In this article antimicrobial stewardship in Bangladesh is discussed.
Interviewee: Md Jahidul Hasan, M.Pharm.
Interviewer: Timothy P. Gauthier, Pharm.D., BCPS
Posted 27 October 2020
Antimicrobial use and resistance varies geographically, but across the world antimicrobial stewardship (AS) and antimicrobial stewardship programs (ASPs) can serve as critical towards supporting safe and appropriate antimicrobial drug use. To learn about challenges from around the globe, we have been interviewing pharmacists at different countries about antimicrobial stewardship. So far we have has interviewed pharmacists from Uganda, Thailand, Japan, Costa Rica, Australia, and Canada.
Recently a colleague was kind enough to connect me with Md Jahidul Hasan and he was agreeable to an interview about antimicrobial stewardship in Bangladesh. Following some correspondence the following was developed. For readers new to this series I recommend reviewing some of the other country interviews in addition to this one. It is amazing how different yet still similar the stories are. We hope you enjoy learning about antimicrobial stewardship in Bangladesh here, as we all seek to defend antimicrobial drugs.
1. How did you get involved as an antimicrobial stewardship as a pharmacist?
Antimicrobial resistance is one of the highly focused global healthcare problems which is spreading fast all over the world. It is responsible for significant morbidity and mortality. Bangladesh is a densely populated country in South Asia. Irrational use of antibiotics is a burning issue here. Prescribers, general citizens and stakeholders are not sufficiently aware to this issue. As a result, the antibiotic resistance crisis is turning into an invincible issue in Bangladesh, and day-by-day, the list of available last line potential antibiotics is shortening. Unfortunately, there is no national antimicrobial surveillance data and antimicrobial stewardship programs are not actively present either in government nor in private hospitals.
Square hospital is a tertiary care private hospital in Dhaka, Bangladesh. Since its inception, this hospital has been producing its own antibiogram to support its physicians to practice judicious use of antibiotics. Due to a shortage of manpower, lack of policies, and administrative weaknesses, stewardship was not effectively uninitiated. I joined as a pharmacist at Square hospital ltd. (SHL) in 2013. In 2015, I started critical care clinical pharmacy practice there, and initially I started my practice in ICU of that hospital. Since then, I met with some medical professionals with big heart who had a huge interest to develop antimicrobial stewardship for SHL. I found my interest in antimicrobial utilization/ antimicrobial resistance (AMU/AMR) at that time after meeting with them and showed my personal interest to them in working for stewardship development. We four persons first started to sit together (1 ICU physician, 1 surgeon, 1 microbiologist and a pharmacist [me]) and made a small committee where none of us had any experience on stewardship, but we had big ambition to establish it for SHL.
They requested for me to make a survey initially in the hospital regarding the current practices of antibiotic practices in all medical specialties. I did it with massive hard work and demonstrated those data to all physicians of SHL in medical CME with my team. We found a hugely positive response in favor of AS from the physicians at that CME and my team was fully charged to work more. Basically, we worked for ASP beyond our official tasks and we worked hard. Since then, I am engaged with our ASP and in 2018, I was nominated as the “Coordinator” of our ASP where one physician was the chairman and one was the general secretary of the ASP committee. Simultaneously, I was doing research on infectious diseases which potentiated my roles in the ASP.
Currently, I am also the ‘Team Coordinator” of the ASP Surveillance team at SHL. I found a Fellowship opportunity in “International Course on Antibiotics and Resistance (ICARe)”, institut Pasteur (Oct 2019) in Annecy, France. I am also a trained member (trained in 2018) trainer as well with the “Bangladesh AMR Response Alliance (BARA)”, a nationwide program for AMU/AMR jointly organized by the United Nations Food and Agriculture Organization (UN/FAO), World Health Organization (WHO), and Ministry of Health and family Affairs of Bangladesh. In 2018, I received a complementary membership from American College of Clinical Pharmacy for my pioneering activities in the establishment of clinical pharmacy in Bangladesh and prominent role in ID/Stewardship. Furthermore, “Pharmacists Without Boarders”, Canada, is supporting me to increase my efficiency/potential in stewardship. In 2019, one of the members came to visit and observe my practice in Bangladesh. These experience helped me a lot to contribute in the improvement of our ASP. This is how I got involved with ASP at SHL which to my knowledge is the country’s only active antimicrobial stewardship program, currently.
