Antimicrobial stewards promote judicious use of antibiotics to preserve their effectiveness
. All healthcare professionals, including pharmacy professionals, should consider themselves stewards who can make important interventions in the fight against antimicrobial resistance (AMR)
Community pharmacy needs to embrace antimicrobial stewardship (AMS). During their contacts with the public, pharmacy teams should seize the opportunity to educate their patients on preventing illness; explain why antibiotics are not always prescribed; show patients how to effectively manage self-limiting infections that do not require antibiotics (such as cold and flu); advise when to contact a health professional; and explain the importance of antibiotic adherence and not sharing prescribed antibiotics with others.
Use only when needed
The rise of antibiotic resistance is causing treatments around the world to fail, including in the UK. Drug-resistant infections already lead to 700,000 deaths worldwide every year, and it is estimated that AMR could cause 10 million deaths per year by 2050 if we do not act now
Without antibiotics, we cannot treat simple chest infections or urinary tract infections (UTIs), nor can we ensure that life-saving treatments, such as organ transplants and chemotherapy, or even childbirth, remain safe. Using antibiotics when they are not necessary jeopardises our healthcare, so patients must understand that they should not take these precious medicines when they do not need them.
In 2010, results of a meta-analysis showed that people who are prescribed an antibiotic in primary care for a respiratory infection or a UTI have increased risk of developing bacterial resistance to that antibiotic
. This effect is greatest in the month immediately after antibiotic treatment, but the risk may persist for up to 12 months.
The pharmacy team has an essential role in discouraging inappropriate use of antibiotics that could contribute to antimicrobial resistance
These results emphasise the important message that when patients take antibiotics for self-limiting infections, in which they are unlikely to be effective, there are unwanted consequences. Even the use of narrow-spectrum antibiotics, such as amoxicillin, can increase resistance to other antibiotics. It is critical that antibiotics are used only where they will be beneficial, to reduce unnecessary harm to patients.
Cold and flu symptoms are most likely caused by viral infections on which antibiotics have no effect. Instead, they can usually be self-managed, without seeing a doctor for prescribed medicines, if the patient has no co-morbidity. The pharmacy team has an essential role to discourage inappropriate use of antibiotics that could contribute to AMR; promote prevention and self-care; and deliver health messages, such as the expected duration of symptoms (i.e. that cold symptoms usually start to relieve within seven days, although a cough may persist for a few weeks
). Providing this information helps to manage the patient’s expectations of the normal symptom duration for self-limiting infections.
Stewardship in community pharmacy
Sharing advice on preventing and controlling infection is an important responsibility of pharmacy teams, alongside ensuring appropriate antibiotic prescribing.
Community pharmacy teams can increase the public’s awareness of antibiotic resistance. Public Health England (PHE)’s ‘Keep Antibiotics Working’ national campaign supports efforts to reduce unnecessary prescriptions. Resources, including posters and leaflets that can be displayed and provided to customers, are available through the PHE Campaign Resource Centre. These materials raise awareness of the issue, explain the risks of taking antibiotics when they are not needed (such as reducing their effectiveness in future, side effects or infection), and reduce expectations for antibiotics.
World Antibiotic Awareness Week and European Antibiotic Awareness Day in November each year provide a good opportunity to run a local awareness campaign within community pharmacy. This campaign could involve something as simple as displaying the Keep Antibiotics Working posters, having antibiotic quizzes or crosswords available for patients to complete while they are waiting for their prescriptions, or carrying out an antibiotic audit.
Pharmacy teams should also support the uptake of flu vaccination, either by offering their patients a flu service or signposting them elsewhere. The flu vaccine is recommended for people aged 64 years or over, who are pregnant, or who have certain medical conditions
Research suggests that inappropriate prescribing could result from patients who expect or demand antibiotics without understanding that they may not be effective for their illness
. Pharmacy teams can tackle this lack of understanding by giving advice when customers visit the pharmacy feeling unwell with cold or flu-like symptoms.
Where appropriate, staff can recommend medicines that may alleviate symptoms or pain; provide self-care advice, such as getting plenty of rest and emphasising the importance of drinking water; and explain that fever is a sign that the body is fighting infection, and that it usually gets better by itself. Paracetamol can be recommended if the patient’s fever makes them feel uncomfortable. Patients should be reminded to throw away their used tissues and wash their hands frequently to avoid spreading their infection.
