Vol. 37 No.4
Dec. 31 2021

Asia Pacific Antimicrobial Stewardship Preceptorship Program


Genevie Wang1, Chun-Wen Cheng2, Ting-Shu Wu2, Cheng-Hsun Chiu3, Hsuan-Ling Hsiao1,4
1Department of Pharmacy, Linkou Chang Gung Memorial Hospital
2Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University
3Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Chang Gung University
4Department of Respiratory Therapy, Chang Gung University


A one-year Asia Pacific antimicrobial stewardship (AMS) preceptorship program was developed and implemented by Linkou Chang Gung Memorial Hospital (CGMH) in 2018 and healthcare professionals from several hospitals in the Philippines and Vietnam participated. The project aimed to equip the participants with not only expertise and leadership necessary for establishing and/or improving antimicrobial use, but also techniques on enhancing strategy implementation. It involved pre-training teleconferences, one-week multi-disciplinary AMS workshop at CGMH, post-training teleconferences and finally, the mentors traveled abroad to conduct on-site inspections. The purpose of this article is to share CGMH’s approach (i.e., from advance preparations to implementation and follow-up) on making the preceptorship program a success. The importance of engaging the pharmacist in such activities is also discussed herein.

Key words:antimicrobial resistance (AMR), antimicrobial stewardship program (ASP), antimicrobial stewardship preceptorship program

I. Introduction

Antimicrobial agents are one of the greatest medical advances of the 20th century, however, they are quickly becoming useless due to antimicrobial resistance (AMR) and the pipeline of antimicrobials under development is limited. We therefore are heading for a post-antibiotic era in which infections caused by AMR microorganisms are becoming insusceptible to antimicrobial agents1. With the misuse of antimicrobials in multiple sectors (healthcare, veterinary, agriculture), drug resistance is now a pervasive phenomenon worldwide. Infections caused by AMR microorganisms usually result in longer durations of hospital stay, higher mortality, and reduced labor efficiency, adversely impacting patients' health and well-being2. The extensive health and economic implications associated with antimicrobial resistance has made it one of the most pressing public health issues the world faces today3. Linkou Chang Gung Memorial Hospital (CGMH) spares no effort in combatting AMR. It has been the first in 2004 to develop and deploy a hospital-wide computerized antimicrobial approval system prospectively auditing the use of antimicrobial agents4. In 2006, a steering committee comprising experts in antimicrobial stewardship (AMS) was established and has now accumulated more than ten years of experience in improving antimicrobial use among the in-patient, out-patient, and emergency departments. Furthermore, Linkou CGMH was selected to serve as one of the regional demonstration centers assisting in the implementation of the nationwide Antimicrobial Stewardship Program (ASP) led by Taiwan's Centers for Disease Control (CDC) from 2013 to 2015. Over the past years, Linkou CGMH have applied the ‘One Health' concept in the implementation of AMS initiatives. AMS is important to address the problem of AMR, but efforts of workers across sectors at the local level are never sufficient alone5. The Lancet Infectious Diseases Commission and World Health Organization have highlighted the need for a collaborative approach to support resource-limited countries in optimizing antimicrobial use through education and stewardship6. As part of our determination to deliver on the commitment of addressing public health problems, we sought to advance the ASP at some hospitals in Southeast Asia using a multifaceted, interprofessional mentoring program designed to help pharmacists, physicians, and nurses in resource-limited settings implement ASP or improve existing ASP in their institutions.

II. Description of the Mentoring Program

The Asia Pacific AMS Preceptorship Program was an important segment of a bigger project which has the following objectives:

1. To sort out all the AMS initiatives Linkou CGMH has taken throughout the years and to disseminate the information through scholarly work.

2. To support CGMH's ID physicians, nurses, pharmacists, and medical technologists in completing additional training to specialize in AMS mentoring.

3. To develop a comprehensive AMS curriculum consisting of lectures and workshop sessions that is suitable for implementation in the AMS preceptorship program for hospitals overseas.

Training of two batches of foreign delegates began in 2018 (Figure 1). A total of 18 delegates from the Philippines (PHL) and Vietnam (VNM) were invited to participate in the mentoring program at no cost to the institution. The overall attendance was tabulated for presentation (Table 1).

Figure 1. Timeline of Events of the Asia Pacific AMS Preceptorship Program

Table 1. Attendance Breakdown of the Asia Pacific AMS Preceptorship Program

The AMS steering committee of Linkou CGMH served as the mentors and had several meetings to discuss the operations and logistics of the mentoring program before the official launch. In April, mentees were briefed via teleconference and were requested to provide mentors with information that describe current stewardship activities in their institutions. The mentees were finally welcomed to Linkou CGMH in May and June for their weeklong training on AMS, which consisted of lectures delivered in English, case discussions, hands-on activities, multidisciplinary ward rounds, pharmacy visit, and clinical laboratory tour. The Filipino and Vietnamese participants were trained on a separate schedule but with identical scope and content (Figure 2).

