Improving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone

There is global concern over increasing antibiotic resistance rates due to poor antimicrobial stewardship, particularly in low-income and middle-income countries where there are limited diagnostic facilities, fewer doctors per capita and inadequate control over the production and sale of antibiotics. This quality improvement project was designed to improve the antimicrobial prescriptions practices of paramedical staff in the outpatient department of a rural district general hospital in Masanga, Sierra Leone, West Africa. At baseline, 57 of 66 (86%) of patients were prescribed at least one antimicrobial. On further review of 243 prescriptions for 128 patients, only 161 (66%) antimicrobials were deemed appropriate for the named diagnosis when compared with international guidelines or senior medical opinion, and 86 (35%) prescriptions had the correct drug, dose and course-length. A full, empirical antimicrobial guideline was written and introduced to local staff via a number of different methods, including: one-to-one feedback, announcements in general meetings and printed copies placed in each outpatient room. After the first cycle, the choice of appropriate antimicrobial had improved to 85% and the correct drug, dose and course-length to 53%. Unfortunately, 2 months after the second cycle, coinciding with the departure of the international internal medical physician, the rates had degraded to 65% and 43%, respectively. This study shows that implementing an empirical antimicrobial guideline can be effective at improving appropriate antibiotic prescription but that other measures are required for sustainable change. It is suggested that projects designed to change practice in low-resource countries should include national staff from the outset to improve longer term sustainability.