In this article an Australian pharmacist with expertise in antimicrobial stewardship & infectious diseases is interviewed about antimicrobial stewardship in Australia.
Interview with: Tony Lai, BPharm, GradDipClinPharm, MClinPharm, MSHPA
Interview by: Timothy P. Gauthier, Pharm.D., BCPS
Last updated: 19 August 2020
Pathogenic microorganisms do not respect man made boundaries and pose a universal threat to humans worldwide. In battling these organisms, the spread of microbial drug resistance which renders our antimicrobial armamentarium ineffective is of significant concern. Antimicrobial stewardship has emerged as a mechanism for attempting to combat antimicrobial resistance and pathogenic organism.
Microbial resistance issues and antimicrobial stewardship efforts vary significantly by county and geographic ecological constructs, but the there is much we can learn from each other fighting similar battles worldwide. This is the motivation for articles hosted on this website like this one about antimicrobial stewardship in different countries around the world.
Recently I had the good fortune of connecting with Tony Lai who is an antimicrobial stewardship pharmacist in Australia. He was kind enough to accept the offer to do an interview and following our correspondence the below text was developed. Here are insights on antimicrobial stewardship in Australia from a pharmacist’s perspective…
1. How did you get involved as an antimicrobial stewardship as a pharmacist?
My initiation into antimicrobial stewardship (AMS) as pharmacist all started almost a decade ago in March 2011. My Director of Pharmacy called me into his office and said “Hey Tony, I have a project I want you to be involved in called “antibiotic stewardship”. It was antibiotic rather than antimicrobial at the time because AMS wasn’t a common acronym in 2011, there was only one formal AMS pharmacist position in the state and it was not yet a national health standard required for Australian hospital accreditation. Numerous hospitals in Sydney did have a “restricted antibiotic formulary” with a phone approval service but that’s really as much of an AMS service that was provided at the time. The project my director wanted me to champion was helping develop a new online AMS approval program we called “eASY” and he also wanted me to produce tangible benefits with intravenous to oral antibiotic switch. We showed success quickly with our AMS program which led our AMS team winning the state quality improvement award “NSW Health Award: Harry Collins Award for Achievement in Reducing Healthcare Associated Infections” in 2012. This was my baptism into AMS as I developed a warm relationship with the Infectious diseases (ID) doctors and absorbed as much ID clinical experience as I could.
At the time, no courses were available and there were no local experts to find as mentors so I really had to start from scratch. This is when I looked to what was available overseas and this is when I noticed Debra Goff’s work. She was a keynote speaker at one of our Australian ID conferences (Australian Society for Antimicrobials (ASID)) and this is when I completed the MAD-ID Making a Difference in Infectious Diseases: Antimicrobial Stewardship Program to equip myself further.
What sparked my interest really early on was I always thought infectious diseases was one of the cool specialities as a young rotational clinical pharmacist. The teams would ask for a consultation and the ID guys/ladies would come along, wave their magic wands, and suggest an antibiotic with a special approval number to allow its use. In addition to this, there was a gap in the antibiotic market and an upcoming demand for more antibiotics. It was an opportunity be a specialist pharmacist in a new area at the time and if I was to get experience, I could be a local expert really quickly.
I’m sure if you speak to my colleagues they will agree that I love teaching and this is led to my involvement in numerous professional activities to help build future budding AMS pharmacists. In the past, I’ve been involved in lecturing Masters of Pharmacy and MPH students, mentoring and managing other AMS pharmacists, supervising honours students and presenting/tutoring at ID/AMS conferences. My regular favourite thing to do is spending time with a newly recruited pharmacists and give a crash course in antibiotics.
Since its inception, I am a proud and active member of the Clinical Excellence Commission (CEC) AMS expert advisory committee, which is involved to strategic approaches of improving and equipping AMS services in public hospitals around the state. The CEC is the NSW Health’s safety and quality arm.
2. What is the status of antimicrobial stewardship in Australia?
My personal view is that we are lucky to have a very developed AMS status in Australia. I think this is strongly attributed to AMS being mandated as a National Health Standard by our federal healthcare body, Australian Commission on Safety and Quality in Health Care (aka “The Commission”). This has provided great impetus for hospitals around Australia to create full time equivalent funded AMS positions in both pharmacy and infectious diseases (Table 3.1).
