Abstract Background Hospital pharmacists are an integral part of antimicrobial stewardship (AMS) programmes globally. Currently, little is known as to how hospital pharmacists see their role and involvement within the AMS framework. Objectives To assess the current level of involvement of Australian and French hospital pharmacists in AMS programmes and identify barriers limiting their involvement in AMS. Methods Hospital pharmacists throughout Australia and France were invited to participate in a nationwide online survey throughout March–May 2016. The survey was promoted through the national hospital pharmacists’ association in Australia, while a stratified sampling method was used in France to invite pharmacists working in a variety of hospital settings. Results Invitations to participate in this survey were sent to 334 Australian pharmacists and 482 French pharmacists. Responses from 133 Australian and 126 French pharmacists were included for analysis. A total of 78.4% (203/259) of pharmacists reported the presence of an AMS programme. Pharmacists were most likely to be involved in AMS through assessing total antibiotic consumption and participating in AMS committee meetings. Barriers to participating in AMS included a lack of time and substantial non-clinical activities limiting involvement in AMS. Differences in responses were found between the two countries. Conclusions While the majority of pharmacists reported the presence of an AMS programme, multiple barriers to participation were identified by pharmacists in both countries. Further research should consider how to overcome the identified barriers to optimize the involvement of pharmacists in AMS. Introduction Antimicrobial stewardship (AMS) has been defined as ‘the optimal selection, dosage and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance’.1 In an era of widespread antimicrobial resistance to current drugs and few new drugs being developed and becoming available, AMS is one of the most important and utilized interventions used globally with the aim of decreasing overall antimicrobial use, misuse and resistance.2 Healthcare authorities internationally have identified the necessity to support and promote AMS in healthcare settings, including in Europe, the USA and Australia.3–7 Although members of the AMS hospital team can vary depending on the organization’s structure and resources, the majority of guidelines available around the world advocate the need for a pharmacist to be a member of the team.3,5–8 Numerous studies have investigated the effectiveness of AMS programmes in hospitals.9–11 However, to the best of our knowledge, no research has been conducted comparing perceptions and involvement of hospital pharmacists in AMS programmes in different countries. The role and responsibilities of pharmacists as a member of the healthcare team can vary depending on the country of practice (Table S1, available as Supplementary data at JAC Online), along with differences in formal education of pharmacists, including training in specialty areas. For example, in the USA formal education and training of pharmacists in infectious disease is available and is indeed recommended for any pharmacist who is a member of an AMS team.11,12 This formal training consists of a 1 year postgraduate pharmacy practice residency and a 1 year postgraduate infectious diseases (ID) specialty residency.13 This ID specialty residency training provides the opportunity for students to work with and learn from ID experts, gain experience in advanced pharmacy practice related to ID, conduct research, and teach students from both pharmacy and other health-related backgrounds.14 Over recent years, opportunities for training in ID and AMS have also become available for pharmacists in the UK.15,16 Pharmacists are increasingly getting recognition as AMS practitioners and for their role in ensuring the appropriate use of antimicrobials in their practice settings. This formal education and opportunity to specialize in ID is not currently available to pharmacists in Australia.3 In France, the opportunity to specialize in certain areas of pharmacy is available to undergraduate pharmacy students; however, this is limited to practice areas (e.g. hospital pharmacy or community pharmacy) and does not focus on specific disease states;17 in particular, specialized training in ID for pharmacists is not available (although a postgraduate qualification in antibiotic prescribing is available) and there is a lack of clinical pharmacy practice in both hospital and community settings.18,19 Medical practitioners, however, are required to undergo substantial postgraduate education and training in order to qualify as ID physicians.20,21 This current lack of formal training for pharmacists may also impact on the involvement and contribution of pharmacists to AMS teams. We were therefore interested in exploring the perceptions of hospital pharmacists around AMS, including its perceived importance, barriers to optimal participation and perceptions of pharmacist involvement in certain aspects of hospital AMS programmes. In