Figure 2. Weeklong Training Schedule

Soon after the weeklong training concluded, the mentors had regular follow-up teleconferences with the mentees to continually provide oversight on process improvement changes. At the end of the program, the mentors traveled abroad to conduct on-site inspections and the 2014 CDC checklist for core elements of hospital ASP was used to assess if necessary principles and actions to improve antimicrobial use were in place7.

III. Experience with the Program

In recent years, health authorities in Vietnam and the Philippines have been earnestly trying to further improve their regulatory landscape for antimicrobial stewardship. They have urged institutions to apply national guidelines and best practices for implementing and evaluating ASP. The mentors have observed that stewardship concepts were relatively easy for delegates to understand because they had some background on AMS before being accepted into the program. However, their information technology infrastructure and experience in outcomes measurement was inadequate.

The mentors placed emphasis on teaching ASP metrics and process/outcome measurement all throughout the weeklong training. During the last day, the participants got hands-on experience with generating and analyzing quantitative data on antimicrobial use to perform clinical and economic outcome analyses. The mentors also offered a strategy to overcome the lack of ASP-specific information technology; delegates were taught techniques on the surveillance of antimicrobial consumption using Microsoft Excel.

To ensure that the antimicrobial-related healthcare services of the hospitals involved in this program were meeting standards, the mentors were grouped into two pairs and each pair was sent abroad to conduct foreign site inspections in November 2018. Inspections were carried out around the 2014 CDC checklist for core elements of hospital ASP (Table 2). Non-conformities were dealt with straightaway and followed up accordingly to guarantee that areas for improvement were being addressed.

Table 2. An outline of the abridged 2014 CDC checklist for core elements of hospital ASP and the summarized results of the facilitators’ assessment

Even after the official ending of the project, contact with one particular hospital in the Philippines was not lost; they remain engaged with the mentors to discuss about their progresses and challenges in AMS implementation. Baseline and follow-up data documenting significant improvements was shared with the mentors (Table 3).

Table 3. Self-assessment of changes and progress in a hospital in the Philippines

IV. Insights and Lessons Learned

With pharmacists' expertise on and influence over antimicrobial use within the health system, they have a responsibility to take prominent roles in ASPs and participate in the infection prevention and control programs. However, the most important component of a pharmacist-driven ASP is the knowledge of the pharmacist in the area of infectious diseases (ID)8. Without beyond-basic understanding of ID and appropriate antibiotics for the treatment of specific infections, ASP pharmacists can face significant challenges in bringing a positive influence over antimicrobial use within the health system.

From the drafting of the project proposal to the planning, organizing, and implementation of this project, the pharmacists of Linkou CGMH have made enormous contributions. The pharmacist, member of the hospital's AMS team since its founding in 2006, hold a pivotal position in making this project a success. Not only did the pharmacist deliver lectures on the topics “The Role of the Pharmacist in ASP” and “ASP Metrics and Process/Outcome Measurement,” but also helped spearhead the project's all other pharmacy-related activities (i.e., pharmacy visit, hands-on workshop on antimicrobial consumption surveillance, conference calls, and the terminal foreign site inspections).

Currently, there are no standard, universally accepted metrics which reflect intervention effectiveness. Since the choice of metrics is primarily influenced by resource and data availability, an institution should tailor its choice of strategies to its needs and available resources. Sustained funding from the administration and enthusiastic medical staff support are also needed for program success9,10. While inaccessible electronic health records and other ASP-specific information technology make ASP implementation and surveillance difficult, unfamiliarity in the use of process/outcome measurement poses an even greater challenge. Mentoring by individuals with stewardship experience advances the learning curve, removes barriers limiting progress, and expedites the maturation of a stewardship program11.

Despite suffering setbacks that would have discouraged the implementation of effective ASP, the hospitals involved in this mentoring program still demonstrated commitment to support clinicians in daily stewardship duties and ensure successful antimicrobial-related outcomes. Their willingness to learn from each other's stewardship successes and failures continues to foster collaboration. Linkou CGMH is obligated to continually provide support and practical recommendations for hospital staff both locally and abroad, especially in resource-constrained settings. 

Figure 3. Photo opportunity during the opening ceremony (A), ASP Team Meeting (B), hands-on workshop (C), panel discussion (D), clinical laboratory tour (E), pharmacy visit (F), pharmacist-led ward rounds (G), case discussion (H), lecture session (I), photo opportunity after the on-site inspection (J).








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