ORCID Profile
0000-0002-5306-3254
Current Organisation
University of Oxford
Does something not look right? The information on this page has been harvested from data sources that may not be up to date. We continue to work with information providers to improve coverage and quality. To report an issue, use the Feedback Form.
Publisher: Cold Spring Harbor Laboratory
Date: 20-11-2022
DOI: 10.1101/2022.11.19.22282535
Abstract: Blood culture (BC) s ling is recommended for all suspected sepsis patients prior to antibiotic administration. Here, we aimed to identify barriers and enablers to BC s ling in three Southeast Asian countries. We conducted a systematic review of studies evaluating barriers/enablers to BC s ling from 1900 to 2020 globally (PROSPERO, CRD42020206557). Using the findings of the systematic review, we developed and conducted a Theoretical Domains Framework (TDF)-based survey with a case scenario question among doctors and final-year medical students in Indonesia, Thailand and Vietnam. In the systematic review, we identified 6,175 unique records from the databases, of which 25 met the eligibility criteria. Studies were conducted in 37 high-income countries (HICs) and 41 low-and middle-income countries (LMICs). Of 14 TDF domains, three and seven were not assessed in HICs and LMICs by the studies included in the systematic review, respectively. 1,070 medical doctors and 238 final-year medical students completed the survey. The proportion of respondents who would definitely take BC in the case scenario was 89.8% for Thai, 50.5% for Vietnamese and 31.3% for Indonesians (p .001). Eight TDF domains were considered key in influencing BC s ling, including ‘no awareness of guideline [TDF-knowledge]’, ‘low priority of BC [TDF-goals]’, ‘no intention to follow guidelines [TDF-intention]’, ‘level of doctors who can order or initiate an order for BC [TDF-social professional role and identity]’, ‘no norms of BC s ling [TDF-social influence]’, ‘perceived cost-effectiveness of BC [TDF-environmental context and resources]’, ‘regulation on cost reimbursement [TDF-behavioural regulation]’ and ‘consequences that discourage BC s ling [TDF-reinforcement].’ However, there was substantial heterogeneity between the countries across most domains. Evidence on barriers and enablers to BC s ling is limited globally. We identified in idual, socio-cultural and environmental barriers/enablers to BC s ling across different countries, which represent potential targets for interventions. Context-specific multifaceted interventions at both hospital and policy levels are required to improve diagnostic stewardship practices. Wellcome Trust, UK (220557/Z/20/Z).
Publisher: Cold Spring Harbor Laboratory
Date: 10-09-2021
DOI: 10.1101/2021.09.05.21263144
Abstract: Antibiotic overuse is one of the main drivers of antimicrobial resistance (AMR), especially in low and middle-income countries. This study aimed to gain an understanding of perceptions, views, and practices regarding AMR, antibiotic prescribing, and stewardship (AMS) among hospital physicians in Jakarta, Indonesia. cross-sectional, self-administered questionnaire-based survey, with descriptive statistics, exploratory factor analysis (EFA) to identify distinct underlying constructs in the dataset, and multivariable linear regression of factor scores to analyse physician subgroups. Six public and private general hospitals in Jakarta in 2019. 1007 of 1896 (53.1% response rate) antibiotic prescribing physicians. EFA identified six latent factors (overall Crohnbach’s α=0.85): awareness of AMS activities awareness of AMS purpose views regarding rational antibiotic prescribing confidence in antibiotic prescribing decisions perception of AMR as a significant problem and immediate actions to contain AMR. Physicians acknowledged the significance of AMR and contributing factors, rational antibiotic prescribing, and purpose and usefulness of AMS. However, this conflicted with reported suboptimal local hospital practices, such as room cleaning, hand hygiene and staff education, and views regarding antibiotic decision-making. These included insufficiently applying AMS principles and utilising microbiology, lack of confidence in prescribing decisions, and defensive prescribing due to pervasive diagnostic uncertainty, fear of patient deterioration or because patients insisted. Physicians’ factor scores differed across hospitals, departments, work experience and medical hierarchy. AMS implementation in Indonesian hospitals is challenged by institutional, contextual and diagnostic vulnerabilities, resulting in externalising AMR instead of recognising it as a local problem. Appropriate recognition of the contextual determinants of antibiotic prescribing decision-making will be critical to change physicians’ attitudes and develop context-specific AMS interventions. The self-developed questionnaire in this study identified a relevant set of attributes through a factor analysis optimization process, with adequate content, face and construct validity and internal reliability. This study adds important value in the absence of adequately validated instruments regarding antimicrobial resistance and stewardship, with particular applicability for LMIC. This study had a large, varied respondent s le and high response rate among physicians at six public and private hospitals in Jakarta, Indonesia, and identified differences between physicians across hospitals, departments, work experience and medical hierarchy, which can guide priority-setting and tailoring of stewardship interventions. However, non-participation and the convenient hospital s le could have introduced selection bias, and the data are not necessarily representative for Jakarta or Indonesia. Factor analysis is based on using a “heuristic”, which leaves room to more than one interpretation of the same data and cannot identify causality.
