antimicrobial stewardship in fiji - monash university · • a questionnaire for doctors was...
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MathewPeckTravellingScholarshipProgramFacultyofPharmacyandPharmaceuticalSciences
MonashUniversity,ParkvilleCampusMelbourneAustralia
Antimicrobial Stewardship in FijiContributions by Alistair Pickmere November 2015
and Kyle Booth January 2017
as part of the Fiji National Antimicrobial Resistance Action Plan
Senior Pharmacists Network Event May 30, 2017
TheMathewPeckTravellingScholarship• ThescholarshiphonoursMathewPeck,aBachelorofPharmacystudentwho
diedtragicallywhiletravellinginSouthAmericaaftercompletinghisfirstyearofstudy.Mathewwascommittedtoaddressinginternationalhealthissuesbyusingpharmacytoimprovepeople’slives.Thisscholarship,establishedbyhisparentsandfamily,isalegacytohim.
• WewouldliketothankthePeckfamilyforestablishingthisscholarshipinMathew'smemory,andalsothescholarshipselectioncommitteewhochoseusforthiswonderfulhonourandopportunity.OnbehalfofallthepreviousMathewPeckScholarsandusboth,thankyoutothefacultyandespeciallytothedonorswhosupportthisscholarship- withoutthem,wemaynotbeabletocontributetothisvitalresearch.
• Readaboutsomeotherscholarshiprecipientsherehttps://ozpharmavols.wordpress.com/student-placements/mat-peck-scholarship/
• MonashUniversitylinkhttp://www.monash.edu.au/pharm/alumni/support/scholarships/mathew-peck/
RepublicofFiji
PharmaceuticalExpenditure2005
The Fiji Islands
Introduction• In2014,theWHOdeclaredantimicrobialresistanceasaglobal
healththreatthatrequiresurgentcollaborativeaction.
• Alarmingratesofresistancetohospitalandcommunity-acquiredinfectionshavebeenreportedglobally,withsomeofthehighestratesreportedintheWesternPacificRegion.
• TheMinistryofHealthandMedicalServices,Fijiidentifiedantimicrobialresistanceasoneofthepriorityagendas.
• InNovember2015FijidevelopedaNationalActionPlanonantimicrobialresistancebasedonatemplateprovidedbytheWHOWPRO.
TheFijiNationalActionPlanObjectives
1. Improveawarenessandunderstandingofantimicrobialresistancethrougheffectivecommunication,educationandtraining.
2. Strengthennationallycoordinatedsurveillancesystems.
3. Optimizetheuseofantimicrobialmedicinesinhumanandanimalhealth.
4. Establishandensuregovernance,sustainableinvestmentandactionstocombatantimicrobialresistance.
ImplementationFramework§ StrategicOperationalPlan
§ ReviewandEvaluation
Implementation1. NationalAntimicrobialResistancecommitteesetupincluding
§ MinistryofHealthandMedicalServices(ChairpersonandSecretary)§ MinistryofAgriculture(includesVeterinarydept.)§ MinistryofEducation§ DepartmentofEnvironment§ DepartmentofFisheries§ MedicalInstitutions(UniversityPSMandFijiNationalUniversity)§ PrivateSector(PharmaceuticalandGPs)§ ConsumerCouncil§ CustomsAuthority§ BioSecurityAuthorityofFiji[BAF]Advisorsofthecommittee§ GMUrepresentative§ WHO(reportingtotripartiteagreement)
2. ProjectPharmacistappointed- todevelopandoverseetheimplementationofaNationalPlanofOperationsandreporttothecommittee
PlanofOperations:developedbyProjectPharmacist
Morethan50categoriesofactivitiestoaddresstheStrategicObjectivesareincorporatedincluding• Identifiedareasthatrequiredsituationanalysesorfurtherinformation
toinformthedesignofactivities- tobegatheredunderthesupervisionoftheProjectPharmacist– including
Attheendof2015tobedonebyAlistairPickmere
1. Gatherinformationabouttheknowledgeantibiotics,theiruseandresistance,ofbothprescribersandpatientsinDivisionallevelhealthservices
2. Gatherinformationsurroundingtheuseoftherestrictedlastlineantibiotic– colistin- inmajorhospitals
Atthebeginningof2017tobedonebyKyleBooth
3. GatherinformationconcerningtheunderstandingoftheconceptsofAMSbyprivateretailpharmacistsandhospitalpharmacist.
Acknowledgments1. Atthebeginningof2015,beforethedevelopmentoftheFijiNational
AMRPlan,JessicaDayment,alsoaMathewPeckScholarshiprecipient,performedastudyoftheuseoftherestrictedantibiotic-meropenem– inthemajorFijihospitalsunderthesupervisionoftheFijiMoHMSPharmaceuticalServices.
