Stewardship from across the globe

Hello. My name is Adrian Brink. I’m a clinical microbiologist from Johannesburg, and I’d like to share with you a specific antimicrobial stewardship programme that we’ve been involved in. In South Africa, we don’t have enough infectious disease resources, neither microbiologists in all hospitals. We also don’t have ID pharms or clinical pharmacists in every hospital, so we had to use existing resources to embed an initial, basic stewardship programme, a sustainable one, in all of the hospitals that participated in this programme. So we chose a prospective ordered pharmacist, non-specialised, pharmacist-driven, audit and feedback strategy to implement across 47 rural and urban hospitals.

The interventions that the pharmacists chose, or that we chose for the pharmacist, were so-called low-hanging fruit, implying that they are easy, obtainable interventions without ID resources. They were, for example, duration of therapy longer than seven days, duration of therapy longer than 14 days, a redundant cover, many doctors don’t know overlapping spectra between gram-negative and gram-positive antibiotics. We also did an intervention to make sure that cultures were taken prior to empirical therapy, for example.

The target was these five low-hanging fruits, and every pharmacist then were allocated stewardship time from their daily activities to go to the wards and ICUs and to measure patients more than seven days of therapy, 14 days, et cetera, intervene, and discuss that with a doctor to reduce overall consumption, which was the aim of the study. The model that we used for improvement amongst the non-ID pharms was the Breakthrough Series Collaborative, which you’re going to learn about later. It involved six weekly or two monthly teleconferences with all the pharmacists in the so-called PDSA cycles, which you’re also going to learn of.

Overall, the five interventions over a two-year period led to a 12 and 1/2% reduction in overall consumption in these 47 hospitals. Hello, my name is Sujith Chandy, and I am here to talk to you a little bit about antibiotics stewardship programmes in India. As you know, India is rather a diverse country, with religion, culture, economics, language being different in different parts of the country. This diversity translates itself into the health structure too. On the one hand, there are government facilities throughout the country. On the other hand, there are private facilities. And each has its own way of doing things. Then comes the rural versus the urban facilities.

And as in most cases, the urban facilities seem to be much more populated in terms of health-care professionals and equipment. This kind of diversity has its own issues as far as medicine use is concerned. And among medicines, antibiotics are a significant proportion of medicine use. Therefore, antibiotic use differs based on whether it’s a private or a government, or whether it’s an urban or whether it’s a rural. What is stocked what is prescribed, what is dispensed– even among the pharmacy, our chemist shop outlets all differ. Therefore, stewardship, in the true sense of the word, is a huge challenge because of this diversity. Each state has very standard treatment guidelines, and each state has its own diagnostic network.

They differ, and the guidelines differ, and the way it’s implemented differs. Nevertheless, certain states are doing rather well when it comes to implementing these guidelines, and some are not. The big hospitals throughout the country tend to have rather well-formed antibiotic stewardship programmes, especially as many of these hospitals are in the process of being accredited. They may have not just antibiotic policies; they may have restriction use policies and guidelines. They have good diagnostic lab setups, all of which may aid in improving antibiotic use. But there are parts of the country where diagnostic setups just do not exist.

There are parts of the country where there are absolutely no guidelines, or no policies in place for antibiotics stewardship, so a lot of it depends on the whims and fancies or the practices of health-care professionals. There are remote areas where physicians or health-care professionals just do not exist. And therefore, over-the-counter use, practices by non-allopathic health-care practitioners all play a part in antibiotic use. So as you can see, the stewardship per se means different things in different places. The regulation has also stepped in, with antibiotics now coming under the list of prescription-only.

Well, the Indian Council of Medical Research and other notable agencies have been trying to do their best when it comes down to antibiotic stewardship. So in the last few years, there’s been activity in terms of having a national training for antibiotic stewardship infection and control through the guise of the ASPIC programme and other such programmes. We are hoping that these small initiatives, both in the hospitals and nationally, could play a part in improving stewardship throughout the country. Thank you.