A major pharmacist-led antimicrobial stewardship programme at 47 private hospitals in South Africa achieved an 18% cut in antibiotic use – saving medicines and money and improving healthcare – found a study that included researchers from Ampath Laboratories, Netcare and the universities of the Witwatersrand, Pretoria and Ohio State. They recommend rolling out the programme in the public sector, writes Karen MacGregor for MedicalBrief.
An accompanying editorial in The Lancet Infectious Diseases, by University of KwaZulu-Natal scientists not involved in the study, notes: “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.”
Antimocrobial and antibiotic resistance is a health threat globally, and reducing unnecessary use of antibiotics is one response – and was the driver behind the stewardship programme.
In September 2015 the Center for Disease Dynamics, Economics and Policy published a report citing evidence that the effectiveness of antibiotics was decreasing globally and calling for strong antibiotic stewardship – especially the reduction of antibiotic overuse.
A meta-analysis confirmed that interventions to reduce excessive prescription of antibiotics can reduce antimicrobial resistance and improve treatment outcomes, says The Lancet article article “Antimicrobial stewardship across 47 South African hospitals: An implementation study”, by Dr Adrian J Brink of Ampath National Laboratory Services and colleagues*.
But few studies provide information about key aspects of interventions or the effectiveness of antimicrobial stewardship in resource-strapped settings – this was the study’s aim. “A global survey of stewardship activities revealed that only 14% of respondents in Africa and 53% in Asia had any form of antimicrobial stewardship programme,” the article states.
There is little understanding of why doctors over-prescribe antibiotics. Dr Brink told MedicalBrief: “The behavioural determinants dictating local and African antibiotic prescribing is unknown.
“It might relate to ‘uncertainty avoidance’ – a concept where doctors would rather give antibiotics if they don’t know if a patient has an infection or not. There is no training, undergraduate or postgraduate, in stewardship and neither in infection control.”
The primary goals of the initiative were to launch antimicrobial stewardship programmes in 47 hospitals, and to attain a 10% reduction in antibiotic consumption. Both of these goals were achieved – indeed, there was an 18% drop in antibiotic consumption, indicating that these programmes can succeed in environments where expertise and resources are limited.
The stewardship programme used five ‘process measures’ to prevent over-use of antibiotics – starting antibiotics before cultures had been done; more than seven days of antibiotic treatment; more than 14 days of antibiotic treatment; more than four antibiotics at the same time; and concurrent double or ‘redundant’ antibiotic coverage.
“We chose the five process measures on the basis of a previous survey of private and public hospitals in South Africa, in which excessive antibiotic consumption was found to include prolonged duration, multiple concurrent antibiotics, and redundant coverage,” the researchers write. “For all interventions, pharmacists consulted the doctor before changes were made.”
There were three phases – pre-implementation, implementation and post-implementation.
Before implementation of the five-year study, which was conducted between October 2009 and September 2014, a survey found that 41 of the hospitals had no stewardship programmes. None of the hospitals had local antibiotic policies or guidelines.
“Hospital managers were not involved, antimicrobial stewardship programme committees did not exist, and reporting and feedback of data were haphazard,” the authors write.
The new initiative was implemented in a diverse group of urban and rural hospitals operated by Netcare in seven of South Africa’s nine provinces.
The private hospitals had 9,424 registered beds including 1,601 intensive care and high-care beds. There were 64 pharmacists employed at the hospitals, but the 4,295 doctors involved were self-employed.
Pharmacists, doctors, hospital and nursing managers, and infection prevention specialists received training on the targeted process measures. There were learning cycles hosted every six to eight weeks initially, and then as needed. There was support from the project manager. After obtaining permission from doctors, pharmacists recorded interventions weekly.
The implementation phase was from February 2011 to January 2013, and was staggered. By September 2011, 36% of the hospitals had implemented the model and by February 2012, 68% were doing the targeted stewardship interventions. By September 2012, 85% of the hospitals were auditing all five process measures.
Antibiotic consumption was calculated from hospital dispensing, with the primary parameter being daily doses per 100 patient days. Pharmacists audited the five measures, recorded their interventions and wrote monthly reports. The project manager provided monthly feedback on data and individualised goals for pharmacists and managers.
During implementation, some 117,000 patients received antibiotics at the hospitals during 104 weeks of measurement and feedback. There were 7,934 interventions by pharmacists recorded, suggesting that nearly one in 15 prescriptions required intervention.
The researchers found that 39% of the pharmacist interventions were for excessive duration of antibiotic treatment – treatment duration was the measure that improved the most.
“By the post-implementation phase, from February 2013 to September 2014, the model had been embedded in pharmacist practice, with daily auditing of the five targets for improvement becoming the routine standard of care for patients receiving antibiotics,” says the article.
