Antimicrobial stewardship in rural districts of South Africa: growing a positive culture

Background: The success of medical specialist-led antimicrobial stewardship activities in urban tertiary health care settings has been well documented. The issue of antimicrobial resistance remains an ongoing concern. This has particular relevance in primary health care communities treated from sub-district health services, which are organised around level-one district hospitals. District hospitals are typically staffed by generalist clinicians or medical officers with minimal access to the medical specialist physicians and pathologists who are available in the urban academic centres. Coordinated team-based activities aimed at implementing the South African Antibiotic Stewardship Programme (SAASP) principles of antimicrobial use are necessary. Methods: This open forum article describes the process of growing an institutional culture around antimicrobial stewardship from the perspective of a 90-bed district hospital and a regional referral hospital located in the rural Garden Route District of the Western Cape province. Results: A team of generalist health workers, inclusive of a family physician and medical officers, pharmacists and nursing colleagues, conducted weekly antimicrobial stewardship ward rounds. A clinical pathologist from the National Health Laboratory Service (NHLS), based at George Regional Hospital, consulted on these ward rounds monthly and provided guidance and advice to medical staff via telephone, email and WhatsApp. Undergraduate medical students and registrars in family medicine also attended these ward rounds and learnt from resulting discussions. This strengthened quality of care for patients and provided a platform for shared ongoing learning. Conclusion: This model can be applied to similar settings within South Africa, and further afield