Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach & Governance

Objectives

South Africa’s Antimicrobial Resistance Strategy Framework applies a One Health approach to preserve antimicrobial effectiveness, improve infection outcomes, promote responsible antimicrobial use in people and animals, and support animal health and livestock production. It links human, animal, agricultural, veterinary and environmental health, recognising that antimicrobial resistance requires coordinated action across these sectors.[1]

• Strengthen cross-sector understanding, cooperation, communication, governance and accountability for antimicrobial resistance and antimicrobial use.[1][2]
• Improve access to and appropriate use of diagnostics, including diagnostic stewardship, to guide empiric and targeted treatment.[1][2]
• Optimise surveillance and reporting of antimicrobial resistance and consumption in human and livestock settings at local, district, provincial and national levels.[1][2]
• Intensify infection prevention and control, hygiene, vaccination, biosecurity, animal husbandry and environmental risk management to prevent infections and limit transmission.[1][2]
• Promote appropriate antimicrobial prescribing, dispensing and administration through antimicrobial stewardship, with a primary focus on antibiotics for bacterial infections other than tuberculosis and potential applicability to antifungals.[2]
• Support implementation through legislation, education, communication and research as strategic enablers.[2]

The framework seeks to embed antimicrobial-resistance activities within routine government and health-system structures, rather than create wholly separate programmes. It provides a practical governance blueprint spanning national, provincial, district and health-establishment levels, while allowing provinces and facilities to adapt priorities to local needs, baseline conditions and available resources.[2][3]

Priority-setting is intended to use situational analysis of antimicrobial resistance, antimicrobial use, infection prevention and control, biosecurity, surveillance capacity and implementation gaps. Provinces should identify a limited number of practical, high-impact interventions for facilities, generally directed towards reducing unnecessary antimicrobial use while improving safe and effective treatment.[4][5]

Implementation

Implementation uses tiered One Health governance, led nationally by the National Department of Health and supported by coordinated action across government departments, provinces, districts, health establishments, laboratories, professional bodies, civil society and private-sector partners. The Ministerial Advisory Committee on Antimicrobial Resistance provides multidisciplinary, intersectoral national advice, coordination, advocacy and oversight, while provincial, district and hospital stewardship committees translate the framework into operational action.[6][2][3]

• Coordinate national implementation through the Affordable Medicines Directorate in the National Department of Health, which serves as the national focal point and secretariat for the Ministerial Advisory Committee on Antimicrobial Resistance.[7]
• Engage agriculture, environmental affairs, science and technology, education, finance, trade, industry and other sectors in human, animal and environmental interventions, research, professional education and resource mobilisation.[2][8]
• Establish a Ministerial Advisory Committee on Antimicrobial Resistance with up to 25 core members, authority to co-opt relevant expertise and, subject to ministerial approval, establish subcommittees.[8][9]
• Adapt national objectives and standards through provincial departments, which should implement activities across districts and establishments, establish supporting budgets, monitor implementation and submit six-monthly progress reports through Provincial Antimicrobial Stewardship Committees.[7][10]
• Appoint provincial and district antimicrobial-resistance champions with authority, resources, training and budget to establish structures, build support, address barriers, coordinate information and drive improvement.[11][12]
• Integrate district action through District Health Management Offices and multidisciplinary District Antimicrobial Stewardship Committees, linked to pharmacy and therapeutics committees, quality structures, public health, laboratory, environmental, water, sanitation, waste-management and veterinary services.[12][13]
• Position hospital antimicrobial stewardship committees within existing hospital, clinical or infection-prevention-and-control arrangements, with leadership, medical, pharmacy, nursing, microbiology and infection-prevention representation.[14]

Operational delivery combines stewardship, diagnostic practice, infection prevention and control, surveillance, training and communication. Facilities are expected to use prescribing tools such as essential medicines lists, standard treatment guidelines, antibiotic-prescribing guidance and prescription charts; conduct cultures before treatment where appropriate; document indications; review treatment after culture results; de-escalate or stop therapy when justified; switch from intravenous to oral treatment where suitable; and improve surgical prophylaxis and administration practices.[15][16][17]

