Antimicrobial resistance (AMR) is one of the greatest threats facing humanity. Action to tackle the problem must be taken now. Policies already exist at international, regional and national level. Pharmacists are increasingly being involved in providing their expertise when AMR policies are being formulated and implemented. Pharmacists have a key role to play in the implementation of the World Health Organization’s (WHO) Global Action Plan to tackle AMR (1).
The International Pharmaceutical Federation (FIP) is a global federation of national associations of pharmacists and pharmaceutical scientists. In order to support these associations in their fight against AMR, FIP has prepared this briefing document. It is an overview of the different activities for AMR prevention that community and hospital pharmacists are involved in.
Their roles include providing advice on health promotion, infection prevention and immunisation. Another role for pharmacists is evaluating whether an antimicrobial treatment is needed through a process of triage. If antibiotic treatment is not needed, pharmacists treat the minor ailments. If it is needed, they can provide antibiotic treatment or refer to GP or a specialist for accurate diagnosis.
Pharmacists are experts in medicines. They ensure optimal management of antimicrobial treatment, and can provide adherence support for short- and long-term infection. Pharmacists act on medicine interactions and in cases where patients need special support (for example, if the form of the medicine is changed). They ensure the quality of medicines and their safe disposal. In hospitals pharmacists are leading stewardship programmes, and provide expertise on sterilisation and hygiene. Specific emphasis is given to collaborative approaches and actions with stakeholders.
These examples of pharmacists’ activities are illustrated by campaigns and programmes developed by pharmacists and their associations around the world. The objective of this document is not to provide an exhaustive list of all activities, but to provide food for thought for future action. It also aims to stimulate discussion with different partners and to provide a foundation for future formulation of recommendations or policy statements.
1. Antimicrobial resistance (AMR) as a global public health threat
1.1 Defining terms: Responsible vs. irresponsible use of antimicrobials
Since the discovery of penicillin in 1928 by Alexander Fleming, antibiotics have been the bedrock of many of the greatest medical advances. (2) Penicillin, which is an outstanding agent in terms of safety and efficacy, saved the lives of many people during the Second World War. (3) Antibiotics also made possible safe minor surgery and routine operations, which without antibiotics could become high risk procedures owing to an increased likelihood of sepsis. (2)
Although these types of medicines are generally known as “antibiotics”, “antimicrobials” is a more accurate term. They are active substances of synthetic or natural origin which destroy bacteria, viruses and fungus, suppressing their growth or their ability to reproduce in animals or humans. (3)
AMR arises when bacteria and other pathogens evolve to be able to resist to the medicine that has previously been used to combat them (5). Resistant microorganisms can survive or even grow in the presence of a concentration of antimicrobial that is usually sufficient to inhibit or kill microorganisms of the same species that did not develop resistance mechanisms. (3) This important feature was foreseen by Alexander Fleming, who in his speech when receiving the Nobel Prize in medicine made a warning about the possibility of creating resistant organisms, if antibiotics were used irrationally. (6) This means that the problem began immediately after the industrialised production and mass use by the population.
1.2 Why is AMR a problem?
1.2.1 Current Status
The emergence of AMR is a complex problem driven by many interconnected factors, in particular the overuse and misuse of antimicrobials. (7) Antimicrobials have been overused all over the world and the widespread impact and increasing prevalence of AMR has been well documented. (8) In developed countries, a study (9) has shown that Australia has been one of the highest users of antibiotics. The authors state that the defined daily dose in Australia is nearly 23/1,000 population/day compared with less than 15 for Denmark, the Netherlands and Sweden.
Another study published in 2013 (10) describes consumption of antibiotics for systemic use in the community ranging from 10.8 defined daily doses (DDD) per 1,000 inhabitants and per day (the Netherlands) to 32.0 DDD per 1,000 inhabitants and per day (Greece); a 2.9-fold difference, which is similar to that seen in previous years. The population-weighted EU/EEA mean consumption was 22.4 DDD per 1,000 inhabitants and per day, representing a continuing increase over the past five years for the EU as a whole, as well as for six individual countries.
Although irrational use of medicines is the main cause of AMR, as described in a recent WHO report, (6) there are other important factors to consider, for example, practices in the agricultural industry and animal husbandry. In these activities, antimicrobials are given as treatments to animals or as additives in feeds, and their misuse can be at the heart of the AMR problem. Discrepancies between regulatory requirements and prescribing/dispensing realities for animal antimicrobial use are often worse than in human medicine. (11) In addition, antimicrobials that are used as growth promoters are not considered as medicines, but as feed additives. (12) (13)
Antibiotic-resistant bacteria arising from agricultural practices enter human environments and transfer to people and goods, thus creating a possibility for AMR to cross national borders. (14)
Bacteria of international concern are: Escherichia coli, which is showing resistance to third-generation cephalosporins, including resistance conferred by extended spectrum beta-lactamases, and to fluoroquinolones; Klebsiella pneumonia, which can be resistant to third-generation cephalosporins, including resistance conferred by extended spectrum beta-lactamases and to carbapenems; Mycobacterium tuberculosis, which is resistant to a variety of antimicrobials; and Streptococcus pneumoniae, which can be non-susceptible (resistant) to penicillin. (6)
1.2.2 Future Trends
AMR may be the greatest challenge to face healthcare in the 21st century (15). Four factors that will largely determine the future extent of AMR have been analysed: pathogen and microbial ecology; prescribing and dispensing practices; population characteristics; and health care policy. (16) (17) It is estimated that more than half of all medicines are inappropriately prescribed, dispensed, or sold. (18)
AMR is increasing even in places of where antimicrobials are controlled. For example: data published in multicentre studies in the United States, Europe and Latin America show an increasing level of resistance in bacteria isolated from hospitals. (19)
AMR is also influenced by the massive increases in trade and human mobility brought by globalisation. In the 1990s, for example, a resistant Pneumococcus sp. first identified in Spain quickly spread to Argentina, Brazil, Chile, China Taiwan, Colombia, Malaysia, Mexico, the Philippines, the Republic of Korea, South Africa, Thailand, the USA, and Uruguay. (12).
AMR also indirectly affects the treatment of non-communicable diseases. Modern cancer treatments often suppress patients’ immune systems, making them more susceptible to infections. Therefore without an effective antimicrobial to prevent or treat infection, chemotherapy would become a much riskier recommendation. (5)
Some 300 million people are expected to die prematurely because of AMR over the next 35 years and the economic cost will be significant, with the world economy being hit up to $ 100 trillion by 2050 if we do not take action. (5)
2. Need for better management in AMR
2.1 Burden on health
The damaging effects of AMR are already being seen across the world. Resistant infections currently claim at least 50,000 lives each year across Europe and the USA, and hundreds of thousands are dying in other areas of the world. (5)
The threat is also severe in developing countries, where tuberculosis (TB), malaria and HIV/AIDS are having an enormous impact. (5) Since TB and HIV/AIDS have long-term regimens of treatment. Some degree of AMR is expected to occur, even when treatments are optimal. (6) But treatment failure caused by AMR contributes to: additional side effects from more toxic treatments; longer hospital stays; psychological disorders due to reduced quality of life; the burden on family; and a greater likelihood of death as a result of inadequate or delayed treatment. And this is not including costs arising from surveillance and follow-up activities associated with trying to control resistance itself. (20) An example is the treatment of patients with multi-drug resistant TB, who can undergo a two-year treatment programme. (21)
AMR also affects patients who are not infected with resistant organisms. Because of the increasing rate of resistance among common pathogens, broader-spectrum agents are now required for the empirical therapy of many common bacterial infections. These agents are usually more expensive, have more deleterious effects on protective microflora, and can be more toxic or less effective. (15) For example third-generation cephalosporins or fluoroquinolones are recommended for the treatment of hospital inpatients with community-acquired pneumonia rather than a narrow-spectrum agent, such as penicillin. (15)
2.2 Economic burden
Globally, very little information has been published on the economic burden of AMR on health care systems. Studies that do exist are predominantly hospital-based, and these suggest that the costs are almost exclusively related to the length of hospital stay and treatment, and do not include costs associated with morbidity and early mortality.
