REVIEW ANTIBIOTICS
Facing a
post-antibiotic era
Why pharmacists need to be on the front line in the fight against antibiotic resistance.
By Sheshtyn Paola
I
magine a world where your patients
could suffer or die from a bacterial
infection usually cleared up with
a round or two of easily available
antibiotics, such as ceftriaxone or
amoxicillin. This is a future the world
is steadily heading towards unless
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prescribing and use of these oncecalled ‘miracle drugs’ is pulled back
and radically transformed.
In Australia, the prevalence
of bacteria resistant to multiple
types of antibiotics—also known as
‘superbugs’—is increasing. Strains
of Escherichia coli (E. coli), that cause
many urinary tract infections, and
‘golden staph’ (Staphylococcus aureus),
a common cause of skin infections,
have already developed resistance to
a number of antibiotics. Failure of
the last-resort antibiotic treatment
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NPS MEDICINEWISE RESISTANCE FIGHTER MESSAGES
Antibiotics don’t work for cold or flu as they have no effect on viruses
Antibiotics will not help you recover faster from a viral infection
Antibiotics should only be taken as prescribed and not shared with friends or family
It is possible to pass on antibiotic resistant bacteria to others
Green snot doesn’t mean you need antibiotics—it can be a sign that the immune system
is fighting the infection, not that the illness is getting worse
• The best way to prevent the spread of germs is by practising good hygiene
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for gonorrhea has even occurred
in Australia.
Before the discovery of antibiotics,
the fatality rate for S. aureus
bacteraemia was at 80%, and the
fatality rate for pneumonia caused
by Streptococcus pneumoniae
reached as high as 40%. Of patients
who developed endocarditis in the
pre-antibiotic era, 97% died.
Antibacterial therapy has prevented
millions of premature deaths due
to bacterial infection, but resistance
threatens to take us back to a time
when acquiring a bacterial infection
was often fatal.
antibiotic treatment to cure infections,
say the authors.
No control
Uncontrolled use of antibiotics in
both humans and animals is the
cause of this looming crisis, explains
Dr Morgyn Warner, an infectious
diseases physician and clinical
microbiologist at the University
of Adelaide. The single biggest
issue is the use of antibiotics when
unnecessary, she says, because overuse
allows bacteria carrying resistant genes
to survive and spread.
Australia has one of the highest
“When presented with an ‘old’ antibiotic prescription...
pharmacists need to determine whether the patient
is trying to treat a simple cold or flu”
“The spread of resistance in
healthcare settings and the community
threatens the enormous gains made
by the availability of antibiotic
therapy,” says Dr Deborah Friedman,
an infectious diseases specialist and
associate professor with Barwon
Health in Victoria, in her review of
antibiotic resistance.
“Broadly speaking, infections caused
by resistant bacterial strains lead to up
to two-fold rates of adverse outcomes
compared with similar infections
caused by susceptible strains,” they
found.
These adverse outcomes may be
clinical (i.e. death or treatment
failure) or economic (i.e. costs of
care, length of stay) – reflecting both
treatment delays and the failure of
antibiotic prescribing rates in
the world according to AURA
2016, Australia’s first report on
antimicrobial use and resistance in
human health. In 2014, almost half
(46%) of Australians had at least one
antimicrobial dispensed to them.
Surgical prophylaxis was the most
common reason for antimicrobial
prescriptions in hospitals and had
the highest level of inappropriate use,
with 40.2% of prescriptions deemed to
be inappropriate.
Excessive duration of antibiotic
use is also common in Australian
hospitals, according to the 2014
National Antimicrobial Prescribing
Survey (NAPS), while another area
of concern is overly broad spectrum
antibiotic therapy.
“Clinicians and patients believe
antibiotics have few adverse effects,
leading to prescribing ‘ just in case’,
or for longer than necessary,” says
Dr Warner. “Upper respiratory
infections, chronic skin ulcers
and asymptomatic bacteriuria
in the elderly are the leading
conditions for which antibiotics are
unnecessarily prescribed.”
Prescribing habits are likely driven
by long-standing practice, rather
than reference to the latest clinical
evidence, Dr Warner points out.
Pharmacists and nurses need to be
supported to speak out and help
transform overprescribing patterns.
