Knowledge and Perceptions of Final-Year Nursing Students Regarding Antimicrobials, Antimicrobial Resistance, and Antimicrobial Stewardship in South Africa: Findings and Implications to Reduce Resistance.

Antimicrobial resistance (AMR) is being increasingly seen as the next pandemic due to high morbidity and mortality rates, with Sub-Saharan Africa currently having the highest mortality rates driven by high rates of inappropriate prescribing in ambulatory care. In South Africa, nurses typically provide a range of services, including prescribing, in public ambulatory care clinics. However, little is currently known about the perception of final-year nursing students regarding antibiotic use, AMR, and antimicrobial stewardship (AMS). Consequently, we sought to address this important evidence gap. A quantitative descriptive study using a self-administered online questionnaire via Google Forms® was undertaken among six universities in South Africa offering a Baccalaureus of Nursing. Knowledge on the classes of antibiotics, organisms covered, and mechanism of action was lacking. The sample size to achieve a confidence interval of 95% with a 5% error margin was 174, increased to 200 to compensate for possible attrition. Only 15.3% of nurses knew that ceftazidime is not a fourth-generation cephalosporin, and only 16.1% knew that clavulanic acid does not decrease inflammation at the site of infection. In addition, only 58.9% and 67.7% agreed that the prescribing of broad-spectrum antibiotics and poor infection control, respectively, increase AMR. AMS was also not a well-known concept among final-year nurses. The lack of knowledge regarding antibiotics, AMR, and AMS among final-year nurses could have important repercussions in practice once these nurses are qualified. Consequently, this information gap needs to be urgently addressed going forward with updated curricula and post-qualification educational activities to reduce AMR in South Africa.

Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction.

Antimicrobial resistance (AMR) is a growing problem worldwide, including South Africa, where an AMR National Strategy Framework was implemented to instigate antimicrobial stewardship programmes (ASPs) and improve antimicrobial prescribing across sectors. To address the need to assess progress, a sequential mixed methodology with an explanatory research design was employed. In Phase 1, a self-administered questionnaire was completed by healthcare professionals (HCPs) from 26 public sector healthcare facilities across South Africa to assess compliance with the Framework. The results were explored in Phase 2 through 10 focus group discussions and two in-depth interviews, including 83 participants. Emerging themes indicated that public healthcare facilities across South Africa are facing many challenges, especially at entry level primary healthcare (PHC) facilities, where antimicrobial stewardship activities and ASPs are not yet fully implemented. Improved diagnostics and surveillance data are a major shortcoming at these facilities. Continuous education for HCPs is deficient, especially for the majority of prescribers at PHC level and health campaigns are nearly non-existent. Involvement and visibility of management at certain facilities is a serious shortfall. Consequently, it is important to call attention to the challenges faced with improving antimicrobial prescribing across countries and address these to reduce AMR, especially in PHC facilities, being the first point of access to healthcare for the vast majority of patients in developing countries.

Compliance with South Africa's Antimicrobial Resistance National Strategy Framework: are we there yet?

Antimicrobial resistance (AMR) is a growing problem worldwide. South Africa has recently released its Antimicrobial Resistance National Strategy Framework (referred to as the Framework) to instigate antimicrobial stewardship programmes (ASPs). Consequently, there is a need to assess compliance with the Framework. METHODS: Descriptive study design, collecting quantitative data, among pre-selected public healthcare facilities. One healthcare professional from each participating facility, involved in ASPs, was invited to participate. RESULTS: Overall 26 facilities from 8 provinces participated. Average compliance to the Framework was 59.5% for the 26 facilities, with 38.0% for community health centres, 66.9% for referral hospitals and 73.5% for national central hospitals. For 7 facilities compliance was <50% while 5 facilities were >80% compliant. CONCLUSION: Although some facilities complied well with the Framework, overall compliance was sub-optimal. With the introduction of universal healthcare in South Africa, coupled with growing AMR rates, ongoing initiatives to actively implement the Framework should be targeted at non-compliant facilities.

Status of antimicrobial stewardship programmes in Nigerian tertiary healthcare facilities: Findings and implications.

OBJECTIVES: The problem of antimicrobial resistance (AMR) is increasing worldwide, with health-related and economic consequences. This is a concern in Africa, including Nigeria, the most populous country in Africa, with its high rates of infectious diseases. Approaches to reducing AMR include instigating antimicrobial stewardship programmes (ASPs) in hospitals. Currently, no information is available regarding the extent of ASPs in Nigerian hospitals. Consequently, the objective was to address this starting in tertiary hospitals. METHODS: This was a cross-sectional, questionnaire-based study among tertiary healthcare facilities. Tertiary hospitals were chosen initially since if there are concerns in these training hospitals, such concerns will likely to be exacerbated in other hospitals. RESULTS: Completed questionnaires were received from 17 of 25 tertiary healthcare facilities across five of the six geopolitical regions of Nigeria. Ten (59%), four (24%), two (12%) and one (6%) respondents were in internal medicine, infectious diseases, medical microbiology and clinical pharmacology, respectively. Only six healthcare facilities (35%) had a formal organisational structure and a team responsible for ASP. Facility-specific treatment recommendations, based on local AMR patterns, were available in only four facilities (24%). Policies on approval for prescribing specified antimicrobials and formal procedures for reviewing their appropriateness after 48h were present in only two facilities (12%). A cumulative antimicrobial susceptibility report for the previous year was available in only two facilities (12%), and only one facility routinely monitored antimicrobial use. CONCLUSION: Significant inadequacies in the availability of ASPs were observed. This needs to be urgently addressed to reduce AMR rates in Nigeria.

Amphotericin B in the Management of Fungal Infections in a Neonatal Intensive Care Unit (NICU): Experiences in a Teaching Hospital

Background:Hospital-acquired pathogens cause considerable morbidity and mortality in preterm infants. Neonatal candidaemia plagued the neonatal ICU at Dr. George Mukhari Hospital. The standard treatment of candidaemia at the time of the study was fluconazole 10 mg/kg/day. The use of amphotericin B was introduced after identifying a problem with fluconazole resistance.Method:The application of the amphotericin B treatment protocol was monitored in the first 20 patients. A test dose of 0.25 mg/kg was administered with 0.25 mg/kg/dose increments until a maintenance dose of 1 mg/kg/dose was reached. Patients were kept on amphotericin B for one week after the first culture came back negative and were discharged as soon as the second blood culture also came back negative and they were clinically doing well. The patients' responses to amphotericin B were evaluated according to the laboratory data and clinical response.Results:Seventeen patients remained and were treated with amphotericin B for an average of 18.5 days (median=11 days) until the first negative Candida culture could be obtained; with a cumulative dose of 20.8 mg (median=19.2 mg) on average. The period to response in this study was relatively short.Conclusion:The specific strain cultured in this NICU could be eradicated with continuous use of amphotericin B. Further clinical investigation and improved infection control practices will be needed to decrease the incidence of invasive Candida infections; the duration of hospital stay associated with these infections and the side-effects associated with amphotericin B