The latest report from WHO, “AMR — Global report on Surveillance 2014” (6), shows estimates of economic burden, and the data are worrying. In the EU alone costs are estimated at about 1.5 billion euros annually. (22) In the USA, infections with resistant pathogens cost the health-care system in excess of US$20bn annually and generate more than eight million additional hospital days. The annual societal costs exceed US$35bn.
In addition, the report, which summarises Canadian studies, provides data on the economic burden of meticillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Mycobacterium tuberculosis and multidrug-resistant Neisseria gonorrhoeae, but data for other pathogens are limited. The annual costs of isolating MRSA and managing colonised or infected patients have been estimated at CAD $1,363 and CAD $14,360, respectively, the total for all Canadian hospitals being CAD $42–59m. (23) The incremental annual costs for managing vancomycin resistant enterococci (VRE)-colonised patients were estimated at CAD $6,732 per patient and CAD $5–16m for all Canadian hospitals. (23)
2.3 R&D gaps
While the development of AMR has been accelerating, development of new antimicrobial agents has slowed substantially during the past several decades. (24) For example, the aging of the USA population has shifted medicine discovery efforts towards agents for chronic medical conditions that are more prevalent among the elderly, such as hypercholesterolemia, hypertension, mood disorders, dementia, and arthritis. (7) This situation could explain why as of early 2012, only 109 antibiotics are in the pipeline and 70% of these are in early stages of development. Only 31 potential candidates are in Phase II trials and nine candidates in Phase III trials. (24) And there is no guarantee of any of these reaching the market.
Only two classes of new antimicrobial have come to market over the past 30 years (22) and the number of new molecular entity antibiotics approved by the USA Food and Drug Administration (FDA) continues to decrease. (24) Between 1983 and 1992, 30 new antibiotics were approved in the USA, but only seven have been approved since 2003. (14) Between 1968 and 2000, no new classes of antibiotics were discovered, and although two classes were discovered in 2000 and 2003 it is worth noting that these targeted only gram-positive bacteria; there remain no new class candidates for gram-negative bacteria. (20)
However, even an increase in development of new antimicrobials is not a guarantee that AMR will be stopped, since microbes are constantly evolving under the exposure to antimicrobials. Therefore the responsible use of antimicrobials remains crucial or new medicines may soon become ineffective.
3. Translation of needs into AMR policies
Reducing AMR requires global action, education and promotion. Guidelines and policies can provide tools for prescribers and dispensers to educate patients on antimicrobial use and the importance of adherence to prescribed treatments, and to ensure patients receive medicines appropriate to their clinical needs in doses that meet their individual requirements for an adequate period and at the lowest cost to them and their community. (6) Surveillance and prudent use of antibiotics by medical, pharmacy and veterinary professionals are urgently needed. Economic incentives combined with increasing R&D initiatives leading to interest in the development of new antimicrobial medicines are also part of a solution. (25)
Control of the development of AMR can be achieved via collaborative health personnel practice and the involvement of all stakeholders. (26)
3.1 Policy at international level
International AMR policies aim at prudent use of antimicrobials and infectious disease prevention, combined with surveillance of resistance and antimicrobial use. (26) In 2001, the WHO published its “Global Strategy for Containment of Antibiotic Resistance” (27), which involves all these factors. In 2004 the WHO investigated which diseases are considered a health threat with a pharmaceutical gap. The results were reported in its “Priority Medicines for Europe and the World” document. (28)
FIP has been monitoring WHO policies. In response to AMR rising up the global health agenda, in 2008 FIP issued its “Statement of policy — control of antimicrobial resistance” (29), through which FIP takes responsibility for professional leadership through a range of AMR activities.
In 2014, the WHO invited FIP and other stakeholders to contribute to its report “Antimicrobial resistance: global report on surveillance 2014” (6). It provided for the first time as accurate a picture as possible of the magnitude of AMR and the current state of surveillance globally. It called for coordinated approach and formulated a base for a Global Action Plan on AMR.
The Global Action Plan on AMR was approved in May 2015. (1) Its highlights are summarised in Appendix 1. Through the process of development of this plan, FIP promoted best practices and the role of pharmacy in the selection, procurement, distribution and use of antimicrobial medicines and demonstrated that pharmacists contribute to optimisation of antimicrobials use, for instance through antimicrobials stewardship programmes. (30)
3.2 Policy at regional or national level
An important step in providing better management or surveillance in AMR is to develop strategies or plans involving different areas, including government, health authorities and healthcare associations. In some countries, AMR policies or plans have been developed to cope with different AMR scenarios and/or prevention. At present, British, German, Australian, Indian, American, Chinese, Israeli, Brazilian, European and South American policies cover these specific issues of AMR policies:
- Take action in main areas such as surveillance, prevention of communicable diseases and infection control through the prudent use of antimicrobial agents. (24) (28) (31) (32) (33) (34) (35) (36)
- Research and development of alternative products and/or new antimicrobial medicines. (33) (34) (37)
- Protection and promotion of public and animal health evaluation and supervision of medicines for human and veterinary use. (3) (28) (33) (34)
- Comprehensive collaboration between government and health professionals to improve antibiotic stewardship (34) (38) (39) (36)
- Control of unnecessary or inappropriate use of medically important antimicrobials in food animal production that is not beneficial to public health. (3) (35) (36)
- Factors influencing the development of AMR and the interactions between them (40)
Since Australia’s consumption of antibiotics is among the highest in the developed world, there have been moves by the Australian Federal Government to address AMR. The issue is to be targeted in an upcoming national strategy that promises better prescribing and greater surveillance to combat the threat of so-called superbug-resistance. (41) For the first time, the federal departments of health and agriculture have vowed to work together to limit the risk to human health. The 2015–19 policy calls for a “One Health” surveillance system, collecting data on antibiotic use in humans and animals and evidence of resistance in food and patients, and identifying emerging problem areas, with Australia set to tap into international networks.
A good example of a collaborative body with the remit of working for interdisciplinary collaboration in issues related to safeguarding the possibility of effective use of antibiotics in human and veterinary bacterial infections is Strama (the Swedish Strategic Programme against Antibiotic Resistance). (36)
3.3 Strategies developed by pharmacists
Pharmacists’ role in demystifying the perception that antibiotics are needed to treat colds and other minor ailments was highlighted in the Pharmaceutical Group of the European Union (PGEU) statement on “Community Pharmacists’ Contribution to the Control of Antibiotic Resistance” (42).
In addition, a WHO report: “The role of pharmacist in encouraging prudent use of antibiotics and averting antimicrobial resistance: a review of policy and experience in Europe”, (43) presents a number of issues that policy-makers may wish to consider with a view to strengthening their efforts to tackle AMR, such as enhancing the prudent use of antibiotics. The report was developed by the Health Technology and Pharmaceutical Programme in collaboration with WHO-EURO regional office, the PGEU, Europharm Forum, and the WHO Collaborating Centre for Drug Development and Pharmacy Practice at Pharmakon (Denmark). Besides this, a paper “Pharmacists have decisive role in combating antibiotic resistance says new WHO European survey” (44) highlighted pharmacists’ role in AMR prevention and control, following a survey carried out by the WHO-EURO regional office.
The United Kingdom Clinical Pharmacy Association Infection Management Group (IMG) has worked closely with hospital pharmacists for many years developing and leading on UK antimicrobial stewardship initiatives solely and in collaboration with other UK infection societies and government agencies. (45)
4. Pharmacists’ contribution to the AMR fight
4.1 In the community
Community pharmacists are often the first point of contact for the public and they have a pivotal role in advising patients on minor ailments and referring them when required to their doctor. They are often the entry gate to health system on account of their accessibility.
That accessibility has been evaluated in Australia, where a recent study indicates that between July 2011 and July 2012, 94% of Australians aged 18 years and over reported using a pharmacy health care service. This proportion increases to 99% for Australians aged 65 years and over. (19) This situation gives pharmacists the unique opportunity to offer an effective medication therapy management and counselling on consumption of medicines and also engage patients in their appropriate, efficacious, safe and responsible use. (46)
Furthermore, due to their special position in the community pharmacists can educate and lead the general public in their medication-related needs. Roles played by community pharmacists include health promotion, triage and optimal treatment management.
