In an effort to learn more about antimicrobial stewardship across the globe this article provides an interview of an antimicrobial stewardship pharmacist working in Thailand by two antimicrobial stewardship pharmacists working in the United States.
Interviewee: Sang Usayaporn
Interviewers: Krutika Mediwala, Pharma.D. and Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
[Last updated: 4 October 2019]
Antimicrobial resistance is a major public health issue today and healthcare providers worldwide are actively working on ways to address priority items. As we seek to overcome the challenges ahead it can be valuable to exchange ideas and gain a greater understanding of the problem at hand. This is the motivation for this interview. Here two antimicrobial stewardship pharmacists from the United States interview an antimicrobial stewardship pharmacist from Thailand.
1. What is your perspective on the state of antimicrobial stewardship in Thailand?
Similar to other world regions, antimicrobial resistance is an issue of considerable importance in Thailand. There is growing concern about antimicrobial resistance in both community and hospital settings, thus antimicrobial stewardship is quite a hot topic and a new concept to tackle the problems in Thailand.
Thailand developed a national strategic plan on antimicrobial resistance in 2016 based on the WHO global action plan on antimicrobial resistance. They identified six strategic actions to address the problems; one of them is to improve antimicrobial stewardship and infection control. This action is an attempt to promote antibiotic stewardship at all levels of health facilities, in order to achieve the goals that are a 50% reduction in morbidity from antibiotic-resistant infections and a 20% reduction of antimicrobial consumption in humans. This is consistent with the Thai goals. Even though it is very challenging to get the results, we are trying our best.
At this time we are beginning to initiate the program across the country and are developing guidelines on antimicrobial stewardship for various resource levels of healthcare facilities. We are also having a problem of using antimicrobials in animals and agriculture, so one health approach is needed to take into account when developing national antimicrobial prescribing policies.
2. How do you feel antimicrobial stewardship is different in Thailand versus the United States?
In a literal sense, antimicrobial stewardship in Thailand isn’t much different from the United States (U.S.). We have followed the IDSA guidelines and CDC core elements of antimicrobial stewardship. This noted, there are several aspects of antimicrobial use and factors responsible for inappropriate antimicrobial use in Thailand, which might not be common in the U.S.
- The context of using antibiotics differs greatly from the U.S. because people can get access to some antibiotics easily without prescriptions in Thailand. Patients often seek an antibiotic themselves for minor ailments such as the common cold, because they believe it can help make them feel better quickly without concern for adverse effects or ecologic consequence. Furthermore, outpatient clinics in Thailand (especially in public hospitals) are too busy to talk to patients in depth about the benefits and harm of unnecessary antibiotic use. It leads to the overuse of antibiotics.
- The differences in the epidemiology of antimicrobial resistance are also making a difference in clinical practice. Gram-negative resistance in Thailand is a bigger threat compared to the U.S. For example, community-acquired ESBL-producing Enterobacteriaceae is known to exist and is of particular concern. Sometimes, this makes it difficult to decide on empiric therapy, and leads to overuse of broad-spectrum antibiotics.
- Carbapenem-resistant Acinetobacter baumannii and metallo-beta-lactamase producing CREs are endemic in Thailand. Since antibiotics targeting these resistance patterns are few and far in between, or in production, clinicians have to use ineffective or unsafe antibiotics such as colistin. This in turn can drive inappropriate use, further perpetuating the resistance problem, ultimately leading to treatment failure and adverse drug events.
- Regarding resources, most hospitals in Thailand don’t have electronic health records software and medical records are typically written in the patient’s paper charts. That causes us to have difficulty in identifying target patients and tracking patient’s data during antimicrobial stewardship activities.
These are challenges for us to make improvements in antimicrobial use in Thailand.
3. What path did you take to become an antimicrobial stewardship pharmacist in Thailand?
When I was in residency training I realized that antimicrobial resistance is a serious problem in my country and I also had a passion for ID and antibiotics. This lead me to be involved in a project on antimicrobial stewardship at King Chulalongkorn Memorial Hospital. I was able to participate in experiences involving stewardship activities (e.g., prospective audit and feedback, dose optimization, and outpatient parenteral antimicrobial therapy [OPAT]) at the hospital.
After finishing my residency, I was still uncertain about my end goal, and I was eager to learn more. Luckily, I got a great opportunity to do ID rotations at the University of Kentucky College of Pharmacy. I saw how antimicrobial stewardship succeeded in the U.S. and saw how ID pharmacists worked alongside physician champions to optimize antimicrobial use. I remembered observing many stewardship initiatives at UK Healthcare (e.g., antibiotic timeout, penicillin skin testing, vancomycin AUC monitoring, and asymptomatic bacteriuria guideline). My rewarding experience with Infectious Diseases consult service and antimicrobial stewardship gave me great tools to bring back to my county.
