Guidelines on Implementation

of the
Antimicrobial Strategy in South Africa:
One Health Approach & Governance

June 2017

MINISTERIAL ADVISORY COMMITTEE ON ANTIMICROBIAL RESISTANCE

NATIONAL DEPARTMENT OF HEALTH AFFORDABLE MEDICINES DIRECTORATE

GUIDELINES ON IMPLEMENTATION OF THE ANTIMICROBIAL STRATEGY IN SOUTH AFRICA:
ONE HEALTH APPROACH & GOVERNANCE

JUNE 2017

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Table of Contents

Abbreviations and Acronyms 4

Definitions of Key Terms 5

Foreword and Introduction by the Director General of Health 7

Purpose of the Guide 8

How to use the guide 8

SECTION I – ONE HEALTH APPROACH 9

SECTION II: GOVERNANCE AT NATIONAL LEVEL 10

1. The Role of National Departments 10

2. Governance Structure at National level 10

2.1 Composition of the MAC-AMR 10

2.2 Role and function of MAC-AMR 11

3. Focal point for implementation at National level 12

4. Communication and reporting lines 12

SECTION III: GOVERNANCE AT PROVINCIAL LEVEL 13

Roles and responsibilities of the Provincial Departments 13

1. Ensuring accountability, leadership and Governance at Provincial Level 14

1.1 Formation and positioning of the PAMSC Governance Structure 14

1.2 Composition of the PAMSC 14

1.3 Responsibilities of the PAMSC 15

2. Communication and reporting lines 17

3. Conduct a situational analysis to determine baselines and priorities for AMR 17

3.1 Stakeholder mapping 18

3.2 Collection of retrospective data 18

3.3 Review key policies and legal frameworks 19

3.4 Prioritise AMR interventions 19

SECTION IV: GOVERNANCE AT DISTRICT HEALTH MANAGEMENT OFFICE LEVEL 20

Roles and responsibilities of District Health Management Office 20

1. Ensuring accountability, leadership and Governance at District Health Department Level 20

AMR Champions in the District 20

1.2 The District AMS Committee (DAMSC) 20

1.3 Responsibility of the District AMS committee 20

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SECTION V: GOVERNANCE AT HEALTH ESTABLISHMENT LEVEL 6
The Roles and responsibilities of health establishments 6

1. Ensuring accountability, leadership and governance at hospital level 6

1.1 Hospital Antimicrobial Stewardship Committee (HAMSC) 6

1.2 Positioning of the HAMSC 6

1.3 Composition 6

1.4 Responsibilities of the HAMSC 7

SECTION VI: MONITORING & EVALUATION AND REPORTING FOR THE IMPLEMENTATION
OF THE AMR PROGRAMME 24

Appendix A – Antibiotic consumption reporting 27

Appendix B - Priority specimens & pathogens for surveillance of AMR 30

Appendix C: Audit tool for AMS practices 32

Appendix D – IPC and AMS intervention definitions 33

Appendix E – IPC and AMR National Core Standards 35

Reference list 37

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Abbreviations and acronyms
BC Blood Culture
BSI Blood stream infection
AMR Antimicrobial Resistance
AMS Antimicrobial Stewardship
CA-UTI Catheter-Associated Urinary Tract Infections
CLABSI Central Line-associated Bloodstream Infection
CDDEP Center for Disease Dynamics, Economics and Policy
CEO Chief Executive Officer
CRE Carbapenem-Resistant Enterobacteriaceae
CLABSI Central Line-associated Bloodstream Infections
COO Chief Operating Officer
DAMSC District Antimicrobial Stewardship Committee
DBE Department of Basic Education
DCST District Clinical Specialist Team
DDD Defined Daily Doses
DEA Department of Environmental Affairs
DHEL Department of Higher Education & Learning
DTI Department of Trade and Industry
DHMO District Health Management Office
DST Department of Science and Technology
EDP Essential Drugs Programme
EML Essential Medicines List
EPI Expanded Programme on Immunisation
ESBL Extended Spectrum Beta-Lactamases
FIDSSA The Federation of Infectious Diseases Societies of Southern Africa.
GAP GAP Global Action Plan
GLASS Global Antimicrobial Resistance Surveillance System
HAI Healthcare-associated infection
HAMS Hospital Antimicrobial Stewardship Committee
IPC Infection Prevention and Control
IPCP Infection Prevention and Control Practitioner
LIS Laboratory Information System
MAC Ministerial Advisory Committee
MCH Maternal and Child Health
MDRO Multi-drug Resistant Organisms
NAP National Action Plan
NCS National Core Standards
NDOH National Department of Health
NEMLC National Essential Medicines List Committee
NHLS National Health Laboratory Service
NEMLC National Essential Medicines List Committee
NMC Notifiable Medical Conditions
OHSC Office of Health Standards Compliance
PAMSC Provincial Antimicrobial Stewardship Committee
PIPC Provincial Infection Prevention Committee
PPE Personal Protective Equipment
PTC Pharmaceutical & Therapeutics Committee
QA Quality Assurance
SAASP South African Antibiotic Stewardship Programme
SASCM South African Society for Clinical Microbiology
SSI Surgical Site Infection
STC Standard Treatment Guidelines
STG Standard Treatment Guidelines
TB Tuberculosis
VAP Ventilator-associated pneumonia

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Definitions of Key Terms
Antibiotic: Natural, semi-synthetic or synthetic substance which is derived from other microorganisms. It may be
bactericidal (kill bacteria) or bacteriostatic (inhibit bacterial growth). Classified into groups according to the mechanism
of action e.g. beta-lactams.

Antifungal: Natural, semi-synthetic or synthetic substance, which may be fungicidal (kill fungi) or fungistatic (inhibit
the growth of fungi) and are used to treat and prevent infections caused by fungi such as Candida, Pneumocystis and
Cryptococcus.

Antimicrobial: A substance that may be natural, semi-synthetic or synthetic, which can kill or inhibit the growth of
microorganisms. Includes antibiotics; antivirals; antifungals; antihelmithics; and antiprotozoals.

Antimicrobial Stewardship (AMS): is an individual or multi-disciplinary, systematic approach to optimising the

appropriate use of one or more antimicrobials to improve patient outcome and limit emergence of resistant pathogens
whilst ensuring patient safety.

Antimicrobial resistance (AMR): one or more changes occurring in a microorganism that renders an antimicrobial
used to treat or prevent it, ineffective. When a microorganism is rendered resistant to the majority (or all antimicrobials),
it is often referred to in the lay press as a ‘superbug’.

Biosecurity: Represents a set of preventative procedures and measures that are designed to protect a given population
(human or animal) against harmful biological organisms and products.

Catheter-Associated Urinary Tract Infection (CA-UTI): Urinary tract infection in a patient with an in-dwelling urinary
catheter (see detailed definition in annexure C).

Central Line-Associated Blood Stream Infections (CLABSI): Primary bloodstream infection occurring in a patient
with a central line (see detailed definition in annexure C).

Diagnostic stewardship: the coordinated intervention to improve and measure the appropriate use of
microbial diagnostics to identify pathogens and guide therapeutic decisions by promoting: appropriate
and timely selection and collection of specimens; accurate and timely testing; and reporting of results.
Infection prevention and control: A systematic approach to prevent infectious diseases and control their spread in the
community and to patients and healthcare workers in healthcare establishments. Establishments. Infection prevention
refers to measures, practices, protocols and procedures that are geared towards preventing the transmission of infection
within a healthcare setting. Infection control refers to the investigation and management of an outbreak, thereby
preventing further spread of infection within healthcare facilities.

Hang time – the time from prescription (be it hand written or as part of an electronic order) of an intravenous medication
(in this case an antimicrobial), to the time of infusion of said medicine.

Healthcare-associated infection: an infection that is acquired in a healthcare facility by a healthcare user, healthcare
worker or visitor to a health care facility. Such an infection should not have been clinically or radiologically apparent
at the time of admission or at the time of initial contact with the healthcare facility. The term includes infections that
appear after discharge, including any infection in a surgical site up to six weeks after the operation. Also included are
occupational infections among staff of the facility.

Healthcare provider: A person providing health services in terms of any law including in terms of the Allied Health
Professionals Act; Health Professions Act; Nursing Act; Pharmacy Act; Dental Technicians Act.

Health establishment: the whole or part of a public or private institution, facility, building or place, whether for profit or
not, that is operated or designed to provide treatment; diagnostic or therapeutic interventions; nursing; rehabilitative,
palliative, convalescent, preventative or other health services.

Health worker: any person who is involved in the provision of health services to a health care user, but does not include
a health care provider. Health workers include lay workers, administrative staff, cleaners and catering staff.

Hygiene: conditions and practices that help to maintain health and prevent the spread of diseases, for example
environmental cleaning; sterilisation of equipment; hand hygiene; water and sanitation; and safe disposal of waste.

Ministerial Advisory Committee on AMR (MAC-AMR): a multi-disciplinary, intersectoral committee mandated to

advise the Minister of Health on matters relating to Antimicrobial Resistance; to coordinate intersectoral efforts nationally;
provide advocacy and awareness; as well as monitoring and evaluation of the implementation of the AMR Strategy
Framework.

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One Health approach: an integrative effort of multiple disciplines and multiple government sectors and partners working
locally; nationally, and globally to attain optimal health for people, animals, and the environment.

Outbreak among animals: An outbreak among animals is characterised by the occurrence of a new infectious or parasitic
diseases in a group of animals, or its occurrence in a new setting.

Outbreak among humans: An outbreak is the occurrence of cases of disease in excess of that which would normally
be expected in a defined community, geographical area or season. An outbreak may occur in a restricted geographical
area, or may extend over several countries. It may last for a few days or weeks, or for several years.

In the context of AMR, an outbreak is often defined as the occurrence of multiple cases of infection with a specific
resistant microorganism, that is usually of the same strain, arising from a single (common) source or multiple sources.

Para-veterinarian is a person who renders services that supplement those deemed to pertain specifically to a veterinarian
including Animal Health Technicians; Laboratory Animal Technologists; Veterinary Nurses; Veterinary Technologists;
and Veterinary Physiotherapists.

Personal Protective Equipment (PPE): Items specifically used to protect healthcare personnel from exposure to body
substances or from droplet or airborne organisms. This includes, but is not limited to, gloves; aprons; gowns; caps; face
covers; and protective eye wear. Personal protective equipment for people handling animals refers to specific items
used to protect personnel working with animals from such hazards as allergens; infectious/zoonotic diseases; physical
hazards such as bites, noise, burns, chemical hazards;and to protect animals from the introduction of diseases from
humans.

Prescriber: Any person authorised to prescribe medicines in terms of the Medicines Act (Act 101 of 1965).

Surgical site infection (SSI): An infection that occurs after surgery at the site of incision or deep structures related to it

Surveillance is the systematic, longitudinal collection, analysis and interpretation of data, closely integrated with
timely dissemination of results to those who require them so that remedial action can be taken. The final phase in the
surveillance chain is application of the information to disease control and prevention. Appropriate surveillance of AMR
can be used to:

• Measure the burden of disease: to estimate the incidence rates of infections caused by resistant and non-
resistant pathogens;
• Monitor trends in infections caused by resistant and non-resistant pathogens as a basis for treatment guidelines;
• Identify high-risk areas for further interventions;
• Detect and monitor outbreaks and epidemics in order to mount appropriate responses;
• estimate the case-fatality rates from infections caused by resistant and non-resistant pathogens;
• Determine the effectiveness of control measures and;
• Provide data for research on transmission and the susceptibility of isolates to antimicrobial agents.
Veterinarian: any person who is registered in terms of the Veterinary and Para-veterinary Professions Act to practice the
profession of veterinarian.

