Pharmacists key to reducing antimicrobial resistance

A third report outlining the ongoing threat of antimicrobial resistance has been released by the Australian Commission on Safety and Quality in Healthcare (ACSQHC). While the overall use of antibiotics is declining, many pathogens are continuing to develop resistance to treatment, indicating the need for greater education amongst all healthcare practitioners.

The report is the latest in a series of studies which have drawn from data collected by the Antimicrobial Use and Resistance in Australia (AURA) Surveillance System, which was established to better understand the relationship between prescribing practises in hospitals, community pharmacies and aged care homes with antimicrobial resistance.¹  

The latest report compiled information from 2016–2018, analysing an unprecedented amount of data, with the amount of hospitals and aged care homes participating in the National Antimicrobial Utilisation Surveillance Program (NAUSP) and Aged Care National Prescribing Survey doubling in recent years.¹

While the data indicated that overall use of antibiotics fell between 2015–2017 for the first time in 20 years, Australia remains in the top 25% of countries with the highest community antimicrobial use. Furthermore, common pathogens such as E. coli, Salmonella, Neisseria gonorrhoeae and Neisseria meningitidis are showing increased resistance to major drug classes.¹

How can pharmacists help?

While pharmacists are not prescribers, pharmacist and researcher at the University of Tasmania and PSA Tasmania branch committee member Jackson Crawn, told Australian Pharmacist that there are a range of ways pharmacists can help to reduce the use of unnecessary antimicrobials.

Firstly, he urged pharmacists to remain informed about the appropriate uses for antimicrobials via the Therapeutic Guidelines and UpToDate. He noted that this is especially important given the ever-changing nature of infectious disease guidelines due to local and global antimicrobial resistance patterns.

‘The knowledge from these guidelines then needs to be applied to every antimicrobial prescription undergoing a pharmacist review. Is the drug appropriate for the infection? Are the dose and duration of therapy appropriate? If it doesn’t match the guidelines, why doesn’t it and is this reasonable?’ he said.

This process can be particularly challenging given that the original prescription is often based on years of experience successfully using a particular antibiotic, despite a more evidence-based alternative being recommended in updated versions of the guidelines.  

‘The thing to remember with antimicrobials is that there is very rarely one ‘correct’ answer so assessing each prescription on a case by case basis and determining if it’s reasonable is very important. This is why education, collaboration and embedding a pharmacist at the point of prescribing is so important,’ Mr Crawn said.

Mr Crawn also noted that, while hospital pharmacists’ ability to promote antimicrobial stewardship is aided by an onsite pathology team and access to microscopy, culture and sensitivity reports. While the introduction of My Health Record will likely make this information available to all pharmacists, at present community pharmacists are faced with the time-consuming and challenging process of sourcing case notes and lab results. This is a process that can be difficult in a busy community pharmacy setting, and is often a barrier for the promotion of antimicrobial stewardship.  

Even so, he encouraged pharmacists to question consumers on long-term antimicrobial therapy, asking them if they have had the appropriate microbiology testing, reminding them to have regular follow-ups with their doctor, and referring back to their GP for persistent infections.

Mr Crawn also noted that pharmacists have a role to play in patient education, particularly in situations where patients are suffering from conditions such as ear, nose, throat and chest infections. where antimicrobials are the expected treatment.

‘The pharmacist has a fundamental role in educating patients not just on when antibiotics are appropriate, but when they’re not. For these patients, emphasising that many conditions are self-limiting and recommending products for symptom relief is key,’ he said.

He also said that pharmacists could have a valuable impact on one of the report’s key findings, that 50% of antibiotic prescriptions are ordered with repeats, half of which are filled within ten days.¹

‘The use of “take until finished” has long been utilised in the pharmacy environment, but in some instances it may not be appropriate,’ he said, urging pharmacists to clarify the intended duration of treatment where possible.  

‘In terms of promoting antimicrobial resistance, overtreating (especially with the incorrect antibiotic) is just as bad as undertreating. This may mean a phone call to the doctor if the patient isn’t able to clarify any concerns,’ he said.

‘If the issue is ongoing, have a discussion with the GP clinic about whether repeats are being automatically added. More importantly, if a patient presents a repeat weeks or months after the initial supply, alarm bells should be ringing. Unless there is a sound clinical reason for this, the patient should be referred to a doctor,’ he said.

Mr Crawn urged pharmacists to be aware of signs in consumers that their medicine might not be working. He suggested physically marking the borders of skin infections to be able to monitor the spread of the infection, as well as regularly inspecting infected wounds for pus, redness, swelling or heat.

‘Depending on the severity of the deterioration, the patient will need referral to a GP or the emergency department. But the pharmacist’s input shouldn’t stop there – if you’re familiar with the treatment guidelines you could recommend a second or third line therapy, or perhaps initiate a discussion with the laboratory on what the most appropriate antimicrobial choice could be based on the sensitivities of the pathogen.

‘It’s really about getting involved and taking that next step to make sure the patient gets the right antimicrobial at the right dose for the appropriate duration,’ he said.

A collaborative effort

Mr Crawn said that the results of the report indicated a clear need for a multidisciplinary approach to antimicrobial prescribing.

‘Antimicrobial stewardship is only successful if everyone involved is on board,’ he said, noting that in hospitals, this means support from key stakeholders such as hospital management and the senior physicians who prescribe antimicrobials on a daily basis.

‘Pharmacists play a major role in terms of contributing to the committees that monitor and implement antimicrobial stewardship programs, as well as providing education to nurses, doctors and other allied health staff,’ he said.

Mr Crawn urged community pharmacists to engage with their local GP clinics, health centres and pathology services and work together to promote antimicrobial stewardship.

The report also identified areas for improvement within the aged-care sector, where over 50% of prescriptions are given to residents with no symptoms.¹

Mr Crawn said that this represented an opportunity for pharmacists to become more involved with medication management and education within aged-care facilities.  

‘In my opinion, the most successful intervention of all to improve antimicrobial prescribing is to embed a pharmacist wherever the prescribing occurs – on a hospital ward round, in the aged care facility, in the GP clinic. Pharmacists need to be available to provide their expertise when it’s needed the most,’ he said.

References

1. Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2019: third Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC; 2019. At: https://www.safetyandquality.gov.au/wp-content/uploads/2019/05/AURA-2019-Report.pdf