Antibiotic Stewardship


Antibiotic stewardship is the responsible use of a critical and threatened health resource, namely the antimicrobial agents we depend on to prevent and treat infectious disease. Stewardship implies not only appropriate clinical decision-making for individual patients, but a population perspective that maximizes overall benefits, minimizes adverse events and costs, and, importantly, delays the onset of widespread microbial resistance to commonly used antibiotics.

Antibiotic stewardship is urgently needed because of rising rates of antimicrobial resistance, a limited manufacturing pipeline of new agents, and the morbidity burden and large costs associated with disease that is improperly treated. The misuse of antibiotics is an international problem. Infections with multi-drug resistant organisms kill about 25,000 people a year in Europe and around 19,000 in the United States. S African figures are not known but we do have the distinction of being a world leader in prevalence of gram-negative organisms with resistance (ESBL) to beta-lactam antibiotics.

Firstly, the Best Care…Always! campaign aims to raise awareness of antibiotic prescribing issues – highlighting both misuse, and appropriate use. Secondly it aims to test and implement a small set of defined interventions that measurably and positively impact the situation. Foremost among those interventions are ICU prescribing rounds, the development of tools that both document and assist prescribing decisions, including guidelines, and the development of a team approach that supports the prescriber.

Although the biggest infectious disease threats to our population, these epidemics are not currently the focus of the campaign or the antibiotic stewardship intervention. Clearly however, principles of good antimicrobial prescribing apply as much to TB and HIV/AIDS as to any other infectious disease.

This component of the campaign differs from the infection prevention interventions in that what works is not fully established. In that sense, this is both a research and an improvement initiative. Once we have learned what works, it can be spread to other sites.

No. The scientific evidence suggests that limiting choice to only a few antibiotics may be counterproductive and that diversity is important. On the other hand, many local and international experts believe it is time to change the rules of the game – “it may well be time now to challenge the right of doctors to prescribe whichever antibiotic they wish, including the dosage and duration” (G Richards, A Brink) and to guide clinicians towards optimal, evidence-based practice.

Antibiotic Prescribing Chart

It may be helpful to separate antimicrobial prescribing from the ordering of other pharmaceuticals. A separate order form for in-hospital use could contain suggestions or guidelines as well as serve as a data collection instrument.

The data we would be interested in includes:

 Indication for the drug (therapy or prophylaxis)

 Specimen taken

 Source of infection

 Condition that is being treated

It could also contain key information that would affect drug selection, dose and duration, such as allergies, kidney or liver impairment, and could contain visual flags for extended duration of therapy.

Antibiotic Prescribing Tool download

The BCA Antibiotic Stewardship Getting Started Kit

Change concepts, measurement and principles from three SA private hospital groups.

Antibiotic Stewardship Getting Started Guide download
Antibiotic Stewardship Maps download
Antibiotic Stewardship Proposed Care Bundle download
Antibiotic Patient Level Reporting Tool download

BCA Antibiotic Stewardship Measures

Empiric therapy without confirmation

Antibiotics without appropriate cultures

Inappropriate combinations

“Double coverage” i.e. concurrent antibiotics in any of these three groups:

Gram-negative cover (GNB)

  • Piperacillin/tazobactam
  • Cefepime
  • Imipenem
  • Meropenem
  • Ertapenem
  • Ciprofloxacin
  • Levofloxacin

Gram-positive cover (GPC)

  • Linezolid
  • Teicoplanin
  • Vancomycin

Anti-fungal cover

  • Amphotericin
  • Fluconazole
  • Voriconazole
  • Caspofungin

≥4 agents concurrently

Excessive duration of treatment

>7 days
>14 days

  • These are guidelines, based on South African susceptibility data, and this list is not exhaustive.
  • Occasional exceptions to the guidelines are to be expected but should be clinically justified.
  • These are not funding guidelines.

3rd and 4th generation Cephalosporins

Ceftriaxone may be appropriate prophylaxis for open reduction of a closed fracture

Extended spectrum penicillins

Pip-tazo is appropriate in theatre for bowel perforation cases but this does not constitute prophylaxis, as these patients will be treated for several days


Carbapenems are appropriate in theatre for bowel perforation cases but this does not constitute prophylaxis, as these patients will be treated for several days


Vancomycin is inappropriate with the exception of penicillin-allergic patients where you do not want to use clindamycin or failure of previous surgery involving prosthetic material due to MRSA sepsis




  • Dr Marthinus Senekal, Pathologist, Pathcare laboratories, Cape Town
  • Andriette van Jaarsveld, Clinical Pharmacist, MediClinic

Defined Daily Dosage (World Health Organisation)

Cost data do not by themselves adequately tell the story of antibiotic utilisation. Defined Daily Dosage is a World Health Organisation metric for drug utilisation. A DDD is the average maintenance dose of the drug when used for its major indication in adults. Improved understanding of antibiotic overuse (and underuse) is possible using DDDs.

DDDs are thus suitable for:

  • Comparisons of drug utilization
  • Evaluation of long term trends in drug use
  • Assessing the impact of certain events on drug use

In this DDD-NAPPI Crosswalk produced by Discovery Health (last updated November 2013) the DDD column contains the amount of drug in each NAPPI-coded product in relation to the WHO defined daily dosage for that drug. The crosswalk contains over 1200 antibiotic products.

This system provides a tool for assessing the impact of Best Care Always and of other attempts to reduce infection rates and improve prescribing of antimicrobials, in hospital and outpatient settings.

This list excludes topical antibiotics, anti-viral agents (e.g. ARVs) and anti-TB drugs. It includes anti-fungals.

No guarantees of accuracy or integrity are offered. Contribution to the QA process is welcomed.

Stewardship Drivers

These “secondary drivers” are derived from research done by IHI and CDC. Each objective could be accompanied by one or more measures, with appropriate tasks and workflow to achieve the objectives.

 Promptly identify patients who require antibiotics

 Obtain cultures prior to antibiotics

 Start treatment promptly

 Specify expected duration of therapy

 Make antibiotics and start date visible at point of care

 Consider local susceptibility before starting therapy

 Determine and verify antibiotic allergies – adjust accordingly 

 No antibiotic combinations without evidence 

 Right dose and interval

 Stop or de-escalate based on results of culture

 Adjust when transitions of care or changes in condition

 Monitor for toxicity

 Provide data on resistance, adverse drug events, C difficile, cost, adherence to recommended practice

 Make expertise available to doctors at point of care 

External guidelines and references