Perception and practices of community pharmacists towards antimicrobial stewardship in Lahore, Pakistan

Antimicrobial stewardship situation analysis in selected hospitals in Zambia: findings and implications from a national survey

Background

Antimicrobial stewardship (AMS) programs are critical in combating antimicrobial resistance (AMR). In Zambia, there is little information regarding the capacity of hospitals to establish and implement AMS programs. The objective of this study was to conduct a baseline assessment of WHO core elements for an AMS program implementation in eight hospitals in Zambia.

Materials and methods

We conducted an exploratory cross-sectional study from September 2023 to December 2023 using a self-scoring Periodic National and Healthcare Facility Assessment Tool from the World Health Organization (WHO) policy guidance on integrated AMS activities in human health. Eight public hospitals were surveyed across the five provinces of Zambia. Data was analyzed using the WHO self-scoring tool and thematic analysis.

Results

Overall, 62.5% (6/8) of the facilities scored low (below 60%) in implementing AMS programs. Most facilities had challenges with reporting AMS feedback within the hospital (average score = 46%), Drugs and Therapeutics Committee (DTC) functionality (average score = 49%), AMS actions (average score = 50%), education and training (average score = 54%), and leadership commitment to AMS activities (average score = 56%). The overall score for all AMS core elements was average (56%). All the hospitals (100%) did not have an allocated budget for AMS programs. Finally, there were neither antibiograms to guide antimicrobial utilization nor AMS-trained staff in more than 50% of the hospitals surveyed.

Conclusion

This study found low AMS implementation in these public hospitals, especially where DTCs were non-functional. The identified challenges and gaps require urgent attention for sustainable multidisciplinary AMS programs.

The role of community pharmacists and their perception towards antimicrobial stewardship in Baghdad, Iraq

Background

This study aimed to assess the role of community pharmacists and their perception toward antimicrobial stewardship, in addition to identifying factors influencing their perception and practices in community pharmacy.

Methods

A cross-sectional study was carried out among community pharmacists regarding antimicrobial stewardship. Convenience sampling was used to obtain the required sample from a community pharmacy in Baghdad. In total, 381 participants have completed the survey.

Results

The majority of the participants (85.6%) strongly agreed/agreed that "antimicrobial stewardship programs reduce the problems of antibiotic resistance"; and 85.5% of them strongly agreed/agreed that community pharmacists required adequate training on antibiotics use. In addition, high percent of community pharmacists (88.4%) strongly agreed/agreed that pharmacists have a responsibility to take a prominent role in antimicrobial stewardship programs and infection-control programs in the health system. The total score of perception was significantly influenced by older age groups, postgraduate degrees, and experience of 6-10 years (p < 0.001). This study also showed that 65.4% of pharmacists always/often advise patients to continue the full course of antimicrobials, and 64.9% of them reported always/often considering clinical and safety parameters before dispensing antibiotics. The role of pharmacists was significantly influenced by the younger age group, females, higher degree in pharmacy, experience of 3-5 years, and medical complex pharmacy (p < 0.001).

Conclusion

Community pharmacists have a good perception toward antimicrobial stewardship programs, but their role is still limited. More efforts are needed to design better strategies for antimicrobial stewardship in community pharmacy.

Tackling antimicrobial resistance in primary care facilities across Pakistan: Current challenges and implications for the future