“For sustained change to occur,
attitudes about antibiotic use and
relationships between prescribers,
pharmacists and nurses need to
change to become more cooperative
and less hierarchical,” she says.
An ageing problem
In addition to overprescribing, the
validity of old or repeat prescriptions
is also an avenue of inappropriate
use. A recent Australian study led
by researchers from the School
of Pharmacy at the University of
Queensland found nearly one in ten
(9%) antibiotics was dispensed from
prescriptions that were more than
one month old, and more than one
in five (22%) were dispensed from a
repeat prescription.
Pharmacists need to be aware
that old or repeat prescriptions of
antibiotics may indicate inappropriate
use, says lead author and pharmacist
manager, Ian Fredericks.
“When presented with an ‘old’
antibiotic prescription – one which
has not been prescribed during a
recent consultation with a doctor
– pharmacists need to determine
whether the patient is trying to treat a
simple cold or flu,” says Fredericks.
“If so, they should strongly
discourage the patient from having the
prescription dispensed by reinforcing
NPS MedicineWise’s Resistance Fighter
campaign messages,” he says (see box).
Pharmacists are the last line of
defence in educating patients who may
be planning to use antibiotics in an
unhelpful way, says co-author Therese
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REVIEW ANTIBIOTICS
“One of the most
important things
pharmacists
can do is engage
patients in
conversation
in order to
manage their
expectations...”
is engage patients in conversation in
order to manage their expectations.
“HMRs are an opportunity to talk
with patients around the need for
antibiotics and to try to reassure them
that they are not needed for infections
such as the common cold, upper
respiratory tract infections, sinusitis
and so on,” says Rigby.
“Community pharmacists have
an important role in educating and
reassuring the patient that antibiotics
are not needed for the common cold
and won’t provide the symptom relief
they are looking for.”
It’s also still reasonably common
for GPs to provide a patient with
a prescription when they present
with cold symptoms, Rigby says, but
pharmacists need to speak up to
counter this trend. “And because
HMRs are collaborative with the GP,
it’s also an opportunity to have that
conversation with the GP,” she adds.
Correct disposal
Kairuz, who is a senior lecturer at
James Cook University’s College of
Medicine and Dentistry.
“An important take-home
message is that pharmacists should
exercise their responsibility as
custodians of medicines, as part of
the medication counselling service,”
says Kairuz.
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As healthcare workers on the front
lines, pharmacists are indeed well
placed to educate customers about
proper antibiotic use and provide
better alternatives. Consultant
clinical pharmacist Debbie Rigby, who
regularly conducts home medicines
reviews (HMRs), says one of the most
important things pharmacists can do
Unused antibiotics also need to be
disposed of in a correct way, or they are
able to enter the natural environment
where they make their way into
our food and water, contributing
even further to the transmission of
antimicrobial resistant genes. Pharmacy
researcher Judith Singleton explains
that active pharmaceutical ingredients
(APIs) such as antibiotics enter the
environment through excretion,
incorrect disposal, bathing, and release
from drug manufacturing facilities.
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REVIEW ANTIBIOTICS
“Most people would not be aware
that bacteria in the waste treatment
process can reactivate some
inactivated molecules, so a significant
proportion of APIs are entering the
aquatic environment… This includes
antibiotics, thus contributing to the
antimicrobial resistance problem,”
says Singleton.
“Consumers are also tipping things
(particularly liquids) down toilets and
sinks or throwing away in rubbish
destined for landfill. These methods
for disposal create entry points for
drugs to reach the environment.”
She encourages all pharmacies
to sign up to the Return Unwanted
Medicines (RUM) project,
allowing customers to return all
unwanted medicines.
“Pharmacists, with their
professional commitment to the
quality use of medicines and their
active participation in the medicines
management pathway, already
play an important role in the more
sustainable use of pharmaceuticals,”
says Singleton along with research
colleagues Lisa Nissen, Nick Barter
and Malcolm McIntosh.
“They have the potential to
play an even greater role with the
environmentally responsible disposal
of pharmaceutical waste, and the
education of other health professionals
and the general public on this topic.”
Luc Besançon, general secretary
and CEO of the International
Pharmaceutical Federation agrees
that pharmacists worldwide will
play a key part in turning the tide
against antimicrobial resistance.
