Pharmacist (Malaysia), NCAS mentee Antimicrobial Stewardship in Malaysia vs Australia: Identifying and closing the gaps presented by, Hoey Lin Oh Pharmacist (Malaysia), NCAS mentee

Overview Background AMS activities in HRPB, Malaysia Comparison between the AMS strategies in Malaysia and Australia Gaps Action Plan

Background Healthcare system in Malaysia Public Private Government Revenue Individual Health care insurance Line Item Budget Fee for Service Adapted from Rozita Halina Hussein, Institute for Health System Research Malaysia. Asia Pacific Region Country Health Financing.

Background National Infection and Antibiotic Control Committee, Medical Care Quality Section, Pharmaceutical Division and the Family Health Development Division Encourage to be implemented, but not mandatory for accreditation Outline Policy 5 core strategies Team: governance, role and members Activities Program measurement

Background Third largest public hospital Capacity: 990 beds Specialty: A&E ICU General medical Haematology Nephrology Orthopaedic Paediatric Surgical (General, Neuro, Paediatric, Plastic)

Background Started since 1st October 2013 Hospital Director Hospital Infection Control and Antibiotic Committee (HIACC) Antimicrobial Stewardship Team (AMS) Started since 1st October 2013 2 ID physicians 1 Clinical Microbiogist 9 Clinical pharmacists

Restriction & approval system Surveillance & feedback mechanism Core strategies of Hospital AMS Restriction & approval system Formation of AMS team Regular AMS rounds Prospective audit Surveillance & feedback mechanism Protocol on Antimicrobial Stewardship Program in Healthcare Facilities. Ministry of Health Malaysia. 2014. 

Honorary observership in Australia Started on16th November 2016 Background of the AMS program in Australia AMS & ID rounds in Royal Melbourne Hospital Education session AMS tools Special visits Victorian Comprehensive Cancer Centre (VCCC) Victorian ID reference laboratory (VIDRL) Victorian Healthcare Associated Infection Surveillance System (VICNISS) Therapeutic Guideline Ltd (TGL) Other hospital (AMS programs) Research project Started on16th November 2016

Comparison in the AMS strategies between Malaysia & Australia

AMS team D HRPB Malaysia Australia Acute metropolitan Hospital: AMS team D HRPB Ph Hub and spoke model Difference: Workforce capacity Hub and spoke model

Guidelines & protocols Malaysia Free Australia Charged National guideline Local guideline Difference: Access and adherence of the national antibiotic guideline Availability of local guideline

Controlled anti-infective Restriction and Approval system Malaysia Australia Electronic approval system MOH formulary (My BlueBook) Controlled anti-infective 1. IV Cefoperazone/Sulbactam 2. IV Ertapenem 3. IV Imipenem/Cilastatin 4. IV Meropenem 5. IV Levofloxacin 6. IV Linezolid 7. IV Polymyxin B & E 8. IV Vancomycin 9. IV Tigecycline 10. IV Ceftaroline 11. IV Voriconazole 12. IV Caspofungin 13. IV Anidulafungin Any doctor Difference: More efficient approval system Real time review of the antimicrobials order Provision of decision support on antimicrobial prescribing No delay for standard approval

Post prescription review & intervention Malaysia Australia Triage by pharmacists Post prescription review Point of care intervention Centralised assistive technology New role of pharmacy technician in AMS triage patients follow up data collection & audit report Difference: Manual and time consuming Scattered information and workflow New role of pharmacy technician

Audit Malaysia Australia Annual Point Prevalence Survey Major hospitals National benchmarking data is not available Antimicrobial consumption Defined daily dose Special audit tools Larger number of hospitals National benchmarking data is available Antimicrobial consumption Defined daily dose Hospital antibiogram (revise local guidelines & protocols) Difference: Scale of the audit Availability of benchmarking data

Report & feedback Malaysia Australia One way communication Difference: One way vs interactive communication

Education Malaysia Australia Difference: Education for consumers Manual vs electronic

Others Clinical pathway Implementation of a nurse and/or pharmacist-led IV to oral switch antibiotic pathway and evaluation of its impact in hospitalised inpatients in the general medical units

Others Victorian Healthcare Associated Infection Surveillance System (VICNISS) State wide surveillance program Infection control practitioner Epidemiologists

Gaps identified Strategies Gaps 1. Guideline & protocols Level of adherence to the national antibiotic guideline Local antibiotic guideline/ protocol 2. Restriction and approval system Manual, time consuming process, delay in approval Poor decision support for junior prescribers 3. Post prescription review & intervention Manual, scattered information and workflow Time consuming 4. Audit Only covers major hospitals No national benchmarking data 5. Report & feedback Variation in reporting format One way communication 6. Education Less focus on consumers

Action plan Strategies Action plan 1. Guideline & protocols Develop the local antibiotic guideline/ protocol Revise the members of auditors and reviewers 2. Restriction and approval system Centralised assistive technology Integrate the electronic system Telehealth system 3. Post prescription review & intervention 4. Audit Refine and enhance the audit tool 5. Report & feedback Propose for standard template for reporting Interactive communication 6. Education Consumer engagement and education Electronic material

Challenges Engagement of the stakeholders and healthcare team members Implementation of innovation and technology Resources and funding Gaps between public and private setting Sustainability of the programme

Acknowledgement Guidance, National Centre of Antimicrobial Stewardship VIDRL VICNISS AMS team, RMH VIDS team, RMH Pharmacy department, RMH Therapeutic Guideline Ltd