Appropriate use of antimicrobials: An ongoing and coordinated effort

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Introduction

The development of antibiotics in the 1940’s was a significant breakthrough in public health.1 _{Antibiotics transformed health}

care by dramatically reducing morbidity and mortality due to infectious diseases and have allowed for major advancements in medicine such as surgery and organ transplants to be made possible.1 _{On the contrary, the widespread use and overuse}

of these agents, has resulted in the development of resistant organisms.1,2 _{As early as 1945, Sir Alexander Fleming, the discoverer}

of penicillin, foresaw this phenomenon and famously cautioned that the rampant overuse of penicillin would cause an epidemic of drug resistant organisms3_:

“The microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out … In such cases the thoughtless person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.”

Globally, antimicrobial resistance is now considered a major threat to public health and without urgent coordinated action by many stakeholders, the world is headed for a post-antibiotic era, in which common easily treatable infections can once again kill.4,5

This situation is compounded by the rapid decline in discovery and development of new antibiotics.5 _{Although the lull in drug}

discovery has been eased to some extent in recent years, new products are mostly targeting gram-positive organisms. However it is the emergence of resistant strains of gram-negatives which currently poses a greater threat to human life, with very few antibiotics that can combat them in the development pipe-line.5,6

The antimicrobial resistance (AMR) landscape

Mechanisms of antimicrobial resistance

Antimicrobials are agents that kill or inhibit the growth of microorganisms and encompass antibiotics, antifungals, and antivirals.2 _{Antimicrobial resistance (AMR) develops when}

microorganisms adapt and grow in the presence of antimicrobials, rendering treatment with an antimicrobial drug ineffective.2,6

The factors leading to AMR are complex and multifactorial.7

Essentially, resistance occurs due to a natural evolutionary process which equips the microorganisms with mechanisms with which to counteract the effects of the antimicrobials.7 _{Antimicrobial}

resistance can happen, for example, when a microorganism produces an enzyme that destroys the drug directly (e.g. β-lactamases which degrade β-lactam antimicrobials).7 _{It can}

also occur through a genetic mutation of the pathogen, resulting in alteration of bacterial enzymes (e.g. mutated DNA-gyrases that resist quinolone binding) or changes in membrane permeability to antimicrobials (caused by efflux pumps) or protection of the target by DNA-binding proteins (known as Qnr).7 _{Development of}

resistance in a single microorganism or location can unpredictably and rapidly spread through various mechanisms, for example, through the exchange of genetic material between resistant and susceptible microorganisms (horizontal gene transfer) or through transmission in human and animal populations via food, water and the environment.2,4

Prevalence of AMR

One of the cornerstones of the management of infectious diseases, and the basics of public health, is surveillance of drug-resistant infections and antimicrobial consumption.8 _Availability

Appropriate use of antimicrobials:

An ongoing and coordinated effort

Department of Pharmacy, Faculty of Health Sciences, Sefako Makgatho Health Sciences University

Correspondence to: Hannelie Meyer, e-mail: [email protected]

Keywords: rational antibiotic use, antimicrobial stewardship, antimicrobial (antibiotic) resistance

Abstract

The world is on the brink of a post antibiotic era and antibiotic resistance is no longer a prediction for the future; it is happening right now, across the world, and has the potential to put public health efforts into disarray. Despite the wealth of programmes and information, South Africa is not exempt from the threat of increasing antimicrobial resistance. An overview of the persisting issue of antimicrobial resistance, the current trends in antimicrobial stewardship and strategies for rational antibiotic use is provided. Specific emphasis is placed on the role of the pharmacist in containing antimicrobial resistance across the different practice settings, and working in collaboration with other healthcare professionals.

