KQM;

1. Evolving Roles of Pharmacists in
Antimicrobial Stewardship
Mediadora C. Saniel, MD, MBA-H
2019 PPHA National Covention
May 4, 2019
Davao City

2. Outline
• Rationale for antimicrobial stewardship
(AMS)
• AMS in the Philippines
• Role of pharmacists in current AMS program
• Expanding the role of pharmacists

3. Air pollution and climate change
Noncommunicable diseases
Global influenza pandemic
Fragile and vulnerable settings
Antimicrobial resistance
Ebola and other high-threat pathogens
Weak primary health care
Vaccine hesitancy
Dengue
HIV

4. AMR as a Global Public Health threat
• AMR kills
• AMR hampers the control of infectious diseases
• AMR increases the costs of health care
• AMR jeopardizes health care gains to society
• AMR has the potential to threaten health security,
and damage trade and economy
WHO fact sheet, 2011

7. Review on Antimicrobial Resistance 2014

8. Review on Antimicrobial Resistance 2014

10. The Antibiotic Resistance
Surveillance Program (ARSP)
• Very alarming rates of
resistance among various
pathogens
▫ Escherichia coli
▫ Klebsiella spp.
▫ Pseudomonas aeruginosa
▫ Acinetobacter spp.
▫ Streptococcus pneumoniae
▫ Staphylococcus aureus
▫ Neisseria gonorrheae

11. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP

12. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
Administrative Order no. 42 s. 2014
Office of the President
The Inter-Agency
Committee on AMR
(ICAMR)
Chairs:
DOH
DA
Members:
DTI
DILG
DOST

13. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
The Philippine Action Plan to Combat AMR:
One Health Approach
Launched in Nov 2015:
the National AMR
Summit to celebrate
the World Antibiotic
Awareness Week 2015

14. Vision of the the PNAP
A nation protected against the threats of
antimicrobial resistance
Mission of the PNAP
To implement an integrated, comprehensive, and
sustainable national program to address antimicrobial
resistance geared towards safeguarding human and animal
health, and preventing interference in agricultural, food,
trade, communication and environmental sector activities.
Philippine National Action Plan on Antimicrobial
Resistance - One Health Approach (2019-2023)

15. The Philippine Action Plan to
Combat AMR – One Health
Approach
Governance
and
Leadership
Surveillance and
laboratory capacity
Access to essential
medicines of
assured quality
Enhance infection
prevention and control
across all settings
Awareness
and
Promotion
Research and
Development
RATIONAL
ANTIMICROBIAL
USE AMONG
HUMANS AND
ANIMALS
ANTIMICROBIAL
STEWARDSHIP
PROGRAM (PPS)

16. Pubmed citations on antimicrobial or antibiotic stewardship
over the past 20 years
O.J. Dyar et al. / Clinical Microbiology and Infection 2017

17. What is Antimicrobial Stewardship?
• A program or set of interventions
• An approach or method or strategy
• A philosophy or ethic
• A means to tackle antimicrobial resistance
• A description of goals
• A description of activities

18. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
ANTIMICROBIAL STEWARDSHIP
The concerted implementation of systematic, multi-
disciplinary, multi-pronged interventions to ensure
the appropriate use of antimicrobials
RIGHT
Choice of antibiotic
Route of administration
Dose
Time
Duration
To improve patient
outcomes
To prevent or slow
the emergence of
AMR
Minimize harm to
the patient and
future patients
To reduce health
care–related costs

19. CDC Antibiotic Treatment in Hospitals:
Core Elements
1. Leadership commitment: Dedicate necessary
human, financial, and IT resources
2. Accountability: Appoint a single leader
responsible for program outcomes-this is usually
a physician
3. Drug expertise: Appoint a single pharmacist
leader to support improved prescribing
4. Act: Take at least one prescribing improvement
action, such as “antibiotic timeout”
5. Track: Monitor prescribing and antibiotic
resistance patterns
6. Report: Regularly report to interdisciplinary
team the prescribing and resistance patterns,
and steps to improve
7. Educate: Offer team education about antibiotic
resistance and improving prescribing practice
Centers for Disease Control and Prevention. MMWR. March 2014. 63; 194-200.

20. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
NATIONAL AMS PROGRAM

22. The critical role of
pharmacists in antimicrobial
stewardship is obvious!

23. Roles/Responsibilities of Clinical Pharmacist
• Assists in coordinating and implementing AMS activities
• Assists in the development /dissemination of guidelines, monitoring of
antimicrobial use and AMR, and in assessing the performance of AMS
program
• Ensures/enforces compliance to all AMS policies, guidelines and
procedures
• Performs POC interventions to optimize the patient’s antimicrobial
therapy
• Educates pharmacy staff and students on AMS
• Coordinates with medical/nursing staff to ensure timely administration
of appropriate antimicrobials
• Identifies cases that require review by ID specialists
• Provides drug info and advice on dose, drug interactions and ADRs
• Evaluates antimicrobial prescribing behaviour and provides feedback to
prescribers
Manual of Procedures for Implementing AMS Programs in Hospitals. DOH

24. A dedicated multi-disciplinary AMS Committee and Team, supported by the
hospital administration, shall be responsible to successfully implement, perform
and monitor the AMS Program in each hospital.
Core Element 1: Leadership

25. 25
• Hospital administrator
• Infectious diseases
physician when available
or opinion leading
prescriber
• Pharmacist
• Clinical microbiologist
• Infection prevention &
control professional
• Nursing leadership
• Hospital epidemiologist
• Information systems
specialist
AMS Committee
• Infectious diseases
physician when available
or opinion leading
prescriber
• Pharmacist
• Clinical microbiologist
• Infection prevention &
control professional
• Clinical nurse consultant
or clinical nurse educator
• Allied health
• Other relevant health care
providers
AMS Team
 Infectious Disease Specialist
 Pharmacist
 Medical Microbiologist or Medical
Technologist trained in bacteriology or
microbiology
 Representative from the Management
(policy & planning unit)
 IPC Nurse

26. Core Element 2: POLICIES,
GUIDELINES and CLINICAL PATHWAYS
National Antibiotic Guidelines
- outlines the recommended approach to
the treatment of many infectious diseases
across a range of body systems and aims
to facilitate consistency of care and
quality use of antimicrobials across
hospitals
Hospitals with the necessary capabilities should
adapt the National Antibiotic Guidelines to their
hospital’s context, by taking into account
 local microbiological and antimicrobial
susceptibility (antibiogram) patterns;
 local antimicrobial consumption, costs
and availability;

27. Follow our Local Guidelines

28. • AMR surveillance
–monitoring resistance patterns and antimicrobial
susceptibility in the hospital can inform:
▫ empirical antimicrobial therapy choices
▫ the development of hospital-specific clinical
guidelines, antibiotic policies and AMS
strategies;
▫ the impact of prescribing practices, infection
control and AMS activities on resistance rates.
CORE ELEMENT 3:
SURVEILLANCE OF ANTIMICROBIAL USE
AND RESISTANCE

29. • Antimicrobial usage/consumption
- provides critical information on the
antimicrobial prescribing/usage patterns within
the hospital and/or specific patient groups
- enables the institution and policymakers to
monitor the progress of AMS programs and assess
the impact of strategies/ interventions
CORE ELEMENT 3:
SURVEILLANCE OF ANTIMICROBIAL USE
AND RESISTANCE

30. 0
50
100
150
200
250
DDD/1000
Patient
Days
2015
2016
2017
2018
Restricted Non-Restricted
DDD/1000 Patient Days of Antimicrobials
Source: HICEC, The Medical City

31. Core Element 4: ACTION
AMS ACTIONS/ INTERVENTIONS
PERSUASIVE interventional
strategies
Prospective audit of antimicrobial
prescribing and direct intervention
and feedback (Audit and feedback)
Point-of-care (POC) interventions
RESTRICTIVE interventional
strategies
Antimicrobial restriction and
pre-authorization
Seventh day automatic stop
order

32. CORE ELEMENT 4:
ACTION

33. POINT-OF-CARE INTERVENTIONS CAN INCLUDE:
• appropriate use of guidance,
• indication for antibiotic,
• choice of agent,
• route [IV vs. oral] of administration of treatment,
• timeliness of treatment,
• likelihood of on-going infection or not,
• use of diagnostic tests for investigation,
• interpretation of microbiology with a view to de-
escalation
• duration of therapy.

