In this article a Spanish pharmacist with experience in the field of infectious diseases discusses antimicrobial stewardship in Spain.
Interview with: Eduardo Clot Silla; Pharm.D., Ph.D.
Hospital Pharmacy specialist—Institut Guttmann, Ocular Pharmacology and General Microbiology Associated Professor Universitat Politècnica de Catalunya
Interview by: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP
Article posted: 1 October 2021
Antibiotic 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 India, Bangladesh, Uganda, Thailand, Japan, Costa Rica, Australia, New Zealand, and Canada.
Recently I connected with Dr. Clot Silla via Twitter. He is a Spanish pharmacist with advanced experience in the area of infectious diseases and antimicrobial stewardship. Through our correspondence the following was developed, providing a pharmacist’s perspective on antimicrobial stewardship in Spain.
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 Spain here, as we all seek to protect our precious antimicrobial drugs for future generations!
1. How did you get interested in antimicrobial stewardship as a pharmacist and what path did you take to reach where you are today?
My interest in antimicrobial stewardship dates back to my time as a student in pharmacy. Possibly, when we started talking about terms like “antibiotic crisis” or “post-antibiotic era”, my attention turned to this discipline, because of the enormous impact it represents. In fact, when an 18-year-old Pharmacy student begins to be spoken to in these terms, he can’t help but imagine that there is a lot of work to be done to avoid losing one of the most powerful pharmacotherapeutic tools in our arsenal.
On the other hand, to see how infectious diseases continue to be a very important cause of morbidity and mortality in our environment along with the fact that our activity has a very high impact, not only on an individual patient but on society as a whole and public health, made infectious diseases catch me as an area where our profession can make key contributions. I think it is difficult to resist a discipline in which what we do in a particular patient can translate into a very important benefit or harm in society.
From that moment on, I felt trapped by this discipline because, in a way, it summarizes everything I find most interesting in clinical pharmacy: pharmacotherapy, patient care, pharmacokinetics, pharmacodynamics, multidisciplinary work (essential and always intellectually enriching) and public health.
There has also been a good dose of chance in my career. At the end of my studies at the Faculty of Pharmacy, I was working for two years at the Hospital del Mar in Barcelona, formerly known as “the hospital for infectious diseases” where there is a long tradition of vocation towards infectious diseases and anti-infective pharmacotherapy. To all this we must add the enormous luck of having been able to share my practice as a pharmacist with professionals as wise as Dr. Santiago Grau from whom I have always said that I have learned everything I know about antimicrobial therapy from him and that, fortunately, I continue to learn from him.
In the different hospitals where I have worked as a hospital pharmacy specialist, I have ended up devoting part of my time to anti-infective therapy and, therefore, continuing education has been one of the most important cornerstones in the exercise on infectious diseases. The final impetus was given by Dr. Stan Deresinsky, who, along with his team, taught an antimicrobial stewardship course that was definitive in the way I approach this exciting job.
2. What is the status of antimicrobial stewardship in Spain?
Regarding the situation of antimicrobial stewardship in Spain, it is convenient to have some very important points in mind.
Firstly, the feeling is that we have started too late in dealing with the issue of the antibiotic crisis in our country, so we are at a clear disadvantage compared to other countries in Europe. Probably, our panorama of resistances would be considerably different if we had followed the example of countries like the United Kingdom or the Netherlands.
Secondly, Spain continues to be one of the first consumers of antibiotics which is by no means good news in the field of antimicrobial stewardship.
Considering these two points together with the devastating phrase that the IDSA pronounced some years ago “antibiotics are almost over, it is time to act” there are plenty of reasons to get to work.
3. What are the pharmacists in Spain doing to improve antimicrobial stewardship in Spain?
One of the first actions to take was to know what the real state of antibiotic consumption in Spain was using data collection methodologies and common indicators for the whole country.
