Antibiotic stewardship: Factors influencing the choice and outcomes of antimicrobial therapy in a resource-limited, rural, public hospital in uMkhanyakude District, KwaZulu-Natal, South Africa: pre-intervention phase

Abstract

Background: Resistance to antimicrobial agents has been growing rapidly and is currently a matter of concern world-wide. Irrational use of antibiotics has been highlighted as a major cause of resistance, among others.Aims: To establish whether antibiotic prescribing at the hospital is done according to principles of rational antibiotic prescribing and to establish factors that influence the choice and outcomes of antimicrobial therapy at Mseleni hospital.Objective: To perform an audit of all antibiotic prescriptions written at the hospital for a period of two months. Method: A data collection tool was developed and made available to all prescribers whose permission had been obtained. The tool was used to obtain information necessary to dispense antibiotics. This information was analysed to establish the extent to which prescribers at this hospital apply the principles of antibiotic prescribing, based on the National Standard Treatment Guidelines and Essential Medicines List (STGs and EML).Results: A hundred data collection tools (representing 100 prescriptions) meeting the inclusion criteria were selected for analysis.. Antibiotic therapy was indicated in 98% (98; n=100) of all prescriptions. In total, 16 antibiotics were prescribed 124 times. In approximately 97% (120; n=124) of cases, the prescribed antibiotic correctly matched the most likely cause of the infection. Infections were confirmed for five patients. Antibiotics were prescribed according to the National STGs and EML in 41% (19; n=46) of prescriptions. Doses were prescribed as recommended by these guidelines in 88% (88; n=100) of prescriptions. Intravenous (IV) antibiotics were prescribed for 43% (26; n=60) of inpatients. Of these, 65% (17; n=26) were later switched to oral antibiotics. Hang times were one hour or less in 25% (6; n=24) of patients receiving IV antibiotics, and between 2–56 hours in the remainder.Conclusions: National Treatment Guidelines and medicine availability influenced choice of antibiotics. Lack of microbiological cultures led to empiric prescribing. Communication between prescribers, nurses and pharmacists influenced outcomes.Recommendations include: Administering first doses of IV antibiotics immediately after prescription; switching IV therapy to appropriate oral therapy when patients’ conditions allow; pharmacists routinely monitoring antibiotic use; utilising microbiological tests to identify patients who need antibiotics; and providing resistance patterns.