Mapping the Implementation of a Clinical Pharmacist-Driven Antimicrobial Stewardship Programme at a Tertiary Care Centre in South India

Abstract

In many parts of the world, including in India, pharmacist roles in antimicrobial stewardship (AMS) programmes remain unexplored. We describe the evolution and effect of the role of adding clinical pharmacists to a multidisciplinary AMS at a tertiary care teaching hospital in Kerala, India. Through effective leadership, multidisciplinary AMS (February 2016) and antitubercular therapy (ATT) stewardship programmes (June 2017) were established. Clinical pharmacists were introduced as core members of the programmes, responsible for the operational delivery of key stewardship interventions. Pharmacy-led audit and feedback monitored the appropriateness of antimicrobial prescriptions and compliance to AMS/ATT recommendations. Between February 2016 and January 2017, 56% (742/1326) of antimicrobial prescriptions were appropriate, and 54% (318/584) of recommendations showed compliance. By the third year of the AMS, appropriateness increased to 80% (1752/2190), and compliance to the AMS recommendations to 70% (227/325). The appropriateness of ATT prescriptions increased from a baseline of 61% (95/157) in the first year, to 72% (62/86, June 2018–February 2019). The compliance to ATT recommendations increased from 42% (25/60) to 58% (14/24). Such a model can be effective in implementing sustainable change in low- and middle-income countries (LMICs) such as India, where the shortage of infectious disease physicians is a major impediment to the implementation and sustainability of AMS programmes.

Barriers and facilitators of implementing interventions to improve appropriate antibiotic use in low- and middle-income countries: a systematic review based on the Consolidated Framework for Implementation Research

“…In 23 studies, the common challenges faced by implementers and researchers were related to resources, including insufficient financial support for sustaining antimicrobial stewardship activities, shortage of human resources (such as microbiologists, pharmacists, and infectious disease specialists), and lack of technological support to facilitate the administration of interventions [ 38 , 42 – 46 , 48 – 50 , 58 , 62 , 63 , 67 , 69 – 71 , 73 , 75 – 77 , 79 , 85 , 86 ]. It was also commonly reported that prescribers participating in ASPs were often too busy to perform intervention activities.…”

“…Additionally, six studies reported that lack of motivation prevented behavior change of prescribers, as some were concerned about complaints from patients or reduction in salary if they refused to prescribe antibiotics [ 39 , 48 , 62 , 78 , 84 , 86 ].…”

What does antimicrobial stewardship look like where you are? Global narratives from participants in a massive open online course

“…Pharmacist-driven or pharmacist-led AMS programmes have been shown to improve antimicrobial prescriptions where there is a lack of availability of ID specialists. 26 , 27 However while it was recognized by the learners that involving pharmacists and nurses in AMS is beneficial, they believed the distinct roles remain ill-defined in many countries, creating a potential obstacle in the implementation of global AMR priorities. Even though theoretical advances from academia or policy describe nurses’ roles, these are yet to be translated to clinical settings.…”

Assessing feasibility of establishing antimicrobial stewardship programmes in two provincial-level hospitals in Vietnam: an implementation research study

“…This was reflected in the national guideline on AMS implementation originally issued in 2016 and updated in 2020 13 14. Sustained reductions have been achieved in antibiotic use by AMS teams across different settings including the example of non-specialist pharmacist-led programme in South Africa27 and clinician-led and clinical pharmacist-driven AMS programme in India 28. In our study, despite having no experience in clinical interactions, our junior pharmacists have been building their PAF capacity and gained promising results in the number of audits with feedback to the doctors.…”

“…13 14 Sustained reductions have been achieved in antibiotic use by AMS teams across different settings including the example of non-specialist pharmacist-led programme in South Africa 27 and clinician-led and clinical pharmacist-driven AMS programme in India. 28 In our study, despite having no experience in clinical interactions, our junior pharmacists have been building their PAF capacity and gained promising results in the number of audits with feedback to the doctors. Although the results were highly variable between hospitals, this shows the feasibility and potential of involving pharmacists in the prescription-based strategies for AMS programmes in LMICs.…”