The essential role of pharmacists in antibiotic stewardship in outpatient care: An official position statement of the Society of Infectious Diseases Pharmacists

Pharmacists combating antimicrobial resistance: A Delphi study on antibiotic dispensing

BACKGROUND

The daily work of community pharmacists includes dispensing antibiotics, but little is known about how this should be done to ensure quality use of antibiotics.

OBJECTIVE

To define specific tasks of the community pharmacist when dispensing antibiotics and to assess to what extent these tasks can be implemented in practice in Europe.

METHODS

A Delphi study with community pharmacist experts in the European Economic Area. Statements on potential tasks for pharmacists during the antibiotic dispensing process were based on a systematic literature review. Participants rated the statements for importance and feasibility of implementation in practice in 3 rounds on a scale from 1 to 9. Consensus of importance was defined as ≥ 80 % of experts rating a statement between 7 and 9. An online expert meeting was conducted between rounds 1 and 2. Scores for all statements were analysed descriptively.

RESULTS

Overall, 38 experts from 21 countries participated in the study. Experts reached consensus on 108 statements within 5 themes: 1) collaboration with prescribers, 2) checking prescriptions and dispensing, 3) counselling, 4) education, and 5) pharmacy services. Potential tasks included advising and collaborating with prescribers, performing safety checks, and having access to specific prescription information. Additionally, pharmacists should counsel patients related to the dispensed antibiotic and on antimicrobial resistance and infectious diseases. With few exceptions, pharmacists should not dispense antibiotics without prescriptions or prescribe antibiotics. Consensus on feasibility of implementation was only reached for statements in the categories "counselling patients" and "education". Barriers to changing practice included structure of the healthcare system, resistance to change from prescribers or pharmacy staff, lack of time and finances, legal barriers, and patient expectations.

CONCLUSION

Community pharmacists have an important role when dispensing antibiotics. This study provides important steps towards better community pharmacy antibiotic dispensing practices throughout the EEA.

Opportunities and Barriers to Pediatric Antimicrobial Stewardship by Community Pharmacists

Community Pharmacists (CPs) are easily accessible and can advocate for the appropriate use of antibiotics in children. Semi-structured interviews were conducted with 47 CPs and 46 parents/caregivers. Both groups expressed challenges to intervening when antibiotics have already been prescribed and highlighted the need for more support for CPs to make informed decisions.

Knowledge, attitudes, and practices of primary healthcare practitioners regarding pharmacist clinics: a cross-sectional study in Shanghai

BACKGROUND

Pharmacist clinics offer professional pharmaceutical services that can improve public health outcomes. However, primary healthcare staff in China face various barriers and challenges in implementing such clinics. To identify existing problems and provide recommendations for the implementation of pharmacist clinics, this study aims to assess the knowledge, attitudes, and practices of pharmacist clinics among primary healthcare providers.

METHODS

A cross-sectional survey based on the Knowledge-Attitude-Practice (KAP) model, was conducted in community health centers (CHCs) and private hospitals in Shanghai, China in May, 2023. Descriptive analytics and the Pareto principle were used to multiple-answer questions. Chi-square test, Fisher's exact test, and binary logistic regression models were employed to identify factors associated with the knowledge, attitudes, and practices of pharmacist clinics.

RESULTS

A total of 223 primary practitioners participated in the survey. Our study revealed that most of them had limited knowledge (60.1%, n = 134) but a positive attitude (82.9%, n = 185) towards pharmacist clinics, with only 17.0% (n = 38) having implemented them. The primary goal of pharmacist clinics was to provide comprehensive medication guidance (31.5%, n = 200), with medication education (26.3%, n = 202) being the primary service, and special populations (24.5%, n = 153) identified as key recipients. Logistic regression analysis revealed that education, age, occupation, position, work seniority, and institution significantly influenced their perceptions. Practitioners with bachelor's degrees, for instance, were more likely than those with less education to recognize the importance of pharmacist clinics in medication guidance (aOR: 7.130, 95%CI: 1.809-28.099, p-value = 0.005) and prescription reviews (aOR: 4.675, 95% CI: 1.548-14.112, p-value = 0.006). Additionally, practitioners expressed positive attitudes but low confidence, with only 33.3% (n = 74) feeling confident in implementation. The confidence levels of male practitioners surpassed those of female practitioners (p-value = 0.037), and practitioners from community health centers (CHCs) exhibited higher confidence compared to their counterparts in private hospitals (p-value = 0.008). Joint physician-pharmacist clinics (36.8%, n = 82) through collaboration with medical institutions (52.0%, n = 116) emerged as the favored modality. Daily sessions were preferred (38.5%, n = 86), and both registration and pharmacy service fees were considered appropriate for payment (42.2%, n = 94). The primary challenge identified was high outpatient workload (30.9%, n = 69).

CONCLUSIONS

Although primary healthcare practitioners held positive attitudes towards pharmacist clinics, limited knowledge, low confidence, and high workload contributed to the scarcity of their implementation. Practitioners with diverse sociodemographic characteristics, such as education, age, and institution, showed varying perceptions and practices regarding pharmacist clinics.

Evaluation of Antimicrobial Stewardship Programs and antibiotic prescribing patterns among physicians in ambulatory care settings in Jordan

OBJECTIVES

Currently, there is an urgent need to implement an Antimicrobial Stewardship Program (ASP) in outpatient settings since nearly half of the antibiotic prescribing is inappropriate or unnecessary. The implementation of ASP should emphasize educational interventions that are more interactive. This study examines the adoption of outpatient ASP by physicians in Jordan.

METHODS

A cross-sectional study was conducted between 2 March 2022 and 20 May 2022 at major hospitals in Jordan. The survey was distributed randomly among (n = 187) Jordanian physicians.

