National Antibiotic Guidelines

Objectives

Establish and implement Mauritius’s National Antibiotic Guidelines as a national antimicrobial stewardship framework that promotes responsible, evidence-based antibiotic use, reduces antimicrobial resistance, antibiotic-associated harm and avoidable infections, improves patient outcomes, preserves antibiotic effectiveness, and uses health-care resources efficiently.[1][2]The guidelines apply to antibiotic prescribers nationally, principally address bacterial infections and public-sector medicines, and support equivalent-spectrum substitutions where private-sector availability differs.[3]

• Reduce antibiotic misuse, overuse and unnecessary exposure, including treatment where infection is not clinically supported, while promoting the narrowest effective spectrum, appropriate dose, route and shortest effective duration.[4][5]
• Align prescribing and formulary policy with the World Health Organization Access, Watch and Reserve classification, promote Access antibiotics where suitable, limit Watch and Reserve use, and preserve Reserve agents for multidrug-resistant infections.[6][7]
• Strengthen microbiological diagnosis, culture- and susceptibility-guided treatment, local antibiogram use, timely prescription review and de-escalation of therapy.[4][5][8]
• Provide comprehensive clinical guidance across adult, paediatric and neonatal care, including condition-specific treatment, prophylaxis, dosing in renal impairment, haemodialysis, therapeutic drug monitoring, pregnancy risks, interactions and management of sepsis caused by multidrug-resistant organisms.[9][10][11][12]
• Develop a costed national action plan on antimicrobial resistance with defined goals, outcomes, timelines, structures and responsibilities, integrated where appropriate with infection prevention and control policy and annual government planning.[7]
• Improve public and professional awareness through regular antibiotic-awareness campaigns, school education on infection prevention and control, and pre-service and in-service stewardship training.[8]
• Ensure access to quality-assured, affordable antibiotics, including appropriate dosages and paediatric formulations, while regulating non-approved fixed-dose combinations, prescription-only supply and substandard or falsified products.[13]

Implementation

Deliver stewardship through national coordination and facility-level multidisciplinary implementation, combining enforceable prescribing controls, standard treatment guidance, diagnostics, surveillance, education, audit and feedback.[7][8][14]The Ministry of Health and Wellness, its Antibiotic Technical Working Group, the antimicrobial resistance focal point, regional health directors, clinical departments, pharmacy, laboratory services, professional stakeholders and World Health Organization contributors support development, review and implementation.[15][2][3]

• Establish a national antimicrobial stewardship technical working group with Ministry focal-point representation and formal links to antimicrobial consumption, resistance-surveillance and infection-prevention and control groups.[7]
• Embed stewardship in facility management through endorsed action plans, leadership committees, designated leaders or champions, multidisciplinary teams and measurable management-performance expectations.[14]Larger hospitals may use full multidisciplinary teams, while smaller or resource-limited facilities may use a prescriber, nurse or pharmacist, or a stewardship champion with access to expert advice.[14]
• Define collaboration between stewardship and infection prevention and control programmes, including merged arrangements where resources are limited.[16]Use isolation and contact precautions for patients colonised or infected with multidrug-resistant organisms in accordance with national infection-prevention guidance.[3]
• Implement practical prescribing interventions through ward rounds, bedside consultations, telephone advice, preauthorisation, prospective audit with feedback, targeted therapy reviews and priority-department interventions.[4][17]Require documentation of indication, dose, route, duration and stop date, and review prescriptions at 48 to 72 hours with culture results and clinical response.[4][5][18]
• Restrict selected higher-risk antibiotics through specialist oversight, culture submission and time-limited authorisation, including controls for piperacillin/tazobactam, glycopeptides, colistin, meropenem, linezolid, tigecycline, ceftazidime-avibactam and aztreonam.[19]Limit meropenem courses unless further review and authorisation are obtained, with additional consultant or specialist controls in neonates.[19][20]
• Support safe treatment through timely quality-assured laboratory and imaging services, accessible microbiology or infectious-disease advice, formulary controls, standardised prescription records, renal-dose adjustment and therapeutic drug monitoring for selected agents.[17][18][21]
• Apply source control and non-antibiotic management where clinically indicated, including drainage, debridement, surgery, catheter removal or replacement, supportive care and avoidance of antibiotics for conditions that are usually non-bacterial or self-limiting.[22][23][24][25]
• Compile national antibiotic-consumption data on quantities and types purchased or distributed, distinguishing facility and community sectors where possible and using World Health Organization methodology.[8]Monitor resistance through laboratory pathogen identification and susceptibility testing, compare findings across facilities, identify trends and investigate outlier facilities.[8][26]
• Conduct facility audits or point-prevalence surveys covering indication, antibiotic choice, dose and duration; monitor medicines purchased, prescribed and dispensed; update facility antibiograms; and provide prescribers with findings and specific action points.[27][28]
• Report regular stewardship activity, antibiotic-use and intervention data to facility personnel and regional or national technical working groups, and assess progress against measurable short- and long-term targets.[16]National surveillance progress is tracked annually through the Tracking Antimicrobial Resistance Country Self-Assessment Survey within the Tripartite monitoring and evaluation framework.[29]
• Provide dedicated, sustainable and budgeted support for stewardship, including staff salaries, training and information-technology capacity; the material does not specify total allocations, funding sources or itemised implementation costs.[8][14]

