antimicrobial stewardship in fiji - monash university · • a questionnaire for doctors was...

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


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.



PhysicianSurveyResponse

• Therewereindicationsthatprotocolsforuseofcolistinwerenotreadilyavailableornotconsultedandtimelyaccesstocolistinwhenitwasindicatedwasnotgood.Thereseemedtobepoorinter-departmentalcoordinationbetweenmicrobiology,pharmacy andmaintenanceofadequateIPC,thatledtoentirelyunfavorablepatientoutcomes.

• Therewassomeperceivedneedforempiricaluseofcolistin



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


Methods2• Answersgivenbytherespondentswererecordedinawaythatenabled

theirrecordinginthesoftwareforlaterinterpretation.• IftheiranswersrelevanttoAMSindicatedtheywereunsureofthe

meaningofAMStheywereprovidedwiththeexplanatoryleaflettoreadbeforethesubsequentquestionswereasked.

• Aftercompletingtheoralquestions,thepharmacistswereaskedtocompleteashortwrittenquestionnaire.

• Surveygizmosoftwarewasusedtorecordthequestionsandresponsesandtoprovedagraphicrepresentationoftheresults.

Hospital pharmacy waiting area


Summariseddiscussionofresults1Understandingrationaluseofantibioticsandantibioticresistance.• Therewasgoodawarenessofthenatureofantimicrobialresistanceandthe

factorsthatcontributetodevelopmentofresistanceandagreementthatrationaluseofantibioticsisessential.

• Therewasagreementthatuseofantibioticscouldbeimprovedgreatlybutbarrierswouldneedtobeaddressed.CompliancewithandorientationabouttheABSTG2011isimportantbutthepublicationneedstobeupdated.

• Nursesalsohavearoleinthemaintenanceofrationaluseofantibioticsandtheirroleneedstobedefinedandstrengthenedbyongoingeducation.

• Patientpressuretoprescribeantibioticsforinappropriateconditionsisstrong.Ongoingeducationofhealthprofessionalandthepublicisneeded- notjustduringtheannualAntibioticAwarenessWeek.

• Thereisinsufficientattentiontolaboratoryresultsbuttheslowturnaroundfromthelaboratoryoftenledtoempiricaluseofsecondlineorlastlineantibiotics.


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



• Controlofprescribingisneededintheprivatesectoraswellasthepublicsectorsoneedstobeincludedinnationalcampaignsforrationalprescribing.AlthoughtheFijiNationalMedicinalProductsPolicy(NMPP)statesthatstandardtreatmentguidelinesaremeanttoguideprescribingthroughoutFiji,inpracticethatdoesnotseemtohappen

• Somepharmacistswilldispenseantibioticswithoutprescriptionssoregulatorycontrolmustbeenforced.

• Patientpressurecancontributetothesupplyofunnecessaryandunprescribedantibiotics.

Tonextslide



• AlmostallrespondentsbelievedantimicrobialresistanceisalreadyaseriousprobleminFiji.Themarginaluseofmicrobiologyteststoguideprescribingofantibioticstogetherwiththeempiricaluseofstrongerbroadspectrumantibioticsisamajorcontributor.LackofawarenessinbothhealthprovidersandtheFijicommunityneedstobeaddressed.

• Thosewhowerelesssurethatresistanceisalreadyaproblemfeltthatmoreresearchwasneededtodeterminetheextentoftheproblemandmonitoringneedstoberoutinelydoneintheprivatesectoraswellasinthepublicsector.

• Concerningsomeissuestherewasnoconsensus.Forexamplesomebelievedcounsellingpatientswasundertakenwhileothersbelieveditwasnot.Thisresponsedemonstratesthatthereissomevariationinthepracticesinretailpharmacies.

