Antimicrobial Stewardship in Turkey – A Clinical Pharmacist’s Perspective

In this article, a pharmacist from Turkey with advanced training in the area of infectious diseases provides insights on antimicrobial stewardship in Turkey.

Interview with: Emre Kara, MSc., Ph.D.

Interviewer: Timothy P. Gauthier, Pharm.D., BCPS, BCIDP

Article Posted 1 August 2023

A man colonized with extensively drug resistant Acinetobacter baumannii gets on a plane. A woman colonized with pan-drug resistant Pseudomonas aeruginosa gets on a train. How many hours or days will they travel for? Where will they visit along their journey? What will be their final destination? Will they inadvertently spread their drug-resistant pathogens to other people or environments over the coming days, weeks, months, or years?

The threat of antibiotic resistance is relevant to us all and antimicrobial stewardship is necessary for all nations of the world. That is the driving force behind this series of articles which has been ongoing since 2018, bringing insights from Nigeria, India, Bangladesh, Uganda, Thailand, Japan, Costa Rica, Australia, New Zealand, Canada, Spain, and the United Kingdom. Here, we seek to learn from others and share stories of our progress on stewardship globally.

In this article we will be focusing on antimicrobial stewardship in Turkey. I had the good fortune of connecting with Dr. Emre Kara at the European Congress on Clinical Microbiology and Infectious Diseases in 2022, who lives and works in Turkey as a pharmacist practicing in the area of antimicrobial stewardship. He was open to doing this interview providing his insights on antimicrobial stewardship in Turkey and correspondence over about a year and a half led to this article.

We hope you will find it interesting, here are insights on antimicrobial stewardship in Turkey…

1. How did you get interested in antimicrobial stewardship as a pharmacist and what path did you take to reach where you are today? 

Clinical pharmacy in Turkey is still developing. The first clinical pharmacy education started with a bachelor’s degree at Marmara University in 1991 and Hacettepe University in 1994. Since 1996 at Marmara University and 2014 at Hacettepe University, academicians with a doctorate in clinical pharmacy have carried out postgraduate education. This program has later spread to the health sciences institutes of many universities. Formal postgraduate training started in 2018 (clinical pharmacy specialization training). This 3-year program consists of theoretical courses, case presentations, intensive clinical training and a thesis.

I graduated from Pharmacy in June 2014. Three months later, I started my clinical pharmacy education as one of the first six postgraduate students of Hacettepe University Faculty of Pharmacy, Clinical Pharmacy Department Master’s Program. 

In the first year, we attended clinical rounds in internal medicine wards and had theoretical courses. During our bedside patient follow-up, we ran into an infectious diseases (ID) consultant who was following some of the ward patients. We introduced ourselves and made some recommendations for a few patients. Later on, the ID consultant started to ask if we had any recommendations. After a while, we participated in the ID ward rounds with the ID consultants Dr. Unal and Dr. Inkaya. This is how my first contact with infectious diseases started.

As the second year of my master’s education was close, I was in a hurry to decide on the topic and method for my master’s thesis with my advisor (Dr. Demirkan). Considering the cases I frequently observed in the infectious diseases ward and the framework of the literature review, we thought that drug-related problems in people living with HIV were an important issue and needed to be studied. We decided to perform this study in the outpatient HIV clinic. Thus, my master’s thesis, which will continue for the next one year in the infectious disease outpatient clinic, has begun. During this period, I had the opportunity to attend many meetings, seminars, conferences and congresses on infectious diseases held both in Hacettepe Hospitals and other institutions and cities. I improved myself in infectious diseases issues.

In infectious diseases, in addition to the patient and the drug, the microorganism is the third component of the disease. The decision and research processes require analytical thinking, and the diagnosis and treatment process is similar to uncovering a mystery (like Sherlock Holmes), which was exciting. My curiosity and enthusiasm still continue. 

After completing my master’s degree, I started my doctorate education in the same department. During the first two years of my doctoral education, I attended many lectures, seminars, meetings and conferences. I also participated in ward rounds in internal medicine wards, intensive care units, adult and pediatric infectious diseases and oncology wards. For my doctoral thesis, we formed an antifungal stewardship team. We demonstrated that a pharmacist-driven antifungal stewardship program improved the quality of antifungal therapy and patient care in an institution where the use of systemic antifungals is restricted to the approval of ID physicians. The publication can be found here.

About one year after completing my doctoral thesis, I started to work as an assistant professor in the same department. I participate in the training program of our residents and several clinical projects in collaboration with the Department of Infectious Diseases. 

