Antimicrobial stewardship across 47 South African hospitals: an implementation study

Summary

Background

The available data on antimicrobial stewardship programmes in Africa are scarce. The aims of this study were to assess the implementation of an antimicrobial stewardship programme in a setting with limited infectious disease resources.

Methods

We implemented a pharmacist-driven, prospective audit and feedback strategy for antimicrobial stewardship on the basis of a range of improvement science and behavioural principles across a diverse group of urban and rural private hospitals in South Africa. The study had a pre-implementation phase, during which a survey of baseline stewardship activities was done. Thereafter, a stepwise implementation phase was initiated directed towards auditing process measures to reduce consumption of antibiotics (prolonged duration, multiple antibiotics, and redundant antibiotic coverage), followed by a post-implementation phase once the model was embedded in each hospital. The effect on consumption was assessed with the WHO index of defined daily doses per 100 patient–days, and the primary outcome (change in antibiotic consumption between phases) was assessed with a linear mixed-effects regression model.

Findings

We implemented and assessed the antimicrobial stewardship programme between Oct 1, 2009, and Sept 30, 2014. 116 662 patients receiving antibiotics at 47 hospitals during 104 weeks of standardised measurement and feedback, were reviewed, with 7934 interventions by pharmacists recorded for the five targeted measures, suggesting that almost one in 15 prescriptions required intervention. 3116 (39%) of 7934 pharmacist interventions were of an excessive duration. The antimicrobial stewardship programme led to a reduction in mean antibiotic defined daily doses per 100 patient–days from 101·38 (95% CI 93·05–109·72) in the pre-implementation phase to 83·04 (74·87–91·22) in the post-implementation phase (p<0·0001).

Interpretation

Health-care facilities with limited infectious diseases expertise can achieve substantial returns through pharmacist-led antimicrobial stewardship programmes and by focusing on basic interventions.

Funding

None.

Introduction

In September, 2015, the Center for Disease Dynamics, Economics & Policy published a report into the state of the world's antibiotics,¹ citing evidence that the overall effectiveness of antibiotics has been decreasing globally and calling for strong antibiotic stewardship in its broadest sense—specifically the reduction of antibiotic overuse in human beings. A Cochrane meta-analysis² confirmed that interventions to reduce excessive prescription of antibiotics to inpatients can reduce antimicrobial resistance and improve microbiological and clinical outcomes. However, few studies provide data about the key interventional components and the effectiveness of antimicrobial stewardship programmes in resource-limited settings.2, 3 A global survey⁴ of stewardship activities revealed that only 14% of respondents in Africa and 53% in Asia had any form of antimicrobial stewardship programme in place.⁴

Although many methods of improving prescribing practice have been studied, one of the core strategies is the use of prospective audits and feedback.2, 3, 5, 6 In this approach, investigators review current antimicrobial use and make recommendations with regard to appropriateness in terms of several predefined measurements, all of which can be implemented in health-care facilities irrespective of size.2, 3, 6 The most obtainable targets in low-resource settings are unknown. However, limitation of duration of antibiotic use and use of multiple concurrent antibiotics, including redundant coverage, might represent such targets.6, 7, 8, 9

In South Africa, the main barriers to implementation of antimicrobial stewardship programmes in almost all public and private hospitals have been inadequate infectious diseases expertise and resources; additionally, in large hospital networks, the geographical distribution of these institutions has also hindered implementation. The aim of this study was to assess the reduction of overall antibiotic consumption across a diverse group of 47 urban and rural hospitals in South Africa through the implementation of an antimicrobial stewardship strategy that uses existing resources.