Antimicrobial Stewardship in Nepal and the Role of Clinical Pharmacists

Mr. Suman Shahukhal, is a clinical pharmacist and pharmacovigilance officer, currently serving in the Pharmacovigilance and Drug Counselling Unit under the Department of Pharmacotherapeutics and Toxicology at Dhulikhel Hospital.

Antibiotics transformed medicine by making previously fatal infections treatable. But today the world faces a rising threat: antimicrobial resistance (AMR), when microbes evolve to become resistant to antimicrobial agents.

To raise global awareness and encourage best practices, the World Health Organization (WHO) coordinates World AMR Awareness Week (WAAW) every year, from November 18–24. The campaign promotes the message that “Antimicrobials: Handle with care,” emphasizing the importance of responsible use across all sectors: human, animal, and environmental.

For countries like Nepal, where infectious diseases remain a major burden, this threat is especially serious.

What is Antimicrobial Stewardship?

Antimicrobial stewardship (AMS) refers to coordinated strategies to optimize the use of antimicrobial agents—to ensure the right drug, at the right dose, for the right duration, for the right infection, with the right documentation. The aim is to improve treatment outcomes, reduce misuse of antimicrobials, and slow the emergence of resistance.

The LMIC Challenge: When Access and Excess Collide

In low- and middle-income countries such as Nepal, AMS faces unique difficulties:

• Antibiotic access and misuse often coexist: some people may lack access, while others may overuse or misuse them.
• Community pharmacies may dispense antibiotics without a prescription.
• Diagnostic capacity is often weak, so empirical (broad-spectrum) prescribing is common. Limited access to rapid diagnostic tools like Respiratory Panel PCR and urine antigen testing due to cost.
• Use of antibiotics in agriculture and animal husbandry contributes to resistance across the human–animal–environment “One Health” interface.
• Surveillance and data systems may be under-resourced, limiting actionable evidence.

In Nepal:

• A recent survey among poultry farmers found that 87.8% (531/605) had used antibiotics, yet only about half (49.8%) were aware of AMR, and just 12.7% had good practices toward prudent antibiotic usage (Adhikari et al., 2024, MDPI).
• A point-prevalence survey in intensive care units (ICUs) found that 92.85% of ICU patients were on antibiotics, with 67.5% of prescriptions empirical and broad-spectrum antibiotics being common (Pandey et al., 2023, Cambridge University Press & Assessment).
• Community pharmacy dispensers in one district showed that while about 60.3% had medium knowledge on antibiotics, 46.6% had low practice scores regarding AMS (Sharma et al., 2023, Cambridge Core).
• A news editorial cites a figure of 37.8% of all prescribed medications in Nepal being antibiotics, higher than WHO standards (Kathmandu Post, 2024).

Nepal’s Response: Promising Steps Forward

Nepal has made notable progress in establishing frameworks and initiatives to address AMR, guided by the “One Health” approach that integrates human, animal, and environmental health.

• National Action Plan on AMR (2024–2028): Endorsed by the Government of Nepal, this plan aligns with the global “One Health” approach to strengthen governance, surveillance, and antimicrobial stewardship (Ministry of Health and Population [MoHP], 2024; mohp.gov.np).
• Capacity building and training: The WHO and MoHP jointly organized provincial-level training workshops to institutionalize AMS programs in hospitals and improve healthcare workers’ capacity for rational antibiotic use (WHO, 2024a; who.int).
• Diagnostic and laboratory–clinician collaboration: Initiatives have been launched to Enhance diagnostic stewardship: Improve collaboration between clinicians and laboratories for evidence-based prescribing (WHO, 2024b; who.int).
• Integrated AMR surveillance (Tricycle Project): Nepal completed the WHO Tricycle Project, integrating AMR surveillance across human, animal, and environmental sectors, focusing on ESBL-producing E. coli (WHO, 2024c; who.int).
• Updated national treatment guidelines: The 2023 revision of the National Antimicrobial Treatment Guidelines prioritizes the use of ‘Access’ group antibiotics as per the WHO AWaRe classification, reinforcing antimicrobial stewardship (MoHP, 2023; mohp.gov.np).