2. What is the status of antimicrobial stewardship in Bangladesh?
Few private and public hospitals couple of years back took the initiative and developed a few stewardship guidelines at institution level, Bangabandhu Sheikh Mujib Medical University (BSMMU) was one of those hospitals in Bangladesh. But unfortunately, those guidelines are not followed by the prescribers and just remain in their website. Even though, no surveillance was there due to the absence of practicing the guidelines. The use of antibiotics in Bangladesh at its rural and urban level is still not judiciously practiced by prescribers and people are largely unaware about the related harm of the antibiotic resistance in their current life and in future generations. Overall, the positive feeling and the will to have a stewardship-like program at the institution level exists among the practicing doctors, stake holders and policy makers but it is still not happening at this alarming moment of AMR.
Differently, Square hospital started to develop a stewardship program but the main aim was to make a practical link between the antibiotic prescription and the goal of stewardship from the beginning. Currently, in Bangladesh, antimicrobial stewardship is only actively present in Square hospital among all the private and public hospitals in Bangladesh. No, Bangladesh is not a very progressive country in this regard but, government and international agencies (UN, UN/FAO, UNFPA, USAID, UKAID, WHO, and MSH) are working for its establishment and few initiatives have recently been taken.
3. What are pharmacists in Bangladesh doing to improve antimicrobial stewardship?
Pharmacists are not widely engaged with ASP activities. In Bangladesh, hospital pharmacy is limited to only few mega private hospitals since 2005 and community pharmacy, in most cases, are not regulated by graduate pharmacists. As a result, to generate new stewardship pharmacists is difficult at this moment in Bangladesh and current course curriculum in pharmacy schools do not focus on antimicrobial stewardship as much as needed to produce future stewardship pharmacist. As far as I am aware I am the only stewardship pharmacist at this moment in Bangladesh actively working for ASP expansion at my institution. I am from this same educational culture of the country but I was able to develop myself because of my huge interest and an excellent close-team support. At SHL, we are implementing AS now only in in-patients.
Overall this sector for pharmacists is still growing slowly. Bangladesh is much enriched in industrial pharmacy because of its huge pharmaceutical export oriented business and the education system focuses in industrial pharmacy, not in hospital, community or clinical pharmacy. Nowadays, pharmacy schools are focusing on these sectors. Government-initiated models of pharmacy practice exist at the community level throughout the country and graduate pharmacists in these model pharmacies are successfully serving patients with antibiotic prescriptions. Basically they focus on the prescribed antibiotics’ dosages, regimen, course, and counseling on possible adverse events. But these are not supporting the AS at institution level. Except me, no other pharmacists are involved in such program because ASP is not actively available in other setups. However, clinical pharmacy was initiated where I work in 2015. In turn, specialized practice fields are very new in Bangladesh.
We started our ASP from a zero-level where we knew nothing about how a stewardship program runs or what are the threats coming up. But our institutional support helped us to develop such a program for the first time in Bangladesh. I am trying to expand my works to enhance the potentiality of stewardship and to increase my team members who will be involved in ASP soon. In some mega private hospitals like SHL, few pharmacists are working for pharmaceutical care. Few pharmacists are involved in guideline development in their institutions but, I am the only one involved in the guideline development committee for ASP and AMU. I am the only one working as a frontline clinical pharmacist on a COVID-19 primary care team at this moment in Bangladesh and involved in the clinical COVID-19 guideline development committee and monitoring committee at my hospital. In addition, a pharmacy and therapeutic committee (PTC) is not available in most of the private and public hospitals in Bangladesh and as a result, scope for pharmacists to involvement in this regulatory body in different hospitals is very limited. Here in SHL, we have such strong and active PTC and being the coordinator of this committee with other pharmacists (one secretary and one member), I am actively participating in the guideline development and regulatory activities of the committee.
4. What is the most important lesson you have learned working in the field of antimicrobial stewardship?
I have learned that nothing is impossible.
