Theme 1-Current State of Antimicrobial use
Regarding the current use of antimicrobial agents, all respondents said that irrational use of antibiotics is a major problem in Nigeria. S2 noted “there’s no guided use, anybody just says this is what they want. As a pharmacist, we try to restrict use, but the prescribers will say by the time patients come to them, they have used several antibiotics thus leaving them with no choice but to use higher class or new generations of antibiotics. The medical representative’s influence cannot be neglected. They give data of new antibiotics or fixed-dose combinations to prescribers, those in turn end up yielding and prescribing these drugs”.
The most antibiotic use problem identified is wrong selection of antibiotic followed by overprescribing. The issue of inappropriate prescribing may tend to be higher in PHC settings of which a majority do not have laboratories and some have nurses or community health extension workers as managers. Many of these facilities admitted to having access to antibiotics that should ideally be restricted for use in primary care such as floroquinolones and cephalosporins, and it seems some of the personnel do not understand antibiotic use restriction (P1, P2).
Theme 2- Laboratory and Antimicrobial Resistance Surveillance Report
The secondary and tertiary healthcare facilities have laboratories, in the primary healthcare centres, only one of the four local government sampled has a laboratory in the local government headquarter where culture and sensitivity tests can be done. The others refer patients to other laboratories (either in the state hospital or privately owned (P1, P4). The tertiary institution alone has regular surveillance report only on HCAIs because of the stand-alone infection control unit that gives updated reports. Respondents linked antimicrobial resistance to patients who have either self-medicated or have been given antibiotics in drug outlets like patent medicine dealers or pharmacies and to poor infection control in hospitals. The pattern of resistance in HCAIs shows coagulate negative, Staphylococcus aureus, Pseudomona aereuginosa, Klebsiella spp, Providential species, Enterobacter, Citrobacter, alkaliginase. The highest resistance being coagulase negative Staph aureus, and the lowest is Alkaliginase and Citrobacter (T4).
Regarding resistance to antimicrobial agents, S1 pointed that “from lab results, the sensitivity pattern can be very discouraging. Common ones like Penicillins (amoxyl) Cephalosporins (Ceftriaxone) etc are no more effective, some organisms are only sensitive to floroquinolones and imipenem which are not cheap. it therefore becomes difficult to start requesting for drug like imipenem to teat common urinary tract infection”.
Theme 3- Presence and functionality of Formal Antimicrobial Stewardship Practice
The idea of AMS in practice setting was welcomed by all responders in the tertiary and secondary facilities as a means to restrict antibiotic use, unfortunately none of the facilities have a formal AMS program. Most participants identified the role of government policy as key to institutionalizing AMS, in addition to providing national guideline on antimicrobial use which is currently lacking. T2 mentioned “Government involvement if it is committed will have positive impact, in addition to policy makers. I am not aware of antimicrobial guideline, what I am aware of is guideline for use of drugs in hospitals i.e standard treatment guideline. I can’t say it’s being in use”.
At the primary healthcare level, the concept of antimicrobial stewardship was vague to most of the participants, thus they were briefly enlightened. P4 said, “I don’t really understand what it means. But if it has to do with effective use of antibiotics then it is a program that should be encouraged and taken seriously”.
Theme 4: Likely Barriers to AMS
T3- “ AMS is difficult because we are going to experience friction e.g autonomy in auditing prescriptions, without management backing it won’t work”
T2- “there is no commitment from the leadership of the hospital. In Nigeria, we have this general attitude of not implementing policies. ”
S2- “likely barrier is our professional rivalry, it’s for everybody to realize that we are in this workplace for the benefit of patients”
T3- “one of the things with bringing guideline for hospital use is if the hospital has an antibiogram. To do this effectively, we need very good working relationship with pharmacist, doctors, clinical microbiologists etc. in most institutions in Nigeria, there is this rivalry that may make it difficult to work together seamlessly”
Shortage of healthcare professionals
S3- “In the state, generally, there’s a dearth in manpower. Imagine no qualified staff to run those specialized laboratories”.
T3- “AMS is an intensive program, we are few with other professional duties, so there will be need for dedicated staff”
Poor laboratory services
S3- “in the institution, reporting is a problem, poor lab services like we talked about. Antibiotic resistance involves testing”
Lack of training for healthcare professionals
S1- “In my institution, adequate education of health professionals and update on current use of antimicrobial guidelines is a big challenge”
Theme 5: Facilitators to instituting AMS
All respondents expressed willingness to start off AMS and believed their institutions have the capacity to fully implement the program and to sustain it. The presence of an already functional Drug and Therapeutics Committee (DTC) was cited as an initiator to AMS. In the tertiary institution, T1 stated “we already have a crop of professionals who are interested in this program, the necessary professionals are present in this hospital”
In the secondary healthcare facilities, participants noted that the DTC is new. S2 said “currently due to staff strength depletion, the committee is not meeting up to its responsibility. It’s a new committee. The pandemic made transfer of staff to the isolation center for Covid, that has affected its running”
Another facilitator mentioned by a responder in the tertiary institution is the information technology unit. T3- “The information technology unit in the hospital can be leveraged on. For example, the antibiogram I talked about can be generated from the infrastructure already on ground”
Infection Prevention and Control (IPC) program
Theme 1- Thoughts about IPC
Some participants reported that the recent pandemic highlighted the importance of IPC in healthcare systems. Only the tertiary hospital reported having a formal IPC team with a reporting channel, funding and guideline. In the secondary and primary facilities there is no formal IPC, but IPC activities are carried out by the IPC pillar an offshoot from COVID pandemic charged with the responsibility to oversee the IPC activities in all state hospitals (T5, S4). One of the participants S5 from the state ministry of health noted “I don’t think we have a formal IPC as described, but part of what Edo State IPC pillar is doing is to inform the various hospital and the public on prevention of nosocomial infection which is key to preventing spread of infection”.