2. What is the status of antimicrobial stewardship in Turkey, based on what you see in your practice

Antimicrobial stewardship in Turkey, like clinical pharmacy, is still an emerging field of science. Almost all of our hospitals have an infection control committee and a rational drug use committee, but many of them do not actively offer antimicrobial stewardship. The number of hospitals in our country with a structured and active antimicrobial stewardship team is quite limited. The concept of antimicrobial stewardship is relatively new in Turkey. In our hospital, local algorithms were developed, and the morning report application was launched in 2019. In 2021, the implementation of a comprehensive audit and feedback for antimicrobial treatments was initiated under the leadership of Dr. Uzun, and samples of antimicrobial treatments were selected and evaluated (still ongoing). Studies will be planned for de-escalation and iv-oral switch programs for antimicrobials.

In addition, an antimicrobial stewardship committee was founded in 2022. This committee has an infectious diseases physician, infection control physician, chief physician, chief pharmacist, clinical pharmacist (myself), infection control nurse, and participants from hospital administration. Meetings are held approximately every three to six months, and studies are carried out to solve the problems in antimicrobial management. 

The use of many antimicrobial drugs has been restricted, including cefepime, piperacillin-tazobactam, meropenem, vancomycin, teicoplanin, linezolid, daptomycin, voriconazole, posaconazole, amphotericin B. Infectious diseases physicians’ approval is required to initiate or continue treatment with these drugs. This restriction is actually a helpful tool for antimicrobial stewardship. 

In our country, important steps have been taken to limit the use of antimicrobial drugs not only in hospitals but also outside the hospital. Currently, it is not possible to buy antimicrobial drugs from community pharmacies without a prescription. However, despite these restrictions, our country still continues to be among the countries with the highest consumption of antimicrobial drugs among OECD countries. 

3. What are pharmacists in Turkey doing to improve antimicrobial stewardship? 

We know that one of the cornerstones of antimicrobial stewardship is pharmacists (especially clinical pharmacists). Particularly, the role of pharmacists in choosing the correct dose, dosing interval, treatment duration and administration route of drugs has been proven positively by many studies. Considering the pharmacokinetic and pharmacodynamic (PK/PD) properties of drugs, the continuation of the treatment process is very important for the efficacy and safety of treatments. Pharmacists provide significant benefits in PK/PD with the knowledge they have learned and transferred to clinical practice during bachelor and postgraduate education.

Currently, approximately 20 pharmacists attend postgraduate clinical pharmacy education in our department and also participate in ward rounds in our hospital. In addition to infectious diseases, the services attended to ward rounds are oncology, intensive care units, internal medicine, nephrology, rheumatology, hematology, psychiatry, neurology, pediatric intensive care and newborn. Clinical pharmacy interns in these services receive training and gain experience. In addition, they convey their suggestions about both the service-specific drug treatments and the other drugs of the patients to the service team.

Our hospital has a 10-bed ward for infectious diseases. The main activity of the department of infectious diseases is consultation-based. Our infectious disease specialists (Dr. Unal, Dr. Akova, Dr. Uzun, Dr. Metan, Dr. Inkaya, Dr. Dizman, and Dr. Sonmezer) provide consultation services to all units of the hospital, and approximately 200 patients are followed up and treated daily in the hospital. We try to ensure that each consultant ID team includes a clinical pharmacy student or graduate clinical pharmacist. Still, we can reserve 3-4 clinical pharmacists (including myself) for this place simultaneously in order to organize everyone’s rotations. I take part in the WhatsApp communication groups of the ward round teams that do not have a pharmacist, and I try to answer the questions asked in this group by calling.

As clinical pharmacists, our most significant contribution to antimicrobial doses in Hacettepe University Hospitals has been in the administration of loading doses and the administration of the first 24 hours dose for beta-lactams independently of renal function in critically ill patients with renal dysfunction (intensive care, sepsis, septic shock).

Although my workload has increased considerably due to my duties as a lecturer, researcher and other associations, a day as an infectious diseases clinic pharmacist is typically as follows:

• Reviewing the laboratory findings, clinical status and treatments of the patients followed and writing notes on the treatment process updates
• Participation in the clinical ward rounds
  • Notifying the ward round team of my recommendations about the patients
  • Answering questions of the team
  • Recommendations usually include:
  • Adjusting drug doses according to renal, liver functions and patient weight
  • Managing adverse effects of drugs
  • Managing drug-drug interactions
  • Therapeutic drug level monitoring and adjustment of drug doses according to TDM results
  • Duration of treatment
  • Drug selection according to guidelines
  • De-escalation
  • Switch to oral therapy

4. What is the most important lesson you have learned when it comes to antimicrobial stewardship? 

The most important thing I have learned from antimicrobial stewardship is that it helps me understand the importance and value of working with healthcare professionals from different disciplines. In the team, each stakeholder is a piece of the puzzle. I learned that we can handle things we cannot handle alone when we join our forces and resources. Each stakeholder involved in antimicrobial stewardship is truly a complement to the other, and the team would be incomplete without one.