2. InAugust2015CrystalYimanAustralianpharmacist(GriffithsUni)workingwiththeFijianMoHMS&supportedbytheAustralianGovernmentvolunteerprogramcoordinatedastudyof5000Fijiansrepresentingallareasofthenation(attendinganationalfestivalinSuva)togatherinformationaboutcommunityperceptionsandunderstandingoftheroleanduseofantibiotics.
https://ozpharmavols.files.wordpress.com/2015/12/antibiotic-awareness-survey-report-final.pdf
ThefindingsofboththosestudiesalsohelpedguidethedevelopmentofthePlanofOperations.
• AllreportsofVCPstudents’studiescanbedownloadedfromhttps://wordpress.com/page/ozpharmavols.wordpress.com/60
Alistair’sStory
AlistairPickmere
B.ScB.Pharm(Hons)G.Dip.App.Sc
RoyalChildren’sHospitalMelbourne
2015MathewPeckScholarshipRecipient,MonashUniversity
Whatthisopportunityenabledmetodo• Carryouttwoinvestigationsofantibioticunderstandingand
use– fromtheprescribers’andpatients’perspectives;andoneinvestigationofcolistinuseinhospitals- inFijiinNovember/December2015,andreportfindingsandrecommendationstotheFijiMinistryofHealthinApril2016
• AttendAntibioticAwarenessWeekfunctionsorganisedbytheWorldHealthOrganisationandTheFijianMinistryofHealthgaininginsightintothepractisesandprinciplesrequiredinsuchenvironments
• FacilitatecommunicationbetweentheCWMHandMelbournebasedHospitalsfollowingmyreturntoMelbourne.
AlistairPickmereNov/Dec2015OPDStudyTogetabetterunderstandingofknowledgeaboutantibioticsinFiji,surveyswerecarriedoutundertheleadershipoftheFPBSCEssentialMedicinesAuthority1.togetabetterunderstandingoftheknowledgeandattitudesofpatientsandprescribersintheclinicoutpatientsettings.• Methods:FivebusyDivisionalHealthCentreoutpatientfacilities,thatwere
closeenoughtoSuvatoenableconvenientaccessinthetimeavailable,werechosenforinvestigation.TheEMAintroducedtheinvestigatortothestaffandpatients.
• AntibioticprescriptionsdispensedbythepharmaciesduringthepreviousweekwerecollectedfromthepharmacistsandreviewedbytheinvestigatorinthelightoftheFijiAntibioticSTG3andotherrelevanttexts.Thediagnosisassociatedwithprescribedtreatmentwasnotedontheprescriptionstoenablesuchreview.
• Apreparedpatientquestionnairewasusedasthebasisofthediscussionwithpatientswhohadreceivedprescriptionsforantibiotics.Itcoveredpatients’understandingoftheroleofantibioticsandhowtheyshouldbeused.Continuednextslide
AlistairPickmereNov/Dec2015OPDStudyMethodscontinued
• AquestionnaireforDoctorswaspreparedtocollectprescribers’perceptionsaboutrestrictions,guidelines,‘patientpressures’andpatternsmotivatingtheprescriptionofantibiotics.
• TheresultsofthequestionswererecordedinSurveyGizmosoftwareandtheresultsofopenendedquestionswererecordedbyhandforlaterentryinthedatabase.
• TheSurveyGizmowasusedtogeneraterawanalysisofthedataandtoprovidegraphicrepresentationoftheresults.Thoseresultswerecombinedwiththeinvestigator’snarrativetogenerateareport.
Forthefullreportincludingresults,discussion,conclusionsandrecommendationseehere:
https://wordpress.com/page/ozpharmavols.wordpress.com/60
InvestigatingknowledgeanduseofantibioticsatfiveDivisionalHealthCentreout-patientclinicsinFiji- 1
FindingsAnalysisofperceptionsconcerninguseofantibiotics• Theprescriptionsprovideda‘picture’oftheprevalentinfectionsbeing
treated,primarilyskinandrespiratorytractinfectionssuggestingacampaignfocussingonpersonalhygienecouldbebeneficial.