Building a Culture of Stewardship

To sustain AMS in Nepal and LMICs, the following are key:

1. Regulate antibiotic access: Enforce prescription-only antibiotic sales and monitor dispensing practices among community pharmacies.
2. Improve diagnostics and data: Build affordable lab capacity, generate local resistance data (Hospital’s Own Antibiogram), and provide feedback to prescribers.
3. Educate: Healthcare professionals—including prescribers, nurses, pharmacists, animal-health workers—and the public need to understand when antibiotics are truly needed.
4. Initiate AMS in hospitals: Form stewardship committees, monitor antibiotic use, and ensure guideline adherence.
5. Adopt One Health: Human, animal, and environmental sectors must coordinate on surveillance, policy, and antimicrobial usage.
6. Monitor and feedback: Use data from surveillance and prescribing audits to inform policy and practice.

Role of Clinical Pharmacists in AMS: Opportunities & Current Status

The case for clinical pharmacists:
Clinical pharmacists are uniquely positioned to support antimicrobial stewardship (AMS) initiatives through their expertise in pharmacotherapy, dosing optimization, drug interactions, drug-use monitoring, and patient counseling. A Nepal-based article on Clinical Pharmacy Education and Practice in Nepal explicitly identifies AMS as a priority area requiring trained pharmacists (Shrestha et al., 2020). Moreover, a multicenter study, though not Nepal-specific, found that pharmacist participation in AMS teams achieved high acceptance rates (greater than 85%) for their recommendations (Wenhao, 2025).

Current status & challenges in Nepal:

• While some hospitals in Nepal have appointed clinical pharmacists, their involvement in AMS teams remains limited. Many hospitals do not have fully functional Drug & Therapeutics Committees (DTCs), Drug Information Centres (DICs), or adequately resourced pharmacy services (Poudel & Prajapati, 2020).
• A recent survey of community pharmacy dispensers in municipalities, including Dhulikhel (Kavrepalanchok district), found that while ~60% had medium-level knowledge regarding antibiotics and ~50% had positive perceptions of AMS, 46.6% had low practice scores regarding AMS (Shrestha, Shrestha, & Acharya, 2025).
• Key challenges noted in the 2023 review of AMS in Nepal include insufficient staffing, limited diagnostic capacity, physician resistance, and lack of pharmacist manpower/training to support AMS (Khanal et al., 2023).

Where can clinical pharmacists add value?
Given the context above, clinical pharmacists in Nepal can contribute in the following ways:

• Prospective audit and feedback: Review antibiotic prescriptions (choice, dose, duration) and intervene in real-time or shortly after initiation.
• Guideline and formulary support: Assist in developing institution-specific antibiotic guidelines and restricted-antibiotic lists, and support implementation of formulary restrictions.
• Dose optimization and special populations: Adjust doses for renal/hepatic impairment, monitor drug interactions and toxicities, and select safer drugs for pregnant women to avoid teratogenic effects.
• Education and training: Lead educational sessions for prescribers, nurses, pharmacists, and lab personnel on rational antibiotic use and AMS principles.
• Data monitoring and consumption metrics: Track antibiotic use metrics (e.g., Days of Therapy [DOT] per 1000 patient-days), report trends to AMS committees, and identify high-use, high-risk areas.
• Patient counseling and antimicrobial discharge stewardship: Ensure patients understand antibiotic regimens, adherence, and when to report issues or adverse drug reactions.
• Interprofessional liaison: Link microbiology results (AST) with prescribing practices; collaborate with lab, clinician, and clinical pharmacists for diagnostic stewardship.

Recommendations to strengthen clinical pharmacist involvement:

• Hospitals should ensure dedicated clinical pharmacist staffing with protected time for AMS activities (not just dispensing at pharmacy counters).
• Pharmacy curricula and continuing professional development (CPD) programs in Nepal should emphasize AMS and clinical pharmacy skills.
• Hospitals should formally include clinical pharmacists in AMS committees and rounds, with clearly defined roles.
• Establish performance metrics for pharmacist interventions (e.g., number of antibiotic reviews, acceptance rate of pharmacist recommendations, cost savings, reduction in DOT) to demonstrate value.
• Strengthen infrastructure: Improve access to patient records, microbiology data, and antibiotic consumption data to support pharmacist intervention.
• Foster culture change: Build trust and communication between pharmacists and physicians so pharmacist recommendations are accepted and acted upon.

