Implications of the South African National Drug Policy on prescribing patterns: a case study of the Limpopo province.

BACKGROUND: The South African National Drug Policy (SA-NDP) was introduced to promote rational medicine use (RMU). This study evaluates the quality of prescribing in the public healthcare sector in South Africa's Limpopo province following the World Health Organization's (WHO) rational prescribing standards. In addition, the prescribing practices in South Africa were compared to other African countries. METHODS: A prospective cross-sectional survey of patients' prescriptions was conducted in Limpopo, South Africa, from October to December 2018. Findings were compared with the WHO reference values (WHO-RV), and the International Network of Rational Use of Drugs (IRDP) tool was used to measure the degree of rational prescribing. The optimal IRDP value was defined as 1. Study findings were compared with results from a previous study conducted in Limpopo and studies from Ethiopia and Eritrea. RESULTS: Six hundred prescriptions were reviewed. The mean (SD) age was 43.9 ± 24.4 years (females = 56.5%). The average number of drugs prescribed (4.3, IRDP = 0.47) was higher than the WHO-RV (< 2). Generic prescribing (43%, IRDP = 0.43) and medicines prescribed from the essential medicines list (EML) (90%, IRDP = 0.90) were less than the WHO-RV (100%, respectively). Antibiotics (28%, IRDP = 1) and the number of injections prescribed (8%, IRDP = 1) were below the WHO-RV (< 30% and < 20%, respectively). The number of medicines prescribed was higher compared to previous years (4.3 vs. 3.4). Antibiotic prescribing declined (28% vs. 63.4%). Generic prescribing (43% vs. 41.7%) and medicines prescribed from the EML (90% vs. 93.1%) did not improve. A higher number of medicines were prescribed in this study compared to Ethiopia (1.7) and Eritrea (1.8), and a lower number of antibiotics were prescribed compared to Ethiopia (58.2%) and Eritrea (54.5%). Generic prescribing was low compared to Ethiopia (95.6%) and Eritrea (94.9%). All studies showed reduced injection prescribing (6.6-15.9%) and similar prescribing from the EML (90-95%). CONCLUSIONS: There is an increased potential for drug-drug and adverse reactions with the increased number of prescribed medicines; however, the patient's clinical needs may warrant using multiple medicines. There is a need for generic prescribing to reduce medicine expenditure.

A call for social accountability within pharmacy education: Partnership, competency, and leadership.

INTRODUCTION: To address the needs of the community, social accountability (SA) needs to be integrated in health education, especially pharmacy education. This is part one of a two-part commentary that focuses specifically on partnership, competency, and leadership as it relates to SA within pharmacy education. COMMENTARY: Here the need for partnership in SA, competency of SA in pharmacy education, and leadership in SA is discussed. IMPLICATIONS: Integration of SA in pharmacy education can be challenging, however good leadership, a competency framework, and partnership with change agents can assist with this transformation.

A call for social accountability within pharmacy education: Concepts, relevance, and accreditation.

INTRODUCTION: Social accountability (SA) is a leap to excellence in health education. While pharmacists are ideally situated in the healthcare setting to practice SA through research, service, and practice, SA is underrepresented in pharmacy education. COMMENTARY: Here the foundational concepts of SA, the relevance to pharmacy education, as well as the accreditation considerations for the implementation of SA are discussed. IMPLICATIONS: There is a need for SA to be implemented in pharmacy education to address health equity, quality, and improve patient health outcomes.

Design, Implementation, and Assessment Approaches Within an Advanced Human Immunodeficiency Virus (HIV) Elective Course.

Introduction: An estimated 38 million people are living with human immunodeficiency virus (HIV) worldwide. Pharmacists are well positioned to provide care to patients with HIV, but gaps in HIV education among pharmacists exist. Recognizing the need to educate and prepare future pharmacists, a 2-credit advanced HIV elective course was created for Doctor of Pharmacy students at Washington State University College of Pharmacy and Pharmaceutical Sciences in the United States, and Masters of Clinical Pharmacy students from University of Western Cape School of Pharmacy in South Africa. Methods: Course topics included diagnosis and treatment of HIV in children and adults, management of common comorbidities, pre-exposure prophylaxis, pharmacogenetic applications, and antiretroviral drug-drug interactions. Course effectiveness was evaluated using student examination results. Student perceptions were evaluated using pre- and post-course self-assessments involving abilities, confidence, and attitudes toward caring for people living with HIV. Results: Student pharmacists demonstrated competency in HIV knowledge, demonstrated skills in application to clinical-based scenarios, and reported significantly improved confidence and abilities as well as positive changes in attitudes toward people with HIV. Conclusion: This course contributed to student learning across different student cohorts in an institutional program in the United States including successful execution of distance learning and clinical application for students at a program in South Africa.

