In this interview a pharmacist discusses his career path and experiences, plus provides insights on the state of antimicrobial stewardship in Costa Rica.
[Last updated: 31 August 2018]
Antimicrobial resistance in pathogenic microorganisms threatens human health across the globe. As such, many countries have been taking steps towards improving safety and appropriateness related to antimicrobial drug use.
Examining antimicrobial stewardship efforts between nations, various differences exist. This is due to variability in laws, culture, drug availability, professional training programs, practice trends, and more. Add to this that the needs of a given institution can very significantly and stewardship champions have some major challenges ahead of them for improving antimicrobial drug use. Regardless of these differences however, there is still much we can learn from each other in our antimicrobial stewardship endeavors which contribute to a global cause.
Not long ago I had the opportunity to meet Dr. José Pablo Díaz Madriz, who is an antimicrobial stewardship pharmacist in Costa Rica. Having no idea what the challenges he faced were and what it was like practicing in his country, I reached out and asked him for an interview. He graciously accepted and the following was composed.
Here are insights on antimicrobial stewardship in Costa Rica…
1. What motivated you to get involved in antimicrobial stewardship as a pharmacist in Costa Rica?
Just when I started working as a clinical pharmacist in 2011, I was assigned a project to improve the use of antibiotics in the hospital where I work (Hospital Clínica Bíblica). A couple of months later, we received a visit from two pharmacy interns from the University of Arizona (Benjamin Guthrie and Emily Lundeen), who made part of their professional internship in Costa Rica through the agreement that exists between their university and the University of Medical Sciences Of Costa Rica (UCIMED). They taught me the concept of Antimicrobial Stewardship Programs (ASPs) and gave me information about the Society of Infectious Disease Pharmacists. This included information about the SIDP stewardship certificate programs (available here).
I really liked the concept of antimicrobial stewardship since the very beginning, especially because I saw it as an opportunity to specialize in this area and also because it was evident, that there was a lot of work to be done in my hospital.
Thanks to the support of the Hospital Clínica Bíblica and UCIMED, I was able to complete the SIDP Antimicrobial Stewardship Certificate Program and then I did rotations with the ASP team of the Banner – University Medical Center in Tucson and in the Hennepin County Medical Center in Minnesota. This is how I got involved in antimicrobial stewardship as a pharmacist.
2. Could you describe your perspective on the state of antimicrobial stewardship in Costa Rica?
From my point of view, it is something that is becoming increasingly known, however, many health professionals in the country do not know what the PROAs are, as we call ASPs in many Latin American countries. Translated into English, PROA stands for “Programmes for Optimizing the use of Antimicrobials.”
A very important milestone in my country is that a few months ago, the National Strategy for Combating Antimicrobial Resistance was published, and this document stimulates the formation of ASPs in the health centers of the country, as an official recommendation of the Ministry of Health. In addition, the Costa Rican Association of Infectious Diseases and the National Association of Hospital Pharmacists have been developing workshops, meetings, and some other activities to inform people about ASPs.
In addition, we receive support from the Pan American Health Organization (PAHO). They have offered help to all hospitals without programs with their implementation and this is really important, because their intervention facilitates the support of the hospital authorities.
Another important thing happening right now is that in the National Commission for Combating Antimicrobial Resistance we are working on a proposal to use a mandatory national electronic prescription system for antimicrobials. This is very important because there is evidence that despite regulations there are pharmacies in Costa Rica selling these drugs without prescription and also because with this tool we will be able to track antibiotic consumption and prescribing patterns nationwide.
3. What are the top challenges antimicrobial stewardship programs face in Costa Rica?
At a public level, we have the social security system (C.C.S.S.), which provides coverage to 100% of the Costa Rican population and in the main hospitals of this health system we can find several efforts to form ASPs. However, the budget is a limitation, so the staff has little time to work exclusively on stewardship activities. Meanwhile in the CCSS, it is necessary to extend the ASP to other levels of care, like regional hospitals and ambulatory clinics.
At the private level, implementations are complicated, because compliance with policies is difficult to achieve and restrictions are impossible, mainly because doctors are not direct employees of hospitals. So, for example in my hospital, we have to negotiate with physicians and try to convince them of the importance of our recommendations.
In terms of bacterial resistance data, at the national level we do not have much information available, despite the fact that we are a small country.
With regard to medicines, the main problem is that many antimicrobials do not reach our market or take a long time to arrive. This is for several reasons, but mainly because we are a small market. To mention some examples, at this time, we do not have important drugs such as: ceftazidime-avibactam, meropenem-vaborbactam, daptomycin, fidaxomicin, or isavuconazole, among others.
