This article highlights the many ways in which pharmacists in hospital
and community settings can influence antimicrobial stewardship (AMS)
Diane Ashiru-Oredope MPharm DipClinPharm MRPharmS PhD
Pharmacist Lead; Antimicrobial Resistance Programme,
Public Health England, London, UK
Naomi Fleming BPharm MRPharmS
Pharmacist Microbiology and Infectious Disease, Kettering General Hospital, Northamptonshire, UK
David Ladenheim BPharm MRPharmS DipClinPharm
East and North Herts NHS Trust, Hertfordshire, UK
The World Health Organization defines antimicrobial resistance (AMR) as “the resistance of a microorganism to an antimicrobial medicine to which it was originally sensitive. Resistant organisms (including bacteria, fungi, viruses and some parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antifungals, antivirals, and antimalarials, which means that standard treatments become ineffective and infections persist increasing the risk of spread to others”.1
Antimicrobial resistance poses a major threat to the future of healthcare with significant clinical, public health and economic implications; resistant infections claim at least 25,000 lives each year across Europe.2 The problem is undoubtedly increasing. In 15 EU countries, >10% of bloodstream Staphylococcus aureus infections are caused by methicillin-resistant Staphylococcus aureus (MRSA) and several of these countries have resistance rates close to 50%.3
The use and inappropriate use of antimicrobial drugs is a recognised driver for resistance and reductions in resistance has been shown to coincide with shifts in prescribing practice.3,4 Until 2007, for example, the UK saw major increases in both cephalosporin and quinolone resistance amongst Escherichia coli and Klebsiella spp, however since 2007 resistance to these have decreased/plateaued (LabBase and BSAC data).4 This fall in resistance coincides with a large reduction in cephalosporin and quinolone use due to national antimicrobial stewardship guidance, which was introduced to reduce Clostridium difficile infections nationally.3
In contrast, many treatment regimens have been replaced with penicillin/ beta-lactamase inhibitors. This may be adding to the selection for carbapenamase producers, which are currently on the increase.5
Figure 1: European Commission Five-Year AMR Action Plan 2011.
(1) Strengthen the promotion of the appropriate use of antimicrobials in all Member States
(2) Strengthen the regulatory framework on veterinary medicines and on medicated feed
(3) Introduce recommendations for prudent use in veterinary medicine, including follow-up reports
(4) Strengthen infection prevention and control in healthcare settings
(5) Introduction of a legal tool to enhance prevention and control of infections in animals in the new Animal Health Law
(6) Promote, in a staged approach, unprecedented collaborative research and development efforts to bring new antimicrobials to patients
(7) Promote efforts to analyse the need for new antibiotics into veterinary medicine
(8) Develop and/or strengthen multilateral and bilateral commitments for the prevention and control of AMR in all sectors
(9) Strengthen surveillance systems on AMR and antimicrobial consumption in human medicine
(10) Strengthen surveillance systems on AMR and antimicrobial consumption in animal medicine
(11) Reinforce and coordinate research efforts
(12) Survey and comparative effectiveness research
National and international policies on AMR
Guidance and action plans to deal with the threat of antimicrobial resistance have been provided at both national and international levels.6–8
At the 68th World Health Assembly in May 2015, a global action plan to tackle antimicrobial resistance was endorsed. The goal of this plan is “to ensure, for as long as possible, continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them”.6
At a European level, the European Commission published the Action Plan against the rising threats from antimicrobial resistance in 2011.7 The Commission put in place a Five-year Action Plan against antimicrobial resistance. This action plan is based on the 12 key actions in Figure 1.
While international guidance will provide an overarching direction, it is expected that countries will use this to develop their own national actions plans. In the UK for example, the Five-Year Antimicrobial Resistance Strategy was published in 2013.8 This sets out national actions to address the key challenges of AMR in the UK. The focus of this guidance is highlighted in ‘seven key areas for future action’.
Further to this, national antimicrobial stewardship toolkits for primary and secondary care have been published to assist organisations in the UK in fulfilling their obligations with regards to AMR.9,10
Figure 2: Common roles and duties of specialist antimicrobial pharmacists
- • Writing antimicrobial guidelines and policies
- • Making anti-infective formulary decisions (choosing which antimicrobials should be available on the Trust formulary)
- Being available by phone or pager for referrals/advice
- Performing multidisciplinary antibiotic review rounds
- Attending Trust infection prevention and control committee meetings
- Maintaining awareness of local resistance patterns
- Horizon scanning
- Attending ward rounds on specialities with high antibiotic use
- Education for all levels and specialties of staff
- Monitoring and surveillance of antimicrobial usage
- Consultation and patient review
- Managing the implementation/introduction of new agents across the Trust
- Prescribing of antimicrobials
- Outpatient parenteral antimicrobial therapy (OPAT) services.
