Improving primary care antimicrobial stewardship by implementing a peer audit and feedback intervention in Cape Town community healthcare centres
DOI:
https://doi.org/10.7196/SAMJ.2022.v112i10.16397Keywords:
community health care, primary health careAbstract
Background. The increasing prevalence of antibiotic resistance is a major threat to public health. Primary care, where 80% of antibiotics are consumed, is a pivotal setting to direct antimicrobial stewardship (AMS) efforts. However, the ideal model to improve antibiotic prescribing in primary care in low-resource settings is not known.
Objective. To implement a multidisciplinary audit and feedback AMS intervention with the aim to improve appropriate antibiotic
prescribing at primary care level.
Methods. The intervention was implemented and monitored in 10 primary care centres of the Cape Town metropole between July 2017
and June 2019. The primary and secondary outcome measures were monthly adherence to a bundle of antibiotic quality process measures and monthly antibiotic consumption, respectively. Multidisciplinary audit and feedback meetings were initiated and integrated into facility clinical meetings. Two Excel tools were utilised to automatically calculate facility audit scores and consumption. Once a month, 10 antibiotic prescriptions were randomly selected for a peer review audit by the team. The prescriptions were audited for adherence to a bundle of seven antibiotic process measures using the standard treatment guidelines (STG) and Essential Medicines List (EML) as standard. Concurrently, primary care pharmacists monitored monthly antibiotic consumption by calculating defined daily doses (DDDs) per 100 prescriptions dispensed. Adherence and consumption feedback were regularly provided to the facilities. Learning collaboratives involving representative multidisciplinary teams were held twice-yearly. Pre-, baseline and post-intervention periods were defined as 6 months before, first 6 months and last 6 months of the study, respectively.
Results. The mean overall adherence increased from 19% (baseline) to 47% (post intervention) (p<0.001). Of the 2 077 prescriptions
analysed, 33.7% had an antibiotic prescribed inappropriately. No diagnosis had been captured in patient notes, and the antibiotic chosen was not according to the STG and EML in 30.1% and 31.7% of cases, respectively. Seasonal variation was observed in prescribing adherence, with significantly lower adherence in winter and spring months (adjusted odds ratio 0.60). A reduction of 12.9 DDDs between the pre- and post-intervention periods (p=0.0084) was documented, which represented a 19.3% decrease in antibiotic consumption.
Conclusion. The study demonstrated that peer reviewed audit and feedback is an effective AMS intervention to improve antibiotic
prescribing in primary care in a low-resource setting. The intervention, utilising existing resources and involving multidisciplinary
engagement, may be incorporated into existing quality improvement processes at facility level, to ensure sustainable change.
References
Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. Lancet Infect Dis 2014;14(8):742-750. https://doi.org/10.1016/ s1473-3099(14)70780-7
National Department of Health, South Africa. South African Antimicrobial Resistance National Strategy Framework 2017 - 2024. Pretoria: NDoH, 2017. https://www.knowledgehub.org.za/elibrary/ south-african-antimicrobial-resistance-national-strategy-framework-one-health-approach (accessed 28 September 2021).
National Department of Health, South Africa. Implementation Plan for the Antimicrobial Resistance Strategy Framework in South Africa : 2014 - 2019. Pretoria: NDoH, 2015. https://www.knowledgehub. org.za/elibrary/implementation-plan-antimicrobial-resistance-strategy-framework-south- africa-2014-2019 (accessed 28 September 2021).
National Department of Health, South Africa. Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance. Pretoria: NDoH, 2017. https://www. knowledgehub.org.za/elibrary/guidelines-implementation-antimicrobial-strategy-south-africa-one- health-approach (accessed 28 September 2021).
Brink AJ. Antimicrobial stewardship (AMS) in the community. Clin Pulm Med 2016;23(1):1-10.
