The impact of a digital intervention to decrease antimicrobial duration across 38 South African private hospitals

Introduction: Prolonged antimicrobial durations remain a key contributing factor for overuse of antimicrobials in hospitals. This is exacerbated by prescribers not indicating a duration of treatment on prescriptions.The implementation of the first South African multihospital integrated electronic medical record (EMR) system offered the opportunity for digitally enabled antimicrobial stewardship (AMS) interventions to support existing pharmacist-driven strategies for AMS.This study evaluates the impact of enforcing a specified duration at the point of electronic antibiotic prescription across a network of 38 private hospitals in South Africa. Methods: The EMR was introduced from 2019 in clusters across the hospital network. Frontline multidisciplinary AMS program members requested the field for duration of therapy for antimicrobials to be made mandatory on all electronic antimicrobial prescriptions, regardless of indication.In March 2023, this digital intervention was implemented and subsequently included an ‘ending soon’ electronic notification for clinician review to stop or continue therapy if clinically indicated. Clinical pharmacists continued with audit and feedback activities as before for all other interventions.The impact of this digital intervention on overall antimicrobial consumption using the defined daily dose (DDD) per 100 bed day methodology was assessed comparing the pre intervention period (August 2022-February 2023) to the post implementation period (March 2023- October 2023). The Mann-Witney U Test was used for statistical analysis. Results: The digital intervention led to a reduction in mean antimicrobial consumption of defined daily doses per 100 patient–days from 121.11 (95% CI 118.71 and 123.51) to 109.33 (95% CI 107.1 and 111.46) pre/ post intervention (p<0·0003) for 267316 and 314745 total antibiotic prescriptions per period respectively. Discussion: This is the first multi-hospital study in South Africa that has demonstrated a positive clinical AMS outcome because of the implementation of a digitally enabled intervention. Whilst there is evidence to support the impact of automatic stop orders and or mandatory end dates for antimicrobial prescriptions implemented in various hospital systems globally, the uniqueness of this intervention is that an ‘ending soon’ notification was triggered prior to the prescribed end date with an option to continue or stop treatment. This provided clinicians an opportunity to re-evaluate the need for continuation of antibiotic therapy. This multi-disciplinary collaborative initiative is the first time that prescribers were required to take ownership of the duration of antibiotic therapy at scale, enabled by the EMR platform, to become key-role players in AMS review, which resulted in further reducing overall antibiotic consumption. Conclusion: Unnecessary extended antimicrobial duration is a ‘low hanging fruit’ high impact AMS intervention. This digital intervention made a significant impact on reducing antibiotic consumption across multiple private hospitals. Analysis to ascertain any unintended consequences as a result of this intervention on patient outcomes is underway.