Antibiotics are gradually becoming less effective against bacteria worldwide, and this issue is of particular concern in economically-developing nations like Pakistan. We undertook a scoping review in order to review the literature on antimicrobial use, prescribing, dispensing and the challenges associated with antimicrobial resistance in primary care (PC) settings in Pakistan. Furthermore, this review aims to identify potential solutions to promote appropriate use of antimicrobials in Pakistan. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist, a comprehensive scoping review was conducted to review the literature of antimicrobials used, prescribed and dispensed in PC settings in Pakistan. Google Scholar and Pub-Med were searched for the period 2000-2023. Papers were analyzed on the basis of eligibility i.e., included antimicrobial use, prescribing and dispensing practices by general population at homes, by prescribers in outpatient departments of hospitals and by pharmacists/dispensers in community pharmacies, respectively. Two researchers analyzed the articles thoroughly and disagreements were resolved through discussion with a third reviewer. Both quantitative and qualitative research studies were eligible for inclusion. Additionally, the selected papers were grouped into different themes. We identified 4070 papers out of which 46 studies satisfied our eligibility criteria. The findings revealed limited understanding of antimicrobial resistance (AMR) by physicians and community pharmacists along with inappropriate practices in prescribing and dispensing antibiotics. Moreover, a notable prevalence of self-medication with antibiotics was observed among the general population, underscoring a lack of awareness and knowledge concerning proper antibiotic usage. Given the clinical and public health implications of AMR, Pakistan must prioritize its policies in PC settings. Healthcare professionals (HCPs) need to reduce inappropriate antibiotic prescribing and dispensing, improve their understanding of the AWaRe (access, watch and reserve antibiotics) classification and guidance, monitor current usage and resistance trends, as well as implement antimicrobial stewardship (ASP) activities starting in targeted locations.

Nurses' Perceptions, Involvement, Confidence and Perceived Barriers Towards Antimicrobial Stewardship Program in Pakistan: Findings from a Multi-Center, Cross-Sectional Study

Purpose

Antimicrobial resistance (AMR) is leading to greater therapeutic cost, length of hospital stays, adverse events, morbidity and mortality. Hospital-based antimicrobial stewardship programs (ASPs) engaging physicians, pharmacists, microbiologists and nurses are considered as effective way to ensure appropriate use of antimicrobial agents. The aims of our study were to assess nurses' perception, involvement, confidence and barriers towards hospital-based ASPs, and use the findings to provide future guidance.

Methods

A web-based, cross-sectional study was conducted among the nurses serving at eleven hospitals of Punjab province of Pakistan during a period of two months (December 2021-January 2022). Data were collected using a validated self-administered questionnaire. All data were analyzed using SPSS version 22.

Results

A total of 583 nurses participated in the study (response rate = 77.7%). All the participants were female staff nurses and 86% had a minimum of 3 years of working experience. The overall median score on the perception towards ASPs among the nurses was 18 (IQR: 16, 19) on a 0 to 20 scale whereas median score on the involvement in ASPs was 18 (IQR: 15, 37) on a 0 to 64 scale. Median perception and involvement score were statistically significantly differed by age (p < 0.001) and years of experience (p < 0.001). The overall median score on the confidence to perform ASP activities was 22 (IQR: 14, 24) on a 0 to 28 scale. Lack of knowledge, insufficient support from administration, and heavy workload were found to be the common barriers to perform ASP.

Conclusion

Our study concluded that Pakistani nurses have positive perception but limited involvement in ASPs. Moreover, they are confident to perform ASP besides many barriers.

Antimicrobial dispensing process in community pharmacies: a scoping review

BACKGROUND

Antimicrobial resistance remains a major global public health concern, and antimicrobial dispensing in community pharmacies is an important factor in preventing this damage. However, the current literature focuses on the technical and attitudinal aspects related to antimicrobial dispensing, with little emphasis on the interventions provided in this service. Thus, this study aimed to determine the antimicrobial dispensing process in community pharmacies.

METHODS

A scoping review was performed in September 2020 using the PubMed, EMBASE, LILACS, Web of Science, and Cochrane databases. The search terms included words related to dispensing, antibacterial agents, and pharmacies in various combinations. Two reviewers screened the titles, abstracts, and full-text articles according to the eligibility criteria, and extracted the data. The findings were presented in a descriptive form.

