Antimicrobial Stewardship in Fiji

Transcription

1 Antimicrobial Stewardship in Fiji Contributions by Alistair Pickmere November 2015 and Kyle Booth January 2017 as part of the Fiji National Antimicrobial Resistance Action Plan Senior Pharmacists Network Event May 30, 2017 Mathew Peck Travelling Scholarship Program Faculty of Pharmacy and Pharmaceutical Sciences Monash University, Parkville Campus Melbourne Australia

2 The Mathew Peck Travelling Scholarship The scholarship honours Mathew Peck, a Bachelor of Pharmacy student who died tragically while travelling in South America after completing his first year of study. Mathew was committed to addressing international health issues by using pharmacy to improve people s lives. This scholarship, established by his parents and family, is a legacy to him. We would like to thank the Peck family for establishing this scholarship in Mathew's memory, and also the scholarship selection committee who chose us for this wonderful honour and opportunity. On behalf of all the previous Mathew Peck Scholars and us both, thank you to the faculty and especially to the donors who support this scholarship - without them, we may not be able to contribute to this vital research. Read about some other scholarship recipients here Monash University link

3 Republic of Fiji Pharmaceutical Expenditure 2005 The Fiji Islands

4 Introduction In 2014, the WHO declared antimicrobial resistance as a global health threat that requires urgent collaborative action. Alarming rates of resistance to hospital and community-acquired infections have been reported globally, with some of the highest rates reported in the Western Pacific Region. The Ministry of Health and Medical Services, Fiji identified antimicrobial resistance as one of the priority agendas. In November 2015 Fiji developed a National Action Plan on antimicrobial resistance based on a template provided by the WHO WPRO.

5 The Fiji National Action Plan Objectives 1. Improve awareness and understanding of antimicrobial resistance through effective communication, education and training. 2. Strengthen nationally coordinated surveillance systems. 3. Optimize the use of antimicrobial medicines in human and animal health. 4. Establish and ensure governance, sustainable investment and actions to combat antimicrobial resistance. Implementation Framework Strategic Operational Plan Review and Evaluation

6 Implementation 1. National Antimicrobial Resistance committee set up including Ministry of Health and Medical Services (Chairperson and Secretary) Ministry of Agriculture (includes Veterinary dept.) Ministry of Education Department of Environment Department of Fisheries Medical Institutions (University PSM and Fiji National University) Private Sector (Pharmaceutical and GPs) Consumer Council Customs Authority BioSecurity Authority of Fiji [BAF] Advisors of the committee GMU representative WHO (reporting to tripartite agreement) 2. Project Pharmacist appointed - to develop and oversee the implementation of a National Plan of Operations and report to the committee

7 Plan of Operations: developed by Project Pharmacist More than 50 categories of activities to address the Strategic Objectives are incorporated including Identified areas that required situation analyses or further information to inform the design of activities - to be gathered under the supervision of the Project Pharmacist including At the end of 2015 to be done by Alistair Pickmere 1. Gather information about the knowledge antibiotics, their use and resistance, of both prescribers and patients in Divisional level health services 2. Gather information surrounding the use of the restricted last line antibiotic colistin - in major hospitals At the beginning of 2017 to be done by Kyle Booth 3. Gather information concerning the understanding of the concepts of AMS by private retail pharmacists and hospital pharmacist.

8 Acknowledgments 1. At the beginning of 2015, before the development of the Fiji National AMR Plan, Jessica Dayment, also a Mathew Peck Scholarship recipient, performed a study of the use of the restricted antibiotic - meropenem in the major Fiji hospitals under the supervision of the Fiji MoHMS Pharmaceutical Services. 2. In August 2015 Crystal Yim an Australian pharmacist (Griffiths Uni) working with the Fijian MoHMS & supported by the Australian Government volunteer program coordinated a study of 5000 Fijians representing all areas of the nation (attending a national festival in Suva) to gather information about community perceptions and understanding of the role and use of antibiotics. The findings of both those studies also helped guide the development of the Plan of Operations. All reports of VCP students studies can be downloaded from

9 Alistair s Story Alistair Pickmere B.Sc B.Pharm (Hons) G.Dip.App.Sc Royal Children s Hospital Melbourne 2015 Mathew Peck Scholarship Recipient, Monash University

10 What this opportunity enabled me to do Carry out two investigations of antibiotic understanding and use from the prescribers and patients perspectives; and one investigation of colistin use in hospitals - in Fiji in November/December 2015,and report findings and recommendations to the Fiji Ministry of Health in April 2016 Attend Antibiotic Awareness Week functions organised by the World Health Organisation and The Fijian Ministry of Health gaining insight into the practises and principles required in such environments Facilitate communication between the CWMH and Melbourne based Hospitals following my return to Melbourne.

