# Pharmacokine-Led Antimicrobial Stewardship Programme in Two Tertiary Hospitals in Malawi
###### Abstract  
The ultimate goal of antimicrobial stewardship (AMS) programmes is to decrease the occurrence and spread of antimicrobial resistance (AMR). In response to this, a pharmacist partnership was established between Malawi and Wales (UK) with the aim of strengthening antimicrobial stewardship (AMS) activities in Malawi, with the initial project focusing on two tertiary referral hospitals. The Global Point Prevalence Survey (GPPS) was undertaken for the first time in Malawi at these sites and demonstrated a prescribing rate slightly lower than the African average, with ceftaxone indicated for almost every bacterial infection. An educational intervention was also delivered, with a train-the-trainer approach upstilling pharmacists at the two sites, who then cascaded co-produced training sessions to an additional 120 multidisciplinary health professionals. A toolkit to support AMS at an individual patient level was also developed and disseminated to provide an ongoing reference to refer to. Both the trainings and toolkit were well received. Over the course of this project, significant progress has been made with the AMS programmes at the two sites, with local staff empowered to implement AMS activities. These interventions could be easily replicated and scaled and support the delivery of some of the AMS elements of the Malawi Ministry of Health National Action Plan for Antimicrobial Resistance.  
antimicrobial stewardship; point prevalence survey; education; referral hospital; toolkit; CwPAMS; health partnerships +
Footnote †: journal: _articticollection of the American American Society_  
Footnote †: journal: _articollection of the American Society_  
some high-income countries have prioritised the AMR fight [7; 11], LMICs face challenges in the fight against AMR.  
Globally, antimicrobial misuse and overuse propagates the development and escalation of AMR [1; 4; 8; 9; 11; 12; 13; 14]. Optimising the use of antimicrobial agents is therefore a key element of the global response to the AMR crisis [2; 3; 4; 9; 11]. Many countries are adopting the concept of antimicrobial stewardship (AMS) at national and organisational levels [2; 4; 7; 8; 15; 16; 17; 18; 19]. Implementation of AMS activities in LMICs has proved to be challenging due to a high infectious disease burden, limited access to some useful antibiotics, unregulated use of antibiotics in the community, and limited diagnostic capacity to guide clinical decision-making [19; 20; 21; 22]. In Malawi, there is an urgent need to set up locally adapted, sustainable, and scalable interventions to contain the problem of AMR. Responding to this need, the Republic of Malawi developed a National Action Plan (NAP) for Antimicrobial Resistance Strategy (2017-2022) [23].  
In response to the Malawi NAP and worldwide need to fight against AMR [4; 11; 12; 23; 24], volunteers from the Pharmaceutical Society of Malawi (PHASOM) and the Welsh Antimicrobial Pharmacy Group (WAPG) formed the Malawi-Wales Antimicrobial Pharmacy Partnership. In 2021, the partnership secured a Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) grant to work with two referral hospitals in Malawi, Kamuzu Central Hospital (KCH) and Muzuzu Central Hospital (MCH), located in the central and northern regions and caring for almost 7.5 and 2.3 million Malawians, respectively [25]. The aim of the project was to support and expand AMS activities, which were in their infancy within the two hospitals. This included introducing a regular point prevalence survey (PPS) to establish baseline antimicrobial prescribing practices and monitor change, the development of a practical AMS toolkit to support AMS at a patient level, and multi-disciplinary training sessions to build capacity and support the delivery of a robust and sustainable AMS programme within KCH and MCH.