Antimicrobial resistance is an increasing public and global health issue so, as such, it is important for all pharmacists to take action
Diane Ashiru-Oredope MPharm DipClinPharm MRPharmS PhD
Pharmacist Lead; Antimicrobial Resistance Programme,
Public Health England, London, UK
As pharmacists we are very aware of our lifesaving tools: antibiotics. Since they were introduced 70 years ago, the number of deaths from infections and infectious diseases has dramatically reduced. Not only are antibiotics important for treating infections such as pneumonia, meningitis and tuberculosis, which commonly killed prior to their discovery, antibiotics are also essential to prevent infections during other treatments such as cancer treatment, caesarean sections and many surgeries.
Although these lifesaving drugs are now commonly available, we may once again enter an era where simple infections can kill. This is because antimicrobial resistance continues to rise across the world.1 The antimicrobial resistance (AMR) problem is compounded by the fact that the discovery of new antibiotics is at an all-time low.
The consequences of increasing antibiotic resistance are dire. In Europe alone 25,000 people already die each year because of antibiotic resistant bacteria.2 When we consider that deaths from road traffic accidents in EU countries is recorded as 48,000 per year,3 this is a huge number to die from antimicrobial resistance. Apart from the tragic human cost, the healthcare expenses and productivity losses amount to over €1.5 billion. These numbers are believed to be an underestimate.4
In addition to public health issues, a meta-analysis by Costello et al in 2010 showed that individual patients who are prescribed an antibiotic for a respiratory or urinary tract infection can develop bacterial resistance to that antibiotic, which may last for over 12 months after the antibiotic was prescribed.5 The more often a patient has a course of antibiotics, the more opportunities patient’s bacteria have to develop persistent resistance or resistance to multiple antibiotics.5
Tackling antimicrobial resistance is important because antimicrobial resistance:6
- Increases mortality; the death rate for patients with serious infections treated in hospitals is about twice that of patients with infections caused by non-resistant bacteria.
Antibiotics have reduced community-acquired pneumonia (CAP) mortality from 38% to 12% (co-morbidities/elderly); young, otherwise healthy <1% compared to 10%; cellulitis <1% compared to 11%.7,8
- Hinders the control of infectious diseases.
- Reduces the effectiveness of treatment, allowing infections to persist and increases the risk of spreading resistant microorganisms to others.
- Threatens a return to the pre-antibiotic era where infectious diseases can become untreatable and uncontrollable or simple infections from cuts and bruises once again kill.
- Increases the costs of healthcare, economic burden to families and society.
More expensive therapies are required and antimicrobial resistance leads to longer durations of illness and hospital stay, increased use of intravenous antimicrobials, often in hospital rather than on outpatient parenteral antibiotic therapy (OPAT) schemes, and due to this an increase cost to society due to time off work.
- Jeopardises the healthcare gains that have been made to society. Achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised.
As well as antimicrobial resistance, antibiotics can have severe adverse effects. An important one to be aware of is the risk of antibiotic-associated diarrhoea that could be caused by Clostridium difficile (C. difficile). It is important that pharmacists are familiar with the symptoms of this infection, the antibiotics more commonly associated with it and the guidelines on its diagnosis and management.9 Ciprofloxacin (quinolones), co-amoxiclav (broad spectrum penicillins), clindamycin and cephalosporins (third generation), commonly referred to as the ‘4Cs’, are known risk factors for C. difficile infections. As pharmacists, it is important that patients with diarrhoea that could be due to C. difficile following antibiotic treatment are not sold or advised to take antispasmodics, such as loperamide. These agents can increase the severity and length of disease due to the prolonged contact time of C. difficile toxins in the colon.6
While we cannot eradicate antibiotic resistance, everyone (this includes the government, professional bodies, healthcare staff and the public) can take some key steps to limit the risks. It is the responsibility of all healthcare professionals to address the in appropriate use of antibiotics.
The urgency, scale of the problem and importance of reducing the threat from antimicrobial resistance is highlighted in the global AMR report by World Health Organisation (WHO).10 To achieve this goal, the global action plan sets out five strategic objectives:
- To improve awareness and understanding of antimicrobial resistance.
