International Antimicrobial Stewardship

Briefly describe your daily antimicrobial stewardship practices 

My daily Antimicrobial Stewardship (AMS) practices align with the core elements outlined by the CDC and also encompass various practices that I have witnessed and picked up along the path of my career so far. Ours is a pharmacist-led AMS program in our tertiary care hospital (Accountability) and we provide Drug Expertise when it comes to antimicrobial use in our centre.

When it comes to the activities involved in the actual implementation of AMS (Action), we utilize mostly prospective audit and feedback in 3 major domains:

Microbiology domain:

• One interesting activity I participated in during my time at Tufts Medical Centre was the “Micro rounds”, where all infectious diseases (ID) physicians and pharmacists would assemble in the microbiology lab to discuss cases and reports on a daily basis. We have adapted the same model in my hospital. The cases worked up during the previous days are discussed, and positive and negative cultures are noted. With the active involvement of microbiologists, decisions regarding therapy are expedited which has helped us achieve better patient outcomes. This underlines the importance of this year’s Antibiotic Awareness Week theme -"Preventing Antimicrobial Resistance Together".

• We also use a bundle approach for bacteraemia due to Staphylococcus aureus and Candida species. This ensures appropriate therapy and avoids untoward effects later.

Pharmacy domain

• We have come up with a list of high end antibiotics for our institution. Each morning we identify patients receiving these drugs and look at the appropriateness of the prescription.

• We provide recommendations for renal dosing and body weight based dosing of antibiotics. Pharmacists also recommend IV to oral switch of antibiotics whenever feasible.

Syndromic approach

• This approach helps us in reviewing the compliance of antimicrobial prescriptions with the hospital antimicrobial policy.

• Our program also reviews surgical prophylaxis compliance.

As part of AMS, we collect the antimicrobial consumption data as well as other process metrics like percentage compliance, escalation/de-escalation rates, etc. This helps us in Tracking and Reporting our data to the different stakeholders. My team includes a lot of pharmacy interns rotating with us, and we empower them in training in the basics of ID pharmacy. We are also actively involved in teaching our nursing staff and doctors on different aspects of AMS.

What stewardship initiative or antibiotic awareness effort are you most proud of that you have participated in or led?

My journey in becoming an ID Clinical Pharmacy Specialist has been very rewarding. Our pharmacy school education lacks the vertical integration of theory with clinical practice, especially since I belonged to one of the pioneer batches in the country. When I started my clinical practice it was very challenging and that’s when I decided to get trained in ID and AMS. This venture has helped me to become the first Board Certified Infectious Diseases Pharmacist in India, which in turn helped me to become the first pharmacist representing India as a SHEA International Ambassador this year. These credentials have helped me in advocating the roles of clinical pharmacists in AMS to a much larger crowd in both pharmacy and medical fraternities. I finally feel that our voices are heard.

Right now, the initiative I am most proud to be a part of is the Antimicrobial Resistance (AMR) Declaration Trust in India. The first time the threat of antimicrobial resistance in India was addressed in a very serious way was during the 2nd annual meeting of the Clinical Infectious Diseases Society (CIDS) of India in 2012 in Chennai. This ‘Practical not Perfect’ approach aimed at formulating implementable recommendations to tackle antimicrobial resistance in India led to the creation of a road map document - popularly known as “The Chennai declaration”. An extension of this is the AMR Declaration Trust which is primarily constituted by medical doctors. I was invited to be a part of this elite team and we are now in the process of developing many different impactful resource materials to fight against AMR. One among them is a module to help the undergraduate medical students understand the basics in AMR and AMS, which will be integrated in their official curriculum syllabus.

Another major initiative that I was a part of was the development of the Federation of Clinical Pharmacists in India (FCPI). This again is a not-for-profit organization aimed towards clinical pharmacy excellence in the country. Under the FCPI, the first specialty forum we have started our journey with is the Infectious Diseases Forum. We are also in the process of conducting the first ever International ID Clinical Pharmacy Congress in India in January 2023.

What does “Being Antibiotics Aware” mean to you?

Personally to me, "Being Antibiotics Aware" in my practice means to know in depth about your bugs, drugs, and diseases. This will ultimately help me in identifying gaps in optimizing my antimicrobial therapy recommendations to combat AMR.

To those working with me, “Being Antibiotic Aware” means that I should be able to empower them to follow the best antimicrobial handling practices like appropriate prescribing and infection prevention.

It also means making the public and the common man aware of the global threat of AMR and thereby make them understand the urgency to stop misusing antibiotics and the importance of healthy habits to prevent the spread of infections. My team has started to reach out to the nearby schools in our community to educate the younger generation regarding AMR.

What is one pearl you have for all clinicians to help them be antibiotic stewards?

“Primum non nocere” – this translates to “First, do no harm” according to the Hippocratic oath. This is not only applicable to the patient you are treating now, but also your future patients. Antibiotics are not innocuous and the feeling that adding an antibiotic won’t cause any harm to the patient usually results in overprescribing. I have seen most of the unjustified broad antibiotic prescribing patterns with clinicians who are not sure of what infection they are treating or what bugs they are targeting. Knowing your bugs, drugs, and diseases is extremely important to avoid antibiotic misuse.

The famous phrase – “treat the patient and not the lab report” is also very relevant. Whenever a culture pops positive, clinicians are driven to prescribe antibiotics in fear of impending sepsis. One very useful tool that I use in assessing culture reports is an app called ID Consult. This app was developed by a few ID physicians from my state, Kerala, and was created to help any clinician in the country who needs help with making sensible antibiotic choices. Within this app a segment called ‘Interpretation of Culture Report’ provides an easy algorithmic, point of care solution to your culture report.

As we are celebrating Antibiotic Awareness Week this year, it is very essential that we all come together to make the dream a reality - “All Healthcare Professionals can Be Antibiotics Aware”.

Grace Mary John, PharmD, BCIDP

Believers Church Medical College Hospital, Kerala, India

· Infectious Diseases Clinical Pharmacy Specialist

· Assistant Professor – Department of Pharmacology and Clinical Pharmacy

· Head – Department of Clinical Pharmacy

· Assistant Director

SHEA International Ambassador 2022, India

President – Federation of Clinical Pharmacists in India