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discuss and formulate a consensus statement on AMS programs for acute-care hospitals in the Asian region. In a pre-meeting survey, the experts answered questions relating to AMS program goals and outcome measures, team structure, AMS interventions, the importance of information technology systems, the strategy of combining AMS and infection control, and stakeholder advocacy. At the 2-day meeting, the experts reviewed the available medical literature then discussed the results of the survey in relation to gaps and challenges in Asia. After the meeting, draft consensus statements based on this discussion were distributed to each panel member for review and comment, and these statements were revised accordingly. This process was repeated until final con- sensus was reached in November 2017.


Search strategy and selection criteria


A system adapted from the Grading of Recommendations Assess- ment, Development and Evaluation (GRADE) system was used to rate the strength of recommendations for AMS program interven- tions and the quality of the supporting evidence (Table 1).8 Evidence for these recommendations was primarily based on updated Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) guidelines and recent systematic reviews and meta-analyses of interventions, including from hospitals in the Asia-Pacific region.8,16–18 We also searched PubMed for relevant English language articles using terms such as “antimicrobial resistance,”“antimicrobial stewardship,” and “Asia” from 2000 through August 2017.


Key findings and recommendations Gaps and challenges facing implementation of AMS in Asia


The common gaps and challenges that can hinder implementa- tion of AMS programs in Asia and potential solutions to over- coming them are listed in Table 2. A critical concern is the lack of routinely collected epidemiological AMR data in Asian countries, which makes planning difficult.4–7 A paucity of epidemiological data contributes to low awareness of the scale of the problems associated with the misuse of antibiotics.5 Compounding the low awareness of AMS program benefits, hospital administrators and prescribers in overworked and


Anucha Apisarnthanarak et al


of AMS programs in many Asian hospitals.2,10,13,19,20,22 Ongoing training and education should encourage and emphasize the importance of AMS activities.11,13,20,23 Strengthening microbiology laboratory and information technology capacity to deliver reliable and timely data on causative pathogens and antibiotic susceptibility is particularly important for implementation of AMS.2,13 As hospitals differ in terms of AMS program status, we recommend that each hospital assess the AMS gaps using an AMS assessment checklist (Supplementary Material S1) and prioritize actionable steps (Supplementary Material S2) to overcome the barriers.


overcrowded, resource-poor hospitals often do not prioritize AMS because they perceive themselves to have more immediate chal- lenges, primarily patient care and potentially infection con- trol.2,9,11,12,19,20 The pharmaceutical industry can support discussion among the stakeholders, which occurred during the preparation of this document, but the industry is often seen as a negative influence, especially when financial incentives are offered for prescribing antibiotics.2,11,12,19–21 Provider resistance is another important barrier to the widespread implementation of hospital AMS programs.9,11,19 Resource constraints pose a major barrier to the implementation


AMS program goals


The primary objective of a hospital AMS program is to achieve best clinical outcomes related to antibiotic use while minimizing toxicity and limiting the selective pressure on bacterial popula- tions that drive the emergence of AMR.24


AMS process and outcome measures


Before an AMS program is implemented, outcome measures need to be chosen that prospectively evaluate the efficiency of the AMS program in relation to its goals.24,25We recommend selecting a combination of commonly used process and outcome measures (Table 3) and accounting for data and resource availability.26 Process measures, such as antibiotic consumption and appropriate antibiotic use, should be evaluated to confirm compliance with the AMS program. An effective AMS programcan improve outcomes, such as length of hospital stay, rates of MDR bacterial infection or coloni- zation, and treatment-related costs.16–18,27,28


Table 1. Grading System Used to Rate the Strength of Guideline Recommendations and Quality of Supporting Evidencea


Strength of Recommendation


Strong Weak Extent of Consensus


Most or all healthcare professionals would endorse the recommended course of action, and only a small proportion may not (eg, 9–11 panel members agree with the recommendation).


Most health care professionals would endorse the recommended course of action, and a proportion would not (eg, 6–8 panel members agree with the recommendation).


Quality of evidence Type of Evidence High


Moderate Low Very low Randomized controlled trials (≥1)


Well-designed nonrandomized controlled trials (>1); cohort or case-controlled studies (preferably from >1 center); multiple time- series; or large effect from uncontrolled studies


A well-designed nonrandomized controlled trial (≥1); cohort or case-controlled studies (preferably from >1 center); multiple time series; or large effect from uncontrolled studies


Opinions of respected authorities, based on clinical experience, descriptive studies, or expert committee reports aBased on the US Grading of Recommendations Assessment, Development and Evaluation (GRADE) system used in current IDSA/SHEA guidelines.12


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