Adherence to the Core Elements of Outpatient Antibiotic Stewardship: A Cross-Sectional Survey in the Tertiary Care Hospitals of Punjab, Pakistan

Background: There is a growing global interest in hospital-based antibiotic stewardship programs (ASPS). Centers for Disease Control and Prevention (CDC) recommends clinicians and facilities in outpatient department (OPD) to adhere to a set of stewardship activities called the Core Elements of Outpatient Antibiotic Stewardship (CEOAS). CEOAS includes 4 core elements for OPD facilities and clinicians each, ie, commitment, action, tracking and reporting, and education and expertise. Aim: The aim of this study was to evaluate the adherence of OPDs in tertiary care hospitals to CEOAS. Design and Setting: A cross-sectional study in the hospitals in Punjab, Pakistan. Methods: Study was reported as per STROBE guidelines. Data were collected from hospitals based on purposive sampling on the CEOAS framwork. On a summative scale, positive response to each core element worthed a score and higher the score better the adherence. Descriptive statistics was used for categorical variables while independent t-test computed group differences. Results: Fifty-three tertiary care hospitals (n=22 public, n=31 private) participated (response rate=86.9%). No hospital reported "perfect" adherence. Overall, facilities and clinicians in OPDs were moderately adherent. Subgroup analysis indicated that hospitals in public and private were poorly (4.9) and moderately (6.0) adherent to CEOAS respectively, however, private clinicians scored significantly higher in action, and tracking and reporting. Tracking and reporting of antibiotics and education of patients and clinicians emerged as top deficiency areas in facilities and clinicians respectively. Conclusion: Significant gaps exist in the adherence to CEOAS. The deficiency areas highlighted in the study should be given priority in future policy shift.