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of surveillance data is a critical requirement for action.6,8 _However,

surveillance data worldwide is poor and improvement has been recommended.6,8 _{According to the latest data available, there has}

been an increase in antibiotic consumption, driven by irrational prescribing and growing economies particularly in low and middle income countries, to such an extent that global consumption increased by 36% in the period between 2000 and 2010.6,9,10

Worldwide, AMR is increasing in prevalence resulting in infections that are difficult and expensive to treat. Currently, a number of common infections such as urinary tract infections, diarrhoea, gonorrhoea, tuberculosis, and other respiratory diseases are becoming more difficult to treat.4,6 _{Subsequently, terms like}

‘super-bugs’, multi-drug resistant (MDR), extensively drug-resistant (XDR), methicillin-resistant Staphylococcus aureus  (MRSA), vancomycin-resistant enterococci (VRE), pan-vancomycin-resistant bacteria, New Delhi Metallo-beta-lactamase-1 (NDM-1), Klebsiella pneumoniae

carbapenemase (KPC) and second-line therapy, feature increasingly and prominently in our medical diction.2,4,6

In 2014 an estimated 450 000 new cases of tuberculosis (TB) were reported in South Africa, with 1.8% of new cases and 6.7% of previously treated cases estimated to have MDR-TB.11 _Recent

surveillance data from the Centre for Disease Dynamics, Economics and Policy’s (CDDEP) online interactive tool, ResistanceMap, paint an even more dire picture of the AMR landscape.12 _In

2014 Escherichia coli resistance to fluoroquinolones was 28%, methicillin-resistant Staphylococcus aureus (MRSA) was 31% and

Klebsiella pneumoniae resistance against carbapenems showed an

increasing rate from 2% in 2013 to 4% in 2014.12,13

Irrational antibiotic use is not only limited to human use but also in agriculture.6,9,14 _{An estimated 80% of all antibiotics used globally}

are used for the purpose of animal health, for growth promotion in feed animals, or for agriculture and aquaculture to prevent or treat infection.13,14 _{These practices are posing a significant public health}

threat, contributing to drug-resistant pathogens.9,14 _Estimated

antimicrobial consumption in livestock in 2010, is projected to rise by 67% by 2030, and nearly double in Brazil, Russia, India, China, and South Africa.9,12

South Africa evidently is using a large amount of antibiotics in food-producing animals, including a number of antibiotics that have been banned for use in other countries.15,16 _Evidence

has shown that when required to treat or prevent infection, the practice of treating the entire herd instead of the infected animal, or administering antibiotics for extended periods of time using sub-therapeutic concentrations, is prevalent.6,15 _{This is further}

compounded by the use of antibiotics for growth promoters without veterinary prescriptions and the lack of controls in the sale of antibiotics to farmers by veterinarians.6,15

Consequences of AMR

Antimicrobial resistance threatens to reverse the gains of antimicrobials in advancing modern medicine.16 _{While the real}

magnitude of the problem is unknown, and the methods for measuring economic impact of resistance are not well elucidated, the monetary cost of treating antibiotic resistant infections

globally is estimated to be several billions of dollars per year.6,15

Worldwide, it is estimated that 10 million deaths per year, and 2% to 3.5% reduction in global gross domestic product by 2050, will be a direct result of the current trends in AMR.8

In a clinical setting, infections caused by resistant microorganisms may require more toxic therapy that can lead to adverse outcomes. In addition, in-hospital mortality rates and extended hospital stays will increase as a result of AMR.4 _{This is coupled with an up to}

two-fold increase in hospital-acquired infections and costs for patients with resistant versus susceptible infection, due to infections which are more difficult and more expensive to treat.4,6

The societal and economic impacts of AMR are myriad.4 _{For the}

patient, some drug resistant micro-organisms require physical isolation from society in order to minimise transmission which may result in loss of work and family time.4,17 _{Furthermore, the patient}

may incur costs for extra visits to the doctor and lengthened hospitalisation, possible second-line treatments, laboratory tests and other diagnostic costs.4

Lastly,AMR has the potential to cause calamitous effects on international travel and trade resulting from the cross-border transmission of resistant infections.2

Strategies to combat antimicrobial resistance

Global action plan on antimicrobial resistance

Several regional and global resolutions have called for action on specific health aspects related to AMR.2,4,18 _{In 2008, the Global}

Antibiotic Resistance Partnership (GARP) was established to help developing countries build capacity and establish policies to deal with the growing problem of AMR.19 _{Following a World Health}

Assembly resolution in 2015, a global action plan on AMR was developed for adoption by member states, to produce national strategic plans to combat AMR.18 _{The overall goal of the action}

plan is to ensure, for as long as possible, continuity of the ability to treat and prevent infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.18 _{To achieve this overall goal, the}

following five main strategic objectives were set out18_:

• Improve awareness and understanding of antimicrobial resistance through effective communication, education and training