- Auditing and review of antimicrobial use across Trusts
- Contributing to quality targets (for example, sepsis campaigns)
- Multidisciplinary team (MDT) outpatient clinics
- C. difficile MDT ward rounds
- Antimicrobial therapeutic drug monitoring advice and guidance.
Antimicrobial stewardship (AMS) can be described as a package of measures designed to ensure the optimal selection of therapy for patients for the best clinical outcome while minimising toxicity.11 This involves choosing the right drug at the right dose for the right duration for the right indication and includes urgent treatment (within one hour) in the case of severe sepsis or septic shock. AMS aims to prevent the overuse, inappropriate use and abuse of antibiotics and in so doing minimise the development of resistance at patient and community levels.
Across Europe at any one time within hospitals, 30% or more patients will be on at least one antimicrobial.12 This is why all pharmacists have an important role in AMS; not just specialist antimicrobial or infectious diseases pharmacists.
Role of the specialist pharmacists
Over the years, the role of pharmacists in leading AMS programmes has expanded,13–20 and interventional studies have shown the positive impact of having pharmacists as part of antimicrobial stewardship teams.16–20
The role of the specialist pharmacist will vary from one country to another and indeed from one organisation to another, Figure 2 provides an outline of the more common roles and duties of the specialist antimicrobial pharmacist.
Some aspects of the role of a specialist pharmacist are ubiquitous. For example collecting prescribing data (surveillance) and optimising antimicrobial prescribing.
Surveillance of antimicrobial consumption and antimicrobial resistance data are essential to understand the development and actions required to reduce antimicrobial resistance. In Europe, the European Centre for disease prevention and Control (ECDC) collects, analyses and disseminates surveillance data on 52 communicable diseases and related special health issues from all 28 European Union (EU) Member States and two European Economic Area (EEA) countries (Iceland and Norway). More specifically in the context of antimicrobial use, the European Surveillance of Antimicrobial Consumption Network (ESAC-Net) is a Europe-wide network of national surveillance systems. It provides European reference data on antimicrobial consumption. ESAC-Net collects and analyses data on antimicrobial consumption from EU and EEA/EFTA countries, both in the community and in the hospital sector. The data gathered by ESAC-Net is used to provide timely information and feedback to contributors on indicators of antimicrobial consumption. These indicators provide a basis for monitoring the progress towards prudent use of antimicrobials.
Individual countries also have surveillance programmes. The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) published their first report in 2014.21 This report brought together antibiotic consumption data from community and hospital settings across England for the first time. Similar programmes are available in Scotland, Wales and several European countries. In 2014, a study publicly provided the total antibiotic-use data for 13 non-EU countries and areas (Eastern Europe) of the WHO European region for the first time.22
A review evaluating the impact of interventions from the perspective of AMS and optimising prescribing was published in 2013.23 This meta-analysis showed that a wide variety of interventions have been shown to be successful in changing antibiotic prescribing to hospital inpatients. It suggests that restrictive interventions (that is interventions that put a limit on how antibiotics are prescribed) work faster than persuasive interventions (interventions that advised physicians how to prescribe or gave them feedback about how they prescribed). It also found that the effectiveness of some restrictive interventions diminishes over time so when a restriction is justified it may be helpful to win hearts and minds through additional persuasive components.23
All pharmacists have a role in AMS.
In addition to specialist pharmacists, all hospital pharmacists have a role in AMS as part of their day-to-day role.
Pharmacists and their teams can register to become Antibiotic Guardians via
www.antibioticguardian.com (Public Health England’s campaign supporting AMR) and choose a pledge about what they can personally do to help preserve these vital medicines. It is also important to promote this campaign to members of the public, who will receive a short training video on antibiotic resistance and are given an optional opportunity to choose a pledge.25
Monitoring antibiotic use and adherence to guidelines
Hospital pharmacists have a role to play as they ‘clinically screen’ drugs as part of their everyday practice. Advice should include the provision of guidance on antibiotic dosing regimens, like in cases of organ dysfunction (for example, renal adjustment), being based on therapeutic monitoring for drugs with a narrow therapeutic index, or for highly drug-resistant bacteria, where higher doses may be required.