particular, we were interested in how these responses compared between pharmacists based in Australia and those based in France, and the strengths and opportunities available in both countries to maximize pharmacist involvement in hospital AMS programmes. France and Australia are both considered as having an advanced degree of implementation of AMS programmes in hospitals, because these programmes are a key part of the accreditation/certification of hospitals, making these two countries ideal for comparison (Table S1).22,23 Methods This was a cross-sectional survey of Australian and French hospital pharmacists investigating their involvement in AMS-related activities. We complied with published guidelines for the reporting of survey results.24 An online survey was made available to participants for a period of 3 months (March–May 2016). The survey aimed to gather data on the following areas: demographics, practice settings, and current practice and pharmacist involvement in AMS activities within their practice settings. Additionally, the survey contains two perception scales to measure the perceived importance of AMS and perceived barriers to pharmacist participation in AMS. Participants were also given the opportunity at the end of the survey to provide comments on this subject matter area. The survey was available in both English and French, and is available as Supplementary data in English. Survey development Survey questions were identified and developed by a senior pharmacy academic with expertise in ID and AMS (S. T. R. Z.), based on existing literature and common components of AMS programmes that pharmacists are regularly involved in and can contribute to.2,25,26 The survey tool was made available for review and comments to academics and clinicians with expertise in ID and pharmacy in France and Australia. In both countries the survey tool was piloted amongst six practising hospital pharmacists in France and three pharmacists in Australia before being made available for the study. The survey was developed in English and translated to French when distributed to pharmacists in France. Survey deployment Considering the aims of the study, we were interested in views of pharmacists involved in AMS in both Australia and France. Given the differences in the organization of hospital pharmacist services between the two countries, the sampling strategy was adopted to suit the circumstances of the individual country. The availability of the survey was promoted to all hospital pharmacists in Australia by circulating an invitation to participate to the members of the Society of Hospital Pharmacists of Australia’s (SHPA’s) Infectious Diseases Committee of Specialty Practice through e-mail (with two subsequent reminder e-mails while the survey was open) to participate in the survey. The survey was also promoted through the society’s newsletter and directors of pharmacy e-mail network encouraging participation from pharmacists involved in AMS. Members of the SHPA and specialty committees are pharmacists employed in a variety of practice settings, including private and public hospitals, servicing metropolitan and regional areas, and offering various medical specialty services. In France, an alternative recruitment strategy was used as there was not a single mailing list for pharmacists that could assist with promoting the survey. The official directory of healthcare facilities (Annuaire Politi) was consulted to obtain a list of pharmacy-serviced institutions, including acute care hospitals, rehabilitation centres and long-term care facilities (when part of standard hospitals). These were divided into public and private, and to each subgroup a randomization of 1:3 was applied in order to select a representative sample. The network of public hospitals in the Paris region (39 university teaching hospitals) was considered as a separate subgroup and further selected with the same randomization procedure. This was done in order to obtain the same proportion of Parisian hospitals as non-Parisian hospitals. Our hypothesis was that involvement of pharmacists in AMS in Parisian hospitals probably differs from their involvement in non-Parisian hospitals. If only one method of randomization had been used, over- or under-representation of Parisian hospitals may have occurred in our sample, which would have introduced selection bias. Invitations to participate in the survey were sent by e-mail; for facilities with more than one pharmacist, the invitation e-mail was sent to the head of the pharmacy facility, with a request to forward it to the pharmacist most involved in AMS activities. Three reminder e-mails were sent to the facility. For those facilities that did not have a valid e-mail address, the pharmacy was contacted via telephone. Up to four phone calls were made in an attempt to contact each of these facilities. Participation in the survey was voluntary and without compensation and survey responses were kept completely anonymous. The survey could be answered without responding to all questions, which provided some flexibility for