The importance of becoming an Antibiotic Guardian

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

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

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.

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:

Across the European region, 53 countries adopted a strategic action plan on AMR in 2011. The seven key areas for action identified include:

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:

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:

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:

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

I   Interactions

S  Side effects

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.