9 Education and training

I’m Dr Iretiola Fajolu, a consultant paediatrician with the Lagos University Teaching Hospital, a member of the hospital antimicrobial stewardship committee, and chairman of my departmental antimicrobial stewardship committee. I’ll be talking about when and where to start using that experience in the department.

Where to start: involving the key stakeholders is important to ensure a successful programme. It is also important to identify the members of your AMS team and keep them informed. It is necessary to have a baseline data to use as a starting point to identify the need for stewardship, and also to measure the success of the programme.

The hospital antimicrobial stewardship committee made a presentation of the results of the global point prevalence survey of antimicrobial consumption and resistance to all members of the departments. This helped create awareness of the problem of high rates of antimicrobial use in the hospital. A case presentation was also done, which highlighted the gaps in the routine investigations and antibiotic management of infections in our department. The commitment for an intervention to improve antibiotic prescribing was obtained from our members, and the Departmental Antimicrobial Stewardship Committee was settled.

The members of the department also decided on the stewardship strategy to use, and prospective audits, intervention and feedback was agreed upon. The duties of the Departmental AMS Committee were to draw up an antibiotic guideline, and also to monitor compliance to the guideline and the hospital antibiotic policy.

Our first challenge was developing the antibiotic guideline. There was no antibiogram to base our choice of antibiotics on, so the first draft was based on existing guidelines from other countries, and also on a knowledge of common causative agents and the likely sensitivity. The initial draft was sent to individual members of the department for input, but the response was poor. It was then resent, this time asking for input from units instead of from individuals. This resulted in a better response.

The final draft was then sent out and we asked that it be used in the department. This process took some time, and it was almost discouraging. This also coincided with the dissemination of the hospital antibiotic policy. Our next duty was to monitor compliance to the antibiotic guideline and also to the hospital antibiotic policy. The areas of focus were targeted prescription, closed prescription, de-escalation, collection of culture samples before commencing antibiotic therapy and also the use of biomarkers for diagnosing infections.

The next challenge however, was manpower to carry out prospective audits, intervention and feedback. We decided to do a study to assess the feasibility of involving medical students for data collection on antibiotic use with the help of a checklist to reduce the work burden for healthcare professionals. This was a retrospective review of case notes.

It afforded the medical students early training and practice in rational antibiotic use. This was found to be feasible, and was incorporated as part of the training of medical students in the department. It is now being done as a prospective audit. The aspect of feedback is, however, yet to be assessed, as the programme is still in the early phase or in the departments. Thank you.

Oh, there are the challenges. We are working in low-resource settings. And we have the three Ms – are never sufficient – manpower, money, material. They are not sufficient. So we have to manage where we are. But even that as well: shortage of manpower is key. If there is nobody to go on a ward round, a robot cannot do institution, make intervention. So we need manpower. We are very short. And it’s actually affecting hours. So we need manpower.

Multidisciplinary ward rounds should be improved on. It’s not adequate yet. We see mission some challenges when we go to the world, inadequate review of, or untimely review of, hospital formulary. When an hospital has been there for more than ten years, new drugs are not brought on board, you know? So it’s affecting to affect the AMS.

Failure or litanies of review medication errors. Where we see some intervention, we see some errors and we want to – if it’s not done on time, or we cannot reach the prescriber, the patient will not start their medication on time. And that will affect rational use of the antibiotics.

Open prescription, opened-up prescription for antimicrobial agents and other drugs; lack of communication between prescribers and pharmacies – where we are not really communicating, they use or lose sheets or wrong forms to document administration of IV drugs, which are not even filed in the case notes. And so we cannot really follow up on use. Poor documentation of drugs is that our documentation of drugs not administered, and no dissemination of relevant information to our stakeholders.