PatientSurveyresponses• Patientresponsesindicatethatthereisanurgentneedformoreand
ongoingeducationofthecommunityabouttheroleandusesofantibioticsandhowandwhentheyshouldbetaken.Theconceptofantibioticresistancewasnotcomprehendibleinthemajorityofpatients.
InvestigatingknowledgeanduseofantibioticsatfiveDivisionalHealthCentreout-patientclinicsinFiji- 2
FindingsAnalysisofperceptionsconcerninguseofantibioticsPhysicianSurveyResponses
• Physiciansresponsesconflictedthoseofthepatients- identifyingpatientpressuretoprescribeantibioticsasaregularoccurrence.Physiciansidentifiedthattheydohaveallresourcesnecessaryavailable,howevertheyarepoorlyaccessibleandused(includingcurrentSTG).
StockMaintenance
• Maintenanceofreliablesuppliesofappropriatestockisanissue.Lackofpharmaceuticalswithinthehealthserviceisunacceptableespecially whenitisduetopoormanagementwhichseemstobethecase.
Recommendations1.Basedonanalysisofprescriptions
• Considerthepreparationofprintedprescriptionformsthatencouragetheprovisionofcorrectcompleteinformationtoberecorded.
• Ensurethatallprescribershave accesstocurrentSTGs
• Considercontinuingeducationprogramsfornursesandphysicians
• ImplementacommunityhygienecampaignthatincludesscabiespreventionandtreatmentincollaborationwiththeConsumerCouncil.
• Implementandroutinelyrevisedatacollectionofprevailinginfections,antibiotictherapiesutilisedandapparentresistanceswithinthedivisionalhealthcenters
• EnsurethattheMoHMS websiteisup-to-datewithinformationandreferencesthatarerelevanttoantimicrobialmanagementinFiji.
Recommendations2.BasedonPatients’responses
• Implementongoingeducationinthecommunityabouttheroleandusesofantibioticsandhowandwhentheyshouldbetakenaswellas theconceptofantibioticresistance
• Distributeleafletsanddisplaypostersinclinics,retailpharmaciesandchurchesanddevelopandpresentregularRadio andTVspots.
• PartnerwiththeConsumerCouncilofFijiasmuchaspossible
• Provideeducationmaterialfordeliveryinregularshortsessionsofwaitingroomeducationbyclinicstaffthatcanbeprovidedatatimejudgedtocatchmostpatients.
Recommendations3
BasedonPhysicians’responses
• Considerinvestigationoftheresistancepatternofchestinfectionstoassessamoxicillinresistance.
• DevelopownershipofSTGs- ProvideAntibioticSTGs(ASTG)toeveryindividualmedicalstudentandprescriberinFiji,ensureindicatedmedicinesinstock to allowforadherencetoSTG
• DevelopfurthereducationfordoctorsincollaborationwiththeFijiMedicalCouncilandfornurseswiththeFijiNursingCouncil.
• IncollaborationtheUniversityMedicalFaculty,theFijiMedicalCouncilandtheFijiSchoolofNursingincludeCPDpointsforthiscontinuingeducation
Recommendations2Donations(ItwasfoundthatdoctorsinclinicshadbeenaskingfordonationsofmedicinesfromTaiwan– againsttheNationalFijiDonationGuidelines)
• DistributetheFijiDonationGuidelinesasabrochuretoallclinicsandprovidetheFijiMedicalCouncilwithcopies.
• ProvideFijiDonationGuidelinesasabrochureandasfullcopytoMoHMSofficialsandrelevantFijipoliticians
• ProvideFijiDonationGuidelinesasabrochuretoRotaryandothersimilarclubs.
• ProvideFijiDonationGuidelinesasabrochuretoallforeignmissions
• Maintainappropriatestocksothattherewillbenoincentivetolookfordonations.
Recommendations
2.Stockmaintenance
• Maintaincorrectstocklevelsinallhealthfacilities,§ prescribeaccordingtotheSTGs
§ maintainrecordsofpatientconditionsandtreatmentsand
§ usethedatatogenerateordersfortheappropriatequantities.
• FPBSCwillsupplyorderformsthatfacilitateappropriatequantificationandordering,andwillexamineordersandconsultappropriateclinicalstaff.