Also, continuous self-development is an important part of this program because it is necessary to keep up with the very rapid changes in antimicrobial treatments and microorganisms. The war between microorganisms and humans, which has been going on for hundreds of years, continues without losing its warmth. As we develop new weapons against them, they continue to increase their defensive measures against these weapons. It is necessary to learn and remember the pharmacological properties, indications, adverse effects and other important characteristics of each new drug and transfer it to clinical practice. 

Most of the pharmacists in our department do not work directly on infectious diseases, but almost all of them are involved in a study on infection. In other words, antimicrobial management touches all pharmacists and even all health professionals at some point, even if they do not work primarily on infectious diseases.

5. What is the most pressing antimicrobial stewardship issue in Turkey today? 

I think the most pressing antimicrobial stewardship issue, including in our institution, is the inappropriate use of antimicrobials for surgical prophylaxis. The use of antimicrobials for surgeries that do not require prophylaxis, the wrong choice of antimicrobial drugs (unnecessary broad spectrum), the inappropriate dosage of antimicrobials, and the prolonged continuation of prophylaxis after surgery (sometimes even after the patient is discharged) are among the leading problems. 

Excessive use of carbapenems is another major problem because we have carbapenem-resistant Acinetobacter spp. and Enterobacterales in our hospitals. Antimicrobial agents that we can use to treat carbapenem-resistant microorganisms are very limited.

In addition, the lack of adherence to national and international guidelines/rules in selecting empirical treatment and the lack of an approach supported by local susceptibility data in selecting treatment are among our essential problems.

6. What do you predict the future holds for antimicrobial stewardship in Turkey? 

I am very hopeful about where our country is heading regarding antimicrobial stewardship in the future. There are several reasons for this hope. Awareness and knowledge levels of both health professionals and the community on antimicrobial resistance and rational drug use have increased considerably across the country. Now we’re going to start collecting the fruits of that. I believe that more concrete and strong steps can be taken hereafter. Participation in the meetings and training organized by ESCMID (European Society of Clinical Microbiology and Infectious Diseases) is relatively high in our country, and antimicrobial governance constitutes a large part of these meetings.

Similarly, the societies in our country have begun to devote more space to this issue. Experiences gained in international meetings are now being demanded and applied in our country as well. At least one session has been reserved for antimicrobial stewardship in our national congresses. In other words, preliminary information was provided, methods were determined, and even implementations started. We will start to get the results as soon as possible and discuss these results both nationally and internationally. 

As an important and pleasing development for clinical pharmacy, the Ministry of Health started to assign clinical pharmacy specialists to hospitals this year. One clinical pharmacist for every 100 hospital beds will be obligatory. I think that both clinical pharmacy services and antimicrobial management will improve in hospitals with new clinical pharmacists in hospitals.

References & Readings

ABOUT THE INTERVIEWEE

Emre Kara, MSc., Ph.D.

Dr. Kara graduated from the Inonu University, Faculty of Pharmacy and received his MSc. degree in 2016 and a Ph.D. degree in 2022 in Clinical Pharmacy at the Hacettepe University-Ankara. He has been working as a committee member in the Antimicrobial Stewardship Team at the Hacettepe University Hospitals. His main research interests are implementing clinical pharmacy/pharmaceutical care in infectious disease, intensive care and internal medicine. He has more than 30 articles published in SCI-e and ESCI indexed journals. He is currently an executive committee member of the TUKED (The Society of Turkish Hospital and Institutional Pharmacists), and member of the Turkish Society of Clinical Pharmacy (KED), European Society of Clinical Pharmacy (ESCP), International Association of Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT), The International Pharmaceutical Federation (FIP), Society of Turkish Hospital Infections and Control (HİDER), Turkish Society of Intensive Care Specialists (TUYUD) and Society of Turkish Infectious Diseases and Clinical Microbiology Specialization (EKMUD), Drug Researchers And Applicants Society. In addition, he serves as a working group member in the Turkish Society of Clinical Microbiology and Infectious Diseases (KLİMİK) Antibiotic Resistance Working Group and Society for the Clinical Microbiologists of Turkey (KLİMUD) Antimicrobial Stewardship Working Group.

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