They have a variety of roles to
play – from increasing awareness
in their communities, to providing
vaccination services that reduce the
number of infections and, therefore,
antibiotic use.
“The main role that pharmacists
can play is in ensuring the right
dose, at the right time, in the right
patient. In other words, ensuring
the responsible use of medicines.
Involving pharmacists in preventing
antimicrobial resistance makes the
implementation of successful policies
more likely,” says Besançon.
His additional advice is for
healthcare workers to stay strong and
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HOW TO GUIDE PATIENTS
Steps to reduce the chance of resistance developing due to inappropriate use of antibiotics:
• Encourage your patients to take the prescribed dose and complete the whole course of
treatment prescribed by the doctor. Even if they are feeling better, this reduces the chance
that some bacteria will survive and become resistant.
• Remind patients not to share antibiotics with other people or keep leftovers. This is important
because the type of antibiotic may not be targeted to the bacteria causing that particular
infection, and the dose and amount leftover may not be enough to destroy it—creating more
opportunity for resistant bacteria to develop and multiply.
• Get involved in the RUM project and set up an adequate waste collection system at
your pharmacy (returnmed.com.au). Unwanted medicines are then taken away for high
temperature incineration.
• Educate patients on proper waste disposal and remind them to bring unused medicines to your
pharmacy for proper disposal. Currently, many consumers are tipping unused medication down
toilets and sinks, or throwing them away in rubbish destined for landfill.
• Share with patients the simple steps required to avoid infections and prevent them from
spreading—washing hands regularly with soap and water, throwing away tissues, covering
their mouth when sneezing or coughing, avoiding placing hands near the eyes, nose or mouth,
avoiding sharing kitchenware and cutlery, and keeping household surfaces clean.
• Spread the word within your personal networks—antibiotic prescribing is currently too
high and needs to be pulled back. Speak out amongst your colleagues about the
inappropriate use of antibiotics.
committed in the face of resistance
– quite literally. “A substantial
decline in antimicrobial resistance
can take a number of years of
sustained change in prescribing
practices. Perseverance is needed
to see the results of antimicrobial
stewardship… We must be careful
not to lose momentum.”
The need for action has not
been lost on pharmacy bodies in
Australia. PSA national president Joe
Demarte says pharmacists can and
should play a fundamental role in
antimicrobial stewardship.
“The pharmacy profession
in partnership with the federal
government, other health practitioners
and consumers, must make an effective
and sustained contribution to a
national response to antimicrobial
resistance,” he says.
“Advice about the use of antibiotics
must be disseminated to consumers…
ensuring that patients have a good
understanding of their illness
and realistic expectations of its
progression. In some cases, patients
may require advice on symptomatic
treatments,” says Demarte.
Educating patients, starting
conversations with doctors, and
organising adequate waste disposal
in the pharmacy are all practical
ways pharmacists can start making
a difference today. Healthcare
professionals and organisations across
the world need to join together to turn
back the tide of antibiotic resistance
worldwide – starting now.
•
Australian Commission on Safety and Quality in Health Care 2016, AURA 2016: First Australian report on antimicrobial use and
resistance in human health.
Besançon L. Antimicrobial resistance. What will it take to turn the tide? Pharmacists! Journal of Pharmacy Practice and Research,
2016; 46 (1): 4-5.
Fredericks I, Hollingworth S, Pudmenzky A, Rossato L, Kairuz T. ‘Repeat’ prescriptions and antibiotic resistance: findings from
Australian community pharmacy. International Journal of Pharmacy Practice, online 13 June 2016.
Friedman ND, Temkin E, Carmeli Y. The negative impact of antibiotic resistance. Clinical Microbiology and Infection 2015; 22 (5):
416-22.
NPS MedicineWise 2015, Antibiotic resistance: the facts.
Singleton A, Nissen L, Barter N, Macintosh M. The global public health issue of pharmaceutical waste: what role for pharmacists?
Journal of Global Responsibility 2014; 5 (1): 126-37.
Warner MS. Managing antimicrobial resistance requires data, action and new attitudes towards antibiotics and prescribing. Journal
of Pharmacy Practice and Research 2016; 46 (1): 8-9.
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