11 Alistair Pickmere Nov/Dec 2015 OPD Study To get a better understanding of knowledge about antibiotics in Fiji, surveys were carried out under the leadership of the FPBSC Essential Medicines Authority 1. to get a better understanding of the knowledge and attitudes of patients and prescribers in the clinic outpatient settings. Methods: Five busy Divisional Health Centre outpatient facilities, that were close enough to Suva to enable convenient access in the time available, were chosen for investigation. The EMA introduced the investigator to the staff and patients. Antibiotic prescriptions dispensed by the pharmacies during the previous week were collected from the pharmacists and reviewed by the investigator in the light of the Fiji Antibiotic STG3 and other relevant texts. The diagnosis associated with prescribed treatment was noted on the prescriptions to enable such review. A prepared patient questionnaire was used as the basis of the discussion with patients who had received prescriptions for antibiotics. It covered patients understanding of the role of antibiotics and how they should be used. Continued next slide

12 Alistair Pickmere Nov/Dec 2015 OPD Study Methods continued A questionnaire for Doctors was prepared to collect prescribers perceptions about restrictions, guidelines, patient pressures and patterns motivating the prescription of antibiotics. The results of the questions were recorded in Survey Gizmo software and the results of open ended questions were recorded by hand for later entry in the database. The Survey Gizmo was used to generate raw analysis of the data and to provide graphic representation of the results. Those results were combined with the investigator s narrative to generate a report. For the full report including results, discussion, conclusions and recommendation see here:

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15 Findings Investigating knowledge and use of antibiotics at five Divisional Health Centre out-patient clinics in Fiji - 1 Analysis of perceptions concerning use of antibiotics The prescriptions provided a picture of the prevalent infections being treated, primarily skin and respiratory tract infections suggesting a campaign focussing on personal hygiene could be beneficial. Patient Survey responses Patient responses indicate that there is an urgent need for more and ongoing education of the community about the role and uses of antibiotics and how and when they should be taken. The concept of antibiotic resistance was not comprehendible in the majority of patients.

16 Investigating knowledge and use of antibiotics at five Divisional Health Centre out-patient clinics in Fiji - 2 Findings Analysis of perceptions concerning use of antibiotics Physician Survey Responses Physicians responses conflicted those of the patients - identifying patient pressure to prescribe antibiotics as a regular occurrence. Physicians identified that they do have all resources necessary available, however they are poorly accessible and used (including current STG). Stock Maintenance Maintenance of reliable supplies of appropriate stock is an issue. Lack of pharmaceuticals within the health service is unacceptable especially when it is due to poor management which seems to be the case.

17 1. Based on analysis of prescriptions Recommendations Consider the preparation of printed prescription forms that encourage the provision of correct complete information to be recorded. Ensure that all prescribers have access to current STGs Consider continuing education programs for nurses and physicians Implement a community hygiene campaign that includes scabies prevention and treatment in collaboration with the Consumer Council. Implement and routinely revise data collection of prevailing infections, antibiotic therapies utilised and apparent resistances within the divisional health centers Ensure that the MoHMS website is up-to-date with information and references that are relevant to antimicrobial management in Fiji.

18 2. Based on Patients responses Recommendations Implement ongoing education in the community about the role and uses of antibiotics and how and when they should be taken as well as the concept of antibiotic resistance Distribute leaflets and display posters in clinics, retail pharmacies and churches and develop and present regular Radio and TV spots. Partner with the Consumer Council of Fiji as much as possible Provide education material for delivery in regular short sessions of waiting room education by clinic staff that can be provided at a time judged to catch most patients.