4.1.1 Health Promotion
126.96.36.199 Encouraging healthy habits
Pharmacists can encourage healthy habits and promote good health through their whole community. In this regard, pharmacists are communicators on healthy lifestyles and hygiene practices and have taken part in health promotion campaigns on a wide range of topics.
For example, the Japan Pharmaceutical Association led a communication campaign on Actions against Lifestyle Diseases and Promotion of Good Health (See Activity 1) focused on a specific population. Also, Pharmacists in Denmark focused on men and their health and being fit in their “Men’s Health Week” campaign in 2013. (See Activity 2)
188.8.131.52 Educating on infection prevention
Infection prevention and control is an essential strategy to reduce infection and the subsequent increased use of antimicrobials. Pharmacists are involved in such strategies.
In the UK, the Royal Pharmaceutical Society designed a leaflet to encourage people to visit local pharmacies for sexual health advice and protection against sexually transmitted infections. (See Activity 3) Moreover, pharmacist continuously lead the control of infectious diseases such as chlamydia and syphilis with a simple action of selling condoms. Additionally, several initiatives have been aimed at raising awareness of issues around antimicrobials to both healthcare professionals and the public. Examples include, “E-bug”, which provides educational resources for primary and secondary schoolchildren about antibiotics, and “Antibiotic Guardian”, which invites its website users to make a pledge to use antibiotics sensibly. The website includes different statements for nurses, pharmacists, patients, doctors, families etc.
Furthermore, the Scottish Antimicrobial Prescribing Group (SAPG) has developed a plan, “Self help guide to treating your infection” for use by community pharmacies. The plan includes an on-line survey of all community pharmacists in 2015 to seek their feedback on usefulness of materials and identify any learning needs with respect to providing advice on self-limiting infections. (See Activity 4)
In India in November 2015, the theme of Indian National Pharmacy Week will be AMR-related. It will raise awareness on the spread of AMR spread and ways to reduce it.
184.108.40.206 Infection control via immunisation
Immunisation is an important part of any infection control strategy. It helps reduce the misuse of antimicrobials. In the case of viral vaccines, protection from a virus will reduce the number of viral infections which in some cases are mistakenly diagnosed as a bacterial infection and thus treated with antimicrobials. For example, there is a common misuse of antibiotics against influenza. (47)
Currently, opportunities to vaccinate are being missed. Increasing numbers of vaccine providers, such as pharmacists, create new opportunities to widen access to immunisation services and improve coverage among adults. (48) There is a growing evidence that vaccination by pharmacists increases vaccination rates in hard-to-reach groups, but also among people eligible for vaccination but who have not received it. (49) (50)
In countries where they are allowed to vaccinate, pharmacists are increasing their participation in vaccination activities. (51) In the USA 50 states have statutes that permit pharmacists to administer vaccines. (52) They are functioning as vaccine advocates, vaccine facilitators, and vaccine administrators, with the support of the American Pharmacists Association and the US Centers for Disease Control and Prevention’s National Immunisation Programme, which have developed a training course to prepare pharmacists for active participation in immunisation programmes. (49)
In the UK, pharmacists have launched a new service (53) whereby they offer a seasonal flu vaccination to patients. (See Activity 5) Also in Portugal, the National Association of Pharmacies organised for the first time a nationwide pharmacy-based influenza immunisation campaign to increase the coverage of flu vaccines for population with higher risks. (See Activity 6)
In Ireland, pharmacists supported by the Irish Pharmacy Union delivered seasonal flu vaccinations across the country to eligible at-risk groups, (pregnant women, and people with chronic illnesses). It was found that 23% of the patients who received an immunisation from their pharmacist had never received a flu vaccine before, 81% of these patients were considered to be at risk. Some 90% of all patients who received an immunisation were in this “at-risk” group. (50) (54) (See Activity 7) An immunisation campaign focused on patients with chronic disease such as diabetes was also developed in Belgium. (See Activity 8)
Programmes involving immunisations are evidence of a significant leap toward pharmacist’s involvement in direct patient care. (55) It increases the degree of trust between pharmacists and patients, which is so important when educating adults about the benefits of vaccines and, in some cases, solving possible myths or beliefs around vaccination.
In the context of this document, triage is a process of assessing whether patients in the pharmacy can be successfully treated by the pharmacist or whether they need to be referred to another healthcare professional. The stages of triage are described in detail below.
220.127.116.11 Assessment of the need for antimicrobials
18.104.22.168.1 Treatment without antimicrobial
People suffering from flu or respiratory problems may think a treatment with antibiotics is needed. Pharmacists can give the proper counselling for such health problems, ensuring that patients have a good understanding of their illness and realistic expectations of its progression.
Pharmacists regularly assist patients even when a prescriber has made the appropriate evidence-based decision not to prescribe an antimicrobial. In these cases the patient may require advice on symptomatic treatment. It is not uncommon for the pharmacist to have to manage any beliefs or ongoing expectations that the patient may have about the need for an antimicrobial. Health professionals can deliver key messages to patients about the inappropriate use of antimicrobials and their own role in minimising the development of resistance.
The Pharmaceutical Society of Australia has developed a programme “Pharmaceutical Society of Australia’s Pharmacy Self Care (PSC)”, which provides education modules for pharmacists and their assistants, via fact cards, covering over 85 most-frequently-asked-about health topics. (See Activity 9)
The Community Pharmacists Association of Thailand developed a campaign to prevent unnecessary use of antibiotics for non-bacterial infections and to tackle increasing antibiotic resistance in the country under the slogan “Mirror, mirror on the wall, do I need antibiotics at all?” People could check their throat in the mirror and screen if the symptoms of the illness were viral or bacterial with the pharmacist support. (See Activity 10)
Pharmacists in Spain launched a communication campaign with the slogan: “Do not ask us for antibiotics but for information”. The aim was to discourage patients from using antibiotics without prescription and to improve rational use of antibiotics. (See Activity 11) Another similar campaign was developed in Costa Rica by the College of Pharmacists, supported by patient leaflets and poster on rational use of antibiotics. (See Activity 12)
The General Council of Official Colleges of Pharmacy of Spain organised a campaign to raise awareness among the population of the risks of self-medication to treat flu symptoms, especially on the use of antibiotics to cure seasonal flu. (See Activity 13)
Pharmacists in the UK led an “Ask your pharmacist” week campaign to encourage people to avoid unnecessary visits to the doctor and instead seek the support of local pharmacies to stay well during the winter. (See Activity 14)
In Scotland, a Minor Ailments Service provided by community pharmacies supported patients through the sale or supply of medicines for the treatment of symptoms where infection is considered to be viral, eg, upper respiratory tract infection. (56) A similar Minor Ailments Service is evolving in England. (57)
The National Association of Pharmacies in Portugal organised a workshop for children, entitled “Protect yourself from Influenza A!” to educate them on H1N1 flu and how to avoid catching it. (See Activity 15) It focused on improving community knowledge about diseases that do not need antimicrobial treatments.
To support pharmacists when counselling patients who look for information about antimicrobial treatments to treat minor infections, the Pharmacy Guild of Australia launched a national systemised platform “Guild Programmes” for delivering professional health services. It also supports pharmacies to use Personally Controlled Electronic Health Record (PCEHR) that would facilitate counselling with access to patients’ medication history. (See Activity 16)
Similarly, the Czech Pharmaceutical Society led a campaign focused on antibiotic resistance to raise awareness of ways to prevent it. (See Activity 17)
22.214.171.124.2 Need for antimicrobial handled by pharmacist
In some countries pharmacists are legally allowed to prescribe antibiotics in clearly specified cases. Fast and reliable diagnostic tests are required to help pharmacists to identify an infection as bacterial rather than viral and guide the appropriate use of antimicrobials. In the UK, according to the Royal Pharmaceutical Society, the Longitude prize is on offer to those who can develop quick and reliable diagnostic tests. In addition, there has been recent publicity around the use of a C-reactive protein test to help identify antibacterial infections.