• Strengthen the knowledge and evidence base through surveillance and research

• Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures

• Optimise the use of antimicrobial medicines in human and animal health

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The global action plan provides the framework for national action plans to combat AMR.18 _{For each of the objectives, key actions are}

stipulated to combat AMR, which should be taken by the various actors involved, using an incremental approach over the next 5–10 years.18 _{Antibiotic resistance is covered in great detail,}

however, reference is made to existing action plans for viral, parasitic and bacterial diseases, including HIV/AIDS, malaria and tuberculosis.18 _{Special emphasis is placed on strengthening of}

already existing principles of antimicrobial stewardship.18

South African Antimicrobial Resistance National Strategy Framework, 2014–2024

In South Africa, GARP conducted a situation analysis of antibiotic use and resistance.19 _{This situational analysis highlighted the}

emergence of ‘super-bugs’ and the need for action to contain AMR.20 _{Subsequently, the South African Antibiotic Stewardship}

Programme (SAASP) was established under the auspices of the Federation of Infectious Diseases Societies of Southern Africa (FIDSSA), comprising of members from the private and public sector, to strengthen antibiotic stewardship and education in South Africa.20,21

In 2014, the National Department of Health in South Africa, published the Antimicrobial Resistance (AMR) National Strategy Framework, 2014–2024, in response to the preceding WHO global strategy for containment of AMR and advocacy by SAASP.13,21

This strategy defines South Africa’s approach to manage AMR, limit further increases in resistant microbial infections, and improve patient outcomes.13 _{The vision is “to ensure the}

appropriate use of antimicrobials by healthcare professionals in all health establishments in South Africa to conserve the efficacy of antimicrobials for the optimal management of infections in

human and animal health.”13 _{South Africa’s national AMR strategy}

framework consists of four building blocks with strategic objectives that are reinforced by four key enablers (Figure 1).13,20

The strategic framework emphasises a governance model which is supported by relevant laws in order to ensure success of each objective and enabler, and to allow for oversight, monitoring and evaluation.13,20 _{The antimicrobial governance model is enabled}

through a multidisciplinary inter-sectorial ministerial advisory committee comprising of key stakeholders on AMR.13,20 _{Prior to}

the promulgation of the strategic framework for the AMR national strategy and the corresponding implementation plan, there was no single national guideline to address antimicrobial resistance, although the objectives and enablers were promoted in one form or another in various documents.13,14,17 _{For example, the Essential}

Medicines List (EML) and Standard Treatment Guidelines (STGs) recommend principles for the use of antimicrobials at different levels of the South African healthcare system.14 _{The National Core}

Standards for health establishments in South Africa endorse AMS and infection control and prevention interventions at the different facility levels.20

Antimicrobial stewardship in South Africa

Antimicrobial stewardship (AMS) is defined as a multidisciplinary, systematic approach to optimising the appropriate use of all antimicrobials to improve patient outcomes and limit the emergence of resistant pathogens whilst ensuring patient safety.18,24 _{Antimicrobial stewardship programmes in South}

Africa as well as other countries have shown to be successful in promoting rational antibiotic use, improve patient outcomes and reduce adverse consequences of antibiotic use, including antibiotic resistance, toxicity and unnecessary costs.22-24

Despite not having an outright mandate from the National Department of Health, the South African Antibiotic Stewardship Programme (SAASP) provides leadership, advocacy, and strengthening of antibiotic stewardship, in the public and private sectors in South Africa.22 _{They have published treatment guidelines}

on antibiotic prescribing, offer courses and educational materials on antimicrobial stewardship and an antibiotic prescription chart is available for use on its website.22

Antimicrobial Resistance Governance

Enhanced

Surveillance

Antimicrobial

Stewardship

Infection Prevention

and Control

Figure 1.

Strategic framework for the antimicrobial resistance national strategy

The strategic framework emphasises a governance model which is supported by relevant laws in

order to ensure success of each objective and enabler, and to allow for oversight, monitoring and

evaluation.

_{The antimicrobial governance model is enabled through a multidisciplinary}

inter-sectorial ministerial advisory committee comprising of key stakeholders on AMR.

_{Prior to the}

promulgation of the strategic framework for the AMR national strategy and the corresponding

implementation plan, there was no single national guideline to address antimicrobial resistance,

although the objectives and enablers were promoted in one form or another in various

documents.

