In this article pharmacists from Canada and the United States interview a pharmacist from Japan about his perspective on antimicrobial stewardship.
[Last updated: 16 March 2019]
The growth of antimicrobial resistance has gained attention globally as one of the greatest public health threats of the 21stcentury. In 2015, the World Health Organization released a global action plan on tackling this growing problem through increased awareness, surveillance, infection prevention, new therapeutic and diagnostic technologies, and antimicrobial stewardship.
With increasing international travel and air travel expected to double by 2036, antimicrobial resistance knows no borders. Japan, an island nation of 127 million people with densely populated urban centers is not immune to this public health threat. Health care professionals in Japan have joined the efforts to address antimicrobial resistance and the harms of antibiotic overuse.
Pharmacists across the globe are key partners in the fight against antimicrobial resistance, and as the pharmacotherapy expert they are pivotal in antimicrobial stewardship efforts. As such, Japan’s pharmacists are playing a growing role in antibiotic stewardship programs. Although we have different challenges with respect to antibiotic availability, differences in health care system models, and different languages, there is much to learn and share from each other about the burgeoning field of antibiotic stewardship.
To learn more about the role of pharmacists in antimicrobial stewardship in Japan, we reached out to Shutaro Murakami, BScPharm, a Board-Certified Infectious Disease Chemotherapy Pharmacist and Infection Control Pharmacy Specialist in Tokyo, Japan. We are grateful to learn from him.
The following interview provides insights on antimicrobial stewardship in Japan from a pharmacist’s perspective…
1. Could you describe your perspective on the state of antimicrobial stewardshipin Japan?
In the past few years in Japan, antimicrobial stewardship programs (ASPs) have been on the rise. I think that the major reasons for this trend are the implementation of a national action plan on antimicrobial resistance (AMR)  by the Japanese government in 2016 and increased financial incentives provided to Japanese healthcare institutions since 2018 for promoting ASPs. In general, financial incentives are usually provided after an institution has established a record of success in accordance with the government’s policies. This process may be the reverse of that seen in the United States or other countries.
There are several challenges with respect to antimicrobial use in Japan. First, oral antimicrobial use accounted for over 90% of total antimicrobial consumption, much of which was unnecessary . Second, the strong hierarchy of the medical system gives only doctors the right to prescribe medications. Third, each medical staff member has numerous duties, including some which are non-essential, such as inventory management and reducing redundant documentation in the pharmacy. Finally, public awareness about antimicrobial use is still very low, and means of educating the general public about this topic are needed . Japan has a universal health care system allowing people easy access to medical care. This may be contributing to the over-prescription of drugs including antimicrobials (e.g., for the common cold).
Nonetheless, the situation surrounding ASPs in Japan has gradually improved. Multidisciplinary ASP teams have been established (mainly in an inpatient setting at present) in various Japanese hospitals to work on problems related to antimicrobial use, and their efforts have gradually led to improvements in outcomes including patient education. For example, at our tertiary care hospital we have implemented a successful, hospital-wide, once-weekly, post-prescription review with feedback that has served as a model for other hospitals in Japan . We have also begun implementing ASPs in outpatient settings, particularly in the emergency department . Moreover, we published a new method for calculating vancomycin exposure using therapeutic drug monitoring data on the drug in an inpatient setting . Other hospitals in Japan have followed suit with their own ASPs, and many workshops and conferences are being held to promote ASPs. I think the current trend will continue to gain pace in the foreseeable future.
2. How do you feel antimicrobial stewardship is different in Japan versus other countries like Canada and the United States?
I feel that at present doctors occupy the chief management role because ASPs led by pharmacist are not always successful, due partly to the perception fostered by the medical hierarchy in which pharmacists have less authority than physicians in these matters. The Japanese healthcare system also does not have the concept of a clinical pharmacist. Therefore, many antimicrobial stewardship teams here are run by a physician-led multidisciplinary team consisting of physicians, pharmacists, and other medical staff.
Although gathering more data on antimicrobial consumption is imperative, I feel that data management is not performed sufficiently and infrastructure (e.g., information technology [IT] systems) in hospitals are poorer in Japan than in other developed nations, partly because data management is currently labor-intensive.