Ventilator-Associated Pneumonia (VAP): A pneumonia in a patient who has been intubated and ventilated for at least 48
hours before onset of pneumonia.

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Foreword and introduction by the director general of health
South Africa pledged its commitment to the World Health Assembly resolution
EB134/37 “Combating antimicrobial resistance including antibiotic resistance”,
adopted in May 2014 to develop a National Action Plan (NAP) on antimicrobial
resistance (AMR). By October 2014 our Antimicrobial Resistance National
Strategic Framework, 2014-2024 (AMR Strategic Framework)1 was developed
and launched with the commitment of most of the key stakeholders within the
human and animal health; agriculture; as well as science and technology sectors;
to support interventions to combat antimicrobial resistance in the country.
The AMR Strategic Framework, defines South Africa’s approach to manage
AMR and limit further increases in resistant microbial infections, and improve
patient outcomes and livestock production and health. The vision is “to
ensure the appropriate use of antimicrobials by healthcare and animal health
professionals in all health establishments in South Africa to conserve the efficacy
of antimicrobials for the optimal management of infections in human and animal
health”.
As outlined in the Global Action Plan (GAP) of the World Health Organisation (WHO), Food and Agriculture Organisation
(FAO) and World Organisation for Animal Health (OIE) 2, the NAP must follow a “One Health” approach. Therefore
these guidelines seek to introduce the One Health approach firstly at a governance level, both at national and provincial
levels, by describing the interconnected, interdisciplinary, intergovernmental nature of the governance structures and
framework embedded within the AMR Strategy Framework for animals and humans. Future guidelines will address the
implementation of AMS interventions at health facility level.

The AMR Strategy Framework consists of five interconnected strategic objectives to tackle antimicrobial resistance
(AMR)(Figure 1)
Figure 1 - The South African AMR Strategy Framework with the strategic objectives and key enablers (Use this as a footnote
to the Figture)
1. Promote understanding and cooperation on AMR as a One
Health issue across human, animal, agricultural, veterinary
and environmental health sectors; and to strengthen,
coordinate and institutionalise inter- and multi-disciplinary
efforts through national, provincial, district and health
establishment level governance structures;
2. Foster the appropriate use of diagnostics to identify
pathogens and guide treatment by promoting appropriate
and timely selection and collection of specimens, accurate
and timely testing, accurate and timely reporting of results;
3. Optimise and report on surveillance of AMR in indicator
organisms from humans and livestock at local, district,
provincial and national levels; in order to provide reliable
resistance data at health establishment and farm level; and
to optimise empiric or targeted antibiotic choice.
4. To intensify infection prevention and control, biosecurity
and animal husbandry to prevent the spread of microbes to
patients and amongst animals respectively. To reinforce the
importance of vaccination programs in prevention;
5. Promote appropriate use of antimicrobials in humans and animals through antimicrobial stewardship.

Four strategic enablers, including legislation; education; communication; and research; support development of the
five objectives. These enablers are described in the ‘Implementation Plan for the Antimicrobial Resistance Strategy
Framework in South Africa: 2014-2019’ 3 (hereafter termed the ‘Implementation Plan’).
As we embark on this challenging journey to combat AMR, we continue learning from our successes and challenges,
and those of our collaborative partners in all sectors - human, animal, agriculture, environmental, public and private
sectors- as well as finance, science and technology, trade and industry and education. Working together we can change
direction to contain AMR and ensure that people have access to safe and effective antimicrobials. And to this end, we
are committed as the NDOH to driving these actions.

Ms Precious Matsoso
Director General: National Department of Health

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Purpose of the Guide

Guidelines on Implementation of Antimicrobial Stewardship in South Africa: One Health Approach & Governance
(hereafter termed AMS One Health & Governance Guide) is intended to act as a blueprint for the steps to be taken by
South African healthcare and veterinary workforce to enact AMS at national, provincial, district and health establishment
levels as appropriate, in line with the Strategic Framework and Implementation Plan. It aims to provide a practical, step-
by-step or ‘how to’ guide, addressing the governance framework at each level of the health system.

National guidelines for management of multi-drug-resistant tuberculosis and HIV are already the subjects of national
programs and updated regularly. Although this guide pertains to the stewardship of all antimicrobials, its focus will be
on stewardship of antibiotics used to treat bacterial infections other than tuberculosis, addressing the gaps relating to
antibiotic stewardship from an overarching, national perspective. As the approach to stewardship of antifungals shares
the same principles as that of antibiotics, the suggested interventions can be applied equally to antifungals.

How to use the guide

This guide is divided into six sections:

Section I focuses on the One Health approach towards tackling the AMR Strategic Framework and how this will be
effected through the intersectoral partnership between the National Departments of Health; Agriculture Forestry and
Fisheries (DAFF); and Environmental Affairs (DEA). Areas where potential synergies and collaboration between the
sectors may occur are highlighted.

Section II describes the national governance structure for AMR i.e., the MAC-AMR. It speaks to the interdisciplinary and
intergovernmental nature of this governance structure ensuring a national One Health response.

Section III discusses provincial governance structures including their responsibilities and actions in terms of conducting
a situational analysis on AMR to inform Provincial policy and implementation.

Section IV provides guidance to district health systems to incorporate the AMR interventions within existing structures
and programs such as the District Clinical Specialist Teams (DCST’s).

Section V provides guidance to health establishments, specifically hospitals, in establishing governance for AMR within
existing structures and includes the specific roles and responsibilities of these governance structures.

Section VI describes the Monitoring and Evaluation system for determining progress towards achievement of
Implementation Plan activities and sets out the necessary reporting imperatives and indicators.

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SECTION I – ONE HEALTH APPROACH

For the AMR Strategy Framework to achieve its intended outcomes, significant collaboration and coordination across
national departments and all three spheres of government is needed. According to the World Health Organisation’s
(WHO) Global Action Plan (GAP) for antimicrobial resistance (AMR) 5, tackling AMR requires a “One Health” approach –
“an integrative effort of multiple disciplines and multiple government sectors and partners working locally, nationally, and
globally to attain optimal health for people, animals, and the environment.” Together, the three make up the One Health
triad; the health of each being inextricably connected to that of the others.

In its most basic form, a description of One Health recognizes the relationships between human, animal and environmental
health, and applies inter- and multi-disciplinary tools to solve complex public health problems. Of the 1,461 diseases
now recognised in humans, approximately 60% are due to multi-host pathogens characterised by their movement
across species6. Over the last three decades, approximately 75% of new emerging human infectious diseases have
been zoonotic7 The One Health concept supports a position that the health of animals, humans and the environment are
interlinked, and that diseases that impact on all three must be solved through improved communication, cooperation,
and collaboration across disciplines and institutions. An example would be national surveillance efforts to improve the
country’s ability to track and monitor resistance across sectors. It could provide a single repository for surveillance data
and support integrated submission into the WHO Global Antibiotic Surveillance System (GLASS) database 8.

By signing the AMR Strategy Framework, the South African Veterinary Council, which regulates the veterinary and
para-veterinary professions; and the Department of Agriculture, Forestry and Fisheries (DAFF) have shown their
commitment to the control of AMR. The South African Veterinary Strategy (2016-2026) contains aspects critical to AMR
and appropriate antimicrobial use in animals and states as one of its short-term objectives (1-3 years) that it will clearly
define the interventions of state veterinary services to the AMR Strategy Framework and Implementation Plan to ensure
the One Health approach is followed.

Figure 2 - Antimicrobial Resistance as a One Health interconnected challenge.

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SECTION II: GOVERNANCE AT NATIONAL LEVEL

Governance at national level through the MAC-AMR provides strategic oversight. Structures within the provinces,
districts and health establishments (dealt with separately in subsequent sections) play a vital role in operational oversight
in support of national governance as shown in figure 4.

It is important to note that whilst these AMR guidelines focus on antibiotic and antifungal resistance, governance
structures already exist for other programs such as HIV, TB and malaria. Antibiotic resistance activities should be
incorporated wherever possible into existing governance structures with clear lines of communication and reporting.

1. The Role of National Departments

National Department of Health

The NDOH is primarily responsible for setting the AMR strategy, vision, mission and directing the country towards
a specific outcome. It is also the key stakeholder to ensure a “One Health” approach is followed for this strategy by
constituting the intersectoral governance structure.

Department of Agriculture, Forestry and Fisheries (DAFF)

DAFF is the key partner with the NDOH in ensuring a collaborative, integrated approach to animal and human AMR
interventions. It will promote surveillance in the agricultural sector specifically in livestock for AMR and align the AMR
Strategy Framework with the South African Veterinary Strategy and DAFF’s policy development.

Department of Environmental Affairs (DEA)

Another key partner alongside the NDOH and DAFF is the DEA, ensuring a One Health approach to management of
antimicrobials and AMR organisms in waste, water and the environment.

Department of Science & Technology (DST)

The DST will identify and fund AMR as a national health priority through its statutory funding agencies. In addition, the
DST will set up integrated platforms to support research into AMR and develop strategic partnerships with industry for
novel diagnostics and antimicrobials.

National Treasury
The National Treasury will earmark funding for activities of importance to AMR from a One Health approach within the
relevant national departmental budgets for AMR.

Department of Trade & Industry (DTI)

The DTI will support the implementation of this AMR Strategy by controlling and monitoringthe import of antimicrobials
for the pharmaceutical and agriculture sectors as well as the export and import of animal products to ensure the absence
of antibiotic residues and microbial contamination, particularly contamination by antibiotic resistant bacteria so that only
high quality products enter and leave the country.

Department of Basic Education (DBE)

The DBE will be key partners in developing programs to educate school children and, by extension, their parents on
appropriate hygiene, food safety, and antimicrobial use.

Department of Higher Education & Learning (DHEL)

Ensure that AMR knowledge forms part of the core curriculum and scopes of practice of relevant healthcare professionals
via the Higher Education Quality Committee of the Council for Higher Education in collaboration with the relevant
statutory Professional Councils.

2. Governance Structure at National level

The primary national governance structure for antimicrobial resistance is the MAC-AMR, a multi-disciplinary committee
within the NDOH, which includes intersectoral members from DAFF, DEA, DST, DTI, and DBE/DHEL working together
to optimise the national One Health response to AMR.

2.1 Composition of the MAC-AMR

The composition of the committee as per the Terms of Reference and the types of specialities are described below. The
MAC-AMR shall consist of not more than 25 core members and additional co-opted members to attend meetings as
their expertise is required.

The Committee may appoint, subject to the approval of the Minister, subcommittees as it may deem necessary, to
investigate and report to it any matter within the purview of the Committee in terms of the AMR Strategy Framework.