AlistairPickmere- 2- ColistinstudyIntroduction:Colistinisanexpensive‘last-resort’broad-spectrumantibacterialagent,thatisusedtotreatmulti-resistantAcinetobacterbaumannii(anopportunisticorganismthatoftencausesnosocomialinfections)andcertainother spp.Therefore,colistinuseandmisuseraisesthepotentialforthedevelopmentofsignificantbacterialresistancewithprofoundclinicalimpactontheFijianhealthcaresystem.AstudywasundertakentodeterminetheextentoftheintravenoususeofcolistinandtherationaleandreasonsforitsuseinthreehospitalsinFijiduringthetimeithasbeenavailableinFiji.
Methods:Recordsoftreatmentweresoughtandanalysedforpatientswhohadbeentreatedwithcolistin.Informationfromphysicianswasgatheredabouttheiruseofcolistin;MicrobiologyandInfectiousDiseasesteamswereinterviewed;costissueswereexploredandresistancepatternsoforganismswereexamined.
Investigatingcolistin usageinFijiattheColonialWarMemorialHospital,LautokaHospitalandLabasa Hospital
fromAugust2014toNovember2015
Patientcharacteristics
• Therewereatotal25patients - 24Adult(16andabove),1paediatricpatient.Only6hadfullmedicalprofilesandrecordsavailable.
• 14patientswhorequiredcolistininprevious18monthshaddiedfromassociatedconditions.
• Allpatientswerewithintheintensivecaresetting,apartfromonewhichwaswithintheAcuteSurgicalUnitawaitingtransfertoICU.
• Onepatientwasidentifiedassuitableforcolistintreatmentbutdied followingtransferfromLabasa toCWMH
InvestigatingcolistinusageinFijiattheColonialWarMemorialHospital,LautokaHospitalandLabasa Hospital
fromAugust2014toNovember2015
Infectioncharacteristicsnecessitatingcolistinusage
• Acinetobacterbaumanniiwastheorganismofinfectionin19cases,AcinetobacterJuniiintwocases,followedbythreeinfectionsbyPseudomonasaeruginosaandanunmarkedMRO.OrganismswereidentifiedfromBloodCulture,PleuralAspirate,TrachealAspirate,PeritonealFluid,Sputum,IDCtipsandWoundSwabs.
Colistinstudy:Results,ConclusionsandrecommendationsPatientrecords
• Comprehensivepatientrecordsarenotroutinelymaintainedandretrievablesodruguseevaluationstudies(DUEs)cannotbeundertaken,diagnosesstatisticscannot bemaintainedandquantitiesofmedicinesneededfortreatingthosedisease/conditionscannotbeestimated.
Stock-outs• Therearestock-outsofmedicinesinthewards,infectioncontrolconsumable
andequipment,laboratorysupplies.Thissituationundermineseveryaspectofpatientcareinthehospitals.
• PatientTreatment• Patientstreatedwithcolistinweresufferingfrominfectionsthatwarranted
prompttreatmentwithcolistin.• Inadequateinfectionpreventionandcontrol(IPC)(oftenduetoinadequate
supplies)fosteredthedevelopmentofnosocomialMDRorganisms.• Thereissuboptimalunderstandingamongprescribersoftheuseofprotocols
andstandardtreatmentguidelines(STGs)andthesedocumentsarenotalwaysreadilyavailablesoadetailedguidelinefortheuseofcolistinisneeded.ThethirdeditionoftheAntibioticGuidelineswaspublishedin2011.Itistimeforthattoberevised.
InvestigatingcolistinusageinFijiattheColonialWarMemorialHospital,LautokaHospitalandLabasa Hospital
fromAugust2014toNovember2015
PhysicianSurveyResponse
• Therewereindicationsthatprotocolsforuseofcolistinwerenotreadilyavailableornotconsultedandtimelyaccesstocolistinwhenitwasindicatedwasnotgood.Thereseemedtobepoorinter-departmentalcoordinationbetweenmicrobiology,pharmacy andmaintenanceofadequateIPC,thatledtoentirelyunfavorablepatientoutcomes.
• Therewassomeperceivedneedforempiricaluseofcolistin
InvestigatingcolistinusageinFijiattheColonialWarMemorialHospital,LautokaHospitalandLabasa Hospital
fromAugust2014toNovember2015
InfectionPreventionandControl(IPC)Response
IPCiscompletelyinadequate. Thereishighlydetailedrecordkeepinghoweverinadequatemonitoring,withlittleintervention.ThereisnobudgetorallowanceortimegivenforIPCeducation,trainingandresourcing.Noguidelinesorprotocolsarewritten.Thereisrelianceon‘lackofbudget’,asthereasonforinadequate activities.AneonatalintensivecareunitoutbreakatCWMcost$32,000FD.Thereisveryinadequatesupplyofbasicantimicrobialsupplies: soaps/disinfectantsandotherequipment.
