Background/Objectives: The overuse and misuse of antibiotics contribute to antimicrobial resistance (AMR) globally. The appropriateness of antibiotic prescribing at the primary healthcare (PHC) level must be urgently addressed to reduce high levels of inappropriate antibiotic prescribing and associated AMR. This study aimed to develop quality indicators, based on the World Health Organization (WHO)’s Access, Watch, Reserve (AWaRe) guidance, to assess the appropriateness and quality regarding antibiotic prescribing in public PHC settings in South Africa. Methods: Potential indicators were identified from indicators developed by City St George’s, University of London (SGUL); a review of AWaRe-based indicators; and the results from point prevalence surveys at PHC clinics in South Africa. The indicators were developed using the RAND/UCLA Appropriateness Method. In Round 1, 12 experts individually rated 78 indicators for clarity and appropriateness. In Round 2, 10 experts rated 89 indicators for appropriateness and feasibility during an interactive online meeting. Results: The final set had 61/89 indicators (68.5%) that were rated both appropriate and feasible with agreement. Dental infections (9/9; 100%) alongside skin and soft tissue infections (11/13; 84.6%) had the highest percentage of indicators that were rated appropriate and feasible with agreement. Lower urinary tract infections (6/11; 54.5%) and general (4/8; 50%) categories had the lowest percentage of indicators rated appropriate and feasible with agreement. Conclusions: The process proved valuable in developing potential indicators for use in future antimicrobial stewardship programmes to improve antibiotic prescribing in public sector PHC facilities in South Africa and beyond.

Background/Objectives: Inappropriate antibiotic prescribing in primary healthcare (PHC) contributes to bacterial antimicrobial resistance (AMR). Antibiotic stewardship, including measuring the appropriateness of antibiotic prescribing using quality indicators, is a priority in PHC where most antibiotics are used. Using previously developed WHO AWaRe classification-based quality indicators, we aim to test the clinimetric properties of 13 acute respiratory tract infection (RTI) quality indicators and qualitatively explore factors influencing PHC antibiotic prescribing in South Africa. Methods: We conducted a mixed-methods exploratory feasibility study using point prevalence surveys (PPSs) with clinimetric assessment and prescriber interviews. PPSs were conducted at four PHC facilities in Gauteng province that had taken part in previous PPS studies, alongside face-to-face interviews with PHC personnel. Results: In total, 52/52 (100%) RTI patients received antibiotics. Four (30.8%) indicators achieved scores above 85%, while six (46.2%) scored below 50%. All indicators had applicability scores ≥10%. Twelve (92.3%) indicators had a measurability score of 100%, while one (7.7%) had a measurability score <75%. Twelve (92.3%) indicators met all predefined acceptable scores for applicability and measurability. No participant knew of the WHO’s AWaRe classification and none had specific training on antibiotic prescribing and AMR. They also had no antibiotic stewardship programmes (ASPs) or specific antibiotic-prescribing guidelines at their facilities. Key factors affecting antibiotic prescribing included shortages, patient expectations and fear of complications. Conclusions: The indicators demonstrated acceptable clinimetric properties in South Africa. Robust locally validated indicators, combined with ASPs promoting the AWaRe classification, are imperative for accurate assessment and improvement of antibiotic prescribing.

What is Known and Objective?: Methotrexate (MTX) is the cornerstone therapy for rheumatoid arthritis (RA) but is associated with potential haematologic and hepatic toxicities. In South Africa, treatment guidelines emphasise regular laboratory monitoring and folic acid supplementation to enhance treatment safety and reduce adverse effects. This study evaluates the implementation of these safety measures in a resource‐constrained public health setting. Methods: A retrospective review of electronic health records was conducted for adult RA patients (≥ 18 years) who had been prescribed oral MTX for at least six months in the Western Cape Province between January and December 2022. Data collected included patient demographics, MTX and folic acid prescriptions, laboratory test results (white cell count [WCC], platelet count [PLT] and alanine aminotransferase [ALT]) and comedications. Laboratory abnormalities were classified according to the WHO reference ranges. Correlation analysis assessed associations between MTX/folic acid doses and laboratory values. Results and Discussion: Among 820 patients included in the study (82.1% female, mean age 55 ± 13 years), 94.9% were prescribed folic acid at the initiation of MTX and 96.2% at their most recent visit. Monitoring adherence improved over time: At MTX initiation, 71.8% had baseline WCC/PLT and 72.2% had ALT records; within 6 months of the last visit, over 88% had follow‐up laboratory results. Most patients had normal laboratory results at follow‐up (WCC: 85.9%; PLT: 73.8%; ALT: 90.4%). Spearman’s correlation analysis did not identify significant associations between MTX/folic acid dose and laboratory values, likely reflecting narrow dose ranges and limited subgroup size. These findings highlight the success of safety monitoring practices and the coprescription of folic acid in reducing the risks associated with MTX. What is New and the Conclusion?: This study demonstrates that MTX safety monitoring and folic acid supplementation are well integrated into public RA care in South Africa, with a low incidence of laboratory abnormalities. Our exploratory correlation analysis did not identify significant associations between MTX/folic acid dose and laboratory values; however, this likely reflects narrow dose ranges and limited subgroup data rather than the absence of effect. These findings highlight the success of current safety practices while underscoring the need for larger, prospective studies to better characterise dose–toxicity relationships.

The South African Family Practice is a peer-reviewed scientific journal, which strives to provide primary care physicians (and their teams), as well as researchers, with a broad range of scholarly work in the disciplines of family medicine, primary health care, rural medicine, district health and other related fields. SAFP publishes original research, clinical reviews, and pertinent commentary that advance the knowledge base of these disciplines.