Time for pharmacy to unite in the fight against antimicrobial resistance
To mark European Antibiotics Awareness Day, Philip Howard, Diane Ashiru-Oredope, Mark Gilchrist and colleagues describe how pharmacy can help combat resistance
To mark European Antibiotics Awareness Day, Philip Howard, Diane Ashiru-Oredope, Mark Gilchrist and colleagues describe how pharmacy can help combat resistance
With the number of new antibiotics in the pipeline at an all-time low and the number of infections due to antibiotic-resistant bacteria continuing to increase, antimicrobial resistance (AMR) remains a major clinical and public health issue and an important threat to the future of healthcare. The importance of accelerating progress in tackling AMR is well established and the chief medical officer’s 2011 report and the new UK five-year AMR strategy for 2013 to 2018 set out the Government’s priorities and objectives.
The AMR strategy, developed by the Department of Health in collaboration with several key organisations, highlights seven key areas for action:
- 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
European Antibiotics Awareness Day
One of the programmes to address antimicrobial resistance is the annual European Antibiotic Awareness Day (EAAD) on 18 November. EAAD aims significantly to enhance public and professional awareness on the importance of using antibiotics responsibly to help control the increase in AMR.
In England, the DoH, its expert Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI), Public Health England (PHE), devolved administrations and professional bodies, including the Royal Pharmaceutical Society, collaborate on EAAD.
- The DoH sending a letter to chief executives of clinical commissioning groups, secondary care trusts and directors of public health inviting participation
- Central hosting of a range of educational materials that can be used in local campaigns and initiatives, on the DoH website. The available materials for EAAD 2013 are listed under “Resources” viewable on PJ Online. Similar materials are available in Wales , Scotland and Northern Ireland
- Commissioning editorials in national professional and scientific journals to increase professionals’ awareness
- Promoting national guidance, for example, TARGET (“Treat antibiotics responsibly, guidance, education, tools”) toolkit for primary care, the national antimicrobial stewardship guidance for secondary care — “Start smart then focus” and the recently published “Antimicrobial prescribing and stewardship competencies”
- Producing an evaluation report
(see http://bit.ly/EAAD2012-EvaluationReport )
Plans for EAAD 2013 have used recommendations from evaluation of previous years’ activities to build on their most successful aspects and extend its reach outside the healthcare setting.
For the first time, the focus of EAAD also includes showcasing case studies of good work as well as greater involvement from community pharmacy and veterinary colleagues.
The Veterinary Medicines Directorate and the Department for Environment, Food and Rural Affairs, along with several veterinary professional bodies, the PDSA and the Bella Moss Foundation, have produced a wide range of resources and are also using EAAD as a lever to remind veterinary surgeons, farmers and pet owners of the importance of prudent antibiotic use and good hygiene in the prevention and treatment of infections.
What can pharmacy do?
Pharmacy needs to unite and act to tackle AMR (see Panel). The different sectors of pharmacy have a significant role in the delivery of the five-year AMR strategy, and now is the time for the RPS to provide clear leadership in ensuring a joined up approach across the profession and beyond. In 2014, the RPS will be publishing professional standards for public health which will include clear guidance on antimicrobial stewardship.
What pharmacists can do
There are specific actions relating to European Antibiotics Awareness Day that all pharmacists and pharmacy technicians can take:
Hospital pharmacy has been at the heart of delivering antimicrobial stewardship for many years. Audit of the implementation of the 2011 “Start smart then focus” guidelines for England has shown improvements in prescribing standards,1,2 but still there is currently no formal benchmarking system outside the number of meticillin-resistant Staphylococcus aureus bacteraemia or Clostridium difficile cases to compare trusts.
The new UK AMR strategy has specified an action to monitor resistance rates for common bug-drug combinations, and new tools will be introduced to compare antimicrobial use between hospitals. A new national programme in England — the English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) — will focus on understanding and integrating antimicrobial usage and resistance in primary and secondary care and will collaborate with other stakeholders to develop quality measures and methods to monitor effects of antimicrobial stewardship strategies nationally.3 Similar programmes are also established in Scotland, Wales and Northern Ireland.
The UK Clinical Pharmacy Association Infection Management Group (IMG) has worked closely with hospital pharmacists for many years developing and leading on UK antimicrobial stewardship initiatives solely and in collaboration with other UK infection societies and government agencies.
In early 2014, the group, working together with the RPS, will launch an “Infection and antibiotic stewardship” curriculum with AMR at its centre. This curriculum will provide a learning framework for pharmacists in all pharmacy sectors wishing to be involved in infection.
Community pharmacists remain an under-used resource in the fight against antimicrobial resistance. This is recognised in the recent call for research proposals by the DoH (www.prp-ccf.org.uk). However community pharmacy has a key role in managing patient expectations about antibiotics, particularly around the common winter symptoms, and should be working closely with GP practices and CCGs to support effective self-care and appropriate referral. They can also have an impact in reducing inappropriate antibiotic prescribing for flu symptoms by increasing uptake of flu vaccination.
