National Antimicrobial Stewardship Program in Saudi Arabia; Initiative and the Future

General Administration of Pharmaceutical care start the implementation of pharmacy strategic plan in 2012. More than thirty national program of pharmacy practice started during the period 2012-2015. National Antimicrobial stewardship program among them. The program highly demand at our county because of poor perception of antibiotics and misuse of antibiotics, and poor adherence of antibiotics guidelines. The program consisted of several committee at MOH level, regional, peripheral hospital and primary care centers. Antimicrobial stewardship guidelines, policy and procedures, and antimicrobial stewardship key performance indicators to follow up the program. The program started at MOH hospitals; expand to cover primate care centers and private’s institutions. National Antimicrobial Stewardship program is crucial practice at health care organizations to prevent antibiotics misadventures, improve clinical outcome of treating infections disease and avoid additional economic burden on health care system in Saudi Arabia


Introduction
In 2013, general administration of pharmaceutical care at Ministry of health in Saudi Arabia started pharmacy strategic plan [1]. The plan contained five strategic goals, with seventeen initiatives and eighty-three projects. Those projects consisted of several pharmacy practices and clinical pharmacy programs [2]. National Antimicrobial stewardship program among them, thus project activated in 2014 at overall hospitals [3]. The Central Committee of Antimicrobial stewardship headed by the author, it founded to organize the program in 2013. The committee consisted from several memberships including but not limited to medical doctor, are presentative from infection control, are presentative from the laboratory, ID clinical pharmacist from different regions. The committee established strategic of the program for next five years started from local MOH hospitals at Riyadh city then expanded to other areas. Within two to three years privates sectors should be included as explored in Table 1.

Antimicrobial Stewardship Program
There are several potential problems found at local country stimulate the high demand of antimicrobial stewardship system. For instant; dispensing antibiotics without a prescription and that found 77.6% of 327 community pharmacies dispensed antibiotic without a prescription and break pharmacy law in Saudi Arabia, and another cross-sectional study showed that is 51% of 285 medication dispensed without prescription [4,5]. Some patients had a poor perception of using antibiotic. In cross section study of a survey distributed to more than 400 patients. The study showed that is more than 50% of the patient not aware of dangerous of antibiotics utilization and more 50% recommended antibiotic to their families, 23% used antibiotic for two days only, and 19.4% admitted to taking antibiotics without prescription to their medical illness [6].
Also increasing of resistance of microorganism with different of isolates, the type of heath care service, and regions all over Saudi Arabia and even during mass gathering Hajj period [7][8][9][10][11][12][13][14][15]. The high resistance increases the economic burden on health care system by 20-60% [16]. From the previous problem, most of the countries in the world start to establish antimicrobial stewardship program [17][18][19]. There are some hospitals in Gulf countries including Saudi Arabia applied this program and they found are duction of inappropriate prescribing antibiotics, reduction healthcare associated infection and decreased the length of hospitalization period and mortality metric, and reduction of antibiotics cost [20]. In the local studies should reduction of antibiotics, reduction of multidrug resistance microorganism, increase compliance of antibiotics guidelines in adults and pediatrics population [21][22][23][24].

Antimicrobial Stewardship Program in Kingdom of Saudi Arabia
In late 2014, a Central Committee at MOH sent a memorandum to start the Antimicrobial stewardship program at very hospitals in Kingdom of Saudi Arabia with formulation antibiotic committee and the antibiotic team as explored in Table 2 and memo activated in early 2015. Others MOH hospitals or primary care centers and privates hospital or community pharmacies will start within 1-2 years according to the strategic plan. The central committee published Antimicrobial stewardship manual for the program. The program consisted of empirical therapy of common infectious disease in Saudi Arabia, data collection form of some selected antibiotics, sensitivities pattern of common bugs from general microbiological, restricted and controlled antibiotics, policy and procedures of prescribed antibiotic. Maybe the unique advantages of program manual were the conversion of general guidelines to antibiotic physician order. Each disease has a particular form of identified organism, and option listed of first choice antibiotic, second line option, and third line option, the physician has to follow the sequence options. All physician orders will convert as computerized physician order entry (CPOE) in the nearest future. If a medical doctor wishes to prescribe other antibiotics not listed in the form, justification of non-adherence should mention. Also, the program contained two-type key performance indicator. One administration KPI adopted from center disease control the USA. Other clinical KPI adopted from the literature and some application examples as explored in Table 3. [25,26]. Those indicators to follow up the implementation of the program. The central committee of the program invited all regions to formulate regional Antimicrobial committee with same type members and qualifications of the central committee. All parts formulated them. Then educational awareness workshop had conducted to them. Then all regional committees conducted an educational program for their peripheral hospitals and primary care centers in their regions. The majority of hospitals formulated Antimicrobial hospital committee and stated implement the program. All the program related issues started in January 2015.

Monitoring Antimicrobial stewardship Medications and Use
Antibiotics Consumption

Open Access Journal of Surgery
At the first step of program implementation, the central committee requested antibiotics consumption and resistance pattern of bugs before and after starting the program. Still the program as an early stage in the process of data collecting. Several challenges faced the program including seldom of Human Resources Infections disease physicians, clinical pharmacist, and microbiologist. We try to replace ID specialist by consultant internal medicine and replace ID clinical pharmacist by trained pharmacist. Other challenges were using of international guidelines for treating infections disease. Unfortunately, we do not have basic of epidemiological data of bug resistance pattern, the central committee decided to apply the international guidelines and work parallel of data collection of drug resistance, then after one year of program implementation the central committee will revise the international guidelines and make local Saudi guidelines.

Conclusion
The antimicrobial stewardship program expand in the coming years to cover all MOH, government institutions, and private sectors with properly gets all the application advantages decrease resistance pattern of the organism, decrease antibiotics usages, and saving of additional cost.