StudyofFijiPharmacists’UnderstandingoftheConceptofAntimicrobialStewardship

OverallFindings1• Thereweredifferencesbetweentheretailandthehospitalpharmacists.• Inallthreehospitals,notmanypharmacistsunderstoodtheconceptofwhat

AntimicrobialStewardshipbutmostwereabletoexplainsomeofthestewardshipobjectivestheyalreadyfulfillaspharmacists.AllpharmacistsIsurveyedagreedthatasapharmacistitwasnecessarytohaveaprominentroleinastewardship

• Positively,eachpharmacistunderstoodtheinfluencetheycouldhaveonthegrowingissueofresistance.

• Therewereconcernswithprescribersandtheirmethods,andaboutretailpharmacistswhogaveantibioticsoverthecounterwithoutprescriptions

• RetailPharmacistshighlightedhugeissueswithindividualsonlypurchasingafewdaystreatmentwithantibioticsinsteadofafullcourseduetounaffordability.


OverallFindings2• AllpharmacistscouldlistthebenefitsofhavinganAntimicrobialStewardship

inplace,buttheywouldalsolistbarrierstheywouldfaceforasuccessfulimplementation:Humanresources,finances,awarenessandtime

• Poorcommunityhealthliteracywasabigconcern.Inappropriateuseofantibioticsforsymptomaticreliefofheadaches,painandespeciallythefluwascommon


Recommendations1RecommendationsweremadeincollaborationwiththeProjectPharmacistandmyAustraliansupervisor.

HospitalPharmacists

• Increasethestaffinglevelsofthepharmacydepartmenttoaneffectivelevelsupportedbyarealisticsalary.

• ProvideadequatetrainingandresourcesupportfortheimplementationofoptimalAMS.

• Ensurethatundergraduatecurriculainmembersofteamsofhealth-relatedprofessionsinthehospitalsettingincludeRUM,AMRandAMS.

• Addressthestockissuesasaprioritybyintroducingandmaintainingasystemofrecordkeepingthatwillleadtoquantificationofneedsofappropriatesuppliesoftherightmedicines.Reliablesuppliesoftherightmedicineswillbeensuredbybasingordersontheaccuratelykeptpatientrecordsofdiagnosestreatedappropriately.


Recommendations2(HospitalPharmacy)

• StrengthentheroleoftheNationalMedicinesandTherapeuticsCommitteeanditsrelationshipwithallhealthcareworkers

• UpdatetheAntibioticStandardTreatmentGuidelinesasapriority,distributeitandpromoteitsuse

• Developandimplementasystemforroutineregularauditofantibioticprescribingandpatientresponsetobeundertakenbyhospitalpharmacists(dependingonstafflevelsbeingadequate).

• Developandimplementastrategyforateamapproachbetweenallhealthcareworkersandmutualrecognitionoftheroleofallteammembers

• Developasystemforfollowingupresultsoflabtestssotheappropriatemedicinesareavailable,dispensedtothepatientsandrecordedappropriately;andtheireffectmonitored.

• Developthenecessarytoolsandtrainpharmacystafftomonitoractivitiestoensuretheaboveactionsareoccurringcorrectly.


Recommendations1(RetailPharmacy)

IncollaborationwiththeFijiPharmaceuticalSociety(FPS)pharmacistsshouldbeequippedtoparticipateintheAMSprograminFiji.

• Ongoingcollaborativelinksmustbedevelopedandmaintainedbetweenthepublicandprivatesectorsofpharmacy.

• Privatemedicalpractitionersmustbeincludedinprogramstopromotetheuseofantibiotictreatmentguidelinesthatmustbecurrenttogaincredibility.

• TheAntibioticStandardTreatmentGuidelines2011mustbereviewedandupdatedasapriority

• TheFijiMedicalSocietyshouldbeactivelyinvolvedininitiativesanddevelopco-ownershipoftheAMSprogram

• Fiji’sretailpharmacistsmustbeincludedinnationaleducationactivitiestostrengthentheircapacitytoparticipateinallrationaluseofmedicineinitiatives– notjustconcerningantibiotics.


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

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