While we rarely encounter multidrug-resistant microorganisms which cannot be treated with antimicrobials, the proportion of methicillin-resistant Staphylococcus aureus (MRSA) and penicillin- resistant Streptococcus pneumoniae isolates in Japan is high . We should therefore continue to improve on our current ASPs to change this situation.
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3. What path did you take to become an antimicrobial stewardship pharmacist in Japan?
Japanese pharmacy school education changed in 2006 to last a total of 6 years until graduation. The curriculum now requires not only the standard course of study but also undergraduate training experience in the community and at a hospital pharmacy. Before 2006, the programs were only 4 years long, and undergraduate training was not required. The role of the pharmacist in Japan has gradually changed from the customary duties of dispensing prescriptions to working in the clinical setting due to an increasing demand for the clinical expertise of the pharmacist and the various, new financial incentives I mentioned in my response to question #1.
I usually serve as an antimicrobial stewardship pharmacist and work with infectious disease physicians, an infection control nurse, and a microbiology laboratory technician. Although our team is small and we work only part-time on antimicrobial stewardship  we have done our best to implement an effective ASP, have published our research findings, and continue to plan improvements in the ASP. From my point of view, such activities and collaborations in clinical and academic settings in Japan will continue to increase in number.
4. What is pharmacy practice like in Japan?
I think that most pharmacists in Japan are just like staff pharmacists in the United States. Clinical pharmacists are largely unknown in Japan, but this fact may be slowly changing as I mentioned above.
Some pharmacists participate in various teams (e.g., antimicrobial stewardship team, infection control team, palliative care team, etc.), but many do not. Japanese pharmacists spend a lot of time checking and reviewing medications, particularly after a patient’s admission, and are therefore unable to perform medication reconciliation effectively at many hospitals. Moreover, we usually follow patients at every clinically important juncture, such as the start of new chemotherapy or other medication, to ensure that the treatments do not exceed the acceptable parameters. Most hospitals have similar systems in place with slight variations due to the hospital’s size and whether it is a teaching hospital or an acute care hospital.
For example, the institution where I practice is a community tertiary care center with 790 beds, 29 subspecialties, and a fixed number of ~50 pharmacists The day is divided into 3 shifts, and each shift is divided into time for central or clinical duties. We do not make a clear distinction between staff and clinical pharmacists, as a pharmacist in Japan have both central and clinical duties.
5. What role do pharmacists play in antimicrobial stewardship in Japan?
From the point-of-view of the institution, pharmacists play an important role in antimicrobial stewardship programs, particularly in data maintenance (e.g., upkeep of electronic medication administration records and barcoding medication record. Days-of-therapy and antimicrobial use density based on the defined daily dose as a metric are almost always used by pharmacists in Japan. Therapeutic drug monitoring (TDM) of vancomycin, aminoglycosides, and voriconazole is also one facets of the ASP and is conducted widely by pharmacists at many institutions. For example, we perform about 1,500 TDM of vancomycin annually to assist primary care providers. Moreover, some pharmacists detect problems, suggest effective interventions, and help implement ASPs. Studies on the outcomes of ASPs written by pharmacists as the first author have begun to be published.
On the other hand, from the point of view of public health, few pharmacists are seen as playing an essential role, with physicians being more active in this area. I think that more pharmacists should aggressively take part in public health in the future.
6. What do you perceive to be the greatest challenge that antimicrobial stewardship pharmacists in Japan face today?
I think that an effective national training program with clear benchmarks for clinical pharmacy and academic work by pharmacists is required. Although various societies independently grant Board Certification in Japan, a systematic training program in clinical pharmacy provided by the government (e.g., post-graduate residency programs in the United States) is lacking. There is also the problem of the poor recognition of clinical pharmacists in Japan. Enhancing awareness of their importance among the medical staff and public is important.
Moreover, an effective surveillance system in hospital epidemiology (e.g., antimicrobial consumption, ventilator-associated events, and surgical-site infection) does not exist widely. ASPs are made up of small numbers of staff at many Japanese hospitals. More robust and competent surveillance systems are needed at every institution.