Application of consolidated framework for implementation research to improve Clostridioides difficile infection management in district hospitals.

BACKGROUND: Clostridioides difficile infection (CDI) contributes the global threats of drug resistant infections, healthcare acquired infections and antimicrobial resistance. Yet CDI knowledge among healthcare providers in low-resource settings is limited and CDI testing, treatment, and infection prevention measures are often delayed. OBJECTIVES: to develop a CDI intervention informed by the local context within South African public district level hospitals, and analyze the CDI intervention and implementation process. METHODS: A CDI checklist intervention was designed and implemented at three district level hospitals in the Western Cape, South Africa that volunteered to participate. Data collection included a retrospective medical records review of patients hospitalized with C. difficile test orders during the 90 days post-implementation. Patient outcomes and checklist components (e.g. antibiotics) were collected. Qualitative interviews (n = 14) and focus groups (n = 6) were conducted with healthcare providers on-site. The Consolidated Framework for Implementation Research (CFIR) and the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) were applied to collected data and observations in order to identify drivers and barriers to implementation and understand differences in uptake. RESULTS: One of the three hospitals displayed high intervention uptake. Highly relevant CFIR constructs linked to intervention uptake included tension for change, strong peer intervention champions, champions in influential leadership positions, and the intervention's simplicity (CFIR construct: complexity). Tension for change, a recognized need to improve CDI identification and treatment, at the high uptake hospital was also supported by an academic partnership for antimicrobial stewardship. CONCLUSIONS: This research provides a straight-forward health systems strengthening intervention for CDI that is both needed and uncomplicated, in an understudied low resource setting. Intervention uptake was highest in the hospital with tension for change, influential champions, and existing academic partnerships. Implementation in settings with fewer academic connections requires further testing of collaborative implementation strategies and proactive adaptations.

Cathelicidins and defensins antimicrobial host defense peptides in the treatment of TB and HIV: Pharmacogenomic and nanomedicine approaches towards improved therapeutic outcomes.

Tuberculosis (TB) and human immunodeficiency virus (HIV) represent a significant burden of disease on a global scale. Despite improvements in the global epidemic status, largely facilitated by increased access to pharmacotherapeutic interventions, slow progress in the development of new clinical interventions coupled with growing antimicrobial resistance to existing therapies represents a global health crisis. There is an urgent need to expand the armamentarium of TB and HIV therapeutic strategies. Host mediated immune responses represent an untapped reservoir of novel approaches for TB and HIV. Antimicrobial peptides (AMPs) are an essential aspect of the immune system. Cathelicidins and defensins AMPs have been studied for their potential applications in TB and HIV therapeutic interventions. Genetic polymorphism across different population groups may affect endogenous expression or activity of AMPs, potentially influencing therapeutic outcomes. However, certain genetic polymorphisms in autophagy pathways may alter the downstream effects of nano-delivery of cathelicidin. On the other hand, certain genetic polymorphisms in beta-defensins may provide a protective role in reducing HIV-1 mother-to-child-transmission. Pharmaceutical development of cathelicidins and defensins is disadvantaged with complex challenges. Nanoparticle formulations improve pharmacokinetics and biocompatibility while facilitating targeted drug delivery, potentially minimising the risk of immunogenicity or non-specific haemolytic activity. This review aims to explore the potential viability of using cathelicidins and defensins as novel pharmacotherapy in the management of TB and HIV, highlight potential pharmacogenomic implications in host mediated immunity and AMP therapeutic applications, as well as propose novel drug delivery strategies represented by nanomedicine for AMPs.

Comparative Evaluation of Pharmacy Students' Knowledge and Skills in Maternal and Child Health: Traditional versus Integrated Curriculum.