Infection prevention and control includes hand hygiene, environmental and isolation-room cleaning, screening and isolation of high-risk patients, decolonisation where appropriate, standard and transmission-based precautions, safe reprocessing of medical devices, adequate supplies of personal protective equipment and cleaning materials, and oversight against National Core Standards.[16][17][18]

Monitoring combines governance, process, output and outcome measures. National indicators assess stewardship governance, infection-prevention-and-control staffing, availability of cleaning supplies and essential antibiotics, standards compliance, resistance patterns, antimicrobial consumption and selected effects on infectious-disease mortality among mothers and infants. Governance reporting is biannual or annual, stock indicators quarterly, standards-compliance measures annual, and process measures quarterly.[19][20]

Surveillance uses laboratory, pharmacy, sentinel-site and facility data. Antimicrobial consumption may be measured as defined daily doses per 100 patient days in hospitals or per 1,000 inhabitants in population-based reporting, while resistance surveillance focuses on priority organism-antibiotic combinations, including ESKAPE pathogens and Candida bloodstream isolates. National Institute for Communicable Diseases pathologists and epidemiologists analyse and publish relevant surveillance data, with facilities using results to guide empiric treatment and local stewardship decisions.[21][22][23][24]

Resource arrangements are mainly embedded in existing departmental and provincial systems. National Treasury is expected to earmark funding for priority One Health activities, the science and technology sector is expected to support research funding, and provincial and district structures should establish or input into budgets and account for expenditure. The available material does not specify quantified budgets, allocations or funding gaps.[8][7][15][13]

Monitoring & Evaluation

Monitoring and evaluation are structured across national, provincial, district and health-establishment levels to assess implementation of the Antimicrobial Resistance Strategy Framework, antimicrobial stewardship, infection prevention and control, antimicrobial consumption and resistance trends. The Ministerial Advisory Committee on Antimicrobial Resistance (MAC-AMR) sets minimum intervention standards and monitoring arrangements, while national monitoring and evaluation indicators assess progress against strategic objectives.[9][19]

• Monitor governance functionality, including antimicrobial stewardship structures, infection prevention and control staffing, availability of cleaning supplies and essential antibiotics, and compliance with antimicrobial stewardship and infection prevention and control standards.[20][25]
• Classify indicators as input, process, output, outcome and impact measures. Input measures assess governance, process measures assess implementation of standards and guidance, output measures assess resistance and consumption changes, and outcome or impact measures include infectious-disease mortality among mothers and infants.[19]
• Report governance indicators biannually or annually, stock-availability indicators quarterly, standards-compliance indicators annually, and process-compliance indicators quarterly.[20]
• Require provincial Antimicrobial Stewardship Committees to submit six-monthly progress reports to MAC-AMR and require district committees to report antimicrobial consumption, resistance, notifiable-condition outbreaks and healthcare-associated infections twice yearly to district, provincial and national structures.[7][10][13]
• Require hospital Antimicrobial Stewardship Committees to oversee local stewardship activities, monitor usage and resistance, coordinate stewardship teams, and submit six-monthly reports to provincial committees.[14][26]

Surveillance is defined as systematic, longitudinal data collection, analysis, interpretation, dissemination and use for disease control and prevention. It is intended to measure resistance burden, identify high-risk areas, detect outbreaks, assess control measures, estimate case-fatality rates and support research on transmission and susceptibility.[6][1]