At the state level there was the National Plan against antibiotic resistance that consists of various objectives, but the main ones would be the reduction of the consumption of antimicrobials as well as the decrease in the need for use of these drugs. Another interesting point of this program is its global approach, since it also considers not only human health, but also animal health, a fact often forgotten in antimicrobial resistance prevention policies. Therefore, this national plan has as main objectives:
- Monitor the consumption of antibiotics and the appearance and behavior of resistances
- Control antibiotic resistance (by strengthening local PROA programs (Programs for Optimizing Antimicrobials), we will talk about them later).
- Prevention of the need for antibiotic use
- Training in matters of resistance.
At the regional level, there is a program called VinCAT in Catalonia. This program establishes a unified surveillance of nosocomial infections in Catalonia. Its mission is to reduce nosocomial infection rates through continuous, active and unified epidemiological surveillance. The objectives of this program are nine and they are ambitious.
- Assessment of the prevalence of nosocomial infections
- Monitoring of catheter-associated bacteriemia
- Surveillance of surgical infection
- Surveillance of nosocomial infection in intensive care units
- Surveillance of microorganisms with specific resistance problems, such as MRSA or Clostridium difficile infections
- Promotion of the establishment of antimicrobial stewardship programs in each hospital
- Surveillance of nosocomial infection in nursing homes
- Surveillance of infections in pediatrics and neonatology
- Hand hygiene monitoring
These objectives, many and ambitious (I do not know any Pharmacist who does not like to think big) aim to know the patterns of consumption and resistance to be able to reduce the use of antimicrobials and optimize it when necessary.
One of the objectives that have been set at national level is the reduction of the consumption of antimicrobials below the European average. Local antimicrobial stewardship programs have a special role in this case.
These three programs (the national program for antibiotic resistance, the VinCAT program in Catalonia and each of the antimicrobial stewardship programs) both those of each hospital and the community, have allowed since 2017 to reverse the trend in the consumption of antimicrobials, which since that year has been in decline. There is still much to be done, but we are getting the results we desire.
With all this, what I intend to say is that the involvement has been totally transversal, from individual pharmacists to health care authorities.
As I said before, it’s all a matter of teamwork. This is what we do and it has really been of great impact on all pharmacists who, for one reason or another, are dedicated to the pharmacotherapy of infectious diseases, the integration into truly multidisciplinary teams.
The reason is very simple too What pharmacists always seek is to achieve excellence in the quality of care we provide to our patients. I believe that one of the most important contributions has been to raise awareness that the quality of care consists of both the realization of a correct diagnosis and the application of the most appropriate pharmacological and non-pharmacological treatments, being the use of medicines a key aspect in obtaining a favorable clinical result, especially considering that the use of antimicrobials is key in obtaining these optimal results.
Our task begins, in the selection of medicines used in the treatment of infectious diseases. For this, our role as professionals devoted to the drug is fundamental, selecting antimicrobials in an extremely rigorous way that uses various criteria such as efficacy / effectiveness, available scientific evidence about the drugs (e.g., indications, adverse effects and their incidence, dosage regimen, interactions, pharmacokinetics / pharmacodynamics), and economic issues… although probably more than half of the weight for each decision is held by the criteria of efficacy and safety.
Because the inappropriate use of antimicrobials has been unquestionably linked to the selection of resistant strains as well as an increase in reinfection rates, the primary (although not the only) role that the pharmacist specializing in infectious diseases should assume is that of correcting errors that may have been committed in the prescription of antimicrobial therapeutics. This first approach includes reviewing the suitability of the antimicrobial spectrum used, reverifying the treatment in the presence of causal agent identification, reducing excessive treatment durations, and implementing sequential therapy whenever possible.
More globally, we have identified four areas in which a pharmacist specializing in antimicrobial therapeutics should participate:
- Monitoring of antibiotic use, locally, regionally, and statewide
- Alerting prescribers
- Continuous training for health professionals
- Active participation in antibiotic use policies in a hospital
For all this, the first step was to redesign the continuous training plans of pharmacists who are dedicated to infectious diseases. For this, it has had the invaluable collaboration of the Scientific Societies.
On the other hand, the policies for the use of antibiotics have been redesigned, which have gone from having a monolithic approach to having a multidisciplinary approach. The design of antibiotic policies must be multidisciplinary (personally, now that these types of approaches have been implemented, I do not know how it has been possible to spend so much time working the professionals separately). Our task involves all professionals in the management of infections and their control, from diagnosis to administration of the drug.
