Community pharmacy vital to tackling antimicrobial resistance, summit hears

Community pharmacies across England should be commissioned to manage minor infections to help the NHS reduce its dependence on antibiotics and halt rising resistance, a conference on the issue has heard.

A nationally commissioned minor ailments scheme would allow pharmacists to manage patient expectation around the need for antibiotics and improve appropriate use of these medicines, according to Philip Howard, consultant antimicrobial pharmacist at Leeds Teaching Hospitals NHS Trust.

He said this approach should be introduced as part of efforts to halt the rising levels of antibiotic prescribing in the NHS, which have been linked to increased resistance.

The call came at a summit on antimicrobial resistance hosted by the Royal Pharmaceutical Society (RPS) at its London headquarters on 6 November 2014, where experts from across the NHS met to discuss steps to protect the nation’s stock of effective antibiotics.

At the event, the leadership organisations for pharmacists, GPs, hospital doctors and nurses – including the RPS – called for the NHS to set annual targets to reduce antibiotic use to 2010 levels. Antibiotic use in the NHS has risen by 6% since 2010, while overuse of antibiotics is linked to a rise in microbial resistance.

The RPS recently launched a campaign calling on NHS England to introduce a national minor ailments scheme.

Howard, speaking in his capacity as an RPS spokesman, said: “We have lots of community pharmacies out there; they are open long hours each day and often at the weekend. Patients who present with minor ailments — we know it’s 5% of GP consultations and 3–8% of emergency department consultations — let’s get them into community pharmacy, where there are no antibiotics sitting on the shelves.

“They can deal with some of those minor infections that don’t need antibiotics, and refer the ones that do need treatment to the most appropriate place to deal with it.

“What we need to do is look north of the border, where it’s standard in Scotland to have minor ailment schemes. Let’s utilise all community pharmacies out there: I think that would make a big impact.”

He also questioned whether the NHS should start to add indications to prescriptions, to allow dispensers to check the appropriateness of antibiotic prescriptions against best practice guidelines.

Isabel Boyer, lay member of the Antimicrobial Resistance and Healthcare Associated Infections (ARHAI) advisory committee, said community pharmacies had “a huge role to play” helping families manage minor infections before they contact other primary care services such as their GP.

She said the NHS needed to give “clear, simple messages” about the appropriate use of antibiotics, because awareness of when and how best to use the medicines was low among the public.

A perfect storm

John Watson, deputy chief medical officer, said gloomy predictions about the problems that widespread antimicrobial resistance would cause the health service were “warranted”.

“This is, as others have described, a perfect storm,” he said. “A whole series of processes and procedures that we now take for granted in medicine would become either very difficult or impossible. The kind of antibiotic cover that’s used to enable bowel surgery and some other kinds of surgery to go ahead; the cover that makes chemotherapy for malignancies and for people having immunosuppression in association with transplantation — those things are threatened by this rise in antimicrobial resistance.”

He spoke of the need to commit to “three Ps” — prevent infection, preserve antibiotics, and promote the development of new antimicrobials, new approaches to infection management and better and easier rapid diagnostics.

Chris Butler, a GP in South Wales and professor of primary care at the University of Oxford, said: “Every year you can see an increase in antibiotic resistance. This is a bit like the climate changing before our eyes: this is the global warming of medicine, and it’s happening in real time.

“There’s a big impact on health services’ resources, which are already under tremendous pressure,” he said. “It adds to the cost of healthcare.”

Butler said the response from primary care to these issues was “confused”. “There’s huge variation in both whether to prescribe and what to prescribe. Wherever we see that kind of variation, it’s a signal we need better research, better evidence and better guidelines,” he said.

Professional education needed

Butler said the reasons why GPs prescribe antibiotics were complex: GPs often say they know the evidence, but find it is difficult to implement in practice. In addition, some question whether there is a correct balance between the needs of the individual patient in front of them and those of society. The lack of rapid diagnostics, pressures on general practice and fear of medico-legal problems also complicate the picture, he said.

But, he added, it is important to understand that the interests of the patient are the same as the interests of society: to preserve the effectiveness of antibiotics by using them sparingly.

Michael Moore, RCGP national clinical champion for antimicrobial stewardship, said: “A large part of the problem is in primary care: 80% of antibiotics are prescribed in primary care. GPs have to take ownership of the problem.”

Peter Davey, lead clinician for clinical quality improvement at Dundee’s School of Medicine, said professional behaviour change around antibiotic use was key in secondary care.

He also spoke about the need for multidisciplinary teamwork to improve antibiotic use, and the importance of professional education. “We need to profoundly rethink professional education; learn in practice, learn in teams, and see education as a culture change intervention,” he said.