Monitoring & Evaluation

The guideline combines national and facility-level antimicrobial stewardship monitoring, using antibiotic-consumption, prescribing-quality, microbiology and resistance information to guide feedback, clinical review and guideline updates. It identifies stewardship teams, technical working groups and facility leadership structures as the principal mechanisms for oversight, although many clinical chapters specify only patient-level review rather than programme-level evaluation.[4][7][8][14]

• Establish a national mechanism to monitor and evaluate implementation of the national antimicrobial resistance action plan, including antimicrobial stewardship and infection-prevention-and-control activities.[7]
• Compile national antibiotic-consumption data on the quantities and types of antibiotics purchased or distributed, distinguishing facility and community sectors where possible and following World Health Organization methodology.[8]
• Use laboratory identification and susceptibility testing to collate resistance results across facilities, identify trends and investigate outlier facilities that may require support.[8][26]
• Track the national surveillance indicator annually through the Tracking Antimicrobial Resistance Country Self-Assessment Survey within the Tripartite monitoring and evaluation framework for the Global Action Plan on Antimicrobial Resistance.[29]

At facility level, action plans should measure progress and accountability, and antimicrobial stewardship should form part of management performance indicators. Facilities are expected to maintain multidisciplinary stewardship leadership, with models adapted to available resources, ranging from full hospital teams to a single champion supported by specialist advice.[14]

• Conduct audits or point-prevalence surveys to assess antibiotic indication, agent, dose and duration against applicable policy and guidance.[27]
• Monitor antibiotics purchased, prescribed and dispensed in collaboration with pharmacy services.[27]
• Assess compliance with stewardship interventions, including documentation of antibiotic indications in medical records.[27]
• Develop and regularly update facility antibiograms using antibiotic-use and resistance data, and use findings to inform clinical-guideline revision where appropriate.[27][28]
• Provide prescribers with findings and specific action points based on antibiotic use, resistance rates and prescribing appropriateness.[27]

Regular antimicrobial stewardship activity reports should be disseminated to facility personnel and regional or national antimicrobial stewardship technical working groups. These reports should include antibiotic-use or consumption data and describe stewardship interventions. Progress should be assessed through local-use analysis and evaluation of intervention impact against measurable short- and long-term targets and goals.[16]

The clinical guidance adds several operational controls. Stewardship teams should monitor prescriptions, treatment response and antibiotic use, provide feedback, and support staff and patient education. Prescriptions should be reviewed after 48 to 72 hours, with durations or stop dates recorded, and treatment should be de-escalated when culture results permit.[4][5]Restricted antibiotics require specialist oversight, culture-based reassessment and, for selected medicines, time-limited authorisation.[19]

Surveillance evidence is used to establish the rationale for stewardship. Reported measures include carbapenem non-susceptibility in Klebsiella pneumoniae, antibiotic defined daily doses, the proportion of World Health Organization Access-list antibiotics used, unnecessary treatment initiation, dosing errors and excessive treatment duration.[2]Hospital antibiograms provide susceptibility percentages by organism, patient setting and antibiotic, but their interpretation is constrained by varying collection years and limited sample sizes.[30][31]Local resistance information from the Central Health Laboratory is also used in treatment decisions for multidrug-resistant organisms.[32]

Clinical monitoring requirements include therapeutic drug-level testing and renal-function-based dose adjustment for selected antibiotics, with specified trough, peak or interval testing arrangements for vancomycin, gentamicin and amikacin. The Central Health Laboratory does not currently provide serum amikacin or colistin testing.[10][21]Neonatal care relies on culture results, inflammatory markers, clinical observations and repeat blood cultures until sterility where bloodstream infection is confirmed.[11]

Important limitations remain. The source often does not specify quantitative targets, a common indicator set, evaluation methods, audit schedules, reporting intervals or formal escalation and accountability arrangements. The national checklist proposes monitoring and evaluation, and facility guidance requires reports and action plans, but neither supplies a complete standardised reporting timetable or outcome framework in the provided material.[7][16][27]

Costing & Financing

Financing information is principally normative rather than quantified. The material calls for dedicated funding for a costed national antimicrobial resistance action plan covering short- to medium-term activities of one to three years and/or longer-term activities of five years, but it provides no monetary allocation, funding source, funding gap or economic assumption.[7]

• Provide human and financial resources to develop and disseminate national standard treatment guidelines where these are absent.[7]
• Support affordability and continued access to quality-assured antibiotics, including suitable formulations and paediatric doses, while preventing substandard or falsified products.[13]
• Allocate dedicated, sustainable and budgeted support for stewardship salaries, training and information-technology capacity, and link government funding criteria to implementation across facilities.[8][14]
• Address resource constraints affecting clinical delivery, including limited public-sector access to cefazolin, unavailability of selected serum drug-level tests, and the stated possibility of Ministry assistance with procuring unavailable antibiotics.[21][33][20]

No explicit prices, expenditure estimates, programme budgets, allocations, financing sources, cost-effectiveness analyses or quantified resource gaps are provided in the supplied material. Accordingly, the financial scale and affordability implications of laboratory surveillance, diagnostics, training, stewardship staffing, information technology, restricted-antibiotic review and procurement cannot be determined.[7][8][16][27]