This process is known as the six ‘R’s
- Reassurance — reassure the patient about the infection;
- Reasons — explain why antimicrobials are not normally necessary;
- Relief — suggest suitable over-the-counter preparations for symptom relief — for example, paracetamol for pain;
- Realistic — give a realistic timeframe during which the patient can expect to start feeling better;
- Reinforce — provide written information to support the advice that has given;
- Rescue — explain when to seek further help.
Offer advice on what to do if the symptoms get worse. Some symptoms may suggest serious illness and should be assessed urgently, such as the skin feeling cold or having a strange colour, or developing an unusual rash; confusion, slurred speech or drowsiness; difficulty breathing (including breathing quickly, turning blue around the lips and the skin below the mouth, or the skin between or above the ribs getting sucked or pulled in with every breath); severe headache and vomiting; chest pain; drooling or difficulty swallowing; coughing up blood; feeling a lot worse; and symptoms lasting much longer than usual (in the case of a common cold, more than three weeks).
If a serious ailment or a bacterial infection is suspected, the patient should be reffered to the most appropriate nearby clinical service — for example, NHS 111, out-of-hours GP, walk-in centres, or to A&E if it is an emergency.
Community pharmacy needs a culture shift towards AMS. As well as checking appropriate antibiotic prescribing and dispensing antibiotics, pharmacies also have a duty to promote cold and flu prevention, advise on good self-care without antibiotics, and raise patients’ awareness that antibiotics aren’t needed for self-limiting conditions.
Pharmacy teams can commit to these AMS efforts by becoming ‘antibiotic guardians’. Individual staff members can sign up at https://antibioticguardian.com/ and pharmacies can register at http://antibioticguardian.com/organisations/. Display the certificate in the pharmacy, share the message on social media using #AntibioticGuardian and tell patients that they can pledge to join the fight against AMR too.
- Health Education England has bite-sized e-learning sessions on antimicrobial resistance at: https://www.e-lfh.org.uk/programmes/all-our-health/
- Public Health England’s TARGET Antibiotics Toolkit provides free resources and training for healthcare professionals in community and general practice at: https://www.rcgp.org.uk/TARGETantibiotics
Source: Diane Ashiru Oredope
Diane Ashiru-Oredope, lead pharmacist, Antimicrobial Resistance (AMR) and Healthcare Associated Infections Division, National Infection Service, Public Health England; committee member, United Kingdom Clinical Pharmacy Association Pharmacy Infection Network; member, Royal Pharmaceutical Society Expert Advisory Group on AMR; global AMR lead, Commonwealth Pharmacists Association.
Declaration of interests: Ashiru-Oredope has not received any funding to author this opinion piece.
Acknowledgements: Tracey Thornley, honorary professor in pharmacy practice, University of Nottingham; Rosie Allison, research project support officer, Public Health England; and Cliodna McNulty, joint clinical lead, Primary Care and Interventions Unit, Public Health England are acknowledged for reviewing this piece.
Ravi Sharma, director for England at the Royal Pharmaceutical Society and senior general practice pharmacist, said: “Pharmacists who help people to self-manage their cold and flu symptoms play a really important part of our prevention and antibiotic stewardship agenda. Pharmacists should be taking the lead on this as a profession. They are the most accessible point of healthcare in the NHS; you don’t need an appointment to see a community pharmacist, or their teams, for advice and support. I think it’s crucial that we empower pharmacy teams to support people in their communities to self care.”
Aimi Dickinson, pharmacist professional support manager at Boots, said: “It’s brilliant that we’re putting the antimicrobial stewardship agenda front and centre in the management of cold and flu. When it comes to helping patients to self care, I think we do the basics really well, but there’s always room for improvement. Sometimes conversations about cold and flu can feel a little bit transactional, because of their nature, but we must not downplay their importance — they offer real value to patients.”
David Russell, pharmacist manager at Well and chair at Community Pharmacy Sheffield, said: “One of the things we need to change is patients’ perceptions of the help they can get in the pharmacy, and when they don’t need antibiotics. During our roundtable discussion we heard that only 11% of patients come to the pharmacy for advice on cold and flu. We need some patient education over self care. We need to train the whole team to deliver a clear, consistent message and help patients to understand how long these conditions are likely to last, and how long until they start to feel better — without antibiotics.”
The Pharmaceutical Journal, September 2019. doi: 10.1211/PJ.2019.20206996
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