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Figure 3 - MAC composition
Representation from Regulatory bodies and Human and animal health Other
Government departments government institutions professionals
Core Members
Department of Health: Sector Wide National Health Laboratory Microbiologists/Pathologists (public Information systems or
Procurement Services sector and private sector) data warehouse specialist
(communicable diseases)
Department of Health: National Institute for Infectious Disease Specialist Epidemiologist
Communicable Diseases Communicable Disease
Representative of Agriculture, Infection Control Specialist Health Economist
Forestry and Fisheries
Representative of Science and Veterinarian
Technology
Representative of Department of Paediatrician specialised in Infectious
Higher Education & Learning Diseases
Hospital Pharmacist – (public sector
and private sector)
Community Pharmacist
District Pharmacist
Family Physician
Co-opted Members
Representative of Minister of Medicines Control Council HIV Drug resistance
Basic Education committee
Representative of Minister of South African Nurses Council TB Drug resistance
Trade and Industry committee
Representative of Minister of Health Professional Council of Malaria committee
Correctional Services South Africa
Representative of Military South African Pharmacy Council
Services
Representative of Department South African Veterinary Council
of Health: Hospital Services and
Health Workforce
Representative of Department of Civil Societies
Health: Primary Health Care

2.2 Role and function of MAC-AMR

The MAC-AMR will:
• Advise the minister on the appropriate approach for the country to improve antimicrobial use (focusing on
antibiotics) to reduce resistance in humans, animals and the environment;
• Set minimum standards of activities or interventions that are to be implemented by the institutions/health
establishments and determine the monitoring and evaluation system to track outcomes and impact;
• Advise the minister on appropriate communication messages for public awareness campaigns and health
science professional education strategies on AMR.

The MAC-AMR will effect the following work package:

I. The institutionalisation of effective systems of public and private sector stewardship at national, provincial and
institutional level, across the One-Health spectrum.
II. National structured surveillance and reporting systems for antimicrobial use and resistance in human and animal
sectors. This will include:
a. Surveillance of national antibiotic consumption using provincially reported data and antibiotic use data
from other sources including import and supplier data.
• An annual, national antimicrobial consumption point prevalence survey will be completed in sentinel
surveillance centres.
b. Surveillance of countrywide antibiotic resistance including public and private sector to document trends
in resistance for the essential ‘Bug-Drug’ combinations (Appendix A), directed by WHO GLASS, or those
organisms considered of importance or as part of the Notifiable Medical Conditions (NMC) regulations
by province. This will include:
• Updating and publication of the South African antibiotic resistance maps produced by the NHLS/
NICD and benchmarked internationally through collaboration with the CDDEP;
• Evaluation of the threat and communicating the epidemiological and clinical consequences of
new multi-drug resistant organisms (MDRO) introduced into South Africa to Provincial Heads of
Department and other key stakeholders as NMC.
III. Ensure access to appropriate antimicrobials and vaccines in the following areas:

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 a. Human health; provide recommendations to the National Essential Medicines List Committee (NEMLC)
for alterations to the Essential Medicines List (EML) in line with changes in antibiotic resistance levels
in the country based on surveillance data.
b. Animal health includes adopting the OIE List of Antimicrobial Agents of Veterinary Importance to enable
comparison with the WHO’s list of critically important classes of antimicrobials for humans. Overlap of
the lists will provide further information, allowing an appropriate balance to be struck between animal
health needs and public health considerations.
IV. Ensure access to appropriate diagnostic tests and national guidance on their appropriate use (diagnostic
stewardship).
V. Review progress towards achieving the implementation of these guidelines as well as compliance to the standards
for AMS and Infection Prevention and Control (IPC) within the NCS in all health establishments. Collaboration
will be sought with the Office of Health Standards Compliance (OHSC) to identify health establishments where
poor or inappropriate AMS and IPC practices are creating a risk for the safety of patients.
VI. Develop national antibiotic stewardship prescribing guidelines for South African prescribers, which are
harmonised to the EML and Standard Treatment Guidelines (STGs), providing algorithms for treatment of
common bacterial infections in adults and in children.
a. Regular review, of these guidelines to ensure that changes in national antibiotic resistance patterns are
reflected in the recommendations.
VII. National community advocacy, awareness and education campaigns to reduce inappropriate use of antibiotics
in human and animal health. This will include the development of public health messaging on good antibiotic
practices and conservation of the antibiotic resource, working with NDOH communications and the media. An
annual campaign for World Antibiotic Awareness Week will be developed.
VIII. The phased in, appropriate use of antimicrobials in animal husbandry and/or the optimal use of antimicrobials
critical to humans based on appropriate risk assessments and in line with the recommendations of the WHO
and OIE.
IX. Development and implementation of prevention strategies focusing on infection prevention and control and
enhanced vaccination programmes.
X. Development of core curricula on antibiotic resistance for health and veterinary professionals. This will include
oversight of National and Regional AMS training courses and training delivery process including the review of
implementation progress, changes to training materials, and directing priority geographic areas for training.
XI. Research into molecular mechanisms of resistance, dissemination of resistance, new drugs and diagnostics
including rapid and/or point-of-care diagnostics.

3. Focal point for implementation at National level

Currently the Affordable Medicines Directorate within the NDOH is the focal point for coordinating the implementation
of the AMR Strategy Framework. This aligns with this Directorate’s focus on rational medicine use. It also acts as the
Secretariat for the MAC-AMR and monitors the implementation efforts and status through meetings with the Provincial
Heads of Pharmaceutical Services on a quarterly basis.

4. Communication and reporting lines

The MAC-AMR will establish a communication framework to ensure that all issues related to AMR management are
communicated timeously and effectively to internal and external stakeholders.

Figure 4: Communication channel for Ministerial Advisory Committee on AMR

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SECTION III: GOVERNANCE AT PROVINCIAL LEVEL

Roles and responsibilities of the Provincial Departments

Provinces are responsible for taking the strategic objectives and standards set at National level and adapting them to
suit their operational model and existing health, operational and governance structures.

Responsibilities of the Provincial Department of Health include:

• Implementation and application of minimum standards for AMR and AMS;

• Rolling out of activities across districts and health establishments in order to meet these standards;
• Ensuring that budgets are set up to support the implementation of AMR activities;
• Providing the monitoring and evaluation functions to determine progress towards achieving the AMR actions
and activities whilst monitoring and supporting the institutions/health establishments to implement.

The Head of Health oversight role will mainly be focused on human health, although strong ties need to be developed
with the environment, sanitation and water departments as part of the National Development Plan in each province.

Responsibilities of the Provincial Veterinary Services include 1 :

• Strengthening and maintaining provincial veterinary laboratories to support appropriate use of antibiotics and
by implication food safety;
• Ensuring collaboration between Communicable Disease Control (CDC) at provincial level and with state
veterinarians at district level;
• Promoting disease prevention through optimal vaccination of animals against both viral and bacterial infections
to limit primary and secondary bacterial infections and the concomitant use of antibiotics;
• Setting safety standards for food of animal origin for local consumption at the same level as for international
consumers through a National Food Control Agency and residue and AMR testing through a residue monitoring
programme in collaboration with NDOH;
• Biosecurity, hygiene and cleanliness measures for farms.

Figure 5 - Steps in implementation of governance structures at provincial level

1 As articulated in the South African Veterinary Strategy (2016 – 2026); March 2016 DAFF

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 1. Ensuring accountability, leadership and Governance at Provincial Level
Governance of the Provincial AMR response sits with the Head of Department of Health and is facilitated through a
Provincial AMS Committee (PAMSC) or structure.

The role of the PAMSC is to provide oversight and coordination for provincial AMS activities, and to provide 6-monthly
progress reports to the MAC-AMR.

1.1 Formation and positioning of the PAMSC Governance Structure

The formation and position of the PAMSC within the provincial management structure is at the discretion of
the Provincial Head of Health; the PAMSC should form a stand-alone, independent committee with clearly
defined lines of communication between the Pharmaceutical and Therapeutics Committee (PTC), the Provincial
Infection Prevention Committee (PIPC), and the Quality Committees. A representative from PTC and IPC should
serve on the PAMSC to ensure communication channels between the committees.
It may be beneficial for the Provincial governance structures from the public sector to have representation within
the AMS committees from the Private Sector. This will allow the PAMSC to have an understanding of what is
happening within a city / region and not just what is happening within the public health facilities. Alternatively,
the private sector can be invited to attend the PAMSC on a regular basis to present their AMS activities and
surveillance information.

1.2 Composition of the PAMSC

Should include the following key members as the core team (i.e. minimum):
a. Infectious disease specialist or prescribing specialist clinician, and paediatric infectious disease specialist or
prescribing paediatrician;
b. Medical microbiologist;
c. Provincial head of Pharmaceutical Services;
d. Provincial head of IPC ;
e. Provincial head of Nursing;
f. Head of Procurement for medicines and medical supplies;
g. District health services representative or family physician working in the district
h. Provincial Director of Veterinary Services;
i. Environmental affairs representative (water and sanitation).

In provinces with additional resources the following additional members can be added:
a. Clinical Pharmacist;
b. Intensive Care Specialist;
c. Quality Improvement/Assurance practitioner;
d. Clinician representative from private sector;
j. Representation from Provincial Lab and Blood Services;
k. Representation from the Provincial EPI Programme;
e. Provincial Epidemiologist;
f. Quality Improvement/Assurance practitioner;
g. Provincial Data Manager.

Functions of the chairperson and members of the PAMSC

Ensuring that the PAMSC is functional requires all members and the chair to fulfil their functions adequately, attend
meetings as required, and provide the necessary input and advice needed. Therefore, guidance of the functions of these
individuals is defined here to ensure the chair and members are aware of their responsibilities.

The functions of the Chairperson:

• Articulating the goal of the committee and ensuring that the decisions and interventions determined by the
committee are in line with these goals, the policies of the province and the relevant National Drugs Policy and
AMR Strategy Framework;
• Foster an evidence-based culture for decisions and interventions whilst still encouraging the exploration of new
methods and ideas;
• To encourage a multidisciplinary approach to be taken to the decision and interventions of the committee and
ensure that each discipline’s views are sought when issues are identified or new goals and interventions are
designed;
• To support the involvement of veterinary health professionals and other co-opted members from different sectors
and ensure they are able to enhance the decisions of the committee through their inputs, views and knowledge;
• To ensure that all members follow the code of ethics, confidentiality and disclosure of interest procedures and
principles in their work within the committee.

14
The chair should be the highest ranking provincial manager under whose brief AMS falls.
The chair should garner respect in terms of decisions and their status in the health community, they should have the
authority to make decisions and act with integrity and should passionate about AMR.

The functions of the members

• Be conversant with the documentation pertaining to scheduled meetings, minutes of meetings and other reports
to ensure that discussions at the committee are fruitful and informed decisions are taken;
• Provide expert advice and knowledge when called for;
• Ensure that as representatives of their discipline or designation i.e. pharmacist or clinician, they represent the
views of that discipline and not only their specific role or function, institution, or organisation;
• Provide inputs as required in relation to the decisions, reports and documents developed by the committee; in
relation to interactions, presentations or communications with provincial staff in the institutions which will be
implementing the improvements.

Role of the Provincial AMR Champion

• Appointed by the HOD to guide the establishment of governance structures, provide secretariat support initially
and facilitate implementation of AMR activities within the province;
• Play a vital advocacy role throughout the province to gather support, buy-in, generate awareness and help
overcome barriers to implementation;
• Be an energetic, motivated individual who is passionate about AMS and who will drive its implementation with
enthusiasm and commitment;
• The province should ensure that this individual is given the authority and mandate to work freely within the
province, the necessary resources, training and budget to undertake the activities needed to implement and
drive improvement work going forward;
• Provide secretariat functions if required to the Committee by ensuring that the necessary information,
documents and reports are disseminated to all members; maintain records of meetings and decisions taken;
and communicate decisions to all members and other committees with which the PAMSC has close ties such
as the PTC, IPC and Quality committees.