- To strengthen knowledge through surveillance and research.
- To reduce the incidence of infection.
- To optimise the use of antimicrobial agents.
- Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Across the European region, 53 countries adopted a strategic action plan on AMR in 2011. The seven key areas for action identified include:
- Strengthen intersectoral coordination.
- Strengthen surveillance of antibiotic resistance.
- Promote rational use and strengthen surveillance of antibiotic consumption.
- Strengthen infection control and surveillance in healthcare settings.
- Prevent emerging resistance in the veterinary and food sectors.
- Promote innovation and research on new drugs.
- Improve awareness, patient safety, and partnership.
Individual countries also have specific/tailored national strategic plans based on the action plans set by the WHO. For example the UK published its Five-Year Antimicrobial Resistance Strategy in 2013.11 This strategy sets out the government’s plan to tackle antimicrobial resistance. Seven key areas for action were identified. These include:
- Improving infection prevention and control practices.
- Optimising prescribing practice.
- Improving professional education, training and public engagement.
- Developing new drugs, treatments and diagnostics.
- Better access to and use of surveillance data.
- Better identification and prioritisation of AMR research needs.
- Strengthened international collaboration.
In September 2014, the public health agency in England, Public Health England, launched a new campaign for healthcare professionals and members of the public to tackle antimicrobial resistance – Antibiotic Guardian.12 This was launched as part of plans for European Antibiotic Awareness Day in collaboration with the Department of Health, Veterinary Medicines Directorate of the Department for Environment Food & Rural Affairs (DEFRA), devolved administrations, professional bodies and members of the public. Although raising awareness had been heightened over the years, this campaign was focused on increasing engagement rather than awareness alone.
The campaign used the behavioural insights methodology implementations intention model ‘if-then’ to formulate tailored pledges for different societal groups. It calls on healthcare professionals and members of the public to choose a pledge promoting how people can individually make better use of antibiotics and help save these vital medicines from becoming obsolete. By choosing a pledge on www.antibioticguardian.com and registering, the individual becomes a registered antibiotic guardian.
European Antibiotics Awareness Day (EAAD) is a Europe-wide initiative that takes place annually on 18 November. The aims of EAAD include:
- Educate and inform patients and healthcare professionals about the appropriate use of antibiotics.
- Motivate healthcare professionals to prescribe antibiotics more appropriately.
- Educate and inform patients and healthcare professionals about the importance of preventing resistance to antibiotics.
The campaign matters because we have to stop the overuse and misuse of antibiotics, which is leading to many bacteria becoming resistant to these essential medicines. It is important that both healthcare professionals and members of the public know that antibiotics are already becoming ineffective and everyone needs to work together now to slow the rate of resistance in order to preserve these key medications.
This problem affects everyone and everyone can do something. As a pharmacist, you can take a simple personal action by visiting the Antibiotic Guardian website and choosing one pledge that you will carry out to help save these vital medicines.
In addition, there is a video on the website which can be shared with family, friends, customers and patients to educate on antimicrobial resistance.
As health professionals, alongside making your Antibiotic Guardian pledge, you can participate in European Antibiotic Awareness Day by sharing relevant antimicrobial resistance information and resources from your country with other healthcare professionals and members of the public.13
The public also have a key role in reducing their demand for antibiotics. A recent study found that nearly all general practitioners feel pressurised by patients asking for antibiotics for self-limiting infections such as colds, flu, coughs and sore throats even when not needed at all.14 Hence, educating patients is important.
Other simple actions that pharmacists can take as antibiotic guardians are:
- Counsel patients on appropriate antibiotic use when dispensed.
The FRAIS mnemonic can help:15
F Finish the course as prescribed
R Regular intervals (for example, six-hourly, eight-hourly, etc.)
A After, with or before food
S Side effects
- Counsel patients on antibiotic resistance, as appropriate.
- Counsel patients on adverse effects of antibiotics, in particular what to do if diarrhoea occurs.
- Recommend symptomatic therapy for non-vulnerable patients with self-limiting illness.
- Staying up-to-date and following antimicrobial prescribing guidance.
- Having a copy of the local guidelines on antibiotic prescribing available within the pharmacy.
