Implementing National Antimicrobial Stewardship Program (ASP): Our Singapore Story

Abstract

Background. Antimicrobial resistance is a key global healthcare problem. A recent national survey showed marked increase in carbapenem resistance in Enterobacteriaceae. In 2009, National Antimicrobial Taskforce (NAT) recommended the implementation of Antimicrobial Stewardship Programs (ASPs) in all public hospitals (PH) to curb the problem. In 2011, Ministry of Health (MOH) approved funding for this implementation and proposed several key performance indicators to measure outcomes. This study aims to describe ASP's implementation nationally and review their outcomes to date. Methods. Government funding was provided to set up ASP teams-consists of Infectious Diseases (ID) physician, microbiologist, ID pharmacists and part time executive. Manpower funding was based on bed ratios and complexity of patient care. Intervention bundles include hospital prescribing guidelines, audit with feedback and prescribers' education. Furthermore, computerised decision support system (CDSS) was introduced to guide clinicians in appropriate prescribing (according to hospital guidelines), and to aid in surveillance of antibiotic utilization and resistance rates. Results. To date, ASP is implemented in all local PH and CDSS was introduced in 4 out of 7 (57.1%) PH. However, ASP models vary between PH, with some PH adopting hospital-wide audit of selected antibiotics, while others may audit all antibiotics in selected patient populations. Rates of appropriate prescriptions of audited antibiotics increased from 60% to 80%, while average acceptance rates remained stable at 66%. For key clinical outcomes, ASPs reduced length of stay (LOS) without compromising patients' safety, reduced rates of adverse drug reactions, Clostridium difficile infections, infection-related readmissions, and decreased 30-day mortalities. Cost analysis of SGH-ASP patients' hospital bills showed an estimated savings of $1.33million for 2014. Conclusion. ASP in Singapore's PH has been successfully implemented, resulting in improved rates of appropriate prescriptions of audited antibiotics to >70%, without compromising patient safety. More importantly, this translated to significant reduction in LOS, rates of adverse drug reactions and infection-related readmissions.