If you work hard, have patience, ambition and enthusiasm, then you can achieve your goals even if you initially know very little about what you are trying to do. I believe this and same thing happened to me. Once my small team and I knew very little about antimicrobial stewardship, its principles, its prerequisites and its implementation system but, we had a unique vision and that was to bring all the prescribers on a same platform for judicious use of antibiotics at Square hospital through a environment of trust and togetherness.
At first we started with surgical prophylaxis and it was little bit easier for us to adopt. Our strategy was to make an antibiotic use guideline in a very simple way considering the current practices and available antibiotics on a particular type of infections such as urinary tract infections (UTI) and respiratory tract infections (RTI), by the current expert/leading doctors on this infection of our hospital. The stewardship committee invited people to develop a guideline by themselves on their relevant infection topic. It was a nice experience that they developed their own guideline with their own interest and knowledge, they advised their juniors to follow this, and they were very positive to agree and resolve when the surveillance team found an irrational antibiotic use case made by them.
When we started the surveillance of our RTI guideline at practice sites, we were doubtful whether the doctors would support us or not in their actual practice. The surveillance team started to collect real practice data randomly and submitted to the ASP committee. Then committee talked with the corresponding doctors and they corrected themselves. Once the situation was changed dramatically, they followed their guideline strictly, and on their surveillance day, they invited the team to come and evaluate their practices. This experience was tremendous and I have learnt how to manage seemingly impossible issues because of it.
5. What is the most pressing antimicrobial stewardship challenge facing Bangladesh today?
People do not take AMR seriously unless they have their own sufferings with untreatable infections or a life-threatening experience. Another one is that lack of initiatives from the government and private sectors to establish an emphasis for ASP initiatives. Hospital administrators do not take this issue as seriously as it to be taken. Doctors do not follow the existing standard guidelines and do not care the available antibiograms. They mostly depend on their medical experience and seek to make their patients happy with fast recovery from infections. On the other hand, patients demand for antibiotics from the doctors expecting an early recovery and sometimes, doctors are bound to do this.
Without a national policy and relevant practice guidelines, this scenario is difficult to change in large scale. Frontliners have the WHO’s AWaRe category of antibiotics and BARA are working towards implementing this guideline in the practice. They are providing training, social gatherings and media coverage on AMR for improving the awareness level among the prescribers and local citizens. But these activities are not enough to establish a rational antibiotic use environment in Bangladesh. These challenges are delaying the establishment of ASP in all hospitals and declining the interest of change makers to work more.
6. What do you predict the future holds for antimicrobial stewardship in Bangladesh?
Antimicrobial stewardship is a real need to combat AMR worldwide. Bangladesh is walking on its way to start a countrywide initiative for ASP. I hope that in near future, Bangladesh will emphasize ASPs in every private and public hospital, and the government will ensure it is effectively running everywhere. But we need more pharmacist in the hospitals to efficiently develop an AS program. Otherwise, active stewardship will not be possible to establish. A good team work (doctor-clinical pharmacist-microbiologist-hospital authority-nurse) can make it possible. To date, there is no training or study facility on clinical pharmacy as well as antimicrobial stewardship in Bangladesh. The country will have to concentrate on this.
We are happy to initiate an active ASP at SHL but, ASP is required in all hospital in Bangladesh to receive its benefits. I worked hard for it and was solely dedicated for its establishment. Today, we are doing its surveillance in RTI, UTI and surgical prophylaxis, and getting good feedback from the respective physicians. Still, we are learning and we started without any proper direction. But we had dream and specific targets. So, this is possible if an organization or a country sets it as a goal.
My journey in the initiation of clinical pharmacy and my active pioneer involvement in the country’s first and still only antimicrobial stewardship program at Square hospital has given me huge confidence and trust on me that “YES, WE CAN!”
Antimicrobial stewards in Bangladesh
ABOUT THE INTERVIEWEE
Md Jahidul Hasan, M. Pharm.
Clinical Pharmacist (ICU & ID/Stewardship)
Clinical Pharmacy Services
SQUARE Hospitals Ltd.
Dhaka, Bangladesh
Fellow (ICARe’19) from Institut Pasteur
Trained on Critical Care, India/FIP
Associate member, American College of Clinical Pharmacy (ACCP)
Member, Hospital Infection Society (HIS), UK
Member, Bangladesh AMR Response Alliance (BARA), UN/FAO, Bangladesh
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