Evolving Roles of Pharmacists in

Antimicrobial Stewardship
Mediadora C. Saniel, MD, MBA-H
2019 PPHA National Covention
May 4, 2019
Davao City
 Outline
• Rationale for antimicrobial stewardship
(AMS)
• AMS in the Philippines
• Role of pharmacists in current AMS program
• Expanding the role of pharmacists
 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
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
Review on Antimicrobial Resistance 2014
Review on Antimicrobial Resistance 2014
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
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
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 NATIONAL
Week 2015
ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP
Philippine National Action Plan on Antimicrobial
Resistance - One Health Approach (2019-2023)

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

ANTIMICROBIAL
Research and
STEWARDSHIP
Development
PROGRAM (PPS)
Pubmed citations on antimicrobial or antibiotic stewardship
over the past 20 years

O.J. Dyar et al. / Clinical Microbiology and Infection 2017

 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
 ANTIMICROBIAL STEWARDSHIP
The concerted implementation of systematic, multi-
disciplinary, multi-pronged interventions to ensure
the appropriate use of antimicrobials

Choice of antibiotic
To prevent or slow
RIGHT

Route of administration To improve patient

the emergence of
outcomes
AMR
Dose
Minimize harm to
Time the patient and
To reduce health
care–related costs
future patients
Duration

NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP

 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.
NATIONAL AMS PROGRAM

NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP

 The critical role of
pharmacists in antimicrobial
stewardship is obvious!
 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

 Core Element 1: Leadership
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.
 AMS Committee AMS Team

• Hospital administrator • Infectious diseases

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

25
 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;
Follow our Local Guidelines
CORE ELEMENT 3:
SURVEILLANCE OF ANTIMICROBIAL USE
AND RESISTANCE
• 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

• 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
 DDD/1000 Patient Days of Antimicrobials
Restricted Non-Restricted
250

200
2015
DDD/1000 Patient Days

2016
150 2017
2018

100

50

Source: HICEC, The Medical City

 Core Element 4: ACTION

AMS ACTIONS/ INTERVENTIONS

PERSUASIVE interventional RESTRICTIVE interventional

strategies strategies

Prospective audit of antimicrobial

prescribing and direct intervention Antimicrobial restriction and
and feedback (Audit and feedback) pre-authorization

Point-of-care (POC) interventions Seventh day automatic stop

order
CORE ELEMENT 4:
ACTION
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.
 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
 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
Program Indicators
Process and outcome indicators
Philippine AMS Implementing Guidelines
 AMS Training Hubs in the Philippines
Philippine General Research Institute for Southern Philippines
Hospital, Taft Manila Tropical Med, Alabang Medical Center, Davao

Corazon Locsin Jose B. Lingad Memorial

Montelibano Regional Hospital
Memorial Regional
Hospital,
Bacolod City

NATIONAL ANTIMICROBIAL STEWARDSHIP TRAINING WORKSHOP

AMS Training Program for Hospitals

Current Status
T Level III 100%
A (114/114)

R 85.50%
Level II
(283/331)
G
E Level I + 0%
(0/791)
T Others (Mother and Child,
Specialty)
Overall percentage of hospitals
Department of Health
trained: 32.12%
(397/1,236)
Antimicrobial Stewardship Program in Primary
 • 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
Department of Health
Antimicrobial Stewardship Training for Hospitals
2018
De-escalation of therapy based on culture
reduced mortality.
RRR= 56%
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

RISING BEYOND
EXPECTATIONS
 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
 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
 Research
• What works and does not work
• Enablers and barriers
• Impact evaluation, incl. cost-effectiveness
 Education

• Undergrad/postgrad curricula
• Continuing prof’l educational activities
Pharmacist-Driven Antimicrobial Stewardship
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)
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
Longitudinal cohorts survey of mean antibiotic consumption for three phases of the
Netcare antimicrobial stewardship model

www.thelancet.com/infection Vol 16 September 2016

 AMS WORKS with
PHARMACISTS AS LEADERS
 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
 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
 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)
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
One Health, IACG recommendations and the Sustainable Development Goals

No Time to Wait: Securing the future from drug-resistant infections. AICG. April 2019
 DDD/1000 Patient Days of Antimicrobials
Restricted Non-Restricted
250

200
2015
DDD/1000 Patient Days

2016
150 2017
2018

100

50

Source: HICEC, The Medical City

 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
 Antimicrobial Stewardship Toolkit:
Quality of Evidence to support interventions
CORE STRATEGIES SUPPLEMENTAL STRATEGIES
Formulary restrictions and Streamlining / timely de-escalation of
preauthorization* therapy*
Prospective audit with intervention Dose optimisation*
and feedback*
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
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
Antimicrobial Stewardship Treatment Algorithm
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

True Drivers of AMR in Philippines

PATIENTS

HEALTH
PROFESSION
ALS
INDUST
RY

Source: The Philippine Action Plan to Combat Antimicrobial Resistance

Front-and Back-end Antimicrobial Stewardship Strategies
 CORE ELEMENT 5:
EDUCATION
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 72