An example of an effective community pharmacy process is the Chlamydia Test and Treat service launched in the UK. Patients who were confirmed as having a positive Nucleic Acid Amplification Technique (NAAT) result for chlamydia detection received Clamelle (azithromycin). Their sexual partners received the medicine too. (See Activity 18) The American Pharmacists Association developed an activity to prevent Lyme disease. Pharmacists dispense two 100mg doxycycline tablets for six months to patients who had been exposed to Ixodes scapularis (deer tick) as a prophylactic treatment; and provided counselling on how to take the medicine (a broad-spectrum antibiotic of the tetracycline class), signs and symptoms of Lyme disease and prevention strategies for possible future tick attachment. (See Activity 19)
126.96.36.199.3 Referral for accurate diagnosis and management of common infections
After an accurate assessment, pharmacists can offer to treat minor health problems or infections with an over-the-counter medicine. If a serious health problem is identified and the person needs to see a physician or specialist, pharmacists refer the patients to the appropriate health professional..
For example, in India, TB is estimated to cost society some $3bn. (58) The government in its plan to fight TB uses DOTS strategy. (DOT, directly observed treatment, is a standard strategy for the diagnosis, treatment and management of TB.) Thereby it is ensured that patients complete the course of treatment, helping to reduce the chances of development of AMR. Since 43% of presumptive TB cases come to the pharmacy for advice or to buy medicine, DOTS is led by pharmacists. Pharmacists refer patients properly to the DOTS facilities to increase their chance of correct diagnosis and treatment. The Indian Pharmaceutical Association in collaboration with PSG College of Pharmacy conducted a DOTS-TB training programme for pharmacists from the hospital and community sectors with emphasis on rational use, no sale of antibiotics without a prescription, counselling patients for adherence, etc.
A similar initiative to engage pharmacies to make contributions to the case detection rate and cure rate in community areas has been implemented in the Philippines. (59)
4.1.3 Optimal treatment management
Pharmacists are trained in the management and responsible use of medicines and they play a major role in improving outcomes for patients taking antimicrobials through encouraging adherence in short- and long-term treatments.
188.8.131.52 Adherence support
184.108.40.206.1 Short-term infections
The Association of Danish Pharmacists developed a campaign under the slogan “Unless you take your antibiotics to the end, you might believe that the treatment does not work”. The core target of this campaign were the parents of young children. (See Activity 20) In a similar campaign in 2014, Danish pharmacists provided parents with checklist chart for antibiotics. They could use that chart to put small stickers with “smileys” indicating that the child has already taken the medicine. (See Activity 21)
In the UK, NHS Wales developed a “Choose Pharmacy Programme”, software that allowed the dispensing to registered patients of medicines for common ailments free of charge without a doctor’s prescription. This gave pharmacists an opportunity to guide people with regard to their antimicrobial treatment, if necessary. (See Activity 22)
Furthermore, in the UK, a smartphone application for antimicrobial guidelines (MicroGuide) was developed by pharmacists and medical microbiologists in an NHS hospital and has been licensed to over 45 other NHS hospitals. The app content can be edited by clients according to local resistance patterns and clinician preferences. In February 2015, MicroGuide was awarded the NHS Innovation Challenge Prize in the Infection Control category, providing investment for the development of a decision-support system within the app to better tailor antibiotic therapy to individual patients according to severity of illness and risk of resistance. (60) Another smartphone application “IAPP” was found to have a positive effect on antimicrobial prescribing in hospitals in both medicine and surgery. (61)
The Pharmacy Guild of Australia ran a programme designed to address medicine non-adherence called “medAdvisor”. It allows patients to manage their medicines and treatment plans and support their adherence by using a program available on smartphones, tablets and web browsers, with alerts via notification when to take their medicine, when their refills are running low, etc. (See Activity 23) Also, in Ireland, the Irish Pharmacy Union sought to improve rational use and adherence, and highlight the potential side effects of antibiotics and how they might be avoided via posters and booklets. (See Activity 24)
220.127.116.11.2 Long-term infections
In the control of diseases such as TB that require long-term treatment, especially in patients who are HIV/AIDS positive, the most important challenge is adherence. DOTS supervised by pharmacists is the best option. As an example, a study compared adherence by DOT under pharmacy supervision with self-administered treatment (SAT) in Spain. DOT implemented through pharmacy offices was much more effective than SAT. In the DOT group, 75.2% of patients completed treatment and were cured compared with only 26.7% in the SAT group (62).
In the Philippines pharmacists involved in “The Pharmacy DOTS Initiatives (PDI)” are trained to carry out interventions geared towards the provision of information about TB, about why the dispensing of anti-TB medicines without a valid prescription must be discouraged and about the role of the pharmacy to refer patients to DOTS facilities. (59) They provide wide access and convenience for patients seeking TB information or medication.
18.104.22.168 Interactions minimisation
Medicines interactions (63) may occur as a result of accidental misuse or a lack of knowledge about the active ingredients. Pharmacists advise on how to use medicines correctly, including the dosage, adverse side effects or potential interactions with other medicines, treatments, food or drinks. For example: casein and calcium present in milk decrease the absorption of ciprofloxacin. (64)
Pharmacists take advantage of their knowledge to avoid medicine therapeutic failures and subsequent bacterial resistance as a result of sub-therapeutic level of the medicine in the systemic circulation. They also counsel people on when and how to take medicines, and the specific hours after or before meals.
22.214.171.124 Specific cases
Sometimes the challenge to taking medicines is the medicine itself, for example, where children do not like the flavour. In those situations, pharmacists must support parents and make them aware of how important it is for children to finish their treatment. Pharmacists can adjust the dosage forms by using syrups, for example, in which the medicines can be mixed and dissolved so that children can take them more easily.
Moreover, the dosage or pharmaceutical formulation needs to be appropriate to the patients’ needs (for example, small doses for paediatric patients or easy-to-swallow pharmaceutical formulation for patients with dementia). In many countries, pharmaceutical formulation can be prepared extemporaneously in the pharmacy.
Currently, FIP is working on “FIP-WHO technical guidelines: points to consider in the provision by health-care professionals of children-specific preparations that are not available as authorised products”.. The subject of the document is the compounding technique applied by pharmacists to produce medicines from active pharmaceutical ingredients or using authorised medicines when no commercially available, authorised, age-appropriate or adequate dosage form exists.
126.96.36.199 Ensuring quality of medicines
Quality of medicines is a crucial factor in the prevention of AMR. Counterfeit medicines are major threats to public health and antibiotics are one of the most counterfeited groups. (65) Counterfeit medicines may have no therapeutic effect or may even be toxic. Moreover, if the medicine has the correct active pharmaceutical ingredient, but it is not in a proper quantity, this may increase AMR rates if they are antimicrobials. Pharmacists protect the integrity of the supply chain, and procure medical products only from reputable sources. They are alert to differences in quality of packaging, labelling or leaflets and in physical appearance of medicinal products (66). Pharmacists are a vital asset in assuring the safety of patients through their active participation in the fight against counterfeit medicines.
That antimicrobial dispensing must be always with a prescription and also in certified pharmacies or drugstores was a simple but important message in a campaign developed by the General Council of Official Pharmacy Schools in Spain, to raise public awareness on procuring antimicrobials only from reliable sources. (See Activity 25)
188.8.131.52 Collection of unused antimicrobials
Many patients store antibiotics from uncompleted courses, well beyond the expiry date, and later take them for self-diagnosed conditions or give them to family members and friends. (67) Pharmacists can help to prevent this.
In Belgium, an activity carried out by Association Pharmaceutique Belge in 2011, invited patients to return their unused antibiotics, since these leftovers create a double concern: self-medication and their use when antibiotics are inappropriate, leading to the spread of AMR. (See Activity 26)
Community pharmacies in Argentina launched a campaign “Do not throw away your medicines” to educate the public on how to dispose of their (antimicrobial) medicines safely, to reduce misuse of unused medicines and to protect the environment. (See Activity 27)
In this regard, FIP is developing a report on Green Pharmacy Practice. It has as an underlying premise that pharmacists should accept a degree of responsibility for changing the entire medication-use process so as to minimise the environmental effects of prescribing, dispensing, pharmaceutical care, disposal of unused medicines and, ultimately, reducing metabolic waste discharge into the environment. The report also will provide practising pharmacists with the necessary information and tools for taking environmental aspects into consideration in their daily professional activities.