The functions of the Secretariat

• Develop and maintain an annual schedule for the meetings;
• Convene and make all the necessary logistics arrangements for the meetings;
• Advise on administrative and regulatory matters;
• Compile and maintain minutes and other records of the meeting in consultation with the Chair;
• Coordinate and facilitate any research required for the committee to perform its functions;
• Compile relevant documents to be tabled at the Head of Department meetings communicating work of the
PAMSC;
• Maintain information regarding the performance of the committee.

1.3 Responsibilities of the PAMSC

Each PAMSC is responsible for the following set of activities:

I. Surveillance of AMR and antimicrobial use in the province – PAMSC must report to the Head of Department
and the MAC-AMR every 6 months on the following:
a. Antimicrobial (antibiotic and antifungal) consumption using data available from the Head of Pharmacy
(listed in Appendix A). The level of detail will vary depending on the source of data. Wherever possible,
consumption should be expressed in defined daily doses / 100 patient days (DDD/100 patient days)
for inpatients, to account for differences in bed occupancy and size of facilities. Volume of antibiotics
dispensed from the pharmacy or the amount of antibiotics ordered by the Hospital may be reported
if pharmacy-dispensing data is not available. Outpatient data can be reported as defined daily doses
without a denominator;
b. Antimicrobial (antibiotic and antifungal) resistance – utilising the reports from the NICD (pathologist-
microbiologist or epidemiologist) and private sector pathologist from designated laboratory groups.
Antibiotic resistance profiles must include the bug-drug combinations defined by WHO GLASS (listed
in Appendix B) with at least annual review with feedback of important trends to health establishments
and districts.
c. Outbreaks of MDRO (defined in the Health Act as an NMC using Category 3 reporting) in Provincial
institutions should be reviewed by the PAMSC, which should work closely with the provincial outbreak
response team and NICD/NMC team to control the outbreak.
d. Healthcare-Associated Infections (HAI) – reports from hospital-level AMS committees and from
the Provincial Infection Prevention and Control Practitioner (IPCP) detailing rates for Central Line-
Associated Bloodstream Infection (CLABSI), CA-UTI, surgical site infection (SSI), and Ventilator-
Associated Pneumonia (VAP) at tertiary and secondary level hospitals, each quarter. It is therefore very
important that the PAMSC has access to, and communicates with, the Provincial IPC Committee if it is
a separate committee;

15
 II. Provide guidance to the health establishments to support their development of AMS activities, and ensure
there is mentorship to these hospitals. This must occur in relation to these guidelines plus the NCS for health
establishments. The PAMSC should also support the rollout of, and compliance with, HAI control bundles9, at all
hospitals. This mentorship may be accomplished via provincial visiting teams, the DCST’s or through agreement
with partners with expertise in AMR supporting the health system in the province;
III. Monitor and track progress towards achievement of implementation activities and targets set against indicators
and Quality Improvement Programmes for AMR;
IV. Provide access to tools to support implementation of AMR activities including antimicrobial prescription
charts, EML, STGs and national antibiotic prescribing guidelines in all hospitals, and tools for monitoring AMS
implementation measures;
V. Assist in allocating funding and budgets for AMR within existing sources and monitor and account for budget
use for AMR interventions;
VI. Provide access to in-service training for clinicians, nurses, pharmacists and allied health care professionals in
the province in AMS and related IPC, through workshops at regional training centres (see below);
VII. Ensure collaboration between Communicable Disease Control (CDC) at provincial level and with state
veterinarians at district level to manage outbreaks and also to improve the use of antibiotics important in
humans following the One Health approach.

Figure 6 – Role and Responsibilities of the PAMSC

Surveillance

One Health
alignment with Guidance and
animal health mentorship for
and implemantation
environment

Role of
PASMC

Access to Monitor and

inservice training tracking
progress

Funding and
budget support

16
 2. Communication and reporting lines

The PAMSC shall establish a communication framework to ensure that all issues related to AMR management
are communicated timeously and effectively to internal stakeholders.

Figure 7 – Communication and reporting lines for PAMSC

Provincial HOD Health

- Provincial PTC Provincial

Provincial AMS Veterinary
- Provincial IPC services,
Commi ee
- Provincial Quality environment,
Commi ee water & sanita on
Departments

Possible to combine in one structure at

district level

District PTC District AMS Commi ee

Ins tu onal AMS forum

Ins tu onal PTC within exis ng hospital
Quality forums

3. Conduct a situational analysis to determine baselines and priorities for AMR

The purpose of a situation analysis is to provide an overview of current status of AMR and its drivers in the province. It
will help to underpin the provincial strategic vision and operational planning for AMR and will provide the basis for setting
priorities and implementation activities. It includes the following:

i. Stakeholder mapping: compiling a list of key stakeholders on AMR from human and animal health,
environment (Table 1);
ii. Collection of retrospective data - on antimicrobial use as per Appendix A and AMR for key organisms as per
Appendix B. Understanding the current capacity and structures for surveillance in health establishments, for
IPC and for similar biosecurity in animal health and environment to define the One Health approach for the
province;
iii. Reviewing key policies and legal frameworks - such as the provincial waste management and environmental
legislation and other legislation dealing with AMR;
iv. Prioritise AMR interventions – firstly define implementation interventions based on AMR status and key areas
of gaps and challenges and identify interventions with the most impact.

17
 3.1 Stakeholder mapping
Ensuring that AMR activities follow the One Health approach requires the relevant stakeholders within each sector to be
identified. It is also important to identify the expertise within each sector to cover AMS, IPC, education and other aspects
of support for AMR interventions. Categories of stakeholders to be identified are contained in Table 1.

Table 1 - Stakeholders at provincial level

Human health Animal Health Environment
DOH representatives in IPC, pharmacy, clinical DAFF Water
services, inspectorate, quality assurance Provincial veterinarian Sanitation
Public Health veterinarian, veterinary patholo- Housing
gists
Education institutions in the province Veterinary teaching institutions
Agricultural colleges
Public and private sector clinicians Public and private sector veterinarians
Veterinary public health experts

3.2 Collection of retrospective data

In order to define priority interventions for AMR in the province, it is critical to first understand what the current status
or situation of antimicrobial use and resistance is, what the IPC practices are, and where there are challenges in
implementation with respect to AMR. Data should be collected from existing sources to determine baselines and
interviews should be held with key stakeholders to identify the AMR status and interventions in place (Table 2).

Table 2 - Baseline information for situational analysis

Situational Analysis
Surveillance data Source Clinical care practices Source
AMR IPC against the NCS* & ICAT tool 9
Levels of resistant bacteria as per NHLS/NICD • Environmental cleaning practices IPCP
the WHO GLASS drug/bug combina- • Hand hygiene practices
tions in Annexure B, • Screening of patients
IPCP and health facilities • Isolation practices
Hospital acquired infection rates • Decolonisation practices

Immunisation coverage EPI and Districts

Antimicrobial use Governance structures
Antibiotic use as per Annexure Provincial Pharmacist/ Audit – governance structures in sample of
A, DDD’s calculation included in depot facilities
Appendix A AMR committees that are functional * Provincial Pharmacist/
IPC committees that are functional * Hospital CEO’s and
Provincial Pharmacist/ * functional = members appointed, TOR Clinical managers
Antimicrobial availability depot available, meetings held as per TOR,
% availability of antimicrobial in minutes of meetings with actions being
the facility over a period of a year addressed
defined as the proportion of all fixed Provincial Pharmacist/
clinics, that had stock-out of ANY AMR strategies in place Hospital CEO’s and
antimicrobial item for any period Formulary restrictions Clinical managers
Preauthorisation
Prospective audits with feedback
Multidisciplinary stewardship teams and
rounds
Trend analysis of use and resistance
IPC supplies AMS practices (audit tool in Appendix C)
Hand hygiene product availability IPCP and Inspectorate Culture taking prior to commencement of Baseline audits by
over a period of a year units antibiotics AMS Committee
PPE available over a period of one Documented indication for antibiotics
year Review of antibiotic with culture results
Cleaning products and cleaning Change in antibiotic – stopping/de-
equipment availability over a period escalation/substitution/addition of agents
of a year IV to oral switch
Decontamination & sterilisation of Duration of therapy
medical devices over a year;
Availability of single use devices,
such as ventilator tubing, over a 12
month period;
Functioning bedpan washer disinfec-
tors over a period of one year.
Key informant interviews with major
stakeholders to understand:
• Current AMR challenges
• Current AMR interventions and
activities
‘* NCS – see Appendix E

18
 3.3 Review key policies and legal frameworks
This includes reviewing existing provincial legislation such as provincial waste management and environmental
legislation; policies on essential medicines lists and formularies; performance management; and scope of work
policies to ensure that AMR activities become embedded within the daily activities of all staff.

3.4 Prioritise AMR interventions

The baseline data collected above will help the province identify areas of concern where AMR interventions are required.
It is important to define a goal for the AMR program. This goal will guide the interventions and allow tracking of
improvements in AMS activities. It also becomes a source of accountability for the PAMSC and a motivator for an
acceleration of change in behaviours.
In the vast majority of cases this would be to reduce antimicrobial use in facilities in the province. The quantum and
period over which this reduction will occur will need to be determined by the PAMSC in consultation with the facilities
and other stakeholders.
An initial set of interventions should then be chosen that will improve appropriate use. These two or three interventions
should be easy to implement, with minimal changes to normal process and have the biggest impact as the priority
interventions in each health establishment. Examples of these interventions include 10-22 with definitions in the Appendix D :

Table 3 - AMR interventions

Intervention options
IPC AMS
1. Hand hygiene compliance 1. Formulary restrictions based on AMR and antimicrobial use
2. Improved environmental cleaning practice in 2. Pre-authorisation
public areas and clinical areas 3. Multidisciplinary stewardship teams and rounds
3. Isolation room terminal cleaning practices 4. Prospective audits with feedback to prescribers, study, act on the following
4. Screening of patients at high risk indicators:
5. Isolation of infected patients • Culture taking prior to commencement of antibiotics;
6. Decolonisation • Empiric treatment against STG’s
7. Functioning bedpan washer disinfector in • Documented indication for antibiotics;
clinical areas • Review of antibiotic with culture results;
8. Single patient use ventilator tubing in intensive • Change in antibiotic – stopping / de-escalation / substitution / addition of
care areas agents;
9. Appropriate decontamination and sterilisation • IV to oral switch;
reprocessing of medical devices. (WHO: • Batching of intravenous antimicrobials;
Decontamination and Reprocessing of Medical • Duration of therapy monitoring and intervention;
Devices for Healthcare Facilities, Sept 2016) • Hang time;
• Surgical prophylaxis choice and duration of therapy.
Administration of antibiotics
• Correct dose
• Correct duration
• Correct frequency
• Correctly documented

The basic definitions for each of these interventions are provided in the Appendix D and will be described in detail in the
implementation guidelines which are to follow.

These prioritised interventions and actions need to be reflected within the AMR Implementation Plan for the province
and will be monitored against the M&E framework in Section VI.