RESULTS

It was found that more than half of the physicians were females (51.9%). The participants who reported not including antibiotic stewardship-related duties in position descriptions were (40.1%). While (46.5%) of participants reported writing and displaying public commitments supporting antibiotic stewardship in ambulatory care settings. Physicians' adoption of (action) core elements of ASPs in ambulatory care settings was positive. Almost (24.6%) reported a lack of self-evaluation of their antibiotic-prescribing practices. It was reported that (69.5%) of physicians used effective communication strategies to educate patients about when antibiotics are necessary.

CONCLUSION

It was fair adoption of the core elements in the ambulatory care settings among Jordanian physicians. Progress necessitates a comprehensive strategy tailored to the needs of the health system.

Health system barriers to the implementation of the national action plan to combat antimicrobial resistance in Vietnam: a scoping review

BACKGROUND

Vietnam is among 11 countries in the Western Pacific region that has developed a National Action Plan for Antimicrobial Resistance (NAPCA).

METHODS

This scoping review characterises health system barriers to the implementation of the Vietnam NAPCA, with reference to the WHO Health Systems Framework.

RESULTS

Over 7 years, between 2013 and 2020, the Ministry of Health (MOH) of Vietnam has been implementing activities to achieve the six NAPCA objectives. They include revision of regulations needed for antimicrobial resistance (AMR) prevention programs; formation and operation of national management bodies; improvement of antimicrobial stewardship (AMS) in hospitals; maintenance of surveillance systems for AMR; provision of trainings on AMR and antibiotics use to doctors and pharmacists; and organization of nation-wide educational campaigns. Limited cooperation between MOH management bodies, shortages of human resource at all health system levels, a low degree of agreement between national and hospital guidelines on antibiotic use, low capability in the domestic supply of standardised drugs, and unequal training opportunities for lower-level health professionals present ongoing challenges. Actions suggested for the next period of the NAPCA include a final review of what has been achieved by the plan so far and evaluating the effectiveness of the different components of the plan. Different options on how to improve coordination across sectors in the development of a new NAPCA should be put forward.

CONCLUSIONS

The 6-year implementation of the Vietnam NAPCA has yielded valuable lessons for AMS in Vietnam, guiding the development of future national plans, with a central focus on scaling up AMS in hospitals and promoting community AMS programs to combat AMR.

A comparison between antibiotic utilisation in public and private community healthcare in Malaysia

BACKGROUND

There are two parallel systems in Malaysian primary healthcare services: government funded public primary care and privately-owned practices. While there have been several studies evaluating antibiotic utilisation in Malaysian public healthcare, there is a lack of literature on the use of antibiotics in the private sector. There is a dire need to evaluate the more recent performance of public vs. private community healthcare in Malaysia. As such, this study aimed at measuring and comparing the utilisation of antibiotics in the public and private community healthcare sectors of Malaysia in 2018-2021.

METHODS

This study was a retrospective analysis of antibiotic utilisation in Malaysian primary care for the period of 1 January 2018 until 31 December 2021 using the nationwide pharmaceutical procurement and sales data from public and private health sectors. Rates of antibiotic utilisation were reported as Defined Daily Doses per 1000 inhabitants per day (DID) and stratified by antibiotic classes. The secondary analysis included proportions of AWaRe antibiotic category use for each sector and proportion of antibiotic utilisation for both sectors.

RESULTS

The overall national antibiotic utilisation for 2018 was 6.14 DID, increasing slightly to 6.56 DID in 2019, before decreasing to 4.54 DID in 2020 and 4.17 DID in 2021. Private primary care antibiotic utilisation was almost ten times higher than in public primary care in 2021. The public sector had fewer (four) antibiotic molecules constituting 90% of the total antibiotic utilisation as compared to the private sector (eight). Use of Access antibiotics in the public sector was consistently above 90%, while use of Access category antibiotics by the private sector ranged from 64.2 to 68.3%. Although use of Watch antibiotics in the private sector decreased over the years, the use of Reserve and 'Not Recommended' antibiotics increased slightly over the years.

CONCLUSION

Antibiotic consumption in the private community healthcare sector in Malaysia is much higher than in the public sector. These findings highlight the need for more rigorous interventions targeting both private prescribers and the public with improvement strategies focusing on reducing inappropriate and unnecessary prescribing.

Antimicrobial stewardship strategy implementation and impact in acute care spinal cord injury and disorder units

CONTEXT

Antimicrobial Stewardship Programs (ASPs) are crucial to optimizing antibiotic use. ASPs are implemented in the Veterans Health Administration (VAs), but they do not target the needs of populations at high risk for resistant infections, such as spinal cord injury and disorder (SCI/D).

OBJECTIVE

The goal of this study was to assess key ASP leader and SCI/D clinicians' perceived level of implementation and impact of 33 Antimicrobial Stewardship (AS) strategies.

METHOD

SCI/D clinicians and ASP leaders across 24 VA facilities with SCI/D units were surveyed. Participants rated their perceived level of impact ("high", "mild", "low") and perceived level of implementation ("not", "partially", "fully") for 33 AS strategies in SCI/D units in VAs. Strategies were grouped into core elements which they support. We conducted a Fisher's exact test to assess differences between respondent perceptions based on role (SCI/D clinicians versus ASP leaders).

RESULTS

AS strategy implementation varied across VA facilities. Of the AS strategies, pre-authorization was perceived to be highly impactful (78%) and fully implemented (82%). SCI/D clinicians and ASP leaders rated AS strategies differently such that SCI/D clinicians were less aware of implementation of AS strategies related to reporting requirements; further, SCI/D clinicians rated strategies which guide treatment duration and which limit C. difficile antibiotic exposure as more impactful than ASP leaders. Ratings for facility-wide and SCI/D unit ratings did not significantly differ for impact or implementation.

CONCLUSION

Implementation practices varied across VA facilities. Future work should implement highly impactful AS strategies according to facility and unit needs.