_{For example, the Essential Medicines List (EML) and Standard Treatment Guidelines}

(STGs) recommend principles for the use of antimicrobials at different levels of the South African

healthcare system.

_{The National Core Standards for health establishments in South Africa endorse}

AMS and infection control and prevention interventions at the different facility levels.

Antimicrobial stewardship in South Africa

Antimicrobial stewardship (AMS) is defined as a multidisciplinary, systematic approach to optimising

the appropriate use of all antimicrobials to improve patient outcomes and limit the emergence of

resistant pathogens whilst ensuring patient safety.

_{Antimicrobial stewardship programmes in}

South Africa as well as other countries have shown to be successful in promoting rational antibiotic

use, improve patient outcomes and reduce adverse consequences of antibiotic use, including

antibiotic resistance, toxicity and unnecessary costs.

Despite not having an outright mandate from the National Department of Health, the South African

Antibiotic Stewardship Programme (SAASP) provides leadership, advocacy, and strengthening of

antibiotic stewardship, in the public and private sectors in South Africa.

_{They have published}

treatment guidelines on antibiotic prescribing, offer courses and educational materials on

antimicrobial stewardship and an antibiotic prescription chart is available for use on its website.

The National Department of Health recently prepared a draft Practical Guide to Antimicrobial

Stewardship in South Africa.

_{This guide is intended to act as a blueprint for all healthcare}

professionals in the public and private sector, to enact AMS in line with the Strategic Framework and

interdisciplinary efforts through national and Health Establishment level governance structures

Promote appropriate use of antimicrobials in human and animal

health through antimicrobial

stewardship

Enhance infection prevention and control, including

vaccination Optimise surveillance

and early detection of antimicrobial

resistance

Key enablers

reform for health systems strengthening  Education of all levels

of health providers in human health and agriculture  Public awareness  Research into novel

diagnostics and new antimicrobials

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The National Department of Health recently prepared a draft Practical Guide to Antimicrobial Stewardship in South Africa.23

This guide is intended to act as a blueprint for all healthcare professionals in the public and private sector, to enforce AMS in line with the Strategic Framework and Implementation Plan, at all levels of care.23 _{The document further aims to be a practical,}

step-by-step or ‘how to’ guide, addressing the four pillars of the Strategic Framework.23 _{With the practical approach taken in the}

guide, much broader AMR programme activities and interventions are specified, compared to what is stipulated for AMS in the National Core Standards.23 _{A useful monitoring and evaluation}

framework for AMS implementation is offered for each level of the health system.23

Central to the theme of AMS is the need to develop a collaborative practice between clinicians, pharmacy staff, microbiologists, laboratorians and infection control specialists in order to provide the best outcome for the patient, reduce healthcare costs and curb the emergence of infections and drug resistant organisms.22,25,26

Pharmacists’ role in combatting antimicrobial

resistance

One of the main drivers of AMR is the widespread and inappropriate use of antimicrobials.6 _{Pharmacists are the custodians of medicines}

and are mandated to meet the healthcare needs of the population through the supply of safe, effective and quality medicines and providing of pharmaceutical care by taking responsibility for the outcomes of therapy.25 _{They have an important role to play}

in the community in that they often serve either as the first port-of-call for the patient in the healthcare-seeking chain, as well as a last contact when medicines are dispensed.25,27 _{In this gateway}

function, pharmacists have opportunities to providing information to the general public as well as clinicians in judicious antibiotic use and thus preventing unnecessary antibiotic use, which is strongly associated with increased resistance.27,28 _{Figure 2 illustrates the}

role the pharmacist can play in response to the inappropriate use of antibiotics specifically.24,27,28-32

In 2008, the International Pharmaceutical Federation (FIP) published a pioneering statement of policy control of antimicrobial medicines resistance.28 _{Similarly, the South African Pharmacy}

Council’s Good Pharmacy Practice (GPP) aims to strive for quality pharmaceutical services for all the people of South Africa.29

Although not explicitly to be used in relation to antimicrobials, the rules in the GPP serve as minimum standards with which the pharmacist can fulfil their role in antimicrobial stewardship.29,30

Lately, there have also been updated recommendations released by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA) to complement current antimicrobial stewardship strategies.31,32