19
SECTION IV: GOVERNANCE AT DISTRICT HEALTH MANAGEMENT OFFICE LEVEL

Roles and responsibilities of District Health Management Office

The District Health Management Office (DHMO) and its associated sub-District management structures are primarily
responsible for the coordination and planning of health services in the associated district hospital, community and
primary healthcare clinics within that district and sub-district. Much emphasis is being placed on ensuring that health
services are delivered in a holistic and integrated fashion, removing silo-based care, which is programme driven,
towards the Integrated Chronic Disease Management approach. AMR activities are evidence-based; driven by protocol
and standard treatment guidelines;;, with the nurse and primary care doctors being the main drivers of prescribing and
use. Districts are at the forefront of the community and therefore will have an even larger responsibility for public health
awareness and education activities, targeting the specific behaviours of concern for AMR in each community.

The DHMO also collaborates and works closely with other governmental sectors such as water and sanitation;
environmental services; and waste management services at municipalities and these departments are integral to the
One Health approach of AMR especially at this community level and formalised through the Integrated and District
Development Plans.

1. Ensuring accountability, leadership and Governance at District Health Department Level

As AMR requires a multidisciplinary approach, it will initially draw on the various clinical and non- clinical areas of
expertise within the existing DHMO and sub-District structures to fulfil the roles as defined below. The AMR function has
not been placed within a single individual’s role to fulfil. Rather the focus is on starting with a core group of individuals
within a District AMS Committee (DAMSC) who are supported to provide these activities in the district under the guidance
of the existing management structures and committees and through the advocacy role of the AMR Champions.

1.1 AMR Champions in the District

The AMR Champions should be appointed by the District Manager to guide the establishment of AMR management
structures, provide secretariat support initially and facilitate implementation of AMR activities within the district and its
health facilities. This role should be fulfilled by the Manager of Pharmaceutical Services and the family Physician within
the DCST’s.

Their role will be as advocates for AMR activities throughout the district: to gather support; generate buy- in, raise
awareness and help overcome barriers to implementation of activities to combat AMR. They should be energetic,
motivated individuals who are passionate about AMS and who will drive its implementation with enthusiasm and
commitment. The DHMO should ensure that these individuals are given the authority and mandate to work freely within
the district, the necessary resources, training and budget to undertake the activities needed to implement and drive
improvement work going forward.

They will also function to provide a secretariat role if required to the DAMSC by ensuring that the necessary information,
documents and reports are disseminated to all members, maintain records of meetings and decisions taken and
communicate decisions to all members and other committees with which the DAMSC has close ties such as the District
PTC and other management committees of the District Manager’s office.

1.2 The District AMS Committee (DAMSC)

The DAMSC should be constituted out of 5 core individuals/roles:

i. Family practitioner from the District Clinical Specialist Team;

ii. Manager Pharmaceutical Services;
iii. Manager Clinical Support Services, Coordination and Quality Management;
iv. General practitioner from the community;
v. Sub District manager.
The role of AMR should fall directly within each one of these individuals’ job descriptions which will happen over time. In
additional to the following members may from time to time also be involved with the work of the DAMSC:

i. Health Programme Coordinators – HIV/TB, MCH etc.

i. Infection control professional;
ii. Quality assurance;
iii. NHLS;
iv. Procurement manager;
v. Human Resource Development manager;
vi. Environmental health/Public health managers from other departments such as Water Affairs,
Sanitation, Waste Management and Veterinary services.

20
The DAMSC may also want to request the expertise of the microbiologist from the local NHLS lab, or specialists such as
paediatricians or infectious diseases specialists from nearby academic/tertiary or regional hospital as outreach.

The DAMSC will communicate and report to the District Manager and the relevant management structures as per that
specific district relevant to AMR as well as the district PTC and the provincial AMR structures (Figure 4).

1.3 Responsibility of the District AMS committee

I. Surveillance of AMR and antimicrobial use in the district – The DAMSC must report to the District Manager, the
PAMSC and the MAC-AMR biannually on the following:

a. Antibiotic and antifungal consumption using data available from the District Pharmacist as per Appendix
A;
b. Antibiotic resistance data for the District Hospital– utilising the reports from the NICD (microbiologist
or epidemiologist) and private sector labs. Antibiotic resistance profiles must include the bug-drug
combinations defined in Appendix B with at least annual review with feedback of important trends to
health establishments and districts;
c. Outbreaks of notifiable medical conditions;
d. Healthcare-associated infections (HAI) – reports from clinics of surgical site infection (SSI).
II. Provide guidance and awareness education to the clinics and community general practitioners on the importance
of appropriate antibiotic use. To support this, the DCST’s should include a prescription chart review during their
facility visits to monitor the following:

a. Compliance with the STG’s for infectious conditions – correct drug for condition, dose, and frequency;
b. Practically assess whether nurse prescribers are diagnosing bacterial infections appropriately and
following the correct protocols for treatment as part of the Integrated Chronic Disease Management
approach.
III. Monitor and track progress towards achievement of implementation activities and targets set against indicators
and Quality Improvement Programmes for AMR.
IV. Provide access to tools to support implementation of AMR activities including antimicrobial prescription charts,
EMLs, STGs and national antibiotic prescribing guidelines in all clinics.
V. Provide input into funding needs and budgets for AMR activities.
VI. Provide access to in-service training for general practitioners, nurses, pharmacists and allied health care
professionals in the district in antibiotic stewardship and related infection prevention control, through workshops
at regional training centres (see below).
VII. Ensure a link to the intersectoral environmental, veterinary and public health and the local municipalities on
AMR issues following the One Health approach. This will include providing yearly inputs into the planning and
execution of AMR activities as part of the greater District Health Plans and Integrated Health Plans.

21
SECTION V: GOVERNANCE AT HEALTH ESTABLISHMENT LEVEL

The Roles and responsibilities of health establishments

Health establishments are the fundamental drivers of the activities that will impact on AMR. They will need to identify
how the proposed management structures will fit into already existing oversight structures, how they can adapt their
operational processes to improve management of AMR and how they can strengthen already existing programmes
such as IPC and the Expanded Programme on Immunisation (EPI) to support the objectives of reducing the burden of
infections and preventing the spread thereof. They also have a fundamental role in educating the patients, caregivers,
community, healthcare providers and health workers to change their behaviours to prevent infections, prevent their
spread and ensure the appropriate use of antimicrobials.

1. Ensuring accountability, leadership and governance at hospital level

1.1 Hospital Antimicrobial Stewardship Committee (HAMSC)
The role of the HAMSC is to provide oversight and coordination for AMS activities at the institution, including the
activities of the Hospital’s AMS team(s), and to provide 6-monthly progress reports to the PAMSC.

1.2 Positioning of the HAMSC

The position of the HAMSC within the hospital management structures is at the discretion of the CEO. The HAMSC
may either form a stand-alone committee or be incorporated into the agenda of either the hospital’s IPC or another
clinical committee. If AMS is positioned within an already existing committee, AMS activities defined below must be
included in the agenda of that committee as standing items. There must be clearly defined lines of communication and
feedback provided between the HAMSC and other relevant hospital committees, heads of nursing, pharmacy, quality
improvement, other relevant heads of departments, as well as with the PAMSC.

1.3 Composition
It is critical that the highest-ranking member of each component of the AMS response represents the hospital on the
HAMSC. This is to ensure translation of policy into action, and is especially important in choosing the most senior level
administrator.

The committee should consist of the following core members:

a. Chair should be the CEO or highest ranking management representative of the hospital;
b. Senior physician of the hospital;
c. Head of Pharmacy Services of the hospital;
d. Infection Prevention & Control Practitioner of the hospital;
e. Head of Nursing – or highest ranking nurse manager, under whose brief AMS falls;
f. Medical Microbiologist - where not available, either the most experienced member of the National Health
Laboratory Service that services the hospital, OR a seconded microbiologist from another NHLS or private
laboratory.

Additional members who can be included, depending on the size of institution and their access to resources, include:

a. Other clinicians representing each clinical department of the hospital or as a minimum the key departments
consuming the most antibiotics – e.g., ICU, surgery, emergency medicine, gynaecology and/or obstetrics;
b. Adult Infectious Diseases Specialist (where not available, a prescribing specialist clinician, family practitioner or
equivalent with experience in AMS);
c. Paediatric Infectious Diseases Specialist if the hospital is a specialist paediatric hospital or has joint adult and
paediatric services. Where a paediatric Infectious Diseases specialist is not available, a prescribing specialist
paediatrician with experience in AMS or similar at the level of family practitioner or equivalent should substitute;
d. Quality Improvement/Assurance practitioner;
e. Ward pharmacist or any pharmacist trained in AMS.

22
 1.4 Responsibilities of the HAMSC

I. Surveillance – HAMSC must monitor and report on:

a. Antimicrobial usage data from pharmacy – ideally data from each hospital department should be
presented in Defined Daily Doses per hundred patient days (DDD/100 patient days) for ward patients
and as DDD for emergency unit and outpatients. However, the institutions should look at the data
available and work with existing data constraints moving towards the ideal. The list of antibiotics for
reporting will depend on the level of that facility in terms of the EML (Appendix A);
b. Local antibiotic resistance profile data of microorganisms in each facility collected from the local
NHLS laboratory, some facilities refer to regional referral laboratory for processing and reports would
be available at regional level. Hospital-wide bug-drug combinations as defined in Appendix B should
be reviewed and reported annually to the PAMSC. Resistance profiles should also be fed back to all
clinicians in the hospital on a 6 monthly basis and presented as part of the quality committee agenda
to the management staff;
c. Outbreaks of MDRO in the hospital should be reviewed by the HAMSC, which should work with the
hospital’s IPC team, the provincial outbreak response team, and NICD (when necessary) to control
the outbreak according to the Health Act;
d. Hospital-acquired infections – institutions must phase in the monitoring of rates for the number of
CLABSI, CA-UTI, and SSI and/or VAP (if surgery and/or ICU services are provided at the hospital).
Number of C. difficile infections per hospital should also be reported. 12-monthly data should be
reported to the PAMSC. The IPCP plays a critical role in providing this information, along with the
microbiologist or laboratory staff in the hospital;
e. Volume of infection-related laboratory investigations (blood cultures, CRP, PCT, white blood cell
count) from NHLS laboratories servicing the hospital;
II. Follow up with existing IPC structures are that all clinical areas follow standard precautions and appropriate
additional (transmission-based) precautions as required to reduce the risk of transfer of contagious and resistant
pathogens to patients and staff. Supervise terminal cleaning of isolation facilities after patient discharge;
III. Coordinate the activities of the hospital’s antibiotic stewardship team/s. Identify clinical units in need of support;
IV. Ensure that regular feedback is given to all prescribers on the status of AMR interventions and surveillance
information as part of ongoing feedback and awareness. Consideration should be given to reporting systems
for prescribers who consistently do not follow protocols and guidelines and should be dealt with through the
HAMSC and the Management of the hospital;
V. Provide regular in-service training in AMS and IPC for clinicians, nurses, and allied health care professionals,
through access to antibiotic stewardship ward rounds, web-based training materials and workshops at regional
training centres;
VI. Coordinate and publicise the hospital’s participation in awareness days related to AMS/IPC i.e., World Hand
Hygiene day (5th May), Infection Control Week (September), Pharmacy Month (September), and World
Antibiotics Awareness Week (November).

23
SECTION VI: Monitoring & Evaluation and Reporting for the implementation of the AMR programme

Monitoring and Evaluation (M&E) aims to assess the extent to which the desired strategic objectives of the AMR Strategic
Framework have been achieved.

In the Implementation Plan, an indicator for each strategic objective has been set out in addition to short-, medium-, and
long-term targets for the strategy period. This includes the overarching impact indicators, which seek to evaluate the
impact of the AMR strategy for specific organisms and in specific clinical circumstances.