InvestigationreportsDrugUseEvaluationReportInvestigatingcolistinusageinFijiattheColonialWarMemorialHospital,LautokaHospitalandLabasaHospitalfromAugust2014toNovember2015
(AlistairPickmere,RashikaGounder,JeremaiaMartaika,BeverleySnell).
InvestigatingknowledgeanduseofantibioticsatfiveDivisionalHealthCentreout-patientclinicsinFiji,November,2015(AlistairPickmere,NarginaMacalinao,JeremaiaMartaika,BeverleySnell).
BothreportssubmittedtotheMinistryofHealthFijiinApril2016https://wordpress.com/page/ozpharmavols.wordpress.com/60
WhatIhavedonefollowingthisopportunity• Continuedbuildingontherelationshipsbuiltduringmytime,
andfacilitatednewlinesofcommunicationbetweenFijiandamajortertiaryhospitalin
• BuildingrelationshipsalongsidepreviousMathewPeckScholarshipRecipientsininternationalaidprojects.
• GainedaninternshiptheRoyalChildren’sHospitalMelbourne,andbeenallocatedastheInfectiousDiseaseIntern.
• Maintainedactiveinterestandsupporttofuturescholarshiprecipients.
THANKYOU
NowovertoKyle
Kyle’sStory
KyleBooth
VictorianCollegeofPharmacy
MonashUniversity
2016MathewPeckScholarshipRecipient,MonashUniversity
KyleBooth:InvestigatePharmacists’understandingofAMSconceptsinbothretailandhospitalsettings
UndertheguidanceoftheFijiNationalAMSProgramProjectPharmacist,MsRashikaGounder,studieswereundertakentoobtaininformationabouttheexistingunderstandingbypharmacists,inretailandhospitalsettings,ofAMSconceptswhichwouldinformthestrategiestobedevelopedintheFijiNationalAMSprogram.
ApprovalwasgrantedbytheFijiMinistryofHealthandMedicalServicesResearchandEthicsdepartmentandbytheFijiPharmaceuticalSociety
Whatthisopportunityenabledmetodo• Carryouttwoinvestigationsofunderstandingoftheconceptsof
AntimicrobialStewardship(AMS):amongretailcommercialpharmacistsandhospitalpharmacistsinFijiinFebruary2017,anddevelopareportfortheFijiMinistryofHealthandMedicalServices(MoHMS)
• CommutearoundSuvaandsomeneighboringvillagestovisitretailpharmacies,speaktoeachpharmacist,andobtainanswerstothestudyquestionnaire.
• VisitthemajorhospitalstotalktoPharmacistsandPharmacyTechniciansabouttheirunderstandingofAMS– travellingbyroadtoLautokaandbyairtoLabasa.
• AnalyseanddiscussthefindingsoftheseinvestigationswithFijiancolleagues.
• LearnanenormousamountaboutAMRandAMSissuesandpharmaceuticalsystemsinFiji.
• MeetwithAustralianvolunteersworkinginFijiandexploreandenjoyextra-curriculaactivitiesaroundFiji– aboveandbelowwater.
Myassignment
• Myresearchwasdrivenbytwostudies;onedirectlywithpharmacistsintheSuvaareawhoworkedinretailpharmacies,whiletheotherconsistedwithclinicalpharmacistsinthreemainFijianhospitals.Bothstudiesfocusedontheunderstandingoftheconceptofanantimicrobialstewardship,throughaquestionnaire-basedsurveythatIbuiltinthefirstweekofmytripunderthesupervisionoftheFijianAMSProjectPharmacist.
StudyofFijiHospitalPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Methods1• AuthorisationwasobtainedfromtheMoHMSStatisticsandEthics
Department.• AquestionnairewasdevelopedbytheAMSprojectpharmacistandthe
interviewerandfieldtestedbeforebeingfinalised• AshortexplanationofAMSwasprepared.• PharmacistsandpharmacisttechniciansworkinginColonialWarMemorial
Hospital(CWMH),LautokahospitalandLabasaHospitalwereidentifiedbythePrincipalPharmacistineachhospitaltheninterviewedindividually.