The minimum roles of the pharmacist in encouraging judicious use of antimicrobials and minimising antimicrobial resistance in the different practice settings are cross-cutting across most sectors of pharmacy. Table I shows examples of the specific roles pharmacists can play in AMR in line with the building blocks of the national strategy framework for AMR in South Africa.13,18,20,22,23,27-35

The goal of these efforts is always to improve health outcomes for the patient, i.e. reduced morbidity and mortality, minimise hospital-acquired infections, limit the emergence of drug-resistant organisms and lower healthcare costs.13,20

Hospital pharmacist

In the clinical environment, pharmacists may play an oversight role amongst healthcare professionals by formulating and monitoring adherence to standard treatment guidelines, including rational antibiotic prescribing by clinicians.25,26 _{The pharmacist and the}

nurse can actively collaborate in AMS programmes in the ward, acute and outpatient setting, to optimise antimicrobial use and combat AMR.26 _{Ideally, doctors should be part of such an}

integrated team. 26

As a core member of a multi-disciplinary antibiotic stewardship committee, the pharmacist can also provide appropriate guidelines regarding empiric and prophylactic use of antibiotics through the use of evidence-based medicine principles.27,28,29 _{These include}

antibiotic cycling, de-escalation therapy, dose optimisation and/ or parenteral to oral conversion when applicable.24,28,32-34 _The

hospital pharmacist through collaboration with the laboratory services, can ensure the availability of rapid diagnostic testing such as accurate point of care tests to guide clinicians on the most appropriate use of antibiotics.30

The hospital setting is ideal for prospective audit and feedback after two or three days of treatment in order to ensure the right drug is prescribed at the right time for the right diagnosis.33 _{This is}

more so for targeted antibiotics such as those that treat emerging drug-resistant bacterial infections.24,33,34

These activities require professional diligence through continuing education programmes of prescribers and dispensers as well as prospective monitoring and evaluation to avoid irrational prescribing.21

Community pharmacist

The community pharmacist has a vantage point in being able to directly initiate therapy.29 _{The pharmacist in this instance}

may recommend alternative treatment for minor infections and reassure patients of the inappropriateness of antibiotics for viral infections.25 _{The community pharmacist must exercise due}

diligence in upholding the law and not permit the over-the-counter sale of antibiotics.25 _{In instances when an antibiotic is}

indicated, the pharmacist can then advise the patient to complete the course and warn of possible side-effects or interactions in order to aid adherence.25 _{Technologies such as electronic measurement}

devices can be used to improve adherence to antibiotic therapy.30

The community pharmacist can teach community members to dispose of any unused medicines appropriately.25 _{The community}

pharmacist has a further role to play in promoting preventative measures of limiting infection such as good hygiene and vaccination campaigns.29

Academic pharmacist

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providers on the rational use of medicines and AMS.26,35 _Although

AMS training is included in the undergraduate pharmacy curriculum, a recent study amongst final year pharmacy students reported significant differences between the eight universities in the country, with 90% of students indicating that they would like more training on AMS.35 _{Central to their role in AMS, academic}

pharmacists can also develop curricula for continuing professional development in this field so as to improve current and future performance of all health practitioners as well as veterinarians.23

Academic pharmacists are in the ideal position to contribute towards collection and interpretation of surveillance data and conduct research, in collaboration with other members of the healthcare team.23,33,34

Industrial and wholesale pharmacist

In their role in AMS, manufacturing pharmacists have an obligation to ensure the manufacture of safe, efficacious and good quality medicines.27,29 _{In addition, they should proactively seek to}

promote innovation and research on new antimicrobials as well as ensure the steady production of essential antimicrobials to meet supply.29 _{Pharmacists practising in a wholesale environment can}

ensure that only authorised channels of distribution are used to supply the medicines to hospital and community pharmacies in order to minimise the availability of counterfeit and substandard medicines, and the rerouting of essential antimicrobials to non-approved clients.28

7

Figure 2. Inappropriate antibiotic use and the role of the pharmacist24,27-32

In 2008, the International Pharmaceuticals Federation (FIP) published a pioneering statement of policy control of antimicrobial medicines resistance.28 _{Similarly, the South African Pharmacy} Council’s Good Pharmacy Practice (GPP) aims to strive for quality pharmaceutical services for all the

