So to start off, can you tell me what it is you do and your role in this institution? Good afternoon. My name is Marc Mendelson. I’m a professor of infectious diseases at the University of Cape Town. I head up the Division of Infectious Diseases and HIV Medicine. And I’m a general infectious disease specialist, but my main focus is on antibiotic resistance and, particularly, developing national and international policy on antibiotic resistance and finding ways of delivering antibiotic stewardship in low middle income countries. And my role at Groote Schuur and University of Cape Town is to lead the efforts in mitigating antibiotic resistance. It’s interesting that you mention antibiotic resistance.
And one of your publications, I came across the view that there is a lack of unity in the definition of whether we should be focusing on antibiotic stewardship or antimicrobial stewardship. What is your view on this? Well, I think we need to focus on what we actually want to talk about. And we need to focus also on the terms that we use will depend on who we’re talking to. So antimicrobial resistance or AMR is a term that has got a lot of political traction at the highest level. It’s being propagated as the term to use at high-level international meetings, at ministerial briefings. And at that level, there is an understanding of what it means.
And in fact, although it focuses mainly on resistance of bacteria to antibiotics, in other words, antibiotic resistance, it does recognise that resistance to viruses, such as HIV, to protozoa, such as malaria resistance, and specific bacteria, a bacterial group, i.e. Mycobacterium tuberculosis, resistant tuberculosis is also important. So at a high-level, there is an international recognition. The problem with the term antimicrobial resistance comes when you’re trying to improve public awareness and awareness in non-specialist health care professionals. Because firstly, the public don’t understand the term AMR. Most people have had an antibiotic at one time or other in their lives. And they can relate to the term antibiotic resistance.
And the studies that have been done in a number of countries suggest that the term antimicrobial resistance leaves people pretty unimpressed, pretty unsure of what you’re talking about, a little bit disconnected from the main problem. So I prefer to try and concentrate on what we’re talking about today as being antibiotic resistance, i.e. resistance of therapeutics against bacterial infections. When you mentioned that the term antimicrobial resistance does not catch on to everyone, do you mean the general population or health care specialists? Well, firstly, the general public don’t understand the term. And secondly, when you’re talking about antibiotic resistance to health care professionals, if you use the term antimicrobial resistance, that actually has a much broader term.
And it doesn’t focus down on what we’re really trying to focus on here, which is antibiotic resistance in bacteria, which is a major public health crisis, global crisis. In certain places in the world, South Africa in particular, obviously, HIV prevalence is so high. And there is an increasing amount of resistance in HIV. So there, we’re talking about antiretroviral resistant or antiviral resistance. It’s very important that we use the terminology correctly so that we know the people that we’re talking to know what we’re trying to do with and trying to focus on. And you have implemented and championed stewardship in this institution. Yeah. Can you share some of your experiences doing this?
We joined with other colleagues in South Africa to form South African Antibiotic Stewardship Programme known as SAASP, which basically was there to advocate for antibiotic resistance becoming a focus of attention at the highest levels, but also to try and start implementing antibiotic stewardship interventions in hospitals. And in this hospital, in 2011-12, we started with a pilot study on two medical wards to introduce a specific antibiotic prescription charge, which made doctors focus and prescribers focus much more on the details of the prescription and why they were prescribing the antibiotic that they were to prescribe. And along with that, we then started weekly ward rounds alternating in the two different wards.
And we went around in a multidisciplinary team with a ID specialist, microbiologist, pharmacist, and infection control sister, along with the junior doctors in the Department of Medicine who were looking after the patients. And we went bed to bed, and we looked at the antibiotic prescription charts. And we discussed each case. And we gave teaching. And we looked basically at the end of that year at the total amount of antibiotics consumed on those two wards compared to the previous year where there had been no intervention. And what we showed was a 20% reduction in antibiotic consumption just on those two wards. And that study continued. And five years later, we did an economic analysis, which showed that we had been consistent.
That we had been able to maintain that sort of level of antibiotic reduction. That there was a significant cost saving just on antibiotic costs, not on anything else, but just an antibiotic costs of over 3 million rand just on those wards. And so that’s how we started with really trying to develop antibiotic stewardship ward rounds. At Groote Schuur hospital, now the antibiotic stewardship chart that we piloted in that study has now become used in all clinical areas. So antibiotics can only be prescribed on that chart. And there are multidisciplinary ward rounds taking place in seven different wards and clinical areas in the hospital across medicine, surgery, orthopaedics. We also outreach to UCT affiliated hospitals doing antibiotic stewardship ward rounds.
And there’s also now a separate antibiotic stewardship team for the intensive care units run by colleagues. So that both the general wards and the ICUs are covered. So that’s the intervention we made. We also put in other interventions to try and improve antibiotic stewardship in the hospital. And they follow very much the national Programme. And those include, firstly, getting buy-in from senior administrators in the hospital. So if you don’t have buy-in from your CEO and your chief operating officer of the hospital, it’s not going to work. So we’re very lucky to have their support.
We constituted a hospital antibiotic or antimicrobial stewardship committee, which is a multidisciplinary committee involving management, health care practitioners for the antibiotic stewardship team composition that you would expect with laboratory clinicians, pharmacists, and infection control nurses, but also we have representatives from each of the different specialties and clinical areas in the hospital. I’ve described the teams that we’ve developed and the prescription charts. And we also integrate antibiotic resistance or antimicrobial stewardship work with infection control work. We have very good laboratory support, which is critical, so-called diagnostic stewardship, or the proper use of diagnostic tests. And so that’s how we’ve built the antibiotic stewardship Programme in this hospital. Have you experienced any challenges with stewardship? Many. There are many challenges with stewardship.
The greatest challenge with stewardship– well, the greatest challenge with implementing any new method is in getting buy-in. Now, as I said, we’re very lucky to have buy-in from our CEO and high level. But the critical issue of stewardship is to get understanding and buy-in from the more senior prescribers, the consultants. And it varies very much. There are some consultants in the hospital that have taken this on board very seriously and become excellent antibiotic stewards themselves. And there are others who, because of many reasons, not least because the South African psyche in medicine, in clinical medicine in general, is of physician autonomy and the sanctity of autonomy. And they don’t like the idea that they’re being directed towards maybe changing practise.
And the other problem has been is in behaviour change is also that as this Programme’s been rolled out, and the junior doctors who go on the rounds are actually being trained, there’s this hierarchical problem between a junior doctor that knows more than a senior doctor that makes the decisions. And also, obviously, the power dissonance is such that juniors are less likely to question their senior’s antibiotic prescribing. So that’s been a major challenge. The other major challenge is that we live in a country with a massive, massive burden of infectious diseases. So although we can try and steward appropriately, you still need to use antibiotics.
And unfortunately, without proper infection prevention, in terms of good vaccination coverage, reduction of diarrheal diseases with clean water and sanitation for the population, better infection control, our hand hygiene performance is terrible. Again, it’s behaviour change and putting in mechanisms in place. But that has impacted adversely on antibiotic stewardship. And I think those are the major challenges that we face, which are not so different to other areas, I think. And the other, the last challenge I would say would be a human resource challenge that there just aren’t enough people with enough hours in the day to be actually given the opportunity.
So this is particularly true of pharmacists who would really like to be on the wards more and interface on rounds. And you know, they’re very pushed for time on many different roles they have to play. And therefore, it’s actually the human resources side which is a major challenge. We’d like a much larger team and a much larger group of people who maybe not be dedicated to stewardship in itself alone, but in their job are given time to be able to conduct stewardship.