34. Core Element 5:
EDUCATION
All hospitals should aim to provide training and continuous
education on AMS to all its healthcare staff, who are in contact
with patients on antibiotics: prescribers, nurses, clinical
pharmacists, microbiologists, and midwives, medical students
and paramedical staff
didactic presentations, printed/electronic materials,
roadshows, concurrent- or post-audit feedback
Educational strategies must also be targeted to patients and
their care-givers on basic principles of infection prevention and
control, personal hygiene, handwashing and core messages on
AMR and AMS

35. Core Element 6:
PERFORMANCE EVALUATION
crucial in guiding the progressive implementation of
the program both at the health facility and national
level, ultimately towards achieving the goals of the
national agenda to combat AMR.
The AMS Committees of all hospitals are to submit to
the DOH Pharmaceutical Division an annual AMS
program monitoring report for tracking of progress of
the AMS Program.
Process indicators
Outcome indicators

36. Program Indicators

37. Process and outcome indicators

39. Philippine AMS Implementing Guidelines

40. NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
AMS Training Hubs in the Philippines
Philippine General
Hospital, Taft Manila
Research Institute for
Tropical Med, Alabang
Southern Philippines
Medical Center, Davao
Jose B. Lingad Memorial
Regional Hospital
Corazon Locsin
Montelibano
Memorial Regional
Hospital,
Bacolod City

41. Department of Health
Antimicrobial Stewardship Program in Primary
AMS Training Program for Hospitals
Level III
Level II
Level I +
Others (Mother and Child,
Specialty)
T
A
R
G
E
T
Current
Status
100%
(114/114)
85.50%
(283/331)
0%
(0/791)
Overall percentage of hospitals
trained: 32.12%
(397/1,236)

42. Department of Health
Antimicrobial Stewardship Training for Hospitals
2018
• Adherence to AMS guidelines
• De-escalation
• Switching from IV to oral rx
• Therapeutic drug monitoring
• Antibiotics restriction
• Bedside consultation
show significant impact on clinical outcomes,
adverse events, costs, resistance rates, or
combinations of these

43. De-escalation of therapy based on culture
reduced mortality.
RRR= 56%

44. The majority of studies reported a positive effect of hospital
antibiotic stewardship interventions. However, we cannot draw
general conclusions about the effectiveness of such interventions
in low- and middle-income countries because of low study quality,
heterogeneity of interventions and outcomes, and under-
representation of certain settings.
Bull World Health Organ 2018

45. RISING BEYOND
EXPECTATIONS

46. LEADERSHIP
• Pharmacists can lead a hospital’s AMS
program
• Pharmacists can lead AMS at PHC level
• Pharmacists can play a lead role in the
country’s national AMR and AMS programs

49. Innovations in implementing AMS
Strategies
Innovative strategies have to be developed
– must be adapted to variations in settings, type of
HFs, resources
– can NOT be a one-size-fits-all approach
– alternative models of non-ID led AMS programs

50. Research
• What works and does not work
• Enablers and barriers
• Impact evaluation, incl. cost-effectiveness

51. Education
• Undergrad/postgrad curricula
• Continuing prof’l educational activities

52. Pharmacist-Driven Antimicrobial Stewardship

54. A pharmacist-driven, prospective audit and feedback strategy for
antimicrobial stewardship in 47 urban/rural hospitals led to a
significant reduction in mean antibiotic consumption (DDD/ 100
patient-days) from 101.38 (9% CI 93.05-109.72) to 83.04 (74.87-
91.22)

55. Targeted process measures:
Cultures not done before starting empirical antibiotics
More than 7 days of antibiotic rx
More than 14 days of antibiotic rx
Use of >4 antibiotics concurrently
Redundant/double antibiotic coverage

56. Longitudinal cohorts survey of mean antibiotic consumption for three phases of the
Netcare antimicrobial stewardship model
www.thelancet.com/infection Vol 16 September 2016

