A pharmacist-driven antibiotic stewardship (AS) program in a large, diverse hospital network in South Africa achieved an 18% reduction in antibiotic consumption, demonstrating that such programs can work in settings where expertise and resources are limited, according to a report published yesterday in The Lancet Infectious Diseases.
The program focused on such steps as preventing excessively long antibiotic treatment regimens and using several of the drugs at the same time. Most of the hospitals had never had any kind of antimicrobial stewardship program before.
The project involved Netcare Hospitals, a private network with 47 urban and rural facilities across South Africa. The authors included Netcare officials and academic researchers from South African universities and from The Ohio State University.
The report says that information about the content and effectiveness of hospital AS programs in resource-limited settings such as Africa is scarce. For example, a global survey revealed that only 14% of respondents in Africa and 53% in Asia had any form of AS program.
Focus on process measures
The research team decided to focus on several "process measures" that may indicate or contribute to overprescription of antibiotics: diagnostic cultures not done before starting empirical antibiotic treatment; more than 7 or 14 days of antibiotic treatment, depending on the infection; more than four antibiotics at the same time; and concurrent double or redundant antibiotic treatment.
The primary goals were to effect a 10% reduction in antibiotic consumption and to launch AS programs in all 47 hospitals.
The 5-year study, from October 2009 through September 2014, began with a survey of existing AS efforts in the hospitals, which revealed that 41 of the 47 had no such programs. Next, pharmacists, doctors, hospital and nursing managers, and infection preventionists received training concerning the targeted process measures.
Pharmacists then began auditing the five measures, recording their interventions, and providing monthly reports to the project manager. The project manager provided monthly feedback that included antibiotic consumption data and individualized goals for the pharmacists and their managers. In turn, the pharmacists fed information on the progress of implementation and changes in antibiotic consumption to doctors, hospital managers, and AS program committees.
During the project's 2-year implementation phase (February 2011 through January 2013), antibiotic prescriptions for 116,662 patients were reviewed. Pharmacist interventions numbered 7,934, signaling that 1 in 14.7 prescriptions required intervention, the authors said.
Before the project was implemented, the overall mean consumption of antibiotics was 101.38 defined daily doses per 100 patient-days (95% confidence interval [CI], 93.05–109.72). During the post-implementation phase (Feb 1, 2013, to Sep 30, 2014), overall consumption was down to 83.04 daily doses per 100 patient-days (95% CI, 74.87–91.22), a significant reduction of 18.34 doses (P < .0001).
The authors found that 39% of the pharmacist interventions were for excessive duration of antibiotic treatment, and treatment duration was the measure that improved the most.
Project sparked competition
By the post-implementation phase of the project, the team writes, "the model had been embedded in pharmacist practice, with daily auditing of the five targets for improvement, becoming the routine standard of care for inpatients receiving antibiotics." They add that the use of "comparative tables and multiple graphs describing the success or otherwise of each hospital or region, led to competitiveness, particularly among pharmacists and doctors."
The findings, the researchers said, "confirmed that antimicrobial stewardship is possible despite most hospitals never having practised stewardship before, the wide geographical distribution, the large number of hospitals involved, and the necessity to coordinate the interventions throughout all the hospitals simultaneously."
They emphasized that their results were achieved "in a range of geographical and socioeconomic settings by health-care workers without infectious diseases training. . . . We should not underestimate the role of the non-infectious diseases pharmacist in promoting interdisciplinary engagement in stewardship programmes in hospitals or across health systems."
Effort draws high praise
In an accompanying commentary, three South African experts who were not involved in the study warmly praised the project's success in reducing antibiotic consumption through the efforts of personnel without special infectious disease training. The three are Yogandree Ramsamy, MBChB, David J. J. Muckart, MBChB, and Koleka P. Mlisana, MBChB, all of whom work at the University of KwaZulu-Natal in Durban, among other affiliations.
"By patient and meticulous planning and the adoption of a few simple sequential interventions, they have shown that a significant reduction in antimicrobial prescribing can be achieved," they wrote. "Furthermore, these effective changes were implemented by clinicians, nurses, and pharmacists eager to learn antimicrobial stewardship skills, denouncing the myth of the need for infectious disease and microbiological specialists for such successes."
The three commentators also observe that the study was done solely in private-sector institutions, "an affluent component of the South African health-care system." They suggest that the data would be more "robust" if public hospitals been included in the project, and express confidence that similar results could be accomplished "in the overcrowded and understaffed public sector."
In other observations, the commentators write, "There is no quick fix for antimicrobial resistance. The only practical solution is to preserve whatever weaponry remains at our disposal, to avoid wastage, and to take more careful aim." As demonstrated by the findings, "Cooperation and collaboration are the keys to success."
Brink AJ, Messina AP, Feldman C, et al. Antimicrobial stewardship across 47 South African hospitals: an implementation study. Lancet Infect Dis 2016 (published online Jun 13) [Abstract]
Ramsamy Y, Muckart DJJ, Mlisana KP. Antimicrobial stewardship in South Africa: a fruitful endeavor. (Commentary) Lancet Infect Dis 2016 (published online Jun 13) [Introduction]