Empowering Low- and Middle-Income Countries to Combat AMR by Minimal Use of Antibiotics: A Way Forward

Antibiotic overuse poses a critical global health concern, especially in low- and middle-income countries (LMICs) where access to quality healthcare and effective regulatory frameworks often fall short. This issue necessitates a thorough examination of the factors contributing to antibiotic overuse in LMICs, including weak healthcare infrastructure, limited access to quality services, and deficiencies in diagnostic capabilities. To address these challenges, regulatory frameworks should be implemented to restrict non-prescription sales, and accessible point-of-care diagnostic tools must be emphasized. Furthermore, the establishment of effective stewardship programs, the expanded use of vaccines, and the promotion of health systems, hygiene, and sanitation are all crucial components in combating antibiotic overuse. A comprehensive approach that involves collaboration among healthcare professionals, policymakers, researchers, and educators is essential for success. Improving healthcare infrastructure, enhancing access to quality services, and strengthening diagnostic capabilities are paramount. Equally important are education and awareness initiatives to promote responsible antibiotic use, the implementation of regulatory measures, the wider utilization of vaccines, and international cooperation to tackle the challenges of antibiotic overuse in LMICs.

How can we tackle the overuse of antibiotics in low- and middle-income countries?

INTRODUCTION

Antibiotic overuse is a pressing global health concern, particularly in low- and middle-income countries (LMICs) where there is limited access to quality healthcare and insufficient regulation of antibiotic dispensation. This perspective piece highlights the challenges of antibiotic overuse in LMICs and provides insights into potential solutions to address this issue.

AREAS COVERED

This perspective explores key factors contributing to antibiotic overuse in LMICs, encompassing weak healthcare infrastructure, limited access to quality services, and deficiencies in diagnostic capabilities. It discusses regulatory frameworks to curb non-prescription sales, the role of accessible point-of-care diagnostic tools, challenges in implementing effective stewardship programs, the expanded use of vaccines, and the importance of health systems, hygiene, and sanitation.

EXPERT OPINION

In this article, we emphasize the need for a comprehensive approach involving collaboration among healthcare professionals, policymakers, researchers, and educators. We underscore the importance of improving healthcare infrastructure, enhancing access to quality services, and strengthening diagnostic capabilities. The article also highlights the significance of education and awareness in promoting responsible antibiotic use, the role of regulatory measures, the expanded utilization of vaccines, and the need for international collaboration to address the challenges of antibiotic overuse in LMICs.

Perceptions of community pharmacists regarding their role in antimicrobial stewardship in Pakistan: A way forward

Background

Antimicrobial resistance is one of the biggest challenges to healthcare resulting in increased morbidity and mortality, and associated with drug resistant infections. Community pharmacists (CPs) can play a key role in antimicrobial stewardship (AMS) programs to aid the prudent use of antibiotics, and in infection prevention and control.

Objective

The aim of this study was to assess perceptions of CPs regarding their role, awareness, collaboration, facilitators and barriers towards effective AMS practices in Pakistan.

Method

ology: A descriptive, cross-sectional study design was adopted, where convenience and snowball sampling methods were applied to enroll respondents (pharmacists working at these community pharmacies in different cities of Pakistan) of the study. After sample size determination, n = 386 CPs were enrolled. A pre-validated questionnaire was used regarding CPs roles and perceptions in association with AMS. Statistical analysis was performed using SPSS v. 21.

Results

The results of the study reported that 57.3% (n = 221) of CPs had strong familiarity with term AMS. 52.1% (n = 201) of CPs agreed that they require adequate training to undertake activities in AMS programmes in their setting. The results of the study showed that 92.7% (n = 358) of the pharmacists thought real time feedback would be helpful. Significant association was observed in AMS awareness, approach, collaboration and barriers with regards to the respondents' gender, age groups and levels of experience in a community pharmacy.

Conclusions

The study concluded that CPs were aware of AMS programmes, their relevance and necessity of AMS in their everyday practice, but had inadequate training and resources to implement it in Pakistan.

Factors Influencing the Implementation of Antimicrobial Stewardship in Primary Care: A Narrative Review

Antimicrobial resistance (AMR) is directly driven by inappropriate use of antibiotics. Although the majority of antibiotics (an estimated 80%) are consumed in primary care settings, antimicrobial stewardship (AMS) activities in primary care remain underdeveloped and factors influencing their implementation are poorly understood. This can result in promising stewardship activities having little-to-no real-world impact. With this narrative review, we aim to identify and summarize peer-reviewed literature reporting on (1) the nature and impact of AMS interventions in primary care and (2) the individual and contextual factors influencing their implementation. Reported activities included AMS at different contextual levels (individual, collective and policy). AMS activities being often combined, it is difficult to evaluate them as stand-alone interventions. While some important individual and contextual factors were reported (difficulty to reach physicians leading to a low uptake of interventions, tight workflow of physicians requiring implementation of flexible and brief interventions and AMS as a unique opportunity to strengthen physician-patients relationship), this review identified a paucity of information in the literature about the factors that support or hinder implementation of AMS in primary care settings. In conclusion, identifying multilevel barriers and facilitators for AMS uptake is an essential step to explore before implementing primary care AMS interventions.

A Novel GPPAS Model: Guiding the Implementation of Antimicrobial Stewardship in Primary Care Utilising Collaboration between General Practitioners and Community Pharmacists

Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is central to implement antimicrobial stewardship (AMS) programmes in primary care. This study aimed to design a GP/pharmacist antimicrobial stewardship (GPPAS) model for primary care in Australia. An exploratory study design was followed that included seven studies conducted from 2017 to 2021 for the development of the GPPAS model. We generated secondary and primary evidence through a systematic review, a scoping review, a rapid review, nationwide surveys of Australian GPs and CPs including qualitative components, and a pilot study of a GPPAS submodel. All study evidence was synthesised, reviewed, merged, and triangulated to design the prototype GPPAS model using a Systems Engineering Initiative for Patient Safety theoretical framework. The secondary evidence provided effective GPPAS interventions, and the primary evidence identified GP/CP interprofessional issues, challenges, and future needs for implementing GPPAS interventions. The framework of the GPPAS model informed five GPPAS implementation submodels to foster implementation of AMS education program, antimicrobial audits, diagnostic stewardship, delayed prescribing, and routine review of antimicrobial prescriptions, through improved GP–CP collaboration. The GPPAS model could be used globally as a guide for GPs and CPs to collaboratively optimise antimicrobial use in primary care. Implementation studies on the GPPAS model and submodels are required to integrate the GPPAS model into GP/pharmacist interprofessional care models in Australia for improving AMS in routine primary care.

