Stewardship programme tackles over-prescription of antibiotics in hospitals

While state hospitals undoubtedly present different health structures and challenges‚ a recent model implemented in private hospitals across the country has suggested ways to reduce the use of antibiotics.

TMG Digital, 19 June 2016

South African hospitals‚ with limited expertise and resources‚ can help reduce patients' excessive antibiotic intake through antimicrobial stewardship (AS) programmes‚ according to a recently published study. AS is a coordinated programme that promotes the appropriate use of antimicrobials (including antibiotics)‚ improves patient outcomes‚ reduces microbial resistance‚ and decreases the spread of infections caused by multidrug-resistant organisms‚ according to the Association for Professionals in Infection Control and Epidemiology (APIC).

APIC said that misuse and overuse of antimicrobials is one of the world's most pressing public health problems. It said infectious organisms adapt to the antimicrobials designed to kill them‚ making the drugs ineffective, adding that people infected with antimicrobial-resistant organisms are more likely to have longer‚ more expensive hospital stays‚ and may be more likely to die as a result of an infection.

According to a report published in The Lancet Infectious Diseases last week‚ by focusing on basic interventions‚ the study provides suggestions to help prevent "excessively long antibiotic treatment regimens and using several of the drugs at the same time". During the study‚ an AS programme was implemented in 47 private hospitals operated by Netcare in seven of country's provinces.

Following consultation with various doctors‚ the researchers "decided to focus on several process measures" that may indicate or contribute to over-prescription of antibiotics. These measures included: diagnostic cultures not done before starting empirical antibiotic treatment; more than seven 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 study revealed that the primary goals were to "effect a 10 percent reduction in antibiotic consumption and to launch AS programmes in all 47 hospitals". This, after it was found that that 41 of the 47 had no such programmes. The five-year study‚ from October 2009 through September 2014‚ included a two-year "implementation phase" in which 116 662 antibiotic prescriptions were reviewed. Pharmacist interventions numbered 7 934 suggesting that almost one in 15 prescriptions required intervention.

Some of the key tips for implementing the AS model provided by the study included: formalising measurable goals for the hospital group; forming antimicrobial stewardship programme committees; mandating so-called protected pharmacist stewardship time to do antibiotic audit rounds; developing and launching a toolkit consisting of a standardised template using Microsoft Excel to facilitate uniform process measurement and data recording; recording the pharmacist's interventions every week for all inpatients on antibiotics either initially in the intensive care and high-care units and thereafter in selected wards or in all units at once; and submitting data every month to an antimicrobial stewardship programme project manager.

By the final phase of the study (the post-implementation phase)‚ the authors noted that 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". The study‚ however, also revealed 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.

Additionally, 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 commentators‚ Yogandree Ramsamy‚ David Muckart and Koleka Mlisana‚ all of whom work at the University of KwaZulu-Natal in Durban‚ however‚ did suggest that while the study was done solely in the private sector‚ the data would be more "robust" if public hospitals had been included in the project. They expressed confidence that similar results could be accomplished "in the overcrowded and understaffed public sector".