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A quick win strategy from South Africa

Dr Adrian Brink outlines the strategy implemented in 47 hospitals in South Africa to improve antibiotic prescribing.
Hello. My name is Adrian Brink. I’m a clinical microbiologist in Johannesburg, South Africa. I’ll share with you in this quick win the implementation of a stewardship programme using a quality improvement model and behaviour change techniques, but using non-specialised pharmacist in a prospective audit and feedback strategy across 47 hospitals, urban and rural. This quick win will reflect some of the principles that you were taught in the prior five weeks. And systematically, stepwise, we’ll be sharing with you how this stewardship programme was introduced without ID resources.
Before we chose this specific interventions for the pharmacists, we did a survey of antibiotic prescribing practices in South African in intensive care units, both in the public and in the private sector, which dictated the interventions we chose for pharmacists in this improvement model.
Depicted in this slide, you will note that inappropriate overuse and misuse was rife in both the public and the private sector. For example, de-escalation was only practised in 24% of the patients. But more importantly, that 72% of the patients had inappropriate duration of antibiotics.
You will also note in this slide that several patients had more than one or two or four or five antibiotics concurrently. This is mainly due to the fact that every time a new doctor is consulted, the previous antibiotic is not stopped, and was one of the interventions– as I’ll show you now– we chose for the stewardship model.
Using the Breakthrough Series Collaborative, the hospital group in which the 47 hospitals that participated in this pharmacist-driven strategy was based in Johannesburg, but had hospitals even up to 2,000 kilometres away, and hence, a specific improvement model was chosen which we refer to as the Netcare model in this instance, which I’m going to go through in detail shortly.
The five areas that were chosen for improvement, we’re going to refer to as low-hanging fruit because we believe that they were easily obtainable in a setting without ID resources. So the five interventions were, first of all, to facilitate later de-escalation, cultures not done prior to the commencement of empiric antibiotics, more than four antibiotics at the same time, more than seven days of treatment, or more than 14 days of treatment, and double cover or redundant cover– for example, two anaerob antibiotics or two antibiotics with similar gramme negative spectrum, et cetera.
So how this model works is as follows. First of all, you need to identify a particular area or issue in the hospital that needs improvement. As I showed you, the five targets for improvement based on the survey. Then, you define collective goals. In this instance, for group-wide implementation in all the hospitals. And, in this instance, as an outcome measure, the overall reduction in antibiotic consumption. You then define the low-hanging fruit based on local and international guidelines. What would be appropriate treatment for longer than seven days or not, et cetera? And, best practise adapted for the South African setting.
The next step would be to form multidisciplinary stewardship committees in your hospital. Or, in this case, in 47 hospitals, most of them had never done stewardship before. You have to present the model to each participating institution. In this instance, by the Netcare quality improvement director, which then modified the model and seeked endorsement by the doctors after presenting it to them at each institution.
After presenting the model face-to-face at each institution, implementation started in a stepwise way, followed by six to eight weekly learning sessions via teleconferencing. During the learning sessions, the project manager and the quality improvement director measured the progress of implementation and measured the antibiotic consumption, and then provided feedback to these pharmacists every six to eight weeks, where everybody participated in the teleconference.
Practically, if one looks at how the stepwise implementation took place, subsequent to introducing the low-hanging stewardship toolkit, some hospitals adopted all five elements at once. Others tackled one at a time, depending on the pharmacist’s time. But during the post-implementation period, 116,662 patients on antibiotics were reviewed, with nearly 8,000 interventions recorded for those five designated examples of low-hanging fruit, indicating that almost 1 in 15 prescriptions for inpatients required a pharmacist intervention. And the majority of patients where the interventions took place were actually in the wards.
What we have here is a run chart that shows 104 weeks of standardised measurement and feedback during every six to eight weekly learning cycle. The aim of the learning cycle is for shared collaborative learning. For example, in this instance, you’ll note initially for the first 30-40 weeks that the percentage of patients in which empirical therapy was given without cultures done was quite high.
But eventually, as the model gained momentum and the pharmacists learned from each other during these teleconferences and they started implementing this in more units and more wards, eventually, at the end of the study, was reduced to less than 0.1% of patients in this hospital group of 47 who received an empirical antibiotic without cultures done prior to prescription.
Similarly, this is a run chart showing all the data for the 47 hospitals after the pharmacists started intervening with patients with a doctor’s permission who were on antibiotic duration for longer than seven days. And as you see, as again, momentum again at the end of the study, a small percentage of patients have, compared to initially introducing the model, actually were on antibiotic therapy more than seven days that did require a pharmacist intervention.
Another run chart for another low-hanging fruit– in this instance, the percentage of patients with double antibiotic cover, double gramme positive cover, et cetera, where the pharmacist had to show the doctor during the prospective audit and for him to only use one antibiotic at the end of the study, less than 0.5% of these patients were on double or redundant antimicrobial cover.
In the pre-intervention period when stewardship activities were erratic in a few hospitals, there was no feedback, there was no proper measurement, et cetera, the antibiotic consumption was actually increasing or at least stagnant, shown here by a statistical model. In the implementation phase, it was significant and even was sustained in the post-implementation phase. Meaning, that this five or these five improvement areas that were targeted for improvement had been embedded into practise.
The final slide will show the mean defined daily doses for all 47 hospitals. And compared to the pre-implementation phase, in the post-implementation phase, a significant reduction in overall consumption occurred at 18.5% reduction in DDDs, targeting only those five low-hanging fruit of duration, double cover, et cetera. But it shows that in a resource-constrained setting, using a formal model for improvement, step-by-step, that it is possible to do stewardship, even if you think you can’t. Based on this quick win, I trust that the next steps you will enjoy as we systematically go through all the elements that made this a successful stewardship programme in a resource-limited setting.

In this video Dr. Adrian Brink introduces a strategy implemented in 47 hospitals in South Africa (a resource limited setting) to improve antibiotic prescribing using the AS techniques that have been outlined throughout the course.

This quick win will enable you to:

  • Understand how, with limited resources (limited ID trained clinicians or pharmacists), obtainable interventions can be achieved: “Picking the low-hanging fruit” of AS

  • Understand how to implement a pharmacist – driven prospective audit and feedback model to initiate and establish a basic Antimicrobial Stewardship (AS) programme in multiple, non-academic, urban or rural/remote institutions

  • Understand how to effect change utilising a formal approach of step-wise change management and quality improvement principles.

If you work in a health-care setting, other than a large academic institution, selecting the most obtainable targets with limited resources (“low-hanging” fruit in reference to AS) might be especially relevant to you.

The simple interventions explained in this video, as opposed to more complex strategies, are ideal if you have not yet begun to initiate an AS programme and would like to know where to begin, what to do and what results you might expect to achieve.

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Antimicrobial Stewardship: Managing Antibiotic Resistance

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