Understanding the landscape for driving antimicrobial stewardship implementation at scale in South Africa

Antimicrobial stewardship (AMS) programmes are essential for responding to antimicrobial resistance, yet implementation at scale remains challenging everywhere, including in South Africa. This study explored the landscape for driving AMS implementation, identified barriers and enablers and identified priorities for subsequent multi-facility interventions.

Phase 1 of a prospective, multi-phased mixed-methods study used participatory action research informed by the Breakthrough Series methodology and Theory U. Health professionals from public and private sectors participated in workshops in Cape Town and Johannesburg. Activities included mapping individual AMS journeys, identifying barriers and enablers at individual, institutional/facility and national/provincial levels, conducting a SWOT analysis and prioritizing potential AMS implementation projects. Data were analysed using descriptive content analysis.

Participants identified substantial enabling factors alongside persistent barriers. Key enablers included mentorship, multidisciplinary collaboration, management support, functional AMS and infection prevention structures, guidelines, diagnostics, national policies and professional society advocacy. Barriers included professional isolation, weak interprofessional relationships, limited funding and staffing, inadequate training, weak governance, poor data use, fragmented public-private and inter-provincial systems, and inconsistent policy implementation. Strengths were identified as being existing programmes and collaboration, weaknesses as resource and education gaps, opportunities as cross-sector collaboration and technology and threats as limited political support and economic constraints. Eight priority AMS areas were identified as collaborative projects for implementation across multiple healthcare settings.

South Africa has important existing assets for AMS implementation, although these are unevenly distributed and inconsistently used. Strengthening leadership and collaboration, leveraging existing structures and implementing context-specific countermeasures may support at-scale AMS implementation.