• Questionswereaskedexactlyaccordingtothepreparedquestionnaireandtheanswerswerenotedmanuallyonaprintoutofthesurvey.Respondentswereencouragedtoprovidemorethanoneanswer.Continuednextslide
StudyofFijiHospitalPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Methods2• Answersgivenbytherespondentswererecordedinawaythatenabled
theirrecordinginthesoftwareforlaterinterpretation.• IftheiranswersrelevanttoAMSindicatedtheywereunsureofthe
meaningofAMStheywereprovidedwiththeexplanatoryleaflettoreadbeforethesubsequentquestionswereasked.
• Aftercompletingtheoralquestions,thepharmacistswereaskedtocompleteashortwrittenquestionnaire.
• Surveygizmosoftwarewasusedtorecordthequestionsandresponsesandtoprovedagraphicrepresentationoftheresults.
Hospital pharmacy waiting area
StudyofFijiHospitalPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Summariseddiscussionofresults1Understandingrationaluseofantibioticsandantibioticresistance.• Therewasgoodawarenessofthenatureofantimicrobialresistanceandthe
factorsthatcontributetodevelopmentofresistanceandagreementthatrationaluseofantibioticsisessential.
• Therewasagreementthatuseofantibioticscouldbeimprovedgreatlybutbarrierswouldneedtobeaddressed.CompliancewithandorientationabouttheABSTG2011isimportantbutthepublicationneedstobeupdated.
• Nursesalsohavearoleinthemaintenanceofrationaluseofantibioticsandtheirroleneedstobedefinedandstrengthenedbyongoingeducation.
• Patientpressuretoprescribeantibioticsforinappropriateconditionsisstrong.Ongoingeducationofhealthprofessionalandthepublicisneeded- notjustduringtheannualAntibioticAwarenessWeek.
• Thereisinsufficientattentiontolaboratoryresultsbuttheslowturnaroundfromthelaboratoryoftenledtoempiricaluseofsecondlineorlastlineantibiotics.
StudyofFijiHospitalPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Summariseddiscussionofresults2Understandingrationaluseofantibioticsandantibioticresistance.• Stockmaintenance:Intheabsenceofsufficientstockoftheappropriatefirstline
antibiotics,secondlineorrestrictedantibioticswereused.Thisfindingisinlinewiththefindingsofthemeropenem useandcolistinusestudies.
• Thestockissuescanbeeasilyresolved.Recordsofpatientconditionsandtheantibioticsappropriateforthoseconditionsmustbethebasisofre-orderingstock.Pharmacistshaveamajorroleinensuringthemaintenanceofthissystem.
• Shortageofstaffhasamajorimpactonmaintainingappropriateuseofantibioticsandthereforeoptimaltreatmentofpatients.Appropriatestaffinglevelswouldleadtoavailabilityofsufficienttimetoundertakethenecessarytasks.Specialisttrainersshouldbeengaged.
• Communicatingwithprescriberspresentsadditionalproblems– theyarehardtofindandsometimesdonotappreciatethefollow-uptoclarifyprescribingissues.
ExtensiontotheLabasaHospitalforA&E,Antenatalcare,EyeClinic,builtbySouthKoreain2009
Patients needing referral from Labasa to Suva are sent by air. This extension provides intermediate services
StudyofFijiRetailPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Methods1• PermissiontoundertakethestudywasobtainedfromtheFijiPharmaceutical
SocietyandtheMoHMSethicscommittee.• AquestionnairewasdevelopedwiththehelpoftheAMSprojectpharmacist.
Thequestionnairewasfieldtestedinoneretailpharmacy(thatwouldnotbeincludedinthesurvey)beforebeingfinalised.
• AshortexplanationofAMSwasprepared.• RetailPharmaciesintheSuvaareawereidentifiedandthepharmacistincharge
ofeachwas contactedbytelephonebytheprojectpharmacistbeforethevisitbytheinvestigator- toexplaintheaimsofthestudyandtheimportanceofinformationtheycouldprovide.
• Beforetheinterview,pharmacistswereaskedtoreadandsigntheintroduction/consentletter. Theaimofthesurveywasexplainedandthepharmacistinchargewasinterviewed.
• (tonextslide).
