## 3 Results
### Ghana
#### 3.3.3 Development of Antimicrobial Management Guidelines Ghana Police Hospital (GPH)  
The baseline PPS conducted at GPH in May 2019 as part of the CwPAMS project highlighted that, for many indications, guideline compliance could not be assessed due to the use of high levels of missing or undocumented guidelines (Table 3). This observation was prominent in two departments: obstetrics and gynaecology (OBGY) and surgery and formed the basis of the work plan developed (Supplementary Materials 1). Following further discussions with surgical and nursing teams, it was highlighted that the protocols for managing a range of conditions, including caesarean operations and post-delivery prophylaxis and surgical wound management, were in use but not available through the national standard treatment guidelines (STGs) or formally agreed-on local protocols. Figure 2: Number of hits of the Ghana Antimicrobial Guidelines page of the CwPAMS App. To enable the assessment of appropriate prescribing, the AMS team led by the local pharmacist communicated the findings from the PPS to the hospital staff at a clinical meeting and highlighted the importance of having approved guidelines for caesarean, post-delivery prophylaxis and the management of surgical wounds in their respective facilities. To promote the acceptance and use of the guidelines in the unit, the AMS team collaborated with the various units through their personnel on the AMS to draft the final documents. The OBY specialists and senior nurses developed the protocols for the OBGY, and the surgeon on the AMS team, who was also the head of the surgical department, led the development of the draft wound management protocols with the surgeons in his unit based on their experience/training (Supplementary Materials 2). For both guidelines, the local pharmacist as part of the AMS Committee in GPH worked with the senior medical/specialist and nursing staff to develop antimicrobial management guidelines within the protocols by assessing the appropriateness of dose, frequency and duration using the British National Formulary, as well as the protocols used at one of the Ghana Tertiary National Referral Hospitals (Korle-Bu Teaching Hospital). These guidelines were then implemented within the hospital. The antibiotics and other drugs required are now included on pre-printed patient medications lists issued routinely for patients receiving caesarean delivery, normal delivery and for those who require post-delivery prophylaxis (Supplementary Materials 3). The adherence to the guidelines developed for the obstetrics and gynaecology department from the results obtained from the post-intervention PPS carried out in February 2020 was found to be 100%. The overall comparison of the compliance by prescribers to the national STG from PPS conducted at GPH in February (2020) revealed an increase from 64.6% in May (2019) to 88%. Tanzania: Observership and Subsequent Pharmacy Leading Delivery of AMS at Kilimanjaro Christian Medical Centre (KCMC) and within Local Community  
AMS and IPC training was delivered to a total of 1056 people, including healthcare professionals at KCMC, and to the wider community, including schools and boda boda taxi drivers (Figure 3). More than one-third of participants in training sessions (36%) were not aware of the main principles of AMS before training. The education campaign then extended beyond the scope of the sessions above, with links being set up between the Kilimanjaro School of Pharmacy and Newcastle University Pharmacy School. These resulted in a joint AMS module being developed for delivery to early years pharmacy trainees, ensuring that pharmacists of the future continue to lead on AMS activity within Tanzania and the UK. This module is also being considered for adaptation to medical schools and dentistry schools within Moshi, Tanzania.