What's next for antibiotics?
The Government’s health policy paper, ‘Our plan for patients’, published in September, outlined plans to enable pharmacies to “manage and supply more medicines such as contraception without a GP prescription, and take referrals from emergency care for minor illnesses or symptoms.” It also stated: “The Government will look to go further in enabling pharmacists’ prescribing powers and making more simple diagnostic tests available in community pharmacy.”
At the time, Dr Richard Van Mellaerts, deputy chair of the General Practitioner’s Committee at the BMA (GPC England), stressed that antibiotics should be prescribed only when absolutely necessary. “Overusing antibiotics risks making them less effective,” he said, “and makes some infections increasingly difficult to treat, which can then actually increase pressure on the health service as patients remain unwell… While community pharmacists already play a hugely supportive role to GP practices, making it easier for others to prescribe antibiotics is not the way to reduce the need for GP appointments or wider pressures in general practice.”
Prescribing in primary care
The Government’s Tackling antimicrobial resistance 2019 to 2024 addendum to the UK’s 5-year national action plan, published in May, outlines three key ways to tackle antimicrobial (antibiotic) resistance. These are: (1) reducing the need for, and the unintentional exposure to, antimicrobials; (2) optimising the use of antimicrobials; and (3) investing in innovation, supply and access.
There is evidence that patients don’t always complete a prescribed course of antibiotics and may use leftover or non-prescribed antibiotics.
Jonathan Pearce, chief executive of Antibiotic Research UK, believes community pharmacists have an important role to play in the stewardship of antibiotics. “It’s not just about whether to give pharmacists more powers to prescribe,” he says. “It’s about ensuring that everyone in primary care has access to the information and assessment tools they need to prescribe the right medicines. Pharmacists should be supported to run trialled and tested stewardship schemes, supported with robust diagnostic tests. Patients must receive the most appropriate treatment, which will often not be antibiotics.”
Research published in July evaluated a community pharmacy antimicrobial stewardship intervention, consisting of the TARGET (treat antibiotics responsibly; guidance, education, and tools) Antibiotic Checklist, staff e-learning, and patient-facing materials.
The research was conducted in two phases: pre-intervention in October 2020, post-intervention in December 2020 to January 2021. The researchers found that after the intervention, staff increased their antibiotic appropriateness checks and patient advice, covering antibiotic adherence, antibiotic resistance, infection self-care and safety netting. Pharmacy staff acknowledged the need for improved communication across the primary care pathway to optimise antimicrobial use.
The TARGET Antibiotic Checklist was included in the 2021/22 Pharmacy Quality Scheme (PQS). Some 74 per cent (8,374) of pharmacies in England (March 2022) submitted data from patients between September 2021 and May 2022 covering 213,105 prescriptions. The English surveillance programme for antimicrobial utilisation and resistance (ESPAUR) report 2021 to 2022, published last month, says: “The high engagement with this scheme suggests stewardship principles are embedded. The PQS is an effective lever for implementing and embedding antimicrobial stewardship at pace in community pharmacy and future PQS activities should continue to build on this.”
Pharmacy teams reported using the patient’s knowledge assessment to tailor their advice to patients for 80 per cent of prescriptions and 32 per cent of patients were provided with an infection self-care checklist.
Jonathan Pearce is supportive. “We already work in partnership with Well Pharmacy to promote the issue of antimicrobial resistance and would welcome the opportunity to work with more pharmacy chains,” he says. “We also welcome the Royal Pharmaceutical Society’s recently launched ‘Antibiotic Amnesty’ campaign, which provides resources and tools for individual pharmacies.”
Many community-based pharmacists in the UK have become independent prescribers and already prescribe antibiotics under minor ailment schemes and PGDs. According to Kajal Narbad, advice and support pharmacist at the National Pharmacy Association, growing these services would be a positive step. “It is important to ensure antibiotics are used correctly; for example, not supplied to treat a viral infection,” she says. “Conditions accessible to diagnosis would be areas for wider use, for example, urinary tract infections, ear infection, impetigo, and chlamydia.”
Last December, the AMR Programme Board of NHS England and NHS Improvement reviewed a proposal for a Pharmacy Integration Fund pilot to develop an enhanced service, following a Community Pharmacy Consultation Service (CPCS) referral, to supply antibiotics to treat uncomplicated lower urinary tract infections (LUTIs) in women aged 16 to 50 years. According to Scottish SIGN guidelines on the management of suspected bacterial LUTIs in adult women, in Scotland UTIs are the second most commonly reported indication for an antibiotic prescription in the community, after respiratory tract infections.
