Evaluating Localized Quality Indicators for Antimicrobial Stewardship in South African Primary HealthcareLocal adaptations improve tracking of antibiotic resistance in South Africa

Background/objectivesBacterial antimicrobial resistance represents a significant global public health challenge. Researchers from City St Georges, University of London, UK, developed global model sets of quality indicators, based on WHO AWaRe guidance, to improve future primary healthcare (PHC) prescribing. These were subsequently adapted to the PHC context in South Africa as an exemplar for developing countries. The study aimed to compare nationally adapted indicators in South Africa with global model indicators to improve future prescribing.MethodsComparative analysis of the two sets of quality indicators, developed using the same Research and Development/University of California Los Angeles (RAND/UCLA) Appropriateness Method (RAM). For the 62 overlapping indicators rated in the second round of the RAM for both sets, the median appropriateness and feasibility ratings, and the level of consensus, were compared. The contextual appropriateness, feasibility, and adaptation of the indicators across public PHC facilities in South Africa were assessed to identify factors that could affect implementation.ResultsOf the 62 overlapping indicators, only six (9.7%) were rephrased for the South African RAM to reflect local guidance. Fifty nine (95.2%) indicators were rated appropriate for the global RAM while all indicators (100%) were rated appropriate for South Africa. For the global RAM, 23 (37.1%) indicators were rated feasible while 60 (96.8%) indicators were rated feasible for South Africa. Seven (11.3%) indicators were rated both appropriate with agreement and feasible with agreement for the global RAM. Forty six (74.2%) indicators were rated both appropriate with agreement and feasible with agreement by the South African panelists, including seven indicators rated both appropriate and feasible by the global panel. The South African indicators adapted from the global set covered seven categories: respiratory tract infections, lower urinary tract infections, skin and soft tissue infections, diarrhea and enteric fever, bacterial eye infections, and dental infections, as well as general indicators.ConclusionsThe South African indicators for public PHCs facilities, adapted from the model global set, show that local adaptation is imperative to reflect differences in national treatment guidelines between countries, prescribing cultures, epidemiology and infectious disease burden. Ongoing barriers include a reliance on paper-based records and poor-quality routine healthcare data.