 _{Optimise antibiotic prescribing}

o Confirm indication for antibiotic use o Use drug (antibiotic) with narrowest spectrum o Correct dose according to renal and/or hepatic

function

o Dose frequency – therapeutic drug monitoring if required

o Duration – should be evidence-based

o Route – depends on site and severity of infection, absorption and whether an orally active antibiotic is available

o De-escalation – convert from parenteral to oral use as soon as possible

 _{Reinforce delayed prescription where appropriate}  _{Use ‘high-dose short-course’ strategy}

 _{Use tools for clinical diagnosis} PRESCRIBERS

Collaboration & cooperation

Communication and education PHARMACIST

 _{Prevent infection – hand hygiene}

 _{Reduce risk of infections – promote vaccination}  _{Advice on self-limiting infections against}

bacterial and viral disease o Duration of symptoms

o Symptoms which require medical attention o Self-care

 Counselling and advice o Do not ask for antibiotics

o Use antibiotics exactly as prescribed o Do not share antibiotics

o Never save antibiotics for later o Do not buy antibiotics over the counter

 _{Tell friends and family about antibiotic}

resistance

 _{Provide information leaflets}

 _{Delay filling of prescription for uncomplicated}

respiratory tract infections

P A T I E N T

P U B L I C ANTIBIOTIC RESISTANCE

↑ Health care costs ↑ Drug-resistant organisms

↑ Morbidity and mortality

 _{Use of antibiotics when not indicated e.g.}

treating minor infections or viral infections

 _{Over reliance on empirical therapy when}

treating infections without laboratory confirmation

 Indiscriminate use of broad-spectrum antibiotics to treat very susceptible bacteria

 _{Unnecessarily prolonged use of antibiotics}

when no longer needed

 _{Antibiotics given at the wrong dosages}

(under/over dosed)

 _{Use of a wrong antibiotic to treat an infection}  _{Patient and parenteral beliefs, fears and}

expectations

 _{Counterfeit or sub-standard antibiotics}  Ease of access to antibiotics by the general

public without a prescription

INAPPROPRIATE USE OF ANTIBIOTICS

I N T E R V E N T I O N

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Table I. The role of the pharmacist in containing antimicrobial resistance18,22,23,25,27-35

H

ospital pharmacist

Enhanced surveillance Antimicrobial stewardship Infection prevention and control

• Monitor patient outcomes and provide information about incidence and prevalence of AMR

• Identify patients at risk of AMR • Post-prescribing audits to monitor

antimicrobial consumption

• Clinical pharmacists to conduct therapeutic drug monitoring (TDM) in collaboration with laboratory services in order to minimise adverse drug reactions

• Strengthen pharmacovigilance systems and adverse drug reaction reporting

• Minimise pharmacy stock-outs to ensure that patient treatment is not interrupted • Prospective monitoring and evaluation of

prescribing habits and compliance to EML, STGs and antibiotic prescribing guidelines

• Establish and enforce the prescribing on antibiotic prescription charts

• Ward rounds to ensure dose optimisation based on patient characteristics and antibiotic susceptibility testing

• Monitoring of antibiotics use: surgical prophylaxis duration; de-escalation and reassessment of treatment need, hang time • Ensure access to EML, STGs and national

antibiotic prescribing guidelines • Develop hospital formulary with limited

number of antibiotics in order to restrict the number and type of antimicrobials used • Pre-authorisation for certain antibiotics, to

ensure necessary oversight for appropriate use • Timeous feedback and interventions to modify

irrational prescribing

• Promote use of algorithms to guide prescribers based on clinical signs and symptoms

• Key member of the hospital infection prevention and control committee • Ensure availability of cleaning agents and

personal protective equipment for hospital staff

• Encourage the use of single-dose packages of sterile drug products rather than multiple-dose containers

• Enhance and encourage hand hygiene in the hospital setting in order to minimise transmission of hospital-acquired infections • Offer continuous training on hand hygiene • Educate and promote vaccination against viral

and bacterial diseases

Communit

y pharmacist

• Prescription review and feedback recommendations in order to track AMR • Prescription review and collection of data on

antimicrobial sales, prescriptions and use to monitor antimicrobial consumption • Prescription review and feedback in order to

give oversight on rational antimicrobial use • Measure success of programmes

• Primary care drug therapy permit holders to prescribe and dispense antibiotics according to EML and STGs using the antimicrobial prescription chart