Interestingly, the use of benchmarking, comparative tables and multiple graphs describing each hospital or region’s success in stewardship “led to competitiveness, particularly among pharmacists and doctors”.
In South Africa, the main barriers to antimicrobial stewardship programmes in almost all public and private hospitals have been lack of infectious diseases expertise and resources. Also, in large hospital networks, geographical distribution has hindered implementation.
The primary finding of the study was that “healthcare facilities with limited infectious diseases expertise can achieve substantial returns through pharmacist-led antimicrobial stewardship programmes and by focusing on basic interventions”, the authors write.
The significant 18% reduction in antibiotic prescription confirmed that antimicrobial stewardship was 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”.
It is crucial to use a range of skills – beyond those of infectious diseases and microbiology – to ensure sustainable success, the researchers argue. “Our study findings suggests that this antimicrobial stewardship model not only had an effect during the implementation phase but also a sustained benefit once the process was embedded within the existing system.”
The substantial returns achieved through pharmacist-led antimicrobial stewardship include saving antibiotics in resource-scarce settings, financial savings and improved health outcomes for patients, Dr Brink told MedicalBrief.
“The point is, using existing resources such as non-specialised pharmacists and training them in a few measures, you can reduces consumption significantly without having infectious diseases experts or clinical microbiologists in every hospital. Not having such expertise is not an excuse anymore for not doing stewardship.”
Public sector roll-out
The study findings support the potential of antimicrobial stewardship programmes to be rolled out across the public sector.
Dr Brink told MedicalBrief: “While one may question the applicability of our findings to the public sector, where the majority of the population in South Africa receive healthcare, given similar documented overprescribing practices we contend that this model could be valuable despite a lack of infectious diseases expertise.
For public hospitals and elsewhere in Africa, the study suggests a model in which pharmacists, doctors, nurses and other health-care providers such as infection prevention practitioners, work together to support stewardship activity.
“It would, however, require commitment from governmental, hospital and clinician leadership to acknowledge and support the cardinal role of non-specialised pharmacists in recruiting multidisciplinary teams and in coordinating interdisciplinary engagement in such an antimicrobial intervention, which was key to our success.”
Indeed, says Dr Brink, under the South African Antibiotic Stewardship Programme, a similar intervention is being planned for community-acquired pneumonia. “We have recruited 60 public sector pharmacists nationally, to train and to implement the principles of the model as a teaching and learning collaborative. We are waiting for ethics approval.”
Creating alternative models for stewardship that can be embedded in existing systems will depend on local context and resources, and will be key to cutting antibiotic over-prescribing across diverse settings, the study says.
By focusing on a vital few interventions, healthcare facilities with limited resources and expertise could have a substantial effect on antibiotic use with less effort, while embedding antimicrobial stewardship practices within existing resource structures and systems.
“This focus on key interventions ensures sustainability and provides a platform for targeting more complex stewardship interventions in the future.”
A positive review
In an accompanying commentary in The Lancet, three South African experts who were not involved in the study praised the project’s success in reducing antibiotic consumption through the efforts of personnel without special infectious disease training, reported Robert Roos for CIDRAP –Center for Infectious Disease Research and Policy at the University of Minnesota.
The three experts are Dr Yogandree Ramsamy, Dr David JJ Muckart and Dr Koleka P Mlisana of 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 commentators, wrote Roos, point out that the study was done solely in private hospitals, “an affluent component of the South African healthcare system”. They suggest that the data would be more “robust” if public hospitals been included – and were confident similar results could be achieved “in the overcrowded and understaffed public sector”.
The reviewers also observed: “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.”
* The authors of the article, “Antimicrobial stewardship across 47 South African hospitals: An implementation study”, are: Dr Adrian J Brink of Ampath National Laboratory Services; Angeliki P Messina of the department of quality leadership at Netcare Hospitals; Professor Charles Feldman and Professor Guy A Richards of the faculty of health sciences at the University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital; Professor Piet J Becker in the research office of the faculty of health sciences at the University of Pretoria; Professor Debra A Goff and Dr Karri A Bauer of the department of pharmacy at Ohio State University and the Wexner Medical Center; and Professor Dilip Nathwani of Ninewells Hospital and Medical School in Scotland; and Dr Dena van den Bergh of the department of quality leadership at Netcare Hospitals, on behalf of the Netcare Antimicrobial Stewardship Study Alliance.
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.
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.
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 7,934 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).
Health-care facilities with limited infectious diseases expertise can achieve substantial returns through pharmacist-led antimicrobial stewardship programmes and by focusing on basic interventions.
LINKS TO ARTICLES AND RESEARCHCIDRAP material The Lancet Infectious Diseases article summary The Lancet Infectious Diseases – Full article