Integrating Antimicrobial Stewardship and Infection Prevention Through Repeated Assessment and Feedback: A Multisite Quality Improvement Initiative in Viet Nam

This multisite quality improvement initiative in Vietnam demonstrates that an integrated antimicrobial stewardship and infection prevention approach, utilizing repeated assessments and feedback, is feasible and effectively drives meaningful improvements in hospital practices and governance to combat antimicrobial resistance in low- and middle-income countries.

The Gist

The Big Picture: Two Teams, One Goal

Imagine a hospital is a busy kitchen. In this kitchen, two major problems can ruin the meal:

1. The "Bad Bugs" (Infections): Germs that spread from person to person or dirty surfaces.
2. The "Wrong Ingredients" (Antibiotic Resistance): Using the wrong spices (antibiotics) too often, which makes the bugs stronger and harder to kill later.

Usually, the team managing the "Bad Bugs" (Infection Prevention) and the team managing the "Wrong Ingredients" (Antimicrobial Stewardship) work in separate rooms. They have their own checklists and don't talk much. This study asked: What happens if we force these two teams to work together in the same kitchen?

The Experiment: A "Health Check-Up" Cycle

The researchers worked with four different hospitals in Vietnam (one big city hospital, two provincial hospitals, and one university hospital). They didn't just give them a lecture; they ran a specific cycle of improvement:

1. The Audit (The Check-Up): They used two specific "scorecards" (tools from the US CDC) to grade the hospitals. One scorecard checked how well they stopped infections (IPC), and the other checked how well they managed antibiotics (AMS).
2. The Feedback (The Report Card): They showed the hospital leaders exactly where they lost points.
3. The Action Plan (The Recipe): The hospital teams sat down together to create a plan to fix those specific weak spots.
4. The Re-Check: A few months later, they graded the hospitals again to see if the scores went up.

What They Found

The study found that when these two teams worked together, the hospitals got better at both tasks. Here is the breakdown:

• The "Low-Hanging Fruit" Was Picked First: The hospitals that started with the lowest scores improved the most. It's like a student who gets a 'C' and studies hard to get an 'A', versus a student who already has an 'A' and can only squeeze out a tiny bit more improvement.
• Leadership and Training Worked Wonders: The biggest improvements happened in areas that didn't cost a lot of money. When hospital bosses got involved, when they held regular meetings, and when they trained their staff, things got better fast.
  • Analogy: It's like realizing you don't need a new car to drive better; you just need to learn the rules of the road and have a co-pilot reminding you to stay in your lane.
• The "Hard Stuff" Stayed Hard: The areas that required building new infrastructure or spending a lot of money (like fixing water safety systems or building new isolation rooms) didn't change much in the short time they had.
  • Analogy: You can teach a chef to cook a perfect steak (training/behavior) in a week, but you can't build a new kitchen (infrastructure) in a week.

The "Secret Sauce": Integration

The main discovery was that integration is key.

• Before, the infection team might say, "Wash your hands!" and the antibiotic team might say, "Don't prescribe that drug!" without talking to each other.
• After the project, they realized that if you stop a germ from spreading (infection control), you don't need to use as many antibiotics. And if you use antibiotics wisely, you stop creating super-bugs that are hard to control.
• By linking their goals, the hospitals created a "virtuous cycle" where better hygiene helped better medicine use, and vice versa.

The Bottom Line

This study proves that you don't need to wait for a massive budget or a new building to make hospitals safer. By simply getting the right people in the same room, giving them a clear scorecard to find their mistakes, and helping them make a plan to fix those mistakes, hospitals in Vietnam were able to significantly improve how they handle both infections and antibiotics.

It's a practical model that says: Stop working in silos, start talking to each other, and you can fix a lot of problems with the resources you already have.