Reducing maternal and child mortality is a health priority in South Africa. Therefore, health professional education should produce graduates that can meet these needs. This study compared the maternal and child health (MCH) knowledge and skills of cohorts of final-year students exposed to a traditional (in 2017 and 2018) and integrated (2019) curriculum using a 34-item questionnaire. Between the 2019 and 2017 cohorts, ANOVA and post hoc analysis showed significant differences in the reproductive and sexual health component which was dispersed in the second and final years of study (p = 0.007, Mean Difference (MD) = 8.3) andneonatal and child care (p = 0.000, MD = 15). while it was only in maternal and antenatal care (p = 0.009, MD = 10.0) for the 2019 and 2018 cohorts. Significant differences were observed in participants' average mean scores (p = 0.000 for 2018 and 2017). The highest mean scores were recorded by the 2019 cohort in the three assessments. A one-sample t-test showed the highest mean differences in the reproductive and sexual health components (p = 0.000; MD 2017 = 12.4, MD 2018 = 14.8, MD 2019 = 20.7). Overall, the integrated MCH curriculum and the longitudinal dispersion of content enhanced students' knowledge and skills.

A description of sodium valproate, lamotrigine and levetiracetam consumption in the Western Cape public sector.

BACKGROUND: The rational use of medicine is fundamental to ensure effective and safe patient medicine treatment, and hence, should be monitored. Undisputable evidence exists for the teratogenic risk factors associated with sodium valproate. Consequently, the Western Cape Department of Health introduced a policy (2019) recommending alternatives for valproate in women of childbearing age, including lamotrigine or levetiracetam as alternatives for patients on antiretrovirals. This study aimed to describe the change in the consumption of valproate, lamotrigine and levetiracetam after a policy implementation in public sector health facilities of the Western Cape, South Africa. METHODS: This observational study followed a quasi-experimental design. Consumption data from the Cape Medical Depot over the period 01 April 2018 to 31 March 2020 were analysed retrospectively. Consumption was presented as a defined daily dose (DDD) per 1000 population per quarter for sodium valproate, levetiracetam and lamotrigine for the Western Cape province, urban and rural areas. Consumption 12 months before was compared with consumption 12 months after policy implementation. RESULTS: Post-policy implementation, valproate consumption remained unchanged provincially (3.3%; p = 0.255), in urban (7.8%; p = 0.255) and rural (1.5%; p = 0.701) areas. Lamotrigine consumption increased significantly provincially (30.7%; p = 0.020) and in urban areas (54.5%; p = 0.002); however, rural (26.1%; p = 0.108) areas did not show significant change. Provincially, valproate consumption remained substantially higher (209 DDDs/1000 population per quarter) compared with lamotrigine consumption (32.22 DDDs/1000 population per quarter). CONCLUSION: In the Western Cape public sector, the consumption of sodium valproate remained unchanged 12 months after policy implementation. Although there were significant increases in lamotrigine and levetiracetam consumption, the consumption was considerably less compared with sodium valproate consumption.

Pharmacists' Approach to Optimise Safe Medication Use in Paediatric Patients.

Paediatric patients are unique, yet challenging patients to care for by pharmacists. Paediatric medicine use requires special consideration. Pharmacists play an important role in educating and counselling patients, carers, and healthcare workers. Further, pharmacists have the necessary knowledge and skills to optimise safe medicine use in paediatric patients. This article provides basic principles for safe practices in paediatric medicine by following the nine rights of medication administration.

Development and Implementation of an Integrated Framework for Undergraduate Pharmacy Training in Maternal and Child Health at a South African University.

The South African Pharmacy Council (SAPC) regulates undergraduate pharmacy education and pharmacy practice. The SAPC Good Pharmacy Practice manual describes the role of pharmacists in maternal and child health (MCH) in line with the recommendation of international health regulatory bodies. However, baseline study findings in 2017 supported literature from around the world that indicated a need for curriculum review and integration to address the knowledge and skills gap in pharmacists' MCH training. This paper describes the development and implementation of an integrated framework for MCH training across the four years of a Bachelor of Pharmacy program. The intervention included didactic lectures, skills practical on infant growth assessment, and an experiential learning component at primary health care clinics and pharmacies. Knowledge and skills assessment on contraception, maternal and antenatal care, and neonatal and child care were carried out pre, eight weeks post, and two years post intervention using the same questionnaire. ANOVA and post hoc analyses showed that participants' knowledge and skills increased post intervention but decreased significantly two years later except in contraception where students experienced longitudinal integration of the MCH component. Generally, participants performed above the university average except in maternal and antenatal care.