National M&E indicators have been set out within the Implementation Plan and will be monitored by the MAC-AMR to
assess the extent to which the desired objectives of the Strategic Framework have been achieved across the country.

M&E indicators are being defined in terms of operational implementation and governance of the AMR framework within
the health establishments. These M&E indicators have been divided into their input, process, output or outcome/impact15:

• Input indicators talk to the establishment of the systems of governance at the various levels of the health system;
• Process indicators measure the implementation of standards or care and AMS/ IPC guidelines either within this
guideline document or within the NCS;
• Output indicators measure how the activities have changed the resistance patterns of AMR organisms and also
influenced the consumption of antimicrobials;
• Outcome/impact indicators attempt to determine whether the program has had any impact on the mortality of
mothers and infants in relation to infectious diseases.

24
 Table 4 - M&E indicators by level of health system
Level of Health establishment District Province National Measure unit Frequency Numerator Denominator
reporting - hospital of
Category of reporting
indicator
Input AMS % of health establishment % of health establishment % of health establishment with % of health biannual # of health Total # of health
governance with functional * AMS gov- with functional * AMS gov- functional * AMS governance establishment establishment establishment in
structures ernance structures ernance structures structures district/ province/
country
IPCP Appointment of an % of health establishment % of health establishment % of health establishment with % of health annual # of health Total # of health
IPCP – yes or no or in (hospitals)? with one or with one or more IPCP one or more IPCP establishment establishment establishment in
progress more IPCP with 1 or more district/ province/
IPCP country
Ratio of formally Ratio of IPCP to acute care Ratio of 1 IPCP per 4-5 National IPC coordinator and annual # IPCP # acute care
trained IPCP to beds 1:250 CHCs/ Clinics department of IPC functional beds in health
acute care beds= establishment
1:250 (WHO: core
components)
IPC cleaning Availability of cleaning Availability of cleaning Availability of cleaning Availability of cleaning supplies % availability quarterly # of all fixed Total # of health
supplies supplies and equip- supplies and equipment as supplies and equipment as and equipment as per NCS list clinics, that establishment in
ment as per NCS list per non NCS list per NCS list had stock-out district/ province/
of ANY clean- country
ing supplies
item for any
period

25
EML - Availability of Essential Availability of Essential anti- Availability of Essential Availability of Essential anti- % availability quarterly # of all fixed Total # of health
antibiotics antibiotics as per EML biotics as per EML in health antibiotics as per EML in biotics as per EML in health clinics, that establishment in
establishments health establishments establishments had stock- district/ province/
out of ANY country
antimicrobial
item for any
period
Process Compliance % compliance with % of health establishment % of health establishment % of health establishment com- % of health annual Score from Total possible
with AMS AMS NCS standards compliant (75% score) with compliant with AMS NCS pliant with AMS NCS standards establishment AMS mea- score for AMS
NCS on last inspection AMS NCS standards standards sures in NCS measures in NCS
standards
Compliance % compliance with IPC % of health establishment % of health establishment % of health establishment com- % of health annual Score from Total possible
with IPC NCS standards on last compliant with IPC NCS compliant with IPC NCS pliant with IPC NCS standards establishment IPC measures score for IPC
NCS inspection standards standards in NCS measures in NCS
standards
Improvement % compliance to pro- % compliance to process % compliance to process % of health quarterly Number of Total number
in AMS cess measures % compliance to process measures measures establishment compliant of process
process measures process mea- measures
measures sures
– based on
intervention
 Level of Health establishment District Province National Measure unit Frequency Numerator Denominator
reporting - hospital of
Category of reporting
indicator
Output AMR % non susceptible for % non susceptible for or- % non susceptible for % non susceptible for % non Annual # of organism Total number
organisms in Annexure ganisms in Annexure B organisms in Annexure B organisms in Annexure B susceptible non of cases of
B Plus Plus Plus organisms susceptible organisms
Plus • % 3rd Generation • % 3rd Generation • % 3rd Generation cultured
• % 3rd Generation cephalosporin non cephalosporin non cephalosporin non
cephalosporin non susceptible Kleb susceptible Kleb susceptible Kleb Pneumonia
susceptible Kleb Pneumonia Pneumonia • % carbapenem non
Pneumonia • % carbapenem non • % carbapenem non susceptible Kleb Pneumonia
• % carbapenem non susceptible Kleb susceptible Kleb • % MRSA
susceptible Kleb Pneumonia Pneumonia • % 3rd Generation
Pneumonia • % MRSA • % MRSA cephalosporin non
• % MRSA • % 3rd Generation • % 3rd Generation susceptible E Coli
• % 3rd Generation cephalosporin non cephalosporin non • % quinolone non susceptible
cephalosporin non susceptible E Coli susceptible E Coli Ecoli
susceptible E Coli • % quinolone non • % quinolone non
• % quinolone non susceptible Ecoli susceptible Ecoli
susceptible Ecoli
AMR animal % AMR in key organisms % AMR in key organisms blood % non Annual # of organism Total number
health blood cultures only) cultures only) susceptible non of cases of
• % 3rd Generation • % 3rd Generation organisms susceptible organisms
cephalosporin resistant cephalosporin resistant cultured
E Coli , Salmonella spp, E Coli , Salmonella spp,

26
shigella spp. shigella spp.
• % quinolone resistance • % quinolone resistance
amongst Ecoli, amongst Ecoli, Salmonella
Salmonella spp, shigella spp, shigella spp.
spp.
Antimicrobial Ratio broad to narrow Ratio broad to narrow spec- Ratio broad to narrow Ratio broad to narrow spectrum Ratio annual J01 CA J01 CE- CR
Consumption spectrum antibiotics: trum antibiotics spectrum antibiotics antibiotics
– human and J01CA + J01CR and J01CA + J01CR and narrow J01CA + J01CR and J01CA + J01CR and narrow
animal narrow spectrum spectrum J01CE + J01CF narrow spectrum J01CE + spectrum J01CE + J01CF
J01CE + J01CF J01CF
Ratio of IV to Oral for NA NA NA Ratio annual/
the following: trend
ciprofloxacin; co-amox- analysis
iclav; ampicillin/amoxi-
cillin, cloxacillin
Consumption of all Consumption of all JO1 Consumption of all JO1 Consumption of all JO1 Consumption of annual/ Inhabitants in
JO1 antibacterials, antibacterials, and specific antibacterials, and specific antibacterials, and specific all JO1 antibacte- trend Consumption province x 1000
and specific ATC ATC antibacterials such as ATC antibacterials such as ATC antibacterials such as rials, and specific analysis in DDD’s or
antibacterials such carbapanems, vancomycin, carbapanems, vancomycin, carbapanems, vancomycin, ATC antibac- for each patient days for
as carbapanems, 3rd gen cephalosporins, 3rd gen cephalosporins, 3rd gen cephalosporins, terials such as antimicrobial hospital x 100
vancomycin, 3rd fluoroquinolones, fluoroquinolones, fluoroquinolones, macrolides in carbapanems,
gen cephalosporins, macrolides in DDD’s per macrolides in DDD’s per DDD’s per 1000 inhabitants vancomycin, 3rd
fluoroquinolones, 1000 inhabitants for clinics 1000 inhabitants gen cephalospo-
macrolides in DDD’s And rins, fluoroquino-
per 100 bed days In DDD’s per 100 bed days lones, macrolides
for district hospitals in DDD’s per
1000 inhabitants
‘*functional means the structure is set up, has a TOR and meets as per the frequency in the TOR
‘# process measures to be determined as part of the implementation process within provinces
Appendix A – Antibiotic consumption reporting
• Reporting of antibiotics consumption

Data from all central, secondary level, and high throughput district level hospitals should be presented in defined daily
doses (DDD) per hundred patient days (DDD/100 patient days).  The consumption data should be informed by the ABC
analysis per antibiotic class and should be stratified by oral and intravenous antibiotics.  The ABC analysis is informed
by the Anatomical Therapeutic Chemical classification system.
• Antibiotics
Consumption data for the following antibiotics are to be collected and reported on:

i. Intravenous antibiotics used in high volumes – amikacin, amoxycillin-clavulanate, ampicillin, azithromycin,

ceftriaxone, clindamycin, cloxacillin, ciprofloxacin, gentamicin, metronidazole and penicillin;
ii. Oral antibiotics used in high volumes - amoxycillin-clavulanate, amoxycillin, azithromycin, ciprofloxacin,
clindamycin, flucloxacillin, and metronidazole;
iii. Antibiotics used for MDRO – carbapenems (ertapenem, imipenem, meropenem), colistin, piperacillin-tazobactam;
and vancomycin
iv. Glycopeptides (vancomycin and teicoplanin), linezolid, daptomycin and ceftaroline
v. It is also important to have a total measure including both oral and intravenous antibiotic consumption to monitor
overall hospital trends;
vi. Antifungals – intravenous: amphotericin B and caspofungin; oral: fluconazole.

• Tools for monitoring antibiotic consumption data

Anatomical Therapeutic Chemical Classification
The Anatomical Therapeutic Chemical (ATC) classification system is a tool to investigate medicine utilization in order
to improve the quality of medicine use. It allows for comparison of medicine consumption at all levels of health care, as
well as internationally.

The ATC classification divides medicines into different groups based on the body organ or system on which they act and
their chemical, pharmacological, and therapeutic properties (WHO Collaborating Centre for Drug Statistics Methodology
2009, available online at http://www.whocc.no/atc_ddd_index).

Daily Defined Doses

A DDD is the assumed average maintenance dose per day for a medicine used for its main indication. This system
allows comparison between products with different dosing regimens. It is important to use the same denominator when
comparing data: for example, if DDDs per 1000 inhabitants are calculated with the provincial census as the denominator
for year-on-year comparison, provincial census data from each year should be used.

Definitions2:

 DDDs per 1000 inhabitants: a rough estimate of the proportion of the population treated daily with a particular
medicine.
o Example: 10 DDDs per 1000 inhabitants per day indicates that 1% of the population on average might
receive a certain medicine daily.
o For the expression of antibiotic consumption at a provincial or district level, census population estimates
could be used as the denominator.
 DDDs per 100 patient days/bed-days: applied when medication use by inpatients is considered; this should be
adjusted for occupancy rate of the institution.
o Example: 70 DDDs per 100 patient days of a medicine provides an estimate of the therapeutic intensity
and suggests that 70% of the inpatients might receive a DDD of the medicine every day.
o Calculating patient days (or bed days): the discharge day for the patient is not counted so as to prevent
inflation of the denominator by partial days (i.e. admission will be seen as a full day).
 DDDs per inhabitant per year: an estimate of the average number of days for which each inhabitant is treated
annually.
o Example: an estimate of 5 DDDs per inhabitant per year indicates that the utilisation is equivalent to the
treatment of every inhabitant with a 5-day course during a certain year.

