Optimizing Medical Resources for the Treatment of Infectious Diseases in South Africa
Davis, Kelly A.
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BACKGROUND: Over the past two decades, healthcare expenditures worldwide have increased dramatically. In an era of rising antibiotic resistance, the need for more effective and efficient utilization of healthcare resources could not be more applicable than in the field of infectious diseases. Based on a review of available literature, several interventions targeted at improving antibiotic stewardship have been successful in decreasing healthcare costs in high income countries. Unfortunately, little research has been done in low income countries, including those on the African continent. South Africa in particular lends itself to further study. Despite spending more of its gross domestic product (GDP) per capita on healthcare than most of its neighbors, South Africa is still faced with many of the healthcare issues present in the rest of the continent, including the rise of multidrug-resistant pathogens and an increased Human Immunodeficiency Virus (HIV) seroprevalence. OBJECTIVE: The objective of this research was to analyze current healthcare practices in the treatment of infectious diseases in South Africa in order to identify areas needing more efficient utilization of resources. METHODS: The objective was accomplished by conducting two prospective observational cohort studies. In the first study, data related to patients presenting to two emergency departments in Cape Town, South Africa, were collected to evaluate the efficacy of clinical decision rules currently used when drawing blood cultures. The decision to collect a set of blood cultures was made by the physician, who then recorded a set of clinical parameters known at the time of collection. In the second study, a quality improvement analysis was done to evaluate effectiveness of current intravenous (IV)-to-oral antibiotic switch therapy practices at a tertiary referral center in Cape Town. During the study, all patients receiving IV antibiotic therapy in the internal medicine wards were followed throughout the course of their IV therapy and were evaluated on their eligibility to switch to oral antibiotic therapy based on a list of criteria. RESULTS: In the first study, 500 blood culture sets were collected from 489 patients. Thirty-nine (7.8%) of these were positive for disease causing pathogens, and 13 (2.6%) contained contaminants. Clinical features that were independently associated with a positive culture result included the presence of diabetes, systolic blood pressure <90 mmHg, diastolic blood pressure <60 mmHg, and a suspected biliary source of infection. Thirty-six (95%) of these positive cultures were found to influence patient management in a significant way. In the second study, 71 (55%) of the 129 patients receiving IV antibiotic therapy met all the criteria for switching to oral antibiotics and only 4 (5.6%) of those were switched once the patient became eligible. Patients eligible for switching were continued on IV therapy for a mean of 3.1 (+/-1.6) days (median=3, Interquartile range (IQR)= 2-4 days) after meeting the criteria, and the most common indications for therapy within this group were community-acquired pneumonia (58.2%), sepsis of unknown cause (13.4%), and urinary tract infection (11.9%). The most common IV antibiotics used in this group were ceftriaxone 1 g (77.6%) and amoxicillin/clavulanate 1.2 g (13.4%). Fifteen (21.1%) of the patients meeting the criteria for switching did not have a blood culture sample taken prior to initiation of therapy. CONCLUSIONS: In the end, the stated objective of the project was met: analyzing current healthcare practices in the treatment of infectious diseases in South Africa helped to identify areas needing more efficient utilization of resources. The first study determined that, while blood cultures are an essential aspect of the treatment of infectious diseases, no consistent set of rules exists that allows physicians to predict when to order these studies. Further, when relying on clinical judgment, the vast majority of blood cultures ordered are negative. The second study identified several key mechanisms that led to inappropriately continued IV antibiotic treatment. The results of both studies highlight the need for more research to facilitate targeted interventions.