This week is World Antibiotic Awareness Week and around the world there has been a focus on promoting both awareness of antimicrobial resistance and the need for antimicrobial stewardship, i.e. responsible usage by clinicians and patients alike. During this time, the KSLP infectious diseases team oversaw the launch of the University of Sierra Leone Teaching Hospitals Complex (USLTHC) Connaught Hospital Anti Microbial Guideline. This is the fruit of over a year’s work, drawing on expertise from a variety of local and international partners. We hope this will be a useful reference for junior doctors at Connaught Hospital, who requested guidelines like these to improve their ability in prescribing as they report not much formal teaching about prescribing in their undergraduate training. Following graduation, they bear huge levels of responsibility, especially as due to well documented human resource constraints, they can find themselves operating fairly independently very early in their careers.
Audit data from Connaught Hospital from March 2016 showed that 76% of medical admissions through the emergency department were prescribed antibiotics, and of those prescribed, 88% had an inappropriate dose, route or frequency. It is evident there was a clear need for simple guidance to help those who provide frontline medical services here with prescribing decisions around this crucial area, especially when it is known that the use of broad spectrum antibiotics (those that target a number of different types of bacteria) drives resistance. This guideline serves as the first formal promotion of antimicrobial stewardship in Sierra Leone but there is much more work to be done – firstly, in improving surveillance data. Without a robust laboratory service in the country, anti-microbial resistance goes largely unrecognised with an ‘out of sight, out of mind’ attitude. However, we know there is widespread, indiscriminate use of broad spectrum antibiotics (e.g ciprofloxacin and ceftriaxone) in the community, so it is unsurprising that worrying levels of resistance are starting to be seen with improved surveillance.
The guidelines were drafted by a committee of clinical and pharmacists from Connaught Hospital and KSLP, drawing on national and international guidelines, and local resistance data (where available). The draft was reviewed by stakeholders in Sierra Leone as well as KSLP technical advisors based in the UK, before being presented to the Drugs and Therapeutics Committee at Connaught Hospital. We know the guideline is not perfect, but we hope the recommendations are an improvement on the current practice. One major constraint is the lack of reliable local sensitivity data, and also data about what are the prevalent pathogens. Consideration was given not only to likely pathogens and resistance mechanisms, but also the affordability of drugs to patients – in the interests of best antimicrobial stewardship principles, we would like to always recommend the most narrow spectrum option available for any given condition, but from our experience in clinical practice, we know if this means going from a once daily administered drug to a four times a day administered drug, the price may quadruple, and become unaffordable.
Tests to confirm diagnosis, either pathological or radiological, are also expensive, and therefore a luxury the junior doctors often have to do without. For this reason, we have not emphasised the antibiotic review in this first edition of the guideline as this principle relies so much on good diagnostic support. This principle states that the antibiotics should be reviewed ideally at 48 hours to see if they can be stopped, changed or stepped down from IV to oral. We have encouraged oral step down, but if there is no additional information to confirm or refute an assumed diagnosis, it is difficult to advocate strongly the other courses of action. In addition, there is the recognition that counterfeit drugs are common in this part of the world, so it is easy to blame the drugs rather than the bugs if the patient is not improving. As a doctor, it is a disheartening environment in which to practice medicine, as you rarely get feedback on whether the right course of action was taken, making it difficult to learn and improve in the crucial early postgraduate stages of training.
It was decided to make use of the smartphone app format, making the resource easily accessible to junior doctors (who all have a smartphone, or perhaps even more than one) and reducing the risk of the documents deteriorating in quality over the years or indeed going missing altogether as we often see in the UK too! To achieve this, we worked with Essential Medical Guidance, based in South Africa, who agreed to host the content on their platform. We hope that using this format will allow changes to be made to content as surveillance data and knowledge evolves in Sierra Leone. We’re very grateful for their support in hosting the guidelines and adapting into the app format and are very proud of the outcome. If the implementation and dissemination is successful then we hope to develop similar guidelines for internal medicine and opportunistic infections which can also be hosted through the Essential Medicine Guidance platform.
So after many months of work, this week we finally launched the app, accompanied by a training session for junior doctors at Connaught Hospital to provide an introduction to antimicrobial resistance and stewardship as well as the functionality of the app. The initial feedback from Junior Doctors was very positive. This launch event also facilitated dialogue between senior clinicians and members of the Pharmacy Board of Sierra Leone, who are leading the delivery of the National Strategic Plan for Combating Antimicrobial Resistance.
Looking to the future, the next steps will be to promote use of the app during mentoring sessions with the junior doctors, complete another audit after implementation, and ultimately continue to develop the ongoing research capacity building projects which are essential to generate local resistance data and inform the next iteration of the guideline. It is also essential to recognise the importance of infection prevention and control (IPC) – with a reduced level of infections there will be less need for antibiotic use. During the launch of the guidelines, we took the opportunity to strengthen messages around IPC best practices, reminding doctors that IPC exists not only to protect the workforce from the patients, but vice versa as well. Ultimately, we hope that by developing a culture of antimicrobial stewardship in Connaught Hospital, it will be possible to reduce the emergence of antimicrobial resistant infections and consequently reduce avoidable deaths from hospital and community acquired infections.