Role of community pharmacists in fighting AMR
27 Nov 2018
Antibiotics, crucial life-saving medicines, were ‘miracle drugs’ of the 20th century, but now they are not always effective against pathogens to cure diseases
World Antibiotic Awareness Week in November 2018 was marked with the slogan 'Think twice. Seek Advice. Misuse of Antibiotics puts us all at Risk'.
Antibiotic resistance (AMR) is a natural process but misuse and overuse of antimicrobials in animals and humans enhance the process. The threat of AMR is a global burden, making some infections more severe and life-threatening.
It's been estimated that by 2050, 300 million people will lose their life prematurely, if the rate of AMR continues to develop at the current rate. This will occur mainly in developing countries like Nepal.
Every year, nearly one million people die from bacterial infections. Research shows that when people move from countries with low levels of antibiotic use to those with high use they have a higher risk of infections with AMR bacteria.
Some examples of bacteria that have already developed resistance to different classes of antibiotics in the last five years are: extensively drug-resistant Salmonella enterica serovar Typhi; multidrug-resistant Mycobacterium tuberculosis (MDR-TB); extensively drug-resistant M. tuberculosis (XDR-TB); extensively drug-resistant Neisseria gonorrhoeae; pandrug-resistant Pseudomonas aeruginosa; pandrug-resistant Klebsiella pneumoniae; methicillin-resistant Staphylococcus aureus (MRSA); vancomycin- resistant enterococci (VRE) and carbapenem-resistant Enterobacteriaceae (CRE).
Community pharmacists are the healthcare entry point for members of the public to access pharmaceutical services. They usually dispense medicines to patients with prescriptions but also sell them without prescriptions when legally permitted. These outlets arepopular in developing countries as they have become the easiest and cheapest way for patients to obtain medicines for general diseases.
Community pharmacists should have training and education on the appropriate use of antibiotics as they have a leading role in changing customer attitude towards consumption of antibiotics.
All staff should be updated with new antibiotic usage guidance and patterns of AMR. In community pharmacies there's a severe shortage of qualified pharmacists. Many research findings have highlighted the fact that even broad-spectrum antibiotics, such as amoxicillin and azithromycin, are being dispensed without a prescription from a health professional.
Laying down the law
Many countries have laws regarding restriction of distribution of antibiotics in the absence of proper diagnosis and prescription; however, due to the lack of implementation of such laws, AMR is still increasing. In resource-limited countries there is a lack of strict strategies to monitor dispensing practices in community-based pharmacies.
Health promotion programmes, such as the health campaign by community pharmacists on keeping the immune system healthy, are essential on a regular basis to reduce AMR. In the context of Australia, pharmacists were involved in a public awareness campaign organized by National Prescribing Services (NPS). In the context of India, public health-related awareness programmes were conducted in several parts of the country in National Pharmacy Week, 2017.
Similarly, community pharmacists should play an important role to make the public aware of good hygiene practices, proper handwashing, intake of healthy food, cessation of smoking and alcohol, isolation of infected people, suggestions on how to cure minor injuries, etc.
Vaccination is good for the nation
Knowledge about the importance of vaccines will increase the rate of vaccination and may help decrease AMR in the future. For effectiveness of the immunization process, the American Society of Health-System Pharmacists has launched a broad programme to improve the rate of influenza immunization.
In many countries, doctors prescribe antibiotics for the common cold, and many patients think they are needed to cure it. The community pharmacist needs to debunk the misconceptions of antibiotic treatment of non-bacterial infections.
The Community Pharmacy Association of Thailand worked with the slogan Mirror, mirror on the wall, do I need antibiotics at all? To prevent the unnecessary use of antibiotics for viral infections. In Spain, a communication campaign was organized with the slogan Do not ask us for antibiotics but for information to discourage the use of antibiotics without proper prescription.
Farming it out
In healthy animals, large amounts of antibiotics have been used for growth promotion and to prevent many diseases. It's been estimated that almost 80% of antibiotics are used in livestock farming, while the rate is much higher in agriculture-based countries.
In Nepal, the use of antibiotics in livestock farming is increasing day by day and is quite heavy compared with neighbouring countries. Most drugs (from classes important to human medicine) are used in animal farming to enhance their growth rate.
The use of antibiotics in Nepalese farms is increasing excessively but exact figures are not available. Most of the farmers purchase antibiotics from local retailers without veterinarian prescription. Data show that the market for veterinary antibiotics in Nepal rose by over 50% from 2008 to 2012.
Ready for action
The Food and Drug Administration (FDA) and concerned stakeholders have made proposals regarding the rational use of antibiotics. For livestock and agricultural farming, pharmacists must select only those antibiotics which are listed as ‘least important’ to human beings by WHO.
Improving hygiene in livestock farming and the proper use of vaccination in animals can reduce the huge amount of antibiotics being used in livestock farming. In 2006, the European Union banned the use of growth-promoting antibiotics to reduce the use of antibiotics in livestock. Similarly, the fluoroquinolone antibiotic ciprofloxacin was used in US poultry farms since 1995 leading to the development of ciprofloxacin-resistant Campylobacter. In 2005, the use of ciprofloxacin in poultry farming was banned by the FDA.
Without immediate action, the world will enter the post-antibiotic period where treatable infections would kill millions of people. Implementation of strict rules and regulations, policies prohibiting the sale of antibiotics without prescription, public awareness, counselling of patients and immunization programmes will help to reduce the ongoing burden of AMR.
Research Faculty, Department of Infectious Diseases and Immunology, Kathmandu Research Institute for Biological Sciences, Lalitpur, Nepal. firstname.lastname@example.org
Quality Controller of Meat Products, Valley Cold Store Pvt. Ltd., Kathmandu, Nepal. email@example.com
Yewale, V. N. (2014). Antimicrobial resistance — A ticking bomb! Indian Pediatrics, 51(3), 171–172. doi:10.1007/s13312-014-0374-3
Collier, P., & O’Neill, L. J. (2018). Two years on: an update on achievement towards the recommendations of the antimicrobial resistance report. Journal of Applied Microbiology, (May), 1–5. http://doi.org/10.1111/jam.13933
Arroll, B. and Kenealy, T., 2005. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database of Systematic Reviews, (3).