Izwan Ishak
1 May 2020
How can pharmacist contribute to reducing the spread of antimicrobial resistance?
Antimicrobial resistance (AMR) is defined as the resistance of a micro-organism to an
antimicrobial medicine to which it was originally sensitive (The Royal College of Pathologists,
2020). A few commonly-encountered bacterial strains that develop resistance to antimicrobials
are Escherichia coli (E. coli), Klebsiella pneumoniae, Streptococcus pneumonia, and
methicillin-resistant Staphylococcus aureus (MRSA) (WHO, 2014). It is estimated that
700,000 people globally die each year due to antibiotic resistance (Smith, 2018). According to
a paper published in 2016 as part of the UK’s Review on Antimicrobial Resistance, if drug
resistant infections are not tackled now, they could kill an extra 10 million people across the
world each year by 2050 (Review on Antimicrobial Resistance, 2014). The root cause of this
problem is multifactorial and stems from the overuse of antibiotics, inappropriate antibiotic
prescribing and dispensing, extensive use in agriculture and veterinary sectors, lack of new
antibiotics, and weak regulatory barriers (Ventola, 2015).
Pharmacist can curb the spread of antimicrobial resistance by ensuring all antibiotic
therapy is clinically indicated. Pharmacist should intervene when an antibiotic is prescribed
without the signs of infection or if the physician’s diagnosis has changed to a condition which
doesn’t require antibiotic therapy. To do this effectively, pharmacist should know the
indication for every antimicrobial that is started for a patient (Schiff, Seoane-Vazquez &
Wright, 2016). Pharmacist must equip themselves with knowledge of quick and reliable
diagnostic test that could facilitate with confirmation of infection such as point-of-care Creactive protein test that is used in diagnosis of lower respiratory tract infection (Huddy et al.,
2016). Having the ability to interpret full blood count results also gives pharmacist the
advantage to recognize signs of infection and discuss with physician on whether an antibiotic
therapy is indicated or not. This is important as a 2018 published scoping review by Jamshed
et al. found that penicillin only or combination with penicillinase inhibitor were the most
common anti-microbial agents dispensed for URTI (Jamshed et al., 2018). They also found out
that in URTI scenarios that used viral cough as the presented problem, the community
pharmacists always dispensed penicillin or penicillin plus penicillinase inhibitor as the
treatment. The dispensing of antibiotic for viral URTI is not appropriate and will only
contribute to antimicrobial resistance. Hence, it is important for pharmacists to recognize signs
of infection and know the indication for each antibiotic prescription before dispensing in order
to discuss with prescriber about the rationale of starting an antibiotic.
Izwan Ishak
1 May 2020
Equipped with knowledge of antibiotic’s mechanism of action and activity spectrum,
pharmacists should be involved in making evidence-based decisions about antibiotic therapy
(Floris, Cluck & Singleton, 2020). Pharmacist must ensure the selection of antibiotic with
adequate spectrum that will target the likely pathogen associated with the diagnosed infection
based on microbiological surveillance data and susceptibility pattern (National Antimicrobial
Guideline, 2019). As soon as blood culture sensitivity results are available, de-escalation of
antibiotic therapy should be done to ensure patient is on the antibiotic with the specific
narrowest spectrum available. If duplicate therapies with overlapping spectra are detected,
pharmacist must discuss with prescriber to discontinue one of the agents. Pharmacist must also
ensure accurate patient records on drug allergy history information including the type of
reaction so that alternative antibiotic could be given even at the start to avoid therapy failure
and minimize the use of second line agents (The pharmacy contribution to antimicrobial
stewardship, 2017). Additional pharmacist-led activities include; individualized dose
adjustments for patients with organ dysfunction (e.g. renal or hepatic adjustment), dose
optimization based on therapeutic drug monitoring, and detection and prevention of antibioticrelated drug-drug interactions (Fortin, 2018). By optimizing antimicrobial therapy, pharmacist
helps to improve patient outcomes while reducing the burden of hospital-acquired infections,
the spread of AMR and consequent healthcare costs (Patient Safety Alert-Stage Two:
Resources Addressing antimicrobial resistance through implementation of an antimicrobial
stewardship programme, 2015).
Besides guiding antibiotic selection, pharmacist must ensure complete duration of
antibiotic therapy with respect to symptoms resolution and prevent unnecessary prolonged
duration of therapy. 72-hours review form is a useful tool to spark the discussion between
pharmacist and prescriber on whether the initial antibiotic used is still appropriate or not
considering the current clinical status of the patient. Pharmacist must also remind the prescriber
to discontinue antibiotic therapy that has time-sensitive indications such as in surgical
prophylaxis. Special order form is used to limit the duration of peri-operative antibiotic and
thus reduce the incidence of surgical site infections, antibiotic use and costs (de With et al.,
2016). When patients’ conditions are stable and they are able to tolerate orally, pharmacist must
prompt the change of IV therapy to oral route. Pharmacist-led parenteral-to-oral switches has
been proven to shorten the duration of parenteral therapy without negatively impacting on
clinical outcomes (de With et al., 2016)
Izwan Ishak
1 May 2020
The importance of educating the public on the correct use of antibiotics could not be
further emphasized as a European survey has shown that a significant proportion of the
population are unaware that antibiotics are ineffective against viruses (53%) and against colds
and flu (47%) (Antimicrobial Resistance, 2010). As the first port of call for patient advice and
management for minor ailments (Pinder, Sallis, Berry and Chadborn, 2015), community
pharmacists must provide self-care advice to patients with self-limiting or viral infections and
recommend appropriate symptom relief, common or minor ailment treatments or referral where
necessary (The pharmacy contribution to antimicrobial stewardship, 2017). Educating patients
on the expected duration of the viral illness will also help to ease their anxiety. When
dispensing antibiotic, it is imperative to educate patients on importance of completing their
course of prescribed antibiotic therapy. Patients should be reminded that antibiotics are not to
be shared or reused and any leftover could be returned to the pharmacy for safe disposal.
Pharmacist must also promote hygienic measures such as proper handwashing habit to reduce
infection in the community. Yearly administration of influenza vaccine can also decrease the
use of antibiotics indirectly by preventing bacterial superinfection after a primary vaccinepreventable illness such as influenza.
Pharmacist as the medication expert and the most accessible healthcare professional
could play a central role in minimizing the spread of antibacterial resistance by being the safe
gate-keeper of antibiotic use. The roles include ensuring antibiotic therapy is clinically
indicated, guiding a rational and evidence-based antibiotic prescribing, ensuring complete
duration of therapy and educating the public about the proper use of antibiotic. By reducing
antimicrobial resistance, current antimicrobial agents’ efficacy could be preserved for the
treatment of future infections.
Izwan Ishak
1 May 2020
Reference lists
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Izwan Ishak
1 May 2020
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Izwan Ishak
1 May 2020
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