Antimicrobial Stewardship: How the Community Pharmacist Can Help

Natalie Kokta, PharmD Candidate, Mylan School of Pharmacy, Duquesne University, Pittsburgh, PA.

According to the Centers for Disease Control and Prevention (CDC), “Antibiotics are a shared resource—and becoming a scarce resource.”¹ In 2013, the CDC estimated that more than 2 million illnesses and 23,000 deaths were caused by antibiotic resistance.² The most modifiable component of complications caused by antibiotic resistance, which leads to increased healthcare costs and poor health outcomes, is antibiotic use. It is estimated that up to 50% of outpatient antibiotic prescriptions are inappropriate,² and are most often indicated for acute respiratory infections. With these statistics on the rise, antibiotic resistance is one of the world’s most pressing health concerns, with cause to limit misuse and overuse of antibiotics.

Stewardship and Its Impact on the War on Antibiotic Resistance

The National Action Plan for Combating Antibiotic-Resistant Bacteria is a plan designed to guide the United States in rising to the challenge of combating the pressing threat of antibiotic resistance.³ This plan was developed in response to President Obama’s Executive Order 13676: Combating Antibiotic-Resistant Bacteria. Slowing the emergence of resistant bacteria and preventing resistant infections from spreading is the first goal listed in the plan.³ This goal includes practicing antibiotic stewardship interprofessionally to improve prescribing practices across all settings in healthcare, including the outpatient community pharmacy.

Antibiotic stewardship is defined as promoting the appropriate selection, dose, duration, and route of administration of antibiotics.⁴ As an antibiotic steward seeking to achieve optimal patient outcomes, limiting adverse events and toxicities, reducing patient care costs, and limiting the drug selection for antimicrobial-resistant bacteria are top priorities.⁴

The National Association of Chain Drug Stores made a pledge to the CDC stating that they “will integrate stewardship principles into existing programs that provide free or reduced price antibiotics to patients; will develop a new educational model on ‘using point of care tests in pharmacies to promote antimicrobial stewardship and combat antimicrobial resistance’; and will aim to examine the literature supporting outpatient antimicrobial stewardship programs, develop the requisite infrastructure for outpatient clinic and pharmacy stewardship programs, and convene member forums to disseminate the knowledge and showcase implementation of neighborhood stewardship programs.”⁵

How Can Community Pharmacists Help?

Pharmacists are unique members of the healthcare team; being able to collaborate readily with providers and patients allows for opportunities to aid in combating antibiotic resistance. These opportunities include intervening to prevent unnecessary antibiotic use, promoting vaccinations, and, most important, educating patients and providers. Pharmacists are often the first healthcare practitioner sought by patients for advice regarding infections. In this capacity, pharmacists have a noteworthy responsibility to be a source of information and education, often leading to the avoidance of a physician visit, which can help alleviate the pressure physicians feel from patients to prescribe antibiotics when their use is not truly warranted.⁶

Listed below are a few opportunities that community pharmacists can take advantage of in their practice settings to contribute to the fight against the war on resistance.

Pharmacists Are a Resource

Keeping up to date with current practice guidelines and recommendations for appropriate antibiotic prescribing in adults and children who are seeking care in the community setting is of great importance. By doing so, pharmacists can act as the “gateway practitioner”⁶ to intervene and prevent unnecessary antibiotic use, and improve antibiotic stewardship. The CDC offers quick reference tables⁷ for practitioners (see www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/index.html). Table 1 summarizes the CDC reference table for adult patients.

Table 1 Quick Reference for Common Adult Patient Antibiotic Treatments in the Outpatient Setting

Source: Centers for Disease Control and Prevention. Adult treatment recommendations. Updated March 4, 2016. www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-treatment-rec.pdf.

Pharmacists Are Educators

Pharmacists are key healthcare educators in the community. Education is a large component of pharmacist-led outpatient stewardship, as studies^8,9 have suggested that patient expectations can influence prescribing habits. Pharmacists have the unique opportunity to include education on antibiotic resistance and stewardship during regular patient interventions already incorporated into their regular workflows.

