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Pharmacists have a critical role in the conservation of effective antibiotics

By Naomi Fleming, Sue Barber and Diane Ashiru-Oredope

In these days of speed and efficiency in community pharmacy, we all breathe a sigh of relief when we get a quick, easy prescription for an antibiotic. However, we should really stop and consider this prescription, because it could require an important clinical intervention.

The Standing Medical Advisory Committee recommended that the prescription of an antibiotic should be “seen as a serious step, similar to the prescription of steroids or any other potentially harmful medicament”.1 Since their discovery, antibiotics have contributed to the reduction in mortality and morbidity from infectious disease and have made other treatments and procedures such as cancer treatments and organ transplantation possible. However, there are individual adverse consequences of antibiotic therapy, for example side effects such as Clostridium difficile infection and tendonitis as well as contribution to the development of resistance both in the individual patient and the general population.2,3

Antibiotic resistance is an increasingly serious patient safety and public health problem world-wide.1,4–6 Resistance is threatening those treatments that depend on antibiotic therapy as well as the treatment of infection itself. Bacteria are becoming resistant faster than new antibiotics are being developed; this threatens the ability of medical teams to treat certain infections and makes antibiotics a highly valuable and finite resource.5,6 For these reasons we need to consider prescriptions for antibiotics with the utmost care and attention and help our patients gain the most from these valuable medicines.

This is particularly important because 80 per cent of antibiotics are prescribed in primary care.1,7 Sore throat, common cold, acute otitis media, acute infective conjunctivitis, acute bronchitis and acute sinusitis are the most common infections presenting in primary care. Evidence shows that antibiotics use in these conditions has limited value,8 and can lead instead to adverse effects, increased consultations, high cost and an increased risk of resistance.8–14

Next month the fourth European Antibiotic Awareness Day (EAAD) will be marked on 18 November (poster below). EAAD is supported in England by the Department of Health, its Advisory Committee on Antimicrobial Resistance and Healthcare-associated Infections, the Health Protection Agency, and professional bodies including the Royal Pharmaceutical Society and the National Pharmacy Association. The aim is to:

  • 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 two key messages for the public are: “Coughs, colds — take care, not antibiotics”and “Antibiotics — misuse them and you may lose them”.

Resources, including patient information leaflets, fact sheets, and educational videos, are available on the DoH website. These can be used by community pharmacists and other healthcare professionals to promote public awareness of the importance of prudent use of antibiotics. This is especially important in winter, which is the peak request and prescribing season for antibiotics.

Key messages

There are four key messages for community pharmacists:

  • Counsel patients on appropriate antibiotic use when prescribed
  • Counsel patients on antibiotic resistance, as appropriate
  • Counsel patients on adverse effects
  • Recommend symptomatic therapy for non-vulnerable patients

Appropriate antibiotic use

Pharmacists are well placed to advise patients about antibiotics, particularly to take them at regular intervals and finish the course. It is also imprtant to provide advice about side effects and interactions between antibiotics and food, and antibiotics and other medicines.

As part of our role in the public health arena it is imperative that we support the antibiotic agenda to reduce the development of antibiotic resistance and minimise patient harm from side effects and drug interactions.

Using the FRAIS mnemonic when counseling every patient that presents an antibiotic prescription can help:


F    Finish the course

   Regular intervals (eg, six-hourly, eight-hourly, etc)

   After, with or before food)

I    Interactions

   Side effects

Antibiotic resistance

There is evidence that antibiotic resistance is linked to antibiotic exposure in a population as well as within an individual.1,2 Recent research has shown that patients prescribed an antibiotic for a respiratory or urinary tract infection can develop bacterial resistance to that antibiotic that may last for up to 12 months after the antibiotic was prescribed. The more often the patient has a course of antibiotics the more opportunity that patient’s bacteria have to develop multiple or ongoing resistance.2

Adverse effects

It is important that all pharmacists are aware of the common adverse effects of antibiotics.  An important one to be aware of is the risk of antibiotic-associated diarrhoea that could be caused by Clostridium difficile. Pharmacists should be familiar with the symptoms of this infection, the antibiotics more commonly associated with it and the guidelines on its diagnosis and management.10 Antibiotics commonly associated with this infection are often referred to as the 4Cs — ciprofloxacin (quinolones), co-amoxiclav (broad spectrum penicillins,) clindamycin and cephalosporins (3rd generation). It is important that patients with diarrhoea that could be due to C difficile following antibiotic treatment are not sold or advised to take anti-spasmodics, eg, loperamide. These agents can increase the severity and length of disease due to the prolonged contact time of C difficile toxins in the colon.10

Symptomatic therapy

Appropriate referral of patients who attend the pharmacy for advice and managing patients’ expectations are essential. This is particularly important in the case of respiratory tract infections where patients often present to the pharmacy before visiting their GP or out-of-hours service. It is important that pharmacists are familiar with reasons why patients should be referred and are able to advise patients on:

 

  • The usual natural history of the illness, including its likely duration (eg, acute otitis media, four days; common cold, one and a half weeks; acute rhinosinusitis, two and a half weeks; acute cough/acute bronchitis, three weeks)
  • Self help, eg, drinking plenty of fluids, resting, pain relief and symptom control
  • When to see their GP


Patients who need to be referred to a GP include those at risk of serious complications on account of pre-existing co-morbidity, such as cystic fibrosis, significant heart, lung, renal, liver or neuromuscular disease, those who are immunosuppressed, and children born prematurely.8

Professional medical advice — especially when patients are provided with advice on what to expect with respect to the course of the illness, including a realistic recovery time and self-management strategies — has been shown to impact on patients’ perceptions and attitude towards their illness and their perceived need for antibiotics.15–17 Written information will help support consultation. Local primary care organisation pharmacy teams may have produced leaflets. Specific patient information leaflets are also available from the Department of Health. It may be useful to refer patients to local minor ailment schemes (where available) for appropriate over-the-counter medicines for their symptoms and highlight possible delayed prescribing strategies with the patient (if referring to a GP).