Inappropriate situations and for antibiotics with good absorption, pharmacists can facilitate the change from intravenous (IV) to oral antibiotic therapy. This has a number of advantages, most notably a reduction in the likelihood of hospital-acquired bacteraemia and infected IV lines.
Pharmacists also should be mindful of the potential for antibiotic-related drug–drug interactions. Interactions concerning the fluoroquinolone and macrolide classes of antibiotic are particularly important in this regard.
Pharmacy teams should be proactive in promoting currently available vaccines and some community pharmacies offer vaccination services such as the influenza vaccine. Vaccines can decrease the use of antibiotics directly by preventing primary infection and indirectly by preventing bacterial superinfection after a primary vaccine-preventable illness, such as influenza.
Education, training and patient/public engagement
Education of other healthcare professionals within their area of practice (secondary or primary care, community health services or community pharmacy teams) is a key role as highlighted by the ‘Start Smart then Focus’ guidance for hospitals from the Department of Health in the UK.10
Keeping up-to-date with individual learning including guideline changes, new evidence and areas of practice such as outpatient parenteral antimicrobial therapy (OPAT) are also very important.
Education sessions for patients or the public are useful ways of delivering key messages, for example talks to patient participation groups at GP practices or having stands at local health awareness events and schools. Pharmacies are ideal locations to promote leaflets with antimicrobial resistance information and self-help information.
It is important to establish the role of community pharmacists in tackling AMR because majority of antimicrobial prescribing occurs in the community. In the UK for example, 79% of all antibiotic prescribing occurs in the community however there are few specialist antimicrobial pharmacists in this sector.21
Historically, the greatest impact of pharmacists on antimicrobial stewardship activities has been reported in secondary care. However pharmacists that work in community settings are an important and often under-used resource to influence prudent antibiotic prescribing in the community and primary care. These include pharmacists in commissioning organisations, GP-based pharmacists, community health services, mental health trusts, offender care services, private healthcare providers and traditional community pharmacists. In England, as part of the Quality Premium (a reward scheme for quality improvement) for antimicrobial targets, pharmacists working in primary care have been tasked with reducing the overall volume of antibiotic prescribing and reducing broad-spectrum antibiotic use ensuring that antimicrobial stewardship is prioritised across primary care.25
In 2014, the Regional Office for Europe of the World Health Organization published a review of policy and experience in Europe on the role of community pharmacists in encouraging prudent use of antibiotics and averting antimicrobial resistance.26 As well as appropriate screening of prescriptions and dispensing of antibiotics, community-based pharmacy teams have a key role to play in improving patient and public awareness of antimicrobial resistance and hospital-acquired infections. Coordinating or participating in local campaigns and promoting national campaigns such as European Antibiotic Awareness Day and Antibiotic Guardian campaigns are a good example of this. Community pharmacists and teams also have key role in managing patient expectations about antibiotics, particularly around the common winter symptoms, and should be working closely with GPs to support effective self-care and appropriate referral including referring patients without reinforcing the need for antibiotics.
Pharmacists have been shown to have a key role in AMS teams, particularly within secondary care. Specialist roles have highlighted the importance and impact of the specialist role to improve prescribing and patient outcomes particularly within inpatient and OPAT settings. In the future, pharmacists’ roles may be increased to prescribing of antibiotics and further involvement in outpatient clinics. Non-specialist pharmacists in the hospital sector have daily opportunities to impact on individual patient care by monitoring antibiotic use and adherence to guidelines, ensuring correct doses, for example, through therapeutic drug monitoring and appropriate antibiotic review, such as encouraging prompt IV to oral switch where appropriate. In the community sector there are few specialist antimicrobial pharmacists and very limited publications on the impact of pharmacists on AMS, despite 79% antimicrobial prescribing occurring in this sector. As detailed in this article there are many ways in which pharmacists in the various settings can influence AMS, particularly by educating the public on AMR, how to take antibiotics appropriately and providing alternative treatment options via minor ailment schemes. The roles of pharmacists with this agenda will continue to evolve and it will be important to capture the impact on patient outcomes of these future roles.
- Antimicrobial resistance is one of the major clinical, public health and economic issues facing our generation. The global nature of the problem means that no one country can act in isolation.
- There are key action areas for all practicing pharmacists irrespective of experience or area of practice.
- We need to increase awareness and understanding of antimicrobial resistance, its implications, and actions to combat it through effective communication, education and training.
- Implement effective antimicrobial stewardship practices to ensure appropriate and judicious prescribing, dispensing and administering of antimicrobials.