19 Recommendations 3 Based on Physicians responses Consider investigation of the resistance pattern of chest infections to assess amoxicillin resistance. Develop ownership of STGs - Provide Antibiotic STGs (ASTG) to every individual medical student and prescriber in Fiji, ensure indicated medicines in stock to allow for adherence to STG Develop further education for doctors in collaboration with the Fiji Medical Council and for nurses with the Fiji Nursing Council. In collaboration the University Medical Faculty, the Fiji Medical Council and the Fiji School of Nursing include CPD points for this continuing education

20 Donations Recommendations 2 (It was found that doctors in clinics had been asking for donations of medicines from Taiwan against the National Fiji Donation Guidelines) Distribute the Fiji Donation Guidelines as a brochure to all clinics and provide the Fiji Medical Council with copies. Provide Fiji Donation Guidelines as a brochure and as full copy to MoHMS officials and relevant Fiji politicians Provide Fiji Donation Guidelines as a brochure to Rotary and other similar clubs. Provide Fiji Donation Guidelines as a brochure to all foreign missions Maintain appropriate stock so that there will be no incentive to look for donations.

21 2. Stock maintenance Recommendations Maintain correct stock levels in all health facilities, prescribe according to the STGs maintain records of patient conditions and treatments and use the data to generate orders for the appropriate quantities. FPBSC will supply order forms that facilitate appropriate quantification and ordering, and will examine orders and consult appropriate clinical staff.

22 Alistair Pickmere Colistin study Introduction: Colistin is an expensive last-resort broad-spectrum antibacterial agent, that is used to treat multi-resistant Acinetobacter baumannii (an opportunistic organism that often causes nosocomial infections) and certain other spp. Therefore, colistin use and misuse raises the potential for the development of significant bacterial resistance with profound clinical impact on the Fijian healthcare system. A study was undertaken to determine the extent of the intravenous use of colistin and the rationale and reasons for its use in three hospital sin Fiji during the time it has been available in Fiji. Methods: Records of treatment were sought and analysed for patients who had been treated with colistin. Information from physicians was gathered about their use of colistin; Microbiology and Infectious Diseases teams were interviewed; cost issues were explored and resistance patterns of organisms were examined.

23 Investigating colistin usage in Fiji at the Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital from August 2014 to November 2015 Patient characteristics There were a total 25 patients - 24 Adult (16 and above), 1 paediatric patient. Only 6 had full medical profiles and records available. 14 patients who required colistin in previous 18 months had died from associated conditions. All patients were within the intensive care setting, apart from one which was within the Acute Surgical Unit awaiting transfer to ICU. One patient was identified as suitable for colistin treatment but died following transfer from Labasa to CWMH

24 Investigating colistin usage in Fiji at the Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital from August 2014 to November 2015 Infection characteristics necessitating colistin usage Acinetobacter baumannii was the organism of infection in 19 cases, Acinetobacter Junii in two cases, followed by three infections by Pseudomonas aeruginosa and an unmarked MRO. Organisms were identified from Blood Culture, Pleural Aspirate, Tracheal Aspirate, Peritoneal Fluid, Sputum, IDC tips and Wound Swabs.

25 Colistin study: Results, Conclusions and recommendations Patient records Comprehensive patient records are not routinely maintained and retrievable so drug use evaluation studies (DUEs) cannot be undertaken, diagnoses statistics cannot be maintained and quantities of medicines needed for treating those disease/conditions cannot be estimated. Stock-outs There are stock-outs of medicines in the wards, infection control consumable and equipment, laboratory supplies. This situation undermines every aspect of patient care in the hospitals. Patient Treatment Patients treated with colistin were suffering from infections that warranted prompt treatment with colistin. Inadequate infection prevention and control (IPC) (often due to inadequate supplies) fostered the development of nosocomial MDR organisms. There is suboptimal understanding among prescribers of the use of protocols and standard treatment guidelines (STGs) and these documents are not always readily available so a detailed guideline for the use of colistin is needed. The third edition of the Antibiotic Guidelines was published in It is time for that to be revised.

26 Investigating colistin usage in Fiji at the Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital from August 2014 to November 2015 Physician Survey Response There were indications that protocols for use of colistin were not readily available or not consulted and timely access to colistin when it was indicated was not good. There seemed to be poor inter-departmental coordination between microbiology, pharmacy and maintenance of adequate IPC, that led to entirely unfavorable patient outcomes. There was some perceived need for empirical use of colistin

27 Investigating colistin usage in Fiji at the Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital from August 2014 to November 2015 Infection Prevention and Control (IPC) Response IPC is completely inadequate. There is highly detailed record keeping however inadequate monitoring, with little intervention. There is no budget or allowance or time given for IPC education, training and resourcing. No guidelines or protocols are written. There is reliance on lack of budget, as the reason for inadequate activities. A neonatal intensive care unit outbreak at CWM cost $32,000 FD. There is very inadequate supply of basic antimicrobial supplies: soaps / disinfectants and other equipment.