Is the number of prescriptions an appropriate metric for outpatient antimicrobial consumption? A comparison between the prescription counts and days supplied

The optimal metric for outpatient antimicrobial stewardship has not been well defined. The number of antibiotic prescriptions per clinic visit does not account for the therapeutic duration. We found only moderate association between prescription-based metrics and days-supplied–based metrics. Outpatient antibiotic consumption metrics should incorporate the duration of therapy.

Identification of Inappropriate Antibiotic Orders During Implementation of a Multidisciplinary Antimicrobial Stewardship Program Within the Primary Care Setting

OBJECTIVE

The aim of the study was to describe implementation of an outpatient antibiotic stewardship program at primary care practices in South Florida and the proportion of appropriate and inappropriate orders and reasons for inappropriateness during the intervention.

METHODS

An antibiotic stewardship committee at a large hospital system implemented aspects of The Core Elements of Outpatient Antibiotic Stewardship at outpatient facilities in 2018. Interventions included an education/awareness campaign directed at prescribers (audit and feedback, routine education at prescribers' meetings, availability of updated guidelines in a shared drive and antibiogram via intranet) and patients (posters, tear-off sheets on symptom relief for viral illness). Orders were evaluated using clinical documentation, current antibiogram, and Infectious Diseases Society of America guidelines. An appropriate order was defined as a correct antibiotic and dose/frequency and duration of therapy. An inappropriate antibiotic order was defined as not meeting 1 or more of the abovementioned conditions. Descriptive statistics assessed the data.

RESULTS

In this retrospective review of 2934 oral antibiotic orders from January 1 to December 31, 2018, 2565 (87.4%) were necessary while 369 (12.6%) were unnecessary. Of 2565 necessary orders, 1448 (56.5%) were appropriate while 1117 (43.5%) were inappropriate. Of 1117 inappropriate orders, 24.9% had all 3 conditions; 41.5% of inappropriate orders were solely due to wrong duration of therapy.

CONCLUSIONS

Although our institution demonstrated commitment to optimizing antibiotic prescribing by providing resources to clinicians and patients about evidence-based antibiotic prescribing, inappropriate antibiotic prescribing was persistent. The interventions used must continue to evolve and include point-of-care access to guidelines and clinical decision support tools.

Mixed-Method Evaluation of a Community Pharmacy Antimicrobial Stewardship Intervention (PAMSI)

The community pharmacy antimicrobial stewardship intervention (PAMSI) is multi-faceted and underpinned by behavioural science, consisting of the TARGET Antibiotic Checklist, staff e-Learning, and patient-facing materials. This mixed-method study evaluated the effect of PAMSI on community pharmacy staffs’ self-reported antimicrobial stewardship (AMS) behaviours. Data collection included staff pre- and post-intervention questionnaires, qualitative interviews, and TARGET Antibiotic Checklists. Quantitative data were analysed by a multivariate ordinal linear mixed effect model; qualitative data were analysed thematically. A total of 101 staff participated from 66 pharmacies, and six completed semi-structured interviews. The statistical model indicated very strong evidence (p < 0.001) that post-intervention, staff increased their antibiotic appropriateness checks and patient advice, covering antibiotic adherence, antibiotic resistance, infection self-care, and safety-netting. Staff reported feeling empowered to query antibiotic appropriateness with prescribing clinicians. The TARGET Antibiotic Checklist was completed with 2043 patients. Topics patients identified as requiring advice from the pharmacy team included symptom duration, alcohol and food consumption guidance, antibiotic side-effects, and returning unused antibiotics to pharmacies. Pharmacy staff acknowledged the need for improved communication across the primary care pathway to optimise antimicrobial use, and PAMSI has potential to support this ambition if implemented nationally. To support patients not attending a pharmacy in person, an online information tool will be developed.

Status of infectious disease content in the professional pharmacy curriculum in Saudi Arabia: Results of a national survey

Objectives

Antimicrobial resistance is one of the main global problems faced by healthcare institutions. Healthcare professionals as service providers must have a basic understanding of this emerging threat; additionally, considering the evolving role of pharmacists in both the community and hospital setting, it is crucial that pharmacists are part of the fight against this threat. Therefore, this study aimed to assess infectious disease subjects covered in the pharmacy curriculum in Saudi Arabia, to evaluate teaching and knowledge assessment strategies concerning infectious diseases, and to explore challenges faced by faculty members in teaching infectious disease courses.

Methods

We constructed a questionnaire with 26 items and sent it to infectious disease faculty members at 26 Saudi Arabian pharmacy colleges. It included questions regarding the faculty and institution, infectious disease topics, hours dedicated to each topic, and tools and strategies used in the courses for better understanding and assessment of students. In addition, we enquired about the faculty members' current satisfaction of, and future plans for, the curriculum.

Results

The questionnaire was completed by infectious disease faculty members, department chairs, or college deans. Among the respondent schools, 85.5% were governmental and 14.5% were private institutions. The majority of colleges (98.2%) followed a semester format schedule, with 67.3% offering solely the Doctor of Pharmacy (PharmD) program. More than 78% of respondents covered all tier 1 infectious disease topics from the American College of Clinical Pharmacy Pharmacotherapy Didactic Curriculum Toolkit. The main tool used for teaching was lectures (94.5%), while patient case application was the main teaching strategy (54.5%). Approximately 63% of respondents thought that the curricula were adequate when they were asked about their opinion of the curricula coverage, and 63.64% thought that the curriculum provided adequate baseline knowledge on infectious diseases for the following 5 years.

