Defining and responding to the contextual drivers for implementation of antimicrobial stewardship in 14 neonatal units in South Africa
Authors: Van Den Bergh Dena , Charani Esmita , Dramowski Angela , Annor Ama Sakoa , Gijzelaar Michelle , Messina Angeliki , Van Jaarsveld Andriette , Goff Debra A , Prusakov Pavel , Balfour Liezl , Bekker Adrie , Cassim Azraa , Govender Nelesh P , Holgate Sandi L , Kolman Sonya , Tootla Hafsah , Schellack Natalie , Reddy Kessendri , Fisher Christine , Conradie Lucinda , Van Niekerk Anika , Laubscher Anje , Alexander Pearl , Naidoo Thanusha , Dippenaar Magdel , Bamford Colleen , Brits Sharnel , Chirwa Pinky , Erasmus Hannelie , Ekermans Pieter , Rungen Lerina , Kriel Teresa , Mawela Dini , Mjekula Simthembile , Nchabeleng Maphoshane , Nhari Ronald , Janse Van Rensburg Marli , Sánchez Pablo J , Brink Adrian ,   NeoAMS Study Team, Cassim Azraa , Nakwa Firdose , Thomas Reenu , Van Kwawegen Alison , Wadula Jeannette , Annor Ama Sakoa , Mawela Dini , Moncho Masego , Motau Martha Tshipo , Nchabeleng Maphoshane , Brits Sharnel , Breytenbach Willem , Els-Goussard Ilse , Grotepass Erika , Portland Alida , Tootla Hafsah , Arendse Ayesha , Fisher Christine , Khumalo Amanda , Mjekula Simthembile , Pillay Shakti , Kader Abdul Qayyum , Govind Chetna , Moodley Vinesh , Naidoo Thanusha , Rungen Lerina , Alexander Pearl , Berlyn John , Dreyer Owen , Maharaj Arisna , Peens Dawie , Pieters Madeleine , van Schalkwyk Emma , Starr Marlon , Bamford Colleen , Kriel Teresa , van der Wal Mariska , Mgudlwa Veliswa , Beukes Colette , Macdonald James , Nhari Ronald , Ndou Tanya , Rapoone Gladys , Taljaard Antia , Aucamp Marina , Conradie Lucinda , Tootla Hafsah , van Niekerk Anika , Chibabhai Vindana , Chirwa Pinky , Kolman Sonya , Nchwee Selebaleng , Bruwer Dina , Dippenaar Magdel , Erasmus Hannelie , Olivier Madaleen , van der Westhuizen Lea , Coetzee Juanita , Ekermans Pieter , Engelbrecht Marleen , van Rensburg Marli Janse , van Tonder Lindie , Bester Tarina , van Blerk Zanli , Laubscher Anje , Lotter Johnny , Venter Liesl , du Toit Heinrich , Coetzee Jennifer , Bartman Deleen , Bekker Adrie , Holgate Sandi , Reddy Kessendri , Hloyi Sinethemba , Isobel Trudie , Radloff Leticia 
Published: January 2025

Abstract

Background
Research on the contextual drivers of antimicrobial stewardship (AMS) programme interventions in neonatal units is limited.

Methods
As part of a prospective mixed-methods multidisciplinary neonatal AMS (NeoAMS) interventional study in 14 South African hospitals, we applied a three-phased process to assess implementation barriers and contextual drivers experienced by participating health professionals. The study included: (Phase one; P1) a survey of pre-intervention barriers and enablers; (P2) written feedback during the study intervention phase; and (P3) semi-structured exit interviews.

Results
Respondents to the P1 survey (n = 100) identified 15 barriers, 9 in the domain of personnel resources, including staffing, time and workload constraints. Other barriers related to limited access to antimicrobial use and surveillance trends, complexity of neonatal care, absence of multidisciplinary team (MDT) AMS and change resistance. For P2, written feedback during implementation (n = 42) confirmed that the MDT approach facilitated systems changes, including policy adaptations, process improvements, strengthened infection control practices, and expansion of AMS MDT roles. MDT benefits were described as aligned team purpose, improved communication, and knowledge sharing. Reported challenges included time to meet and building trust. In P3 interviews (n = 42), improved interpersonal communication, trust, personal growth and confidence building were cited as highlights of working in multidisciplinary AMS teams. Extending the MDT approach to other hospitals, training more health professionals in AMS and increasing management involvement were identified as priorities going forward.

Conclusions
Understanding the organizational and interprofessional context for NeoAMS implementation enabled an MDT approach to develop and optimize neonatal AMS with potential for adoption in similar resource-constrained settings.