4.2 In hospitals
As well as dispensing medicines, hospital pharmacists are also responsible for their purchase, manufacture and quality testing. (68) Pharmacists work closely with medical and nursing staff to ensure that patients receive the best treatment, advising on the selection, dose and administration route. They also provide help and advice to patients in all aspects of their medicines.
These activities make pharmacists strong supporters in the fight against the threat of AMR in hospitals. Their work in multidisciplinary teams puts them in a good position to coordinate strategies for better antimicrobial stewardship and develop processes with regard to such activities as sterilisation and hygiene.
4.2.1 Pharmacist-led stewardship programme
Antimicrobial stewardship programmes in hospitals seek to optimise antimicrobial prescribing in order to improve individual patient care as well as reduce hospital costs and slow the spread of antimicrobial resistance. (69) Pharmacists in the UK have been integral to the development of antimicrobial stewardship guidance for both primary and secondary care (70) and hospitals (71) and the development of antimicrobial prescribing standards.
In secondary care, short term funding from the Department of Health in 2003 (72) established antimicrobial pharmacists to work across teams and networks to ensure antimicrobial stewardship was embedded into hospital infection control practice. This has enabled pharmacists to play important and leading roles in National Health Service hospital antimicrobial teams to ensure antimicrobial guidelines are evidence based, that patients are reviewed daily to stop or de-escalate to less powerful antibiotics and that regular antimicrobial audits and reviews of antibiotic use are performed. Furthermore, some studies have been published that review behavioural change interventions for antimicrobials stewardship in hospitals and that propose using games to develop stewardship initiatives. (73) (74) The ongoing key role that pharmacists play in antimicrobial stewardship in English hospitals was illustrated in a recent survey, (75).
UK hospital pharmacists have been instrumental in reducing prescribing of high-risk broad-spectrum medicines (notably cephalosporins and fluoroquinolones) associated with Clostridium difficile infection and coinciding with a reduction in C. difficile infections and stabilisation in resistance to these antimicrobial agents. Currently there is guidance: “Start Smart – Then Focus: Antimicrobial Stewardship Toolkit for English Hospitals” (76) was published by the Department of Health in England in 2011 and was updated in March 2015. The document was authored by pharmacists with support from infectious diseases physicians and microbiologists.
Researchers at University College London have been identifying worldwide resources and guidance available for healthcare professionals which support education and training in antimicrobial stewardship. Working in partnership with the Royal Pharmaceutical Society, they will develop this into a multidisciplinary open-access database that signposts to existing published material around education and development of antimicrobial stewardship. Once the project has been completed, the final database will be launched as a website “AMSportal.org”.
Expert practice curricula for infection and antimicrobial stewardship have been produced by the United Kingdom Clinical Pharmacy Association Infection Management Group, with the Royal Pharmaceutical Society as an affiliated group, to support pharmacists with the knowledge skills, experience and behaviours to advance in their practice, which will include reducing the spread of antimicrobial resistance. (77)
In the same way, the Australian Commission for Safety and Quality in Health Care coordinates and leads a number of programmes which aim to address antimicrobial resistance and support antimicrobial stewardship, e.g., the Commonwealth AMR and AU Surveillance Project (78), the Healthcare Associated Infection Prevention Programme and Antimicrobial Stewardship Initiative (79), and the Antimicrobial Stewardship Clinical Care Standard (80). In addition, the National Prescribing Service (NPS Medicinewise) is currently running a five-year campaign to reduce prescribing of antibiotics by 25%, to bring Australia in line with the European average. The campaign targets both health professionals and consumers.
All hospitals should have an antimicrobial lead pharmacist who promotes antimicrobial stewardship (81). This is a perfect scenario where pharmacists can manage the correct use of antimicrobials, and have a remarkable and positive impact on AMR prevention.
Many hospital sterilisation services are not provided by a fully-fledged department but by a sub-department under the hospital’s surgical or nursing services. However, pharmacists, with their training in microbiology and aseptic technique, are competent in the functions sterilisation services are expected to perform.. Hospital pharmacists may also have the responsibility of implementing training programmes for hygiene personnel.
4.2.3 Hygiene in hospitals
Evidence suggests that adherence to handwashing protocols by hospital visitors can be as low as 25%, but could be increased to up to 77% through the introduction of a novel intervention, for example by use of disposable gloves during contact with patients and their environment. (82) In a study conducted to determine the rate of nosocomial diarrhoea caused by Clostridium difficile, it was shown that this rate was three times lower in hospitals with “universal use of gloves” (83) In a similar study focusing on vancomycin-resistant enterococci, 39% of staff became contaminated with these organisms, and the cross-contamination of staff decreased by 71% when disposable gloves were used. (83) There is an opportunity here for pharmacists to promote the use of disposable gloves in hospitals.
Pharmacists have also developed specific activities targeting health professionals. The American Society of Health-System Pharmacists launched an initiative to help pharmacists promote the immunisation process amongst their colleagues, and to improve influenza immunisation rates among other healthcare workers. (See Activity 28)
5. Collaborative practice
The level of collaboration between pharmacists and other health care professionals ranges from simple contact through to pharmacists being seen and recognised as core members of the multidisciplinary team with the authority and responsibility to manage and modify medicines therapy. FIP established a working group on collaborative practice in 2009. (84) The main purpose was to develop a robust definition of collaborative practice, identifying the current status and integrating pharmacists into a collaborative health care team to improve patient outcomes.
Furthermore, according to the “Statement on Interprofessional Collaborative Practice” by the World Health Professions Alliance in 2013, (85) improved access to health interventions, efficient use of resources, and reduced increase of AMR occur when health systems embrace interprofessional collaborative practice across the full range of the problem (health promotion, infection control and medicines management).
5.1 Interprofessional collaboration model
In Switzerland, “Physicians and Pharmacist Quality Circles” (PPQCs) were established. These are formed by five doctors and one pharmacist, backed by four health insurance funds. The main objectives were to improve the quality of care, improving the relationship between physicians and local pharmacists and evaluate a continuous interdisciplinary teaching method. Initially they studied 12 therapeutic groups, including antimicrobials. (86) The costs were examined during 2006 and 2007, comparing the price of prescriptions with a control or reference group. It was shown that the costs were lower when PPQC strategies were applied. An evaluation over a nine-year period (1999–2007) showed that there was a decrease of 42% in the cost of medicines in the PPQC group in comparison with the reference group, which represents a US$225,000 saving by GPs alone in 2007. (87) These results are explained by compliance with guidelines, pharmacovigilance, greater use of generics, and continuing education on the rational use of medicines. (66)
Interdisciplinary collaboration therefore has a positive impact on medicines stewardship, including antimicrobial management, and may be of great value in preventing the spread of AMR. Furthermore, it can be applied in any country and can achieve the savings expected by political authorities without compromising quality or patient safety.
5.2 Feedback on prescription
Pharmacists engaged in near-patient clinical roles are able to intervene in the event of inappropriate antimicrobial use. (88) They can work as part of multidisciplinary clinical teams to ensure the correct use of antimicrobials, and can also verify if the choice of agent and treatment plan comply with the national standards that apply in their countries.
In the community, pharmacists can ensure that antimicrobial treatments are appropriate by asking patients handing in prescriptions why they have been prescribed. They can also work with local GPs, or contacts in the primary care organisation or commissioning body, to improve prescribing habits. For example, providing delayed prescriptions could provide patients with an option to initiate antimicrobials only if their condition aggravates. (88)
In UK, a hospital pharmacist chaired a government advisory committee working group to propose quality measures for antimicrobial prescribing in primary and secondary care. (89) The primary care measures have been adopted by the NHS in England through the Quality Premium initiative whereby primary care healthcare commissioning groups are incentivised to reduce total antimicrobial prescribing and prescribing of broad-spectrum agents in particular. (90)
6. Engagement with stakeholders
Multiple interventions are needed to tackle AMR. Pharmacists’ contribution may not be obvious at first glance, since collaboration usually happens within research teams, institutions or organisations. However, pharmacists are an important partner and should be involved in initiatives concerning AMR.