Conclusions

The study revealed variations in infectious disease topics covered and the time dedicated to them among pharmacy colleges in Saudi Arabia. The faculty members who responded to our questionnaire were generally satisfied with their infectious disease curriculum. To the best of our knowledge, this is the first study to assess infectious disease curricula among Saudi pharmacy colleges. Thus, the findings of this study may encourage faculty members to advocate for the standardization of infectious disease courses offered at Saudi Arabian pharmacy colleges.

A systems thinking approach for antimicrobial stewardship in primary care

INTRODUCTION

The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care.

AREAS COVERED

The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries.

EXPERT OPINION

The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.

Antibiotic-Dispensing Practice in Community Pharmacies: Results of a Cross-Sectional Study in Italy

Inappropriate use of antibiotics in the community contributes to the development of antibiotic resistance (ABR), one of the most concerning issues in modern medicine. The objectives of the study were to investigate the knowledge and attitudes regarding ABR and dispensing antibiotics without prescription (DAwP) and to assess the extent of the practice of DAwP among Italian community pharmacists (CPs). A nationwide cross-sectional study using an anonymous, structured, validated, and pilot-tested questionnaire was conducted. The five sections gathered data on demographic and professional characteristics, knowledge and attitudes toward ABR and DAwP, practices regarding dispensing antibiotics with or without prescription and their reasons, counselling on the potential antibiotic side effects and the importance of adherence to medication regimen, and the information sources used to update the knowledge about ABR. About 4 in 10 CPs (37.1%) reported being involved in DAwP, although 93.7% knew that it is illegal in Italy. The vast majority affirmed to have always/often asked clients about their drug allergies (95.5%) and about their medication history (82.5%). Two-thirds (66.2%) warned their clients about the potential side effects of the drugs, and 55% informed them about the importance of completing the full course of antibiotics. Complacency with clients who found it difficult to consult the physician was the most significant predictor of DAwP. A considerable proportion of DAwP was described, so it could be easy for patients to misuse these drugs. Future policies need to enhance the enforcement of existing prescription-only regulations and to develop monitoring strategies to ensure their establishment in real-life practices.

Dispensing of Non-Prescribed Antibiotics from Community Pharmacies of Pakistan: A Cross-Sectional Survey of Pharmacy Staff's Opinion

Community pharmacies are the main channel of antibiotics distribution. We aimed to analyze the dispensing of non-prescribed antibiotics and knowledge of pharmacy staff. We conducted a cross-sectional study in Punjab, Pakistan between December 2017 and March 2018. A self-administered, structured, pretested, and validated bilingual questionnaire was used, and we used chi-square tests in the statistical analysis. A total of 573 (91.7%) pharmacy retailers responded to the survey; 44.0% were aged 31-40 years and all were men. Approximately 81.5% of participants declared that dispensing non-prescribed antibiotics is a common practice in community pharmacies, and 51.1% considered themselves to be authorized to dispense these drugs; 69.3% believed this a contributing factor to antimicrobial resistance. Most (79.1%) respondents believed that this practice promotes irrational antibiotics use, and half (52.2%) considered antimicrobial resistance to be a public health issue. Only 34.5% of respondents reported recommending that patients consult with a doctor prior to using antibiotics, and 61.8% perceived that their dispensing practices reduce patients' economic burden. Approximately 44.9% of pharmacy retailers stated that they have proper knowledge about antibiotics use. Nitroimidazole was the main class of antibiotic dispensed without a prescription. Dispensing of injectable and broad-spectrum antibiotics can be potential threat for infection cure. Poor knowledge of staff is associated with dispensing of non-prescribed antibiotics. This inappropriate practice must be addressed immediately.

Evaluation of a pharmacist-led antibiotic stewardship program and implementation of prescribing order sets

BACKGROUND

It is established that pharmacists can play a role in antibiotic stewardship in inpatient settings; however, there remains a paucity of data regarding pharmacist impact on antibiotic stewardship in outpatient care.

OBJECTIVES

The purpose of this study was to assess the impact of an outpatient pharmacist antimicrobial stewardship program involving the implementation of prescribing order sets on the rate of compliance with guideline-recommended antibiotic use.

METHODS

This was a single-center, retrospective study conducted at a resident-run, adult medicine clinic evaluating the implementation of a pharmacist-led antimicrobial stewardship education program and prescribing order sets. Adult patients were included if they were treated for a diagnosis of urinary tract infection or Helicobacter pylori infection. The primary outcome was a composite of the proportion of antibiotic prescribing that was compliant with guideline-recommended treatment, including indication, antibiotic selection, dose, and duration. The secondary outcomes included an analysis of the individual components of the primary outcome and a subgroup analysis according to infection type.

RESULTS

A total of 115 and 43 patients were included in the preintervention and intervention groups, respectively. No statistically significant difference was observed in the proportion of complete guideline-recommended antibiotic regimens after the implementation of the stewardship intervention (P = 0.703) or in any individual component of the composite outcome. However, a subgroup analysis of each infection type demonstrated statistically significant improvements in both complete H pylori regimens and antibiotic selection.

CONCLUSIONS

Although the implementation of a pharmacist-led antimicrobial stewardship program at an adult medicine clinic did not lead to an improvement in complete guideline-recommended antibiotic prescribing, notable improvements were observed after subgroup analyses.

