Table 2 Summary findings

Pharmacist – The Custodian of Antibiotic Arsenal ^b

• Understanding of the Concept

• Pharmacists have portrayed limited understanding and awareness of the antimicrobial stewardship program (ASP) and WHO AWaRe classification system.

• Notably, only one participant could elaborate on the antibiogram concept.

The State of Antibiotic Utilization in Hospitals

• A System without Antibiotic Policy

• Empirical Prescribing – The Default Mode

• Broad-Spectrum Antibiotic Use – A Common Practice

• There is a growing trend among prescribers to prescribe broad-spectrum antibiotics empirically without susceptibility testing.

• The irrational practice emanates from hospitals’ lack of proper antibiotic use policies.

Availability Drives Prescribing, Prescribing Drives Availability

• Prescribers in public-sector hospitals are encouraged to prescribe antibiotics from the available stock, irrespective of the patient’s specific clinical needs.

• The available stock is eminently overprescribed and depletes shortly after it becomes available, thereby limiting the prescribing choice.

The Procurement Process

• Types of Procurement

• Budgetary Distribution

• Pharmacist’s Role in Procurement

• Demand Generation ^a

• The SML Phenomenon

• Pharmacists with 30% Autonomy ^a

• Lack of Inclusivity in SML ^a

• There are two broad types of procurement methods: bulk and local purchase (LP) procurement, with budgetary distributions of 75% and 25%, respectively.

• Bulk procurement proceeds under the Punjab Procurement Rules (PPR), 2014, using a Standard Medicine List (SML) that specifies medicines and their indicative quantities.

• The SML is considered a limitation in catering to hospitals’ medicinal demands, curtails pharmacists’ prerogative in setting demand, and lacks inclusiveness.

Rationality in Procurement

• Antibiotic Resistance Neglect: An Insouciant Procurement Process

• “Quantity, instead of Quality”

• Access Throughout the Year

• The procurement process does not consider microorganisms’ current resistance patterns or antibiotics’ local susceptibility profile.

• The procurement process primarily focuses on ensuring the availability of antibiotics in quantities that could serve the needs of the maximum number of patients receiving treatment within public-sector hospitals.

• The procurement process cannot provide consistent access to antibiotics throughout the year, especially in outpatient department (OPD) patients.

Clinical Pharmacist – A Potential Antibiotic Steward

• The pharmacist’s clinical input does not influence procurement decision-making.

• Many participants believed that clinical pharmacists can help rationalize the procurement process if involved effectively.

Challenges Besetting the Procurement Process ^b

• Budgetary Constraints

• Irrational Use of Alternative Antibiotics ^a

• Inability to Procure - The SML Factor

• Procedural Delays Affecting Supply Chain

• Hospital Pharmacist - An Administrative Role

• Irrational Prescribing Affecting Access to Antibiotics

• Antibiotics - Drugs of Meagre Importance

• Unavailability of Susceptibility Testing

• Perception Rather Misconception about the Resistance Pattern

• The most pervasive challenge facing health facilities across primary and secondary healthcare department (PSHD) is budgetary constraint, which has a deleterious impact on access to antibiotics and culminates in the irrational use of alternative antibiotics, thereby augmenting antibiotic resistance.

• The limitations presented by the SML and procedural bottlenecks of the procurement process hinder access to antibiotics.

• Overuse of antibiotics and empirical prescribing without susceptibility testing are other major impediments.

• Pharmacists are overburdened with administrative tasks; hence, they offer minimal patient-centered care.

• Policymakers hold a meager understanding regarding the clinical and economic ramifications of antibiotic resistance associated with the misuse of antibiotics.

Recommendations for the Future ^b

• Nurturing the Clinical Role of Pharmacist

• Acceptance in the System

• Clinical Pharmacists: Playing a Part in Procurement

• “Real-time (Resistance) Data”

• Strengthening Clinical Pharmacists with Data

• Infrastructural and Budgetary Requirements

• Implementation of Antibiotic Stewardship Program

• Antibiotic Stewardship – The Vertical Program ^a

• Clinical Audits across the Facilities

• Stewardship Through Procurement

• Continuous Medical Education

• Adhering to WHO’s AWaRe Classification

• Autonomous Procurement

• There is a need to implement an ASP as a vertical program to optimize antibiotic use.

• Antibiotic procurement should be conducted under the umbrella of ASP utilizing a data-driven approach, where susceptibility patterns and local epidemiology must be considered significantly.

• Strengthening the clinical pharmacist’s role through specialized training and fostering acceptance within the system should be the foremost goal.

• Adequate budgetary support for microbiological infrastructure would equip clinical pharmacists with the necessary resistance data to guide antibiotic procurement at the hospital and secretariat levels.

• Integrating the WHO AWaRe system with SML would facilitate rational procurement and subsequent antibiotic consumption within hospitals.