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29 Investigation reports Drug Use Evaluation Report Investigating colistin usage in Fiji at the Colonial War Memorial Hospital, Lautoka Hospital and Labasa Hospital from August 2014 to November 2015 (Alistair Pickmere, Rashika Gounder, Jeremaia Martaika, Beverley Snell). Investigating knowledge and use of antibiotics at five Divisional Health Centre out-patient clinics in Fiji, November, 2015 (Alistair Pickmere, Nargina Macalinao, Jeremaia Martaika, Beverley Snell). Both reports submitted to the Ministry of Health Fiji in April

30 What I have done following this opportunity Continued building on the relationships built during my time, and facilitated new lines of communication between Fiji and a major tertiary hospital in Building relationships alongside previous Mathew Peck Scholarship Recipients in international aid projects. Gained an internship the Royal Children s Hospital Melbourne, and been allocated as the Infectious Disease Intern. Maintained active interest and support to future scholarship recipients.

31 THANK YOU Now over to Kyle

32 Kyle s Story Kyle Booth Victorian College of Pharmacy Monash University 2016 Mathew Peck Scholarship Recipient, Monash University

33 Kyle Booth: Investigate Pharmacists understanding of AMS concepts in both retail and hospital settings Under the guidance of the Fiji National AMS Program Project Pharmacist, Ms Rashika Gounder, studies were undertaken to obtain information about the existing understanding by pharmacists, in retail and hospital settings, of AMS concepts which would inform the strategies to be developed in the Fiji National AMS program. Approval was granted by the Fiji Ministry of Health and Medical Services Research and Ethics department and by the Fiji Pharmaceutical Society

34 What this opportunity enabled me to do Carry out two investigations of understanding of the concepts of Antimicrobial Stewardship (AMS): among retail commercial pharmacists and hospital pharmacists in Fiji in February 2017, and develop a report for the Fiji Ministry of Health and Medical Services (MoHMS) Commute around Suva and some neighboring villages to visit retail pharmacies, speak to each pharmacist, and obtain answers to the study questionnaire. Visit the major hospitals to talk to Pharmacists and Pharmacy Technicians about their understanding of AMS travelling by road to Lautoka and by air to Labasa. Analyse and discuss the findings of these investigations with Fijian colleagues. Learn an enormous amount about AMR and AMS issues and pharmaceutical systems in Fiji. Meet with Australian volunteers working in Fiji and explore and enjoy extracurricula activities around Fiji above and below water.

35 My assignment My research was driven by two studies; one directly with pharmacists in the Suva area who worked in retail pharmacies, while the other consisted with clinical pharmacists in three main Fijian hospitals. Both studies focused on the understanding of the concept of an antimicrobial stewardship, through a questionnaire-based survey that I built in the first week of my trip under the supervision of the Fijian AMS Project Pharmacist.

36 Study of Fiji Hospital Pharmacists Understanding of the Concept of Antimicrobial Stewardship Methods 1 Authorisation was obtained from the MoHMS Statistics and Ethics Department. A questionnaire was developed by the AMS project pharmacist and the interviewer and field tested before being finalised A short explanation of AMS was prepared. Pharmacists and pharmacist technicians working in Colonial War Memorial Hospital (CWMH), Lautoka hospital and Labasa Hospital were identified by the Principal Pharmacist in each hospital then interviewed individually. Questions were asked exactly according to the prepared questionnaire and the answers were noted manually on a print out of the survey. Respondents were encouraged to provide more than one answer. Continued next slide

37 Study of Fiji Hospital Pharmacists Understanding of the Concept of Antimicrobial Stewardship Methods 2 Answers given by the respondents were recorded in a way that enabled their recording in the software for later interpretation. If their answers relevant to AMS indicated they were unsure of the meaning of AMS they were provided with the explanatory leaflet to read before the subsequent questions were asked. After completing the oral questions, the pharmacists were asked to complete a short written questionnaire. Surveygizmo software was used to record the questions and responses and to proved a graphic representation of the results.

