Practising antibiotic stewardship in India - blog from Kerala

Vrinda Nampoothiri (centre) with the ASPIRES team during her recent visit to Imperial College

My experience as a clinical pharmacist in Kerala by Vrinda Nampoothiri – Research Pharmacist, PhD student Amrita Institute of Medical Sciences

Prior to joining the ASPIRES team, I was a clinical pharmacist at Amrita working in the stewardship programme since its initiation in 2016. Although the whole concept of stewardship was new to me, the doctors in the team supported me to understand the concepts and encouraged me to give inputs on patient cases being discussed. The stewardship team ensured that the role of clinical pharmacist was never restricted to data collection alone. I was given the responsibility of auditing the use of selected reserved antimicrobials across the hospital, preparing institutional dosing guidelines for these antibiotics, training clinical pharmacy interns and leading other quality improvement initiatives in the hospital. The job had its own challenges of course. The main challenge I faced was improving the compliance to the stewardship committee recommendations for individual patients. It was difficult to understand the prescription patterns in a few departments and even more difficult to convince them to comply to our recommendations. The team expanded over time and more clinical pharmacists were appointed. Gradually over time the program was able to create impact, especially on appropriateness of antimicrobial prescription, improving compliance to stewardship recommendations etc.

It was while I was working in the stewardship team that I met Dr Esmita Charani when she came to our institution as a part of her PhD. She introduced me to Ethnography and it fascinated me to learn about a research methodology that investigated into why people behave the way they do. When the collaboration with Imperial College London expanded to the ASPIRES project, Iwas really keen to be part of this and applied to work on this project as a research pharmacist. Initially I found the project to be very complex, especially because I was the only member recruited in this project in India. However the team at Imperial College, especially Dr Esmita and Dr Raheelah Ahmad, have been very supportive and provided one to one training to me and other members of the research team. The most challenging step for me was to understand the qualitative research methodology. Dr Esmita was very supportive and helped me understand the methodology through the various weekly tasks and previously published works from the team. Dr Esmita spent 7 weeks in India, during the initial data collection, to provide intense hands on training to the newly recruited researchers. During this period, she helped the researchers to integrate well with the surgical teams and also with one another. She identified key areas where each researcher had to improve and encouraged them to help to one another. Our team has now grown to three full-time researchers, including a anthropologist and an epidemiologist.

I was given an opportunity to spend a week with the ASPIRES team at Imperial College in London. This gave me an opportunity to meet the experts in the different aspects of the project and helped me to understand the intense amount of research being done on the other end of the project. We have also been busy submitting abstracts for funding and poster presentations which helped me to improve my writing skills.

The first international meeting of the ASPIRES study was held in Kerala India on 25-26 November. The ASPIRES study (Antibiotic use and infection management across Surgical Pathways - Investigating, Redesigning and Evaluating Systems ) is an ESRC funded international collaboration between UK (Imperial College London) South Africa ( University of Cape Town), India (Amrita Institute of Medical Sciences), and Rwanda (Butare University). This programme of research aims to address antimicrobial resistance, antimicrobial stewardshipand infection control along the perioperative pathway. This work builds on existing research at Imperial which has highlighted the gaps in antibiotic stewardship and infection control in the surgical pathway.

Antimicrobial resistance (AMR) is a major issue in India due to the infection burden in the country coupled with the widespread irrational use of antibiotics. As an initiative to fight against the rising AMR in India, Amrita Institute of Medical Sciences and Research Centre (AIMS) established an antimicrobial stewardship programme in February 2016. The first step was to create a core stewardship team which included an administrative champion, hospital intensivist, physicians, medical microbiologist and clinical pharmacists. A unique aspect of the Amrita stewardship program is that it is driven by Clinical pharmacists. Although the training of clinical pharmacy began in 2008 in India through a graduate programme called Doctor of Pharmacy, job opportunities are still limited and with responsibilities being restricted to dispensing, manufacturing and marketing of the drugs or hospital based responsibilities including reconciliation of medications, prevention, identification and reporting of adverse drug reactions. At Amrita however, clinical pharmacists have become an integral part of the stewardship team right from the time of its inception and their role grew over time.

The ASPIRES meeting held at Kochi last month was a venue for the whole team to meet one another and discuss about their research activities. The junior researchers in the team, Surya, Pranav and myself, were given an opportunity to share our experience of working with the team. All the experts in the team were very enthusiastic to hear our contributions to the project. The team members appreciated our works and inspired us to work harder. It was also a learning experience for us to understand the immense amount of research being done on antimicrobial use and antimicrobial resistance across the world. The whole research team from India will be participating in a Qualitative research methodology workshop being held in London in February 2019. Working as part of the ASPIRES project has inspired me to champion greater involvement of pharmacists in antibiotic stewardship programmes. I am now, alongside my research post at ASPIRES, registered to undertake a PhD investigating how clinical pharmacy in India can be used as a means of implementing and driving antibiotic stewardship programmes.