Mrs Opanuga, a pharmacy perspective

Good day. I’m Joke Okusanya, a member of the antimicrobial stewardship team. I would like to ask you some questions. We’ll spend a few minutes and then we’ll be through. All right. Please, what is your name, designation, and your place of work? I am Olabisi Opanuga, the head and director of pharmacy in Lagos University Teaching Hospital, Idi-Araba, Lagos. I’m also a member of the antimicrobial stewardship committee. What do you mean by antimicrobial stewardship? Antimicrobial stewardship– AMS– is a quality improvement programme or strategy that promotes a proper use of antimicrobial agents, including their choice, dosing, route of administration, duration, or administration.

And this is geared to improve patient outcomes, reduce microbial resistance, and decrease the spread of infection caused by multidrug resistant organisms, like Pseudomonas aeruginosa. And it’s a collective term of myriad of interventions– targeted antimicrobial prescribing. It operates within the national framework. And it’s driven by quality improvement and patient safety. It’s a function of multidisciplinary antimicrobial management team. And it’s dependent on key relationship with the following structures within the health care organisation– infection control, prevention and control, clinical governance, therapeutic medical management. What are the goals of antimicrobial stewardship?

The primary goal of antimicrobial stewardship is to optimise clinical outcomes and minimise unintended consequences of antimicrobial use, which includes the toxicity, the selection of pathogenic organisms, such as Clostridium difficile emergence or resistance. It’s also got additional benefits, including improving susceptibility rates to targeted antibiotics and optimising resource utilisation. At least it is known that a third of antibiotics are prescribed inappropriately or unnecessarily in most hospitals. AMS promotes the smart use of antibiotics in the face of data demonstrating suppression overuse of antibiotics. So and this leads to total reduction in antibiotic consumption. The aim is to help to optimise antimicrobial prescribing by changing the prescribing behaviours of clinicians. So in doing– like I said, is a multidisciplinary thing.

It takes all-encompassing in nature. It is in nature and involves active engagement with teams that we are going to implement this with. So to aid this and ensure that aid professionals are proactively– they receive feedback and education about their prescribing behaviours. When did you first hear about antimicrobial stewardship? Around 2012, when we started the antimicrobial stewardship committee in my institution.

What is DDD? DDD is Defined Daily Doses. And the main purpose of this DDD system is a tool for presenting drug utilisation statistics with the aim of improving drug use. It’s a WHO tool that was developed. And it is defined as the assumed average maintenance dose per day for a drug for its main indication in adults, assuming the compliance is there. So it’s a technical drug metric system that measures drugs consumption. And we can use it to standardise comparison drug usage between different drugs, between different [INAUDIBLE] shown, between countries. Like I said, it does not really– is a unit of measurement, but it does not reflect the prescribed daily dose. It’s not the same thing. They are different.

They are different. So you can use it to calculate daily drug consumption, cost of drugs, and also to study the frequency of adverse drug reaction. In addition to what I said, DDD can be used to collect utilisation data in various settings. You can use it to collect sales data from the wholesale, dispensing data from the pharmacy, whether electronic or manual. You can use it to collect patient encounter-based data, patient survey data, health facility data, and so on and so forth. We should note that DDDs are used to measure antibiotic use over time and are primarily used by AMS team to monitor the trends within the ward, within the hospital, or a primary care setting.

This allows the team to identify areas for further investigations and use audits and quality improvement methods to address such. Now, what do you mean by antibiotic consumption? Like I said earlier, DDDs are an internationally accepted unit for measuring antibiotic consumption. And it’s used to make comparisons between countries. This indicates or takes into consideration amount of antibiotics consumed in a country or consumed by a study population or consumed in a hospital. And its potential burden ecological of effect and development of antimicrobial resistance is done. In your establishments, what are the daily routine activities of the pharmacist?