Publisher: Elsevier BV
Date: 07-2022
Publisher: Springer Science and Business Media LLC
Date: 14-06-2022
DOI: 10.1186/S13756-022-01126-7
Abstract: Antimicrobial resistance (AMR) is one of the leading global public health threats of the 21st Century. Antimicrobial stewardship (AMS) programmes have been shown to improve antibiotic use and clinical outcomes in high-income settings, but context-specific evidence is lacking on the value and effectiveness of current AMS programmes in low-resource settings. This study sought to explore context-specific underlying barriers to AMS implementation in Indonesian hospitals with a focus on governance practices and structural vulnerabilities. We conducted semi-structured interviews with physicians, surgeons, clinical microbiologists, pharmacists, AMS team leaders, hospital managers, medical students, and national AMR stakeholders, and performed a thematic analysis. Based on 51 interviews conducted between January and October 2020, four main barriers to AMS implementation were evident in the participants' experiences: (1) Ineffective resourcing and institutional buy-in regarding mandatory AMS under hospital accreditation (2) Entangled priorities to generate profits and interprofessional relationships between doctors and hospital managers or AMS leaders (3) Cost-prohibitive bacterial culture testing and thresholds of national health insurance coverage (4) Unreliable infrastructures , including microbiology laboratory and surgical facilities, ensuring high antibiotic usage to cover structural vulnerabilities. Limited progress will be made with implementing AMS in Indonesian hospitals, and in settings with similar structural features, without addressing concerns around governance, competing interests, cost and structural vulnerabilities.
Publisher: Cold Spring Harbor Laboratory
Date: 22-02-2022
DOI: 10.1101/2022.02.20.22271261
Abstract: A major driver of antimicrobial resistance (AMR) and poor clinical outcomes is suboptimal antibiotic use, although data are lacking in low-resource settings. We reviewed studies on systemic antibiotic use (WHO ATC/DDD category J01) for human health in Indonesia, and synthesized available evidence to identify opportunities for intervention. We systematically searched five international and national databases for eligible peer-reviewed articles, in English and Indonesian, published between 1 January 2000 and 1 June 2021 including: 1) antibiotic consumption 2) prescribing appropriateness 3) antimicrobial stewardship (AMS) 4) perceptions among consumers and providers. Two independent reviewers included studies and extracted data. Study-level data were summarized using random-effects model meta-analysis for consumption and prescribing appropriateness, effect direction analysis for AMS interventions, and qualitative synthesis for perception surveys. (PROSPERO CRD42019134641) Of 9323 search hits, we included 100 reports on antibiotic consumption (20), prescribing appropriateness (49), AMS (13), and/or perception (25) (8 categorized in domain). The pooled estimate of overall antibiotic consumption was 110.1 DDD/100 patient-days (95%CI98.5-121.6), with ceftriaxone, icillin and levofloxacin being most consumed. Pooled estimates for overall appropriate prescribing (according to Gyssens method) were 33.5% (95%CI18.1-53.4%) in hospitals and 49.4% (95%CI23.7-75.4%) in primary care. Pooled estimates for appropriate prescribing (according to reference guidelines) were, in hospitals, 99.7% (95%CI97.4-100%) for indication, 84.9% (95%CI38.5-98.0%) for drug choice, and 6.1% (95%CI0.2-63.2%) for overall appropriateness, and, in primary care, 98.9% (95%CI60.9-100%) for indication, 82.6% (95%CI50.5%-95.7%) for drug choice and 10.5% (95%CI0.8-62.6%) for overall appropriateness. The few AMS intervention studies conducted to date suggested potential to reduce antibiotic consumption and improve prescribing appropriateness. Key themes identified in perception surveys were lack of antibiotic knowledge among consumers and non-prescription antibiotic self-medication. Context-specific strategies are urgently needed to improve rational antibiotic use in Indonesian hospitals and communities, with critical evidence gaps concerning private and informal health providers. What is already known? • Indonesia is a potential AMR hotspot, where, based on pharmaceutical sales data, antibiotic consumption increased 2.5-fold between 2000 and 2015, mostly driven by broad-spectrum penicillins, fluoroquinolones and cephalosporins. • Representative contemporary data on antibiotic use are lacking, although anecdotal data suggest antibiotic overuse in the healthcare system, widespread over-the-counter use in communities, and high rates of AMR mostly among common Gram-negative bacteria. • A comprehensive review on antibiotic use in human health in Indonesia has not been conducted to date. What are the new findings? • Available data spanning the past 20 years, suggested that only 34% and 49% of antibiotics were appropriately prescribed in hospital and primary care settings, respectively, although the quality of the evidence was low. • Publications evaluating AMS interventions have been sparse to date, demonstrating the need to strengthen the local research base to develop context-specific and sustainable AMS models. • Community surveys suggested important gaps in antibiotic knowledge, and that non-prescription antibiotic self-medication is common practice, although data to quantify this problem and its drivers are lacking. What do the new findings imply? • Available evidence synthesised in this Review provides important insights in the magnitude and patterns of antibiotic use, and associated patient and health system factors, which helps define opportunities for optimising responsible antibiotic use. • Critical evidence gaps exist on informal and formal private health care providers, geographic areas outside of Java Island, as well as effective AMS models that consider country-specific socio-cultural, economic and political circumstances. • Optimization of antimicrobial use as a means to tackle AMR should be a priority of the national agenda for universal health coverage.
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Ralalicia Limato.