In this article an antimicrobial stewardship pharmacist from Canada is interviewed. Insights and perspectives on the role of antimicrobial stewardship pharmacists in Canada are provided.
Interview with: Bradley J. Langford, BScPhm, ACPR, PharmD, BCPS
Interview by: Timothy P. Gauthier, Pharm.D., BCPS-AQ ID
[Last updated 25th December 2017]
As the world attempts to address the threat of drug-resistant microbial pathogens the field of antimicrobial stewardship has become somewhat of a trending topic. At this time, numerous government bodies and leading organizations from across the globe have come out in support of antimicrobial stewardship efforts, which seek to support the safe and appropriate use of antibiotic, antiviral, antifungal, and antiparasitic medications.
In the United States the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America have published guidelines on implementing an antimicrobial stewardship program (ASP). In addition, The Joint Commission (which is a major accrediting body for American healthcare institutions) has a standard on antimicrobial stewardship that went into effect in January of 2017 and applies to hospitals, critical access hospitals, and nursing care centers.
In reviewing the documents put out by Americans and others on antimicrobial stewardship, one of the recurring themes you will find is that both physicians and pharmacists are key leaders for antimicrobial stewardship programs. As healthcare and pharmacy practices can vary considerably from one country to another, one may wonder how the role of antimicrobial stewardship pharmacists varies from country to country. This is the motivation for the following interview.
To learn more about the activities of antimicrobial stewardship pharmacists in Canada, I reached out to Dr. Bradley J. Langford (who you can find on Twitter @BRxAD). Dr. Langford has significant experience in the field of antimicrobial stewardship and is currently the Lead Pharmacist for Public Health Ontario’s Antimicrobial Stewardship Program. He was kind enough to agree to the interview and this text was developed.
The following provides insights on being an antimicrobial stewardship pharmacist in Canada.
1. What motivated you to become an antimicrobial stewardship pharmacist and what path did you take to get to where you are today?
After completing a hospital pharmacy residency, I started my career as a Drug Use Evaluation (DUE) pharmacist. I knew that pharmacists play a huge role in improving patient care on a one-on-one basis, but I was drawn to opportunities to contribute at a broader scale. Being a DUE pharmacist provided an opportunity to do just that: impact quality of care across a hospital setting.
As a DUE pharmacist I co-chaired our hospital’s P&T Committee and had the opportunity to get involved in many great initiatives including IV to PO switch policies, dose optimization, formulary evaluation, and guidelines. Partially because of their cost, so much of this work was related to antimicrobials, which of course I found to be the most interesting of all drug categories. I was intrigued by the dynamic field of infectious diseases and at the same time was alarmed by rising rates of drug-resistant infections and the massive burden of Clostridium difficile in our hospital.
After attending a talk by Dr. Andrew Morris (@ASPPhysician) on making the case for an antimicrobial stewardship program in 2009 and going to MAD_ID in 2010, I was sold. I helped build an antimicrobial stewardship pharmacist position, then a second position, and advocated for ASP physician funding. Recognizing that there was a need for antibiotic stewardship in all sectors, I more recently went on to take a unique position as an ASP pharmacist consultant in public health, while still maintaining some activity as a hospital ASP pharmacist.
2. What do you see as the core roles for most antimicrobial stewardship pharmacists in Canada today?
In 2013, Canada’s national accreditation body (Accreditation Canada) required that hospitals implement an antimicrobial stewardship program. A lot of recent work has been done to get these programs up and running and to meet accreditation standards. Now most hospitals in the province of Ontario have an ASP, but the extent of resources (funding and staffing) available to do ASP implementation varies a lot. So one key role is to advocate for resources to build and maintain an impactful program. The Association of Medical Microbiology and Infectious Disease (AMMI) Canada put together a great business case template for inpatient antimicrobial stewardship programs.
Another key role is to collaborate with ASP physicians and other clinicians to carry out daily activities that impact the appropriateness of antibiotic use. Of so many strategies available, a key challenge and opportunity is choosing those that best address the issues at the hospital, are appropriate for the resources available, and then to implement them in a way that will actually change practice as anticipated. Some form of prospective audit and feedback seems to be a core role for ASP hospital pharmacists, and there has been a lot of great work from Canada showing the success of this intervention [1,2,3]. As in other jurisdictions, working closely with the microbiology laboratory, not only to develop antibiograms but also implement approaches to guide appropriate antibiotic use (e.g., selective and strategic reporting) is also a key initiative.
Finally, in order to determine that the ASP is effective and where further efforts are needed, measurement is vital. ASP pharmacist involvement in antimicrobial use surveillance and improving access to data, data quality and granularity will likely be a growing role in the near future. Sharing this information with decision makers and prescribers is also very important.
3. What are two or three of the greatest challenges that you perceive exist for antimicrobial stewardship pharmacists in Canada?