instances where pharmacists felt they would be unable to adequately answer certain questions. This study received ethics approval from the University of Tasmania Social Sciences Human Research Ethics Committee (Reference No. H0015477). Data analysis Data collected from the survey were analysed using IBM SPSS Statistics version 23. Descriptive analysis was done as mean (and standard deviation), median or percentages based on the nature of the variables. Cronbach’s α was used to assess the reliability of perceived confidence and perceived barriers to participate in AMS activities. A Pearson χ2 test was used to test the differences on binary variables whereas an independent samples t-test was used for individual items of scales to measure differences between Australian and French pharmacists. Results Survey reliability The perception scales in the survey tool showed excellent reliability. Cronbach’s α for the scale measuring confidence in participating in AMS activities was 0.91 and 0.93 for the Australian and French responses, respectively. For the scale to measure perceived barriers to participate in AMS activities, the Cronbach’s α was 0.85 for both Australian and French responses. Participants In Australia, the invitation to participate in the survey was sent to 334 pharmacists, while in France 482 pharmacists were invited to participate. There were 171 responses received from Australian pharmacists and 165 responses from French pharmacists. A total of 259 pharmacist responses were included for analysis of the results: 133 Australian pharmacist responses (response rate 133/334, 39.8%) and 126 French pharmacist responses (response rate 126/482, 26.1%). A total of 38 responses from Australian participants and 39 responses from French pharmacists were excluded as respondents had either not submitted any answers after entering the survey or only completed some of the first demographic questions, meaning that responses could not contribute to the overall results. A comparison of demographic details between the countries is available in Table 1. Table 1. Participant and hospital characteristics Characteristic Australian respondents French respondents P Participant characteristics mean no. of years experience as a registered pharmacist 13.0 (SD 10.59) 13.9 (SD 8.35) 0.15 had formal ID training 48/128 (37.5%) 78/125 (62.4%) <0.05 Hospital characteristics computerized prescribing available 25/127 (19.7%) 116/124 (93.6%) <0.05 computerized medical records available 55/127 (43.3%) 106/124 (85.5%) <0.05 ID department present 64/130 (49.2%) 12/125 (9.6%) <0.05 ID physician(s) present 92/130 (70.8%) 39/124 (31.5%) <0.05 AMS programme implemented in hospital 122/130 (93.9%) 53/122 (43.4%) <0.05 ID physician(s) involved in AMS in hospitala 108/130 (83.1%) 58/126 (46.0%) 0.02 working in public hospitals 93/130 (71.5%) 51/122 (41.8%) <0.05 median no. of FTE pharmacists per hospital based on no. of beds <100 beds = 1.7 (IQR = 3.25) <100 beds = 1.0 (IQR = 0.31) 100–400 beds = 11.0 (IQR = 12.25) 100–400 beds = 1.0 (IQR = 0.69) 401–700 beds = 34.0 (IQR = 27.50) 401–700 beds = 2.6 (IQR = 2.00) >700 beds = 30.0 (IQR = 34.00) >700 beds = 9.6 (IQR = 16.8) median no. of FTE pharmacists involved in AMS based on no. of beds <100 beds = 0.2 (IQR = 0.48) <100 beds = 0.8 (IQR = 0.50) 100–400 beds = 0.5 (IQR = 0.77) 100–400 beds = 0.75 (IQR = 0.90) 401–700 beds = 1.0 (IQR = 0.48) 401–700 beds = 0.5 (IQR = 1.80) >700 beds = 1.0 (IQR = 1.00) >700 beds = 0.8 (IQR = 1.53) median no. of hours spent by the respondent in patient care/week 15.0 (IQR = 23.50) 1.0 (IQR = 1.00) median proportion of time spent on AMS activities (%) 10 (IQR = 47.00) 10 (IQR = 12.25) Characteristic Australian respondents French respondents P Participant characteristics mean no. of years experience as a registered pharmacist 13.0 (SD 10.59) 13.9 (SD 8.35) 0.15 had formal ID training 48/128 (37.5%) 78/125 (62.4%) <0.05 Hospital characteristics computerized prescribing available 25/127 (19.7%) 116/124 (93.6%) <0.05 computerized medical records available 55/127 (43.3%) 106/124 (85.5%) <0.05 ID department present 64/130 (49.2%) 12/125 (9.6%) <0.05 ID physician(s) present 92/130 (70.8%) 39/124 (31.5%) <0.05 AMS programme implemented in hospital 122/130 (93.9%) 53/122 (43.4%) <0.05 ID physician(s) involved in AMS in hospitala 108/130 (83.1%) 58/126 (46.0%) 0.02 working in public hospitals 93/130 (71.5%) 51/122 (41.8%) <0.05 median no. of FTE pharmacists per hospital based on no. of beds <100 beds = 1.7 (IQR = 3.25) <100 beds = 1.0 (IQR = 0.31) 100–400 beds = 11.0 (IQR = 12.25) 100–400 beds = 1.0 (IQR = 0.69) 401–700 beds = 34.0 (IQR = 27.50) 401–700 beds = 2.6 (IQR = 2.00) >700 beds = 30.0 (IQR = 34.00) >700 beds = 9.6 (IQR = 16.8) median no. of FTE pharmacists involved in AMS based on no. of beds <100 beds = 0.2 (IQR = 0.48) <100 beds = 0.8 (IQR = 0.50) 100–400 beds = 0.5 (IQR = 0.77) 100–400 beds = 0.75 (IQR = 0.90) 401–700 beds = 1.0 (IQR = 0.48) 401–700 beds = 0.5 (IQR = 1.80) >700 beds = 1.0 (IQR = 1.00) >700 beds = 0.8 (IQR = 1.53) median no. of hours spent by the respondent in patient