Evaluating pharmacy students' knowledge and skills in reproductive, maternal, new-born and child health care at a South African university.

BACKGROUND: Maternal and child mortality is a global concern and one of South Africa's quadruple burdens of disease. As easily accessible frontline healthcare workers, pharmacists play an important role in the continuum of maternal and child health (MCH) care according to recommendations by international health regulatory bodies. Pharmacy schools are obliged to train pharmacy students to meet the priority health needs of the population so that graduates are 'fit for purpose'. The baseline study aimed to evaluate the knowledge and skills of 2017 final year pharmacy students who were exposed to a fragmented MCH care curriculum at a university in South Africa to inform curriculum review. METHODS: A descriptive, quantitative, non-randomized study was conducted among final year pharmacy students using a self-administered structured questionnaire. The questionnaire was designed in sections to assess participants' knowledge of reproductive and sexual health (RSH), maternal and antenatal care (MAC), neonatal and child care (NCC) and skills related to infant growth assessment procedures. Data was analysed descriptively using frequencies and percentages. A score of 50% in each section of the questionnaire indicated a pass. Participants assessed their exposure to MCH topics in the curriculum. RESULTS: Of the 89 available students, 61% consented to participate in the study. The average scores attained for each section were; 62.4% for RSH, 54.5% for MAC, 50.4% for NCC and 25.3% for infant growth assessment. The pass rate was 78% for RSH, 56% for MAC, 57% for NCC, and 19% for infant growth assessment. About 13% of the participants passed all the knowledge and the skills sections. Age, gender, being a parent or doing locums did not have any influence on participants' performance. Participants reported that they had more on-campus curriculum content exposure to RSH compared to other MCH care topics. CONCLUSION: Final year pharmacy students showed adequate knowledge of RSH with adequate curriculum exposure. Average knowledge of MAC, NCC and poor skills in infant growth assessment which corresponded to curriculum exposure was observed. The results suggest the need for improvement in the current curriculum in the affected areas to adequately equip students to render desirable services.

Understanding and Responding to Prescribing Patterns of Sodium Valproate-Containing Medicines in Pregnant Women and Women of Childbearing Age in Western Cape, South Africa.

INTRODUCTION: Growing evidence of the teratogenic potential of sodium valproate (VPA) has changed prescribing practices across the globe; however, the impact of this research and the consequent dissemination of a Dear Health Care Professional Letter (DHCPL) in December 2015, recommending avoidance of the teratogen VPA in women of childbearing age (WOCBA) and pregnant women in South Africa, is unknown. We explored trends and reasons for VPA use among pregnant women and WOCBA in the public sector in Western Cape Province from 1 January 2015 to 31 December 2017. METHODS: Using the provincial health information exchange that collates routine electronic health data via unique patient identifiers, we analysed clinical and pharmacy records from 2015 to 2017 to determine prescription patterns of VPA and other antiepileptic drug (AED) and mood-stabilising medicine (MSM) use in WOCBA and pregnant women. Senior clinicians and policy makers were consulted to understand the determinants of VPA use. RESULTS: At least one VPA prescription was dispensed to between 8205 (0.79%) and 9425 (0.94%) WOBCA from a cohort of approximately 1 million WOCBA attending provincial health care facilities per year. Prescriptions were more likely in HIV-infected women compared with HIV-uninfected women (1.1-1.3% vs. 0.7-0.9%; p < 0.001). VPA use in WOCBA remained stable at 0.8-0.9% over the review period despite the 2016 DHCPL. VPA was the most prescribed AED/MSM, constituting 43.2-45.5% of all WOCBA taking at least one such agent, while lamotrigine, the other recommended first-line agent, was only prescribed in 7.8-8.9% of WOCBA. Over 3 years, approximately 663 pregnancies were exposed to VPA, with a steady rise in the number of exposures each year (n = 204, 214 and 245, respectively). CONCLUSION: Despite warnings, VPA remained the most frequently prescribed AED or MSM in WOCBA. Contributing factors are described.

A pharmacist-led prospective antibiotic stewardship intervention improves compliance to community-acquired pneumonia guidelines in 39 public and private hospitals across South Africa.

