Building trust to improve antimicrobial stewardship

Pharmacist filling prescription in pharmacy drugstore
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The Microbiology Society is undertaking a project entitled A Sustainable Future as part of our 75th Anniversary, which aims to highlight the Sustainable Development Goals (SDGs) to our members and empower them to use their research to evidence and impact the goals. Earlier this year, we put a call out to our members to submit case studies in the following three areas: antimicrobial resistance, soil health and the circular economy.

This case study is written by Dr Meher Rizvi, who is an Associate Professor at Sultan Qaboos University, Sultanate of Oman, and a member of the Microbiology Society. It focuses on antimicrobial resistance; a naturally occurring process, whereby micro-organisms (bacteria, viruses, fungi and parasites) can change and adapt over time, either by modifying the target of the antimicrobial, or by developing and exchanging resistance genes.

There is burgeoning problem of antimicrobial resistance (AMR) in India due to overuse of antimicrobials. There is an urgent need to improve compliance and spread awareness about AMR among clinicians.

Whilst developing an antimicrobial stewardship policy at my previous institution (Jawaharlal Nehru Medical College, Aligarh Muslim University, India), I realised the importance of consciously increasing the interaction with clinicians before asking them to adhere to an antimicrobial stewardship policy. I found that talking to physicians and surgeons informally was a great way to start the conversation. I would first ask physicians if they were facing problems with antibiotic resistance, who told me they were often unsure as to the appropriate antibiotic to use, as antibiotic resistance was becoming more and more common. This gave me the opportunity to use my expertise as a medical microbiologist, and I would ask them which antibiotics they usually prescribe empirically and thus, get the conversation rolling. Similarly, I would ask surgeons about pre-surgical prophylaxis and if they were having problems with surgical site infections, which allowed me to delve into the issues they were having.

In order to continue the discussion, my team and I started scaling up our interaction with them over the phone. While taking relevant history, we would take the opportunity to talk about proper sample collection and appropriate empiric treatment, which were confidence building measures. Once we developed a healthy team spirit, I then initiated a dialogue with them on the necessity of developing a local antimicrobial policy based on our antibiograms. The cumulative antibiogram which we prepared was department wide, so that it could be tailored to their individual needs. I had previously undertaken an excellent online antimicrobial stewardship course organised by the University of Dundee, UK, in collaboration with the British Society for Antimicrobial Chemotherapy, which highlighted that in order for an antimicrobial policy to be successful, clinicians needed to feel ownership of the document. Therefore, we helped the clinicians develop the policy, advising them along the way, but allowed them to take ownership of the document.

Another important step in developing the policy was having the movers and shakers of the institute such as the Principal, the Dean, the Medical Superintendent and the Heads of the Department (HODs) involved, which enabled implementation of the policy. An Antimicrobial Policy Committee was established with the Principal as Chairman and other members were carefully selected from each department. The committee members and HODs were sent an official letter from the Principal, which added to the significance of the committee. It was very important to keep the different stakeholders up to date on the progress of the policy to ensure optimal compliance. Once the nuts and bolts were in place, we started a round of meetings which were attended by all the faculty members of the committee. The first few introductory sessions helped to bring everyone on the same page, set the ground rules and have some brainstorming sessions. The ensuing discussions were very illuminating, and it became very apparent that an antimicrobial stewardship policy would be valued by the clinicians. 

Committee members were given a timeline for preparing their individual antimicrobial policy which they would first present in their departments during seminar hours. The focus of this first round was to acclimatise them with the national antimicrobial policy. This first session gave all the doctors exposure to the process of developing a policy and a sense of ownership as it was not being done behind closed doors. Suggestions were welcomed and incorporated if pertinent – this also increased ownership.  The second step was to tailor the policy as per the local antibiogram which we provided them. The next step was presenting at committee level to see what progress had been made. We were very fortunate that the Medical Superintendent made a point to attend these sessions, which increased the visibility and importance of developing the local policy.

Very positive outcomes were observed from these meetings, with lots of brainstorming and useful suggestions. All the departments were involved, and an antimicrobial stewardship policy was successfully created. This policy was then presented by committee members to their respective departments for comments and suggestions. Clinicians were the rightful owners of their departmental policy and it was necessary that their concerns be addressed. Their participation was essential to enhance their compliance in adhering to the policy. Once the policy was released, we sent out certificates to those involved, to congratulate and reward the committee members and departments that were involved. After all this hard work, there is now good compliance to the local antimicrobial policy, which may help to reduce the overuse of antimicrobials.

About the author

Dr Meher Rizvi is an Associate Professor in the Department of Microbiology and Immunology at Sultan Qaboos University, Sultanate of Oman, and a member of the Microbiology Society. She has wide ranging research interests spanning from antimicrobial resistance to neglected diseases, from immunopathogenesis of infectious to studying emerging diseases, as well as hospital acquired infections. Her current research is focused on identifying synergistic combinations to combat antimicrobial resistance, particularly extensively drug-resistant and pandrug resistant Gram-negative bacilli, and helping to improve patient outcome.