Technical Summary

Technical Summary: Integrating Antimicrobial Stewardship and Infection Prevention Through Repeated Assessment and Feedback

Problem Description
Antimicrobial resistance (AMR) in low- and middle-income countries (LMICs) is exacerbated by the interaction between inappropriate antimicrobial use and healthcare-associated infections (HAIs). While Antimicrobial Stewardship (AMS) and Infection Prevention and Control (IPC) are recognized as complementary strategies, they are frequently implemented as separate, siloed programmes in LMICs. This fragmentation leads to duplicated efforts, missed opportunities for system-level improvement, and suboptimal implementation due to weak governance, limited surveillance capacity, and workforce gaps. In Viet Nam, despite national mandates for AMS committees and IPC programmes, implementation remains uneven, characterized by a "know–do gap" and a lack of coordination between clinical, pharmacy, microbiology, and IPC units. There is a critical need for evidence on how to operationalize integrated AMS-IPC approaches in routine hospital settings with varying resource constraints.

Methodology
This study reports a multisite quality improvement (QI) initiative conducted between March and September 2025 across four hospitals in Viet Nam's national AMR surveillance network. The hospitals included a tertiary infectious disease referral centre (National Hospital for Tropical Diseases), two provincial general hospitals, and an academic general hospital, representing diverse baseline capacities.

The intervention followed a four-step integrated QI cycle:

1. Baseline Assessment: Hospitals underwent structured assessments using two US CDC tools: the Global Antibiotic Stewardship Evaluation Tool (G-ASET) to evaluate AMS programme maturity across five domains (leadership, resources, education, specific actions, tracking), and the Infection Control Assessment and Response (ICAR) tool to evaluate IPC capacity.
2. Structured Feedback: Results were shared with hospital leadership and multidisciplinary teams to highlight strengths and gaps.
3. Action Planning and Capacity Building: Multidisciplinary teams developed locally adapted action plans aligning AMS and IPC priorities, particularly regarding priority AMR pathogens. Capacity-building activities included targeted training workshops, development of standard operating procedures, and tools for prospective audit and feedback.
4. Follow-up Assessment: G-ASET and ICAR assessments were repeated 2–5 months later to document changes.

Data were analyzed descriptively using quantitative scores and qualitative thematic synthesis, adhering to SQUIRE 2.0 guidelines. No hypothesis testing or causal inference was undertaken.

Key Results

• Feasibility of Integration: The integrated approach was feasible across diverse settings. All hospitals established multidisciplinary action plans that explicitly linked AMS and IPC priorities.
• AMS Improvements: Overall G-ASET scores increased at all four sites. The most significant absolute gains occurred in hospitals with lower baseline maturity (e.g., +17.5% and +16.6% in provincial hospitals), while the tertiary centre with a high baseline showed modest improvement (+1.5%).
• Domain-Specific Gains: Significant improvements were observed in leadership and governance (more regular committee meetings, formalized action plans), education and training (via targeted workshops), and tracking/reporting (increased use of antibiograms and audit feedback).
• IPC Improvements: IPC practices aligned with AMS priorities improved, particularly in transmission-based precautions and coordination between IPC, microbiology, and clinical teams.
• Persistent Challenges: Areas requiring financial investment or infrastructure, such as water safety and dedicated staffing/budgets, showed limited short-term progress.
• Contextual Factors: Hospitals with prior AMS assessment experience (NHTD, VSUH) had higher baseline scores, but the QI cycle drove improvements even in sites with no prior formal AMS programmes.

Significance and Claims
The paper claims that an integrated AMS-IPC approach, driven by repeated assessment, structured feedback, and context-adapted action planning, is a feasible and scalable strategy for strengthening hospital responses to AMR in LMICs.

• Operationalizing Integration: The study demonstrates that integration can be achieved through shared governance and coordinated planning rather than separate programmes, effectively addressing cross-cutting constraints like weak leadership and insufficient training.
• Differentiated Impact: The findings suggest that interventions targeting governance, workforce capacity, and implementation processes yield measurable improvements even without major infrastructure investment, whereas infrastructure-dependent areas require longer timelines.
• Scalability: The network-based model, leveraging existing surveillance infrastructure and international tools (G-ASET/ICAR), offers a cost-effective pathway for national programmes and donors (such as Fleming Fund-type investments) to transition from data generation to implementation.
• Sustainability: By focusing on facility-level implementation processes and local ownership of action plans, the model aims to sustain gains beyond the initial project period, addressing the gap left by the conclusion of specific surveillance funding phases.

The authors conclude that while downstream clinical outcomes (e.g., resistance rates) were not measured within the project timeframe, the observed improvements in implementation maturity provide a necessary foundation for reducing AMR in resource-limited settings.