4. What are the top challenges antimicrobial stewardship pharmacists face in Costa Rica?
The main challenge is that in Costa Rica the concept of clinical pharmacy is still very new. Just a few of us work outside the pharmacy, although in recent years there has been an increase in the number of clinical pharmacists. I think we can use ASPs to demonstrate the importance of having pharmacists who actively work in the direct care of patients, to increase the safety of the use of medicines and to save resources for hospitals.
Another important limitation in our country is that it has not been possible to establish residency programs at the hospital level for pharmacists. However, in all the stewardship initiatives that I have heard in Costa Rica, pharmacists are being taken into account.
5. What have you found to be low-hanging fruit in your antimicrobial stewardship initiatives?
Undoubtedly our main achievement is in antibiotic prophylaxis, where we have managed to improve the profile of antimicrobial use in many procedures. For example, in cesarean delivery (the most frequent surgery in my hospital), the percentage of optimal selection of antibiotic prophylaxis was 0.5% (n = 553 procedures) in the pre-ASP 6 months period and 80.0% (n = 662) in the post-ASP 6 months period (76.5% absolute improvement). Keep in mind as stated previously, we do not have any restrictions on the use of antibiotics so physician can prescribe any antibiotic they want. We presented our data at IDweek 2017 and the abstract from our project is available here.
Currently, our main working tool is prospective audit with intervention and feedback, through which over the years we have been able to increase the complexity of our work and the acceptance of recommendations to physicians. In this manner, we optimize doses, infusions and selection of antimicrobials on a daily basis.
6. What advice do you have for pharmacists in Costa Rica who are interested in pursuing a career path similar to yours?
The first thing from my point of view is that we should study and train as hard as possible, and also try to look for opportunities to implement clinical pharmacy services, even a couple of hours a day, so they can demonstrate how useful pharmacists can become.
Right now we are starting to develop an investigation related to the functions of Costa Rican pharmacists, so we can develop a strategy to improve our clinical role. I think that is very important that we work together and support each other, so that we have good practices and as soon as possible we can have a standard level of work.
7. What is next for your career as an antimicrobial stewardship pharmacist?
I would like to take the Board of Pharmacy Specialties Infectious Diseases Pharmacists certification to gain BCIDP designation, although it is a bit expensive for a Costa Rican pharmacist when you add the cost of the exam to the cost of all of the predatory resources.
In addition, I hope to continue helping as much as possible with the development of other ASPs in Costa Rica and other countries in the region. For example, since 2017 I have been helping one of the ASPs in a public Costa Rican hospital, I participated through PAHO in a workshop in Guatemala to help them to start implementing the ASPs in that country, and recently I attended a meeting with several professionals from Latin America to decide strategies to train, educate and support ASP professionals from Latin America countries.
Closing Comments
Finally, I want to take this opportunity to thank all those USA pharmacists who have helped me at some point to learn about ASPs, there are many but some are: Dr. Michael Katz, Dr. David Nix, Dr. Kathryn Matthias, Dr. Jan Howard, Dr. Heather Rhodes and also Dr. Rebecca Zadroga (ID-MD).
And I also want to thank people like you who through social networks give us updated information almost every day, I want you to know that your work and that of many others who do similar things, actually have a very important impact on my day to day, and I know that you do it with the only intention to help.
I would like to express my utmost appreciation to Dr. Díaz Madriz for taking the time out of his busy schedule to complete this interview.
ABOUT THE INTERVIEWEE
José Pablo Díaz Madriz obtained his Doctor of Pharmacy degree from the University of Costa Rica and is currently working towards obtaining a Masters of Pharmacology and Medication Management from the University of Costa Rica. In his current position, he serves as a clinical pharmacist for Hospital Clínica Bíblica in the area of infectious diseases & antimicrobial stewardship. He has worked as a temporal advisor for the Pan American Health Organization and served as a member on the National Commission for Combating Antimicrobial Resistance
Dr. Díaz Madriz serves as a preceptor and professor for the University of Costa Rica and University of Medical Sciences Of Costa Rica. He has completed the Society of Infectious Diseases Pharmacists Antimicrobial Stewardship Certificate Program.
He remains active in research, service, and clinical practice. He is passionate about antimicrobial stewardship and is working to improve antimicrobial use in Costa Rica.
You can find him on Twitter @JP_diazm
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