• Optimise surveillance and reporting for indicator organisms in humans and livestock at local, district, provincial and national levels, using reliable health-establishment and farm-level data to support empiric and targeted treatment choices.[1][2]
• Monitor resistance in selected organisms, including ESKAPE pathogens and Candida in blood cultures, through laboratory-based national surveillance and, for some organisms, sentinel-site surveillance.[23][27]
• Publish surveillance data through the National Institute for Communicable Diseases website, with analysis and evaluation undertaken by its pathologists and epidemiologists.[24][28]
• Update and publish national antibiotic-resistance maps, benchmark internationally, and communicate the epidemiological and clinical consequences of emerging multidrug-resistant organisms to provincial leadership and other stakeholders.[29]
• Review provincial resistance profiles at least annually using National Institute for Communicable Diseases and designated private-laboratory reports, including World Health Organization Global Antimicrobial Resistance and Use Surveillance System organism-drug combinations.[15]

Antimicrobial-consumption monitoring uses pharmacy, supplier, import, hospital and district data. Measures include Defined Daily Doses (DDDs) per 100 patient days for inpatient settings, DDDs per 1,000 inhabitants for selected population measures, and DDDs without a denominator where outpatient data require this approach.[9][15][21]

• Analyse consumption by oral and intravenous route, antibiotic class, broad-to-narrow-spectrum ratios, intravenous-to-oral ratios, all J01 antibacterials and selected antibiotic classes.[21][30][22]
• Use standardised reporting templates containing the analysis period, antibiotic description, Anatomical Therapeutic Chemical classification, strength, pack size, dosage form, DDD, quantity issued and patient days.[31]
• Apply consistent denominators, adjust inpatient measures for occupancy, and exclude discharge days from patient-day calculations to avoid inflating denominators.[22][31]
• Conduct antimicrobial-use audits at least every six months, provide annual resistance and use data to prescribers, and assess whether audits demonstrate more rational prescribing, de-escalation and oral switching.[32]

Accountability is supported by inspection-based compliance assessment, committee records, progress reporting, audit feedback, quality-improvement tracking and review of facilities where poor antimicrobial stewardship or infection prevention and control practices create patient-safety risks.[29][11][25]

• Audit stewardship practices including culture collection before antibiotics, documented indications, guideline-concordant empirical treatment, treatment review after culture results, de-escalation, intravenous-to-oral switching and treatment duration.[16][33]
• Audit standard precautions and hand hygiene monthly, assess cleaning and infection-control practices against National Core Standards, and use quality-improvement initiatives to strengthen compliance.[18]
• Review multidrug-resistant organism outbreaks and receive quarterly reports on central line-associated bloodstream infection, catheter-associated urinary tract infection, surgical-site infection and ventilator-associated pneumonia at tertiary and secondary hospitals.[15]

Resistance reports should express results as percentage non-susceptible, normally use the first isolate per patient, and exercise caution where fewer than 30 isolates are available. These data should not be interpreted as infection rates, and their quality depends on appropriate specimen collection and diagnostic testing.[28][33]

Costing & Financing

Financing is largely framed as an implementation responsibility rather than a quantified costed plan. The Department of Science and Technology is expected to identify and fund antimicrobial resistance as a national health priority through statutory funding agencies, while National Treasury is expected to earmark funding for priority One Health antimicrobial-resistance activities within relevant national departmental budgets.[8]

• Establish provincial budgets to support antimicrobial-resistance activities and adapt national objectives and standards to provincial operational and governance arrangements.[7]
• Allocate funding for provincial antimicrobial-resistance interventions from existing funding sources, and monitor and account for expenditure and the use of intervention budgets.[11][15]
• Provide provincial and district antimicrobial-resistance champions with appropriate mandates, resources, training and budgets to support implementation and improvement activities.[11][12]
• Include annual antimicrobial-resistance funding and budget inputs in district and integrated health planning, with district stewardship committees providing input on funding needs.[13]
• Undertake annual audits of antimicrobial use by both volume and cost as part of establishment-level stewardship monitoring.[32]

No monetary budgets, expenditure estimates, allocations, funding-gap assessments, financing targets, resource-mobilisation totals or economic assumptions are specified in the supplied material.[2][7][15][13]