- Encouraging and signposting patients in the ‘at risk’ groups to have the seasonal influenza vaccination — maximising uptake of the vaccination has been shown to decrease use of antibiotics by up to 10 prescriptions per 1000 population.15
- Encouraging regular hand hygiene with the six-step technique to prevent spread of infections.
- Encouraging other lifestyle choices that help to keep the immune system healthy, such as smoking cessation and healthy eating.
Although majority of all antibiotic guardians are from the UK, in the last six months, over 2000 healthcare professionals and members of the public have registered as antibiotic guardians from 69 countries across the world.
Antimicrobial resistance is an increasingly important patient safety, public and global health issue; all pharmacists have a key role in working with patients and prescribers to reduce misuse of antimicrobials. It is important for all pharmacists to take action.
Dr Emma Budd and Miss Lucy Fordham (Public Health England) are acknowledged for their contributions and review of the article.
- Actively promote antibiotic awareness within pharmacy this winter. Country-specific posters, leaflets, videos to educate the public and other pharmacy staff and healthcare professionals are available via http://ecdc.europa.eu/en/eaad/activities/Pages/countryActivities.aspx; there are also materials including quizzes available via www.antibioticguardian.com.
- Choose a pledge at www.antibioticguardian.com and encourage colleagues and staff to pledge.
- Promote the Antibiotic Guardian campaign within the pharmacy and encourage others (healthcare professional colleagues and members of the public/customers) to consider making a pledge.
- Complete a continuing professional development on antibiotics and antibiotic resistance.
- Counsel patients on appropriate antibiotic use and educate them and the public on antibiotic resistance and adverse effects.
- WHO Global action plan to tackle antimicrobial resistance. 2015. www.who.int/drugresistance/global_action_plan/en/ (accessed 8 July 2015).
- ECDC/EMEA Joint Technical Report. The bacterial challenge: time to react. A call to narrow the gap between multi-drug resistant bacteria in the EU and the development of new antibacterial agents 2009. www.ema.europa.eu/docs/en_GB/document_library/Report/2009/11/WC500008770.pdf (accessed 8 July 2015).
- OECD/European Union (2010). Mortality from Transport Accidents”, in Health at a Glance: Europe 2010, OECD Publishing. http://dx.doi.org/10.1787/9789264090316-11-en.
- Smith R, Coast J. The true cost of antimicrobial resistance. BMJ 2013;346:f1493.
- Costelloe C et al. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
- WHO Antimicrobial Factsheet 194. 2015. www.who.int/mediacentre/factsheets/fs194/en/ (accessed 8 July 2015).
- Spellberg B et al. Position paper: recommended design features of future clinical trials of antibacterial agents for community-acquired pneumonia. Clin Infect Dis 2008;47:S249–6.
- Spellberg B et al. Antimicrobial agents for complicated skin and skin structure infections: justification of noninferiority margins in the absence of placebo-controlled trials. Clin Infect Dis 2009;49:383–91.
- Department of Health and Public Health England. Clostridium difficile infection: how to deal with the problem. London: 2008. https://www.gov.uk/government/publications/clostridium-difficile-infection-how-to-deal-with-the-problem. Accessed 8 July 2015.
- World Health Organization. Global action plan to tackle antimicrobial resistance. 2015. www.who.int/drugresistance/global_action_plan/en/ (accessed 8 July 2015).
- Department of Health. UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018. 2013. https://www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018.
- Public Health England. Antibiotic Guardian campaign. 2015. www.antibioticguardian.com.
- ECDC European Antibiotic Awareness Day. Country activities. 2014. Available at: http://ecdc.europa.eu/en/eaad/activities/Pages/countryActivities.aspx
- Robinson S. Nine in 10 GPs report pressure from ‘pushy’ patients to prescribe antibiotics. www.gponline.com/nine-10-gps-report-pressure-pushy-patients-prescribe-antibiotics/infections-and-infestations/bacterial-infections/article/1308308 (accessed 8 July 2015).
- Fleming N, Barber S, Ashiru-Oredope D. Pharmacists have a critical role in the conservation of effective antibiotics. Pharm J 2011;287:465.