Source: https://www.safetyandquality.gov.au/sites/default/files/migrated/NSQHS-Impact-Report.pdf
To further support this, we are extremely fortunate to have Australian Antibiotic guidelines by the Therapeutic Guidelines, NSW state support networks like the CEC, National Centre for Antimicrobial Stewardship (NCAS) and Queensland State wide Antimicrobial Stewardship Program (QSAMSP).
Outside of the hospital, Australia has the National Prescribing Service (NPS) which produce excellent AMS resources in the primary care, general practice and community settings.
The development of AMS is most palpable during Antibiotic Awareness Week every year where a lot of pharmacies compete for the most eye catching stand and perform a national point prevalence audit of antimicrobial prescribing (National Antimicrobial Prescribing Survey [NAPS]).
The culmination of Australia’s progress in AMS is nicely summarised in our recent national AURA report which has longitudinal data on antimicrobial utilisation, appropriateness prescribing and antimicrobial resistance (AMR). This report is great for AMS services to see where the goal posts are. Australia has an excellent AMS resource developed by “The Commision” which is basically a how to guide of running an AMS service in a range of health sectors called “Antimicrobial Stewardship in Australian Health Care 2018”. This has been a significant collaborative work with ID physicians, microbiologists, pharmacists, nurses and health service managers. I think non-AMS pharmacists are really engaged in AMS in their day-to-day work and there are always interesting research questions to answer! Vancomycin is the perfect example, despite our decades of clinical use, we still are finding out more and more how to better use this antibiotic better for our patients. Lots of research careers have been made from vancomycin and is one of many things that continues to keep my job interesting.
3. What are pharmacists in Australia doing to improve antimicrobial stewardship?
AMS pharmacists in Australia are indeed quite inpatient focused but we do have pharmacists actively researching in the gaps in residential care facilities and community pharmacies in primary care. There is great PhD work coming out of NCAS where pharmacists are enhancing the engagement of antimicrobial prescribing in the community pharmacy and general practice setting. NCAS have also developed an antimicrobial prescribing survey for age care facilities to have data as enablers for improving antimicrobial prescribing. In addition to this, Australian pharmacists are researching the quality of antimicrobial prescribing in outpatient parenteral antimicrobial therapy (OPAT) services that is hot off the press in this month’s JAC-AMR. There’s actually a few nice Aussie AMS papers with pharmacist authors in the September issue! One of these is a colleague who has demonstrated reductions in CPE isolates with reduced carbapenem use.
AMS pharmacists in Australia are engaged extensively in organisations at numerous levels in health service delivery. As previously mentioned in question 2, we have AMS pharmacist engagement in state, federal and hospital levels. There are excellent AMS pharmacists networks through our Society of Hospital Pharmacy Australia (SHPA) speciality practice groups. We are extremely fortunate to have numerous opportunities for education support through the SHPA Infectious Diseases seminars, CRE REDUCE seminars, annual ASA and ASID meetings. I particularly love the “Pharmacist workshops” run at the annual ASA meetings. The Australian Antibiotic guidelines is considered our consensus guidelines and there is a lot of expert ID/AMS pharmacist editorial involvement. Our most recent version was so comprehensive that the publishers had to stop providing printed copies of it!
Pharmacists around the country are heavily involved in contributing antimicrobial utilisation data to the National Antimicrobial Utilisation Surveillance Program (NAUSP). This is an excellent surveillance tool to help hospitals target and monitor their AMS interventions and compare usage to peered hospitals in a deidentified manner. NAUSP uses daily defined doses over bed activity at the moment but there is work looking to incorporate days of therapy as a future metric.
4. What is the most important lesson you have learned working in the field of antimicrobial stewardship?
The most important thing I have learned working in the field of AMS is diplomacy. You can be the most well published, knowledgeable pharmacist clinician in all things infectious diseases and antimicrobial but ultimately an excellent antimicrobial steward needs to know how and when to engage our fellow antimicrobial prescribing stakeholders for the maximum impact.
