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

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.

Prevalence, pandemic, preventions and policies to overcome antimicrobial resistance

Antimicrobial resistance (AMR) is a growing concern in Asia, and it is essential to understand the prevalence, pandemic, prevention, and policies to overcome it. According to the World Health Organization (WHO), AMR is one of the main causes of death; in 2019, it was linked to 4.95 million fatalities and caused about 1.27 million deaths. A core package of actions has been provided by WHO to help countries prioritize their needs when creating, carrying out, and overseeing national action plans on antimicrobial resistance. Using a people-cantered approach to AMR, the interventions address the needs and obstacles that individuals and patients encounter when trying to obtain healthcare. The people-cantered core package of AMR treatments seeks to improve public and policymakers; awareness and comprehension of AMR by changing the narrative of AMR to emphasize the needs of people and systemic impairments. Additionally, it backs a more comprehensive and programmatic national response to AMR, which emphasizes the value of fair and inexpensive access to high-quality healthcare services for the avoidance, identification, and management of drug-resistant diseases. The report signals increasing resistance to antibiotics in bacterial infections in humans and the need for better data. In conclusion, the prevalence of AMR in Asia is a significant public health concern, and it is crucial to implement policies and interventions to overcome it.

Accordance of Registered Drug Packages with Guideline-Recommended Treatment Durations for Community-Acquired Pneumonia-A New Antibiotic Stewardship Target?

In most countries, antibiotics for oral administration are put on the market in fixed packages. When there is no exact unit dispensing of antimicrobials, drug pack size may influence prescribers' choice of treatment duration. The aim of this study was to investigate the accordance of approved antibiotic packages with national guidelines for the treatment of community-acquired pneumonia (CAP). For the purpose of this study, criteria were developed to determine the accordance of approved antibiotic packages for treating CAP (criteria), which are based on recommendations from national guidelines for treating CAP. Subsequently, the accordance of approved antibiotic packages with the number of antibiotic doses resulting from the specified criteria was determined. Of 39 identified therapeutic option-package size combinations, 11 were found to be matched (28.2%), meaning there were no leftover medication units after completing therapy, and 28 were mismatched combinations (71.8%), indicating that there were excess doses of antibiotics remaining at the end of therapy. The results of this research showed a significant non-accordance of the approved antibiotic packages with the national guidelines for the treatment of CAP and, consequently, the creation of a large amount of residues of unit doses of antibiotics in the community.

Determining a future policy focus to support antimicrobial stewardship in community pharmacy: A modified Delphi study

Background

Over the past decade, the pharmacy sector's policy, academic and professional spheres have increasingly drawn attention to the opportunities to better leverage the untapped potential of the community pharmacy sector in contributing to global efforts to reduce antimicrobial resistance (AMR). While efforts are in train, progress is slow.

Objective

To draw insights from global experts in the field to identify a broad range of potential future policy directions to support community pharmacists' involvement in antimicrobial stewardship (AMS).

Methods

A modified Delphi technique, comprising two survey rounds to build consensus amongst global community pharmacy sector stakeholders and opinion leaders. In Round 1, participants rated their level of agreement with 28 statements across the three domains of policy design, implementation design, and monitoring and evaluation. Participants were also invited to contribute feedback in Round 1, which was reflected as new statements (n = 10) in Round 2. In Round 2, participants were asked to re-assess Round 1 statements in view of the group consensus and to rate the new statements.

Results

289 participants were invited to participate. 48/289 (17% response rate) completed Round 1, and 25/42 (60% response rate) completed Round 2. Consensus (defined as >70% agreement) was achieved for 79% (n = 30) of the statements across the three domains.

Conclusion

Pharmacy sector experts agreed that acknowledging community pharmacists in AMS national action plans is an important component, signalling a recognition of the sector's contribution to whole-of-nation AMS efforts. Implementation components that achieved consensus reflect the profession's evolution to a professional service driven model, particularly in complementary AMS initiatives including infection prevention and control measures. Context-specific adjustments to support implementing these AMS measures will be required, in addition to striking the appropriate balance to support the pace of increased community pharmacists'involvement in AMS with building whole-of-profession buy-in.

