This article explores antimicrobial stewardship in New Zealand as seen through the eyes of an infectious diseases pharmacist.
Interviewee: Mohammed Issa, B.Pharm.
Interviewers: Timothy P. Gauthier, Pharm.D. & Aditya Shah, M.D.
[Last updated: 13 January 2020]
Over the past few months IDstewardship.com has published articles exploring antimicrobial stewardship in different countries from around the globe. This has included engaging people from Uganda, Thailand, Japan, Costa Rica, and Canada.
It has been valuable to learn from the individuals that have given their time to provide insights and perspectives on antimicrobial stewardship in their country. Antimicrobial resistance is a threat to human health worldwide and there is much we can learn from each other.
Through a connection made on social media, we bring you the latest installment in this series. Here, an infectious diseases physician (@IDdocAdi) and an infectious diseases pharmacist (@IDstewardship) interview an infectious diseases pharmacist in New Zealand (@MohammedIssaID) about Antimicrobial Stewardship.
1. How did you come to be an infectious diseases/ antimicrobial stewardship pharmacist in New Zealand?
My career in pharmacy started after I completed my Bachelors of Pharmacy at the University of Otago in New Zealand. After graduation I completed my internship in a rural hospital and community pharmacy on the West Coast of New Zealand which provided me with training and experience in rural care. This was invaluable as I not only appreciated the constraints in healthcare (particularly in the delivery of specialist services), but also difficulties around outpatient therapy including use of intravenous antibiotics in a population scattered across a large area with quite limited resource.
I was interested in furthering my clinical skills and I quite enjoyed the multidisciplinary approach in patient care that I was exposed to in my hospital training. In turn, I sought postgraduate study in clinical pharmacy and ventured to the North Island where I took a role as a rotational hospital pharmacist, initially embracing general medicine but then taking on a newly established role as an emergency department pharmacist. This role was quite challenging but, also very exciting. My role in the emergency department evolved and it was there that I was exposed not only to the abundance of antimicrobial prescribing in primary care, but also from the emergency department. I was also at the forefront of aiding in the management of life threatening infections – patients critically ill with sepsis requiring appropriate antibiotics.
It is important to note that an interest in infectious diseases was present during my early pharmacy study days. This interest evolved into a passion as my roles changed and my experience in infectious diseases cases (while quite limited) grew. Interest in infectious diseases started off in the form of an appreciation for the interesting pharmacokinetics of the antimicrobials we use, evolving into a desire to protect said interests, and so driving a passion in stewardship.
Training in infectious diseases and stewardship, while limited in my undergraduate course and my postgraduate diploma, provided a scaffold that allowed me to build on and hone utilizing the abundance of resources online including Twitter. This provided me with the initial starting point that was built on and evolved under the guidance of the infectious diseases team at Waikato Hospital through in-house training.
2. With training in Emergency Medicine pharmacy and without formal ID training, what was it like taking a position as a hospital-based antimicrobial stewardship pharmacist?
Pharmacy services here in New Zealand are evolving. More specialized roles such as an emergency department pharmacists or an antimicrobial stewardship (AMS) AMS/ infectious diseases (ID) pharmacists are roles that are new here in New Zealand, despite being established abroad.
I had previously experienced the daunting task of taking up a new, unknown role. Moving from a general hospital pharmacist role to a relatively more specialized emergency department pharmacist role, with little training.
The move to the AMS/ID pharmacist role was similar, although compounded by the fact that I was moving from a smaller secondary hospital to a tertiary hospital and in a bigger city. I was unclear as to what the role actually entailed so while I was slightly nervous about the transition, I was quite excited – daunting nonetheless. Once in the role I felt overwhelmed by how little I knew and the amount of work needed to be done. Even more so for AMS, where I was working to establish a system essentially from scratch.
A few drivers fed my excitement, knowing that I was going to be practicing at a higher level than what I was accustomed to. I was also looking forward to being part of a handful of pharmacists across the country already working in ID and AMS and potentially making a bigger difference – with a potential for this difference to be noted at a national level.
I knew I needed to know and learn more and this excited me the most. While I absolutely loved the emergency department in a small hospital, I could not help but feel that my knowledge was slightly stagnating and this was an opportunity to try something different (needless to say – I had not appreciated it was as bottomless as it is!).
3. Who are some of your core antimicrobial stewardship team members and how do you work together?
This is quite tricky to break down, but I will give it a try.
Infectious diseases and antimicrobial stewardship here at Waikato District Health Board are almost intertwined. So, in essence the ID team consists of one of infectious disease specialist at a time, a registrar, me as the pharmacist, and a clinical nurse specialist.
This team caters for a hospital consisting of around 650 beds and a few peripheral hospitals – serving a population of around 420,000. On a day-to-day basis AMS strategies are carried out by an infectious diseases specialist with a special interest in AMS and me presently. This is however still evolving as we are in the process of broadening and rolling out further initiatives.
