Implementing an Antibiotic Stewardship Program in National Cancer Institute, Sri Lanka
Authors: Gunasekara Samanmalee , Manchanayaka Amali , Bandara Sudheera 
Published: November 2023

Abstract
Bacterial infection is a dreaded complication in cancer patients worldwide. In low resource settings where supportive care facilities are less than ideal this takes on even more greater significance. In recent years, the emergence of antimicrobial resistance (AMR) has become a significant problem worldwide and cancer patients are those among most affected. Treatment of infections due to Multi Drug Resistant (MDR) bacteria represents a clinical challenge because therapeutic options are limited. Overuse and misuse of antimicrobials has been acknowledged as a main driver for resistance development and the need to optimize the use of antimicrobials has been stressed.
National Cancer Institute is not an exception, children with cancer develop infections due to MDR bacteria when they are neutropenic and mortality and morbidity of those infections are very high. Therefore antibiotic stewardship program (AMSP) was implemented in the pediatric units to optimize clinical outcome while minimizing the unwanted effects, with the rational prescribing of antibiotics.
Pediatric Oncology unit comprises of four wards with 150 beds and an intensive care unit with 8 beds. As a preliminary step meetings were conducted to outline a plan of action with the participation of relevant stake holders, microbiology team and pediatric Oncology team. Director of the hospital was also involved to the program. Workshops were conducted to educate and train health care workers and to create awareness on AMR. Antibiogram was established to see the antibiotic resistant patterns of bacterial isolates in the hospital. The audit on antibiotic use was conducted to see the use of antibiotics in the units. Also feedback of the audit was given to the clinicians, it showed deviations from standard practices in the use of antibiotics.
It was noted that the antibiotic resistance rates in the unit was very high for both gram negative and gram positive isolates. Clinical practice guideline on fever and neutropenia was developed based on the sensitivity pattern of the antibiogram. The guideline comprised of introduction, basic investigations, antibiotic recommendations, follow-up assessments and antimicrobial dose and frequency. The clinical practice guideline was displayed as a poster in all units near the doctors table. Small booklet was also printed with pediatric dose, duration and route of commonly used antibiotics with their indications. A new drug chart was introduced to patients' bed head ticket with a separate section for antimicrobials including history of allergy, designation of the prescriber, reminder to collect cultures, dose, route, duration and periodic review. Fourteen antibiotics were included in the preauthorization list, which require approval prior to use.
Antibiotic resistant rates in the unit was alarmingly high. Therefore, there should be a mechanism for continuous monitoring and auditing. Infection control practices need to be strengthen to prevent the spread of MDR organisms. Better coordination between clinical microbiologist and physicians is required on local resistant patterns of microorganisms. Periodic training of hospital staff should be carried out on AMSP, including adverse reactions, antibiotic resistance and optimal prescribing. Evaluation of AMSP and their perceive level of success needs to be performed periodically.