Web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital in Eswatini and the implications

Background: Eswatini is located in Sub-Saharan Africa. There is limited knowledge regarding antimicrobial utilisation among public hospitals across Africa, which is a challenge with rising antimicrobial resistance rates. Objective: To undertake a point prevalence survey (PPS) at Raleigh Fitkin Memorial (RFM) Hospital, the leading regional hospital in Eswatini with the findings driving future programmes. Method: PPS was undertaken at RFM using the Knack web-based application (App) to speed-up data collection, with antimicrobials categorised according to the World Health Organization Access, Watch, and Reserve classification. Each ward was surveyed in one day using patient files. Results: Overall, 68 patient files in 12 wards were surveyed; 88.2% (60/68) received at least one antimicrobial. Prescribed antimicrobials were mainly from the Access group (69.9%), none from the Reserve group. Amoxicillin (24.5%) and ceftriaxone IV (21.6%) were the most prescribed antibiotics. Of concern was that antibiotics were prescribed empirically for all patients (100%) with most administered IV (88.3%; 91/103). In addition, there was no documented switch or stop dates for administered antibiotics or any patient culture or drug sensitivity results recorded. Alongside this, extended courses of antimicrobials were typically administered as part of prophylaxis for surgical patients (80%; 12/15) despite concerns. Conclusion: There were considerable concerns with current antimicrobial use. Identified targets included reducing extended administration for surgical prophylaxis, encouraging earlier switching to oral antimicrobials and undertaking sensitivity testing. In addition, routinely documenting stop dates. The App appreciably reduced data collection times and analysis, and could potentially be used in other low- and middle-income countries

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use. Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known. Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals. Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

Background: The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa. Objective: Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups. Our Approach: Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel. Ongoing Activities: Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality. Conclusion: There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other

Ongoing and planned activities to improve the management of patients with Type 1 diabetes across Africa : implications for the future

BACKGROUND: Currently about 19 million people in Africa are known to be living with diabetes, mainly Type 2 diabetes (T2DM) (95%), estimated to grow to 47 million people by 2045. However, there are concerns with early diagnosis of patients with Type 1 diabetes (T1DM) as often patients present late with complications. There are also challenges with access and affordability of insulin, monitoring equipment and test strips with typically high patient co-payments, which can be catastrophic for families. These challenges negatively impact on the quality of care of patients with T1DM increasing morbidity and mortality. There are also issues of patient education and psychosocial support adversely affecting patients' quality of life. These challenges need to be debated and potential future activities discussed to improve the future care of patients with T1DM across Africa. METHODOLOGY: Documentation of the current situation across Africa for patients with T1DM including the epidemiology, economics, and available treatments within public healthcare systems as well as ongoing activities to improve their future care. Subsequently, provide guidance to all key stakeholder groups going forward utilizing input from senior-level government, academic and other professionals from across Africa. RESULTS: Whilst prevalence rates for T1DM are considerably lower than T2DM, there are concerns with late diagnosis as well as the routine provision of insulin and monitoring equipment across Africa. High patient co-payments exacerbate the situation. However, there are ongoing developments to address the multiple challenges including the instigation of universal health care and partnerships with non-governmental organizations, patient organizations, and pharmaceutical companies. Their impact though remains to be seen. In the meantime, a range of activities has been documented for all key stakeholder groups to improve future care. CONCLUSION: There are concerns with the management of patients with T1DM across Africa. A number of activities has been suggested to address this and will be monitored

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growing prevalence of both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimise the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective. Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective. Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability. Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need

Investigating the effect of interventional programmes in combatting inappropriate use of antibiotics in managing and treating acute gastroenteritis in children younger than five years at the Raleigh Fitkin Memorial Hospital in ESwatini

