EXCLUSIVE Interview with Dr Dilip Nathwani, MD,
by Garance F Upham, editor in chief
Dr Dilip Nathwani, FRCP, FRSE, OBE - Honorary Emeritus Professor of Infection, University of Dundee, Scotland.
Professor Nathwani is a global leader in antimicrobial stewardship [AMS] education and implementation, with a focus on supporting AMS in lower and middle income countries.
Between 2008-2017 he led the highly successful national AMS programme in Scotland, one of the first of its kind worldwide, and since then has led a number of European and Global initiatives aimed at establishing global open access e-learning knowledge exchange platforms on AMR-AMS as well as enabling effective implementation of AMS in human health in a range of countries through his work with many professional societies, BSAC, CIDRAP, WHO, ICARS and the EBRD.
What of Antimicrobial (AMR) Stewardship in Low Middle Income Countries?
AMR Stewardship is knowing what works and by how much, why, where, and with whom (context), and for how long (sustainability).
Question: You are pioneering "AMR stewardship" adapted to low resource settings, can you explain your concept?
Dr Nathwani: According to the Oxford English dictionary, the contextual definition of a steward is "one who manages the affairs of an estate on behalf of his employer”. In the context of antimicrobial resistance (AMR), a number of definitions have been suggested. My preference is for the one adopted by the WHO which defines Antimicrobial Stewardship (AMS) as: "a coherent set of actions which promote using antimicrobials responsibly". This denotes a broad strategy rather than a specific intervention. An antimicrobial stewardship programme, in turn, defines the set of practical actions to be applied in this strategy and should vary depending on the context, the resources, and so on. It is this ability for the interventions or solutions to be adapted, and then effectively adopted, within the healthcare setting in question, which is key to how we approach low resource settings.
Implementation fidelity of human antimicrobial stewardship (AMS) activities is at the heart of effecting change and improving outcomes. Indeed, the term implementation fidelity refers to the degree to which an intervention or programme is delivered as intended. Only by understanding and measuring whether an intervention has been implemented with fidelity can researchers and practitioners gain a better understanding of how and why an intervention works, and the extent to which outcomes can be improved. In short, it is knowing what works and by how much, why, where, and with whom (context), and for how long (sustainability). Moreover, only by beginning to appreciate the barriers across a range of contexts, cultures, geographies and resources will we be able to create and implement appropriate solutions. A large number of AMS approaches are created and evaluated within the context of higher income or developed world-settings. The “implementation fidelity” component of these evaluations even in these settings is often lacking or suboptimal. Despite this, there are good quality studies emerging that provide evidence to suggest that AMS actions are undoubtedly beneficial across a range of outcomes, particularly in the hospital setting, and to a lesser extent in the community setting. There are even fewer evaluations of sufficiently high quality that show these benefits in lower and middle or developing countries (LMICs) although it is widely acknowledged that they are broadly beneficial. There is also a scarcity of studies based in the community or non-inpatient setting where the bulk of poor antibiotic prescribing happens broadly in LMIC’s. With improving implementation fidelity as a focus in working with the WHO we have in the first instance created a basic checklist of core elements for AMS actions (toolkit) in LMIC’s, focused on the hospital setting.[1]
This will, in the future, be supported by further updates and adaptations based on existing and emerging “implementation research in this setting. Indeed, one such example is the Tailoring Antimicrobial Resistance Programmes (TAP) developed by WHO. TAP is a step-by-step guide to designing and implementing a behaviour-change intervention for specific target groups in order to contain drivers of AMR and it will be tested in the AMS context as part of the ICARS (International Centre for Antimicrobial Resistance Solutions) project in Georgia. The WHO, working in collaboration with others, intends to further develop specific advice for outpatient and community settings.
Question: As someone who joined the steering committee of Patients for Patient Safety, when the WHO-UK Patient Safety Program started in 2004 - and was on for ten years - I am excited to read your concept when you write: "Global antibiotic stewardship starts with individual stewards reaching out to each other to share experiences, education, and resources; to collaborate in research and publication, and to set up mentoring programmes” because your project appears as bottom-up? Have you implemented LMIC antibiotic stewardship projects?
Dr Nathwani: Indeed, a number of us as individuals as well as professional leaders belonging to learned health care professional “infection “societies have been passionate and ardent advocates of the role of stewards and professional organisations with a “global stewardship” mindset. Through my Presidency (2015-2018) of the British Society of Antimicrobial Stewardship (BSAC), and in collaborations with an international body of like-minded stewards, as well as a range of other stakeholders, I have led the “mantra of global and contextual AMS learning from shared experience and education that is open access and increasingly digital”[2]. As part of this, we are in the process of building dynamic collaborative AMS networks, locally or regionally, that allow mentoring & relationship building. One such example is ( in the Gulf, Northern Africa and Middle East [3] as well as work in Kenya, India, Russia and Latin America. Other initiatives include accreditation and sharing of knowledge in its different forms- information, data, education, training and research. This Global Infection Learning Hub (final name being considered) will comprise of a range of AMS and AMR related work-streams including COVID-19 resources in light of its undoubted impact on AMS and healthcare system capacity, capability and resilience. These will include an International Partnership Forum, Global AMS Accreditation Scheme, AMS e-Learning Repository, Pandemic Preparedness, Infection Education Hub, Infection Training, Civic Engagement, and AMR, COVID-19, and the Investment Community. An example of the latter is a unique public-private partnership with the European Bank of Reconstruction and Development (EBRD) Join with EBRD against Superbugs[4]. Pfizer, and philanthropists, amongst others, that will support the independent and incremental development of the hub. We hope others will feel compelled to join us in this learning and knowledge-sharing journey.
Question: Dr. Acar was absolutely delighted about his responsibilities with the Fleming Fund - even though he had many others too! - can you tell us more about the Fund's role in supporting poor African countries' efforts?
Dr Nathwani: Whereas I am not directly involved with the work of the Fleming fund I am very supportive of key strands of their work in South Asia, SE Asia, and Africa in relation to surveillance and laboratory capacity and supporting the creation and use of data to support AMR decision making as well as education regarding data/AMR awareness. My slight frustration and hence the premise of my presentation was that the Fleming Fund and the people on the ground that implement its ambition need to engage more with the clinician antimicrobial user community and leadership. This is not micro/ID people but surgeons/ internists, pediatricians, etc. We need to adopt a more improvement science approach to using data so as to make it relevant to “the clinician’s everyday practice”. Presently it is seen rather as a research, governance, or scrutiny/judgemental measure, as opposed to something that will inform clinical decision making and help improve patient outcomes. The need to build relationships, understanding, and close working relations between the laboratory/ epidemiologists and prescribers - and many would add the patient community - is at the heart of this. Changing healthcare systems mindsets about data creation and use requires local leadership, ownership, and cultural change – “ it needs to matter to them”! Data in many cultures is seen as something that is secret and not to be openly shared or learnt from - that is where a cultural shift will be required. Data can often also be seen as punitive as opposed to a beneficial tool!
To its credit, the Fleming Fund is investing in developing good quality educational resources to support its initiatives - Dr Nathwani added - I personally feel that these resources need to be part of the bigger picture of “AMS implementation fidelity” collaborating and aligning with the work of others, such as BSAC and others (mentioned above) as it would be a significant step in the right direction. I certainly would welcome the Fleming Fund to be involved within the learning platform we are currently creating, which can be of interest for the AMR Think-Do-Tank.
References:
BSAC Infection Learning Hub
Infection Learning Hub
Gulf-Middle East- North Africa Educational Collaborative on Antimicrobial Stewardship
BSAC joins forces with development bank to stop superbugs