A pharmacy's role in antimicrobial stewardship

Adrian Pittock , marketing director of Valley Northern explains why pharmacies are vital to help stem antimicrobial resistance (AMR). 

Antimicrobial stewardship strategies form a vital filtration system for our healthcare system but what many don’t consider is the vital role pharmacists play in promoting antimicrobial stewardship (AMS) to ensure the future of treatment for infection is sustainable.

Only certain objects can fit through a filter, such as a sieve or fine mesh. Liquid and small particles will pass through while other particles are stopped in their tracks. The same idea should be applied to prescribing antimicrobials. Certain people need, and therefore, should pass through the filter and receive this treatment, whereas others should be held back by the filter, to try other treatment options before resorting to antimicrobials.

Inappropriate use of antimicrobials, such as antibiotics, is the key driver in the spread of antimicrobial resistance, meaning that infectious microbes are no longer killed by the treatment. Additionally, with the discovery and production of new antimicrobials slowing down, there is greater concern for the sustainability of our current supply of treatment. Ultimately, steps need to be taken to preserve the antimicrobials we already have, which relies on a reinforced filtration system across the entire healthcare sector. 

National backing

The National Institute for Health and Care Excellence (NICE) defines antimicrobial stewardship as "an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness." It encompasses everyone in healthcare.

Professor Dame Sally Davies, the UK's former chief medical officer, said in the 2013 Chief Medical Officer's report: "Antimicrobial resistance poses a catastrophic threat. If we don't act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can't be treated by antibiotics." This alarming notion shows the importance of reinforcing the antimicrobial filter.

NHS England released a Commissioning for Quality and Innovation (CQUIN) in 2016, which was a financial incentive for pharmacies to reduce the indiscriminate or inappropriate use of antibiotics and review antibiotic treatment within 72 hours of administration. The CQUIN framework is intended to reward excellence, encouraging a culture of continuous improvement.

Rebecca Carter, a neuroscience specialist pharmacist based in Oxfordshire, believes a key strategy to achieving CQUIN targets is education. "I would advise focussed training in areas where over consumption of antimicrobials is high, to help them to identify areas in their practice where they may be able to use alternative agents, or increase their knowledge of antimicrobial stewardship."

Responsibility

Community pharmacists have some of the most significant opportunities to intervene and prevent unnecessary antimicrobial use, as patients often go to their community pharmacist first to seek expert advice. This is an opportunity to quash any misconceptions surrounding antimicrobials, as well as to educate the community on infection prevention strategies, including good hygiene, hand washing and vaccinations.

Pharmacy labels are available to affix to pharmacy bags to enhance existing communication strategies. Often, conversations in a pharmacy may be forgotten by the time the customer gets home, but pharmacy labels continue to get the message across for much longer. Labels such as 'complete entire course' will continue to speak volumes for as long as the label is visible. These labels resonate with customers as they take their prescription home, away from the busy pharmacy environment.

Additionally influenza vaccinations should be proactively marketed to vulnerable groups, saving on antimicrobial resources in the long-term. By simply sticking a label on pharmacy bags stating 'flu jabs are available here', this message is clear. Small changes such as using pharmacy labels can complement AMS efforts greatly.

Alternatives

If prescribers aren't sure if antimicrobials are required, delayed (back-up) prescriptions are an alternative to immediate antimicrobial prescribing. It encourages other treatment as a first step, but allows a person to access antimicrobials without another appointment if their condition gets worse. However, a survey in the British Medical Journal found that 72% of the general public were unaware of this delayed system.

With this delayed way of prescribing likely to increase further to complement AMS strategies, patients may require reassurance and advice from their pharmacists as they may have expected to receive antibiotics. With changes like this ongoing, community pharmacists not only need to keep up-to-date with the most recent guidelines, but create a pharmacy environment indicative to AMS. Pharmacies are an ideal place to display antimicrobial resistance and infection prevention leaflets.

When patients bring their antibiotic prescription to a pharmacy, this is an important opportunity for pharmacists to have discussions about what has caused the infection, alternative treatment and the risks of taking antibiotics. Additionally, pharmacists can act as reinforcement within the antimicrobial filtration system, asking questions that GPs may have already asked but are worth asking again. Questions could surround current medicines, hygiene and allergies.

All pharmacists can play their part in slowing down emergence of antimicrobial resistance and conserve precious healthcare resources. Without pharmacist's supportive efforts, a gaping hole would be present in a vital filtration system.