Thesis (MSc)--Stellenbosch University, 2019.ENGLISH ABSTRACT: Patients at the Raleigh Fitkin Memorial Hospital, ESwatini, especially children diagnosed with acute gastroenteritis, are mostly prescribed with antibiotics. Previous data suggest that inappropriate use of antibiotics results in higher antibiotic resistance, extended hospitalisation and increased medication costs. Antibiotic stewardship programmes and clinical practice guidelines can reduce the inappropriate use of antibiotics and improve patient outcomes. Despite increased theoretical awareness of the benefits of antibiotic stewardship programmes, none have been established in ESwatini, and limited comprehensive studies have evaluated their effect in paediatric settings globally. The knowledge, attitude and practices on antibiotic use and resistance have not been determined at the Raleigh Fitkin Memorial Hospital. An 18-month, single-centre process improvement study, comprising a six-month pre-intervention phase, a preparatory period of six months and a six-month intervention phase, was conducted at the Raleigh Fitkin Memorial Hospital to assess the effectiveness of a multifaceted intervention in combatting the inappropriate use of antibiotics and improving the management of acute gastroenteritis and its comorbidities in children aged less than five years. The intervention included the establishment of an antibiotic stewardship programme and the implementation of clinical practice guidelines related to the diagnosis, treatment and management of acute gastroenteritis and its associated comorbidities. Two hundred and thirteen patients participated in the study, with 87 patients in the pre-intervention phase and 126 in the intervention phase. Knowledge, attitude and practices of healthcare professionals were investigated by conducting a survey before and after the intervention phase. An improvement in the appropriateness of antibiotics use was observed in the intervention phase. A decrease in duration of hospitalisation, cost of antibiotics and mortality was observed. During the intervention phase, deaths were observed where severe acute malnutrition was present as comorbidity to acute gastroenteritis, whereas various causes of death were observed during the pre-intervention phase. Most recommendations by the antibiotic stewardship programme team were adopted during the intervention phase. An improvement in knowledge, attitude and practices on antibiotic use and resistance was observed after the intervention phase. The study demonstrates that an antibiotic stewardship programme can improve the appropriate use of antibiotics in children, with limited adverse effects. Clinical practice guidelines play a vital role in providing guidance to prescribers and harmonising therapies. Antibiotic stewardship programmes can improve healthcare professionals’ knowledge, attitude and practices on the appropriate use of antibiotics, and a decrease in antibiotic resistance.AFRIKAANSE OPSOMMING: Pasiënte by die Raleigh Fitkin Memorial-hospitaal in ESwatini, veral kinders wat gediagnoseer is met akute gastroenteritis, ontvang meestal antibiotika as voorskrif. Vroeër ingesamelde data dui daarop dat die onvanpaste gebruik van antibiotika lei tot groter antibiotiese weerstandigheid, langer hospitaalverblyf en verhoogde medikasiekoste. Antibiotiese bestuursprogramme en kliniese riglyne kan die onvanpaste gebruik van antibiotika verminder en die kliniese uitkomste van pasiënte verbeter. Ten spyte van toenemende teoretiese bewustheid van die voordele van antibiotiese bestuursprogramme, is geen sodanige program nog in ESwatini ingestel nie, en min omvattende studies het nog die effek daarvan in pediatriese omgewings wêreldwyd ondersoek. Die kennis, ingesteldheid en praktyke oor die gebruik van antibiotika en antibiotiese weerstandigheid is nog nie by die Raleigh Fitkin Memorial-hospitaal bepaal nie. ’n Agtien-maandelange enkelsentrum-prosesverbeteringstudie, bestaande uit ’n pre-intervensie-fase van ses maande, ’n voorbereidende periode van ses maande en ’n intervensie-fase van ses maande, is by die Raleigh Fitkin Memorial-hospitaal uitgevoer om die effektiwiteit van ’n multi-faset-intervensie vir die teenkamping van onvanpaste antibiotikagebruik en die verbetering van die bestuur van akute gastroënteritis en sy medemorbiditeite in kinders van jonger as vyf jaar, te evalueer. Die intervensie het die vestiging van ’n antibiotiese bestuursprogram en die implementering van kliniese riglyne vir die diagnose, behandeling en bestuur van akute gastroenteritis en sy geassosieerde medemorbiditeite ingesluit. ’n Totaal van 213 pasiënte is by die studie ingesluit, met 87 pasiënte in die pre-intervensie-fase 126 in die intervensie-fase. Die kennis, ingesteldheid en praktyke van professionele gesondheidsorgwerkers is ondersoek deur ’n opname voor en na die intervensie-fase uit te voer. ’n Verbetering in die gepastheid van antibiotikagebruik is waargeneem gedurende die intervensie-fase. ’n Afname in hospitaalverblyf, koste van antibiotika en sterftes is waargeneem. Gedurende die intervensie-fase is sterftes, was ernstige akute wanvoeding as medemorbiditeit van akute gastroenteritis teenwoordig was, terwyl verskillende oorsake vir sterftes gedurende die pre-intervensie-fase waargeneem is. Die meeste aanbevelings wat deur die antibiotiese bestuursprogram-span gemaak is, is aanvaar gedurende die intervensie-fase. ’n Verbetering in die kennis, ingesteldheid en praktyke oor die gebruik van antibiotika en antibiotiese weerstandigheid is waargeneem na die intervensie-fase. Die studie het gedemonstreer dat ’n antibiotiese bestuursprogram die gepastheid van antibiotika-gebruik in kinders kan verbeter, met beperkte klinies nadelige uitkomste. Kliniese riglyne speel ’n onontbeerlike rol om leiding aan voorskrywers te verskaf en om behandeling te harmoniseer. Antibiotiese bestuursprogramme kan professionele gesondheidswerkers se kennis, ingesteldheid en praktyke oor gepaste antibiotikagebruik verbeter en ’n afname in antibiotiese weerstandigheid tot gevolg hê