I learnt many times to pick my battles and to learn when to fight another day despite how inappropriate a certain antimicrobial is (unless the patient was at risk). There is a better time and place; and often a better person to approach. I have learnt that changing the culture of antimicrobial prescribing takes years of rapport building and garnering of mutual respect first. This could be quietly attending ward rounds of target antimicrobial prescribers trying to understand their though processes and quite often mastering the art of small talk. This could be bringing people together to collaborate on quality improvements projects or research. In the era of electronic medication management (eMM), we have all this data at the tips of our fingers and to ask a recalcitrant antimicrobial prescriber to be a co-author of a retrospective analysis gives you the perfect opportunity to begin to talk about their poor choice of antibiotics.
Sadly, we are not taught these soft skills in pharmacy school and is this is very person dependent. Surrounding myself other with AMS/ID colleagues has indeed helped me along the way because it can often be a tough gig. I celebrate the small wins as much as I can (as few as they may seem) but then over years of doing this, I surprise myself at how far antimicrobial prescribing can improve.
Lastly, I’ve also learnt that there is no magic formula for an effective AMS service. Something that has worked in one hospital (or department even) will not mean it will work at the next. I’ve successfully changed a whole respiratory department’s prescribing for pneumonia from cefaclor to cefuroxime in one simply 100 word email. But then I’ve had to participate in 3 years of weekly oncology AMS rounds to stop a department from giving too much gentamicin for febrile neutropenia. AMS interventions are very tailored and individualised.
5. What is the most pressing antimicrobial stewardship challenge facing Australia today?
One of the most pressing AMS challenges we are facing Australia today is probably the inappropriate prescribing of oral amoxicillin-clavulanic acid and cefalexin in hospitals where they have the highest usage and rate of inappropriate prescribing.
1 in every 2 cefalexin prescriptions and 1 in every 3 oral amoxicillin-clavulanic acid prescriptions are inappropriate. This is something I often overlook working at a tertiary paediatric referral hospital where I focus on bigger fish to fry (e.g., all the meropenem and amphotericin B). Antimicrobial utilisation in Australian hospitals have been fairly stable and overall appropriateness of prescribing over the last 5 years has not improved significantly (around 70-75%). There is definitely room for improvement in the area of surgical antibiotic prophylaxis as the most common indication in Australian hospitals where 1 out of 3 prescriptions are inappropriate. There is a big AMS strategic push in Australia to improve prescribing in primary care and expanding our surveillance of AMR and antimicrobial use in areas overlooked (e.g. rural/remote health sectors, age care and in the private sectors).
6. What do you predict the future holds for antimicrobial stewardship in Australia?
The future of AMS in Australia seems to be promising with decent state and federal strategic direction and support. This was published recently in the Australia’s National Antimicrobial Resistance Strategy 2020 & Beyond Report.
There are challenges in AMR in Australia where there are little signs of improvement in Gram positive bacterial resistance rates and Gram negative Enterobacterales is always a serious concern. At a hospital level, I am concerned about delayed access to the newer last line antimicrobials that are not registered in Australia that we often have to resort to (e.g., cefiderocol and meropenem-varborbactam). Australia seems to be considered a small market so we are lagging behind with the registration of these antimicrobials. These expensive antibiotics are infrequently used but when we need it, we need it now! The limitation is that most hospital pharmacies are reluctant to keep them on our formulary in fear of having to discard expired stock in tightly managed pharmacy budgets.
ABOUT THE INTERVIEWEE
Tony Lai (twitter handle: @tonylai_) is the senior antimicrobial stewardship pharmacist in one of the largest paediatric hospitals in Australia (The Children’s Hospital at Westmead). He has over a decade of AMS experience in both adult and paediatric hospitals around Sydney ranging from a district level appointment looking after 2,000 beds to a small regional hospital appointment of 150 beds. He has completed a Masters in Clinical Pharmacy with his thesis looking at posaconazole therapeutic drug monitoring in immunocompromised children. He has keen research interest in AMS and TDM with a particular fascination with aminoglycosides, vancomycin and azoles antifungals. Currently, he is keeping himself busy looking improved Bayesian forecast dosing of vancomycin in neonatal intensive care and salivary voriconazole and fluconazole TDM in immunocompromised children.
Disclosures: The views expressed in this article represent that of the authors and do not necessarily reflect the position or policy of any previous, current, or potential future employers or other organizations in which they provide service.
I would like to extend my utmost gratitude to Tony Lai for taking the time to participate in this interview and share his perspectives on antimicrobial stewardship in Australia.
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