Antimicrobial Stewardship (AMS) Program in Private Hospitals in the Philippines: Its Acceptability, Barriers, and Enablers

Abstract

Background: Antimicrobials are drugs that are often misused and inappropriate antimicrobial prescribing often results in poor clinical outcome and drug resistance. Monitoring and regulation of antimicrobial use is currently being done by the Department of Health through the Antimicrobial Stewardship (AMS) Program. There is a need to determine the factors that affect successful implementation of an AMS program in private hospitals in the Philippines. This study was conducted to identify the enablers and potential barriers in implementing an AMS program in nine (9) private hospitals. Methodology: A concurrent mixed methods design was used to assess various stakeholders’ (physicians, administrators, other AMS members) perceptions of existing or proposed AMS programs, and to identify barriers and enablers in their implementation. Quantitative data were collected using self-administered survey questionnaire to assess clinician’s acceptance of AMS programs. Qualitative data were collected through semi-structured one-on-one interviews of clinicians and other AMS personnel and focus group discussions (FGD) of selected clinician groups. Data were gathered from October 2018 to October 2019. Results: 409 clinicians were surveyed, 52 were interviewed and 46 sat for 13 sessions of FGDs. Overall, the survey established that physicians were well aware of antimicrobial resistance problem. Majority of the clinicians indicated general agreement with the currently practiced antimicrobial protocols in their hospitals and with the AMS program. However, there were disagreements in perceptions with how antimicrobial restrictions impair prescribing practices and overuse of the same. These responses were strong points of discussion during the Key Informant Interviews (KII) and FGDs. All respondents were amenable with the institutionalization of an AMS program in their hospitals. The hospital leadership’s commitment was determined to be the key enabler of a successful AMS program’s implementation. Barriers identified for hospitals with existing AMS programs were: lack of dedicated staff, resistance and/or non-cooperation of physicians, lack of support from non-medical departments, and inadequate cooperation between hospital personnel. Barriers identified, regardless of the status of the AMS programs were: deficiency in knowledge with developing and implementing an AMS program, inadequate information dissemination, unavailability of an IT-based monitoring for antibiotic use, and the influence of pharmaceutical companies on stakeholders with regards to antimicrobial use. Conclusion: Similar enablers and barriers to a successful implementation of an AMS program were seen in the different hospitals. A hospital leadership’s commitment was determined to be the key enabler. The success or failure of any AMS program appears to depend on physician understanding, commitment and support for such a program. By involving the main players in an AMS program- the hospital administrators, clinicians and other key members, perceived barriers will be better identified and overcome, and enablers will help allow a successful implementation of an AMS program. This multi-center study was funded by Philippine Council on Health Research and Development ( PCHRD) and Pediatric Infectious Disease Society of the Philippines ( PIDSP) and was conducted by the PIDSP Research Committee.

Determination of the Enablers and Challenges in the Implementation of Pharmacy-based Antimicrobial Stewardship (AMS) Program in a Level 3 Hospital in Manila

“…The remaining perceived enablers identified were found to be consistent with studies conducted in Saudi Arabia 19 , Australia 10 , 20 , Ethiopia 21 , Scotland 22 , and Henson & TMC AMS Team, and Pagcatipunan et al in the Philippines 11 , 23 . Moreover, the listed remaining enablers have been found to be consistent with the DOH MOP.…”

“…Aligned with the challenges identified from the responses of the AMS clinical pharmacists, both clinical and dispensing pharmacists have also identified the following top five (5) challenges encountered in the implementation of AMS program ( Table 11 ): (1) Prescribing of non-PNF antimicrobial drugs, (2) Lack of time to perform stewardship, (3) Lack of qualified personnel, (4) Lack of hospital management support and information technology support, and (5) Lack of expertise and training in antimicrobial stewardship within the antimicrobial stewardship team. Physician attributes and their resistance to prescribing guidelines by using of non-formulary antimicrobial drugs has also been reported in studies conducted in Australia 10 , Philippines 11 , Hong Kong 39 , and Ethiopia. 21 The other remaining challenges identified are consistent with studies conducted in Australia 10 , private hospitals in the Philippines 11 , Ethiopia 21 , Scotland 22 , and Hong Kong 39 .…”

“…Physician attributes and their resistance to prescribing guidelines by using of non-formulary antimicrobial drugs has also been reported in studies conducted in Australia 10 , Philippines 11 , Hong Kong 39 , and Ethiopia. 21 The other remaining challenges identified are consistent with studies conducted in Australia 10 , private hospitals in the Philippines 11 , Ethiopia 21 , Scotland 22 , and Hong Kong 39 .…”

“…Additional five enablers ( Table 10 ) reported are (1) Education and training of prescribers, (2) Access and adherence to national antibiotic prescribing guidelines, (3) Multidisciplinary AMS approach and Pharmacy-representative in the AMS team, (4) Cooperation, mutual respect, and collaboration of key healthcare professionals, and (5) Good telehealth, internet access, and IT systems (e.g., electronic health records). Education and training of prescribers, as enablers for AMS program implementation 18 , have also been reported in Saudi Arabia 19 , and in the Philippines 11 . Adequate prescriber training and education are key strategies to strengthen the judicious use of antimicrobials, resulting in the delivery of effective AMS services of pharmacists.…”

Hospital pharmacists’ expertise and cooperation towards antimicrobial stewardship in the Philippines: A qualitative study

“…Since the implementation of ASPs, the response to AMR and governance of antibiotic use in hospitals in the Philippines have improved 11 . However, there was a deficiency of implementation strategies in some institutions and disagreements, especially in the prescribing practices, in imposing restrictive policies with antibiotics 12 .…”