Effects of antimicrobial stewardship policy in improving antibiotic utilisation and reducing drug costs in a public hospital in Gauteng Province, South Africa

A dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in Medicine. Johannesburg, 2017.Antimicrobial stewardship (AMS) programmes along with infection and prevention control measures have been shown to reduce the burden of antimicrobial resistance (AMR) in hospitals. There is a global campaign by infectious diseases physicians and other stakeholders for hospitals to implement AMS programmes. In Africa, there have been a limited number of AMS studies conducted although South African private hospitals have published some outcomes on initiation of these programmes in the continent, with the aim of improving patients’ clinical outcomes and reducing the development of resistance to prescribed antibiotics. A formal AMS programme is yet to be implemented in the surgery departments of the Charlotte Maxeke Johannesburg Academic Hospital. This study was conducted in two surgical wards of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). It was a quantitative study combining a prevalence cross-sectional observational stage, and an intervention study. It involved a retrospective review of patient records in the baseline stage followed by an intervention which took the form of a weekly antibiotic round led by an infectious diseases specialist. The appropriateness of antibiotic prescriptions was assessed using the criteria developed by Gyssens and colleagues, while the appropriateness of surgical prophylaxis was determined based on the recommendations of the South African Antibiotic Stewardship Programme (SAASP) and current Standard Treatment Guidelines and Essential Medicines Lists for South Africa. The prices of the antibiotics used were obtained from the central pharmacy of the CMJAH and Masters Price Catalogue list of the National Department of Health, while the prices of laboratory tests were obtained from the Tariff database. The volume of antibiotics consumed was determined by Defined Daily Doses (DDDs)/1000 patient days. In both stages of the study amoxicillin/clavulanic acid was the most frequently used agent. The intravenous route was the most commonly used route of drug administration in both stages of the study. There was a reduction in the proportion of patients who were treated with antibiotics for more than seven days in the intervention stage, from 6.19% in the baseline stage to 2.07% in the intervention stage. A significant reduction in the duration of antibiotic therapy for two days and more was observed from 4.74 ± 4.58 days in the baseline stage compared to 3.96 ± 2.04 days in the intervention stage (p = 0.01). A shift from empiric to culture directed therapy was also observed in the intervention stage compared to the baseline stage. There was a significant reduction in the volume of antibiotic consumption from a total of 739.30 DDDs/1000 patient days in the baseline stage to 564.93 DDDs/1000 patient days in the intervention stage (p = 0.038). Overall, there was a significant reduction of inappropriate antibiotic utilisation from 35% in the baseline stage to 26% in the intervention stage (p = 0.006). A high percentage of inappropriate surgical prophylaxis was found which was mostly due to the incorrect choice of agent with 64.75% and 61.54% in the baseline and intervention stages, respectively. The average antibiotic cost per patient was reduced from R 268.23 ± 389.32 to R 228.03 ± 326.88 in the Vascular Surgery Ward compared to the General Surgery Ward where there was an increase in average cost per patient from R 219.80 ± 400.75 in the baseline stage to R 284.06 ± 461.28 in the intervention stage. Gram-negative bacteria were the most prevalent pathogens in both stages of the study at 53% in the baseline and 54% during the intervention stage. The findings of this study show an improvement in the appropriateness of antibiotic utilisation, reduction in antibiotic consumption and cost reduction in one of the study wards, following implementation of an AMS programme. Also, there was an improvement in culture directed therapy, requests for an appropriate biological specimen for culture, with a consequent increase in the cost of laboratory investigations per patient during the intervention stage, which was due to increases in culture request. Rational antimicrobial prescribing habits, strong AMS interventions along with infection and prevention control measures, sound government policies and surveillance of resistant organisms in Africa will go a long way in preserving our antibiotics and preventing the spread of multidrug-resistant pathogens.LG201