6.1 Monitoring of AMR threats
Surveillance is essential to determine the magnitude of AMR. to establish trends in AMR, and to seek strategies to lessen the impact of AMR. Clinical and research laboratories throughout the world generate resistance data; however, few of them submit these data to appropriate databases that could allow local analysis or linking with a surveillance network. (91)
The first WHO AMR global report issued in April 2014 shows that there are large gaps in the available information on the magnitude of AMR and its impact, and that there are no harmonised standards for collecting information. However, the effectiveness of surveillance data can be enhanced by integrating other types of information or actions by governments around the world. For example, by using evidence that identifies vulnerability to certain infections, infection control strategies can become more focused on reaching those who need the services the most. This makes for a more effective response. Groups especially vulnerable to certain infections vary according to the context. For example, poor and vulnerable groups are at greater risk of TB infection compared with the general population because of overcrowded and substandard living or working conditions, poor nutrition, interaction with other diseases, and migration from, or to, higher-risk communities or nations. Factors such as social isolation, reduced access to health services, lack of trust in the health system and lack of a voice in the community all have a negative impact on health. In this context, TB control cannot be achieved by concentrating on improving averages across the general population. TB control needs to address the specific needs of vulnerable communities. (92)
6.2 R&D of new medicines
Developing new medicines involves a great deal of time, effort, scientific research and expense. R&D in the area of new antibiotics has been low as pharmaceutical companies focus R&D on medicines that give them greater profits and can be used regularly without losing effectiveness, such as antidepressants, statins, and anti-inflammatory medications. (93)
So financial incentives for the pharmaceutical industry are required to encourage them to develop new antimicrobials, especially as there tends to be a low return on investment for such drugs. (94) This is key for future development of therapies that will lower the rates of AMR, or alternatives to antimicrobial therapy.
A body with a strong public health mandate is needed to govern and run the process, by publishing the priority product targets based on predicted areas of medical need, assessing products against those criteria, negotiating the purchase agreements and managing the ethical and practical challenges of global use. Patent policy could help to resolve the conflict between the private profit motives of companies and the public’s interest in conserving antibacterial effectiveness. Collective action on a number of fronts is therefore necessary, including the reform of international patent laws and the coordination of licensing and regulatory requirements, and tax credits advanced market commitments for purchase, payments for conservation, call options and orphan medicines protection. (95)
The best incentives would motivate R&D by pharmaceutical companies and universities with investigative areas to fulfil public health goals. However, the use of public funds to encourage the development of new antibacterials that may be unaffordable to many, even in high-income countries, deserves scrutiny. It is also crucial to bear in mind that such incentives could affect efforts to preserve the effectiveness of existing antibacterials. For example, with the support of WHO and the World Bank, the Multilateral Initiative on Malaria coordinates research on antimalarial products (96) (97) and a similar approach should be considered also for research into new antimicrobials.
6.3 Reduction of antimicrobials in food and the environment
Antimicrobial use in food-producing animals may affect human health through the presence of medicines residues in foods and particularly by the selection of resistant bacteria in animals (13). Currently there is no real understanding of the extent of the use of antimicrobials in animals. They are used in animals for prophylaxis, treatment and growth promotion and those animals serve as a reservoir of resistant pathogens and resistance mechanisms that can directly or indirectly result in antibiotic resistant infections in humans. In North America and Europe it is estimated that about 50% in tonnage of all antimicrobial production is used in food-producing animals and poultry (98). However, further data are needed on antibiotic consumption in food-producing animals worldwide, and on the occurrence of antimicrobial resistance in different countries and different production systems in order to make comparisons between countries and identify priority areas for intervention. (6) Regarding this necessity, the UK Government’s Department for Environment, Food and Rural Affairs (DEFRA) is collecting information on consumption in UK. (99) (100)
Currently, the WHO is working closely with Food and Agriculture Organization (FAO) and World Organization for Animal Health (OIE) to tackle AMR issues at the animal-human interface through better coordination at global level and improved intersectoral and multi-disciplinary collaboration. The WHO, the FAO and the OIE have established a formal tripartite alliance to enhance global coordination and to promote intersectoral collaboration between the public health and animal health sectors as well as in food safety. (6)
It is noteworthy, that the OIE has undertaken an update of all relevant standards on AMR including the OIE list of antimicrobial agents of veterinary importance in the guidelines for risk analysis of foodborne AMR, adopted by the Codex Alimentarius Commission in July 2011 and since 2010. (6)
Furthermore, there is a new concern regarding misuse of antimicrobials and the presence of large numbers of antibiotics in wastewater. Treatments to “clean up” wastewater may be modifying the antibiotics and, by doing so, triggering a rise in antibiotic-resistant bacteria. (101)
Pharmacists are the most accessible healthcare professionals, and are fully competent in all aspects of medicines. They possess scientific knowledge for the entire medicine-use process, including procurement, preparation, storage, security distribution, dispensing, administration and safe disposal.
Pharmacists are in the front line of community health services, and are the entry point for patients to health care and the health system. This position gives them various opportunities: pharmacists serve as communicators and educate on healthy behaviours, they increase the coverage of immunisation in hard-to-reach groups, and they are in good position to explain the importance of using antimicrobials only when these is needed.
The pharmacy is a place where pharmacists evaluate the needs of patients and provide a sort of triage. In this process pharmacists assess whether he or she can successfully treat the patient or whether the patient needs to be referred to another healthcare professional. Depending on the results of the assessment, there are three possible outcomes: the patient can be treated by the pharmacist without antibiotics, the patient can be treated by the pharmacist with antimicrobial treatments where this is legally allowed to happen, or the patient can be referred to another healthcare professional, usually a GP.
Where pharmacists are legally allowed to prescribe antibiotics, fast and reliable diagnostic tests can support them in the proper diagnosis of common infections (such as chlamydia or Lyme disease).
Pharmacists provide effective medication therapy management for both short- and long-term treatments. They support adherence, minimise interactions and ensure quality of medicines. In hospitals, pharmacists lead stewardship programmes and are competent in hygiene and sterilisation.
Pharmacists are fully committed to support the development of programmes to combat antimicrobial resistance, through promotion, prevention and control of antimicrobial treatments, and providing access to high quality treatments in the community and at all levels or care. Pharmacists encourage the commitment of all health care professionals to fight the AMR threat via programmes developed in collaboration with stakeholders.
All of the above can help to prevent AMR in the community and in hospitals, and increases the likelihood of successful antimicrobial policies being implemented.
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Appendix 1. Objectives of WHO Global AMR Action Plan
The WHO Global AMR Action Plan has the following objectives:
- To improve awareness and understanding of antimicrobial resistance;
- To strengthen knowledge through surveillance and research;
- To reduce the incidence of infection;
- To optimise the use of antimicrobial agents; and
- To ensure sustainable investment in countering antimicrobial resistance.
Development of this plan has been guided by the advice of countries and key stakeholders, based on several multi-stakeholder consultations at different global and regional forums.
It urges Member States (and, where applicable, regional economic integration organisations):
- To implement the proposed actions for Member States in the global action plan on antimicrobial resistance, adapted to national priorities and specific contexts;
- To mobilise human and financial resources through domestic, bilateral and multilateral channels in order to implement plans and strategies in line with the global action plan;
- To have in place, by [..] 2017, national action plans on antimicrobial resistance that are aligned with the global action plan on antimicrobial resistance and with standards and guidelines established by relevant intergovernmental bodies.
And invites international, regional and national partners to implement the necessary actions in order to contribute to the accomplishment of the five objectives of the global action plan on antimicrobial resistance.
Appendix 2. Examples of activities organised by the pharmacists associations
These summaries have been developed by FIP, based on a set of references (publications, materials of the activities, newspaper articles etc.). The list of references for a specific activity is available on request.
