A couple of weeks ago, I had the opportunity to meet up with Dr Piotr Chlebicki of Singapore General Hospital (SGH), and we discussed antimicrobial stewardship over a beer (or two). Antimicrobial stewardship – a more nuanced and acceptable term than “antimicrobial control” – refers to any number of interventions in a hospital setting that aims to improve prescription of antimicrobial agents, and it has evolved in response to the growing issue of antimicrobial resistance. The license to prescribe medications is fundamental for doctors, but the bald truth is that we all prescribe medications inappropriately at some point in our professional careers (and sometimes for much of our professional careers without, perhaps, realising it). These events not only have the potential to harm our patients, but – with respect to antimicrobial agents – may also potentially harm “bystanders” or future patients when antimicrobial-resistant pathogens are selected out and transmitted. Hence the primary role of antimicrobial stewardship is to minimise events of inappropriate prescription of antimicrobial agents, and to prevent harm.
In 2008, Piotr and I, along with several other like-minded doctors and a pharmacist, had released a position paper calling for action on antimicrobial resistance in Singapore. We had then variously implemented antimicrobial stewardship programmes (ASPs) in some local hospitals, and lobbied the Ministry of Health (MOH) to support such programmes in all local hospitals. After several false starts, and somewhat to our surprise, it did, providing funding in a big way that would enable the actual employment of doctors and pharmacists to perform the duties of antimicrobial stewardship in the public sector from 2011 onwards for a period of 5 years. Piotr was put in charge of this funding, in effect becoming the ASP “czar” for Singapore. Quite a large proportion of the funding was meant to be used for the development of “computerised decision support systems” (CDSS), taking advantage of the e-prescription systems being implemented in all local public sector hospitals to create accompanying evidence-based algorithms that would prompt immediate guidance for antibiotic prescription.
Of course, there had been ASPs in Singapore prior to this effort in 2011, especially at SGH and Tan Tock Seng Hospital, and it would be nice if their stories were told one day, as these efforts are educational. But none was officially funded or sanctioned to such an extent.
Seven years after the position paper, and almost 5 years from the receipt of MOH funding for implementing ASPs, it is quite clear that ASPs – in some form or other – are thriving in most local public hospitals. The implementation of CDSS is another matter. Most hospitals have not succeeded in setting this up, mostly because of technical and IT-related issues. In the hospital that pioneered CDSS for antibiotics in Singapore, it seems clear from published data that acceptance of CDSS recommendations occurred only for a minority of patients, and doctors tended to override CDSS recommendations if they felt that the patients or their infections were “complex”.
But local ASPs face a different problem today, which is one of succession, especially with regards to physicians. Few of the younger infectious diseases physicians are interested in running ASPs. I do not know the specific reasons, but the primary one may be that antimicrobial stewardship, or at least the versions in Singapore, are radically different from the kind of training that occurs for infectious diseases physicians. In infectious diseases training, the most important thing is to spend time with the patient, and then to spend time poring over the clinical charts and test results, in order to get the “pulse” of things and then come up with an individualised course of therapy. In antimicrobial stewardship, the physician has to pass judgment on whether a prescribed antibiotic on the audit list is appropriate without having to lay eyes on the patient at all, and he or she has to get through quite a long list of patients on most days quickly. The ASP physician also has to keep track of the acceptance rates of his or her recommendations, and needs to constantly visit other departments to explain what the ASP is about as well as to cajole other doctors to “behave better” with regards to prescribing antibiotics. The fear that an antimicrobial stewardship judgment call will turn out to be wrong (with the patient suffering the consequences – and unfortunately more importantly, the other attending physicians losing faith in ASP or castigating the ASP physician) is a very real one, and most infectious diseases physicians I know are uncomfortable with being in such a position.
In some ways, it was a rarity that we could find so many physicians to start up ASPs in local hospitals in the first place, and not surprising that there is a succession gap today. In 2012, we tried to come up with training guidelines for ASP physicians and pharmacists (and nurses), but I do not know to what extent these guidelines have been taken up. Antimicrobial stewardship training probably remains an “orphan child” for infectious diseases and clinical microbiology training, and the real business of running an ASP is in any case unlike what can be codified in a series of guidelines or observed during a short attachment stint.
What is the solution? For the longest time now, I have believed that the physician-led ASP model should gradually transit to a pharmacist-led ASP model.There were many reasons that made the latter impossible at the start, amongst which are:
- The hierarchical structure of hospital healthcare meant that doctors were less likely to accept pharmacist recommendations with respect to antibiotics, and few pharmacists were prepared to speak up to doctors in the past.
- Very few pharmacists in Singapore in 2011 were equipped with the specific infectious diseases knowledge or experience to pass judgment consistently on doctors’ antibiotic prescriptions.
- MOH would probably never have invested so much money if there were no physicians driving the ASP implementation at various hospitals, which is a sad reflection of the hierarchical system of healthcare.
- The role (and actions) of infectious diseases physicians would have been unclear. Many infectious diseases physicians might feel that this was a direct invasion of their “turf” by the pharmacists, and they might influence other doctors negatively with respect to ASP (more than if an infectious diseases physician led the ASP, at any rate).
All these reasons have been whittled away or reduced over time. Pharmacists in general play a far more important role in frontline patient care today, and it is no longer uncommon to see them doing rounds with the doctors and nurses. For the past few years, there has been a drive towards producing specialist pharmacists, with infectious diseases pharmacist specialists recognised locally among others. The number of infectious diseases pharmacist specialists is in double digits today, and increasing annually, compared to less than handful in 2008 (where the specialty was not even recognised). Having many pharmacists being involved in ASPs across the island has also made many of them experienced, and visible to doctors. Acceptance of their antimicrobial stewardship recommendations would come far more readily today and in the future. Local infectious diseases physicians have also had the opportunity to experience ASPs in their own hospitals and therefore understand their place better.
From the payor’s perspective, one can hire 2-3 experienced pharmacists for the price tag of an infectious diseases physician, and antimicrobial stewardship is also ultimately about cost-effectiveness and “right siting”. All it takes now is for one or two hospitals in Singapore to take a step forward and begin this transition. It will most likely go well.