A Quick Guide for Usage of these Guidelines
This guideline aims to assist healthcare workers with antibiotic prescribing for common clinical syndromes in adult patients in South Africa, utilising Local and International guidelines, key publications, and expert opinion.
The international community sits at the tipping point of a post‐antibiotic era, where common bacterial infections are no longer treatable with the antibiotic armamentarium that exists.
In South Africa, the identification of the first case of pan-resistant Klebsiella pneumoniae (Brink et al, J Clin Microbiol. 2013;51(1):369-72) marks a watershed moment and highlights our tip of the antibiotic resistance ‘iceberg’ in this country.
Multi-drug resistant (MDR)-bacterial infections, predominantly in Gram-negative bacteria such as Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Acinetobacter baumannii are now commonplace in South African hospitals.
Whilst a number of expensive new antibiotics for Gram-positive bacterial infections have been manufactured recently (some of which are licenced for use in South Africa), no new antibiotics active against Gram-negative infections are expected in the next 10-15 years. Hence what we have now, needs conserving.
The development of antibiotic resistance is a natural phenomenon. Drug-resistance mutations have been found in 30,000-year old ice blocks. In addition, bacteria may acquire antibiotic resistance mechanisms by horizontal gene transfer. There are over 1000 different naturally occurring enzymes that are produced by different bacteria, which inactivate antibiotics.
The overuse of antibiotics is driving the selection of antibiotic resistance. Given the right circumstances, the resistant bacteria that are selected out can either colonise a patient (be present, potentially transmissible, but not cause clinical disease i.e. infection) or cause infection. It follows that the more antibiotics are used, the greater the likelihood of selecting out antibiotic resistance, and the broader the spectrum of antibiotic that is used, the greater the number of different types of resistant bacteria will be selected out.
The fact that it is estimated that half of all antibiotics prescribed in human health are unnecessary e.g. for viral upper respiratory tract infections, demands our renewed efforts to make antibiotic prescribing appropriate. When it is indicated, an antibiotic must be the right choice at the right dose, dosing interval and route, and for the right duration, and when it is not indicated, that antibiotic must not prescribed.
Rather than be an exhaustive text on infectious diseases, microbiology or clinical pharmacology, the aim of this guide is to give you the practical information you need to perform antibiotic stewardship in an algorithmic manner, which mimics the day-to-day experience of the prescriber.