Mapping the Implementation of a Clinical Pharmacist-Driven Antimicrobial Stewardship Programme at a Tertiary Care Centre in South India

In many parts of the world, including in India, pharmacist roles in antimicrobial stewardship (AMS) programmes remain unexplored. We describe the evolution and effect of the role of adding clinical pharmacists to a multidisciplinary AMS at a tertiary care teaching hospital in Kerala, India. Through effective leadership, multidisciplinary AMS (February 2016) and antitubercular therapy (ATT) stewardship programmes (June 2017) were established. Clinical pharmacists were introduced as core members of the programmes, responsible for the operational delivery of key stewardship interventions. Pharmacy-led audit and feedback monitored the appropriateness of antimicrobial prescriptions and compliance to AMS/ATT recommendations. Between February 2016 and January 2017, 56% (742/1326) of antimicrobial prescriptions were appropriate, and 54% (318/584) of recommendations showed compliance. By the third year of the AMS, appropriateness increased to 80% (1752/2190), and compliance to the AMS recommendations to 70% (227/325). The appropriateness of ATT prescriptions increased from a baseline of 61% (95/157) in the first year, to 72% (62/86, June 2018-February 2019). The compliance to ATT recommendations increased from 42% (25/60) to 58% (14/24). Such a model can be effective in implementing sustainable change in low- and middle-income countries (LMICs) such as India, where the shortage of infectious disease physicians is a major impediment to the implementation and sustainability of AMS programmes.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Divergent and Convergent Attitudes and Views of General Practitioners and Community Pharmacists to Collaboratively Implement Antimicrobial Stewardship Programs in Australia: A Nationwide Study

Setting up an interprofessional team for antimicrobial stewardship (AMS) to improve the quality and safety of antimicrobial use in primary care is essential but challenging. This study aimed to investigate the convergent and divergent attitudes and views of general practitioners (GPs) and community pharmacists (CPs) about AMS implementation and their perceived challenges of collaboration to design a GP–pharmacist collaborative AMS (GPPAS) model. Nationwide surveys of GPs and CPs across Australia were conducted January-October 2019. Chi square statistics and a theoretical framework were used for comparative analyses of quantitative and qualitative data, respectively. In total, 999 participants responded to the surveys with 15.4% (n = 386) response rates for GPs and 30.7% (n = 613) for CPs. GPs and CPs were aware about AMS however their interprofessional perceptions varied to the benefits of AMS programs. CPs indicated that they would need AMS training; significantly higher than GPs (GP vs. CP; 46.4% vs. 76.5%; p < 0.0001). GPs’ use of the Therapeutic Guideline Antibiotic was much higher than CPs (83.2% vs. 45.5%; p < 0.0001). No interprofessional difference was found in the very-limited use of patient information leaflets (p < 0.1162) and point-of-care tests (p < 0.7848). While CPs were more willing (p < 0.0001) to collaborate with GPs, both groups were convergent in views that policies that support GP–CP collaboration are needed to implement GPPAS strategies. GP–pharmacist collaborative group meetings (54.9% vs. 82.5%) and antimicrobial audit (46.1% vs. 86.5%) models were inter-professionally supported to optimise antimicrobial therapy, but an attitudinal divergence was significant (p < 0.001). The challenges towards GP–CP collaboration in AMS were identified by both at personal, logistical and organisational environment level. There are opportunities for GP–CP collaboration to improve AMS in Australian primary care. However, strengthening GP–pharmacy collaborative system structure and practice agreements is a priority to improve interprofessional trust, competencies, and communications for AMS and to establish a GPPAS model in future.

Feasibility of a community pharmacy antimicrobial stewardship intervention (PAMSI): an innovative approach to improve patients' understanding of their antibiotics

BACKGROUND

Community pharmacy staff have an opportunity to play a pivotal role in antimicrobial stewardship (AMS) due to their expertise in medicines and accessibility to patients.

OBJECTIVES

To develop and test the feasibility of a pharmacy AMS intervention (PAMSI) to increase community pharmacy staff's capability, opportunity and motivation to check antibiotic appropriateness and provide self-care and adherence advice when dispensing antibiotics.

METHODS

The PAMSI was centred around an Antibiotic Checklist, completed by patients and pharmacy staff, to facilitate personalized advice to the patient, based on their reported knowledge. An educational webinar for staff and patient-facing materials were also developed. Staff and patients completing Antibiotic Checklists were invited to provide feedback via questionnaires.

RESULTS

In February 2019, 12 community pharmacies in England trialled the intervention. Forty-three pharmacy staff evaluated the educational webinar and reported increases in their understanding, confidence, commitment and intention to use the tools provided to give adherence and self-care advice. Over 4 weeks, 931 Antibiotic Checklists were completed. Staff reported being more focused on giving advice and able to address patients' knowledge gaps (mainly: likely symptom duration; alcohol and food consumption advice; possible side effects from antibiotics; returning unused antibiotics to the pharmacy), resulting in increased self-reported effective and meaningful conversations.

CONCLUSIONS

Implementation of a PAMSI is feasible and effectively promotes AMS. Pharmacy staff and commissioners should consider this within their AMS plans. An optional digital format of the Antibiotic Checklist should be explored, for patients who are not collecting their antibiotic prescriptions themselves, and to save printing costs.

Collaborative Antimicrobial Stewardship in the Emergency Department

Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.

Outcomes of an ambulatory care pharmacist-led antimicrobial stewardship program within a family medicine resident clinic

OBJECTIVE

To determine whether an ambulatory care pharmacist (AMCP)-led intervention improved outpatient antibiotic prescribing in a family medicine residency clinic (FMRC) for upper respiratory tract infections (URIs), urinary tract infections (UTIs), and skin and soft-tissue infections (SSTIs).

DESIGN

Retrospective, quasi-experimental study comparing guideline-concordant antibiotic prescribing before and after an antimicrobial stewardship program (ASP) intervention.

SETTING

Family medicine residency clinic affiliated with a community teaching hospital.

PARTICIPANTS

Adult and pediatric patients prescribed antibiotics for URI, UTI, or SSTI between November 1, 2017, and April 31, 2018 (pre-ASP group), or October 1, 2018, and March 31, 2019 (ASP group), were eligible for inclusion.