 

Other ways to help

Other ways community pharmacists can support this agenda include:

  • Staying up to date and following guidance on the sale and supply of all available OTC antibiotics, including chloramphenicol eye preparations
  • Having a copy of the local PCO guidelines and National Institute for Health and Clinical Excellence guidance on antibiotic prescribing for respiratory tract infections 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 1,000 population18
  • Encouraging regular hand hygiene with the six step technique19 and the “Catch it, bin it, kill it” campaign20 to prevent infection spread
  • Encouraging other lifestyle choices that help to keep the immune system healthy, eg, smoking cessation and healthy eating

Conclusion

Antibiotic resistance is an increasingly important patient safety and public health issue; it is time for community pharmacists to take a more proactive role in working with patients and prescribers to reduce it. It is important for all community pharmacists to:

  • Be aware of the key role they can play in helping to reduce development of antibiotic resistance.
  • Counsel patients on appropriate antibiotic use – the mnemonic FRAIS may be helpful
  • Counsel patients on antibiotic resistance and adverse effects
  • Recommend symptomatic therapy for appropriate illnesses

Promotional materials

The educational and promotional antibiotic materials available from the Department of Health include a leaflet (“Get well soon without antibiotics”), videos and posters. Non-prescription pads, which explain why antibiotics have not been prescribed at a consultation but give patients something to take-away and act as aide-memoire, are also available for prescribers. The materials can be downloaded from the Department of Health website or hard copies requested from DH Publications (order line 0300 123 1002; product codes 290981, 284682, and 290980).


About the authors

Naomi Fleming is antibiotic pharmacist (email naomi.fleming@mkpct.nhs.uk) and Sue Barber is infection prevention and
control nurse at  Milton Keynes Community Health Services. Diane Ashiru-Oredope is pharmacist lead, Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infections and the Health Protection Agency (email diane.ashiru-oredope @hpa.org.uk).


References
1        Standing Medical Advisory Committee The path of least resistance. 1999. Available at: www.advisorybodies.doh.gov.uk/pub/docs/doh/smacexec.pdf. (accessed 11 August 2011).
2        Costelloe C, Metcalfe C, Lovering A, Mant D, Hay A. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:c2096.
3        Goossens H, French M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579–87.
4        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. Available at: www.ema.europa.eu/docs/en_GB/document_library/Report/2009/11/WC500008770.pdf (accessed July 2011).
5        WHO Global Strategy for Containment of Antimicrobial Resistance. 2001 Available at: www.who.int/drugresistance/WHO_Global_Strategy_English.pdf (accessed 11 August 2011).
6        Boucher HW, Talbot GH, Bradley JS, Edwards JE, Gilbert D, Rice LB, et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clinical Infectious Diseases 2009;48:1–12.
7        Wise R, Hart T, Cars O, Streulens M, Helmouth R, Huovinen P, et al. Antimicrobial resistance is a major threat to public health. BMJ 1998;317:609–10.
8        NICE 69: National Institute for Health and Clinical Excellence. Prescribing of antibiotics for self limiting respiratory tract infection in adults and children in primary care. 2008. Clinical guideline available at: www.nice.org. uk/nicemedia/pdf/CG69FullGuideline.pdf (accessed July 2011).
9        Rutten G, Van Eijk J, Beek M, Van der Velden H. Patient education about cough: effect on the consulting behaviour of general practice patients. British Journal of General Practice 1991;41:289–92.
10        Department of Health and Health Protection Agency. Clostridium difficile infection: how to deal with the problem. London: 2008. Available at: www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/documents/digitalasset/dh_093218.pdf (accessed 11 August 2011)
11        Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotic prescribing for acute cough; the effect of perceived patient demand. British Journal of General Practice 2006;56:183–90.
12        Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat (Cochrane review). Oxford: The Cochrane Library; September 2011.
13        Sanders S, Glasziou PP, Del Mar CB. Antibiotics for acute otitis media in children (Cochrane review). Oxford: The Cochrane Library; January 2010.
14        Smith SM, Fahey T, Smucny J, Becker LA. Antibiotics for acute bronchitis. Cochrane database of Systematic Reviews 2004, Issue 4.
15        Butler CC, Rollnik S, Pill R, Maggs-Rapport F, Stott N. Understanding the culture of prescribing: qualitative study of general practitioners’ and patients’ perceptions of antibiotics for sore throats. BMJ 1998;317:637–42.
16        Kallestrup P, Bro F. Parents’ beliefs and expectations when presenting with a febrile child at an out-of-hours general practice clinic. British Journal of General Practice 2003;53:43–4.
17        Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expectations on antibiotic management of acute lower respiratory tract illness in general practice: questionnaire study. BMJ 1997;315:1211–4.
18        Kwong, Jeffrey CS, Maaten S, Upshur REG, Patrick DM, Marra F. The effect of universal influenza immunization on antibiotic prescriptions: an ecological study. Clinical Infectious Diseases 2009;49:750–5.
19        Essential steps to safe clean care . Preventing the spread of infection. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4136275.pdf (accessed 11 August 2011).
20        Department of Health. Catch it, Bin it, Kill it — Respiratory and hand hygiene campaign 2011. Available at:  http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_123234 (accessed 11 August 2011).

Citation: The Pharmaceutical Journal URI: 11086917

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