Let me start with prescription validation and vetting. When we at least get the prescription, the first thing, we validate and vet the prescriptions. We check for potential therapeutic problems, including dosing, dosing problem, duration, route, allergy adherence or side effects– if your patient’s– a drug-drug interaction, if there is any potential. And if we see any, we revert to the prescriber for clarification and resolution. We also ask for review of open prescriptions where they are left open for more than the certain number of days. We dispense drugs, of course. And we do engage in drug production and drug compiling of extemporaneous preparation for individual patients. We individualise it. Patient counselling– we do that before we hand over the drugs to them.

We ask them questions on the problems they face. If there’s any challenge they face, do they have any side effects? What are the things that– we know we have a face-to-face interaction with the patient. Patient, we follow them up. We ask them to– sometimes we give them a phone. We also prepackage a lot of parts. We use a lot of parts in the hospital anaesthetic pack, preop packs, the intubation pack, EBT pack, pharmacy packs– all packs, as it is. We also engage in pharmacist ward rounds and multidisciplinary ward rounds with doctors. Of course, drug procurement, storage, and vetting through our distribution is our duty. Those ones are duties– relevant education and training. We control that.

And then we document relevant documentation. Because if it’s not documented, it is not done. Knowing this routine, can antimicrobial stewardship be accommodated in this routine work? Sure. How? It is the responsibility of the pharmacists to ensure that drugs that are safe, of good quality, efficacious, are available to the patients of various categories, whether NHIAs, retainers, children, adults. We have to ensure that they get the medication that is appropriate to their need. In fact we are responsible for the outcomes of drugs that we give in pharmaceutical care. So we also engage them. We need to engage. We engage prescribers, like I said. We send back. And then we interact. And that is key. We need to have an antibiotic time out.

And that is– it’s critical. It is a critical component of AMS, to improve judicious use or rational use of antimicrobials. It is a strategy that prompts clinicians to re-evaluate the antibiotic appropriateness– whether to de-escalate or escalate or discontinue. We also need to expand our multidisciplinary ward round. It’s not there yet. But we need to improve on it. But there is also– where we have a drug that has both IV and oral, availability that are similar. We point out to prescribers, why don’t you use oral instead of IV, since you achieve the same purpose?

And then we ensure proper storage and distribution of drugs to our patients, making drug information available so that they will know what’s available, the choices they need to make– education and training of all stakeholders. We work with all the stakeholders to develop guidelines and relevant policies. A functional drug therapeutic committee in an institution is very key. Because they review hospital formulary now and then, regularly. In pharmacy, we can monitor the compliance to antibiotic guidelines with our monitor the use of antibiotics. And we can prompt prescribers to comply with the guidelines. DIC, Drug Information Centre, is also what we can use that will help us promote EMA. Because they have a record of 80 hours the pharmacological aspect of it.

We can also do antibiotic use audits or feedback. And we can measure the– as I said, EMA is a myriad of interventions made. And we can measure these impacts of these interventions. We can also conduct operational research. With all this, are there challenges faced by the pharmacists in line with antimicrobial stewardship? There are challenges. We are working in low-resource settings. And we are the three Ms are never sufficient– manpower, money, material. They are not sufficient. So we have to manage over here. But even that, as well– shortage of manpower is key. If there is nobody to go on a ward round a robot cannot do institution, make intervention. So we need manpower. We are very short.

And it’s actually affecting our work. So we need manpower. Multidisciplinary ward rounds should be improved on. It’s not adequate yet. We see mission some challenges when we go to the ward. Inadequate review or untimely review of hospital formulary. When an hospital has been there for going on 10 years, new drugs are not brought on board. So it’s affecting to affect the AMS. Failure or lateness of review medication errors– when we see some intervention, we see some errors, and we want to– if it’s not done on time and we cannot reach the prescriber, the patient will not start the medication on time. And that will affect rational use of the antibiotics.

Open prescriptions– open drug prescription for antimicrobial agents and other drugs. Lack of communication between prescribers and pharmacies– when we are not really communicating. They use or lose sheets or the wrong forms to document administration of IV drugs, which are not even filed in the case notes. And so we cannot really follow up on use. Poor documentation of drugs administered, or documentation of drugs not administered, and no dissemination of relevant information to all stakeholders. Thank you. This will be all for now. Thank you very much. Really appreciate your time with us. Thank you very much. Thank you.