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Skip to 0 minutes and 4 secondsWhy did you choose these particular so-called low-hanging fruit to pick in your AMS model? What did you mean with low-hanging fruit, and why? OK, so going back to the fact that we chose to use pharmacists as our key intervention and leaders of our antibiotic stewardship programme, we understood that we had to find interventions that they could implement reasonably easily with some early wins and successes. And that's an important principle of change. If we make it too huge and too big, then the developmental process is inhibited, and that was an important plus. Now, we also did some reflection on what were the kinds of things that were happening in antibiotic stewardship in our group and in South Africa as a whole?

Skip to 0 minutes and 58 secondsAnd those led to those particular interventions and really, collectively in the South African antibiotic stewardship community, we had understood that those five low-hanging fruit were an important element of the inappropriate use of antibiotics, and it made sense to go and do those first, as part of our intervention. And these were surveyed? People were doing redundant, double anaerobe cover, gram-negative cover? Yes. Why would you chose more than four antibiotics concurrently? Well, surprisingly and you know you'll see in some of the literature-- there actually were numerous examples of patients who had received more than four antibiotics. And part of that is because of the disconnect between different doctors sometimes. They don't talk to each other.

Skip to 1 minute and 51 secondsOne doctor is prescribing one antibiotic, and a different specialist might come along and do something different. And also, the original way in which our prescriptions were handled didn't make it clear that there was already another antibiotic being prescribed. And so as part of that process, we had to go and review that whole process and improve how that was done. And so that was one of the interventions that very quickly reduced. And once we became aware of it, it was a combination of a bad process that didn't make it easy to know, and this issue of the different doctors that would prescribe.

What do the "low-hanging fruit" AS interventions consist of?

Watch the second video with Dr Adrian Brink and Dr Dena van den Berg as she explains the five “low-hanging fruit” chosen for their intervention:

  • Whether cultures were performed prior to antibiotic prescription 
  • Concurrent use of ≥ four antibiotics 
  • Duration of antibiotic therapy >seven days 
  • Duration of antibiotic therapy > 14 days 
  • Concurrent “double-cover” i.e. redundant anaerobe, Gram-negative and Gram-positive cover.

NB: These examples are determined by local needs and priorities. In other healthcare systems surgical prophylaxis, IV to oral conversion are commonly used as “low-hanging”interventions.

It is worth noting that data at all participating sites in the group was collected during pharmacist AMS ward rounds conducted initially in intensive care and high care units followed by audits in wards. For above basic interventions, clinicians were consulted in every instance before changes were affected. Interventions did not occur for established, extended treatment syndromes such as infective endocarditis and other deep-seated infections (e.g. osteo-myeilitis and septic arthritis). In addition, antimicrobials used in patients for HIV infections, Mycobacterium tuberculosis and/or Pneumocystis jiroveciI pneumonia were excluded. Only parenteral use was measured and topical or inhaled antibiotics and antifungal use was excluded in this study.

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This video is from the free online course:

Antimicrobial Stewardship: Managing Antibiotic Resistance

University of Dundee

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