1. Challenges in Setting up a District-Based Antimicrobial Use Surveillance Programme Gous AGS, Van Deventer WV, Pochee E, Tumbo JM, Sorenson TL, Holloway K Medical University of Southern Africa; Madibeng Centre for Research; and the World Health Organization Department of Essential Drugs and Medicines Policy

2. Abstract Irrational prescribing and use of antimicrobials affects individual and public health and favours the spread of antimicrobial resistance and the wastage of health resources. Objective: To set up a district-based surveillance programme of antimicrobial use (for all clinical conditions) and resistance of Escherichia coli in the urine of patients with suspected uncomplicated urinary tract infection, in different parts of the health care system. Design: Descriptive time-series study starting in Oct 2003. Setting: Outpatient and emergency departments of a public district hospital, six primary health care clinics, five private community pharmacies, and five private medical practitioners in Brits/Madibeng district, North West Province, South Africa. Outcome Measures: Adequate number of urine specimens; urine specimens reaching the laboratory in time; reliable transport for staff and specimens; accurate antimicrobial data collection. Results: A number of challenges were identified during the set-up phase and are described here. Conclusions: Setting up an antimicrobial use surveillance programme at district level will provide local data needed to develop interventions. Researchers and donors should be aware of potential challenges. Wide multidisciplinary participation in the planning phase is essential to successful implementation.

3. Problem Statement 1.Irrational prescribing and use of antimicrobials:  Impacts negatively on the health of patients  Places societal health at risk through the development and spread of antimicrobial resistance  Wastes valuable health resources. 2.A district-based antimicrobial use surveillance programme has not been previously introduced in South Africa to assist in combatting the problem of irrational prescribing and use of antimicrobials.

4. Objective To set up a district-based surveillance programme in different parts of the health care system focussing on: qAntimicrobial use for all clinical conditions qResistance of Escherichia coli isolated from urine of patients with suspected uncomplicated urinary tract infection

5. Method Design Descriptive time-series study starting in October 2003. Participating facilities in the Brits/Madibeng District, North West Province, South Africa (see map) qOutpatient and emergency departments of Brits Hospital, a public district hospital qSix primary health care clinics q Three clinics under the North West Department of Health q Two clinics under the Brits/Madibeng City Council q One Non-Governmental Organisation (NGO) clinic qFive private community pharmacies qFive private medical practitioners

6. Method (continued) Map of the study area South Africa

7. Method (continued) Outcome Measures qA total of 200 urine specimens per month q100 E. coli isolates per month qUrine specimens reaching the laboratory in Ga-Rankuwa within 24 hours of collection qFunctional and reliable transport for staff and specimens q30 antimicrobial-containing prescriptions per month per collection site qAccurate antimicrobial use data collection

8. Results Challenges identified during set-up and implementation 1.Existing surveillance programs are confined to academic and tertiary health care institutions; hence, the data represent the use of second- and third-line antimicrobials that in general have a broader spectrum (these data do not reflect use in the community) 2.Finding community partners accustomed to research was not easy and required extensive, lengthy negotiations 3.Commitment of different stakeholders varies

9. Results Challenges identified during set-up and implementation (continued) 4.The logistics of data collection were complicated by: The distance between the sites Remoteness of some sites Lack of regular transport 5.Approval and start of the programme were delayed by: Health management changes Demarcation of districts New appointments in management positions Sensitivity towards research

10. 6.Establishment and ongoing restructuring of the National Laboratory Services 7.Detailed patient information and consent forms had to be designed and translated into several languages to address patients’ historical fear of being exploited and having their human rights violated Results Challenges identified during set-up and implementation (continued)

11. 8.It was a challenge to plan the study without knowing what data sets may need to be collected to identify shortcomings in anti-microbial use and consumption over time at all levels of the health system 9.Training sessions had to be postponed or repeated due to: qLocation of the different sites qLack of transport qStaff workload, preventing the release of staff to attend sessions qStaff turnover

12. Conclusion The first South African antimicrobial use surveillance programme at district level will provide: qLocal data that we intend to use to develop interventions to improve use and contain resistance qGuidelines for setting up surveillance programmes nationally and internationally Challenges have been identified, which other researchers and donors should take into account when writing proposals and allocating funds. Wide multidisciplinary participation in the planning phase requires resources for training and orientation and may be time-consuming, but is essential for successful implementation.