RESULTS

Of the 7713 studies screened, 35 were included, of which 22 (63%) were published in Asia. Most studies followed a cross-sectional design (n = 27), and the simulated patient was the most often used method to assess the antimicrobial dispensing process (n = 22). Moreover, 31 (89%) studies investigated antimicrobial dispensing without prescription, and only four (11%) studies evaluated antimicrobial dispensing with prescription. In the 35 studies, the most frequently asked questions were about drug allergies (n = 19) and patient symptoms (n = 18), and counseling mainly focused on the side effects (n = 14), precautions (n = 14), how to take the medication (n = 12), and duration of medication use (n = 11). Another common intervention was referral (n = 15). Among clinical cases, counseling on medication use occurred often in cases of urinary tract infection (51%) and otitis media (50%).

CONCLUSIONS

Antimicrobial dispensing processes have been primarily investigated in low- and middle-income countries, with a focus on dispensing antimicrobials without prescriptions. During the dispensing process, pharmacists mostly posed minimal questions and counseling, highlighting the deficiencies that persist in this practice. Our results indicate the need for multifaceted strategies, such as implementing educational, regulatory or administrative strategies and changes in cultural background, especially in low- and middle-income countries, that aim to reduce indiscriminate use of antimicrobials. Therefore, qualifying the antimicrobial dispensing process is a fundamental factor for improving the rational use of antimicrobials and reducing microbial resistance.

Knowledge, Attitudes, and Practices of Community Pharmacy Professionals on Poultry Antibiotic Dispensing, Use, and Bacterial Antimicrobial Resistance in Zambia: Implications on Antibiotic Stewardship and WHO AWaRe Classification of Antibiotics

Globally, the inappropriate dispensing and use of antibiotics in animals has contributed to the development of bacterial antimicrobial resistance (AMR). In Zambia, there is insufficient information among community pharmacy professionals on antibiotic use (ABU) and AMR in food-producing animals. This study assessed community pharmacy professionals' knowledge, attitudes, and practices regarding poultry antibiotic dispensing, use, and bacterial AMR in the Lusaka district of Zambia. A cross-sectional study was conducted among 178 community pharmacy professionals between February and April 2022 using a semi-structured questionnaire. Data were analyzed using Stata version 17. Of the total participants (n = 178), 51.1% (n = 91) were pharmacists. The most dispensed antibiotic was oxytetracycline, a Watch antibiotic, mainly without prescriptions. Good knowledge of ABU and AMR was associated with work experience for more than one year (p = 0.016), while good practices were associated with male gender (p = 0.039) and work experience of more than one year (p = 0.011). The study found moderate knowledge, positive attitudes, and moderate practices of pharmacy professionals on poultry ABU and AMR. There was high dispensing of poultry antibiotics without prescriptions, which calls for strict implementation of antimicrobial stewardship and surveillance programs in poultry production in Zambia to reduce AMR.

Community pharmacists' views on their current role and future opportunities for antibiotic stewardship: a French qualitative study

Background

Different healthcare professionals should contribute to antibiotic stewardship (ABS) activities. Involvement of community pharmacists (CPs) has been little explored worldwide to date.

Objectives

To explore French CPs' views on ABS and antibiotic resistance, their role and current practices, and future opportunities for ABS.

Methods

A qualitative study using semi-structured face-to-face individual interviews was performed from May to October 2019 among CPs from north-eastern France. Transcripts of the interviews were analysed using a thematic analysis.

Results

Twenty-seven interviews were conducted. Most participants had a clear understanding of antibiotic resistance and ABS. They considered themselves as 'guardians of the appropriate use of drugs' but often failed to fulfil this mission because of difficult relationships with physicians. Their current ABS practices are: (i) counselling patients about the antibiotic treatment; and (ii) reporting to the prescriber when they identify contraindications/drug interactions. Concerning their potential increased involvement in ABS, CPs felt they could perform more rapid diagnostic testing for sore throat; they were divided on the possibility for them to change the antibiotic prescription made by a physician and were mainly against the possibility of initiating an antibiotic prescription. The idea of systematically collecting unused antibiotics was perceived well by CPs, while unit dose delivery was not.

Conclusions

French community pharmacists are willing to become more involved in ABS activities. Collaboration and trust between pharmacists and prescribers should however be improved.