https://doi.org/10.1097/CPM.0000000000000107
Brink AJ, van Wyk J, Moodley VM, et al. The role of appropriate diagnostic testing in acute respiratory tract infections: An antibiotic stewardship strategy to minimise diagnostic uncertainty in primary care. S Afr Med J 2016;106(6):554-561. https://doi.org/10.7196/samj.2016.v106i6.10857
Farley E, van den Bergh D, Coetzee R, Stewart A, Boyles T. Knowledge, attitudes and perceptions of antibiotic use and resistance among patients in South Africa: A cross-sectional study. S Afr J Infect Dis 2019;34(1):1-9. https://doi.org/10.4102/sajid.v34i1.118
Farley E, Stewart A, Davies MA, Govind M, van den Bergh D, Boyles TH. Antibiotic use and resistance: Knowledge, attitudes and perceptions among primary care prescribers in South Africa. S Afr Med J 2018;108(9):763-771. https://doi.org/10.7196/samj.2018.v108i9.12933
Gasson J, Blockman M, Willems B. Antibiotic prescribing practice and adherence to guidelines in primary care in the Cape Town Metro district, South Africa. S Afr Med J 2018;108(4):304-310. https:// doi.org/10.7196/samj.2017.v108i4.12564
Brink A, Schoeman J, Muntingh G. Undergraduate antibiotic stewardship training: Are we leaving our future prescribers ‘flapping in the wind’? S Afr Med J 2017;107(5):357-358. https://doi.org/10.7196/ samj.2017.v107i5.12496
Wasserman S, Potgieter S, Shoul E, et al. South African medical students’ perceptions and knowledge about antibiotic resistance and appropriate prescribing: Are we providing adequate training to future prescribers? S Afr Med J 2017;107(5):405-410. https://doi.org/10.7196/samj.2017.v107i5.12370
Tonkin-Crine S, Tan P, van Hecke O, et al. Clinician-targeted interventions to influence antibiotic prescribing behaviour for acute respiratory infections in primary care: An overview of systematic reviews. Cochr Datab Syst Rev 2017;(9)CD012252. https://doi.org/10.1002/14651858.CD012252.pub2
Hemkens LG, Saccilotto R, Reyes SL, et al. Personalised prescription feedback using routinely collected data to reduce antibiotic use in primary care: A randomised clinical trial. JAMA Intern Med 2017;177(2):176-183. https://doi.org/10.1001/jamainternmed.2016.8040
Meeker D, Linder JA, Fox CR, et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomised clinical trial. JAMA 2016;315(6):562-570. https://doi.org/10.1001/jama.2016.0275
Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing: A systematic review and quantitative analysis. Med Care 2008;46(8):847-862. https://doi. org/10.1097/mlr.0b013e318178eabd
Borek AJ, Wanat M, Sallis A, et al. How can national antimicrobial stewardship interventions in primary care be improved? A stakeholder consultation. Antibiotics 2019;8(4):207. https://doi.org/10 .3390%2Fantibiotics8040207
Peters SM, Sheik S, Werner JL, Davies MA, Willems B. Antimicrobial stewardship in the Western Cape: A situational analysis of existing facility-level initiatives. S Afr Med J 2021;111(5):421-425. https://doi. org/10.7196/samj.2021.v111i5.14645
Von Pressentin KB, Swanepoel H, Opie JJS, Jenkins LS. Antimicrobial stewardship in rural districts of South Africa: Growing a positive culture. S Afr Fam Pract 2019;61(6):276-281. https://doi.org/10.108 0/20786190.2019.1680009
National Department of Health, South Africa. Standard Treatment Guidelines and Essential Medicines List for South Africa: Primary Healthcare Level 2020 Edition. Pretoria: NDoH, 2020. https://www. idealhealthfacility.org.za/ (accessed 18 October 2021).
World Health Organization (WHO). Defined daily dose (DDD). https://www.who.int/toolkits/atc- ddd-toolkit/about-ddd (accessed 28 September 2021).
National Department of Health, South Africa. Integrated Management of Childhood Illness. Pretoria: NDoH, 2014. https://www.knowledgehub.org.za/system/files/elibdownloads/2019-07/IMCICB-2014. pdf (accessed 12 December 2021).
Boyles TH, Naicker V, Rawoot N, Raubenheimer PJ, Eick B, Mendelson M. Sustained reduction in antibiotic consumption in a South African public sector hospital: Four-year outcomes from the Groote Schuur Hospital antibiotic stewardship programme. S Afr Med J 2017;107(2):115-118. https://doi. org/10.7196/samj.2017.v107i2.12067
Brink AJ, Messina AP, Feldman C, et al. Antimicrobial stewardship across 47 South African hospitals: An implementation study. Lancet Infect Dis 2016;16(9):1017-1025. https://doi.org/10.1016/s1473- 3099(16)30012-3
Peters SM, Sheik S, Werner JL, Davies MA, Willems B. Antimicrobial stewardship in the Western Cape: A situational analysis of existing facility-level initiatives. S Afr Med J 2021;111(5):421-425. https://doi. org/10.7196/samj.2021.v111i5.14645
Pierce J, Apisarnthanarak A, Schellack N, et al. Global antimicrobial stewardship with a focus on low- and middle-income countries. Int J Infect Dis 2020;96:621-629. https://doi.org/10.1016/j. ijid.2020.05.126
Durkin MJ, Jafarzadeh SR, Hsueh K, et al. Outpatient antibiotic prescription trends in the United States: A national cohort study. Infect Control Hosp Epidemiol 2018;39(5):584-589. https://doi. org/10.1017%2Fice.2018.26
Safaeian L, Mahdanian AR, Salami S, Pakmehr F, Mansourian M. Seasonality and physician-related factors associated with antibiotic prescribing: A cross-sectional study in Isfahan, Iran. Int J Prevent Med 2015;6(1):1. https://doi.org/10.4103/2008-7802.151431
Isaacs AA, Manga N, le Grange C, Hellenberg DA, Titus V, Sayed R. A snapshot of noncommunicable disease profiles and their prescription costs at ten primary healthcare facilities in the in the western half of the Cape Town Metropole. S Afr Fam Pract 2014;56(1):43-49. https://doi.org/10.1080/207862 04.2014.10844582
Ivers N, Jamtfedt G, Flottorp S, et al. Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012;(6):CD000259. https://doi.org/10.1002/14651858. CD000259.pub3/full
Brink AJ, van den Bergh D, Mendelson M, Richards GA. Passing the baton to pharmacists and nurses: New models of antibiotic stewardship for South Africa? S Afr Med J 2016;106(10):947-948. https://doi. org/10.7196/samj.2016.v106i10.11448
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