All respondents from PHC mentioned that they are under the State’s IPC program and they receive equipment for their IPC activities from the State’s team. Most respondents revealed that the head of the PHC coordinates IPC activities in the facility and reports to the PHC coordinator of the local government who in turn reports to the State coordinator of IPC.
Theme 2- Role of Training in IPC activities
All facilities engage in training and retraining on a regular basis, some respondents noted that they have attended at least a training on IPC in the past one year (P3,P4). T4 mentioned “ last year alone, we had nothing less than 8 trainings, educating healthcare workers on hand hygiene and waste management, because we know that the hands of these healthcare workers are the most important vehicle for transmitting infections.”
S4 added “that’s the bedrock of IPC. Training helps to reinforce knowledge already acquired and also add new knowledge”
Theme 3- Provision of Adequate Personal Protective Equipment (PPEs)
The tertiary institution has a logistic unit that supplies all PPEs. The COVID-Pillar which is an arm of the state’s COVID committee provides PPEs to all state hospitals and PHCs. However, some respondents reported that provision of such materials are not sufficient and that they had to buy some IPC materials with their personal money (P2,P1, P3). T4 commented on some innovations the unit made recently to cope with inadequate PPEs “we have a logistic unit that ensures we have all PPEs. In fact, we had an indigenous production of some PPEs especially during the hit of COVID as there was tendency of worldwide shortage of PPEs, we started making things, cloth face masks for our admin personnel, long sleeve covers, aprons, face shield. We also made UV light equipment to disinfect some of our PPEs like face shields and eyewear”.
Theme-4 Adequate waste Disposal, Clean and Safe Environment
All responders said they had a system of waste disposal, but only the tertiary facility have good waste segregation into infectious, non-infectious, highly infectious and sharps (T4, T5) At the secondary level one participant (S5) explained the inadequacy in the waste disposal system “I think we still need training on segregation where the waste is generated, we just dump everything together which can be risky for those disposing it eventually, that is scavengers, then good sterilization is needed especially in rural areas where they boil their instruments, that will help”.
Most of the respondents in PHC facilities stated that they take wastes that require incineration to University of Benin Teaching Hospital or the World Health Organization waste disposal facility (P1,P2).
Some participants reported that things are put in place to ensure safe and clean environment in their facilities. Cleaners are trained on proper cleaning practice and waste management (S5, P4, T5). Participant T4 detailed “Our environment is regularly cleaned. Now and during the hit of COVID, we use 0.5% sodium hypochloride solution to clean the floor, the walls and high touch areas such as door knobs and switches even the bedding and mattresses, and everything with same solution. We clean the wards and clinics at least twice daily.”
Theme 5- Hand Hygiene Practice in IPC
Compliance with hand hygiene practice was reported to be generally good at the all facilities, although many participants agreed that there is a decrease in hand washing compared to a year ago when we were in the heat of the COVID-19 pandemic which heightened the level of awareness to strictly adhering to hand hygiene measures among healthcare providers. At the secondary facility, S2 gave a positive response and added areas of improvement “People are strict about it. Each unit has wash hand basin and water. Management has provided liquid soap too. But we can do better in a modern way, instead of bucket we should have running taps in work stations and toilets. Nowadays, you don’t even touch tap heads, they use sensors, same thing goes for soap, this helps control/prevent infection”.
Theme 6- Challenges, Strength and Sustainability of IPC Activities
Limited supply of waste disposal materials and PPEs was cited in all facilities as a major challenge, in the primary and secondary facilities, lack of transportation and shortage of staff hinders waste disposal and other IPC activities. In the tertiary institution, behavioural change or lack of compliance especially by new healthcare workers is another limitation observed, it was noted that other healthcare providers still need to imbibe the culture of IPC activities notably hand hygiene and not something done out of fear (T5, S4, P1, P3).
Regarding the strength of IPC activities, the tertiary institution highlighted management commitment for allowing the IPC team to be self-running. Although no formal IPC in secondary and primary institutions, most respondents praised the government for the provision of PPEs compared to before even if they are sometimes not sufficient and training as their strength and expressed that likely in the future the ideal IPC program will be practiced (T4, S4, P1,P3, P4).
Regarding sustainability of IPC activities, T4 said “as long as the IPC committee is sustained in the facility which is over 20 years now plus an enabling environment for the IPC committee to work, it will go far and be sustained”.
S5 said “on a scale of 1–10, I will say 5. You know as government changes, things can change”.