While I was trained in the States, I started taking part in the SIDP antimicrobial stewardship certificate program, completing it upon my return home. The most useful component was gaining clinical skills which I could use to implement parenteral to oral conversion at my hospital. I think this program, which provides practical experience of ASP implementation, was very useful for me to work on ASP at my hospital. Since then my colleagues and I have been putting a lot of effort into implementing, sustaining, and improving the programs. Now we have antibiotic rounds on pediatric patients and a antimicrobial stewardship committee to support stewardship activities.
4. What is pharmacy practice like in Thailand?
The major role of hospital pharmacists in Thailand remains working as dispensing and compounding pharmacists. Most hospital pharmacists are still busy working in central and outpatient pharmacies since patients still receive their medications from hospitals instead of sending prescriptions to community pharmacies. However, the role of clinical pharmacy is steadily expanding.
Pharmacy practice in Thailand has been moving from product-oriented towards patient-oriented pharmacy services for years. In many hospitals clinical pharmacists are working on direct patient care in both inpatient and ambulatory clinics. Basically, they work with a multidisciplinary team by providing recommendations for improving drug efficacy and safety and carry out rounding on a routine basis which are similar to the U.S. Some hospitals also provide pharmaceutical care services such as drug information services, therapeutic drug monitoring services, and ADR services. Therefore, the role of pharmacist in Thailand has been better than it used to be in terms of recognition and integration into the healthcare landscape.
5. What role do pharmacists play in antimicrobial stewardship in Thailand?
In the past hospital pharmacists primarily take responsibility for drug use evaluations in particular high-cost drugs. Since the rise of antimicrobial stewardship, hospital pharmacists have expanded the role to become more engaged antibiotic stewards. Since ID pharmacists are not available in every hospital in Thailand, a non-ID trained pharmacist is often assigned the task of ASP implementation. It depends on the facility levels, but generally a pharmacist and/or a physician serves as core members of the program.
Owing to a lack of personnel and time, prospective audit and feedback is usually used as a core strategy. On a working day, the pharmacist is responsible for performing medical chart review to ensure and promote optimal antimicrobial therapy, providing recommendations for dosage adjustment and IV to PO conversion, defining appropriate duration, detection and prevention of antibiotic-related drug-drug interactions, giving education for patients, and healthcare professionals. In addition, tracking and monitoring antibiotic consumption are also important tasks that pharmacists undertake duties in the hospital.
There were a few studies conducted in Thailand on the pharmacist’s role in antimicrobial stewardship, including one that was carried out by my team. All studies showed that pharmacists could participate in ASP activities and played a significant role in increased appropriateness of antimicrobial use. Consequently, pharmacists who have expertise in drug therapy and play a crucial role and typically take part in antimicrobial stewardship activities and antimicrobial prescription policies in Thailand.
6. What do you perceive to be the greatest challenge that antimicrobial stewardship pharmacists in Thailand face today?
From my perspective, prescribing behavior and the general public’s knowledge are the greatest challenges. There are many motivating factors that contribute to prescribing behaviors. For example, physicians can feel uncertain about the diagnosis because they think microbiology laboratory data is not good enough to support clinical decision making. In turn, they are reluctant to stop and make any changes to antibiotics even when the specimen culture is reported as negative. Additionally, since the seniority system is very important in Thai culture and there is an existing medical hierarchy, pharmacists might hesitate to ask physicians when an antibiotic seems it may be being used inappropriately. Occasionally it is tough having a conversation with healthcare providers and it is really hard to engage them to accept stewardship interventions. Thus, good communication and education with leadership’s support might be the best way to change the behavior to be appropriate and to overcome the cultural barriers.
Additionally, public behavior is also an important challenge to overcome in many countries. Patients have high expectations of receiving antibiotics from the former experience of a beneficial effect, that might force healthcare personnel to give them an antibiotic. Therefore, the national strategic plan also advocates media to raise public awareness about antimicrobial resistance and appropriate antimicrobial use.
Finally, there are barriers to implementing an ASP in resource-limited settings (e.g., lack of technology, personnel, time). Novel technologies for diagnosis, for instance, rapid-diagnostic tests and biomarkers (procalcitonin) to enhance ASP are rarely used here due to the cost of the tests. Regarding personnel and time, many hospitals have difficulty in implementing a hospital-wide program due to a lack of pharmacy staff. Hospital pharmacists do not have much time to participate in the program due to significant non-clinical activities. Thus, we need to show the benefits of having pharmacist to maintain antimicrobial stewardship in a hospital, so employers see the worth in hiring a pharmacist as an antibiotic steward.
7. What opportunities do you see for antimicrobial stewardship pharmacists in Thailand and across the world to collaborate and learn from each other?
