Reflecting on 10 years of antibiotic stewardship

I spent the day yesterday teaching the 4th year Bachelor of Nursing Students at Stellenbosch University about Quality in Healthcare and Antibiotic Stewardship as part of their Global Health Systems module.

These will be the first nurse graduates from Stellenbosch University in more than a decade, and I couldn’t be prouder to have been given the opportunity to teach them about quality improvement and antimicrobial stewardship.

It may not be the best selfie on a timer, but it is still precious, and better than nothing! I know I’ll look back on this in 10 years’ time with an even broader smile!

18 months ago, my corporate office position was made redundant, and so my career has taken paths that I would not have anticipated pre-Covid! But walking these old paths anew has afforded me the benefit of reflecting on how things have improved – especially when it comes to antibiotic stewardship in the South African context. Time provides distance and perspective. 18 years ago, I walked the same academic hospital corridors and visited the same ICUs as I do now – back then, for clinical facilitation of postgraduate ICU nursing students, and now for these final year undergrads getting some exposure to specialised units. The infrastructure has not changed, but the antibiotic practices sure have (well, mostly!).

I left frontline critical care nursing 16 years ago, and I have also returned to the bedside in that role (one of my many roles!).

There are days (and nights) where it feels like very little has changed in the care of ICU patients – except for antibiotic prescribing practices!

It is humbling to see how diligently cultures are taken before antibiotic commencement; how antibiotics are de-escalated when culture results become available; how antibiotic days are counted and stopped on day 7 – the stuff of dreams merely a decade ago!

I am old enough to remember when it was standard practice for a patient to be on 4-5 antibiotics, and for no one to blink an eye! I remember when this study was published – it looked at antibiotic prescribing practices and their relationship to outcome in South African intensive care units and it was shocking! I remember when measures of inappropriate antibiotic utilisation were proposed (thank you @ABpreservation) and incorporated into an Antibiotic Stewardship Getting Started Kit and how the content of the Getting Started Kit seemed so radical!

Excerpt from the Best Care…Always! Antibiotic Stewardship Getting Started Kit (2011:16)

The Getting Started Kit (which was published in Jan 2011) described the application of quality improvement science to the problem of inappropriate antibiotic utilisation. Basic improvement concepts such as establishing an improvement team; setting an aim; establishing measurement; studying the system; and testing changes that might result in improvement. It didn’t feel that impressive, or that revolutionary at the time, but I have to say, that looking back on it now, I feel immense pride.

In the teaching session yesterday, we unpacked the SA Healthcare quality issues they see daily, and I must admit, that given the magnitude, even I dipped into moments of despondency; that was until I shared the story of the application of quality improvement science to establishing antibiotic stewardship. I hadn’t planned to go down memory lane – it just happened spontaneously as a way of creating hope and providing perspective.

I know there are still many units, and many hospitals where the antibiotic prescribing practices are not appropriate, but now, 10 years on, there are also many units and hospitals where antibiotic prescribing practices are sound and where patients don’t develop infections (and die) from multi-drug resistant organisms. And thank you to Antibiotic Stewards like @SouthAfricanASP who still keep fighting the good fight – I was thrilled to hear one of the student nurses retell a story where she had witnessed you furiously defending good antibiotic prescribing practices!

Healthcare is still far from perfect, but at least there are another 40+ soon-to-be Professional Nurses who have a sound and grounded understanding of quality improvement science and antibiotic stewardship. And given their passion, interest and enthusiasm, inappropriate use of antibiotics is less likely to slide on their watch!

Extended broad spectrum antibiotic cover (and the resultant implications) is not going to happen on these graduates’ watch!