One main challenge, which is not limited to Canada, is to increase the impact and sustainability of our ASP interventions. This will mean embracing behavioural, implementation, and social sciences.
Often education is perceived to be the solution, but literature shows education alone has modest effects at best and is not very sustainable. As ASP pharmacists, we will need to reach out beyond our comfort zone and collaborate with experts in these fields to develop meaningful interventions. A useful Canadian reference to get started is Rx for Change, a database of evidence-based behaviour change recommendations based on target audience. Of course all of this applies broadly beyond Canada, the only real difference is that we all cannot agree how to spell behavio(u)r!
A second challenge is to extend the reach of antimicrobial stewardship pharmacists beyond our hospitals (e.g., rural settings, long-term care and community). In today’s setting of limited resources, this will involve advocacy for funding, collaboration and figuring out ways to best apply our expertise to settings different than what we are used to.
Finally, as talented as we (like to think we) are, clinicians specializing in ASP cannot do it all. In turn, influencing and mentoring others to be stewards in their daily practice will be a challenge worth tackling.
4. What is the role of antimicrobial stewardship pharmacists in improving public health in Canada?
Just by doing what we are doing, ASP pharmacists are contributing to improved public health. But it is important to recognize that although the rate of antibiotic use is highest in the hospital setting, it is only the tip of the iceberg. The volume of antibiotic use in the community is drastically higher. In Canada, 92% of human antibiotic use is in the community (not to mention that the vast majority of overall antibiotic use by weight is in animals). So in order for ASP pharmacists to have the most impact, the approach needs to be more universal.
The Canadian government recently released a framework for addressing antimicrobial resistance. It consists of four key components: surveillance, stewardship, research/innovation, and infection prevention and control. ASP pharmacists’ roles fit firmly into most of these categories, but of course will need to join forces with multiple disciplines to be successful.
5. Do you think antimicrobial stewardship opportunities are different in Canada versus the United States?
In both countries there is evidence of inappropriate antibiotic use in all sectors (hospital, long-term care, community). Despite some key differences between our countries (differences in overall antibiotic consumption, resistance patterns, antimicrobial availability, and health care funding model), we are essentially trying to answer the same question: How can we improve the appropriateness of prescribing, optimize patient outcomes, and minimize the harms of antibiotics for both the patient and population?
On the other hand there are plenty of opportunities to learn from each other’s experiences. For example, in Canada, we do not yet have a mandate for antimicrobial stewardship in long-term care homes. We will certainly look to the U.S. to gain insight as to how to best approach this and how antimicrobial stewardship pharmacists can be leveraged in this role.
6. What do you suppose the future holds for antimicrobial stewardship pharmacists in Canada?
It is certainly an exciting time to be an antimicrobial stewardship pharmacist in Canada as there are so many opportunities to make a contribution. Not only is the number of ASP roles likely to increase, but so is the diversity of these types of positions.
As pharmacists are key players in ASPs and many have been instrumental in building these programs for years, there will be greater opportunities to take on leadership roles. With a need for ASPs in all sectors, I expect to see more unique positions reaching beyond the hospital setting.
With such a rapidly growing field and greater focus on the need for innovation, ASP pharmacists are well-positioned to participate in and lead research focused on improving antibiotic use and ultimately to reduce the harm associated with antibiotics.
Useful Canadian Resources For Healthcare Professionals and/or Patients
- AntibioticWise.ca
- Association of Medical Microbiology and Infectious Disease (AMMI) Canada
- Canadian Association for Drugs and Technologies in Health: Rx For Change
- Do Bugs Need Drugs?
- Public Health Ontario Antimicrobial Stewardship Program
- Sinai Health System/University Health Network Antimicrobial Stewardship Program
About the interviewee…
Bradley J. Langford, BScPhm, ACPR, PharmD, BCPS, is currently the acting Lead Pharmacist for Public Health Ontario’s Antimicrobial Stewardship Program (ASP). His role is to support the advancement of antimicrobial stewardship in all sectors across the province. He is also the Lead Antimicrobial Stewardship Pharmacist at St. Joseph’s Health Centre in Toronto.
Dr. Langford completed his undergraduate training at the University of Toronto, hospital residency at University Health Network, and Doctor of Pharmacy at the University of Colorado.
His main research interests include evaluation of ASP outcomes and incorporating implementation science and knowledge translation to improve the impact of antimicrobial stewardship.
Dr. Langford is also interested in the use of social media to help spread the message about this important cause. He is training his daughter to be a future steward and advocate as well. He, along with Dr. Timothy Gauthier, is co-founder of #ASPChat, a monthly Twitter chat that aims to improve appropriate antibiotic use by stimulating conversation about antibiotic stewardship. You can find him on Twitter at @BRxAD.
I would like to express my sincerest appreciation to Dr. Langford for taking the time to complete this interview and share his perspective about this important healthcare topic.
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