In fact, now pharmacists, once adequately trained in antimicrobial therapy, are integrated into multidisciplinary teams that are integrated by specialists in infectious diseases, specialists in intensive care medicine, microbiologists, and nursing staff.
From the Pharmacy Services there have been different strategies that have been launched for the optimization of antimicrobial therapeutics.
The use of computer programs is being employed to issue alerts for spectrum overlap, restrictive dispensing policies, warning of the start of sequential therapy, and pharmacokinetic monitoring (which reduces nephrotoxicity and costs derived from it by the implementation of management of glycopeptides and aminoglycosides).
In short, we have done a lot of work to reverse the trends of continuous increase in antibiotic consumption in our country. Much remains to be done, but we are on the right track and pharmacists are playing an integral role.
4. What is the most important lesson you have learned when it comes to antimicrobial stewardship?
I have learned two fundamental lessons regarding antimicrobial stewardship.
First of all is to maintain humility. In this discipline you never know enough, and you learn day by day.
Secondly is that much remains to be done in this field. Even with relatively few resource, having purpose can enable us to achieve important objectives that positively impact our patients and society.
5. What is the most pressing antimicrobial stewardship issue in Spain today?
In Spain, as probably in many other countries of the world, the main problem we face is that of multi-drug resistant microorganisms and extremely resistant ones.
It’s frustrating and dramatic in equal parts to find antibiograms that show resistance to virtually every antimicrobial available. Having to communicate this fact to patients or their families is something I think we will never get used to. There is nothing more frustrating than not having therapeutic alternatives. I personally believe that we should no longer approach this problem as emerging, but as clearly established and act according to this fact.
6. What do you predict the future holds for antimicrobial stewardship in Spain?
Regarding what awaits us in the future of the antimicrobial stewardship in Spain, I believe that what we hope to see in the future is a total coordination between the antimicrobial stewardship teams, from the hospital teams to the primary care teams, passing through the centers and hospitals of intermediate care such as the socio-sanitary ones. We must turn the treatment of infectious diseases and antibiotic management policies into a continuum of care without the barriers that currently exist. There are still too many differences in current antibiotic policies at different levels of care and we must try to overcome them.
On the other hand, I think it is important to mention the area of the pharmaceutical industry to encourage them to design and obtain new antibiotics that allow us to treat infections caused by the most resistant microorganisms to the therapeutic possibilities currently available.
With the emergence of the COVID19 pandemic, rarely has the entire world been united in the fight against an infectious disease. My hope is that this spirit of global collaboration will be maintained over the years, not only in the field of virology but also in the whole field of infectious diseases.
ABOUT THE INTERVIEWEE
Eduardo Clot Silla, PharmD
PhD Hospital Pharmacy Specialist Clinical Biochemistry Specialist Institut Guttmann
Associate Professor, Universitat Politècnica de Catalunya
As a pharmacist specialized in Hospital Pharmacy and Clinical Biochemistry, Dr Clot Silla has developed work in different hospital centers at different levels of care, from general hospitals to primary care through intermediate healthcare hospitals. He currently works at Institut Guttmann, one of the most prestigious hospitals specialized in spinal cord injury and neurorehabilitation in Europe.
At all of the sites he has practiced Dr. Clost Silla has been involved in antimicrobial stewardship by actively participating in multidisciplinary groups, developing advisory tasks in antimicrobial prescription, designing antibiotic policies at local and regional levels, and for surveillance and infection control tasks.
He is a member of the Spanish Society of Hospital Pharmacy and associate professor of Ocular Pharmacology and Microbiology at the Universitat Politècnica de Catalunya. You can find him on Twitter @eclotphd.
Note from the Editor: I would like to express my utmost appreciation to Dr. Clot Silla for taking the time to provide his insights in this article.
Disclaimer: The views and opinions expressed in this article are that of the authors and do not necearilly reflect those of any past, current, or potential future employer.
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