# Development of AWaRe-Based Quality Indicators to Assess the Appropriateness of Antibiotic Prescribing in Primary Healthcare in South Africa

## TL;DR

This study developed quality indicators to assess antibiotic prescribing in South African primary healthcare using WHO's AWaRe guidelines.

## Contribution

It introduces a new set of antibiotic prescribing quality indicators tailored for South African public primary healthcare settings.

## Key findings

- 61 out of 89 indicators were rated appropriate and feasible for assessing antibiotic prescribing.
- Dental and skin infections had the highest agreement on indicator appropriateness and feasibility.
- Lower urinary tract and general categories had the lowest agreement on indicator feasibility.

## Abstract

Background/Objectives: The overuse and misuse of antibiotics contribute to antimicrobial resistance (AMR) globally. The appropriateness of antibiotic prescribing at the primary healthcare (PHC) level must be urgently addressed to reduce high levels of inappropriate antibiotic prescribing and associated AMR. This study aimed to develop quality indicators, based on the World Health Organization (WHO)’s Access, Watch, Reserve (AWaRe) guidance, to assess the appropriateness and quality regarding antibiotic prescribing in public PHC settings in South Africa. Methods: Potential indicators were identified from indicators developed by City St George’s, University of London (SGUL); a review of AWaRe-based indicators; and the results from point prevalence surveys at PHC clinics in South Africa. The indicators were developed using the RAND/UCLA Appropriateness Method. In Round 1, 12 experts individually rated 78 indicators for clarity and appropriateness. In Round 2, 10 experts rated 89 indicators for appropriateness and feasibility during an interactive online meeting. Results: The final set had 61/89 indicators (68.5%) that were rated both appropriate and feasible with agreement. Dental infections (9/9; 100%) alongside skin and soft tissue infections (11/13; 84.6%) had the highest percentage of indicators that were rated appropriate and feasible with agreement. Lower urinary tract infections (6/11; 54.5%) and general (4/8; 50%) categories had the lowest percentage of indicators rated appropriate and feasible with agreement. Conclusions: The process proved valuable in developing potential indicators for use in future antimicrobial stewardship programmes to improve antibiotic prescribing in public sector PHC facilities in South Africa and beyond.