One of the key gaps in public knowledge about winter symptoms is the likely duration of a cough, a cold, “the flu” or a sore throat. The “Treat yourself better without antibiotics” public campaign (www.treatyourselfbetter.co.uk), which started on 12 November 2013 and which is being run this winter by Pharmacy Voice and the Proprietary Association of Great Britain, in conjunction with the Self Care Forum (SCF), is designed to highlight symptom duration and the red flags that means a GP consultation may be required, within a key message that antibiotics are not the answer.
The campaign, which includes new advice guides for pharmacists and pharmacy teams are intended to support clinical decision-making in order to help patients manage for the likely duration of their conditions through self-care. The guides are consistent with the messages of National Institute for Health and Care Excellence guidelines, the SCF and the Royal College of General Practitioners TARGET antibiotics resources, which have been promoted through GPs for the past few years.
In addition, the Pharmaceutical Services Negotiating Committee has launched a briefing on “Transforming urgent and emergency care (093/13)”, highlighting the ways community pharmacy can help reduce the pressure of accident and emergency departments and GPs over the winter. Minor ailments account for 18 to 20 per cent of a GP’s workload and 8 per cent of A&E consultations. Minor ailment schemes have been shown to decrease GP attendances for minor conditions and be cost-effective.4,5 These are embedded into Scottish community pharmacy contracts, but the uptake across England, Northern Ireland and Wales is mixed.
There is a great opportunity for CCG lead pharmacists to make sure that antimicrobial stewardship is central to commissioning strategies and to work together with partners across the local health community and with CCG member GP practices to develop and co-ordinate a primary care antimicrobial stewardship programme that includes change in healthcare professional behaviour, management of patient expectations and a system-wide co-ordinated approach. CCG pharmacists can make significant contributions to improving patient outcomes by improving antimicrobial prescribing in primary care.6
Educating pharmacists on AMR
It is important that AMR (including antimicrobial stewardship) is embedded in the education and training of all pharmacists and pharmacy students.
Currently in secondary care, specialist antimicrobial pharmacists and pharmacy technicians take on the education and training of pharmacists and other healthcare professionals. In addition, a Learning@lunch antimicrobial training package is available for pharmacists in secondary care from the Centre for Pharmacy Postgraduate Education (www.cppe.ac.uk/learning@lunch).
For community pharmacy, the CPPE is launching a focal point workshop — “Antimicrobial stewardship in community pharmacy” — which starts in January 2014. From March 2014, antimicrobial stewardship will be included in their free-to-access online learning environment, which offers interactive learning for community pharmacy (www.thelearningpharmacy.com).
The recently published ARHAI and PHE antimicrobial prescribing competencies are also an essential resource for all independent pharmacist prescribers (see “Resources”).
Europe has been ahead of the world on the use of antibiotics in animals. EU legislation states that all antibiotics require a prescription for an animal or herd and antibiotics use for growth promotion was banned.
In a similar manner to how pharmacists focused on human health implement recommendations from the DoH, PHE and professional bodies, veterinary pharmacists have a key role in joining with the VMD and other veterinary professional bodies to promote prudent antibiotic use to vets, farmers and pet owners. The RPS Veterinary Forum has an essential role in ensuring promulgation of messages across both human and animal health.
Antimicrobial resistance is a major clinical and public health issue and a threat to the future of healthcare. Pharmacists and pharmacy teams have a key role to play in helping to control the increase of AMR. It is time for the profession to unite in the fight against antibiotic resistance. The RPS has a key role in providing clear leadership in ensuring a joined up approach across the professional pharmaceuticals bodies.
The following EAAD resources are available at: www.gov.uk/government/collections/European-antibiotic-awareness-day-resources
Resources for primary and secondary care
- Key messages on antibiotic resistance by the DoH, the ARHAI andVMD-DEFRA
- Leaflet — “Get well soon without antibiotics”
- Poster (a refresh of the Hand poster with new logos) — “No amount of antibiotics will get rid of your cold”
- Antibiotic awareness videos, available for download via DoH website in various formats and on YouTube. These are short video clips providing a light-hearted way of reminding people to take care, not antibiotics for use in GP surgeries and other waiting areas. They include “When you’re ill you’ll do anything to feel better”, “Sick as a parrot?”, “Looking for a purrfect remedy for your cough”, “Don’t get prickly if your doctor won’t prescribe you antibiotics” and “Feel like a lame duck?”