“As part of last year’s Winter Access Fund, the North East and North Cumbria introduced a UTI service with community pharmacies, either for walk-ins or for GP referral,” says Professor Philip Howard OBE, regional antimicrobial stewardship lead for NHS England – North East & Yorkshire. “UTIs take up 10 per cent of GP acute consultations. Using the recently updated Scottish SIGN guidelines, one symptom means self-care and two or more symptoms means using a dipstick and antibiotics, depending on results, with a follow up by a community pharmacist. Fifty-two per cent of patients with two or more symptoms get an antibiotic.”
Promoting safer use
A global Sore Throat & Antibiotic (STAR) study, launched last month by the Global Respiratory Infection Partnership (GRIP) and Reckitt (maker of Strepsils and other healthcare products), revealed concerning misunderstandings about how to treat common respiratory conditions, such as a sore throat without antibiotics, especially among adults aged under 35.
More than half of the adults surveyed had taken antibiotics for a respiratory condition such as a sore throat in the previous six months, and three in five adults under 35 believe antibiotics are effective for a sore throat; 45 per cent admitted they don’t know how to treat respiratory conditions without antibiotics.
The STAR study is encouraging pharmacists to discuss antibiotic usage with every customer presenting with a sore throat to address knowledge gaps, and GRIP (www.grip-initiative.org) has produced educational resources for pharmacies to use.
Speaking on behalf of GRIP, Dr Martin Duerden, medical adviser for the diploma in therapeutics at Cardiff University and adviser to the UK Royal College of GPs and to NICE, says pharmacists should see themselves as ‘antibiotic guardians’ with an important role in reducing antibiotic use and conserving them for the future. “They can take the Antimicrobial Guardian pledge,” he says. “A simple step is taking every opportunity to discuss with patients how antibiotics have minimal effects on most common infections, particularly coughs and colds. They should only be considered for more serious infections. Rather than seeking antibiotics, as much as possible, patients should be encouraged to use things like painkillers and throat lozenges – these are much more effective.”
In August, the Royal Pharmaceutical Society (RPS) published a series of documents intended to help community pharmacists tackle inappropriate antibiotic use by raising awareness of antibiotic resistance and the damage that antibiotics can do to the environment. One way to do this would be to run an Antibiotic Amnesty campaign locally, providing safe disposal routes for leftover antibiotics from convenient locations (such as community pharmacies).
Top ten ways to promote safer antibiotic use
- Prescribe antibiotics appropriately and advise on self-care and self-limiting conditions
- Check that prescriptions are appropriate and advise people on how to use them properly
- Educate customers about the effective use of antimicrobials
- Train and educate the pharmacy team
- Promote the best use of NHS resources, such as via minor ailments schemes and flu jabs
- Pledge to become an Antibiotic Guardian
- Join local antimicrobial stewardship (AMS) groups and networks and participate in an amnesty campaign to make sure leftover antibiotics are being disposed of safely
- Raise awareness using posters, leaflets and social media, tying in with national and international campaigns, such as World Antimicrobial Awareness Week every November
- Audit AMS activity in the pharmacy
- Maintain hand hygiene in the workplace to reduce risk of infection (e.g. using alcohol‑based hand rubs and gels).
Source: Royal Pharmaceutical Society
The TARGET suite of resources has been specially adapted for community pharmacy staff to use when supporting patients with prescriptions for antibiotics (the Antibiotic Checklist) or presenting with possible symptoms of infection (Treating Your Infection leaflets).
“All antibiotics can cause harm to patients, so should only be used where there is a proven benefit over self-care,” says Mark Gilchrist, chair of the RPS Expert Antimicrobial Group. “Ensuring that patients and the public understand the importance of self-care for self-limiting infections is a vital role for community pharmacy teams, as is increasing awareness of the importance of the safe disposal of unused or expired antibiotics through pharmacies.
“Many people are erroneously labelled as allergic to penicillins, when this may not be the case, meaning they are treated with antibiotics that require longer or repeated courses. Educating patients visiting community pharmacies on the benefit of an accurate penicillin allergy status would reduce harm and improve patient outcomes.”
Rising antibiotic resistance
According to the World Health Organization (WHO), a growing number of infections – including pneumonia, tuberculosis, gonorrhoea and salmonellosis – are becoming harder to treat because the antibiotics used to treat them are becoming less effective. Antibiotic resistance leads to longer hospital stays, higher medical costs and increased mortality. “Antibiotic resistance is driven by our misuse of these drugs,” states WHO’s website. “Major drivers include inappropriate use (for viral infections, for example), over-use, and even under-use of antibiotics in cases where they are needed… Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill.”
In the latest data published by the UK Health Security Agency (UKHSA), the estimated total number of serious antibiotic resistant infections in England rose by 2.2 per cent in 2021 compared to 2020 (53,985 compared to 52,842).