• Monitor antibiotic prescribing for self-limiting conditions

• Ensure antibiotic prescribed is justified and correct (see Figure 2)

• Delayed antibiotic prescriptions where appropriate

• Education and information leaflets for patients on AMR

• Implement vaccination uptake programmes to reduce the incidence of bacterial and viral infections

• Promote hand hygiene in the community • Increase community awareness on infectious

diseases, their causes and how to prevent them including general infection and prevention measures

Ac

ademic pharmacist

• Conduct proactive research in collaboration with microbiologists which will serve as an early warning system for the emergence and spread of new forms of resistance

• Conducting qualitative research mapping the consumption of antimicrobial medicine through the regular collection of data on sales, prescriptions and use in single or multiple centres

• Development and incorporation of AMS into undergraduate and postgraduate curriculum • Ensure all undergraduate and postgraduate

students participate in AMS ward rounds • Support continuous professional development

in AMS e.g. antimicrobial prescribing course on the antimicrobial prescription chart

• Computerised clinical decision support to guide clinicians on the best choice of antimicrobial agent

• Clinical trials that incorporate AMS in their design

• Assist with pharmacokinetics and

pharmacodynamics to ensure most effective antimicrobial agent is used

• Implementation research

• Develop public education programmes on AMR

• Contribute towards and participate in training programmes in collaboration with other heathcare professionals on infection prevention and control

• Support continuous professional development in infection prevention and control and vaccination e.g. by developing online training materials on infection prevention and control and vaccination

• Participate in campaigns to enhance vaccine uptake for bacterial and viral diseases

Industrial pharmacist

• Collection of data on antimicrobial sales to track antimicrobial consumption

• Manufacture safe, efficacious and good quality medicines

• Promote innovation and research on new antimicrobials

• Ensure steady production of essential antimicrobials to meet supply

• Production and marketing agreements for a

needs-based number of treatments per year • Conduct nationwide health awareness campaigns that promote the appropriate use of antimicrobials and the growing threat of AMR

Regula

tor

y / health sy

st

ems

• Setup and implement national surveillance framework and development of indicators for AMR

• Collate national antibiotic consumption data at all healthcare levels (private and public) • Overseeing role on medicines and diagnostics

to ensure good quality medicines and diagnostic assays

• Minimise substandard and counterfeit antimicrobials in order to ensure good quality medicines

• Formulate and implement antimicrobial prescription charts for use at all health levels in the public and private sector

• Participate in expert committees formulating national EML and STGs

• Regulating contacts with pharmaceutical representatives to limit undue influence on prescribers

• Develop tools to assist with clinical diagnoses in out-patient setting

• Multi-disciplinary collaboration to develop and implement educational and behavioural interventions for appropriate prescribing

• Active and passive surveillance for hospital-acquired infections, outbreaks and control • Programmes to ensure environmental safety i.e.

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Regulatory and health system pharmacist

Pharmacists can participate in the development of national policy, laws and guidelines which will promote appropriate use of antimicrobials and the implementation of such policies where they exist.22,23 _{In particular, they can collaborate with}

health-professional societies and associations to develop and facilitate the implementation of educational and behavioural interventions that will assist in rational antimicrobial use.23

Furthermore, they can ensure legislation, which prevents dispensing without prescription, is enforced and that the antibiotics registered for use are safe, efficacious and of a good quality.25 _{Moreover, such pharmacists can enable an environment}

that ensures that there is minimum influence on prescribing and dispensing by the pharmaceutical industry.22,27

Conclusion

Antimicrobial resistance is a major threat to public health. A post-antibiotic era is fast approaching, calling for an urgent and coordinated action by all stakeholders. South Africa’s AMR strategy framework with its four building blocks (AMR governance, enhanced surveillance, AMS, infection prevention and control) and strategic enablers, aims to ensure the appropriate use of antimicrobials by all healthcare professionals and in all health establishments. The framework provides an opportunity for pharmacists across all practice settings to get involved, collaborate and play a role in this important endeavour. Antimicrobial stewardship specifically has the potential of combating the threat of dwindling antibiotic resources while advancing pharmaceutical care. Pharmacists from all sectors of practice should proactively uphold the principles of rational antimicrobial use and participate in AMS programmes, within the multi-disciplinary healthcare team, and at all levels of care. It is in the interest of public health that change, collaboration and cooperation start with all of us.

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