Antimicrobial Stewardship Practices in the Emergency Department of a South African Tertiary Institution: Patterns and Appropriateness of Antimicrobial Prescribing

Abstract

Antimicrobial resistance is a global health issue, exacerbated by the misuse and overuse of antimicrobials. Emergency departments are crucial settings for antimicrobial stewardship (AMS) efforts due to their high rate of antimicrobial prescribing and risk of misuse. There is a need to research antimicrobial prescribing in South African emergency departments due to insufficient data on appropriate prescribing rates in these settings. This study aimed to determine the patterns and appropriateness of antimicrobial prescribing by physicians in the emergency department of a tertiary public institution. A retrospective review was conducted for the period of August 2020 to July 2021 of patient medical records from the emergency department of a tertiary public academic hospital in South Africa. Patient medical records were reviewed and included if antimicrobials were prescribed or indicated based on the diagnosis. The Medicine Appropriateness Index (MAI) tool was used to evaluate these prescriptions’ appropriateness against the South African Standard Treatment Guidelines (STG), the South African Antibiotic Stewardship Programme (SAASP), and the South African Medicines Formulary (SAMF). Eight hundred and fifty (n=850) patient medical records were reviewed. Among the reviewed patient medical records with guideline-listed diagnoses only 9.6% (n=76/790) of antimicrobial therapies were fully appropriate according to the STG, 8.0% (n=33/415) according to the SAASP and 10.6% (n=43/407) according to the SAMF, as per the MAI tool. The most frequent reasons for inappropriate antimicrobial prescriptions included the choice of antimicrobial (STG: 61.3%; SAASP: 53.0%; SAMF: 53.0%), cost (STG: 51.0%; SAASP: 66.9%; SAMF: 65.3%), inappropriate duplication of spectrum of activity (STG: 63.1%; SAASP: 66.9%; SAMF: 65.3%), and the duration of treatment (STG: 32.5%; SAASP: 54.9%; SAMF: 43.1%). The conditions groups leading to the most emergency department visits and inappropriate antimicrobial prescriptions included skin and soft tissue (19.8%), trauma and injuries (19.2%), lower respiratory tract (15.7%), urinary tract (12.2%) and reproductive system conditions (11.2%). The most frequent antimicrobials prescribed were amoxicillin/clavulanic acid (54.7%), azithromycin (11.1%), metronidazole (6.8%), ceftriaxone (6.2%) and ciprofloxacin v (4.6%). The main reasons for the inappropriate prescribing of these common antimicrobials were the incorrect choice, duration, strength and frequency. The vast majority of antimicrobial prescriptions were inappropriate according to guidelines (STG: 90.4%; SAASP: 92%; SAMF: 89.4%) which highlights the urgent need to establish a functional AMS programme in this emergency department. Key elements contributing to inappropriate antimicrobial prescriptions (such as the choice, cost, spectrum duplication and treatment duration) could benefit from focused AMS interventions. Another area of focus would be to optimise the rational use of amoxicillin/clavulanic acid, given its high prevalence (89.0% of prescribed penicillins) and the frequent issues with inappropriate treatment selection and duration. Overall, these findings emphasise the pressing need for a comprehensive AMS programme to ensure a larger percentage of antimicrobials are prescribed appropriately and within guidelines.