Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal

Antimicrobial resistance (AMR) continues to be a serious global public issue. Unnecessary and inappropriate use of antimicrobials has been identified as a major contributing factor for AMR. Implementation of antimicrobial stewardship programs (ASPs) is valued as a key strategy to combat AMR. Although ASP is a key intervention to improve appropriate use of antibiotics, there is limited experience and research to describe its implementation in low-income countries such as Nepal. Grande International Hospital (GIH) is the first health organization in Nepal to implement and sustain a multidisciplinary ASP and infection control program. Challenges faced in implementing ASP include lack of acceptance from physicians, lack of knowledge regarding antibiotic prescribing, lack of staff for ASP activities, limitations in diagnostic testing to inform ASP, and limitations in antibiotic choice due to antibiotic unavailability. Our ASP includes the following components: an ASP committee, an antibiotic prescribing reference guide with dosage recommendations, inpatient formulary restriction system, educational outreach and programming for physicians and other stakeholders, and periodic review and revision of the program and reference guide. The ASP provided opportunities to address several knowledge gaps across our healthcare institution including improved knowledge and competency regarding rational use of antibiotics, access to quality medicines and better care to patients. It is our hope that, by describing the challenges and opportunities we experienced while implementing our ASP, we can support and encourage other institutions to adapt and implement ASPs in Nepal and other resource-limited settings.