• How to Calculate Antimicrobial Daily Defined Doses (DDD) and DDDs per 1000 Patient Days

2 Introduction to drug utilisation research: Chapter 6: Drug utilisation metrics and their applications. World Health Organisation. Available
from http://apps.who.int/medicinedoc/en/d/Js487e.html

27
Reporting requirements:

An Excel document with the following components are necessary (see Example 1, columns A to K):

1. Date range under analysis

2. Description of antibiotic
3. Anatomic and Therapeutic Classification (ATC) to the 5th level
4. Strength of antimicrobial (including value and unit)
a. Convert all strength values into milligrams
5. Pack size (including value and unit)
6. Dosage form of antimicrobial
7. DDD for each antimicrobial
a. Search DDD for each antibiotic on http://www.whocc.no/atc_ddd_index/
b. Convert all DDDs into milligram
8. Quantity issued
9. Patient days for facility/ward being analysed over the data range under analysis

EXAMPLE 1: Year XX

A B C D E F G H I J K L M N O P

DDD/1000 patient
Patient days (for

Quantity issued
DDD value mg

DDD per pack

Strength unit

period under
DDD unit mg
Admin route

DDD issued
Description

DDD UNIT
pack size

analysis)
Strength

days
DDD
ATC

Unit

CLINDAMYCIN 150 mg J01FF 150 mg 20 Capsule Oral 1.2 g 1200 mg 352 50 2.5 125 355
capsule, 20 capsules
AMOXYCILLIN 250 mg J01CR 250 mg/ 100 ml Oral 1 g 1000 mg 428 20 5 100 234
and
CLAVULANIC ACID 62,5 5ml
mg/5 ml
suspension, 100 ml bottle

Calculating the DDDs:

Calculating DDD per pack:

1. For solid dosage forms, write the following statement in column N:
a. =(Strength value*pack size)/DDD Value (mg)

2. For liquid dosage forms (strength is xxx mg/y ml. The strength value is per y ml and needs to be divided by y to show
the number of units issued), write the following statement in column N:
a. =((Strength value*pack size(ml))/y)/DDD Value (mg)
Calculating DDD issued:
1. Write the following statement in column O:

a. =(DDD per pack*Quantity issued)

Calculating DDD per 1000 patient days:

1. Write the following statement in column P:
a. =(DDD issued/Patient days (for period under analysis))*1000

28
Example of a DDD calculation:
Using the data from Example 1, Year XX (above):
Date range: Year XX

Component Example 1: capsule Example 2: suspension

Description of antimicrobial CLINDAMYCIN 150 mg AMOXYCILLIN 250 mg and
capsule, 20 capsules CLAVULANIC ACID 62,5 mg/5 ml suspension,
100 ml bottle
ATC (5th level) J01FF J01CR
Strength of antimicrobial 150mg 250mg/5ml
Pack size 20 Capsules 100ml
Dosage form Oral Oral
DDD:
· From www.whocc.no/atc_ddd_index/ · 1.2g · 1g
· Convert to milligrams · 1200mg · 1000mg
Quantity issued 50 packets 20 bottles
Patient days for Year XX 352 428
Calculations:
1. DDD per pack =(150mg x 20 Capsules)/(1200mg) = ((250mg x 100ml)/5ml)/(1000mg)
= 2.5 =5
2. DDD issued = (2.5 x 50 packs) = (5 x 20 bottles)
= 125 = 100
3. DDD/1000 patient days = (125/352 patient days) x 1000 = (100/428 patient days) x 1000
= 355 = 234

29
Appendix B - Priority specimens & pathogens for surveillance of AMR

National Surveillance on AMR

Objective of the surveillance on AMR is to report on antimicrobial susceptibility testing results and trends in resistance
to antibiotics for selected pathogens on invasive diseases at all levels of the health care system.

Surveillance methods
The surveillance programme will focus on the ESKAPE pathogens (Enterococcus faecium/faecalis, Staphylococcus
aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Escherichia coli
species) and Candida within blood cultures only as they are the leading causes of nosocomial infections throughout
the world.

This surveillance has already been established at Group for Enteric, Respiratory and Meningeal Surveillance in South
Africa (GERMS SA) since beginning of 2000s and is designed as laboratory based surveillance at national level for
some organisms and at sentinel sites for others (mainly the academic hospitals). Surveillance reports on additional
pathogens such as Candida spp, S. pneumonia can be retrieved form GERMS Annual Report published at NICD
website (www.nicd.ac.za).

Case definitions

Initially surveillance reports will only include blood isolates based on organisms/antibiotics requests as per Table 8 for
the ESKAPE organisms.

Case definition for blood isolate is a single blood culture isolate within 21 days.

Figure 8 - Organisms and antibiotics requirements for AMR surveillance reporting

Organisms Antibacterial class Antibacterial agents
Escherichia coli Sulfonamides and trimethoprim Co-trimoxazole
Fluoroquinolones Ciprofloxacin or levofloxacin
Third-generation cephalosporins Ceftriaxone or cefotaxime and ceftazidime
Cefepime
Fourth-generation cephalosporins Imipenem, meropenem, ertapenem or Doripenem
Carbapenems Colistin
Ampicillin
Polymyxins Amoxicillin/clavulanate
Penicillins Piperacillin/tazobactam
Penicillins/inhibitors Gentamicin and amikacin

Aminoglycosides
Staphylococcus aureus Penicillinase-stable beta-lactams Cefoxitin (cloxacillin/oxacillin)
Klebsiella pneumoniae Sulfonamides and trimethoprim Co-trimoxazole
Fluoroquinolones Ciprofloxacin or levofloxacin
Third-generation cephalosporins Ceftriaxone or cefotaxime and ceftazidime
Cefepime
Fourth-generation cephalosporins Imipenem, meropenem, ertapenem or
Carbapenems Doripenem
Colistin
Polymyxins Amoxicillin/clavulanate
Penicillins/inhibitors Piperacillin/tazobactam
Gentamicin and amikacin
Aminoglycosides
Acinetobacter Tetracyclines Tigecycline or minocycline
baumannii Aminoglycosides Gentamicin and amikacin
Carbapenems Imipenem, meropenem, or doripenem
Colistin
Polymyxins
Pseudomonas aeruginosa Penicillins/inhibitors Piperacillin/tazobactam
Cephalosporins 3rd and 4th Ceftazidime and cefepime
Carbapenems Imipenem, meropenem,or doripenem
Colistin
Polymyxins
Enterococci-both faecalis and faecium Penicillins Ampicillin
Glycopeptides Vancomycin/Teicoplanin
Oxazolodines Linezolid
Lipopeptides Daptomycin
Candida Azoles Fluconazole
Voriconazole
Echinocandin Anidulafungin
Micafungin
Caspofungin
Data will be available on the NICD web site. Analysis and evaluation of reports is performed by NICD pathologists and epidemiologists.

30
In order to make informed decisions about antibiotic choices for empiric treatment protocols, and in order to monitor
antibiotic resistance trends, it is important to be able to review antibiotic resistance rates for certain organisms / organism
groups periodically. This appendix aims to describe the format such reports will take, as well as some of the limitations
of the reporting, and the parameters that are used to generate the reports. This appendix is aimed primarily at clinicians
and hospital managers who may be receiving and reviewing these reports. It is strongly recommended that these reports
be analysed in conjunction with a microbiologist familiar with the laboratory where the testing had taken place.

General principles

• Results will be expressed as % non susceptible.

• Only the first isolate of a given species per patient is included.
• If there are less than 30 isolates of a given species, the results will not be presented unless there are compelling
reasons to do so. Any such data must be interpreted very carefully.
• Data should be presented at least annually. However, more frequent analyses may be necessary in certain situations.
If more frequent analysis is performed, note must be taken of the recommendation that results should not be
presented if <30 of a particular species are present.
• If possible, susceptibility testing data derived using different testing methodologies should not be combined. However,
this is technically challenging from an IT perspective, as the method used to generate the result in the laboratory
is not necessarily captured on the laboratory information system (LIS). The NHLS is working towards standardised
testing methodology, which should resolve this issue. However, it is important to discuss the report with your local
microbiology laboratory to determine if this may be an issue
• The antibiotics reported are those that are routinely tested and reported on all isolates, and that are appropriate for
the species. This means that if some antibiotics are only tested on a selection of isolates (eg colistin which is only
tested on multi-resistant Pseudomonas aeruginosa; or nitrofurantoin which is only tested on urinary tract isolates),
these will not be included in the routine report, although it may be included in a special report.

A general example of the format would be:

% Non Susceptible, 2016, XXX Hospital
Organism Number AMIK GENT CIP CTX CTZ IMP SXT
E. coli 367 45 23 89 65 65 100 45
K. pneumoniae 234 78 65 67 38 38 99 59
E. aerogenes 123 88 79 78 45 48 100 48
E. cloacae 108 91 83 80 35 39 100 23
Proteus spp 201 100 89 95 88 88 100 51

A common query about these reports relates to why some agents are NOT reported for certain organisms. There are
three main reasons for this:

1. The organism (or organism group) is intrinsically resistant, and the agent is not tested as it is of no clinical value.
Examples would include vancomyin for Enterobacteriaceae; clindamycin for enterococci, cephalosporins for
enterococci, macrolides for Enterobacteriaceae, ertapenem for Pseudomonas and Acinetobacter etc.
2. Susceptibility can be deduced from results of other agents. The commonest example is beta-lactam antibiotics and
S. aureus. If S. aureus is susceptible to oxacillin, it is regarded as susceptible to most other beta lactams (except
the penicillins); and conversely, S. aureus resistant to oxacillin (ie MRSA) is regarded as resistant to all currently
available beta lactams. Hence only oxacillin (or cloxacillin) susceptibility is reported.
3. Susceptibility testing is not routinely performed since no standardised methodology or interpretive criteria exist.
Common examples of this would be certain topical agents (such as flamazine, chlorhexidine; as well as ciprofloxacin
or aminoglycosides against streptococci from eye swabs); certain non-fermentative Gram negative bacilli (eg
Stenotrophomonas, Burkholderia).
Limitations

The data does NOT provide an indication of infection rates, and should not be used as such. The only exception would
be susceptibility data from blood cultures, where the data will (by definition) refer to clinically significant isolates; and
the Blood stream infection (BSI) rates themselves may have clinical value (although BSI rates will be influenced by BC
collection practices, among other things)
Due to the limitations of the Laboratory Information System it does not differentiate between hospital and community
acquired infection rates.
Antibiotic Susceptibility Testing (AST) data can contribute to national, provincial and district guidelines, however the
ability to use the data to drive empiric regimens at facility level may be limited. This can be avoided to a degree by
analysing data from specific units (rather than the hospital as a whole); however this comes at the cost of reducing the
number of isolates in the data.
The quality of routine data depends on appropriate specimen collection and use of diagnostic tests to guide treatment
decisions. Standardization at national level for active participation of clinicians in microbiological diagnostics should be
encouraging.

31
Appendix C: Audit tool for AMS practices

Data element Patient 1 Patient 2 Patient 3 Patient 4

Culture taken before antibiotic therapy started
Documented indication for antibiotic
Empiric therapy started as per guidelines
Prompt effective antibiotic treatment
Review of antibiotic with culture results occurred at day 3
Review of antibiotic with culture results occurred at day 5
Changes where documented – indicate what changes were made (stopping/de-
escalation/substitution/addition of agents, change to oral)
TOTALS

Audit tool can be used in multiple wards for multiple number of patients

Scoring = Yes = 1, No = 0, unclear = NC

A constant sample should be performed per week. For example 20 files per week in order to calculate the rate per week.