care/week 15.0 (IQR = 23.50) 1.0 (IQR = 1.00) median proportion of time spent on AMS activities (%) 10 (IQR = 47.00) 10 (IQR = 12.25) a A higher number may state ID physician involvement in AMS compared with number stating that an ID physician is present as involvement may be remotely through telephone consultation or through visiting-physician rights. In both countries there was a significant correlation between the presence of an AMS programme and a larger number of beds (r = 0.15, P < 0.05). In Australia, 88/94 participants working in public hospitals reported that an AMS programme was present at their hospital (93.6%) and 100% (n = 17) of pharmacists working in local and private hospitals responded that they had an AMS programme present. In France, 63.6% of participants working in tertiary care teaching public hospitals (7/11 participants) stated that their hospital had an AMS programme present, while 19/50 respondents (38.0%) working in general public hospitals and 20/44 participants (45.5%) working in private hospitals also agreed with this. Perceived importance of AMS programme objectives Pharmacists in both countries rated AMS as important in fulfilling multiple objectives (Figure 1). Reviewing the appropriateness of antibiotics to select the best treatment for patients and reducing resistance by controlling overuse of antibiotics were seen by pharmacists in both Australia and France as highly important objectives of AMS. There was a significant difference (χ2 test, P < 0.05) between the two countries in the perceived importance of AMS in satisfying medication commission requirements (needed to maintain hospital accreditation or meet clinical standards defined by governing bodies), and Australian pharmacists rated this as being of greater importance than did French pharmacists. Figure 1. View largeDownload slide Mean ratings of how important AMS was in terms of different objectives (on a scale of 0–10, where 0 = did not agree that AMS is important for this component at all and 10 = totally agree that AMS is important for this component). n = 124 Australian pharmacists and n = 115 French pharmacists. Figure 1. View largeDownload slide Mean ratings of how important AMS was in terms of different objectives (on a scale of 0–10, where 0 = did not agree that AMS is important for this component at all and 10 = totally agree that AMS is important for this component). n = 124 Australian pharmacists and n = 115 French pharmacists. Confidence of pharmacists and perceived barriers to performing AMS activities When asking pharmacists about their confidence in participating in different activities related to AMS, participants in both Australia and France reported higher levels of confidence in conducting audits and reporting compliance with antimicrobial restriction policies, and adjusting the dose and frequency of antimicrobials based on patient factors (Figure 2). Similarly, both Australian and French pharmacists reported lower levels of confidence in adjusting the dose and frequency of antimicrobials based on pharmacodynamic parameters and participating in AMS team care rounds. Figure 2. View largeDownload slide Mean score of pharmacists rating their confidence in participating in different activities (based on a Likert scale where 0 = not at all confident and 10 = most confident). n = 117 Australian pharmacists and n = 113 French pharmacists. PD, pharmacodynamic. Figure 2. View largeDownload slide Mean score of pharmacists rating their confidence in participating in different activities (based on a Likert scale where 0 = not at all confident and 10 = most confident). n = 117 Australian pharmacists and n = 113 French pharmacists. PD, pharmacodynamic. Pharmacists in France rated highly that lack of time and paperwork/non-clinical activities had a strong impact on limiting their participation in AMS. While these were also identified as barriers by Australian pharmacists, it was not as significant as French pharmacists reported (Figure 3). French pharmacists identified that a small number of pharmacists had the least impact on limiting AMS participation, while Australian pharmacists rated no access to reliable antimicrobial information as having the least impact (compared with the impact French pharmacists believed this had, who rated this as significantly higher). Figure 3. View largeDownload slide Mean score of the perceived impact that Australian and French pharmacists believed certain factors had on limiting participation in AMS (on a scale of 0–10, where 0 = no impact and 10 = a great impact). An asterisk indicates responses were significantly different between Australia and France at P < 0.05. n = 114 Australian pharmacists and n = 111 French pharmacists. Figure 3. View largeDownload slide Mean score of the perceived impact that Australian and French pharmacists believed certain factors had on limiting participation in AMS (on a scale of 0–10, where 0 = no impact and 10 = a great impact). An asterisk indicates responses were significantly different between Australia and France at P < 0.05. n = 114 Australian pharmacists and n = 