INTRODUCTION: Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals. METHODS: This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared. RESULTS: In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40). CONCLUSION: Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

An Antimicrobial Stewardship Curriculum to Incorporate in the South African Bachelor of Pharmacy Degree Program.

Objective. To develop an antimicrobial stewardship curriculum that is suitable for incorporation in the undergraduate pharmacy degree programs offered by South African schools of pharmacy. Methods. A mixed methods approach was employed involving four consecutive study phases: content analysis, academic review, expert consultation, and curriculum development. The curriculum development phase involved collation of the findings of the prior three study phases. Results. The final proposed antimicrobial stewardship curriculum included recommendations for: level of incorporation of the curriculum in the undergraduate degree program, minimum contact hours, pedagogical techniques, and assessment methods. The curriculum content was split into four units: pharmacology for antimicrobial stewardship, microbiology for antimicrobial stewardship, antimicrobial stewardship in practice, and hospital antimicrobial stewardship. Conclusion. An antimicrobial stewardship curriculum that highlights key findings in relation to the role of the pharmacist in antimicrobial stewardship was developed. This was the first such study conducted in South Africa.

Establishing a pharmacist-prescriber partnership in publicly funded primary healthcare clinics to optimise antibiotic prescribing in the Western Cape: An exploratory study.

BACKGROUND: Promoting evidence-based antibiotic prescribing through successful antimicrobial stewardship (AMS) programmes is critical to preserving the effectiveness of antibiotics for common infections in primary care. This requires a coordinated multidisciplinary effort. Such pharmacist-prescriber partnerships have been effective in high-income countries (HICs). Yet, evidence generated in such countries is not always applicable because of different social determinants of health. METHODS: A multidisciplinary workshop was conducted with pharmacists and clinicians (doctors, nurses) on community-based antibiotic stewardship, the purpose of which was to explore how and where such partnerships might work in publicly funded primary care clinics in the greater Cape Metro region. RESULTS: Participants perceived that promoting effective AMS was a priority for South African primary healthcare. However, it was clear that there are many hurdles to overcome working in settings that are relatively resource-poor. Prescribing guidelines needed to be harmonised. Participants felt that staff training on the principles of AMS should be mandatory. Research was urgently needed to better understand their community's understanding of antibiotic use and AMS, and to champion outreach projects in the community. CONCLUSION: Important stakeholder perspectives in the community were highlighted to promote a multidisciplinary approach to AMS initiatives in primary care. These will need to be addressed to optimise antibiotic prescribing in the community.

Amitriptyline prescribing in public sector healthcare facilities in the Western Cape, South Africa.

BACKGROUND: Inappropriate medication use is a major patient safety concern, especially for the elderly population. Amitriptyline is widely used in primary care in South Africa and a cross-sectional study found that amitriptyline was prescribed potentially inappropriately in 6.5% of elderly patients. An analysis of prescriptions from the Chronic Dispensing Unit in the Western Cape revealed that amitriptyline was one of the most common medicines prescribed without a suitable diagnosis listed on the prescription. OBJECTIVE: The main objective of the medicine use evaluation (MUE) was to determine whether amitriptyline was prescribed in accordance with recommendations from standard treatment guidelines (STG) and essential medicines lists (EML) endorsed by the National Department of Health, South Africa. METHODS: A retrospective, cross-sectional, multicentre review of patients' clinical notes was conducted. The study population was selected by systematic random sampling from adult outpatients who were prescribed amitriptyline for longer than three months. Criteria for evaluation included amitriptyline indication and total daily dose prescribed. RESULTS: Of the sample of 2237 patient medical records reviewed, 1732 (77.4%) included amitriptyline prescriptions that were according to the approved STG indications. For the approved STG indications, amitriptyline was prescribed mainly for osteoarthritis (25.8%), neuropathies (18.5%) and chronic non-cancer pain (17.9%). Major depressive disorders constituted only 8.6% of the patient records reviewed; however, doses were atypically low. The main inappropriate indication for amitriptyline was sleep disorders (16%). CONCLUSION: This MUE has highlighted the need to improve the use of amitriptyline in specific patient populations, e.g. the elderly and patients with sleeping disorders.

Exploring the Implications of a Needs-Based Pharmacy Education Framework Modelled on Population Health: Perspective from a Developing Country.