A web-based point prevalence survey of antimicrobial use and quality indicators at Raleigh Fitkin Memorial Hospital, Eswatini and the implications

Currently there is limited knowledge regarding antimicrobial utilization patterns among public hospitals in Eswatini. This is a concern given rising resistance rates among African countries. This study aimed to address this by determining antimicrobial utilization patterns using a point prevalence survey (PPS) methodology at Raleigh Fitkin Memorial (RFM) Hospital. The findings would be used to identify potential interventions to improve future antimicrobial utilization. A PPS was conducted using a web-based application (App). Antimicrobials were categorized according to the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) classification. Each ward in the hospital was surveyed in one day using patient files. All patients in the ward, admitted by 08h30 on the day of the survey, were included. Ethical clearance was granted by the university and Eswatini Ethics. Overall, 68 patient files in 12 wards were surveyed, with 88.2% (60/68) receiving at least one antimicrobial. The most widely prescribed antimicrobials were amoxicillin (24.5%), and ceftriaxone IV (21.6%), mostly from the Access group (69.9%), and zero from the Reserve group. In the past 90 days prior to admission, most patients (60.3%; 41/68) were not receiving any antimicrobials. Of concern was that antimicrobial use was empirical for all patients (100%) with mostly parenteral administration (88.3%; 91/103). In addition, the majority of surgical prophylaxis patients (80%; 12/15) were given an extended course post surgery. There was also no documented switch or stop dates, or patient culture and drug sensitivity results. Antimicrobial utilization is high at RFM hospital. Identified targets for quality improvement programs include encouraging earlier switching to oral antimicrobials, reducing extended use for surgical prophylaxis and encouraging greater sensitivity testing and documentation stop dates. The development of the App appreciably reduced data collection times and analysis, and would be recommended for use in other public hospitals

Review of Ongoing Activities and Challenges to Improve the Care of Patients With Type 2 Diabetes Across Africa and the Implications for the Future

Background: There has been an appreciable increase in the number of people in Africa with metabolic syndrome and Type 2 diabetes (T2DM) in recent years as a result of a number of factors. Factors include lifestyle changes, urbanisation, and the growing consumption of processed foods coupled with increasing levels of obesity. Currently there are 19 million adults in Africa with diabetes, mainly T2DM (95%), estimated to grow to 47 million people by 2045 unless controlled. This has a considerable impact on morbidity, mortality and costs in the region. There are a number of issues to address to reduce the impact of T2DM including improving detection rates and current access to services alongside addressing issues of adherence to prescribed medicines. There are also high rates of co-morbidities with infectious diseases such as HIV and tuberculosis in patients in Africa with T2DM that require attention. Objective: Document ongoing activities across Africa to improve the care of patients with T2DM especially around issues of identification, access, and adherence to changing lifestyles and prescribed medicines. In addition, discussing potential ways forward to improve the care of patients with T2DM based on ongoing activities and experiences including addressing key issues associated with co-morbidities with infectious diseases. Our Approach: Contextualise the findings from a wide range of publications including internet based publications of national approaches coupled with input from senior level government, academic and other professionals from across Africa to provide future guidance. Ongoing Activities: A number of African countries are actively instigating programmes to improve the care of patients with T2DM starting with improved diagnosis. This recognises the growing burden of non-communicable diseases across Africa, which has been neglected in the past. Planned activities include programmes to improve detection rates and address key issues with diet and lifestyle changes, alongside improving monitoring of care and activities to enhance adherence to prescribed medicines. In addition, addressing potential complexities involving diabetes patients with infectious disease co-morbidities. It is too early to fully assess the impact of such activities, Conclusion: There are a number of ongoing activities across Africa to improve the management of patients with diabetes including co-morbidities. However, more needs to be done considering the high and growing burden of T2DM in Africa. Ongoing research will help further benefit resource allocation and subsequent care

Fixed dose drug combinations - are they pharmacoeconomically sound? Findings and implications especially for lower- and middle-income countries

INTRODUCTION : There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability. AREAS COVERED : Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value. EXPERT COMMENTARY : FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country’s essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.https://www.tandfonline.com/loi/ierp20hj2020School of Health Systems and Public Health (SHSPH