111 French pharmacists. Components of AMS and pharmacist involvement For pharmacists who had an AMS programme actually in place in the hospital where they worked (n = 105 and 98 in Australia and France, respectively), further questions were asked around the current practice of AMS at their place of work. Figure 4 shows AMS activities most commonly implemented in healthcare facilities in Australia and France. Figure 4. View largeDownload slide Pharmacist responses on components of AMS that were practised in all or most clinical areas. An asterisk indicates responses were significantly different at P < 0.05. n = 102 Australian pharmacists and n = 93 French pharmacists. iv, intravenous; TDM, therapeutic drug monitoring. Figure 4. View largeDownload slide Pharmacist responses on components of AMS that were practised in all or most clinical areas. An asterisk indicates responses were significantly different at P < 0.05. n = 102 Australian pharmacists and n = 93 French pharmacists. iv, intravenous; TDM, therapeutic drug monitoring. Pharmacists who had an AMS programme in place at their hospital of work were also asked to identify how involved pharmacists were in different AMS activities. The proportion of pharmacists who stated that pharmacists had an essential role or mostly contributed to the activity is shown in Figure 5. Figure 5. View largeDownload slide Pharmacist responses for level of pharmacy involvement in different AMS activities. An asterisk indicates responses were significantly different at P < 0.05. n = 102 Australian pharmacists and n = 91 French pharmacists. iv, intravenous; TDM, therapeutic drug monitoring. Figure 5. View largeDownload slide Pharmacist responses for level of pharmacy involvement in different AMS activities. An asterisk indicates responses were significantly different at P < 0.05. n = 102 Australian pharmacists and n = 91 French pharmacists. iv, intravenous; TDM, therapeutic drug monitoring. Qualitative comments An overwhelming theme in the comments from both Australian and French pharmacists was a lack of time and funding to deliver optimal AMS services, and comments from pharmacists in both countries also identified that they felt they needed the support of ID physicians to promote adherence to AMS and treatment guidelines. Australian pharmacists made several comments about the need for increased training of pharmacists in ID and AMS, while French pharmacists made comments about the clear role for pharmacists in AMS needing to be better recognized and supported (further details available as Supplementary data). Discussion To the best of our knowledge, this is the first survey comparing the involvement of hospital pharmacists in AMS programmes in different countries. Reliability of the perception scales in the survey tool appeared to be excellent with Cronbach’s α values of >0.8 for both Australian and French responses.27 Our results confirm that pharmacists play key roles both in Australia and France, and have identified barriers limiting their participation. We have also identified major differences between the two countries. Pharmacists in AMS The AMS team should involve a number of health professionals who can offer unique skills and contributions to the team and overall goals. It is recommended that at a minimum the core hospital AMS team should include either an ID physician or microbiologist if available and a pharmacist. Other professionals may also be involved in the larger AMS committee, such as other prescribers, administrators, infection control professionals and information technology professionals. Involving a wide range of professionals can support the team in gaining different perspectives and implementing practices and procedures using a variety of skills.3 As pharmacists are seen as an essential part of the AMS team,3,5,8 it is encouraging that the results of this study confirm that pharmacists in both Australia and France see their role as important. The success of an AMS programme is influenced by having adequate human resources dedicated to the programme.28,29 Pharmacists have also been found in previous research to have a greater interest in participating in AMS activities compared with other health professionals.30 The enthusiasm and ability of pharmacists to participate in AMS should be supported and encouraged to optimize the outcome of programmes and ultimately improve patient care in both Australia and France. Presence of AMS programmes A greater number of Australian pharmacists compared with French pharmacists stated that there was an AMS programme in place at their hospital. While AMS is a requirement for accreditation standards to be met in hospitals in both countries, it has been found that a lack of dedicated and sustainable funding of AMS teams is commonplace in France and prevents the optimal implementation of these activities in most hospitals.18,31,32 This could potentially explain why these pharmacists perceive that no AMS programme is in place at their workplace, particularly if there is a lack of time and funding for pharmacists to be actively involved. Role