57. AMS WORKS with
PHARMACISTS AS LEADERS

58. Challenges to Pharmacist-Driven
Antimicrobial Stewardship
• Prescriber (doctor) pushback
• Lack of clinical pharmacists trained in
infectious disease/antimicrobial stewardship
• Administrative support
– appropriate compensation
• Work load considerations

59. Expanding Role of Pharmacists
in Antimicrobial Stewardship
The Political Will is Already There!
CARPE DIEM!
• Leadership and advocacy
national and local
health facilities/community
• Innovations in implementation
• Research
• Training and Education

60. Acknowledgements
Sources of Slides
• Dr. Regina Berba (UP-PGH)
• Dr. Celia Carlos (RITM)
• Dr. Rose de los Reyes (RITM)
• Dr. Karl Henson/K. Rayos (HICEC, TMC)
• Dr. Rosemarie Arciaga (PIDSP)
• AMR Secretariat ( Pharmaceutical Div.,DOH)

62. A One Health response to address the drivers and impact of antimicrobial resistance
No Time to Wait: Securing the future from drug-resistant infections. AICG. April 2019

63. One Health, IACG recommendations and the Sustainable Development Goals
No Time to Wait: Securing the future from drug-resistant infections. AICG. April 2019

64. 0
50
100
150
200
250
DDD/1000
Patient
Days
2015
2016
2017
2018
Restricted Non-Restricted
DDD/1000 Patient Days of Antimicrobials
Source: HICEC, The Medical City

65. Take Home Messages
CARPE DIEM!
The political will among leaders in the community
of pharmacists is there!
Expectations are high!
CHALLENGES:
Leadership - community,hospital
local, national
Innovations in implementation of AMS
Research
Training and Education

66. Antimicrobial Stewardship Toolkit:
Quality of Evidence to support interventions
CORE STRATEGIES SUPPLEMENTAL STRATEGIES
Formulary restrictions and
preauthorization*
Streamlining / timely de-escalation of
therapy*
Prospective audit with intervention
and feedback*
Dose optimisation*
Multidisciplinary stewardship team* Parenteral to oral conversion*
Guidelines and clinical pathways*
Antimicrobial order forms
Education
Computerized decision support,
surveillance
Laboratory surveillance and feedback
Combination therapies
Antimicrobial cycling
*Strategies with strongest evidence and support by IDSA
Adapted from Dellit TH et al. Clinical Infectious Diseases 2007; 44:159-77; Barlam TF et al. Clinical Infectious Diseases 2016; 62:51 -77

67. Two core ASP strategies have evolved:
 “Front-end strategies” where antimicrobials are
made available through an approval process
(formulary restrictions and preauthorization).
 “Back-end“ strategies where antimicrobials are
reviewed after antimicrobial therapy has been
initiated (prospective audit with intervention
and feedback

68. Antimicrobial Stewardship Treatment Algorithm

69. Main antimicrobial stewardship strategies recommended
to improve antibiotic use at the hospital level
PASSIVE EDUCATIONAL MEASURES
• Developing/updating local antibiotic guidelines, clinical pathways or
algorithms
• Face to face educational sessions, workshops, local conferences
ACTIVE INTERVENTIONS
• Clinical rounds discussing clinical cases, morbidity & mortality meetings,
significant event analysis/reviews
• Prospective audit with intervention and feedback
• Reassessment of antibiotic prescriptions, with streamlining and de-
escalation
• Academic detailing, educational outreach visits
• E-learning resources used as individual or group activities can compliment
traditional learning methods, as a “blended learning” approach
Adapted from Pulcini C and Gyssens IC. Virulence 2013;4:192–202

70. True Drivers of AMR in Philippines
Source: The Philippine Action Plan to Combat Antimicrobial Resistance
INDUST
RY
HEALTH
PROFESSION
ALS
PATIENTS

71. Front-and Back-end Antimicrobial Stewardship Strategies

72. CORE ELEMENT 5:
EDUCATION
72
Informal education for AMS practitioners
 Identify mentor with ID expertise for case
discussions
 Attend ward rounds with ID specialist
 Observership with a clinical microbiologist
 Join ID professional organizations
 Attend ID professional meetings
 Participate in ID-related continual education
programs
 Read ID-related journals and articles
 Participate in ID journal club