We realised that AMS needed more oversight and leadership, especially for a hospital with 650 beds. Large scale initiatives were needed and we required some empowerment. This drove us to set up an Antimicrobial Steering Group, for which we fortunately were able to recruit volunteers from a large number of clinical services (e.g., pediatrics, critical care, emergency department, nephrology, microbiology, pharmacy) and presently chaired by Quality and Patient Safety to ensure stewardship initiatives are not seen to be driven by an infectious diseases circle. This also helped us ensure initiatives were ‘suited’ for the services we wanted to roll them out to. It additionally has empowered our stewardship initiatives further, allowing them to get prioritized where required. The group remains in its infancy having been set up a year ago and while made up of ‘volunteers’ at the moment, is filled with passion and drive – which has been quite exciting to see.
I suspect with the growing concern of antimicrobial resistance this team and its influence will grow and evolve to allow for more day to day impact – which we are presently quite limited in being able to carry out.
4. Are there differences between community and academic hospitals in New Zealand when it comes to antimicrobial stewardship and infectious diseases practice?
As discussed above, formal AMS programs and pharmacists would be found in larger hospitals and less likely in the smaller secondary hospitals. Infectious diseases services would be also similar but access to them has broadened where formal consultation pathways are available for smaller hospitals.
5. How do antimicrobial stewardship leaders communicate with prescribers in New Zealand?
- Literature published around antimicrobial use particularly in primary care – often led by the Auckland group
- Education sessions to primary care physicians and general practitioners
- Monthly stewardship group meetings
- Grand round education sessions – twice a year generally
- House officer education and pharmacy education sessions
- Infection prevention study day education sessions
- Some DHBs have employed AMS ward rounds
- Not formally present at Waikato
- Active surveillance on carbapenems presently
- AMS interventions however provided on infectious diseases ward rounds are usually discussed with the team involved with the patients care – often verbal where possible/feasible but may utilize patients notes to relay AMS interventions in addition
6. Which problem pathogens are you seeing on a regular basis as complex infectious diseases cases come your way?
Locally, at Waikato, the infectious diseases service has embraced the need to actively consult on all Staphylococcus aureus bacteremia cases and more recently Candida bloodstream infections – driven by the amazing work published in the literature showing mortality improvements (thanks Twitter!). Staphylococcus aureus would typically account for around 60% of our workload (which is a lot!), over the years we have noted a rise in methicillin-resistant Staphylococcus aureus (MRSA) and which would account for around 15% of our Staphylococcus aureus.
Of course like the rest of the world we are petrified of the incoming resistant Enterobacteriaceae including the OXA-48 and NDM isolates. They remain in relative low numbers at the present – 100 cases in the last year for the country, but are quite a trouble to treat – especially as access to safe, less toxic agents are slightly tricky to get a hold of in NZ.
Unfortunately our (Waikato) ESBL rates are going up, where around 10% of E. coli and K. pneumoniae UTI’s were ESBL and 11% of E. coli bacteraemias and 14% of K. pneumoniae bacteraemias were ESBL.
Locally, we do not have too many issues with multi-resistant Pseudomonas or Acinetobacter (yet!) which is reassuring.
7. What is clinical pharmacy like in New Zealand, from an antimicrobial stewardship perspective?
Little is available in the literature to understand what clinical pharmacy is like in New Zealand. Publications from the New Zealand hospital pharmacist association (NZHPA) would essentially be the best descriptor of what clinical pharmacy services in NZ endeavor to provide
Pharmacists here in NZ are constantly seeking to establish some of the amazing clinical pharmacist led and pioneered projects internationally and have done so on a few occasions. Despite the enormous amount of work done in NZ by early pharmacists, clinical pharmacy seems to be in constant flux and there is a relentless need to justify clinical pharmacy activities, which of course impacts specialized clinical pharmacist services.
There are multiple reasons for the need to justify positions. The ratio of pharmacists to beds is lower in NZ hospitals compared to other countries such as Australia, the United Kingdom and the USA. You will find a wide practice range (e.g., from single practitioner to 30+ pharmacists per organization) and clinical activities varies significantly between hospitals run by different district health boards. The small and widely distributed nature of the NZ population means that most organizations can only support generalist pharmacists who may have special interests. Postgraduate pharmacist training in NZ differs from that in other countries. Sponsored training positions or residencies such as those available in UK or USA do not exist in NZ.
In turn, many clinical pharmacists have developed specialized clinical pharmacy roles and depending on the role and organization, some will have high-level specific skills for their role while others work with general skills – skills often gained practicing within their role.
