Pharmacists as antimicrobial stewards: ‘the bug stops here’

During a chance conversation at a face-to-face conference a few years ago, I was asked whether I was ‘anti-antibiotic’ or ‘pro-antibiotic’ by another pharmacist, and I have never quite worked out if they were being serious or not. Clearly working as an antimicrobial specialist, I am captivated by the benefit the world gets from antibiotics — what other drug category has such a wide range of uses in so many sectors and clinical specialities? 

Antimicrobial stewardship (AMS) is one of those roles that people outside clinical pharmacy do not fully understand until you explain the stakes. We must get the balance right: too much use and antimicrobial resistance (AMR) and healthcare acquired infections surge, not enough use and sepsis deaths increase. It is all about the right mix of treating the patient as best as we can, while not overdoing it. Every dose of broad-spectrum antibiotics is a small vote in favour of a world where our antibiotics stop working — that’s not hyperbole; that’s evolutionary biology — so we must make them count. 

Uncertainty of the invisible

The central problem of antimicrobial use is that a patient has presented acutely unwell and an infection might be the cause. From the cluster of signs and symptoms present, we only have an idea of whether it is worth starting antibiotics; however, until pathology and radiology results are received, all we have is a provisional and uncertain diagnosis. This is often compounded in an ageing population and in patients with long-standing conditions having unusual infections or not responding to antibiotics in the way that is typical for other adults.

In my own practice and experience, the acuity is ever-increasing, with justifiable demand increasing for antibiotics – hence the need to ensure that those who do not need antibiotics leave them for those that do.

A crisis is here

The spectre of AMR has gone from haunting antimicrobial experts to being something we see repeatedly in soap operas. Infections from resistant pathogens — from urinary tract infections from pathogens excreting antibiotic-busting-enzymes requiring carbapenems, to chest infections not responding to beta-lactams — are surging^​1,2​. Thankfully, there are new options launched in recent years that go some way to resolve these severe pathogens but as practitioners and antimicrobial stewards, we still need to delay resistance for as long as possible to enable further drug development.

Preventing harms from antibiotics

Antibiotics should only be used for as long as they are needed. Great evidence is coming out showing that the arbitrary seven-day course length is not always right^​3,4​.

In the same vein, we should be asking if we can get hospital patients off IV antibiotics sooner. The result would be reducing the risk of phlebitis from IV cannulas, less tying the patient to a drip stand, less time spent mixing up antibiotics, less single-use plastics being used then burnt^​5,6​. All of this would be unnecessary if the patient has started to respond; but wasteful on many levels if oral antibiotics do the job.

Great work is being done in terms of making blood cultures as reliable as possible — through ensuring they’re taken right, processed effectively and the results available to the right person quickly^​7​. Do them wrong and they are useless; do them right and you can optimise the antibiotic choice or hopefully stop them when the test is negative.

Penicillin allergy delabelling — dislodging decades-old ‘dodgy’ data through detailed discussion with the patient^​8–10​ — means that we do not have to use less effective, more toxic antibiotics out of paranoia of an anaphylactic episode. While it can be nerve-wracking to wait for results of a test-dose, getting patients on to flucloxacillin and amoxicillin, instead of teicoplanin and levofloxacin, benefits us all. It is no longer acceptable for years of unnecessary exposure to broader-spectrum alternatives, with all the resistance and adverse-effect burden that comes with them. 

Antibiotic enablers

Stewardship teams are not there to police rigid guidelines but to ensure that antibiotics are used with care and responsibility. Ultimately, we must respect that the clinical team has to balance both the needs of the patient in front of them against the need of everyone in the future. We have enormous respect for the clinical experience of our colleagues, while gently — or not so gently — nudging them to do the right thing. AMS pharmacists learn quickly to be the person who gently, persistently, diplomatically holds that line.

But of course, AMS is a team game. We can all play our part in getting the basics done right — clear diagnosis; right confirmatory teams; fast antimicrobials when patients are septic; thorough review within 48–72 hours to decide the duration that is going to give the friendly bacteria of the patient’s microbiome the least damage.

Antimicrobial resistance is the slow-motion crisis of our era. It does not make headlines the way a pandemic does, but the projections are sobering. AMS teams are not the whole solution — not even close. But we are part of it and, on the days when the work feels like shouting into the void, I try to hold on to that.

The bug stops here — or at least, with our help, it stops spreading quite so easily. That is the wonderful world of AMS.

This article is brought to you as part of a collaboration with the UK Clinical Pharmacy Association (UKCPA).

The views expressed in this article are those of the author and are not attributed to any organisation.

The UKCPA is a member association for clinical pharmacy practitioners that encourages, supports and promotes advanced practice in pharmacy. 

To discover expert-led training, resources for clinical pharmacy practice and access ongoing support from our community of practicing clinical experts, visit the UKCPA website or contact via email.