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Rational use  –  Inspirational examples

Antimicrobial stewardship in South Africa

From October 2009 to September 2014, a pharmacist-driven prospective audit and feedback strategy for antimicrobial stewardship program was implemented and assessed in 47 South African urban and rural private hospitals with limited infectious disease resources and limited stewardship activities.

Data of implementation of antimicrobial stewardship programs in African countries are scarce. The overall aim of the study was to launch and implement an antimicrobial stewardship program in a network of private hospitals to reduce overall consumption of antimicrobials. To achieve this, the stewardship program focused on excessive antibiotic use, in particular redundant therapy such as long duration of treatment and using several drugs with same antimicrobial spectrum simultaneously.

A three-phase study

The study included three phases. Phase one was the pre-implementation phase conducted before introduction of the antimicrobial stewardship program. It included a quantitative survey of current stewardship activities and consumption of antimicrobials. In phase two, the model was introduced in a step-wise manner. Key components included: Defining measurable goals, forming antimicrobial stewardship programme committees, mandating time for pharmacists to do antibiotic audit rounds, auditing of the five process measures, recording the pharmacist’s interventions each week, submitting data every month to project manager, providing feedback to pharmacists on progress of implementation, and in turn to other staff at the hospital. Phase three was the post-implementation phase and consisted of completion of the implementation phase and auditing of the process measures in place in all units of each hospital.

Five targets for improvement

The stewardship model focused on five process measures indicating or contributing to overprescription of antibiotics:

  • Cultures not done before commencement of empirical antibiotics
  • More than 7 days of antibiotic treatment
  • More than 14 days of antibiotic treatment
  • More than four antibiotics at the same time
  • Concurrent double or redundant antibiotic coverage

The antimicrobial stewardship programme was implemented using an adaptation of the Institute for Healthcare Improvement Model and the Breakthrough Series Collaborative. During the two-year implementation phase, pharmacists received training via workshops before performing auditing of the five measures in their hospitals, and then in 6-8 week cycles throughout the project. Pharmacists recorded their interventions and provided monthly reports to the project manager who in turn provided monthly feedback to the hospitals. The feedback included improvements of antibiotic consumption data and compliance with the process measures (or otherwise). The pharmacists then provided information on the progress of implementation and changes in antibiotic consumption to doctors, hospital managers, and stewardship program committees.

Antimicrobial stewardship model.


During the implementation phase, antibiotic prescriptions for 116,662 patients were reviewed. Pharmacist intervened in 7,934 cases, signalling that 1 in 14.7 prescriptions required intervention. Antibiotic consumption did not only decrease, but it decreased with 18%, which was higher than the initial aim of the study of 10%. Greatest improvement was seen in antibiotic treatment duration, though the study had an impact of all five parameters that were targeted.

Graph with curves in different colors representing the five targets for improvement
Local polynomial smoothed curves describing the change over time for the five parameters targeted for improvement.

Stewardship programs could be effective in different contexts

Even though this highlights only one example, the  reduction in use indicates that even if a hospital has never practiced antimicrobial stewardship before and infectious disease resources are scarce, it is possible to successfully implement such a program. Different types of hospitals in different settings were included in the study. Thus, there are no specific hospitals that should be targeted or excluded, but stewardship programs could be effective anywhere. One limitation of the program was that outcome measures were not recorded.

Selected Resources

Resource Description
Antimicrobial stewardship across 47 South African hospitals: an implementation study Journal article describing the stewardship implementation study.
Howard, P. et al. An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J. Antimicrob. Chemother. 70, 1245–1255 (2015).
Brink, A. J. et al. Antimicrobial stewardship across 47 South African hospitals: an implementation study. The Lancet Infectious Diseases 16, 1017–1025 (2016).