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Evidence based QUality Improvement for Prescribing Stewardship in ICU (EQUIPS-ICU): protocol for type III hybrid implementation-effectiveness study

Wagstaff D 1 , Amausi J 2 , Arfin S 3 , Aryal D 4 , Nor MBM 5 , Bonney J 6 Show all authors , Dondorp A 7 , Dongelmans D 8 , Dullawe L 9 , Fazla F 9 , Ghose A 10 , Hanciles E 11 , Haniffa R 7 , Hashmi M 12 , Smith AH 13 , Kumar B 14 , Minh YL 15 , Moonesinghe R 16 , Pisani L 7 , Sendagire C 17 , Hasan MS 5 , Ghalib MS 18 , Frimpong MS 19 , Ranzani O 20 , Sultan M 21 , Thomson D 22 , Tripathy S 23 , Thwaites L 15 , Uddin RAME 10 , Mazlan MZ 24 , Waweru-Siika W 25 , Beane A 7

Affiliations 

  • 1 Centre for Preoperative Medicine, University College London, London, UK. d.wagstaff@ucl.ac.uk
  • 2 Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
  • 3 The George Institute for Global Health, New Delhi, India
  • 4 Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
  • 5 Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
  • 6 Virology Department, Noguchi Memorial Institute for Medical Research, Accra, Ghana
  • 7 Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
  • 8 National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
  • 9 Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
  • 10 Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh
  • 11 Connaught Hospital, Freetown, Sierra Leone
  • 12 Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
  • 13 Faculty of Health Sciences, Busitema University, Mbale, Uganda
  • 14 Department of Critical Care Medicine, Apollo Hospitals Educational and Research Foundation, Chennai, India
  • 15 Clinical Research Unit, Oxford University, University of Oxford, Ho Chi Minh City, Vietnam
  • 16 Centre for Preoperative Medicine, University College London, London, UK
  • 17 D'Or Institute for Research and Education, Sao Paulo, Brazil
  • 18 General Surgery, Wazir Akbar Khan Hospital, Kabul, Afghanistan
  • 19 Department of Anaesthesiology and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
  • 20 Barcelona Institute for Global Health, ISGlobal, Barcelona, Spain
  • 21 Department of Emergency Medicine and Critical Care, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
  • 22 Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
  • 23 Pandemic Sciences Hub and Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, UK
  • 24 Hospital Universiti Sains Malaysia, Kota Bharu, Malaysia
  • 25 Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya
Implement Sci, 2025 Feb 25;20(1):12.
PMID: 40001051 DOI: 10.1186/s13012-024-01413-4

Abstract

BACKGROUND: Approximately half of all antimicrobial prescriptions in intensive care units (ICUs) may be inappropriate, including those prescribed when not needed, in unnecessary combinations or for longer durations than needed. Inappropriate prescribing is costly, exposes patients to unnecessary side-effects and drives population-level antimicrobial resistance, the prevalence and consequences of which are greatest in low- and middle-income countries. However, the implementation of interventions to improve the appropriateness of antimicrobial prescribing has been variable and requires further study.

METHODS: We propose a type III hybrid implementation/effectiveness interventional cohort trial in 35 ICUs in up to 11 low- and middle- income countries. The study intervention is a structured review of antimicrobial prescriptions as recommended by the World Health Organisation. Strategies to support stakeholder-led implementation include development of local protocols, registry-enabled audit and feedback, and education. Evaluation of implementation, and the determinants of its success, is informed by the RE-AIM framework and the Consolidated Framework for Implementation Research respectively. The primary outcome is a composite measure of fidelity, reach and adoption. Secondary outcomes describe the effectiveness of the intervention on improving antimicrobial prescribing. Qualitative interviews will assess relevant implementation acceptability, adaptations and maintenance. A baseline survey will investigate ICU-level antimicrobial stewardship structures and processes.

DISCUSSION: This study addresses global policy priorities by supporting implementation research of antimicrobial stewardship, and strengthening associated healthcare professional competencies. It does this in a setting where improvement is sorely needed: low- and middle- income country ICUs. The study will also describe the influence of pre-existing antimicrobial stewardship structures and processes on implementation and improve understanding about the efficacy of strategies to overcome barriers to implementation in these settings.

TRIAL REGISTRATION: This study protocol has been registered with ClinicalTrials.gov (ref NCT06666738) on 31 Oct 2004. https://clinicaltrials.gov/study/NCT06666738?term=NCT06666738&rank=1 .

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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