Pharmacists' perspectives on recommending herbal medicines for acute infections: a qualitative study

BACKGROUND

Community pharmacists have an essential role in antimicrobial stewardship by providing self-care advice for self-limiting infections.

AIM

To explore community pharmacists' perceptions and experiences of advising patients on management of acute respiratory tract infections (RTIs) and urinary tract infections (UTIs), and to explore issues regarding use of over-the-counter (OTC) medicines, including herbal medicines.

DESIGN & SETTING

A qualitative study using semi-structured interviews with community pharmacists in England.

METHOD

Qualitative interviews with community pharmacists were carried out face to face and by telephone between November 2019 and March 2020. Data were collected through in-depth, semi-structured interviews, recorded and transcribed. A reflexive thematic analysis was undertaken.

RESULTS

In total, 18 community pharmacists were interviewed. Three main themes were identified. Theme 1 was self-management recommendations. Community pharmacists considered patients' preferences when recommending self-management strategies. Some believed that conventional OTC medications had quicker and stronger effects, while others preferred herbal OTCs as a more natural approach, particularly for less severe symptoms. Theme 2 was factors influencing pharmacists' recommendations for acute infections. This included pharmacists' perceptions of patient preferences, nature or severity of illness, research evidence, training, commercial pressures, and patient concerns about medication cost. Theme 3 was pharmacist-patient communication. Pharmacists sometimes experienced challenges with language barriers and patients' expectations of receiving antibiotics. Pharmacists emphasised the importance of being trusted by their patients. There was widespread acceptance of their role in self-management advice for acute illness and interest in the role of herbal medicines, but pharmacists did not feel confident in recommending these.

CONCLUSION

Pharmacists are central to the management of self-limiting infections. There is a need to educate the public about appropriate use of antibiotics and provide training and support for pharmacists on self-management strategies including herbal medicine.

Misconceptions and Knowledge Gaps on Antibiotic Use and Resistance in Four Healthcare Settings and Five European Countries-A Modified Delphi Study

Misconceptions and knowledge gaps about antibiotics contribute to inappropriate antibiotic use and antimicrobial resistance. This study aimed to identify and prioritize misconceptions and knowledge gaps about antibiotic use from a healthcare professionals' perspective. A modified Delphi study with a predefined list of statements, two questionnaire rounds, and an expert meeting was conducted. The statements were rated by healthcare professionals from France, Greece, Lithuania, Poland, and Spain, and from general practice, out-of-hour services, nursing homes, and pharmacies. A total of 44 pre-defined statements covered the following themes: (1) antimicrobial resistance in general, (2) use of antibiotics in general, (3) use of antibiotics for respiratory tract infections, and (4) use of antibiotics for urinary tract infections. Consensus was defined as ≥80% agreement between the professionals during the second Delphi round. For 30% of the statements, professionals from the four settings together reached consensus. In each setting individually, at least 50% of the statements reached consensus, indicating that there are still many misconceptions and knowledge gaps that need to be addressed. Six educational tools (leaflets, posters, checklists) were developed to address the knowledge gaps and misconceptions. These can be used by patients and healthcare professionals to improve the use of antibiotics in practice.

Antimicrobial Stewardship Practices of Community Pharmacists in United Arab Emirates

BACKGROUND

The purpose of this paper is to assess the implementation of antimicrobial stewardship (AMS) activities in community pharmacies in the United Arab Emirates (UAE).

METHODS

A descriptive cross-sectional study in the Emirate of Abu Dhabi, UAE, was conducted using a validated questionnaire. The questionnaire consisted of four AMS outpatient core elements, namely, commitment, action, tracking and reporting, and education and expertise, with each element containing different associated items. Pharmacy teams' responses were categorized into three levels: low, satisfactory, or high.

RESULTS

Fifty-five pharmacy teams participated. Respondents confirmed implementation of at least one item of each AMS outpatient core element: commitment (94.5%), action (94.5%), tracking and reporting (67.3%), and education and expertise (81.8%). In supporting AMS implementation, surveyed teams scored high (81.8%) for action, satisfactory (65.5%) for education and expertise, low (43.6%) for tracking and reporting, and satisfactory (76.4%) for commitment. Attending antimicrobial stewardship programs was found to be a statistically significant predictor of implementation of antimicrobial stewardship activities (p = 0.048).