Clinical pharmacists formally working in AMS in New Zealand are infrequently encountered and are mainly restricted to tertiary level hospitals or teaching hospitals. This is despite the international World Health Organization Global Action Plan against antimicrobial resistance, after which New Zealand (a member state) published a resistance plan in August 2017.
In a survey conducted by a couple of infectious diseases pharmacist in New Zealand a couple of years ago eleven District Health Boards (DHBs) (55%) had a lead AMS pharmacist, with nine having dedicated salaried full-time equivalents (FTEs) for the role. Six of the latter positions were full time (0.9–1.0 FTE), and three were part time (≤0.6 FTE). The six full-time positions resided in the six largest DHBs (based on bed number).
Some pharmacists are however involved in various AMS activities in their day to day practice. Some of this is driven by Pharmac which is the pharmaceutical management agency for NZ. Pharmac is involved in deciding, on behalf of DHBs which medicines and pharmaceutical products are subsidised for use in the community and public hospitals. Pharmac is able to set restrictions around access to antimicrobials – thereby restricting use and requiring certain criteria (often infectious diseases involvement) before prescribing should take place. Essentially a national pseudoforcing function! Abiding with these restrictions is often a task pharmacists (in hospitals and community) are tasked with policing.
Access however to infectious diseases specialists is often an issue in various parts of New Zealand, particularly in small secondary, rural hospitals – which makes applying these restrictions tricky!
8. What do you think are the particular challenges of AMR in New Zealand?
New Zealand is a small nation with a population of less than five million. Access to the latest and greatest medicines is tricky to obtain and fund. Information technology infrastructure and support for AMS is quite hard to come by and is inconsistently available across the country. This further complicates antimicrobial use surveillance, monitoring and forcing functions to ensure appropriate antimicrobial use. One of the drivers to this is perhaps lack of national leadership for AMS.
Despite the publication of the aforementioned antimicrobial resistance action plan, AMS strategies in NZ remain in its infancy. Progress has however have been achieved in veterinary and agriculture use of antimicrobials. Yet lots of work remains around AMS in humans.
Having said all of this, improvements in human use can be observed. For instance my role did not exist 4 years ago! Progress is happening but at a relatively slow rate – the issue however is that antimicrobial resistance (AMR) and AMS is not our health system’s highest priority presently.
9. What is one lesson about antimicrobial stewardship that you can share from your training and experience, that is important for stewards in other areas of the world to be aware of?
Often as stewards we may feel the need to be passive with the delivery of our interventions. AMS however, should be about engagement of clinical services to unravel reasons behind practice and need for interventions. It may even drive the steward to reflect around appropriateness of interventions proposed to clinicians –allowing for improved revision and strengthening of the interventions proposed. It also builds a rapport with relevant services to work synergistically on further projects.
Most clinicians know that we require appropriate antimicrobial use – and often a positive, direct engagement is enough to drive and attract their effort in constructing robust and effective system changes. Changes that are much needed for successful AMS strategies!
Thank you for this opportunity, it has been great getting to work with two legends of AMS/ID twitter – it has been an absolute honor. Working in infectious diseases and AMS is so exciting, and twitter has functioned to enhance my passion on a daily basis with amazing tweets and discussions (thank you #IDtwitter).
A huge thanks to @drcjlittle who got me hooked on the wonderful world of Twitter, the amazing team I am fortunate to work with at @WaikatoDHB including my team leader Julie Vickers and the ID team @KatieWalland, @IdHugh, @SeanMunroe1, @SepsisTrustNZ, @tracey_kunac and @DocJulia1. The ID/AMS pharmacists across NZ that pioneered this role with their amazing work including @dpj_t, @EamonID and @SGardinerNZ.
A final message: Think of little ol’ NZ and we’re always excited to collaborate where possible. You may occasionally get a message, tweet or email with a gnarly question or two, your help and support is always appreciated!
ABOUT THE INTERVIEWEE
Mo has worked as a clinical pharmacist for over five years, working in an array of specialties and roles. Presently captivated in the world of microbiology working as an infectious diseases / antimicrobial stewardship (ID/AMS) pharmacist at Waikato. In addition to introducing an AMS program to the Waikato region, Mo works to optimize the use of antimicrobials for individual patients where possible. Mo’s research presently looks to better understand local antimicrobial prescribing behaviors and confidence. He has embraced the use of Twitter as tool to connect, engage, learn, and educate from professionals globally and is increasingly tweeting ID and AMS tweets.
You can find him on Twitter @MohammedIssaID.
We would like to express our sincere gratitude to Mo for providing his insights and experiences working in the field of antimicrobial stewardship in New Zealand. We greatly appreciate the time he has taken to complete this interview.
Disclosures: The views expressed in this interview represent that of the individuals only and do not necessarily reflect the position or policy of their previous, current, or potential future employers or other organizations in which they serve.