Competence and systemization requires improvement, and a strong argument can be made for including more pharmacists in this effort to improve the quality and implementation of ASPs and related academic work.
7. What opportunities do you see for antimicrobial stewardship pharmacists in Japan and across the world to collaborate and learn from each other?
As the development of information technology accelerates, we have more access to ASPs worldwide. Social networks as well as publication of research enable us to share knowledge across national and institutional borders. Antimicrobial resistance is now spreading widely across the world due to the ease with which we can travel the globe. In this sense, the problem of antimicrobial resistance is one that affects us all.
I had the opportunity of taking part in a very exciting collaborative study with a clinical pharmacist from the United States and my colleagues in Japan . In the study we aimed to create new methods of estimating antimicrobial exposure, focusing on vancomycin use. I feel that such collaboration is very rewarding and essential for me to broaden my horizons and deepen my knowledge since what I can achieve alone is limited. I hope to have the opportunity again to collaborate with antimicrobial stewardship pharmacists and other medical professionals from various countries in furthering the aims of my chosen field.
8. What do you perceive the future holds for antimicrobial stewardship pharmacists in Japan?
Japan’s population is rapidly aging and the nation is now being confronted with various monumental challenges. The scarcity of medical staff and poor infrastructure at almost every hospital also complicates implementing antimicrobial stewardship and infection control activities.
However, on the bright side, these situations may impel us to look for solutions through research using limited resources. More ingenuity will be required and pharmacists will prove to be important players in ASPs. More and more pharmacists are devising effective interventions and establishing a record of successes in clinical research on ASP even with such limited resources. Maximizing the therapeutic effects and minimizing the adverse events in antimicrobial use will contribute to patient care and improve patient outcomes.
In the future, I believe we will see antimicrobial stewardship pharmacists participating in more ASPs not only at their institution, but also in their region and publishing the outcomes of their research internationally.
2. Kamata K, Tokuda Y, Gu Y, Ohmagari N, Yanagihara K. Public knowledge and perception about antimicrobials and antimicrobial resistance in Japan: A national questionnaire survey in 2017. PLoS One 2018;13:e0207017.
3. Honda H, Murakami S, Tagashira Y, et al. Efficacy of a Postprescription Review of Broad-Spectrum Antimicrobial Agents With Feedback: A 4-Year Experience of Antimicrobial Stewardship at a Tertiary Care Center. Open Forum Infect Dis 2018;5:ofy314.
4. Tagashira Y, Yamane N, Miyahara S, et al. Misuse of Discharge Antimicrobial Prescription in the Emergency Department: An Observational Study at a Tertiary Care Center. Open Forum Infectious Diseases 2019;6.
5. Murakami S, Hiroi J, Tokuda Y, Casabar E, Honda H. Methods of estimating vancomycin use in an inpatient setting: days of therapy versus therapeutic drug monitoring-based exposure days. Infect Control Hosp Epidemiol 2019:1-5.
ABOUT THE INTERVIEWEE
Shutaro Murakami, BScPharm, is a Board-Certified Infectious Disease Chemotherapy Pharmacist and Infection Control Pharmacy Specialist in Japan. He is currently employed at Tokyo Metropolitan Tama Medical Center, a 790-bed, tertiary care hospital in Tokyo.
Mr. Murakami earned his BScPharm degree from Kitasato University School of Pharmacy in 2012. His main role as a clinical pharmacist is in antimicrobial stewardship programs (ASPs) in inpatient settings, including conducting pharmacist-led prospective audit and feedback on broad spectrum antimicrobial use, and monitoring the use of selected antimicrobials.
He is interested in measuring changes in antimicrobial utilization and clinical outcomes following ASP implementation. He and his team have recently published a number of ASP studies which have contributed to improving our understanding of the current state of ASPs in Japan.
We would like to express our utmost gratitude to Mr. Murakami for taking the time to share his thoughts and for his important work in our global fight to promote antimicrobial stewardship.
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