Studyof FijiRetailPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Summariseddiscussionofresults1
• Qverall,responsesdemonstratedthatpharmacistsshowedgoodawarenessofthenatureofantimicrobialresistanceandthefactorsthatcontributetodevelopmentofresistance
• Itwasrecognisedthatresistanceisdevelopingwiththeresultthatstrongerantibioticswillbeneededandstrongerantibioticswillnotalwaysbeavailableandaffordable.
• ItwasrecognisedthatgloballyMRSAincidenceisrisingandtreatmentisnotaseffective.UnfortunatelytherearenodataproducedinFijiinaformatthatallowstrackingofcurrentFijianresistance.
• ItwasalsorecognisedgenerallythatcurrentrestrictedantibioticsneedtobeconservedbystrictcontroloftheirusebuttherewasincompleteawarenessoftheexistenceofABthereforetheprivatesectormusttobeincludedroutinelyinrationaluseofmedicinesactivitiestonextslide
Studyof FijiRetailPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Summariseddiscussionofresults2
• Controlofprescribingisneededintheprivatesectoraswellasthepublicsectorsoneedstobeincludedinnationalcampaignsforrationalprescribing.AlthoughtheFijiNationalMedicinalProductsPolicy(NMPP)statesthatstandardtreatmentguidelinesaremeanttoguideprescribingthroughoutFiji,inpracticethatdoesnotseemtohappen
• Somepharmacistswilldispenseantibioticswithoutprescriptionssoregulatorycontrolmustbeenforced.
• Patientpressurecancontributetothesupplyofunnecessaryandunprescribedantibiotics.
Tonextslide
Studyof FijiRetailPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Summariseddiscussionofresults3
• AlmostallrespondentsbelievedantimicrobialresistanceisalreadyaseriousprobleminFiji.Themarginaluseofmicrobiologyteststoguideprescribingofantibioticstogetherwiththeempiricaluseofstrongerbroadspectrumantibioticsisamajorcontributor.LackofawarenessinbothhealthprovidersandtheFijicommunityneedstobeaddressed.
• Thosewhowerelesssurethatresistanceisalreadyaproblemfeltthatmoreresearchwasneededtodeterminetheextentoftheproblemandmonitoringneedstoberoutinelydoneintheprivatesectoraswellasinthepublicsector.
• Concerningsomeissuestherewasnoconsensus.Forexamplesomebelievedcounsellingpatientswasundertakenwhileothersbelieveditwasnot.Thisresponsedemonstratesthatthereissomevariationinthepracticesinretailpharmacies.
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
OverallFindings1• Thereweredifferencesbetweentheretailandthehospitalpharmacists.• Inallthreehospitals,notmanypharmacistsunderstoodtheconceptofwhat
AntimicrobialStewardshipbutmostwereabletoexplainsomeofthestewardshipobjectivestheyalreadyfulfillaspharmacists.AllpharmacistsIsurveyedagreedthatasapharmacistitwasnecessarytohaveaprominentroleinastewardship
• Positively,eachpharmacistunderstoodtheinfluencetheycouldhaveonthegrowingissueofresistance.
• Therewereconcernswithprescribersandtheirmethods,andaboutretailpharmacistswhogaveantibioticsoverthecounterwithoutprescriptions
• RetailPharmacistshighlightedhugeissueswithindividualsonlypurchasingafewdaystreatmentwithantibioticsinsteadofafullcourseduetounaffordability.
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
OverallFindings2• AllpharmacistscouldlistthebenefitsofhavinganAntimicrobialStewardship
inplace,buttheywouldalsolistbarrierstheywouldfaceforasuccessfulimplementation:Humanresources,finances,awarenessandtime
• Poorcommunityhealthliteracywasabigconcern.Inappropriateuseofantibioticsforsymptomaticreliefofheadaches,painandespeciallythefluwascommon
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Recommendations1RecommendationsweremadeincollaborationwiththeProjectPharmacistandmyAustraliansupervisor.
HospitalPharmacists
• Increasethestaffinglevelsofthepharmacydepartmenttoaneffectivelevelsupportedbyarealisticsalary.
• ProvideadequatetrainingandresourcesupportfortheimplementationofoptimalAMS.
• Ensurethatundergraduatecurriculainmembersofteamsofhealth-relatedprofessionsinthehospitalsettingincludeRUM,AMRandAMS.