of pharmacists in AMS Australian pharmacists played a greater role than their French counterparts in AMS activities, such as individualizing antimicrobial drug dosing based on therapeutic drug monitoring, advising doctors on converting intravenous administration of antimicrobials to oral dosing and advising doctors on drug interactions. This demonstrates the greater clinical role that pharmacists in Australia have in hospitals, whereas French pharmacists, although having some involvement in these activities, still played a greater role in tasks such as monitoring antibiotic consumption and managing a list of restricted antimicrobials (which includes antibiotics that require approval for use prior to prescribing or those that may only be used for specific indications and ensuring this list is current and available to prescribers) compared with other activities. These differences could be due to the lower full-time equivalent (FTE) pharmacist positions in French hospitals compared with Australia and therefore fewer human resources involved in AMS. Very few French hospitals indeed created new job positions (for pharmacists, ID physicians or microbiologists) to perform AMS activities, so AMS is usually done as extra work by motivated staff.32 AMS programme activities A formal antimicrobial restriction policy and measuring and reporting antibiotic consumption were activities practised most frequently in hospitals with an AMS programme. These were also the components that received the highest proportion of French pharmacists stating that this happened in all or most clinical areas. As cost containment was an initial goal of implementing AMS programmes, it is unsurprising that these areas are most often seen to be implemented by the majority of hospitals in most clinical areas and are also included as certification indicators for AMS programmes in France.33 French pharmacists were significantly more likely to state that implementing and adhering to an antimicrobial restriction policy happened in all or most clinical areas compared with Australian pharmacists, despite guidelines and recommendations from regulatory healthcare organizations in Australia advising of the importance and value of implementing an antimicrobial restriction policy and system in hospital organizations. Implementation and utilization of antimicrobial restriction policies does vary between Australian hospitals depending on their location, and restriction policies may not necessarily be supported by an AMS programme, which may be reflected in these results.34 Australian pharmacists reported a greater frequency of individualizing antibiotic doses based on serum concentration. Previous research in France has found limited therapeutic drug monitoring available for certain antibiotics in hospital settings, which supports our findings in this survey.35 There was also a higher number of pharmacists reporting adequate resources available to support an antimicrobial restriction policy in Australia. It has been shown elsewhere that computer-based antimicrobial restriction and approval programmes are gaining greater acceptance in Australia, which could explain the adequacy of resources reported here.3,8,36,37 When asked to rate the level of involvement of pharmacists in various AMS activities, participants were more likely to state that contributing and participating in AMS committee meetings and decision making, and monitoring and assessing total antibiotic consumption, were important roles for pharmacists. As pharmacists are seen to be an important member of the AMS team, it is encouraging that a large proportion of pharmacists also see this as a valuable role for them to play.5,33,38 An essential role of the pharmacist internationally is in dispensing and distributing medications, so monitoring and assessing antibiotic consumption as one contribution to AMS is an obvious area where pharmacists could be heavily involved.39–41 Barriers to AMS participation Pharmacists in both countries identified that lack of time and substantial paperwork/non-clinical activities are barriers to AMS participation. This was seen to have a greater impact by French pharmacists compared with Australian pharmacists, although pharmacists from both countries commented on this area. French pharmacists also reported spending less time on patient care activities compared with Australian pharmacists, although a similar proportion of this time was seen to be devoted to AMS activities between the two countries (Table 1). It has been suggested in Australian guidelines that for every 100 beds, at least 10 h of senior pharmacist time should be devoted to AMS activities.3 In France, it has been recommended that in order to implement all AMS activities, 2.5 FTE pharmacists need to be involved in AMS for every 1000 acute care beds.32 Our results, however, demonstrate that variable amounts of time are allocated to AMS in practice. Although AMS is seen as an important activity and requirement in both countries,18,42 these results could again reflect the lack of resources in France to adequately support