First antibiotic use survey in Nepal influences health policy

Since 1999, ongoing national surveillance in Nepal shows antimicrobial resistance (AMR) is rising. However, data analysis on its drivers, such as irrational AMU (antimicrobial use), do not follow the same trend.

To collect such data in real-time, the Fleming Fund country grantee FHI 360, managed by Mott MacDonald, conducted the first AMU Point Prevalence Survey (PPS) series analysing the lack of rational use of antibiotics in Nepalese hospitals – in partnership with the Antimicrobial Use Technical Working Group (AMU-TWG).

We spoke to Senior Technical Specialist Parishan Shrestha and Project Director at FHI 360 Dr Ritu Amatya, on how the project’s insights inspired policy change.

Image shows: Data enumerators (nurses) from Pokhara Academy of Health Sciences collecting AMU PPS data. Credit: Parishan Shrestha.

The first of its kind in Nepal, the AMU survey resulted in major PPS findings at clinical and national health levels, covering six tertiary care hospitals in four out of seven provinces*. This generated critical baseline data on AMU in hospital settings – under the supervision and guidance of the Ministry of Health and Population.

The analysis of PPS from the surveyed hospitals showed a high prevalence of AMU within the World Health Organization (WHO) AWaRe Classification framework.

69% average antibiotic usage
More than 50% of antibiotics used had higher potential resistance
3.2% prescribed antibiotics ‘Not Recommended’

Classifying antibiotics

To classify antibiotic types used, the survey tracked data against the WHO ‘Watch’ category of antibiotics with higher potential to develop resistance. This category far exceeded data against the WHO ‘Access’ category of antibiotics with less potential to develop resistance.

The survey reported the average antibiotic usage to be around 69% with more than 50% of the antibiotics prescribed in the Watch category, and 3.2% of prescribed antibiotics in the WHO ‘Not Recommended’ category which is classified as non-evidence based and unsuitable for clinical use. Alongside the results, it also indicated the need for clear documentation of review and stop treatment dates and prescription reason.

Positive influence

"Encouragingly, the survey series has positively influenced relevant clinical and national health policies. Ongoing interactions, trust, and relationship platforms such as sharing PPS findings support integral components of data and knowledge which are widely accepted and used by healthcare practices in Nepal," said Parishan.

Parishan Shrestha, FHI 360 Nepal

Catalysing intensive discussions with the hospitals over the data gaps identified through the survey, drew attention to the importance of initiating the Antimicrobial Stewardship Programme (AMSP) which is supported by the Fleming Fund.

“AMR workshops, dialogues, and advocacies backed by local and global success stories of the AMSP brought forth recommendations for policies for rational AMU," explained Dr Amatya. “For example, the successful control of AMR at a private hospital in Kathmandu after the restricted use of antibiotics over six years (2015-2020) reinforced the feasibility and usefulness of AMSP in Nepal.”

Dr Ritu Amatya, FHI 360 Nepal

Precise prescribing

Antimicrobial Stewardship (AMS) activities now take place in the surveyed hospitals, with two forming AMS committees and one developing the institutional antimicrobial treatment guideline for more effective AMU.

National expansion of the AMU survey at all levels of hospitals and other clinical practices in Nepal is planned, to obtain a comprehensive understanding of antimicrobial prescribing in-country.

“From a One Health AMR perspective, we advocated for the review and revision of national policies to restrict the use of the WHO ‘Reserve’ category antibiotics - saved for treatment of confirmed or suspected infections due to multi-drug-resistant organisms - in both human health and veterinary sectors," explained Parishan.

Dr Amatya, added: "The project also led to measures taken to help prevent over-the-counter sales of antimicrobials and discourage the use of the WHO Not Recommended antibiotics category, notifying hospitals and healthcare providers nationwide of appropriate prescribing practices."

The National Infection Prevention and Control Guidelines 2023 also mandated an Infection, Prevention and Control committee and the AMSP in all healthcare facilities.

Data enumerators (nurses) from Pokhara Academy of Health Sciences collecting AMU PPS data. Credit: Parishan Shrestha.

Actions and interventions

“Such actions and interventions influenced by the AMU series are crucial for ensuring antimicrobial rational use in Nepal, highlighting the absence of AMU data and need for national baseline information to inform appropriate policy recommendations for AMR containment,” said Parishan.

“Key to the effective uptake of the study is that the process and findings are appropriate with local ideas of what is credible and of value – achieved by early engagement and regular contact with a well-resourced communication infrastructure supporting genuine consultation and dialogue," added Dr Amatya.

The AMU-TWG Chair and Secretary, hospital faculty and the Fleming Fund Country Grant team were investigators of the survey. They identified gaps in the existing system from the findings and prioritised responses to identified needs for rational AMU.

“The greater the engagement of stakeholders with the AMU study concept, design, implementation, and interpretation, the higher the likelihood of data use by the most influential and powerful that can translate into policies and actions on AMR,” explained Dr Amatya.

Clinicians and nurses from Province Hospital, Surkhet collecting AMU PPS data. Credit: Parishan Shrestha.

*B.P. Koirala Institute of Health Sciences, Patan Academy of Health Sciences, Pokhara Academy of Health Sciences, Pokhara Manipal Teaching Hospital, Province Hospital, Surkhet, and Tribhuvan University Teaching Hospital.

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