1. Steady persistence while chasing the elusive: When guidelines and policies for antimicrobial use clash with the 800 pound gorilla Gerald Yonga*, Sital Shah*, Niranjan Konduri # * The Aga Khan University Hospital, Nairobi, Kenya, # Management Sciences for Health, Arlington, VA, USA Third International Conference on Improving Use of Medicines (ICIUM) Antalya, Turkey, November 14-18, 2011

2. Background (1) The 270-bed Aga Khan University Hospital (AKUH) receives a large number of in-patients referred by outside private doctors 465 private doctors refer patients to the hospital and continue to treat them there compared with the 190 hospital-employee doctors. The Drug and Therapeutics Committee (DTC) has been functional since 1998 and meets frequently

3. What is the 800 pound gorilla? One that is dominating or uncontrollable because of great size or power (like it or not, the 800-pound gorilla usually sets the standard – Daya Nadamuni)

4. Background (2) Out of 793 drugs, top 4 drugs (antimicrobials) consumed 9.6 percent of pharmacy budget (2005) Meropenem, an expensive broad spectrum carbapenem was the most consumed antimicrobial Based on data from a drug use evaluation, antibiotic use studies and antibiotic susceptibility testing, there was impetus to contain the irrational use of medicines

5. Objective To correlate antimicrobial policies and multifaceted interventions with trends in antimicrobial consumption.

6. Intervention (1) DTC established a multi-disciplinary antimicrobial sub- committee to include an ICU physician, microbiologist, ICU nurse and clinical pharmacist In Oct 2006, the proposed antimicrobial treatment guidelines was met with stiff resistance from private doctors Consequently, several sub-committees were established comprising multiple, specialist private consultants from various fields, in conjunction with the pharmacist and microbiologist for drafting and reviewing guidelines

7. Intervention (2) The DTC implemented an antimicrobial order sheet that restricted the use of meropenem and six other antimicrobials in 2006-2007 Private physicians felt that prescribing freedom was being restricted and did not support the order sheet With serial advocacy and opinion leader involvement, the antimicrobial order sheet was implemented with great difficulty in 2007

8. Intervention (3)  Six hospital department heads who were designated champions of antimicrobial policy with support from an infectious disease physician organized a series of 10 educational sessions covering antimicrobial guidelines over 10 months in 2006-2007. From 2008–2010, each department head organized  Routine peer feedback to improve antimicrobial prescribing and  Conducted an average of three annual educational sessions to reinforce content of antimicrobial guidelines in relation to practice

9. Findings (1) - Trends in antimicrobial consumption 5 5 5 5 4 Number of antimicrobials among top 10 Number of antimicrobials among top 20 Abstract 1142 – antibiotics comprise 10%-25% of total drug expenditure (33 hospitals)

10. Findings (2) - quantities Introduction of antimicrobial order sheet for restricted antimicrobials

11. Findings (3) - quantities Introduction of antimicrobial order sheet for restricted antimicrobials

12. Implications (1) Consumption of Meropenem significantly declined in 2006-2007 but steadily increased until 2010. Meropenem remains the top consumed antimicrobial representing 7% of the medicines budget. Extraordinary measures will need to be taken to curb irrational use. Abstract 406 – example of carbapenem resistant Enterobacteriaceae for international health regulations Abstract 1057 – only 2 carbapenems retained > 90% activity In an “open-system,” outside private physicians refer a large proportion of in-patients and adopt their individual prescribing habits. Revised strategies for “ownership” of antimicrobial guidelines will need to be devised.

13. Implications (2) There is need to significantly expand in-house laboratory capacity to disseminate findings of antimicrobial sensitivity of various pathogens. Such information can be powerful to change prescribing habits. Compliance to antimicrobial order sheet has been moderate, in part due to clinical pharmacist involvement in specific wards. However, significant use of restricted antimicrobials continue despite issuance of antimicrobial guidelines, educational seminars and involvement of opinion leaders The undergraduate pharmacy curriculum should include a chapter on clinical pharmacy

14. Conclusion Irrational use of antimicrobials remains a challenge despite multifaceted interventions. Managing patient referrals by outside private physicians requires a unique strategy. The linkage of health insurance coverage with key antimicrobials must be explored.