AMS programmes. Another barrier that was often rated by both Australian and French pharmacists as having a greater impact and was reflected in the comments was the feeling that their AMS efforts were not recognized or respected by doctors (which includes doctors from a variety of specialities) (Figure 3). Previous research has also found that a major barrier to pharmacists utilizing their expertise in promoting optimal antimicrobial use is resistance by doctors to following advice from pharmacists.43,44 The traditional dynamics and relationship between pharmacists and doctors needs to change in order for pharmacists to have a greater impact in improving antimicrobial prescribing.44 Difficulties in collaboration between doctors and pharmacists has been found in the area of AMS as well as other practice areas. Factors such as mutual trust and appreciation between the two professions, ability to communicate easily, and knowing that the other health professional is competent and able to offer practical and straightforward support have been found to be desirable to optimize collaboration between doctors and pharmacists.45 Collaboration is also made more difficult when pharmacists have little time to be involved in clinical tasks and participate in activities such as ward rounds, limiting opportunities for doctors to become familiar with and build a professional relationship with pharmacists. Communication between pharmacists and doctors has challenges, in the area of AMS and other practice areas. Pharmacists should ideally provide feedback and advice to doctors face to face, and pharmacists recognize that a key factor in improving this communication and collaboration is by having pharmacists readily available on wards so that they can be easily approached by doctors.43 Strategies that could be valuable in improving relationships and communications between pharmacists and doctors are outlined in Table 2.46–49 Table 2. Strategies to improve communication between pharmacists and doctors43,46–49 Strategy Outcomes Increased presence of pharmacists on hospital wards allow a trusting relationship to build between pharmacists and doctors, promoting a partnership and common goal to optimize patient care In-service education and pharmacist support to doctors and nurses to optimize antibiotic administration and regular feedback of adherence to antibiotic initiatives increased collaboration between doctors, pharmacists and nurses, and awareness of AMS activities Face-to-face meetings between pharmacists and doctors to discuss improved patient management increased understanding and awareness of the roles and activities undertaken by the other profession, increased trust, strategies developed to optimize patient care Any communication should include self-introduction, explanation of role in an individual patient’s care, providing details of planned patient intervention, discussing opinion of other health professionals increases collaboration, minimizes misunderstandings and errors, improves trust between doctors and pharmacists Document comments and suggestions in patient’s notes ensure information is transferred to doctors and is not missed or delayed, especially if multiple doctors are involved in patient management Increased pharmacist presence on ward rounds increased opportunity to use pharmacist skills and knowledge, allows communication and resolution of patient issues in a timely manner Introducing junior doctors to pharmacy staff during induction, inter-professional learning between medical and pharmacy students provides a positive base from which to improve communication and enhance collaboration between health professionals A definitive role for the pharmacist that is different from other health professions identifying the unique role of the pharmacist separate from ID physicians or microbiologists enhances the standing of the pharmacist as a professional equal, who does not simply follow doctors’ instructions Strategy Outcomes Increased presence of pharmacists on hospital wards allow a trusting relationship to build between pharmacists and doctors, promoting a partnership and common goal to optimize patient care In-service education and pharmacist support to doctors and nurses to optimize antibiotic administration and regular feedback of adherence to antibiotic initiatives increased collaboration between doctors, pharmacists and nurses, and awareness of AMS activities Face-to-face meetings between pharmacists and doctors to discuss improved patient management increased understanding and awareness of the roles and activities undertaken by the other profession, increased trust, strategies developed to optimize patient care Any communication should include self-introduction, explanation of role in an individual patient’s care, providing details of planned patient intervention, discussing opinion of other health professionals increases collaboration, minimizes misunderstandings and errors, improves trust between doctors and pharmacists Document comments and suggestions in patient’s notes ensure information is transferred to doctors and