• Addressthestockissuesasaprioritybyintroducingandmaintainingasystemofrecordkeepingthatwillleadtoquantificationofneedsofappropriatesuppliesoftherightmedicines.Reliablesuppliesoftherightmedicineswillbeensuredbybasingordersontheaccuratelykeptpatientrecordsofdiagnosestreatedappropriately.
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Recommendations2(HospitalPharmacy)
• StrengthentheroleoftheNationalMedicinesandTherapeuticsCommitteeanditsrelationshipwithallhealthcareworkers
• UpdatetheAntibioticStandardTreatmentGuidelinesasapriority,distributeitandpromoteitsuse
• Developandimplementasystemforroutineregularauditofantibioticprescribingandpatientresponsetobeundertakenbyhospitalpharmacists(dependingonstafflevelsbeingadequate).
• Developandimplementastrategyforateamapproachbetweenallhealthcareworkersandmutualrecognitionoftheroleofallteammembers
• Developasystemforfollowingupresultsoflabtestssotheappropriatemedicinesareavailable,dispensedtothepatientsandrecordedappropriately;andtheireffectmonitored.
• Developthenecessarytoolsandtrainpharmacystafftomonitoractivitiestoensuretheaboveactionsareoccurringcorrectly.
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Recommendations1(RetailPharmacy)
IncollaborationwiththeFijiPharmaceuticalSociety(FPS)pharmacistsshouldbeequippedtoparticipateintheAMSprograminFiji.
• Ongoingcollaborativelinksmustbedevelopedandmaintainedbetweenthepublicandprivatesectorsofpharmacy.
• Privatemedicalpractitionersmustbeincludedinprogramstopromotetheuseofantibiotictreatmentguidelinesthatmustbecurrenttogaincredibility.
• TheAntibioticStandardTreatmentGuidelines2011mustbereviewedandupdatedasapriority
• TheFijiMedicalSocietyshouldbeactivelyinvolvedininitiativesanddevelopco-ownershipoftheAMSprogram
• Fiji’sretailpharmacistsmustbeincludedinnationaleducationactivitiestostrengthentheircapacitytoparticipateinallrationaluseofmedicineinitiatives– notjustconcerningantibiotics.
StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship
Recommendations2(RetailPharmacy)
• TheAMSprogramactivitiesmustincludemechanismstostrengthenateamapproachtoAMSsoeachteammemberwillvalueothersandgoodtwowaycommunicationbetweenmedicalpractitioners,pharmacists,nurses,consumersandotherswillbetheresult.
• TheMedicinesRegulatoryAuthorityandthePharmacyProfessionsBoardmusthaveactiveconnectionswithretailpharmaciesthroughofficialinspectorstoidentifyandreportonanycontraventionsofpractices.BreacheswillbedealtwithappropriatelybytheTribunalappointedforthepurpose.
• ComprehensiverecordsofpatientprescriptionsmustbekeptaccordingtotheFijiGoodPharmacyPracticeGuideMarch2017.Regularauditsofantibioticprescriptionsshouldbeundertakentoidentifytargetsforinterventionsandeducation.
• TheConsumerCouncilofFiji(CCOF)mustbeinvolvedinnationaleducationprogramstostrengthenAMS.COCFisateammemberintheAMSprogramandconsumersarepartofthewholecommunityaffectedbyAMR.
This activity was introduced by the MoHMS during Antibiotic Awareness Week 2016
Continues twice a week with full participation(stay healthy to minimise need for antibiotics)
Thank you
ReferencesFijiNationalMedicinalProductsPolicyhttp://apps.who.int/medicinedocs/documents/s21601en/s21601en.pdf
FijiNationalPlanonAntimicrobialResistancehttp://www.wpro.who.int/southpacific/mediacentre/releases/2015/Fiji_launches_AMR/en/ andhttps://ozpharmavols.files.wordpress.com/2017/05/amrplannapfiji2015.pdf
FijiNationalAntimicrobialResistancePlan:OperationalPlan2016-2018https://ozpharmavols.files.wordpress.com/2017/05/operational-plan-2016-2018.pdf
FijiGuidelinesforDonationsofMedicalSuppliesandEquipmenthttp://www.health.gov.fj/wp-content/uploads/2014/05/Guidelines-for-Donations-of-Medicines-Medical-Supplies-and-Equipment.pdf
FijiAntibioticStandardTreatmentGuidelines2011http://www.health.gov.fj/wp-content/uploads/2015/04/Antibiotic-Guidelines-3rd-edition-2011.pdf