- Centre piece poster that can be used for public awareness display boards in hospitals, GP surgeries and clinics
- Quizzes and crosswords for healthcare professionals, patients and the public
- Case studies
Specific resources for healthcare professionals in primary care:
- Website banner for primary care promoting the “TARGET antibiotics” website
- “TARGET antibiotics” toolkit is available on the Royal College of General Practitioners website — www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx
Specific resources for healthcare professionals in secondary care:
- Secondary care prescribers checklist — a useful reminder for hospital prescribers of the main considerations for responsible prescribing
- Website banner promoting EAAD, especially “Start smart then focus”
- ARHAI guidance on AMR: “Start smart then focus” — www.gov.uk/government/publications/antimicrobial-stewardship-start-smart-then-focus
- Poster — “Start smart then focus”, a survey of implementation in England
- ARHAI and PHE Antimicrobial prescribing and stewardship competencies
Other useful links:
- Letters to the NHS, primary care and local government — http://bit.ly/18nxLwX
- E-Bug – the educational tool about infections for schools — www.e-bug.eu
- European Centre for Disease Prevention and Control — http://ecdc.europa.eu/en/EAAD/Pages/Home.aspx/
- NHS Choices website, which provides information for patients and the public — www.nhs.uk
- Patient.co.uk, which provides some useful information on antibiotics — www.patient.co.uk
- Health Education England — www.hee.nhs.uk
- National Prescribing Competencies (hosted by NICE) — http://www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf
- Self-care forum — www.selfcareforum.org/
- Treat Yourself Better — www.treatyourselfbetter.co.uk/
- Centre for Pharmacy Postgraduate Education — www.cppe.ac.uk
- Antibiotic Action, an independent UK-led global initiaitve funded by the British Society for Antimicrobial Chemotherapy to educate the public about the need for discovery, research and development of new antibiotics — www.antibiotic-action.com
- Thunderclap, a social networking initiative to sprad the word about antibiotic resistance — http://bit.ly/Antibiotics-Thunderclap
Free antimicrobial stewardship training resources
- EAAD materials — www.gov.uk/government/collections/European-antibiotic-awareness-day-resources
- Centre for Postgraduate Pharmacy Education – www.cppe.ac.uk
- Self-care forum - http://www.selfcareforum.org/
- ARHAI & PHE Antimicrobial Prescribing and Stewardship Competences - https://www.gov.uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies
- Royal College of General Practitioner’s website: (i) TARGET antibiotics toolkit — www.rcgp.org.uk/targetantibiotics ; (ii) Self Care for Minor Ailments e-learning course — www.elearning.rcgp.org.uk/selfcare ; (iii) Managing respiratory tract — www.rcgp.org.uk/courses-and-events/online-learning/ ole/managing-acute-respiratory-tract-infections.aspx ; (iv) Managing urinary tract infections — http://elearning.rcgp.org.uk/course/info.php?id=117
All healthcare professionals, trainees and students can register for an RCGP e-learning account, which provides free access to selected RCGP courses and updates.
- Ashiru-Oredope D, Sharland M, Charani E et al. Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart — Then Focus. Journal of Antimicrobial Chemotherapy 2012;67(Suppl):i51–63.
- Howard P, Cooke, J, Stockley J et al. Antimicrobial Stewardship. Start smart then focus — a survey of implementation in England. Available at: www.gov.uk/ government/publications/european-antibiotic-awareness-day-resources-for-secondary-care (accessed 10 November 2013).
- Ashiru-Oredope D, Hopkins S. Antimicrobial stewardship: English Surveillance Programme for Antimicrobial Utilization and Resistance (ESPAUR). Journal of Antimicrobial Chemotherapy 2013;68:2421–3.
- Sewak NPS, Cairns J. A modelling analysis of the cost of a national minor ailments scheme in community pharmacies in England. International Journal of Pharmacy Practice 2011;19(S1):50.
- Partial impact assessment of proposals to expand the provision of minor ailment services. London: Department of Health, 2008.
- Harris D. Initiatives to improve appropriate antibiotic prescribing in primary care. Journal of Antimicrobial Chemotherapy 2013;68:2424–7.
Philip Howard is consultant antimicrobial pharmacist at Leeds Teaching Hospitals NHS Trust and chairman of the Royal Pharmaceutical Society Consultants Group
Diane Ashiru-Oredope is pharmacist lead at Public Health England and antimicrobial pharmacist at Barking, Havering and Redbridge Hospitals NHS Trust.
Mark Gilchrist is consultant pharmacist, infection at Imperial College Healthcare NHS Trust and chairman of the UKCPA Infection Management Group
Sue Carter is head of medicines management at Coastal West Sussex Clinical Commissioning Group.
Chris Cutts is director of the Centre for Pharmacy Postgraduate Education.
Rob Darracott is chief executive of Pharmacy Voice.
Naomi Fleming is antimicrobial pharmacist at Central and North West London-Milton Keynes NHS Foundation Trust.
Diane Harris is specialist antimicrobial pharmacist at Southern Derbyshire CCG
Barbara Parsons is head of pharmacy practice, at the Pharmaceutical Services Negotiating Committee.
Neal Patel is head of corporate communications at the Royal Pharmaceutical Society.
Correspondence to: Dr Ashiru-Oredope (firstname.lastname@example.org),
Mr Howard (email@example.com) and Mr Gilchrist (firstname.lastname@example.org)
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Citation: The Pharmaceutical Journal URI: 11130187
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