METHODS

The health-system ASP physician and pharmacist provided live education and pocket cards to FMRC staff with local guidelines as a quick reference. Audit with feedback was delivered every other week by the clinic's AMCP. Guideline-concordance was determined based on the institution's outpatient ASP guidelines.

RESULTS

Overall, 525 antibiotic prescriptions were audited (pre-ASP n = 90 and ASP n = 435). Total guideline-concordant antibiotic prescribing at baseline was 38.9% (URI, 53.3%; SSTI, 16.7%; UTI, 46.7%) and improved across all 3 infection types to 57.9% (URI, 61.2%; SSTI, 57.6%; UTI, 53.5%; P = .001). Significant improvements were seen in guideline-concordant antibiotic selection (68.9% vs 80.2%; P = .018), dose (76.7% vs 86.2%; P = .023), and duration of therapy (73.3% vs 86.2%; P = .02).

CONCLUSIONS

An AMCP-led outpatient ASP intervention significantly improved guideline-concordant antibiotic prescribing for common infections within a FMRC.

Antimicrobial stewardship by Australian community pharmacists: Uptake, collaboration, challenges, and needs

OBJECTIVE

To assess community pharmacists' (CPs') awareness and uptake of evidence-based antimicrobial stewardship (AMS) strategies, attitudes toward collaboration with general practitioners (GPs), and needs to improve AMS practices.

METHODS

A nationwide survey of randomly sampled community pharmacies across Australia was conducted in April-October 2019.

RESULTS

The response rate of CPs was 30.7% (613 of 2000) and 592 participating CPs (96.5%) described the key barriers to and facilitators of improving AMS. CPs (447 of 613, 72.9%) were familiar with AMS but felt that they would require training (468 of 612, 76.5%) and access to AMS practice guidelines (566 of 605, 93.6%). Respondents perceived that AMS programs could reduce the inappropriate use of antimicrobials (409 of 612, 66.8%) and the costs of treating infection (508 of 612, 83.0%). CPs often counseled patients (591 of 609, 97.0%) and reviewed drug interactions or allergies (569 of 607, 93.8%) before dispensing antimicrobials. Respondents less often used the national Therapeutic Guidelines: Antibiotic (274 of 602, 45.5%) or assessed guideline-compliance of prescribed antimicrobials (231 of 609, 37.9%). CPs were less likely to communicate with GPs (254 of 609, 41.8%) when an antimicrobial prescription was believed to be suboptimal and perceived that GPs are not receptive to their intervention regarding the antimicrobial choice (500 of 606, 82.6%) and dosage (416 of 606, 68.6%). Point-of-care tests (114 of 596, 19.1%) and patient information leaflets (149 of 608, 24.5%) were used uncommonly. Most respondents supported policies that could foster GP-pharmacist collaboration (560 of 606, 92.4%), limit accessibility of selected antimicrobials (420 of 604, 74.4%), and reduce repeat-dispensing of antimicrobial prescriptions (448 of 604, 74.2%). CPs faced interpersonal, interactional, structural, and resource-level barriers to collaborate with GPs for practicing AMS.

CONCLUSIONS

CPs are aware of the importance of sensible use of antimicrobials but have had limited training and resources to conduct AMS activities. Improving GPs' receptiveness and system structures for increased GP-CP collaboration seem to be a priority to accelerate CP-led AMS implementation. Further study is required to understand the views of stakeholders about the feasibility of implementing evidence-based GP-CP collaborative AMS approaches.

The pharmacist's active role in combating COVID-19 medication misinformation

Pharmacists listen to and dispel medication misinformation daily. Because of their accessibility, pharmacists have the opportunity during pharmacist-patient interactions to begin a dialogue with their patients and provide critical education to improve patient safety and public health. Current examples of pharmacists intervening with medication misinformation include addressing the antivaccination community, educating on the safety of generic drugs, and using evidence-based medicine for antimicrobial stewardship. However, combating medication misinformation in pharmacy practice with patients takes on many forms and can pose a number of challenges. Most recently during the coronavirus disease 2019 (COVID-19) pandemic, a concurrent infodemic has led to claims of pharmacotherapeutic superiority and efficacy unsubstantiated by scientific evidence. Misinformation and partisan politics have also created a distrust in COVID-19 vaccine development. In addition, rogue Internet pharmacies and companies have marketed new and unverified COVID-19 treatments and tests. Pharmacists must actively combat these instances of medication misinformation and educate their patients on how not to fall victim to convincing marketing and misinformation schemes. Pharmacists can help patients recognize misinformation by vetting sources of information and communicating how negative emotional information circulates. In addition, pharmacists combat misinformation with patients by providing accurate alternative explanations in patient-friendly language. Although it is easier to stay silent and let misinformation circulate, pharmacists must work with their health care team members to actively reject misinformation pertaining to medications, COVID-19 pharmacotherapy and vaccinations, and in any future public health crisis.

Antimicrobial Stewardship Practice in the Ambulatory Setting From a National Cohort

Background

The majority of antimicrobial use occurs in the ambulatory setting. Antimicrobial stewardship programs (ASPs) are effective in improving appropriate prescribing and are now required by accreditation bodies.

Methods

This was a cross-sectional, multicenter survey describing the current state of ambulatory ASPs in a national cohort of Vizient member hospitals with ambulatory healthcare settings and serves as a benchmark for stewardship strategies related to program effectiveness.

Results

One hundred twenty-nine survey responses from a variety of institution types across 44 states were received. Survey respondents reported a fully functioning ASP in 7% (9 of 129) of ambulatory practices compared with 88% (114 of 129) of inpatient institutions. Effectiveness in at least 1 antibiotic use-related outcome (ie, utilization, resistance, Clostridioides difficile infection, or cost) in the past 2 years was reported in 18% (18 of 100) of ambulatory and 84% (103 of 123) of inpatient ASPs. Characteristics of ambulatory ASPs demonstrating effectiveness were institution guidelines (89%, 16 of 18), rapid diagnostic testing for respiratory viruses or group A Streptococcus (89% 16 of 18), outpatient antibiograms (78% 14 of 18), and dedicated pharmacist support (72%, 13 of 18). Ambulatory ASP effectiveness was shown to increase as programs met more of the Centers for Disease Control and Prevention (CDC) Core Elements of Outpatient Antimicrobial Stewardship (P < .001).

