ANTIMICROBIAL STEWARDSHIP (AMS)

Quick reference guide

Antimicrobial resistance is recognised as a global public health threat and the UK Government is committed to antimicrobial stewardship (AMS) as a means to slow the development and spread of antimicrobial resistance.¹ In 2016, the UK Government set a target to reduce inappropriate prescribing of antimicrobials by 50% by the year 2020.²

All pharmacists, regardless of setting, have AMS obligations and with over 1.6 million visits each day, community pharmacy teams have a key role in contributing to this target by educating patients and the public on the appropriate, and more importantly inappropriate, use of antimicrobials.  Advising on the prevention and self-care of minor ailments and supporting appropriate use of NHS resources are key roles in AMS.  

This guide will look at how pharmacists and their teams working in community pharmacy can contribute to AMS: it will look at how roles and services already provided by community pharmacy contribute to AMS and consider what else can be done. 

Although aimed at community pharmacy in GB, much of the information in this guidance is relevant to pharmacists in other settings especially those working in primary care or care homes.     

How pharmacists can help

Preventing antimicrobial overuse

Current advice is that people should be encouraged to manage self-limiting conditions themselves and speak to their local pharmacy team³.  Community pharmacy has a good track record of providing advice on the safe and effective use of over-the-counter medicines or self-treatment strategies and is well placed to educate people on the safe and effective use of antimicrobials by: 

  • assessing whether the condition is self-limiting
  • highlighting the difference between a viral and bacterial infection
  • advising on the most appropriate ways to manage the problem
  • advising on the average duration of common self-limiting conditions to reassure the person thereby reducing the risk of them making an appointment with their GP/out-of-hours provider seeking inappropriate antimicrobial prescriptions
  • offering explicit advice on what to do if the symptoms get worse and when to seek further help (i.e. safety-netting)
  • recognising warning symptoms or when someone may need antimicrobials and referring on where appropriate.  

Public Health England has produced a useful guide that can be used across GB.  ‘Treating Your Infection - Respiratory Tract Infection’ includes information on the duration of some common self-limiting respiratory conditions (see below) and also includes advice for people on when it would be appropriate to seek further help from their GP (see Appendix 1 ).

 

Duration of common respiratory infections4

Most are better in

middle-ear infection 8 days
sore throat 7-8 days
common cold 14 days
sinusitis 14-21 days
cough or bronchitis 21 days

 

 

A similar publication for urinary tract infections ‘Urinary tract infection information leaflet’ also from Public Health England is available on the Royal College of General Practitioners website and would be of particular use to pharmacists working in primary care and independent prescribers. 

Other standard self-care and symptom relief advice that will help people self-manage their illness are:

 

  • rest and drinking plenty of fluids
  • use of appropriate over-the-counter medicines e.g. acetic acid 2% spray as an alternative to antibiotic ear drops
  • explicit advice on what to do if the symptoms get worse and when to seek further help (i.e. safety-netting)
  • providing public health advice e.g. hand hygiene to prevent the spread of infection
  • educating people on the key signs of sepsis and when to seek further help (further information available from NHS Choices or The UK Sepsis Trust)
  • providing written resources i.e. leaflets to support the advice given (see Appendix 1)
  • highlight and sign-post people to other self-care resources such as NHS Choices (England), NHS Inform (Scotland) and NHS Direct Wales.

Persons who have been issued with a ‘back-up’ or ‘delayed prescription’ (i.e. to be collected in a specified number of days if their symptoms haven’t improved) would benefit from advice on when and how to use the prescription properly as well as ways of managing self-limiting conditions (above).  

 

Preventing antimicrobial misuse

Where antimicrobials have been prescribed advice should be given on medicines adherence to prevent antimicrobial misuse.  Key messages are to³:

  • confirm the person’s understanding of the correct dose, at the specified time (before, after or with food), for the right duration and via the correct route
  • complete the full course even if symptoms improve
  • return any un-used antimicrobials to the pharmacy - do not dispose at home e.g. by flushing down the toilet/sink
  • not share medicines with others
  • not keep left-over antimicrobials at home as a preventative measure for another time
  • only use or take antimicrobials if they have been supplied from a healthcare practitioner or a pharmacist (do not use prescription-only antimicrobials obtained online without a prescription)
  • not use antimicrobials prescribed for animals.

A sample checklist which can be used when advising people about self-limiting conditions or dispensing prescriptions for antimicrobials can be found in Appendix 2.


Other AMS roles for community pharmacy and potential benefits

Community pharmacy role Benefit
Influenza vaccination service and supporting the uptake of vaccination Can limit the number of people seeing a GP for coughs and runny noses, or for pneumonia (as a secondary infection following 'flu)
Minor Ailments Service (local/national) e.g. Pharmacy First, Welsh Common Ailments Service Engaging in Minor Ailments Services ensures effective and appropriate use of NHS resources by enabling pharmacists to provide advice and support on self-limiting conditions as an NHS service which reduces the burden on primary care services
Hydration messages e.g. in urinary tract infection Providing advice on hydration to people with symptoms of or at risk of urinary tract infection alongside treatment options can help to prevent the incidence of infection
Food hygiene advice (and other public health messaging) Often considered outside the scope of pharmacy but providing food hygiene advice (hand hygiene, cross-contamination prevention, safe food storage etc) can help prevent bacterial food poisoning
Ensuring the appropriateness of an antimicrobial prescription against the local formulary and discussing with the prescriber where there are concerns (i.e. length of treatment, or outside the scope of the local formulary) - access to the ‘summary care record’ to confirm the indication will help facilitate this Contributing to AMS locally and nationally

Further information on the role pharmacists, in all settings, play in AMS can be found in the RPS AMS Policy document.