Activity 1: Actions against lifestyle diseases and promotion of good health
A communication campaign was organised in August 2009 by the Japan Pharmaceutical Association. This campaign focused on actions against lifestyle diseases and the promotion of good health. During this campaign, several topics were developed, such as health promotion, healthy diet and staying fit. This campaign also highlighted the benefits of pharmacists for patient’s health.
Activity 2: Men’s Health Week 2013
In 2013, the Association of Danish Pharmacies carried out a promotional campaign developed in pharmacies for men’s health. During the campaign period from 10 to 16 June, men could have their blood pressure, blood sugar and carbon monoxide measured on select days and times. Free brochures on depression, high blood pressure and blood sugar as well as smoking cessation were provided.
Activity 3: Campaign on sexual health advice from pharmacies
More than 100,000 copies of the “Ask about sexual health” leaflet were distributed to community pharmacies and primary care organisations in 2005 as part of a campaign that coincided with “Ask about medicines week” led by the Royal Pharmaceutical Society in the UK. The aim was to drive home the message that community pharmacists are ideally placed to provide expert help and advice on all aspects of sexual health. This leaflet designed to encourage people to visit local pharmacies for sexual health advice was so successful that the RPS had to reprint it. Copies of the “Ask about sexual health” leaflet were available from the RPS’s public relations unit during the entire year.
Activity 4: Self help guide to treating your infection
The Scottish Antimicrobial Prescribing Group (SAPG) has developed a “Self help guide to treating your infection” for use by community pharmacies. The SAPG carried out an online survey of all community pharmacists in early 2015 to seek their feedback on the usefulness of the materials and identify any learning needs with respect to providing advice on self-limiting infections. This will be followed up by a more in-depth qualitative study of pharmacist attitudes and behaviours in collaboration with Robert Gordon University, Aberdeen. The SAPG expects this will take place in autumn 2015.
Activity 5: Establishing seasonal flu in community pharmacy: an enabling service
In June 2009, in order to prepare pharmacists in offering seasonal flu vaccination services to their patients, the National Pharmacy Association in the UK launched a new service in association with an established flu vaccination provider, The Health Station. This service consisted of a one-day training course specific to vaccination, an operation manual and guidelines for the delivery of this service, a window poster and patient leaflets to promote this service at the community pharmacy. There was also a clinical governance programme with pharmacist support available seven days a week via telephone, and a separate patient helpline.
Activity 6: Immunisation campaign in community pharmacies
In October 2008, the National Association of Pharmacies (ANF) in Portugal organised for the first time a nationwide pharmacy-based influenza immunisation campaign to organise and promote the flu vaccination provided in community pharmacies. The activity was supported with models and tools, including an administration record to support pharmacists in the provision of this new service developed by the ANF. Fifty-three training sessions for pharmacy-based immunisation delivery and 264 sessions for basic cardiac life support took place in 11 districts across Portugal during 12 weeks. This campaign aimed to increase the coverage of flu vaccines for population with higher risks. A similar campaign was organised in 2010–11, highlighting that immunisation at the community pharmacy is simple and easy. The campaign is repeated annually.
In 2008, 1,588 pharmacies took part in the vaccination campaign leading to the vaccination of 159,700 patients (i.e., between 5.5% and 11.3% of all vaccinated patients who are older than 65 years). Half of the vaccines were administered in the first 10 days of October. Nearly 99.5% were satisfied with the immunisation provider, 98.6% with the service operating hours, 98.2% with the waiting time, 98.0% with the privacy, and 96.0% with the information provided. Some 13.1% of patients who have been vaccinated were vaccinated for the first time. A total of 1,842 community pharmacies took part in this flu vaccination campaign in 2009.
Activity 7: Flu vaccinations
In Ireland in 2013, the Irish Pharmacy Union led an activity where pharmacists have delivered seasonal flu vaccinations to eligible patients. The service was available free-of-charge to those in an at-risk group who had a medical card. Eligible at-risk groups included elderly people, pregnant women and people with chronic illnesses. Pharmacists could also provide the service to any patient over the age of 18 who was not in the at-risk category. As a result, 23% of the patients who received an immunisation from their pharmacist had never received a flu vaccine before, 81% of these patients were high-priority (or groups of patients considered at risk), and 90% of all patients who received an immunisation were in this “at-risk” group. Statistical data revealed that community pharmacies contributed to reducing the number of flu cases in Ireland and consequently reduced care costs. Close to 1,400 pharmacists were trained to deliver the flu vaccination in 2011. They have been delivering flu vaccinations since 2011 during the flu season.
Activity 8: Reminding diabetic patients to be immunised against flu
In Belgium in autumn 2007, a pilot project was run by the Belgian Pharmaceutical Association to make the community pharmacy a medium for raising awareness among diabetic patients on the importance of being immunised against influenza and for improving the influenza immunisation rate among these patients.
Later on, in 2009, another pilot project was launched: Belgian pharmacists were asked to identify diabetic patient for whom no sale of vaccination against influenza was recorded, to talk with them about the benefits of influenza vaccination, to disseminate brochures and to refer them to their physicians for a vaccine prescription. For the general population, the vaccination rate increased from 14.8% to 17.3% from 2006–09. Among diabetic patients, the rate increased from 45.6% to 48.6%.
Activity 9: Self-care — health advice for life
The Pharmaceutical Society of Australia launched in 1990 a programme to improve counselling and health promotion by pharmacists. The programme called Pharmaceutical Society of Australia’s Pharmacy Self Care (PSC)” is a membership based programme for pharmacies providing education modules and health campaign tools for pharmacists and pharmacy assistants, and consumer health information resources.
This programme consists of fact cards which cover more than 85 most-frequently-asked-about health topics, classified in 14 different categories. All these resources are reviewed, updated and written by pharmacists for pharmacists.
Activity 10: “Mirror, mirror on the wall, do I need antibiotics at all?” campaign
The Pharmaceutical Association of Thailand organised a campaign to prevent unnecessary use of antibiotics for non-bacterial infections and to battle increasing antibiotic resistance in the country. This initiative started in March 2014 and aims to lower consumption of antibiotics. A simple concave mirror and a picture of a human throat with bacterial infection are made available to consumers trying to buy antibiotics for treating the common cold and cough; consumers can check their throats in the mirror to see if it resembles the throat in the picture and decide whether or not they think antibiotics are needed. This campaign is by Community Pharmacists Association of Thailand called “Mirror, mirror on the Wall, Do I need antibiotics at all?”.
The initiative is part of the Antibiotics Smart Use policy implemented by the Thai Ministry of Public Health.
Activity 11: Do not ask us for antibiotics but for information
In November 2003, the Official College of Pharmacists from Ciudad Real in Spain launched a communications campaign whose slogan was: “Do not ask us for antibiotics but for information”. This campaign aimed to discourage patients from using antibiotics without prescription and to improve rational use of antibiotics.
Activity 12: Don’t ask me to give you antibiotics, ask me for information – communication campaign
To raise awareness and educate patients about rational use of antibiotics and antimicrobial resistance, the College of Pharmacists of Costa Rica ran a communications campaign where patients were invited to ask for advice instead of asking for antibiotics in 2009. This campaign aimed to provide basic information on antibiotics and antimicrobial resistance and how to prevent it. This campaign was supported by patient leaflets and a poster.
Activity 13: Seasonal flu: don’t take medicines without proper advice
In January 2007, the College of Pharmacists of A Coruña, in Spain, organised a campaign to raise public awareness of the risks of self-medication (especially antibiotics) to treat flu symptoms. The campaign also highlighted the rational use of medicines and the effectiveness of measures such as frequent hand-washing to prevent the spread of contagious diseases. This campaign also reinforced the role of the pharmacist as an adviser on which treatment is best for a particular case.
Activity 17: Ask your pharmacist: “Come to pharmacy first” campaign
In 2013, a National Pharmacy Association “Ask your pharmacist” campaign took place in the UK to encourage people to avoid unnecessary GP and accident & emergency visits by instead seeking the support of local pharmacies to stay well during the winter. The theme of the week was “Come to pharmacy first”.
The week was followed by a major new public awareness initiative, in which Pharmacy Voice is a partner, called “Treat yourself better without antibiotics.” It sustained “pharmacy first” messages right the way through winter and beyond.
