A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications.

OBJECTIVE: Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider. METHODS: A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines. RESULTS: The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files. CONCLUSIONS: It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.

Feasibility of using point prevalence surveys to assess antimicrobial utilisation in public hospitals in South Africa: a pilot study and implications.

OBJECTIVES: There is currently a lack of data regarding antimicrobial use among public hospitals in South Africa. This is a concern given their growing use and increasing antimicrobial resistance rates in South Africa. Consequently, the objectives of this study were to firstly determine the appropriateness of point prevalence survey (PPS) data collection instruments for performing antimicrobial utilization studies among public sector hospitals in South Africa; secondly, to determine current antimicrobial utilization in a public sector hospital, and thirdly evaluate the prescribing of antimicrobials with those contained within the national Essential Medicines List and Standard Treatment Guidelines (EML/STGs). The findings will be used to guide future activities in South Africa. METHODS: A PPS was conducted in Dr George Mukhari Academic Hospital. For each in-patient ward, all patients' files were completely surveyed on a single day. The number of patients who were on antimicrobials served as the numerator and the denominator comprised the total number of patients in the ward. RESULTS: 39 wards and 512 patient files were surveyed. The overall prevalence of antimicrobial use was 37.7%, highest in the ICUs. Beta lactamase inhibitors and antimicrobials for tuberculosis were the most prevalent antimicrobials. More than two thirds (83%) of antimicrobial treatment was modified following culture sensitivity test results when requested, and 98% of antimicrobials prescribed were contained within the current EML/STGs. In 10.8% of occasions, antimicrobials appear to have been prescribed other than for treatment, i.e. no systemic infection. There were concerns though with the lack of IV to oral switching. CONCLUSION: The PPS method offers a standardized tool that can be used to identify targets for quality improvement. However, there were concerns with the time taken to conduct PPS studies, which is an issue in resource limited settings. This is being addressed alongside concerns with the lack of IV to oral switching.

Surgical Antimicrobial Prophylaxis Among Pediatric Patients in South Africa Comparing Two Healthcare Settings.

BACKGROUND: Appropriate use of surgical antimicrobial prophylaxis (SAP) is a concern in view of its impact on morbidity, mortality and costs. Little is currently known about SAP in South Africa. OBJECTIVE: To assess compliance to SAP guidelines for pediatric patients undergoing surgery in 1 of 4 surgical subspecialties among hospitals in South Africa. METHODS: An eight-month retrospective chart review in both a teaching hospital and a private hospital between February and August 2015. Prescriptions of antimicrobials as SAP were compared with current SAP Guidelines, consolidated from a literature review, regarding 5 criteria-appropriate antimicrobial selection, dosing, timing of administration, redosing and duration of treatment. RESULTS: We reviewed 224 charts, 112 from each hospital type. The majority (P = 1.000) of patients received SAP when indicated (77.3% and 100.0%, respectively, from the teaching and private hospitals). A noteworthy 21.1% and 45.9% of patients received antimicrobials without an indication, respectively, from teaching and private hospitals. Compliance to all 5 of the criteria was not met by either hospital type. Overall, the teaching hospital met the most criteria (3 out of 5) in 58.8% of situations. CONCLUSIONS: Current SAP practices in South Africa's teaching and private hospitals diverge from current SAP Guidelines. Inappropriate overuse of SAP occurs in both hospital sectors, while underuse was found in the teaching hospital. Full compliance to the 5 criteria was not met by either hospital. Noncompliance was largely attributed to inappropriate selection and dosing. Quality improvement interventions, continued surveillance and local standardized evidence-based SAP Guidelines are needed to improve care. This is already happening.