Such education should include the difference between viral and bacterial infections, explaining why antibiotics will not help when viral infection is suspected, and how improving patients’ knowledge and limiting unnecessary prescribed antibiotics can greatly contribute to the battle the world is facing with antibiotic resistance (Table 2).¹⁰

Table 2 Key Counseling Points for Infection Education

Source: Centers for Disease Control and Prevention. Antibiotics aren’t always the answer. Updated November 14, 2016. www.cdc.gov/features/getsmart/.

When viral infections are suspected by a patient, physician, or pharmacist, appropriate symptomatic care can be recommended by the pharmacist as self-care options to try before seeking antibiotic therapy. Self-care examples for common symptoms associated with viral infections include⁷:

1. Cough can be relieved through the use of cough suppressants and lozenges (key active ingredient, dextromethorphan)
2. Short-term relief of nasal symptoms and coughing can also be achieved through the combined use of decongestants with first-generation antihistamines (key active ingredients, decongestant, pseudoephedrine or phenylephrine; first-generation antihistamine, diphenhydramine or chlorpheniramine)
3. Aches and pains can be relieved through the use of nonsteroidal anti-inflammatory drugs (key active ingredient, ibuprofen).

Pharmacists Support Vaccination

Pharmacists are essential in the promotion of currently available vaccines. By being up to date about vaccines, the use of antibiotics can be decreased directly because vaccines help prevent primary infection, and indirectly because vaccines can prevent serious infection of vaccine-preventable illnesses (eg, influenza).⁶

By screening patients during normal workflow in the community, pharmacists have the ability to identify patients in need of vaccination, and can vaccinate those in need that day because pharmacists are now able to vaccinate in every state.

We Are All Stewards and Have a Responsibility to Assist in Fighting Antibiotic Resistance

To slow the progression of antibiotic-resistant bacteria, all healthcare professionals must work collaboratively and contribute as individuals. We all have a responsibility to assist in the war on antibiotic resistance as stewards in each healthcare setting, especially in the outpatient community. As frontline practitioners, pharmacists especially have a role to play as educators and vaccinators.

Without interprofessional treatment protocols for bacterial infections, antibiotics available for use will continue to decrease because of increased antibiotic resistance. It is vital that we collaboratively take a stand against resistance and limit antibiotic use today to prevent larger problems tomorrow.

Author Disclosure
Ms Kokta received a grant from the Pennsylvania Pharmacists Association.

References

1. Centers for Disease Control and Prevention. Appropriate antibiotic use – saves lives, saves money, makes sense. November 17, 2010. www.cdc.gov/getsmart/healthcare/resources/factsheets/pdf/antibiotic-use.pdf. Accessed October 2016.
2. Centers for Disease Control and Prevention. About antimicrobial resistance. Updated September 8, 2015. www.cdc.gov/drugresistance/about.html. Accessed October 2016.
3. Task Force for Combating Antibiotic-Resistant Bacteria. National action plan for combating antibiotic-resistant bacteria. March 2015. www.whitehouse.gov/sites/default/files/docs/national_action_plan_for_combating_antibotic-resistant_bacteria.pdf. Accessed October 2016.
4. Infectious Diseases Society of America. Promoting antimicrobial stewardship in human medicine. 2016. www.idsociety.org/Stewardship_Policy/. Accessed October 2016.
5. Centers for Disease Control and Prevention. Leaders committed to antibiotic stewardship. Updated December 7, 2016. www.cdc.gov/drugresistance/federal-engagement-in-ar/stewardship-commitment/index.html. Accessed October 2016.
6. McCoy D, Toussaint K, Gallagher JC. The pharmacist’s role in preventing antibiotic resistance. US Pharm. 2011;36:42-49.
7. Centers for Disease Control and Prevention. Adult treatment recommendations. Updated March 4, 2016. www.cdc.gov/getsmart/community/for-hcp/outpatient-hcp/adult-treatment-rec.pdf. Accessed October 2016.
8. Stevenson FA, Greenfield SM, Jones M, et al. GPs’ perceptions of patient influence on prescribing. Fam Pract. 1999;16:255-261.
9. 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;315:1211-1214.
10. Centers for Disease Control and Prevention. Antibiotics aren’t always the answer. Updated November 14, 2016. www.cdc.gov/features/getsmart/. Accessed October 2016.