Pharmacists in low-middle-income countries (LMIC) are few and lack antibiotic stewardship (AS) training. The ability was assessed of non-specialised pharmacists to implement stewardship interventions and improve adherence to the South African community-acquired pneumonia (CAP) guideline in public and private hospitals. This was a multicentre, prospective cohort study of adult CAP patients hospitalised between July 2017 and July 2018. A CAP bundle was developed of seven process measures (diagnostic and AS) that pharmacists used to audit compliance and provide feedback. CAP bundle compliance rates and change in outcome measures [mortality, length of stay (LOS) and infection-related (IR)-LOS] during pre- and post-implementation periods were compared. In total, 2464 patients in 39 hospitals were included in the final analysis. Post-implementation, overall CAP bundle compliance improved from 47·8% to 53·6% (confidence interval [CI] 4·1-7·5, p<0·0001), diagnostic stewardship compliance improved from 49·1% to 54·6% (CI 3·3-7·7, p<0·0001) and compliance with AS process measures from 45·3% to 51·6% (CI 4·0-8·6, p<0·0001). Improved compliance with process measures was significant for five (2 diagnostic, 3 AS) of seven components: radiology, laboratory, antibiotic choice, duration and intravenous to oral switch. There was no difference in mortality between the two phases, [4·4%(55/1247) vs. 3·9%(47/1217); p=0·54], median LOS or IR LOS 6·0 vs. 6·0 days (p=0·20) and 5·0 vs. 5·0 days (p=0·40). Non-specialised pharmacists in public and private hospitals implemented stewardship interventions and improved compliance to SA CAP guidelines. The methodology of upskilling and a shared learning stewardship model may benefit LMIC countries.

Introduction: Limited data exist on Clostridium difficile infection (CDI) in low-resource settings and settings with high prevalence of HIV. We aimed to determine baseline CDI patient characteristics and management and their contribution to mortality.Methods: We reviewed adult patients hospitalised with diarrhoea and a C. difficile test result in 2015 from four public district hospitals in the Western Cape, South Africa. The primary outcome measures were risk factors for mortality. Secondary outcomes were C. difficile risk factors (positive vs negative) and CDI treatment.Results: Charts of patients with diarrhoea tested for C. difficile (n=250; 112 C. difficile positive, 138 C. difficile negative) were reviewed. The study population included more women (65%). C. difficile-positive patients were older (46.5 vs 40.7 years, p<0.01). All-cause mortality was more common in the C. difficile-positive group (29% vs 8%, p<0.0001; HR 2.0, 95% CI 1.1 to 3.6). Tuberculosis (C. difficile positive 54% vs C. difficile negative 32%, p<0.001), 30-day prior antibiotic exposure (C. difficile positive 83% vs C. difficile negative 46%, p<0.001) and prior hospitalisation (C. difficile positive 55% vs C. difficile negative 22%, p<0.001) were also more common in the C. difficile-positive group. C. difficile positive test result (OR 4.7, 95% CI 2.0 to 11.2; p<0.001), male gender (OR 2.8, 95% CI 1.1 to 7.2; p=0.031) and tuberculosis (OR 2.3, 95% CI 1.0 to 5.0; p=0.038) were independently associated with mortality. Of patients starting treatment, metronidazole was the most common antimicrobial therapy initiated (70%, n=78); 32 C. difficile-positive (29%) patients were not treated.Conclusion: Patients testing positive for C. difficile are at high risk of mortality at public district hospitals in South Africa. Tuberculosis should be considered an additional risk factor for CDI in populations with high tuberculosis and HIV comorbidity. Interventions for CDI prevention and management are urgently needed.

Background: Antibiotic resistance (ABR) is a global health crisis. We conducted a cross-sectional survey to describe South African patients’ (n = 782) ABR knowledge, attitudes and perceptions (KAP), differences in KAP between public (n = 379, 48%) and private (n = 403, 52%) practice respondents and associations between attitudes, perceptions and knowledge scores. Methods: Knowledge scores (15 questions) were placed into low (0% – 53%) and high (> 54%) categories (below and above overall mean). Comparisons were conducted using chi-squared and t-tests. Results: Of all respondents, 72% believed it was the human body that becomes resistant to antibiotics, 66% stated that antibiotics are good for treating viruses and 25% of patients believed that people should be given antibiotics on demand. Mean knowledge scores were lower in public sector respondents (public 45%, s.d. 15%; private 60%, s.d. 30%; p ≤ 0.001). Public practice patients with high knowledge scores were more likely to report both negative KAP (antibiotic prescriptions justify doctors’ visits, scientists will discover new antibiotics) and protective KAP (finishing a course of antibiotics, antibiotics do not treat all illnesses). Private practice patients with high knowledge scores were marginally less likely to report negative KAP (wanting antibiotics after long illnesses or when very sick) and more likely to report protective KAP (antibiotics have side effects and are a strong treatment). Conclusion: Our study shows differences in KAP by practice type and that greater knowledge increases the likelihood of protective attitudes, perceptions and behaviours.

Clostridium difficile infection (CDI) is understudied in limited resource settings. In addition, provider awareness of CDI as a prevalent threat is unknown. An assessment of current facilitators and barriers to CDI identification, management, and prevention is needed in limited resource settings to design and evaluate quality improvement strategies to effectively minimize the risk of CDI. Our study aimed to identify CDI perceptions and practices among healthcare providers in South African secondary hospitals to identify facilitators and barriers to providing quality CDI care. Qualitative interviews (11 physicians, 11 nurses, 4 pharmacists,) and two focus groups (7 nurses, 3 pharmacists) were conducted at three district level hospitals in the Cape Town Metropole. Semi-structured interviews elicited provider perceived facilitators, barriers, and opportunities to improve clinical workflow from patient presentation through CDI (1) Identification, (2) Diagnosis, (3) Treatment, and (4) Prevention. In addition, a summary provider CDI knowledge score was calculated for each interviewee for seven components of CDI and management. Major barriers identified were knowledge gaps in characteristics of C. difficile identification, diagnosis, treatment, and prevention. The median overall CDI knowledge score (scale 0–7) from individual interviews was 3 [interquartile range 0.25, 4.75]. Delays in C. difficile testing workflow were identified. Participants perceived supplies for CDI management and prevention were usually available; however, hand hygiene and use of contact precautions was inconsistent. Our analysis provides a detailed description of the facilitators and barriers to CDI workflow and can be utilized to design quality improvement interventions among limited resource settings.

In 2024, the WHO’s Division on Access to Medicines and Health Products issued a call to action for sustainability in the pharmaceutical sector. The initiative, ‘Greener Pharmaceuticals’ Regulatory Highway’, underscored the need to reduce the environmental footprint of medical products. It explicitly called on the regulatory community to adopt initiatives towards ‘innovative approaches in the manufacturing, distribution, and usage of medical products.’ 1 This timely initiative aligns with the growing recognition of interconnectedness between climate change, pollution—including ‘pharmaceutical pollution’—and public health. However, the need to decrease greenhouse gas emissions should not overshadow other relevant areas for action in the pharmaceutical sector. Here, we focus on the negative environmental impact of the inappropriate elimination of pharmaceutical waste generated at the last mile in healthcare.