A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications

Abstract

Objective: Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in lowand middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider. Methods: A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines. Results:The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour ® ) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files. Conclusions: It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.

Antibiotic Use and Stewardship Indicators in the First- and Second-Level Hospitals in Zambia: Findings and Implications for the Future

“…The low rate of CST requests seen among the participating hospitals (3% of occasions) may be due to current limited capacity among the first- and second-level public hospitals to undertake any CST analyses, with CST requests potentially sent to higher hospitals or private laboratories for analysis. This is similar to the situation among a range of hospitals in South Africa, which results in delays in reporting the results impacting on requests in practice [ 56 , 57 ]. The current rate of 3% was appreciably lower though than seen in some other African countries [ 47 , 58 ], as well as among participating hospitals in the Global PPS study (targeted treatment in 19.8% of occasions) [ 18 ].…”

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

“…We are aware of previous publications that have explored antibiotic prescribing rates for infections in ambulatory care across both sectors in South Africa. These include the management of ARIs, adherence rates to current antibiotic STGs and Essential Medicines Lists [ 14 , 37 , 41 ], as well as patient and physician’ attitudes towards the prescribing of antibiotics for ARIs [ 42 , 44 ]. However, we are currently unaware of any study that has been conducted in South Africa to assess key factors behind the high empiric prescribing of antibiotics for UTIs and ARIs in ambulatory care, which includes acute bronchitis, sinusitis and tonsillitis as well as COVID-19 infections.…”

“…However, there have been ongoing activities by the Government in South Africa and other key stakeholder groups in South Africa in recent years to reduce inappropriate use of antibiotics across sectors [ 27 ]. This is reflected by appreciably greater adherence to guidelines among public facilities in ambulatory care compared with the previous situation seen among both private and public ambulatory care facilities [ 14 , 37 , 40 , 41 , 42 ].…”

“…A key element of South African and other NAPs is the documentation of current antimicrobial usage and resistance patterns across all sectors of care [ 27 , 28 , 34 ]. We are aware that there have been a number of studies undertaken in South Africa to monitor prescribing and resistance patterns in ambulatory care; however, these have shown variable findings alongside requests for additional data to guide future strategies [ 14 , 24 , 35 , 36 , 37 ]. In addition, there have been concerns among physicians in South Africa regarding their knowledge of antibiotics and AMR as well as confidence with prescribing antibiotics [ 38 ].…”

“…Ncube et al (2017) also demonstrated high rates of antibiotic prescribing among physicians treating private patients with acute bronchitis [ 41 ], with Manderson (2020), Mathibe et al (2020) and others documenting similar concerns among physicians treating both private and public patients with acute respiratory infections [ 42 , 43 , 44 ]. However, Skosana et al (2022) in their study showed high adherence rates to South African guidelines (93.4%) when HCPs prescribed antibiotics for patients attending community health centres, with ear, nose and throat infections the most common presentation [ 37 ].…”