The Way Forward
The threat of antimicrobial resistance demands active stewardship of antibiotics, and Nepal is making measurable progress. The integration of clinical pharmacists into AMS programs offers a promising avenue to ensure safer, more rational antibiotic use. As hospitals in Nepal build their stewardship capacity, prioritizing pharmacist involvement alongside strong diagnostics, governance, and data-driven approaches will strengthen the fight against AMR, leading to improved patient outcomes, reduced resistance, and cost-effective care.

AMR doesn’t respect borders or incomes. In countries like Nepal, where resources are constrained, antimicrobial stewardship is not a ‘luxury’—it’s a necessity to protect lives, health systems, and the economic future. By combining education, policy, diagnostics, and multisectoral collaboration, Nepal and similar LMICs can help preserve the miracle of antibiotics for generations to come.

References:

1. Adhikari, S., et al. (2024). Antibiotic use and awareness of antimicrobial resistance among poultry farmers in Nepal. MDPI.
2. Pandey, R., et al. (2023). Antibiotic utilization patterns in intensive care units: A point-prevalence survey. Cambridge University Press & Assessment.
3. Sharma, P., et al. (2023). Knowledge, attitudes, and practices toward antimicrobial stewardship among community pharmacy dispensers. Cambridge Core.
4. Kathmandu Post. (2024). Antibiotic prescriptions surpass WHO standards in Nepal. The Kathmandu Post.
5. Ministry of Health and Population (MoHP). (2024). National Action Plan on Antimicrobial Resistance (2024–2028). Government of Nepal. Retrieved from mohp.gov.np
6. World Health Organization (WHO). (2024a). Institutionalizing antimicrobial stewardship in Nepalese hospitals. Retrieved from who.int
7. World Health Organization (WHO). (2024b). Diagnostic stewardship and laboratory–clinician collaboration initiatives in Nepal. Retrieved from who.int
8. World Health Organization (WHO). (2024c). Tricycle Project: Integrated AMR surveillance in Nepal. Retrieved from who.int
9. Ministry of Health and Population (MoHP). (2023). National Antimicrobial Treatment Guidelines (Revised Edition). Government of Nepal. Retrieved from mohp.gov.np
10. Khanal, S., Acharya, U., Trotter, A. B., Tripathi, P., Koirala, S., & Acharya, S. P. (2023). Challenges and opportunities in the implementation of an antimicrobial stewardship program in Nepal. Antimicrobial Stewardship & Healthcare Epidemiology, 3(e58), 1-6. https://doi.org/10.1017/ash.2022.359
11. Poudel, R. S., & Prajapati, A. (2020). Hospital pharmacy profession in Nepal through the eye of a pharmacist. Journal of Chitwan Medical College, 6(2). Retrieved from nepjol.info
12. Shrestha, B., Shrestha, S., & Acharya, U. (2025). Antimicrobial perceptions and stewardship practices among community pharmacy dispensers in Nepal. Antimicrobial Stewardship & Healthcare Epidemiology. Advance online publication.

Mr. Suman Shahukhal
Mr. Suman Shahukhal is a clinical pharmacist and pharmacovigilance officer, currently working in the Pharmacovigilance and Drug Counselling Unit under the Department of Pharmacotherapeutics and Toxicology at Dhulikhel Hospital. He holds a Master of Pharmacy (MPharm) in Pharmaceutical Care and a Bachelor of Pharmacy (BPharm), both from the School of Science, Kathmandu University. He is also an associate member of the Society of Infectious Diseases Pharmacists (SIDP). With a strong background in patient-centered pharmaceutical care, Mr. Shahukhal plays a key role in optimizing medication safety and antimicrobial use within the hospital. He serves as one of the co-leads of the Antimicrobial Stewardship Program (ASP) at Dhulikhel Hospital. In his pharmacovigilance role, he oversees the detection, assessment, reporting, and prevention of adverse drug reactions (ADRs) and medication errors. His areas of expertise include clinical pharmacy practice, pharmacovigilance, antimicrobial stewardship, medication safety, and hospital protocol development.