Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-saharan Africa: a Co-creation Consensus Approach
Authors: Ashiru-Oredope Diane , Garraghan Frances , Olaoye Omotayo , Krockow Eva M. , Matuluko Ayodeji , Nambatya Winnie , Babigumira Peter Ahabwe , Tuck Chloe , Amofah George , Ankrah Daniel , Barrett Scott , Benedict Peter , Boaitey Kwame Peprah , Buabeng Kwame Ohene , Cavanagh Sarah , Charani Esmita , Chikatula Enock , Ghebrehewet Sam , Islam Jasmin , Jani Yogini H , Johnston Esther , Lamorde Mohammed , Malinga Augustine , Mirfenderesky Mariyam , Rutter Victoria , Sneddon Jacqueline , Skone-James Richard 
Published: March 2022

Abstract
Background: Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi-consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa as well as to implement the checklist in health institutions in four African countries.Method:The AMS checklist tool was developed using a modified Delphi approach to achieve local, expert consensus on items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, and Ghana were invited to review, score and comment on items from a published, global AMS checklist. Following their feedback, eight items were re-phrased and 25 new items added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites.Findings: The final tool comprised 54 items. Across the 14 sites, the checklist consistently showed improvements for all AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). Elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions.Conclusion: Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. The study extends existing AMS materials for low and middle-income countries and provides empirical evidence for successful use in practice.