How to create a network to support stewardship and infection prevention

Hello, and welcome to this talk on how to set up an Antimicrobial Stewardship network. I’m Shaheen Mehtar, from the Infection Control African Network and Stellenbosch University in Cape Town. Now, it may be difficult, but not impossible, to start an antibiotic stewardship programme. However, it can be quite challenging to set up an antimicrobial stewardship network . In this short talk, I will give you some ideas and pointers on how to make this possible. A famous adage is that the journey of a 1,000 miles starts with a single step. In Africa, where there’s an acute shortage of staff, and many are multitasking, it requires someone, particularly like you, to take the initiative to start an antibiotic programme.

It gradually includes interested people as we go along. It will take time and effort, but will yield satisfying results. In many countries, including South Africa, the Antimicrobial Stewardship programme started with a vision and determination of a handful of dedicated people. There must be questions in your mind, such as, who should be included in this network? Is the Antimicrobial Stewardship network going to be set up for a health care facility, or is it a wider audience, such as government structures? What is already available that can be used? What else is needed? Once these questions are considered, one can start planning and taking steps towards your goal. Find out who is interested in Antimicrobial Stewardship in your hospital.

There may only be one or two people, and it really doesn’t matter, as long as one starts. Include as many as those that want to be part of this amazing project. Then the next question is, where does one find them? They are in the hospital, and they work in different areas, such as the clinical areas, the microbiology laboratory, the pharmacy, and even in management. If possible, go and see them, or call a meeting and talk to them. Try to engage with them at various levels. Get their opinions and ideas, as many brains are better than one. It is important that a no-blame culture exists. Find out what the skill levels are in your hospital. See who’s interested.

Obviously, you are, and you can start. However, how would they respond to patient care and patient safety? Do they know about appropriate use of antimicrobials? Usually, in my experience, they do not know a lot, and one has to bear in mind that education and training, such as this MOOC, will help to clarify matters. Find out how and when antibiotics are used. And finally, quite importantly, find out where the infection control practitioners are, and work closely with them. Look for low-hanging fruit, something that can be done, and relatively easily, with a bit of modification of behaviour. Here are some examples. Join a ward round and contribute as best you can. This will be a peer-to-peer teaching and discussion round.

Talk to the nurses caring for the patients. Observe them, if possible, and see how they handle medication, particularly the use of antibiotics. One option is also to study clinical and prescription charts. This is not easy to do, but will give you an idea of how antibiotics are used, the route, the number, and so on. Look for evidence of use, such as microbiology result, and how the isolates are relevant to the clinical condition and also, to the prescribed antibiotic. This takes a bit of time, but it does help to start a programme. And then one has to talk to managers and impress upon them the impact of health-care-associated infections, and the huge cost to the health bill.

Show them how money can be saved, and most managers will respond to that. Also ask them if they are prepared to set up an Antimicrobial Stewardship group in the hospital to discuss some matters. And where possible, talk to colleagues in other hospitals to find out what they’re doing, so you don’t have to reinvent the wheel. I would particularly like to address the role of an IPC practitioner here, particularly since I am one myself. Improved infection control practices have been shown to reduce– the reduction of transmission have shown to reduce the need of antibiotics. And this is quite an important factor. Consider the removal of in-dwelling devices when they are not needed.

Preventative measures that are evidence-based definitely are hand hygiene, sterile medical devices, a clean environment, and appropriate use of antibiotics and disinfectants.

Discuss these matters with those responsible for infection prevention. And if there’s no infection prevention practitioner in your facility, invite somebody who is interested in infection control to be part of the Antimicrobial Stewardship meeting, and get their input. If you want to address Antimicrobial Stewardship to a wider audience, start networking across a geographical area, talking to other prescribers and those interested in Antimicrobial Stewardship. Be as inclusive as possible, as there is the concept of One Health, which you’re all familiar with. Get them interested, and see how one can organise them to contribute.

In South Africa, we have an excellent group called SAS, which is the South African Antibiotic Stewardship programme, where the 30+ of us meet and discuss all levels of AMS. And this includes the veterinary and agricultural sector, as well as prescribers and non-prescribers, incuding pharmacists. In fact, the pharmacists in our system play a huge role in Antimicrobial Stewardship. It really works well and has produced some excellent policies very quickly. If this does not happen as soon as you want it to, try a small discussion group at various different specialty levels. And in order to do this, one has to communicate with each other. And how does one do this? The most popular one is a WhatsApp group.

This is easy and easily accessible and easy to do. It has limitations, but also has the advantage to start, where advice can be shared. It works very well in Africa and has been used in different platforms. In ICAN, we have the ECHO, which is the Extension of Community Healthcare Outcome platform, which is a mixture of case-based learning and teaching. It also works very well because it’s on a ZOOM platform, and is easily accessible across Africa wherever there are stable internet connections. We have established the ICAN ECHO hub, and it is working to make sure that information is passed out to the far reaches, where people cannot afford to come into a face-to-face meeting on a regular basis.

Then there is the ICAN Virtual Learning platform, which is also very useful to communicate when you want to talk about longer periods of time, about matters of particular topics or subjects. The value of the online courses, where we can talk to each other and inform each other– the British Society of Antimicrobial Chemotherapy has a wonderful online teaching programme. South Africa has one, too, and I’m sure there are others across the continent. Talk to each other and consult. Develop ideas on how to move Antimicrobial Stewardship forward. And in this case, sometimes face-to-face meetings seem to be best for Africa. The Antimicrobial Network will require you to engage with government and other structures at some point.

We already use the already existing support evidence from the WHO, CDC, BSAC, and in our case, South Africa policies and documents. It will help to promote Antimicrobial Stewardship Network in the country or in a district. Try to get governmental buy-in either at national or local level. Give them ideas on easy implementation, which is the low-hanging fruit, where it is not expensive to implement. However, we need that political commitment. Build up slowly, and try to get funding for expansion of a programme. Here, you see an example from SAS, which is the Antibiotic Stewardship programme, and the antibiotic prescription chart, giving you a lot of information that can be gathered and used effectively as one progresses in this programme.

And this leads to the next bit, which is taking stock after a year or so. One needs to look back and see what has been achieved at any scale, small or large. Has there been modifications in behaviour, such as prescribing, deescalation, IV to oral, and so on? And then think about the next steps, of what is needed to move forward? Get organised in an Antimicrobial Stewardship committee, define roles, and you might consider monitoring an evaluation programme for quality improvement, as this makes very good sense when one has to feed back information. And most importantly, there must be feedback. And the outcome of this will drive the Antimicrobial Stewardship Network forward. Think it through.

Each situation is different in each country and will require different tactics. But I hope some of this information will be useful. Here is an example from South Africa, where the Antimicrobial programme was established and published in the Lancet Infectious Diseases, in 2016, by Adrian Brink and his coworkers. And to summarise, it defines goals, seeks endorsements, and then sets up implementation learning cycles, and continues to improve. And I think this is a reasonable way to go forward, if there is finances. However, any part of this can be used effectively, if there are no resources. Finally, to summarise, just begin or just get started. Even if it is you alone or two or three people and no more, I suggest you begin.

Gather like-minded colleagues on the way. Do things together. Own it, and agree to move forward by being visible. Do not be afraid to publish or to make sure that your data that you’ve gathered can be available to lots of people. Engage with management and government. They need to seriously consider the WHO recommendations as part of their duties and their roles. And finally, get some simple effective tools, such as data collection and feedback evaluation, to move things forward. I hope you’ve found this talk interesting, and I hope it will support you to set up an Antimicrobial Stewardship Network in your region or in your country, or indeed, even in your hospital. Thank you.