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39 Study of Fiji Hospital Pharmacists Understanding of the Concept of Antimicrobial Stewardship Summarised discussion of results 1 Understanding rational use of antibiotics and antibiotic resistance. There was good awareness of the nature of antimicrobial resistance and the factors that contribute to development of resistance and agreement that rational use of antibiotics is essential. There was agreement that use of antibiotics could be improved greatly but barriers would need to be addressed. Compliance with and orientation about the AB STG 2011 is important but the publication needs to be updated. Nurses also have a role in the maintenance of rational use of antibiotics and their role needs to be defined and strengthened by ongoing education. Patient pressure to prescribe antibiotics for inappropriate conditions is strong. Ongoing education of health professional and the public is needed - not just during the annual Antibiotic Awareness Week. There is insufficient attention to laboratory results but the slow turnaround from the laboratory often led to empirical use of second line or last line antibiotics.

40 Study of Fiji Hospital Pharmacists Understanding of the Concept of Antimicrobial Stewardship Summarised discussion of results 2 Understanding rational use of antibiotics and antibiotic resistance. Stock maintenance: In the absence of sufficient stock of the appropriate first line antibiotics, second line or restricted antibiotics were used. This finding is in line with the findings of the meropenem use and colistin use studies. The stock issues can be easily resolved. Records of patient conditions and the antibiotics appropriate for those conditions must be the basis of re-ordering stock. Pharmacists have a major role in ensuring the maintenance of this system. Shortage of staff has a major impact on maintaining appropriate use of antibiotics and therefore optimal treatment of patients. Appropriate staffing levels would lead to availability of sufficient time to undertake the necessary tasks. Specialist trainers should be engaged. Communicating with prescribers presents additional problems they are hard to find and sometimes do not appreciate the follow-up to clarify prescribing issues.

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43 Extension to the Labasa Hospital for A & E, Antenatal care, Eye Clinic, built by South Korea in 2009 Patients needing referral from Labasa to Suva are sent by air. This extension provides intermediate services

44 Study of Fiji Retail Pharmacists Understanding of the Concept of Antimicrobial Stewardship Methods 1 Permission to undertake the study was obtained from the Fiji Pharmaceutical Society and the MoHMS ethics committee. A questionnaire was developed with the help of the AMS project pharmacist. The questionnaire was field tested in one retail pharmacy (that would not be included in the survey) before being finalised. A short explanation of AMS was prepared. Retail Pharmacies in the Suva area were identified and the pharmacist in charge of each was contacted by telephone by the project pharmacist before the visit by the investigator - to explain the aims of the study and the importance of information they could provide. Before the interview, pharmacists were asked to read and sign the introduction/consent letter. The aim of the survey was explained and the pharmacist in charge was interviewed. (to next slide).

45 Study of Fiji Retail Pharmacists Understanding of the Concept of Antimicrobial Stewardship Summarised discussion of results 1 Qverall, responses demonstrated that pharmacists showed good awareness of the nature of antimicrobial resistance and the factors that contribute to development of resistance It was recognised that resistance is developing with the result that stronger antibiotics will be needed and stronger antibiotics will not always be available and affordable. It was recognised that globally MRSA incidence is rising and treatment is not as effective. Unfortunately there are no data produced in Fiji in a format that allows tracking of current Fijian resistance. It was also recognised generally that current restricted antibiotics need to be conserved by strict control of their use but there was incomplete awareness of the existence of AB therefore the private sector must to be included routinely in rational use of medicines activities to next slide

46 Study of Fiji Retail Pharmacists Understanding of the Concept of Antimicrobial Stewardship Summarised discussion of results 2 Control of prescribing is needed in the private sector as well as the public sector so needs to be included in national campaigns for rational prescribing. Although the Fiji National Medicinal Products Policy (NMPP) states that standard treatment guidelines are meant to guide prescribing throughout Fiji, in practice that does not seem to happen Some pharmacists will dispense antibiotics without prescriptions so regulatory control must be enforced. Patient pressure can contribute to the supply of unnecessary and unprescribed antibiotics. To next slide

47 Study of Fiji Retail Pharmacists Understanding of the Concept of Antimicrobial Stewardship Summarised discussion of results 3 Almost all respondents believed antimicrobial resistance is already a serious problem in Fiji. The marginal use of microbiology tests to guide prescribing of antibiotics together with the empirical use of stronger broad spectrum antibiotics is a major contributor. Lack of awareness in both health providers and the Fiji community needs to be addressed. Those who were less sure that resistance is already a problem felt that more research was needed to determine the extent of the problem and monitoring needs to be routinely done in the private sector as well as in the public sector. Concerning some issues there was no consensus. For example some believed counselling patients was undertaken while others believed it was not. This response demonstrates that there is some variation in the practices in retail pharmacies.