CONCLUSIONS

The majority of community pharmacies met the core elements of outpatient antimicrobial stewardship to some degree. There is a significant association between participation in antimicrobial stewardship programs and implementation of antimicrobial stewardship activities by pharmacists in practice.

Consumer perceptions of community pharmacists' involvement in antimicrobial stewardship: A quantitative study

Background Community pharmacist involvement in antimicrobial stewardship (AMS) within primary care is underutilised. Despite this view being consistently held across the pharmacy sector's policy, academic and professional spheres, there is limited understanding of how this positioning aligns with consumers' perceptions and expectations. Objective To explore participants' experience using antibiotics and their engagement with pharmacists to support their use. Methods Online survey of Australian adults recruited via Dynata's research panel in November 2022. Questions were organised into three sections: 1) understanding the participant's use of antibiotics, including their information needs; 2) exploring engagement with pharmacists on a cold and flu enquiry using a vignette question; and 3) demographic information. Results Doctors (42.0%), pharmacists (29.8%) and the internet including general searches (14.3%) were the top three sources for antibiotic information. Information about side effects and anticipated time to effect were more broadly sought from pharmacists than what was provided. Over 50% of respondents indicated alignment between the best practice example of a pharmacist providing cold and flu management advice with their own experience. 17% of respondents indicated that they would seek doctor's advice when considering cold and flu management options compared to 10% seeking pharmacist's advice. No statistically significant results between age groups or gender were observed. Conclusion Better visibility of community pharmacists' involvement in managing minor ailments in primary care, including more explicit linkage of pharmacist-administered vaccination services as an AMS strategy can support optimal antimicrobial use.

The Use of the TARGET Antibiotic Checklist to Support Antimicrobial Stewardship in England's Community Pharmacies

Antimicrobial Stewardship (AMS) requires effective teamwork between healthcare professionals, with patients receiving consistent messages from all healthcare professionals on the appropriate antimicrobial use. Patient education may reduce patients' expectations to receive antibiotics for self-limiting conditions and reduce the pressure on primary care clinicians to prescribe antibiotics. The TARGET Antibiotic Checklist is part of the national AMS resources for primary care and aims to support interaction between community pharmacy teams and patients prescribed antibiotics. The Checklist, completed by the pharmacy staff with patients, invites patients to report on their infection, risk factors, allergies, and knowledge of antibiotics. The TARGET antibiotic checklist was part of the AMS criteria of England's Pharmacy Quality Scheme for patients presenting with an antibiotic prescription from September 2021 to May 2022. A total of 9950 community pharmacies claimed for the AMS criteria and 8374 of these collectively submitted data from 213,105 TARGET Antibiotic Checklists. In total, 69,861 patient information leaflets were provided to patients to aid in the knowledge about their condition and treatment. 62,544 (30%) checklists were completed for patients with an RTI; 43,093 (21%) for UTI; and 30,764 (15%) for tooth/dental infections. An additional 16,625 (8%) influenza vaccinations were delivered by community pharmacies prompted by discussions whilst using the antibiotic checklist. Community pharmacy teams promoted AMS using the TARGET Antibiotic Checklist, providing indication-specific education and positively impacting the uptake of influenza vaccinations.

Scoping of pharmacists' health leadership training needs for effective antimicrobial stewardship in Africa

BACKGROUND

Antimicrobial resistance (AMR) is a global public health concern currently mitigated by antimicrobial stewardship (AMS). Pharmacists are strategically placed to lead AMS actions that contribute to responsible use of antimicrobials; however, this is undermined by an acknowledged health leadership skills deficit. Learning from the UK's Chief Pharmaceutical Officer's Global Health (ChPOGH) Fellowship programme, the Commonwealth Pharmacists Association (CPA) is focused to develop a health leadership training program for pharmacists in eight sub-Saharan African countries. This study thus explores need-based leadership training needs for pharmacists to provide effective AMS and inform the CPA's development of a focused leadership training programme, the 'Commonwealth Partnerships in AMS, Health Leadership Programme' (CwPAMS/LP).