Recently, the 2017 report of antibiotic consumption revealed that the highest volume of antibiotic use in Thailand is mainly in oral antibiotics. If we can reduce antibiotic use in outpatient hospital or clinic and community pharmacy by making it more appropriate, the resistance problem will definitely get better. Community pharmacists can take significant actions on antibiotic dispensing and patient education.
Many healthcare facilities in Thailand were accredited by the Joint Commission International accreditation (JCI). Recently, JCI set antimicrobial stewardship standards for hospitals, requiring an ASP. With the standards falling undertake medication management and use chapter, pharmacists have to take responsibility for implementing the program. This is a great opportunity for hospital pharmacists to expand their role to improve the quality of patient care. Apart from the JCI, the Healthcare Accreditation Institute (HA) is another organization providing hospital accreditation in Thailand. Fortunately, HA also requires the implementation of an ASP. Thus it won’t be so long until every hospital will need ASP pharmacist positions to sustain the programs, especially for hospitals that are seeking JCI or HA accreditation.
This is also a great opportunity for antimicrobial stewardship pharmacists across the world to learn from each other about strategies to improve antimicrobial use and how to overcome implementation barriers. We can share what effective stewardship strategies are with other countries that might face similar challenges. Furthermore, we can take joint action on antimicrobial stewardship research, because sharing research findings and collaborating in research projects can help us fight with antimicrobial resistance together.
8. What do you perceive the future holds for antimicrobial stewardship pharmacists in Thailand?
I would say it is time to make changes and progress rational antimicrobial use in Thailand. Pharmacists who play a vital role in antimicrobial stewardship will contribute and add substantial value in antimicrobial stewardship by providing education and recommendations for optimal antimicrobial use. I also expect to see that pharmacists will be able to make a positive impact on patient outcomes and antimicrobial resistance in Thailand.
In my opinion, the next step would include ASP pharmacists as having more authority to optimize antibiotic use (e.g. dose adjustment and optimization). This can show a significant impact of pharmacist-led antimicrobial stewardship interventions. Pharmacists will also have a responsibility to expand antimicrobial stewardship into other sectors such as outpatient, nursing homes, community pharmacies, and clinics. I hope in the near future we will have more specialty pharmacists including ID pharmacists in Thailand, who are able to help with difficult drug-related problems and sustain antimicrobial stewardship activities.
Lastly, It has been really hard to implement the programs, but it is more difficult to make the programs more robust and durable. From personal experience, my temporary absence, halted the progress of the program as there was no system to maintain and continue the activities. Therefore, we need to build the systems for continuing the program and also need to create an effective workflow. Moreover, we need clinical practice guidelines using our own surveillance data on antimicrobial resistance, and need to show outcomes of what we have been doing in order to make the program keep continuing value.
ABOUT THE INTERVIEWEE
Mr. Sang Usayaporn is a faculty member of the pharmacy practice department at Chulalongkorn University and also serves as an ID pharmacist providing antimicrobial stewardship program support at King Chulalongkorn Memorial Hospital.
He obtained his bachelor’s degree from Chulalongkorn University and completed his residency training in infectious diseases pharmacotherapy at Mahidol University. He also pursued Board Certified Infectious Diseases Pharmacist (BCIDP).
He is interested in antimicrobial resistance and antimicrobial stewardship. He is currently doing research on antimicrobial stewardship in Thailand and now he is a member of a working group on developing national antimicrobial stewardship manual of Thailand. He loves teaching and wants his students to have a passion for ID. He serves as a preceptor for international students including pharmacy students from the U.S.
You can find him on Twitter @ABOsteward.
REFERENCES
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https://www.idthai.org/2015/journal/_file_ar_fulltext/file_ar7f1de29e6da19d22b51c68001e7e0e54.pdf
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10. Apisarnthanarak A, Lapcharoen P, Vanichkul P, Srisaeng-Ngoen T, Mundy LM. Design and analysis of a pharmacist-enhanced antimicrobial stewardship program in Thailand. Am J Infect Control. 2015 Sep 1;43(9):956-9.
11. Chanvatik S, Kosiyaporn H, Lekagul A, Kaewkhankhaeng W, Vongmongkol V, Thunyahan A, et al. Knowledge and use of antibiotics in Thailand: A 2017 national household survey. PLoS One. 2019;14(8):e0220990.
12. Thai working group on Health Policy and Systems Research on antimicrobial resistance (HPSR-AMR). Consumption of antimicrobial agents in Thailand in 2017. http://ihppthaigov.net/DB/publication/attachresearch/421/chapter1.pdf
We would like to extend our utmost appreciation to Sang Usayaporn for taking the time to share his perspectives and complete this interview.
DISCLOSURE: 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 future employers.
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