is not missed or delayed, especially if multiple doctors are involved in patient management Increased pharmacist presence on ward rounds increased opportunity to use pharmacist skills and knowledge, allows communication and resolution of patient issues in a timely manner Introducing junior doctors to pharmacy staff during induction, inter-professional learning between medical and pharmacy students provides a positive base from which to improve communication and enhance collaboration between health professionals A definitive role for the pharmacist that is different from other health professions identifying the unique role of the pharmacist separate from ID physicians or microbiologists enhances the standing of the pharmacist as a professional equal, who does not simply follow doctors’ instructions In the USA, where ID pharmacists undergo formal postgraduate education in this area, pharmacists are heavily involved in directing the AMS team, utilizing dose optimization methods and complex antibiotic selection.50 Similarly, further education and postgraduate opportunities in ID and AMS have become available for pharmacists in the UK, and pharmacists are recognized as having an essential role in a number of areas of AMS. This includes developing and maintaining guidelines on antimicrobial use, ensuring optimal treatment for individual patients, providing education to other health professionals and monitoring the use of antimicrobials in their own facility.15,16 Further recognition and the introduction of formal qualifications specifically for pharmacists in ID in Australia and France may improve involvement and reduce some barriers currently seen by pharmacists to be limiting their role in AMS. Australian pharmacists commented on the need for further education in this survey. Pharmacists would benefit from a formal training programme being available to support their role in AMS. In order to be an effective member of the AMS team, pharmacists require skills and knowledge not only in clinical areas such as antibiotic use and ID, but also skills to assist them in implementing an AMS programme. An AMS training programme for pharmacists should ideally support pharmacists to increase their knowledge in the following areas: general principles of AMS and AMS interventions; antimicrobials; microbiology and laboratory results; common infections; reviewing and analysing current practices and interventions; information technology available to support AMS initiatives; leadership and communication skills and programme building; behaviour change and quality improvement concepts; infection control; and ability to adapt guidelines and protocols to certain population groups.51 Strengths and limitations A strength of this study is that it surveyed pharmacists from a wide variety of practice settings nationwide throughout Australia and France, including both public and private hospitals and facilities with varying numbers of beds and number of pharmacy staff. A potential limitation for the study, however, is the response rate is <50%, meaning that the sample size may not be fully representative of pharmacist opinions and attitudes in the two countries. The survey was also voluntary in nature and therefore pharmacists who have an interest in AMS may have been more likely to respond to the survey. In conclusion, pharmacists in Australia and France had different rates of participation in certain clinical activities associated with AMS. While the implementation of an AMS programme is an important clinical standard for hospitals in Australia and France, the extent to which such programmes are implemented in hospitals and the involvement of pharmacists varies. Reasons for varying involvement in different AMS activities could include a perceived lack of knowledge in AMS, inadequate resources to devote time to participating in AMS activities and a lack of recognition from other health professionals and colleagues. Pharmacists require further support, dedication of resources and adequate education to ensure their skills and expertise are best utilized in AMS programmes. Acknowledgements We would like to thank Sonia Koning from the Society of Hospital Pharmacists of Australia for distributing the survey to pharmacist members with an involvement in ID. Funding This research was supported by the School of Medicine, University of Tasmania, via the internal funding for postgraduate students. Transparency declarations None to declare. Supplementary data Supplementary data, including Table S1, are available at JAC Online. References 1 Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc 2011; 86: 1113– 23. Google Scholar CrossRef Search ADS PubMed 2 Howard P, Pulcini C, Levy Hara G et al. An international cross-sectional survey of antimicrobial stewardship programmes in hospitals. J Antimicrob Chemother 2015; 70: 1245– 55. Google Scholar PubMed 3 Duguid M, Cruickshank M. 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Journal of Antimicrobial Chemotherapy – Oxford University Press
Published: Mar 1, 2018
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