PHARMACY CONNECTION ARTICLE

Antimicrobial Stewardship in Ontario: What’s Your Role

Published on: May 1, 2017

Authors:
Valerie Leung, BScPhm, ACPR, MBA
Antimicrobial Stewardship
Program Lead
Public Health Ontario

Bradley Langford, BScPhm, PharmD, ACPR, BCPS
Consultant Pharmacist, Antimicrobial Stewardship Program
Public Health Ontario

The Challenge

Antimicrobial Resistance (AMR) is an increasing problem globally. The combined impact of increasing prevalence of antibiotic resistance with very few novel antimicrobials on the horizon has the potential to be overwhelming – a recent global review estimates that by the year 2050, global deaths due to antibiotic resistance infections will surpass deaths due to cancer.¹ For this reason, the Government of Canada has committed to working with the provinces to address the threat of AMR.²

What is antimicrobial stewardship?

Antimicrobial stewardship, which refers to a set of coordinated interventions which promote the optimal selection, dosing and duration of antimicrobial therapy, is one part of this overall strategy required to address AMR.³ In other words, it means ensuring those who need antibiotics get the right drug, at the right time, using the right dose and for the right duration.

The emerging role of pharmacists in out-patient antimicrobial stewardship

In 2013, antimicrobial stewardship became an Accreditation Canada Required Organizational Practice (ROP) for hospitals and as a result, almost all hospitals in Ontario now have formal antimicrobial stewardship programs (ASPs) in place.⁴ Pharmacists play a prominent role in these hospital ASPs.⁵

In non-acute care settings, coordinated approaches to antimicrobial stewardship are in early stages of development. Despite the fact that about 80 per cent of all antimicrobials are prescribed in the community,⁶ there are currently very few formal programs in community or long-term care. This may be due in part to the lack of Canadian accreditation requirements in these sectors. As easily accessible healthcare providers with drug expertise, pharmacists working in non-acute care settings have an opportunity to help shape antimicrobial stewardship initiatives in these settings.

Community pharmacists in Ontario already play a key role in infection prevention by providing immunizations so it is a natural next step for pharmacists to become engaged in antimicrobial stewardship as recently articulated by the Canadian Pharmacists Association,⁷ Onttario Pharmacists Association⁸ and CDC Core Elements of Stewardship for Outpatient Settings.⁹ While pharmacists should continue to educate patients on the judicious use of antibiotics and antibiotic-related harms, they should also look for ways to actively collaborate with prescribers in more targeted stewardship strategies such as delayed prescribing. This approach is used for infections such as sinusitis where patients are provided a prescription and instructed to initiate antibiotics only if symptoms do not improve after a specified period of time. In this instance, pharmacists can support prescribers that wish to use delayed prescribing by reinforcing symptom management and when to follow-up when counselling patients.¹⁰

Pharmacists working in primary care collaborative practice environments such as Family Health Teams are uniquely positioned to help promote and implement effective antibiotic audit and feedback strategies, which are gaining momentum. Similar to the use of prospective audit with intervention and feedback in acute care settings, individualized feedback to clinicians and peer comparison of antibiotic prescribing practices are strategies that have been shown to increase guideline adherence and reduce unnecessary prescribing.^11,12

Pharmacists practicing in the long-term care sector can also have a significant impact. The CDC’s Core Elements of Stewardship for Nursing Homes calls for pharmacists to be partners and leaders in antimicrobial stewardship.¹³ It is also encouraging to see that support from consultant pharmacists with training in stewardship contributes to reducing antibiotic use and negative consequences of antibiotic harms in long-term care homes (LTCH).¹⁴ Antibiotic overuse such as prolonged treatment durations for common bacterial infections is a significant problem in Ontario’s LTCHs.^15,16 Research shows that residents in Ontario homes with higher antibiotic use are at an increased risk of antibiotic-related harm.17 To help address this, pharmacists practicing in the long-term care setting can lead a number of activities such as implementing mechanisms to reduce unnecessary antibiotic prescriptions, discourage the use of prolonged antibiotic durations and systematically track antibiotic utilization, all of which contribute to a robust stewardship program.¹³

Antimicrobial stewardship is a shared responsibility which requires the active participation of pharmacists. With pharmacists already playing a leadership role in acute care programs, the timing is right for community pharmacists and those working in long-term care to rise to the challenge of moving antimicrobial stewardship forward in those sectors.

