Global resilience and new strategies needed for antimicrobial stewardship during the COVID-19 pandemic and beyond.

Resilience is having the ability to respond to adversity proactively and resourcefully. The coronavirus disease 2019 (COVID-19) pandemic's profound impact on antimicrobial stewardship programs (ASP) requires clinicians to call on their own resilience to manage the demands of the pandemic and the disruption of ASP activities. This article provides examples of ASP resilience from pharmacists and physicians from seven countries with different resources and approaches to ASP-The United States, The United Kingdom, Canada, Nigeria, Lebanon, South Africa, and Colombia. The lessons learned pertain to providing ASP clinical services in the context of a global pandemic, developing new ASP paradigms in the face of COVID-19, leveraging technology to extend the reach of ASP, and conducting international collaborative ASP research remotely. This article serves as an example of how resilience and global collaboration is sustaining our ASPs by sharing new "how to" do antimicrobial stewardship practices during the COVID-19 pandemic.

A commitment and call to strengthen and expand qualitative research efforts to improve the impact of antimicrobial stewardship.

Inadequate recognition of the value of qualitative research in healthcare, notably in antimicrobial stewardship (AMS), in addition to a lack of publishing space in medical journals has prompted JAC-Antimicrobial Resistance to focus on a qualitative series of AMS papers to incite interest in and support for pivotal qualitative approaches that make an indispensable contribution to our understanding of antibiotic use and how to address antimicrobial resistance. In this series, invited authors with diverse backgrounds and considerable expertise address and review intricate and varying qualitative research methods, behaviour change determinants, interventions and qualitative perspectives, with the aim of strengthening commitment and expanding qualitative initiatives to further the impact of AMS globally.

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.

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.

From guidelines to practice: a pharmacist-driven prospective audit and feedback improvement model for peri-operative antibiotic prophylaxis in 34 South African hospitals.

Background: Few data exist on the implementation of process measures to facilitate adherence to peri-operative antibiotic prophylaxis (PAP) guidelines in Africa. Objectives: To implement an improvement model for PAP utilizing existing resources, in order to achieve a reduction in surgical site infections (SSIs) across a heterogeneous group of 34 urban and rural South African hospitals. Methods: A pharmacist-driven, prospective audit and feedback strategy involving change management and improvement principles was utilized. This 2.5 year intervention involved a pre-implementation phase to test a PAP guideline and a 'toolkit' at pilot sites. Following antimicrobial stewardship committee and clinician endorsement, the model was introduced in all institutions and a survey of baseline SSI and compliance rates with four process measures (antibiotic choice, dose, administration time and duration) was performed. The post-implementation phase involved audit, intervention and monthly feedback to facilitate improvements in compliance. Results: For 70 weeks of standardized measurements and feedback, 24 206 surgical cases were reviewed. There was a significant improvement in compliance with all process measures (composite compliance) from 66.8% (95% CI 64.8-68.7) to 83.3% (95% CI 80.8-85.8), representing a 24.7% increase ( P < 0.0001). The SSI rate decreased by 19.7% from a mean group rate of 2.46 (95% CI 2.18-2.73) pre-intervention to 1.97 post-intervention (95% CI 1.79-2.15) ( P = 0.0029). Conclusions: The implementation of process improvement initiatives and principles targeted to institutional needs utilizing pharmacists can effectively improve PAP guideline compliance and sustainable patient outcomes.

A global call from five countries to collaborate in antibiotic stewardship: united we succeed, divided we might fail.

In February, 2016, WHO released a report for the development of national action plans to address the threat of antibiotic resistance, the catastrophic consequences of inaction, and the need for antibiotic stewardship. Antibiotic stewardship combined with infection prevention comprises a collaborative, multidisciplinary approach to optimise use of antibiotics. Efforts to mitigate overuse will be unsustainable without learning and coordinating activities globally. In this Personal View, we provide examples of international collaborations to address optimal prescribing, focusing on five countries that have developed different approaches to antibiotic stewardship-the USA, South Africa, Colombia, Australia, and the UK. Although each country's approach differed, when nurtured, individual efforts can positively affect local and national antimicrobial stewardship programmes. Government advocacy, national guidelines, collaborative research, online training programmes, mentoring programmes, and social media in stewardship all played a role. Personal relationships and willingness to learn from each other's successes and failures continues to foster collaboration. We recommend that antibiotic stewardship models need to evolve from infection specialist-based teams to develop and use cadres of health-care professionals, including pharmacists, nurses, and community health workers, to meet the needs of the global population. We also recommend that all health-care providers who prescribe antibiotics take ownership and understand the societal burden of suboptimal antibiotic use, providing examples of how countries can learn, act globally, and share best antibiotic stewardship practices.

Antimicrobial stewardship across 47 South African hospitals: an implementation study.

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.

Antimicrobial Stewardship with Pharmacist Intervention Improves Timeliness of Antimicrobials Across Thirty-three Hospitals in South Africa.

INTRODUCTION: Ensuring timely administration of antimicrobials is critical in the management of patients with infections. Mortality increases by 7.6% for every hour of delay in the administration of antimicrobial therapy in patients with sepsis. The time elapsed from the written antibiotic order to actual intravenous administration or 'hang-time' can often be several hours due to logistics within the hospital. Our purpose is to evaluate the change in compliance with administering antimicrobials within an hour of prescription after implementation of a national antibiotic stewardship pharmacist-driven hang-time process improvement protocol. METHODS: This was a prospective multicenter study in 33 South African hospitals from 1 July 2013-30 August 2014. Two pilot sites established the mechanism for noninfectious disease pharmacists to make interventions and document hang-time data. Following this, a hang-time compliance assessment was initiated using the tools of healthcare improvement spread methodology. This consisted of five stages and an implementation toolkit was developed. The pharmacist study coordinator was responsible for implementation, the development of an implementation toolkit and real-time coordination of data with monthly feedback to all sites. RESULTS: A total of 32,985 patients who received intravenous antibiotics were assessed for hang-time compliance with first doses of new antibiotic orders. Over the 60-week period, 21,069 patients received antibiotics within an hour following prescription and were assessed as hang-time compliant. The change in improvement of hang-time compliance following implementation of a pharmacist-driven hang-time process improvement protocol was 41.2% pre-intervention week 1 (164/398) to 78.4% post-intervention week 60 (480/612; P < 0.0001). Pharmacists reviewed and evaluated twice as many patients during the final 4 weeks (1680) compared to the first 4 weeks (834; P < 0.0001). CONCLUSION: Noninfectious disease pharmacists can significantly improve the timely administration of antimicrobials and contribute to low-hanging-fruit antimicrobial stewardship initiatives within a hospital system in a resource-limited country.