48 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Overall Findings 1 There were differences between the retail and the hospital pharmacists. In all three hospitals, not many pharmacists understood the concept of what Antimicrobial Stewardship but most were able to explain some of the stewardship objectives they already fulfill as pharmacists. All pharmacists I surveyed agreed that as a pharmacist it was necessary to have a prominent role in a stewardship Positively, each pharmacist understood the influence they could have on the growing issue of resistance. There were concerns with prescribers and their methods, and about retail pharmacists who gave antibiotics over the counter without prescriptions Retail Pharmacists highlighted huge issues with individuals only purchasing a few days treatment with antibiotics instead of a full course due to unaffordability.

49 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Overall Findings 2 All pharmacists could list the benefits of having an Antimicrobial Stewardship in place, but they would also list barriers they would face for a successful implementation: Human resources, finances, awareness and time Poor community health literacy was a big concern. Inappropriate use of antibiotics for symptomatic relief of headaches, pain and especially the flu was common

50 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Recommendations 1 Recommendations were made in collaboration with the Project Pharmacist and my Australian supervisor. Hospital Pharmacists Increase the staffing levels of the pharmacy department to an effective level supported by a realistic salary. Provide adequate training and resource support for the implementation of optimal AMS. Ensure that undergraduate curricula in members of teams of health-related professions in the hospital setting include RUM, AMR and AMS. Address the stock issues as a priority by introducing and maintaining a system of record keeping that will lead to quantification of needs of appropriate supplies of the right medicines. Reliable supplies of the right medicines will be ensured by basing orders on the accurately kept patient records of diagnoses treated appropriately.

51 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Recommendations 2 (Hospital Pharmacy) Strengthen the role of the National Medicines and Therapeutics Committee and its relationship with all health care workers Update the Antibiotic Standard Treatment Guidelines as a priority, distribute it and promote its use Develop and implement a system for routine regular audit of antibiotic prescribing and patient response to be undertaken by hospital pharmacists (depending on staff levels being adequate). Develop and implement a strategy for a team approach between all health care workers and mutual recognition of the role of all team members Develop a system for following up results of lab tests so the appropriate medicines are available, dispensed to the patients and recorded appropriately; and their effect monitored. Develop the necessary tools and train pharmacy staff to monitor activities to ensure the above actions are occurring correctly.

52 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Recommendations 1 (Retail Pharmacy) In collaboration with the Fiji Pharmaceutical Society (FPS) pharmacists should be equipped to participate in the AMS program in Fiji. Ongoing collaborative links must be developed and maintained between the public and private sectors of pharmacy. Private medical practitioners must be included in programs to promote the use of antibiotic treatment guidelines that must be current to gain credibility. The Antibiotic Standard Treatment Guidelines 2011 must be reviewed and updated as a priority The Fiji Medical Society should be actively involved in initiatives and develop coownership of the AMS program Fiji s retail pharmacists must be included in national education activities to strengthen their capacity to participate in all rational use of medicine initiatives not just concerning antibiotics.

53 Study of Fiji Pharmacists Understanding of the Concept of Antimicrobial Stewardship Recommendations 2 (Retail Pharmacy) The AMS program activities must include mechanisms to strengthen a team approach to AMS so each team member will value others and good two way communication between medical practitioners, pharmacists, nurses, consumers and others will be the result. The Medicines Regulatory Authority and the Pharmacy Professions Board must have active connections with retail pharmacies through official inspectors to identify and report on any contraventions of practices. Breaches will be dealt with appropriately by the Tribunal appointed for the purpose. Comprehensive records of patient prescriptions must be kept according to the Fiji Good Pharmacy Practice Guide March Regular audits of antibiotic prescriptions should be undertaken to identify targets for interventions and education. The Consumer Council of Fiji (CCOF) must be involved in national education programs to strengthen AMS. COCF is a team member in the AMS program and consumers are part of the whole community affected by AMR.

54 This activity was introduced by the MoHMS during Antibiotic Awareness Week 2016 Continues twice a week with full participation (stay healthy to minimise need for antibiotics)

55 Thank you

56 References Fiji National Medicinal Products Policy Fiji National Plan on Antimicrobial Resistance s_amr/en/ and Fiji National Antimicrobial Resistance Plan: Operational Plan Fiji Guidelines for Donations of Medical Supplies and Equipment Donations-of-Medicines-Medical-Supplies-and-Equipment.pdf Fiji Antibiotic Standard Treatment Guidelines rd-edition-2011.pdf