32
Appendix D – IPC and AMS intervention definitions

AMS interventions

1. Formulary restrictions based on AMR and antimicrobial use

The act of limiting the use of a list of medications (formulary) to specific practitioners. A closed formulary may limit
drugs to specific physicians, patient care areas, or disease states via formulary restrictions.
2. Pre-authorisation is a type of formulary restriction whereby certain antimicrobials require authorisation by an
infectious diseases specialist; medical microbiologist or designated senior physician prior to them being dispensed
by the pharmacy or started
3. Stewardship teams and rounds involve a multidisciplinary team with expertise in antimicrobial use that perform
prospective audits with direct intervention and feedback to the prescriber. This involves evaluating the appropriateness
of prescriptions for antimicrobial agents, contacting the prescriber if the order is inappropriate, and recommending
alternative therapy. Feedback to prescribers may be oral or written. The core of the team is usually a prescriber and
pharmacist.
4. Sending of specimens for culture prior to commencement of antibiotics
5. Empiric treatment against the standard treatment guidelines - is antimicrobial therapy begun on the basis of
clinical observations in anticipation/absence of evidence or further information on the causative organism and its
antimicrobial susceptibility profile.
6. Documenting indication for antimicrobials - requires that the need for antimicrobial therapy is documented in the
patient’s notes
7. Change in antibiotic:
a. Stopping – discontinuation of the antibiotic
b. De-escalation – conversion from empiric broad spectrum to targeted narrow spectrum antimicrobial
c. Substitution – change in antimicrobial based on the culture and sensitivity result
d. Addition of agents
8. De-escalation of route - Iv to oral switch describes the practice of converting from intravenous to an effective oral
formulation of antimicrobial
9. Batching of intravenous antimicrobials is where the antimicrobials are given together at a uniform time to ensure
these medicines are administered to the patient at the correct frequency
10. Duration of therapy - review on day 3 of the need for antibiotic based on the culture results and day 5 of the need
to discontinue the antimicrobial
11. Hang time is the time from prescription (be it by hand or as part of electronic prescribing) of an intravenous
medication (in this case an antimicrobial), to the time of infusion of said medicine.
12. Surgical prophylaxis: This refers to the provision of an antibiotic prior to surgery to reduce the incidence of post-
operative infection at the surgical site. Efficacy of surgical prophylaxis is affected by the choice of agent and timing
of administration.

33
IPC interventions

1. Hand hygiene compliance against the standards for cleaning of public areas and clinical areas as per the National
Core Standards
2. Improved cleaning practice: This refers to cleaning practices in the health care facility as a whole, including
public areas, clinical areas, theatre, pharmacy, etc. Cleaning practices include environmental cleaning, handling/
processing of linen, sterilisation or disinfection of equipment, cleaning of blood and body fluid spills. These practices
can be assessed against the National Core Standards
3. Isolation room cleaning practices: This would refer to all cleaning practices taking place in isolation rooms, and can
also be assessed against the national core standards.
4. Screening of patients at high risk for antibiotic resistant bacteria: This can be interpreted quite broadly, but in the
context of AMR will usually refer to screening of patients at high risk for specific bacteria/resistance profiles, such as
MRSA and CRE. Screening practices will vary from institution to institution, and are informed by local epidemiology.
5. Isolation of infected patients: Patients with pathogens that are transmitted by specific mechanisms are isolated
using one of three transmission based precautions – airborne, droplet and contact. Airborne precautions are used
for patients with TB, measles and varicella. Droplet precautions are used for patients infected with organisms that
are spread by large respiratory droplets, such as N. meningitidis, diphtheria, influenza, adenovirus, and pertussis.
Contact precautions are used for patients infected with organisms spread by direct or indirect contact – including
MDRO and Clostridium difficile.
6. Decolonisation: This is the process of active eradication of an organism that is colonising a patient or healthcare
worker. For practical purposes, the only organism for which this is commonly performed is MRSA.
7. Isolation room cleaning practices against the standards for cleaning of public areas and clinical areas as per the
National Core Standards (use of recommended disinfectants)
8. Isolation of infected patients against the standards for cleaning of public areas and clinical areas as per the National
Core Standards
9. Functioning bedpan washer disinfectors on clinical ward areas
10. Appropriate decontamination and reprocessing of medical devices; no reuse of single use medical devices

34
Appendix E – IPC and AMR National Core Standards
R22.(1) The health establishment must minimize the risk of transmission of health care associated infections.
22.(2) (a)(i) The health establishment must ensure that health care personnel use standard precautions.

2.4.2.1.1 There are comprehensive procedures covering standard precautions which includes the following:
2.4.2.1.1.1 Effective hand hygiene practices which includes the use of alcohol hand rub as per WHO
recommendations and appropriate use of hand washing with appropriate Antimicrobial/antiseptic soap; and
appropriate alcohol based hand rub (as applicable)
2.4.2.1.3 The IPC practitioner and unit managers or link nurses audit compliance with standards precautions on a
monthly basis.
22.(2) (a)(ii) The health establishment must ensure that health care personnel practice effective hand hygiene.

2.4.2.3.1 A hand washing drive or campaign is held at least annually.
2.4.2.3.2 The IPC practitioner checks hand hygiene technique is followed by auditing all units on a monthly basis.
2.4.2.3.3 Quality Improvement initiatives to improve hand hygiene are implemented.

R25.(1) The health establishment must ensure that the clinical service areas are kept hygienic and clean.
Criteria and measures
25.(2)(ii) The health establishment must ensure that cleaning agents and equipment approved by the relevant
authority is available for cleaning personnel.

2.4.5.2.1 There is a list of approved disinfectants for use in environmental decontamination approved by the IPC forum
for use in the facility and should include as a minimum:
2.4.5.2.1.1 Chlorine compounds – sodium hypochlorite
2.4.5.2.1.2 Gluteraldehyde 2% formulations
2.4.5.2.1.3 Alcohol cleaning agent
2.4.5.2.1.4 Wet polimer
2.4.5.2.1.5 Plain liquid soap or detergent such as dishwashing liquid or handy Andy

35
Clinical leadership and clinical risk

R16.(1)The health establishment must establish and maintain systems, structures and programmes to mitigate
clinical risk and promote clinical leadership in order to safeguard the quality and safety of health care
services.

(ii) Monitor and oversee interventions to improve the use of antimicrobials as part of an antimicrobial
stewardship programme;

1.1.1.1.1 The Antimicrobial Stewardship Committee is functional with terms of reference. The TOR’s include:

1.1.1.1.1.1 The multidisciplinary membership

1.1.1.1.1.2 Roles and responsibilities and

1.1.1.1.1.3 Frequency of meetings

1.1.1.1.1.4 Purpose of the committee

1.1.1.1.1.5 Meetings occur as per frequency in terms of reference or pharmacist

2.3.1.6.11 Standardised protocols are in place for microbiological investigations of infectious disease including
specimen submission before initiating empirical therapy
2.3.1.6.13 The health establishment conducts audits of antimicrobial use at least 6 monthly to monitor trends in prescribing
2.3.1.6.14 The audits have identified the commonest errors in antimicrobial prescribing and these are communicated
to prescribing clinicians
2.3.1.6.15 The Antimicrobial Stewardship Committee provides updated annual antibiotic resistance and antimicrobial
use data to all prescribing practitioners in the health establishment
2.3.1.6.17 The Clinical Management Group provides access to expert advice on antimicrobial therapy promptly and at
point of care when necessary.
2.3.1.6.18 Audits on antimicrobial therapy show that there is an improvement in rational antimicrobial prescribing
including hang time, de-escalation to narrow spectrum and oral route according to culture results

2.3.1.6.19 The annual in-service education and training plan includes training for all health care professionals on
antimicrobial stewardship
2.3.1.6.2 There is a lead prescribing clinician with the responsibility of driving the antimicrobial stewardship programme
in the health establishment or District
2.3.1.6.20 The Clinical Management Group ensures that records are kept which provide evidence of health care
professionals being trained in antimicrobial stewardship through in-service training or continuing professional
development
2.3.1.6.21 There is educational material available for prescribers and other healthcare professionals on antimicrobial
use and prevention of resistance.
2.3.1.6.23 Annual audit of antimicrobial use both in terms of volume and cost occurs in the health establishment
2.3.1.6.3 The Antimicrobial Stewardship Committee has:
2.3.1.6.3.1 Documented goals towards antimicrobial stewardship
2.3.1.6.3.2 A plan of action to ensure the efficient functioning of the Antimicrobial Stewardship Programme
2.3.1.6.7 Evidence- based local guidelines for the diagnosis, prophylaxis and treatment of common infections have been
drawn up by the health establishment based on national guidance or adopted from national essential drugs list
and standard treatment (for tertiary hospitals only)
2.3.1.6.9 Appropriate antimicrobial protocols are in place for high risk patients/procedures for treating healthcare
associated infections

36
Reference list

1. National Department of Health, The Antimicrobial Resistance National Strategic Framework, 2014-2024; August
2014
2. FAO/OIE/WHO. Sharing responsibility and coordinating global activities to address health risks at the anima-
human-ecosystem interfaces; a tripartite Concept Note, April 2010
3. National Department of Health, Implementation Plan for the Antimicrobial Resistance Strategy Framework in
South Africa: 2014-2019, February 2015
4. National Department of Health, National Core Standards for Health Establishments, 2011
5. World Health Organisation, Global Action Plan for the Prevention and Control of NCDs 2013-2020 (resolution
WHA66.10).
6. World Health Organisation, Global Antimicrobial Resistance Surveillance System (GLASS): Manual for Early
Implementation, 2015
7. Torrey EF, Yolken RH, Beasts of the Earth, New Brunswick, NJ: Rutgers University Press, 2005
8. Taylor LH, Latham SM, Woolhouse ME, Risk factors for human disease emergence. Philos Trans R Soc Lond
B Biol Sci, 356: 983-989, 2001
9. National Department of Health, Infection Control Assessment Tool, April 2012, MSH
10. Goff DA, Bauer KA, Reed EE, Stevenson KB, Taylor JJ, West JE. Is the “Low-Hanging Fruit” Worth Picking
for Antimicrobial Stewardship Programs? Clinical infectious diseases : an official publication of the Infectious
Diseases Society of America. June 2012.
11. Brink AJ, Messina AP, Feldman C, Richards GA. Antimicrobial stewardship across 47 South African hospitals:
an implementation study, Lancet 13 June 2016
12. Boyles TH, Whitelaw A, Bamford C, et al. Antibiotic stewardship ward rounds and a dedicated prescription chart
reduce antibiotic consumption and pharmacy costs without affecting inpatient mortality or re admission rates.
PLoS One; 8: e79747, 2013
13. Center for Disease Control – Core Elements of Hospital AMS Programs, Atlanta, GA: US Department of Health
and Human Sciences, CDC, 2014
14. International Pharmaceutical Federation (IPF) Fighting AMR; the Contribution of Pharmacists, The Hague:
International Pharmaceutical Federation (IPF), 2015
15. Public health England, Start Smart – then Focus; AMS toolkit for English Hospitals, London, PHE, March 2015
16. Infectious Diseases Society of America and Society for healthcare Epidemiology of America; Guidelines for
developing an Institutional Program to Enhance AMS, 2006
17. Australian Commission on Safety and Quality in Healthcare, Australian Hospitals Stewardship Guidance, 2011
18. British society for Antimicrobial Chemotherapy, Stewardship Booklet Practical Guide to AMS in Hospitals, 2014
19. Malaysian Ministry of Health, Protocol on AMS program in healthcare facilities, 2014
20. Messina AP, van den Bergh D, Goff DA. Antimicrobial stewardship with pharmacist intervention improves
timeliness of antimicrobials across thirty-three hospitals in South Africa. Infect Dis Ther, 2015.

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