results
We identified 66 publications with authors originating from Africa (n=23, 34.8%), the Americas (n=29, 43.9%), Asia (n=13, 19.7%), Europe (n=12, 18.2%) and Oceania (n=2, 3%). The publications fell into MMIS-Build (n=16, 24.2%), MMIS-Teach (n=16, 24.2%), MMIS-Check (n=14, 21.2%), MMIS-Sell (n=10, 15.2%), and MMIS-Live (n=10, 15.2%). WG members reviewed their assigned papers, discussed them in virtual meetings, and identified 20 papers as strongly relevant. According to the WG members, the literature reviews and discussion improved their ABG knowledge and perception of the utility of evaluation and education applied to ABG. The multidisciplinary WG composition and the MMIS allowed ABG perspectives of new solutions and ideas. Although using a complex framework as MMIS applied to a scarce literature of ABG was challenging, it promoted a deeper understanding of topics and enhanced group cohesion and communication.

Conclusion
We found a gap in the literature of ABG, especially in LMIC, and it was not often recommended. A lower number of publications within MMIS-Live and MMIS-Sell indicated suboptimal emphasis in sustaining this practice in healthcare. Using the MMIS framework focused discussions of WG members, improved ABG knowledge and clarified the utility of educational interventions.