Point prevalence surveys of acute infection presentation and antibiotic prescribing in selected primary healthcare facilities in North-West and Gauteng provinces of South Africa

Background
The effective management of infections is threatened by antimicrobial resistance (AMR), with an estimated 1.27 million deaths directly attributed to AMR in 2019. There are concerns with antibiotic prescribing in ambulatory care, particularly primary healthcare (PHC) level, and lack of adherence to prescribing guidelines in South Africa, driving AMR. Understanding current infection presentation rates and antibiotic prescribing patterns are needed to develop interventions to improve appropriate antibiotic prescribing in PHC facilities and check compliance with guidelines such as the WHO AWaRe Antibiotic Book. The Antibiotic Prescribing in Primary Healthcare Point Prevalence Surveys (APC-PPS) study is being undertaken globally as part of the ‘Antimicrobial resistance, prescribing and consumption Data to Inform country antibiotic guidance and Local Action’ (ADILA) project to inform this data gap.
Methods
In South Africa, the APC-PPS study is currently being conducted at four PHC clinics in the North-West province and three PHC clinics in Gauteng province. Two surveys are conducted at each facility over a two-week period (one set) and each set is repeated every 4-6 weeks for a total of four sets (eight surveys) over six months to capture any seasonal differences in infection burden or antibiotic prescribing. Each survey is conducted for half a day, representative of a standard clinic session. Data are collected electronically using Open Data Kit (ODK) Collect. For each survey, anonymous consultation data of all patients presenting with acute infection symptoms (present for <14 days) are collected including demographics, underlying conditions, presenting infection symptoms and antibiotic prescribing.
Results
As of April 2024, six surveys in North-West province and two surveys in Gauteng province have been completed with data for 615 patients were recorded. Overall, there were 304 males (49%) and 311 females (51%). The most common symptoms were genital discharge (n=134; 21.8%), painful urination (n=113; 18.4%), acute cough (n=109; 17.7%), sore throat (n=83; 13.5%) and skin swelling or pain (n=67; 10.9%); patients could have had more than one symptom. At least one antibiotic was prescribed for 87.0% of patients (n=533). More than half (53.4%; n=455) of antibiotics prescribed were Access antibiotics, 46.6% (n=397) were Watch antibiotics, and no Reserve antibiotics were prescribed. Ceftriaxone (n=182; 29.7%), amoxicillin (n=180; 29.4%), azithromycin (n=174; 28.4%) and metronidazole (n=170; 27.7%) were the most frequently prescribed antibiotics.
Conclusion
The preliminary results show very high rates of antibiotic prescribing in primary healthcare and high use of Watch antibiotics in this setting. This is a concern which warrants the need for antimicrobial stewardship programmes and further assessment of appropriateness of prescribing in ambulatory care. The study demonstrates the value of collecting infection and prescribing data based around the WHO AWaRe Antibiotic Book guidelines and will enable South Africa to evaluate its antimicrobial use.