Globally, health education reform is directing efforts to strengthen the health system through collaboration between health education and health services. However, collaborative efforts vary between developed and developing countries as the health needs, economic constraints, and resource availability differs. In developing countries, resource allocation is weighed in favor of interventions that will benefit the majority of the population. The question that emerges is: How could health education, service, and research activities be (re-)aligned to optimize return on investment for the health system and society at large? This paper proposes a needs-based pharmacy educational approach by centralizing population health for a developing country like South Africa. Literature on systems-based approaches to health professional education reform and the global pharmacy education framework was reviewed. A needs-based pharmacy educational approach, the population health model which underpins health outcome measurements to gauge an educational institution's effectiveness, was contextualized. An evaluation framework to determine the pharmacy school's effectiveness in strengthening the health system could be applied. A needs-based pharmacy educational approach modeled on population health could: Integrate resources from education, service, and research activities; follow a monitoring and evaluation framework that tracks educational outcomes; and engage with external stakeholders in curricular development and assessment.

Describing medicine therapy management of type 2 diabetes mellitus at primary health care facilities in Cape Town.

BACKGROUND: Rational medicine use aims to optimise chronic disease management and prevent episodes of hospitalisation that economically burden the health care system. Diabetes mellitus is one of the most prevalent chronic diseases globally, yet more than 60% of patients with diabetes are not optimally managed according to their therapeutic glycaemic targets. AIM: To describe the use of glycated haemoglobin (HbA1c) and fasting plasma glucose results in guiding treatment changes in patients with type 2 diabetes mellitus. SETTING: Public sector primary health care facilities in the Cape Town Metropolitan Region in South Africa. METHOD: Retrospective, descriptive study design was employed. Data for an 18-month period were collected during 2014 and 2015. Data were collected from patient medical records and included baseline demographics, laboratory monitoring tests and the patients' last three prescriptions. RESULTS: The study consisted of 575 participants (64% female) with an average age of 57 (± 11.38) years. The average baseline HbA1c for 493 participants with at least one result was 8.78% (± 1.63), and only 28% of these participants reached the glycaemic target at consequent consultations. HbA1c levels were available to guide 245 prescription changes, of which 181 of these results were outside of the target range. Of these, 15.5% had appropriate therapy adjustments, 78.4% had no change or a lateral change in their follow-up prescriptions, and 6.1% had therapy adjustments opposite to what guidelines suggest. CONCLUSION: Glycaemic monitoring indicated consistent suboptimal glycaemic control in more than 60% of participants. Medicine prescribing patterns did not align with the prescribed local guidelines, Society for Metabolism, Endocrinology and Diabetes of South Africa (SEMDSA). The appropriate use and interpretation of HbA1c at a clinic level should be emphasised to promote rational use of medicines that minimise acute hospitalisation episodes and optimise patients' long-term health outcomes.

Knowledge, attitudes and perceptions of antibiotic use and resistance among patients in South Africa: A cross-sectional study.

BACKGROUND: Antibiotic resistance (ABR) is a global health crisis. We conducted a cross-sectional survey to describe South African patients' (n = 782) ABR knowledge, attitudes and perceptions (KAP), differences in KAP between public (n = 379, 48%) and private (n = 403, 52%) practice respondents and associations between attitudes, perceptions and knowledge scores. METHODS: Knowledge scores (15 questions) were placed into low (0% - 53%) and high (> 54%) categories (below and above overall mean). Comparisons were conducted using chi-squared and t-tests. RESULTS: Of all respondents, 72% believed it was the human body that becomes resistant to antibiotics, 66% stated that antibiotics are good for treating viruses and 25% of patients believed that people should be given antibiotics on demand. Mean knowledge scores were lower in public sector respondents (public 45%, s.d. 15%; private 60%, s.d. 30%; p ≤ 0.001). Public practice patients with high knowledge scores were more likely to report both negative KAP (antibiotic prescriptions justify doctors' visits, scientists will discover new antibiotics) and protective KAP (finishing a course of antibiotics, antibiotics do not treat all illnesses). Private practice patients with high knowledge scores were marginally less likely to report negative KAP (wanting antibiotics after long illnesses or when very sick) and more likely to report protective KAP (antibiotics have side effects and are a strong treatment). CONCLUSION: Our study shows differences in KAP by practice type and that greater knowledge increases the likelihood of protective attitudes, perceptions and behaviours.