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Community pharmacists need to get the message across that antibiotic resistance is reaching alarming levels.

“Without urgent co-ordinated action”, common infections and minor injuries could once again kill, a recent report from the World Health Organization (WHO) warns.

“Effective antibiotics have been one of the pillars allowing us to live longer, live healthier, and benefit from modern medicine,” says Keiji Fukuda, the WHO’s assistant director-general for health security. “Unless we take significant actions to improve efforts to prevent infections and change how we produce, prescribe and use antibiotics ... the implications will be devastating.”

The persistence of resistance

Despite antibiotics, infections still impose heavy clinical, societal and economic burdens. The chief medical officer (CMO) notes that infections accounted for 4 per cent of potential years of life lost in England in 2010, 7 per cent of deaths, and were the primary cause of admission for 8 per cent of hospital bed days. In addition, minor illnesses, such as coughs, colds and flu, accounted for 21 per cent of days lost from work due to sickness across the UK in 2011. Overall, infections and infectious diseases cost the UK about £30bn a year.

Headlines regularly highlight the dangers posed by ‘superbugs’ but, in specific cases, concerted efforts by the NHS are beginning to bear fruit. According to the CMO, the number of cases of methicillin-resistant Staphylococcus aureus (MRSA) declined by 84.7 per cent from the peak in 2003/4 to 2011. Clostridium difficile cases fell by 53 per cent between 2008 and 2011.

Nevertheless, Kieran Hand, a consultant pharmacist for anti-infectives at University Hospital Southampton, told Pharmacy Magazine that C. difficile still poses a significant problem and the 2 per cent of patients admitted with MRSA remain challenging to treat. Emerging carbapenemase- producing Klebsiellas pose the greatest threat as they are resistant to antibiotics of last resort and mandate isolation of patients.

Dr Hand and his colleagues regularly face new challenges. For example, according to the CMO, Escherichia coli causes about 36 per cent of bacteraemia cases (MRSA accounts for 1.6 per cent). About 30 per cent of patients with bacteraemia caused by multi-resistant E.coli die, compared with 15 per cent of those with antibiotic-susceptible infections.

Dr Hand explains that this difference in mortality reflects, largely, the increasing number of E.coli in hospitals and the community-expressing resistance mechanisms including extended-spectrum beta-lactamases (ESBL), an enzyme originally identified in Klebsiella. ESBL confers resistance to penicillins and cephalosporins, previously the treatment of last resort for E.coli. “ESBL-producers pose a particular issue in urinary tract infections,” Dr Hand says. “This means we have to prescribe older drugs such as nitrofurantoin and fosfomycin. These are concentrated in the urine and bladder, and are, therefore, less effective against bacteraemia caused by E.coli.”

Vital educational role

Against this background, Dr Hand notes that community pharmacists have a vital educational role, including reiterating that viruses cause 90 per cent of acute bronchitis cases. “Surveys suggest that the message has not been received by patients,” he says.

Pharmacists can also point out that antibiotics cause adverse events and, therefore, should not be used indiscriminately, he says. “Most patients realise that antibiotics can cause skin rashes and diarrhoea but they don’t appreciate that antibiotics can cause rare, but serious, adverse reactions such as Stevens-Johnson Syndrome, or damage the intestinal bioflora that shape immune responses and fight infections.”

OTC medications help most people, says Dr Hand. “I have no hesitation in suggesting OTC treatments for symptom relief combined with information about how long a cough, sore throat or ear infection is likely to last.”

James Davies from Pharmacy Voice’s research and policy team agrees. “Pharmacists should look for opportunities to challenge people’s perceptions. Our research tells us that the public often do not know how long common winter conditions should last. They may access self-care from a pharmacy to start with, but then seek antibiotics from a GP after a few days.

“Pharmacists have an important role reassuring the public that a cough may last for up to three weeks and that they do not necessarily need antibiotics.”

Pharmacy Voice and PAGB’s ‘Treat yourself better without antibiotics’ campaign helped communicate a consistent message from general practice and pharmacy about how long patients can expect symptoms of common ailments to last before asking for antibiotics, says Davies.

Know the guidelines

Dr Hand, who represents pharmacy on the Department of Health’s advisory committee for antimicrobial resistance and healthcare-associated infection, believes that pharmacists could help implement local and national guidelines. “Community pharmacists should be aware of local guidelines so that they can validate prescriptions. They should challenge doctors who prescribe broad-spectrum antibiotics routinely. Antibiotics such as co-amoxiclav and ciprofloxacin should be kept in reserve.”

Leyla Hannbeck, head of pharmacy at the National Pharmacy Association, agrees. “Community pharmacists are ideally placed to provide stewardship on best practice related to the appropriate use of antibiotics.

“Local guidelines may recommend avoiding the use of broad-spectrum antibiotics and instead may advise using appropriate narrow-spectrum antibiotics,” she says. “Community pharmacists should, if necessary, challenge prescribing but should discuss how to handle prescription queries with their local surgeries and clinical commissioning groups or local health board before entering into discussions with individual prescribers.”

Global approach

Community pharmacists alone cannot, of course, prevent the demise of the antibiotic miracle – politicians and professional leaders need to implement a global approach to policy.

For example, according to Nature, Greece, followed by France, tops the European league for antibiotic use. Estonia and the Netherlands prop up the table. On average, a person in Greece or France uses three times as many antibiotics as someone from Holland or Sweden. The UK comes twelfth in the list of 19 countries. The variation, Nature says, highlights the need for standardised international prescribing policies.

Policymakers also need to encourage innovation (see box) and address the vexed issue of antibiotic use in animals. Nature notes that livestock accounts for between 50 and 80 per cent of antibiotic use in many developed countries. Crops, pets and aquaculture account for another 5 per cent, with humans making up most of the difference.

Antibiotic use in UK livestock is relatively well controlled but that is not necessarily the case elsewhere, says Dr Hand. “Poultry imported from South America has tested positive for E.coli resistance to many antibiotics, so pharmacists need to emphasise the importance of good food hygiene – washing chopping boards, washing hands thoroughly and cooking food thoroughly – to prevent people becoming colonised with resistant bacteria from meat.”

Patients are interested in taking antibiotics responsibly, James Davies concludes. “We know that when GPs take the time to explain appropriate use to patients, they really do get it, but often this does not happen – this is where pharmacists come in.

“If pharmacists can embrace this role further, then the current threat described by the WHO might be prevented from worsening.”

 

A WOEFUL LACK OF INNOVATION....

After approving 19 new antibiotics between 1980 and 1984, the Food and Drug Administration in the US approved just three between 2005 and 2009 and one in 2010-12, Nature notes.

Since 2003, regulators approved only two antibiotics (daptomycin in 2003 and ceftaroline in 2010) from classes with new mechanisms of action.

Studies are needed to characterise the potential offered by combination therapy, widely employed in other infections (e.g. HIV and hepatitis C virus) and cancer, Nature suggests.