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Antimicrobial stewardship across 47 South African hospitals: an implementation study - 17/08/16

Doi : 10.1016/S1473-3099(16)30012-3 
Adrian J Brink, DrMD a, , Angeliki P Messina, BPharm b, Charles Feldman, ProfDSC c, Guy A Richards, ProfPhD c, Piet J Becker, ProfPhD d, Debra A Goff, ProfPhD e, Karri A Bauer, PhD e, Dilip Nathwani, ProfMBChB f, Dena van den Bergh, PhD b
on behalf of the

Netcare Antimicrobial Stewardship Study Alliance*

  Netcare Antimicrobial Stewardship Study Alliance members are given in the Supplementary Material

a Ampath National Laboratory Services, Milpark Hospital, Johannesburg, South Africa 
b Department of Quality Leadership, Netcare Hospitals, Johannesburg, South Africa 
c Faculty of Health Sciences, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa 
d Research Office, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa 
e Department of Pharmacy, The Ohio State University, Wexner Medical Center, Columbus, OH, USA 
f Ninewells Hospital and Medical School, Dundee, Scotland, UK 

* Correspondence to: Dr Adrian J Brink, Ampath National Laboratory Services, Milpark Hospital, Parktown, 2193, Johannesburg, South Africa Correspondence to: Dr Adrian J Brink Ampath National Laboratory Services Milpark Hospital Parktown Johannesburg 2193 South Africa

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.

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Vol 16 - N° 9

P. 1017-1025 - septembre 2016 Retour au numéro
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