Case history from Nigeria

The Lagos University Teaching Hospital, where I’m an honorary consultant, is a 761 bed tertiary hospital located in the southwestern part of Nigeria. Anti-microbial stewardship committee was inaugurated in 2012 by the then chief medical director, following a request by me. I had just attended the 2012 ECMID post-education course organised with the British Society for Antimicrobial Chemotherapy. Following this course, as the chairman of the stewardship committee, I was full of enthusiasm to set up our hospital stewardship programme. And the committee members unanimously agreed that we needed one. We also agreed we needed baseline data before commencing the programme.

So, we set up a subcommittee to develop a proposal to methodically obtain this needed data which would serve the basis of our stewardship programme. To my disappointment, It was taking a long time to write the proposal. Besides, some committee members saw a need for funding of the project. And this was recognised as a barrier. This situation continued for a long time, till the advent of the global point prevalence survey of antimicrobial consumption and resistance, the global PPS in 2015. We participated in this survey and were able to obtain the data, cause we considered enough to start the hospital stewardship programme.

As found by this survey, our main problems included very high rates of anti-microbial prescribing, and this was across specialties and wards.

There were also no antibiotic guidelines. Quality indicators revealed very low targeted prescribing, reason for prescribing not written in case notes, nor documentation of stop or review dates of prescriptions, and prolonged surgical prophylaxis. The problems were the same in hospitals across the country. The committee members were alarmed by the findings, and we decided immediately to disseminate the data in order to raise awareness. We did this at a hospital grand round. Because of the big size of our hospital, we decided to set up interventions separately in departments, so we can be effective. We decided to start one department at a time. So, we could use lessons learned in one department, to improve interventions in subsequent departments. We started with paediatrics.

This we did by disseminating the PPS data again, at one of their weekly departmental meetings in 2016. At this meeting, the prescribers agreed with us that they needed an intervention and decided on prospective audit with intervention and feedback. They constituted their antibiotic team, to initiate and ensure the writing of their antibiotic guidelines. The guidelines, however, did not get written until a year later. Similarly, because of nonchalance on the part of all, to discouragement of their team leader. An antibiotic policy based on the findings of the global PPS was given to them also at this time. A big challenge was– I however noted– in the form of inadequate personnel for the perspective audits and with lots of medical students.

We then did a feasibility study on the possibility of our medical students doing the posting in paediatrics, to perform the prospective audits and report back to consultants for feedback and intervention. The findings were reported to prescribers at the faculty conference. Some medical students were trained and used to audit retrospectively antibiotics prescribed. The audits based on institutional policy and departmental guidelines showed that 400 case notes were retrieved and reviewed. We found antibiotics were prescribed for 279 of the children, making prescribing rates of antimicrobials 56.94%. The commonest antibiotics prescribed were cefotaxime, amikacin, and cefuroxime. Empiric therapy was found to be 77%. Culture was performed in only 34% of the children and deescalation done in only 4%. Targeted therapy was 2%.

Antibiotic prescription was judged unnecessary in 13% of the children. Prophylactic use was 26%.

It became clear that prospective audits with feedback and intervention is feasible in the Department of Paediatrics and by extension, other departments in a hospital. The advantages of medical students being included in the audits were one, that it would reduce work burden for the health care professionals, and two, it would afford the students early learning and practise in rational antibiotic use. It was decided therefore, in the Department of Paediatrics, that when medical students resume rotation, they would undergo this training and conduct audits on behalf of their consultants. We decided to also work out how to extend this process to other clinical departments. So far, our only conclusive intervention is education which reduced anti-microbial prescribing rates in a hospital by 30%.

Although it’s had no effect on quality indicators. Hopefully, the department would have commenced a prospective audit and feedback before the next global PPS, so that’s the effect of this intervention can be evaluated. A national working group on anti-microbial stewardship has also been inaugurated in the country by a group of concerned health care professionals and hospitals. For this purpose, the entry points for hospitals has been accepted as participation in global PPS.