The main purpose of medicines labelling and packaging is to provide clear unambiguous identification of the medicine and the conditions for its safe use. This information, together with its format and style, is essential for minimising medication errors by enabling patients, carers and healthcare professionals to select the correct medicine, use it safely and to allow patients to understand and act on the information.
Inappropriate antibiotic use — defined as the deviation from directions provided to the patients by the prescriber, resulting in sub-optimal treatment — may result in exposing bacteria to sub-therapeutic plasma concentrations and/or into the environment, which are drivers of antibiotic resistance. An analysis published in January 2022 showed the 2019 global burden associated with drug-resistant infections was an estimated 4.95 million deaths, with 1.27 million deaths directly related to drug-resistant infections.
Previous work by the ABACUS II project explored the standardisation of both the physical appearance of the antibiotic capsule or tablet, as well as the packaging, to facilitate their identification and help efforts aimed at addressing inappropriate antibiotic use. For example, in some countries, antibiotics are sometimes sold loose so it asked whether a standardised physical appearance for antibiotics might improve recognition and to reduce abuse.
In partnership with the NHS England Antimicrobial Stewardship Lead for North-East and Yorkshire, the antimicrobial stewardship (AMS) research team at the University of Huddersfield designed a study aimed to explore the case to harmonise the physical appearance and/or standard messaging on antibiotic packaging as well as the impact of and barriers to standardising the physical appearance and messaging.
Following ethics approval being granted by the University of Huddersfield, two questionnaires were piloted to seek the views of both the public and pharmacists on these important issues. The definition of ‘harmonised appearance’ given on the questionnaires was ‘having a set appearance and similar design such as context, text, font and layout’.
The definition of ‘standardised messaging system’ given on the questionnaires was ‘a succinct set of information that explains the appropriate usage of antibiotics’. The final version was transferred to Qualtrics, an online questionnaire format and for a five-week period during January and February 2022, public questionnaires were distributed via posters with QR codes and through community pharmacies, other networks and social media. Pharmacist questionnaires were emailed to consenting pharmacists around Huddersfield, Doncaster, Rochdale, Dewsbury and Leeds working across sectors including community, hospital, GP practice and industry.
A total of 174 public responses and 40 pharmacist responses to the questionnaires were received.
It was found that inappropriate antibiotic use by the public was high. Out of 162 responses, 23.5% (n=38) admitted to saving leftovers for future use although only 2.5% (n=4) reported sharing antibiotics with others. Less than a quarter of the public (22.2%; n=36) disposed of unused or leftover antibiotics appropriately by returning them to the pharmacy. Nearly a third — 32.7% (n=53) — admitted they threw their antibiotics in the bin.
All pharmacists (n=40) thought inappropriate antibiotic use needed to be addressed. The majority of pharmacists (55.5%; n=20 of 36 responses) and the public (61.4%; n=86 of 140 responses) think a harmonised antibiotic appearance would reduce inappropriate use.
One proposed improvement — to put the word ‘antibiotic’ on the packaging — was favoured by pharmacists (38.3%; n=31 of 81 responses) and the public (35.3%; n=115 of 326 responses). Pharmacist respondents thought the greatest obstacle to harmonised packaging would be antibiotic manufacturers (38.9%; n=7 of 18 responses).
Most of the public (70.5%; n=98 of 139 responses) and pharmacists (85.3%; n=29 of 34 responses) thought standardised messaging would help reduce inappropriate antibiotic use. A leaflet outlining appropriate use was also favoured by pharmacists (41.1%; n=23 of 56 responses) and the public (47%; n=103 of 219 responses).
Nearly half of pharmacists (47.8%; n=11 of 23 responses) thought that multiple stakeholders (e.g. the Medicines and Healthcare products Regulatory Agency [MHRA]) and manufacturers, could be barriers to standardised messaging. Reasons given were because of the time and cost involved, the multinational nature of manufacturing and regulatory affairs, the collaboration required to reach a global agreement on a set of standards for packaging and the fact that different manufacturers use their brand to strengthen their corporate image.
Inappropriate antibiotic use by individuals who reuse leftovers or share their antibiotics may result in a treatment failure and could lead to increase antimicrobial resistance (AMR). Improvements in antibiotic packaging and patient information leaflets with appropriate disposal instructions could help minimise AMR. The limitation of this study was the low number of practice and industrial pharmacist respondents compared with community and hospital pharmacists.
Public and pharmacist respondents supported the wording ‘antibiotic’ on packaging and a standardised leaflet covering increasing adherence and appropriate disposal of leftovers. The next steps to progressing this work further is through evaluation and collaboration with regulators, manufacturers and other key stakeholders.
Gill Hawksworth, visiting professor, University of Huddersfield;
Mamoon Aldeyab, senior lecturer in Clinical Pharmacy, University of Huddersfield;
Sarah Frank, senior lecturer in clinical pharmacy (experiential learning), University of Huddersfield;
Philip Howard, antimicrobial stewardship lead, NHS England North-East and Yorkshire, and visiting professor, University of Leeds;
Aisha Aktar, Kian Fitzgerald, Amina Shah and Vicky Xie, MPharm students, University of Huddersfield.
- 1Best practice guidance on the labelling and packaging of medicines. Medicines and Healthcare products Regulatory Agency. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/946705/Best_practice_guidance_labelling_and_packaging_of_medicines.pdf (accessed Dec 2022).
- 2Gullberg E, Cao S, Berg OG, et al. Selection of Resistant Bacteria at Very Low Antibiotic Concentrations. PLoS Pathog. 2011;7:e1002158. doi:10.1371/journal.ppat.1002158
- 3Murray CJ, Ikuta KS, Sharara F, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022;399:629–55. doi:10.1016/s0140-6736(21)02724-0
- 4ABACUS II: Exploring the case for a standardised physical appearance of antibiotics. ABACUS. https://abacus-project.org/project/ (accessed Dec 2022).