Activity 15: H1N1 workshop for children
The Pharmacy Museum (branch of National Association of Pharmacies in Portugal), organised a workshop in autumn 2009 entitled “Protect yourself from Influenza A” for schoolchildren. The workshop aimed to educate them on the characteristics of the H1N1 virus, and situations of everyday life where they may be exposed to contagion. The correct techniques for washing hands, and other measures to prevent the spread of influenza A virus, were some of the practices addressed in the playful and fun workshop..
Activity 16: GuildCare — a systemised platform for delivering professional health services by pharmacies (including the MemoCare reminder system to improve adherence)
GuildCare was launched in 2011 by the Pharmaceutical Guild of Australia as part of its initiative to have a national systemised platform for delivering professional health services. Its goal was to ensure pharmacies were ready for the introduction of eHealth and the Personally Controlled Electronic Health Record (PCEHR). The GuildCare software has integrated with existing dispensing software and the GuildCare Software Support Centre provides pharmacies purchasing the software with training and technical support. Some 60% of Australian pharmacies subscribe to the software.
Activity 17: Antibiotic resistance awareness campaign
“The Pharmacy Day”, a campaign organised on 29 October 2009 in the Czech Republic, focused on antibiotic resistance. The campaign slogan was: “Rational use of antibiotics — pharmacists advise you” This campaign included the display of posters in all community pharmacies and the distribution of leaflets to patients. The key information provided in the leaflets was: why antibiotics should be prescribed by a physician; when and how long the antibiotic should be taken for; what food and beverages should be avoided during a treatment; what side effects to expect; when to stop taking antibiotics; and why antibiotics should not be taken on the patient’s own initiative.
Activity 18: Screening and treatment of chlamydia infections
To facilitate the screening and the treatment of chlamydia infections, especially among young adults, the National Pharmacy Association in UK instigated a “Chlamydia Test and Treat” service in 2008. It was offered after azithromycin was officially launched as an over-the-counter Pharmacy medicine. Between five and 10 tests a day were received by GLG Laboratories, the NPA partner in this service. Pharmacists can only supply tablets to individuals who are confirmed as having a positive Nucleic Acid Amplification Technique (NAAT) chlamydia test result, and to their sexual partners without them having to take a test. Some 70% of NPA members are now signed up to provide the service. The service is free for 16 to 24 year olds.
Activity 19: Pharmacist-initiated doxycycline for Lyme disease prophylaxis
To improve public access to Lyme disease prophylaxis following an established Ixodes scapularis tick bite via antibiotic therapy initiated by a pharmacist, the American Pharmacists Association, under a collaborative practice agreement with an infectious diseases specialist physician, trained pharmacists at an independent pharmacy. They dispensed two 100mg doxycycline tablets to patients for a six-month period from May to October 2012. Eight patients participated in the study and completed a follow-up survey. No patients enrolled in the study developed any symptoms of Lyme disease or the disease itself.
Activity 20: Taking antibiotics until the course is finished
A campaign organised by the Association of Danish Pharmacist between 28 October and 1 December 2007 had the slogan “Unless you take your antibiotics to the end, you might believe that the treatment does not work”. The target of this campaign was the parents of young children. Parents could obtain brochures on common illnesses such as impetigo and inflammation of the middle ear, throat, sinuses, lungs and bladder. They were also offered a brochure “Medicines and child”. For the children, the pharmacy association reprinted the story of Kalle Kanin, a rabbit who had pain in his ears. In addition to providing these brochures, pharmacies offered advice on how to give antibiotics to children.
Activity 21: Smiley chart for antibiotics
Pharmacies in Denmark provided medication checklist charts for antibiotics for European Antibiotic Awareness Day on 2014. Parents of children taking antibiotics can use this chart to put small stickers with smileys indicating that the child has already taken the medicine. The chart can be used for other medicines as well. It has been made available on the Danmarks Apotekerforening website so parents can print it.
Activity 22: Choose pharmacy — common ailments scheme
In 2012, NHS Wales started a “Choose Pharmacy — Common Ailments Scheme” programme to encourage patients to consult a participating community pharmacy, rather than their GP for common ailments. The goal is to free time by making pharmacies the first stop for common minor conditions. Thirty-two pharmacies are participating in this programme. Registered patients can be given free medicines without a doctor’s prescription for conditions such as hay fever, threadworm and conjunctivitis. The software used creates a pharmacy health record and includes information about the prescription, and any advice given by the pharmacist. The programme is being advertised via posters, postcards and leaflets.
Activity 23: medAdvisor app to address adherence
The Pharmacy Guild of Australia has designed a programme, “medAdvisor”, to address medication non-adherence. More than 1,000 pharmacies in 2013 across Australia signed up to the programme, which allows patients to manage their medicines and treatment plans via their smartphones, tablets and web browsers. The program alerts the patient via notification if they are due for a refill, if they need to make an appointment with their doctor and when to take their medicines during the day. Around 20% of Australian pharmacies adopted the medAdvisor programme in the first two months of its availability.
Activity 24: Campaign on the importance of correct use of antibiotics
A campaign was run by the Irish Pharmacy Union in 2008 to highlight the importance of correct use of antibiotics. Posters and booklets were displayed in pharmacies, advising patients on antibiotic awareness, how to take them, what side effects to expect, and what to do if a dose was missed.
Activity 25: Antibiotics: always with a prescription
In late 2010, the College of Pharmacists of Castilla and León in Spain organised an information campaign to educate patients on antibiotics and their rational use. This campaign was entitled: “Antibiotics: always with a prescription in the community pharmacy”. It aimed to raise awareness on AMR and the importance of a proper diagnosis (and thus a prescription) before receiving any antibiotic.
Activity 26: Bring left-over antibiotics
The Belgian Pharmaceutical Association led a campaign in 2011 to encourage patients to return their unused antibiotics to a pharmacy. Leftovers create a double concern: not only do they encourage self-medication, even when antibiotics are not appropriate, they also seldom contain sufficient quantities for an effective therapy. They are therefore useless and could even facilitate the emergence and spread of antimicrobial resistance.
Pharmacists were asked to label all dispensed antibiotics with a sticker, provided by the government, that urged the patient to return any leftovers, stating that antibiotics do not belong in a family medicine cabinet. A popup-message was shown at every antibiotic dispensing act to remind pharmacy staff of the sticker. Only 14% of the pharmacies blocked the message during the six-day project, indicating a high acceptance rate
Activity 27: Don’t throw away your medicines
In Argentina, 6 June 2015 was celebrated as “Environment Protection Day”, when pharmacies adhered to an initiative whereby neighbours are invited to go to pharmacies with expired or unused drugs so that they can be disposed of safely.
Activity 28: Pharmacists advocating for immunising healthcare workers against influenza
The American Society of Health-System Pharmacists launched an initiative in 2009 to help pharmacists advocate among their colleagues for influenza immunisation for healthcare workers. This initiative consisted of an online resource centre with the following tools available: a campaign planning checklist; an “Influenza Myths vs. Facts” document; a list of possible immunisation incentives; an online quiz to evaluate knowledge on influenza immunisation; and key links to evidence-based information.
Pharmacists have been invited to relay (and adapt) this campaign within their hospitals.
 Action plan clarifies what resources are required to reach the goal, formulate a timeline for when specific tasks need to be completed and determine what resources are required.
List of abbreviations
AMR – Antimicrobial resistance
FIP – International Pharmaceutical Federation
HIV/AIDS – Human Immunodeficiency Virus/acquired immune deficiency syndrome
OECD – Organisation for Economic Co-operation and Development
OTC – over the counter medicines
TB – Tuberculosis
WHPA – World Health Professions Alliance
WHO – World Health Organization
This document was prepared by Zuzana Kusynová (FIP Policy Analyst and Project Coordinator) with kind input from UK’s Royal Pharmaceutical Society and Pharmaceutical Society of Australia. It was reviewed by [final list of names to be updated once the review process is finalised]. We would also like to thank Margareth Charry (FIP Intern, Colombia) for her work on this document.Leave a reply