- Pharmacy leaders should support clear governance arrangements to facilitate leadership, engagement and accountability for actions to combat antimicrobial resistance.
- World Health Organization. Antimicrobial resistance: global report on surveillance 2014./www.who.int/drugresistance/documents/surveillancereport/en (accessed 8 July 2015).
- Goossens H et al. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579–87.
- European Centre for Disease Prevention and Control Antimicrobial Resistance Interactive Database (EARS-NET) data for 2013. http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/database.aspx.
- Livermore DM et al. Declining cephalosporin and fluoroquinolone non-susceptibility among bloodstream Enterobacteriaceae from the UK: links to prescribing change? J Antimicrob Chemother 2013; doi:10.1093/jac/dkt212.
- 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.
- WHO Global action plan to tackle antimicrobial resistance 2015. www.who.int/drugresistance/global_action_plan/en/ (accessed 8 July 2015).
- European Commission. Action Plan against antimicrobial resistance (AMR) 2011. http://ec.europa.eu/health/antimicrobial_resistance/policy/index_en.htm (accessed 7 July 2015).
- Department of Health. UK 5 Year Antimicrobial Resistance Strategy 2013 to 2018. 2013. www.gov.uk/government/publications/uk-5-year-antimicrobial-resistance-strategy-2013-to-2018 (accessed 8 July 2015).
- RCGP and PHE. TARGET Antibiotics Toolkit. 2014. www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx. (accessed 8 July 2015).
- Public Health England. Antimicrobial Stewardship: Start Smart then Focus. 2015. www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus (accessed 8 July 2015).
- Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc 2011;86(11):1113–23.
- ECDC point prevalence survey of healthcare-associated infections and antimicrobial use in acute care hospitals. http://ecdc.europa.eu/en/activities/surveillance/HAI/reports/Pages/reports.aspx (accessed 8 July 2015).
- Wickens HJ et al. The increasing role of pharmacists in antimicrobial stewardship in English hospitals. J Antimicr Chemother 2013;68(11):2675–81.
- Bumpass JB et al. Outcomes and metrics for antimicrobial stewardship: survey of physicians and pharmacists. Clin Infect Dis 2014;59(3):S108–11.
- Magedanz L, Silliprandi EM, Dos RPR. Impact of the pharmacist on a multidisciplinary team in an antimicrobial stewardship program: a quasi-experimental study. Int J Clin Pharm 2012;34(2):290–4.
- Chen CC et al. Impact of pharmacist-led antimicrobial stewardship using a computerized system with prospective audit and feedback approach in a university hospital. Pharmacotherapy 2011;31(10).
- Perez AL, Trimino EM, Christian M. Improving patient outcomes and decreasing length of stay through pharmacist participation in case management rounds. Pharmacotherapy 2012;32(10):e270–e271.
- Rohde JM, Jacobsen D, Rosenberg DJ. Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative. Clin Ther 2013;35(6):751–7.
- Shah M et al. Cost avoidance through the use of a dedicated clinical pharmacy specialist on a hospitalist service. J Hosp Med 2012;7.
- Tsai JD, Jseng JH, Chen CC. The impact of pharmacist-led antimicrobial stewardship in intensive care units in a regional hospital in Taiwan. Value in Health 2012;15(7):A666.
- Public Health England. English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) English surveillance programme for antimicrobial utilisation and resistance (ESPAUR). https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/362374/ESPAUR_Report_2014__3_.pdf (accessed 8 July 2015).
- Versporten A et al. Antibiotic use in eastern Europe: a cross-national database study in coordination with the WHO Regional Office for Europe. Lancet Infect Dis 2014;PII:S1473-3099(14)70071-4.
- Davey P et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013;4.4. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003543.pub3/pdf/standard Public Health England.
- Antibiotic Guardian. www.antibioticguardian.com (accessed 8 July 2015).
- NHS England. Quality Premium Guidance 2015/16. 2015. www.england.nhs.uk/wp-content/uploads/2015/04/qual-prem-guid-1516.pdf (accessed 8 July 2015).
- WHO Regional Office for Europe. The role of pharmacist in encouraging prudent use of antibiotics and averting antimicrobial resistance: a review of policy and experience in Europe. 2014. www.euro.who.int/__data/assets/pdf_file/0006/262815/The-role-of-pharmacist-in-encouraging-prudent-use-of-antibiotics-and-averting-antimicrobial-resistance-a-review-of-policy-and-experience-Eng.pdf?ua=1 (accessed 8 July 2015).