What else can I do?

  • Choose a pledge as a healthcare professional to support the better use of antibiotics.  Encourage your pharmacy team to be involved as well.  Members of the public are also invited to choose a pledge: see Antibiotic Guardian website.
  • Obtain a copy of your local antimicrobial/antibiotic formulary from your local Area Prescribing Committee (England), Drug and Therapeutics Committee (Scotland) or Local Health Board (Wales).
  • Register for one of the free online training courses for your or your staff e.g. Antimicrobial Stewardship: Managing Antibiotic Resistance from Future Learn.  See the RPS AMS Portal for details of other training courses.
  • Engage with European Antibiotics Awareness Day (November each year) and/or World Antibiotics Awareness Week (November in northern hemisphere).  Further information available from: Antibiotic Guardian.
  • Attend meetings of local AMS groups/networks (e.g. prescribing/formulary development group).
  • Undertake an audit of your AMS activity.
  • Ensure that any alcohol-based handrubs you stock are compliant with British Standards: those containing 60% of isopropyl alcohol are considered effective against the majority of microorganisms.  (Caution: there have been reports that these rubs are being misused because of their high alcohol content.)
  • Speak to your local businesses and/or local schools about coughs and colds and reducing the spread of infection e.g. effective hand-hygiene.   The E-bug project led by Public Health England includes teaching resources on microbes and antibiotics for children aged 7-16; and the E-bug Virtual Science Show, hosted by the British Society for Antimicrobial Chemotherapy, is a resource aimed at children aged 5-7 and includes graphics and games to reinforce AMS messages.

Where to go for further information?

 


Definitions

Antimicrobial

Defined in NICE guideline 15⁵ as including all anti-infective therapies: antibacterial, antifungal, antiparasitic, antiviral

Antimicrobial stewardship

Defined in NICE guideline 15⁵ as:  “an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness”

Self-limiting conditions

Includes, but is not limited to: bronchitis, common cold, community-acquired pneumonia, cough, ear infection, oral thrush, sinusitis, skin infection, sore throat, urinary tract infection, winter vomiting bug

 


References

¹ UK Government.  Antimicrobial Resistance (AMR) Collection. July 2017. https://www.gov.uk/government/collections/antimicrobial-resistance-amr-information-and-resources

² Department of Health. Government response to the Review of Antimicrobial Resistance. September 2016. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/553471/Gov_response_AMR_Review.pdf accessed 22 August 2017

³ National Institute for Health and Care Excellence (NICE). NICE guideline 63. Antimicrobial stewardship: changing risk-related behaviours in the general population. January 2017. https://www.nice.org.uk/guidance/ng63

⁴ RCGP. TARGET Antibiotic Toolkit: TYI-RTI leaflet for community pharmacies. August 2017. http://www.rcgp.org.uk/clinical-and-research/toolkits/target-antibiotic-toolkit.aspx

⁵ National Institute for Health and Care Excellence (NICE). NICE guideline 15. Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. August 2015. https://www.nice.org.uk/guidance/ng15


Appendix 1: Treating your infection - respiratory tract infection Appendix 1: Treating your infection - respiratory tract infection

Appendix 2: Antimicrobial stewardship - checklist for community pharmacy Appendix 2: Antimicrobial stewardship - checklist for community pharmacy

Advising on self-limiting conditions - the 6Rs¹

  • Reassurance - reassure the patient about the infection
  • Reasons - explain why antimicrobials are not normally necessary
  • Relief - suggest suitable over-the-counter preparations for symptom relief e.g. paracetamol for pain
  • Realistic - give a realistic time when the patient can expect to start feeling better
  • Reinforce - provide written information to support advice given
  • Rescue - give safety netting advice i.e. when to seek further help or advice

¹ Adapted from Little P. Delayed or back-up prescriptions for respiratory tract infections . Presented at: TARGET Webinars; 2016. Available at: www.target-webinars.com/webinars/back-up-prescriptions/ (accessed 10 August 2017)

Clinically assessing prescriptions for antimicrobials: practice points

RIGHT DRUG

  • Confirm indication (verbally or from the patient record); is the antimicrobial prescribed appropriate for the infection being treated
  • Check local prescribing guidelines (national guidance / current evidence base)
  • The narrowest spectrum antimicrobial should be used wherever possible; inappropriate use of broad spectrum antimicrobials should be avoided

RIGHT DOSE

  • Is the dose / frequency appropriate for the indication / pharmaceutical form; consider renal function (with e.g. nitrofurantoin) and body weight

RIGHT DURATION

  • Check for appropriate duration of treatment

If concerned about the appropriateness of an antimicrobial discuss with the prescriber

CONSIDER

  • Drug interactions especially with rifampicin or with macrolides (e.g. + statins); also tetracyclines + iron or calcium; fluoroquinolones + iron
  • Any history of allergies to antimicrobials or other medicines (N.B. important to differentiate between allergies and intolerance)

Dispensing prescriptions for antimicrobials

Patient counselling

  • What have you been told about your infection?
  • When have you been advised that you should expect to feel better?
  • Take the medicine at regular intervals, as prescribed, with or without food
  • Finish the course (even if symptoms improve)
  • Return unwanted medicines; do not share with family or friends; don’t keep for future illness
  • Side effects
  • Alcohol consumption (when to avoid)

Offer advice on

  • Self-care and sign-post to self-care resources
  • Vaccinations (e.g. influenza, pneumococcal)
  • Safety-netting (i.e. when to seek further help)
  • Public health advice (i.e. hand hygiene) as infection control measures

Provide a self-care leaflet e.g. PHE leaflet to support verbal advice




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