References

1. Review on Antimicrobial Resistance. Tackling drug-resistant infections globally: Final report and recommendations [Internet]. UK: Wellcome Trust and UK Government; 2016 [cited 2017 Feb 21]. Available from: https://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf
2. Government of Canada. Antimicrobial resistance and use in Canada: A federal framework for action. Ottawa, ON: Her Majesty the Queen in Right of Canada, as represented by the Minister of Health; 2014 [cited 2017 Feb 21]. Available from: https://www.canada.ca/content/dam/canada/health-canada/migration/healthy-canadians/alt/pdf/drugs-products-medicaments-produits/buying-using-achat-utilisation/antibiotic-resistance-antibiotique/antimicrobial-framework-cadre-antimicrobiens-eng.pdf
3. Infection Control & Hospital Epidemiology, Pediatric Infectious Diseases Society . Policy statement on antimicrobial stewardship by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), and the Pediatric Infectious Diseases Society (PIDS). Infect Control Hosp Epidemiol. 2012;33(4):322-7. Available from: http://www.jstor.org/stable/10.1086/665010 (link no longer available)
4. Accreditation Canada. Required organizational practices: handbook 2016. Version 2 [Internet]. Ottawa, ON: Accreditation Canada; 2015 [cited 2017 Feb 21]. This is no longer available. ROP handbook must be purchased.
5. Leung V. Ontario Antimicrobial Stewardship Program (ASP) Landscape Survey [Internet]. Toronto, ON: Public Health Ontario; 2016 [cited 2017 Feb 21]. Available from: http://www.publichealthontario.ca/en/eRepository/ASP_Presentation_Ontario_Landscape_Survey.pdf
6. Public Health Agency of Canada. Canadian antimicrobial resistance surveillance system – report 2016. Ottawa, ON: Her Majesty the Queen in Right of Canada, as represented by the Minister of Health; 2016 [cited 2017 Feb 21]. Available from: https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/drugs-health-products/antibiotic-resistance-antibiotique/antibiotic-resistance-antibiotique-2016-eng.pdf
7. Dattani S. Community pharmacists as antimicrobial stewards? You bet! 2016 Nov 14 [cited 2017 Feb 21]. In: CPhA Blog [Internet]. Ottawa, ON: Canadian Pharmacists Association; [2011] -. Available from: http://www.pharmacists.ca/news-events/cpha-blog/community-pharmacists-as-antimicrobial-stewards-you-bet/
8. Koroluk K. Antimicrobial Stewardship 2016 Feb 4 [cited 2017 Feb 21]. In: Beyond The Counter: Pharmacy in Ontario – yesterday, today and tomorrow [Internet]. Toronto, ON: Ontario Pharmacists Association; [2014] -. Available from: https://beyondthecounter.wordpress.com/2016/02/04/antimicrobial-stewardship/
9. Sanchez GV, Fleming-Dutra KE, Roberts RM, Hicks LA. Core elements of outpatient antibiotic stewardship. MMWR Recomm Rep 2016;65:1–12. Available from: https://www.cdc.gov/getsmart/community/pdfs/16_268900-a_coreelementsoutpatient_508.pdf (link no longer available)
10. RxFiles. Antibiotics & Common Infections Stewardship, Effectiveness, Safety & Clinical Pearls. Saskatoon, SK: RxFiles; 2016. Available from: http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Newsletter-2016-COMPLETE.pdf
11. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ et al. Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. JAMA 2016;315:562–70. Available from: http://jamanetwork.com/journals/jama/fullarticle/2488307
12. Gerber JS, Prasad PA, Fiks AG, Localio AR, Grundmeier RW, Bell LM et al. Effect of an outpatient antimicrobial stewardship intervention on broad-spectrum antibiotic prescribing by primary care pediatricians: a randomized trial. JAMA 2013;309:2345–52. Available from: http://jamanetwork.com/journals/jama/fullarticle/1696098
13. Centers for Disease Control. Core elements of antibiotic stewardship for nursing homes [Internet]. Atlanta, GA: US Department of Health and Human Services, CDC; 2015 [2017 Feb 21]. Available from: https://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
14. Jump RLP, Olds DM, Seifi N, Kypriotakis G, Jury LA, Peron EP et al. Effective antimicrobial stewardship in a long-term care facility through an infectious disease consultation service: Keeping a LID on antibiotic use. Infect Control Hosp Epidemiol 2012;33(12):1185-1192. Available from: http://www.jstor.org/stable/10.1086/668429 (link no longer available).
15. Loeb M, Simor AE, Landry L, Walter S, McArthur M, Duffy J, et al. Antibiotic use in Ontario facilities that provide chronic care. J Gen Intern Med. 2001;16:376–83.
16. Daneman N, Gruneir A, Bronskill SE, Newman A, Fischer HD, Rochon PA, et al. Prolonged antibiotic treatment in long-term care: role of the prescriber. JAMA Intern Med. 2013;173(8):673-82. Available from: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1669102
17. Daneman N, Bronskill SE, Gruneir A, Newman AM, Fischer HD, Rochon PA, et al. Variability in antibiotic use across nursing homes and the risk of antibiotic-related adverse outcomes for individual residents. JAMA Intern Med. 2015;175(8):1331-9. Available from: http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2337257