Conclusions

Antimicrobial stewardship programs are needed in the ambulatory setting, but they are not common. Currently, few ambulatory ASPs in this survey self-identify as fully functioning. The CDC Core Elements of antimicrobial stewardship should remain foundational for ASP development and expansion.

Antimicrobial stewardship in the outpatient setting: A review and proposed framework

Antimicrobial misuse is still a significant problem, and most inappropriate use occurs in the outpatient setting. In this article, we provide a review of available literature on outpatient antimicrobial stewardship in primary care settings, and we propose a novel implementation framework.

A case report of self-medication with over-the-counter fish antibiotic: Implications for pharmacists

OBJECTIVE

The human use of over-the-counter antibiotics intended for the treatment of pet animals has been recognized as a potential barrier to antibiotic stewardship efforts. The objective of this report is to describe a case of self-medication with a fish antibiotic resulting in delayed medical treatment and provide recommendations for pharmacists practicing in outpatient settings on how to best identify and manage nonprescription antibiotic use.

CASE SUMMARY

A 24-year-old man experienced dental pain and "flu-like" symptoms for which he attempted self-treatment with oral amoxicillin 250 mg daily purchased by a family member from a pet store. The amoxicillin was marketed for the treatment of bacterial infection in pet fish. After several days of increasing tooth pain despite the self-medication, the patient presented to an outpatient clinic where he was found to have a molar abscess requiring tooth extraction. The patient responded well to therapy and was counseled to discontinue antibiotic self-treatment.

PRACTICE IMPLICATIONS

Undocumented use of nonprescription antibiotics represents a threat to patient safety. Potential deleterious outcomes include resistance, adverse drug events, and delays in definitive infection treatment. Pharmacists should screen patients for nonprescription antibiotic use, provide them counseling on appropriate antibiotic use, and educate other health care professionals on underrecognized sources of nonprescription antibiotics to increase awareness of this growing issue. Furthermore, antibiotic resistance should be considered when recommending an antibiotic agent for the treatment of infections.

Patient Knowledge and Experiences With Antibiotic Use and Delayed Antibiotic Prescribing in the Outpatient Setting

Background:

Most antibiotic prescriptions originate in the outpatient setting and an estimated 30% are unnecessary. Pharmacists are well positioned to positively impact antibiotic prescribing habits; the role of the community pharmacist in outpatient antibiotic stewardship programs is not well defined.

Objectives:

The objectives of this study were to (1) assess the knowledge of the general public regarding appropriate antibiotic use, and (2) assess the experiences of the general public regarding delayed antibiotic prescriptions.

Methods:

A cross-sectional survey was administered at community pharmacies in Kansas from September 2018 to January 2019. Eligible individuals were older than 18 years and self-reported their ability to speak and read English. The 22-item survey collected demographics, knowledge regarding appropriate antibiotic use, and participant understanding and experiences of delayed antibiotic prescribing. Descriptive statistics assessed demographics and chi-square compared responses between demographics.

Results:

Of 347 surveys completed, respondents were mainly Caucasian (91.6%), female (58.2%), and aged 60 years or older (59.1%). Those with high school education or below were more likely to believe antibiotics kill viruses (43.1% vs 20.9%, respectively; p < 0.01) and that antibiotics work on most coughs and colds (31.4% vs 16.2%, respectively; p = 0.01). Delayed antibiotic prescriptions were more frequently offered to those who had received an antibiotic prescription in the last year compared to those who had not (36.1% vs 15%, p < 0.001).

Conclusion:

Gaps in patient knowledge about appropriate antibiotic use and delayed prescribing present an opportunity for community pharmacists to educate patients and become involved in outpatient antibiotic stewardship.

Antimicrobial stewardship staffing: How much is enough?

Antimicrobial stewardship improves patient care and reduces antimicrobial resistance, inappropriate use, and adverse outcomes. Despite high-profile mandates for antimicrobial stewardship programs across the healthcare continuum, descriptive data, and recommendations for dedicated resources, including appropriate physician, pharmacist, data analytics, and administrative staffing support, are not robust. This review summarizes the current literature on antimicrobial stewardship staffing and calls for the development of minimum staffing recommendations.

Community pharmacy interventions to improve antibiotic stewardship and implications for pharmacy education: A narrative overview

BACKGROUND

Antibiotic resistance is one of the world's most pressing public health problems, resulting in over 23,000 deaths per year. One of the main contributing factors to antimicrobial resistance is antibiotic misuse and overuse. Community pharmacists can play a role in reducing antibiotic resistance, since they are one of the most accessible healthcare professionals.

OBJECTIVE

The purpose of this paper is to describe community pharmacy interventions and strategies to reduce antibiotic misuse and overuse and to discuss the implications for pharmacy training.

METHODS

A narrative overview strategy was employed to identify papers on antibiotic stewardship and the role of the community pharmacist. Our review examined potential stewardship strategies and interventions within community pharmacy practice that provide opportunities for pharmacists to engage or lead in the reduction of antimicrobial resistance.

RESULTS

We describe five promising community pharmacist-led intervention strategies: Collaborative Practice Agreements (CPAs), point-of-care (POC) testing, patient consultations, academic detailing and serving as an advocate for patients and other healthcare providers CONCLUSIONS: This review highlights topics that may warrant increased attention in pharmacy school curricula. Pharmacy schools may want to consider modifying their curricula to address the shifts in practice of the community pharmacist - emphasizing the expanded role of the pharmacist in patient care and public health issues such as outpatient antibiotic stewardship.