METHODS

A mixed methods approach was undertaken. Quantitative data were collected via a survey across 8 sub-Saharan African countries and descriptively analysed. Qualitative data were collected through 5 virtual focus group discussions, held between February and July 2021, involving stakeholder pharmacists from different sectors in the 8 countries and were analysed thematically. Data were triangulated to determine priority areas for the training programme.

RESULTS

The quantitative phase produced 484 survey responses. Focus groups had 40 participants from the 8 countries. Data analysis revealed a clear need for a health leadership programme, with 61% of respondents finding previous leadership training programmes highly beneficial or beneficial. A proportion of survey participants (37%) and the focus groups highlighted poor access to leadership training opportunities in their countries. Clinical pharmacy (34%) and health leadership (31%) were ranked as the two highest priority areas for further training of pharmacists. Within these priority areas, strategic thinking (65%), clinical knowledge (57%), coaching and mentoring (51%), and project management (58%) were selected as the most important.

CONCLUSIONS

The study highlights the training needs of pharmacists and priority focus areas for health leadership to advance AMS within the African context. Context-specific identification of priority areas supports a needs-based approach to programme development, maximising African pharmacists' contribution to AMS for improved and sustainable patient outcomes. This study recommends incorporating conflict management, behaviour change techniques, and advocacy, amongst others, as areas of focus to train pharmacist leaders to contribute to AMS effectively.

Developing a Tool for Auditing the Quality of Antibiotic Dispensing in Community Pharmacies: A Pilot Study

Background: The European Centre for Disease Prevention and Control describes the community pharmacist as the gatekeeper to the quality of antibiotic use. The pharmacist has the responsibility to guard safe and effective antibiotic use; however, little is known about how this is implemented in practice. Aims: To assess the feasibility of a method to audit the quality of antibiotic dispensing in community pharmacy practice and to explore antibiotic dispensing practices in Greece, Lithuania, Poland, and Spain. Methods: The Audit Project Odense methodology to audit antibiotic dispensing practice was adapted for use in community pharmacy practice. Community pharmacists registered antibiotic dispensing on a specifically developed registration chart and were asked to provide feedback on the registration method. Results: Altogether, twenty pharmacists were recruited in four countries. They registered a total of 409 dispenses of oral antibiotics. Generally, pharmacists were positive about the feasibility of implementing the registration chart in practice. The frequency of checking for allergies, contraindications and interactions differed largely between the four countries. Pharmacists provided little advice to patients. The pharmacists rarely contacted prescribers. Conclusion: This tool seems to make it possible to get a useful picture of antibiotic dispensing patterns in community pharmacies. Dispensing practice does not seem to correspond with EU guidelines according to these preliminary results.

Antimicrobial Resistance and Community Pharmacists’ Perspective in Thailand: A Mixed Methods Survey Using Appreciative Inquiry Theory

Global action plans to tackle antimicrobial resistance (AMR) are the subject of ongoing discussion between experts. Community pharmacists have a professional responsibility to tackle AMR. This study aimed to evaluate the knowledge of antibiotic resistance and attitudes to promoting Antibiotic Smart Use (ASU) amongst part and full-time practicing community pharmacists across Thailand. An online mixed-method survey applying Appreciative Inquiry theory was validated and conducted in 2020. Non-probability sampling was used, with online survey dissemination via social networks. A total of 387 community pharmacists located in 59 out 77 provinces seemed knowledgeable about antimicrobial resistance (mean score = 82.69%) and had acceptable attitudes towards antibiotic prescribing practices and antimicrobial stewardship (mean score = 73.12%). Less than 13% of pharmacists had postgraduate degrees. Postgraduate education, training clerkship, preceptors, and antibiotic stewardship training positively affected their attitudes. The community pharmacists proposed solutions based on the Appreciative Inquiry theory to promote ASU practices. Among these were educational programmes consisting of professional conduct, social responsibility and business administration knowledge, up-to-date legislation, and substitutional strategies to compensate business income losses.

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.