| Antibiotic resistance is everybody’s problem and will
need a concerted and long-term strategy if there is not to be a return
to the pre-antibiotic
era. These words were spoken by Richard Wise, chairman of the government’s
Standing
Advisory Committee on Antimicrobial Resistance (SACAR), at the
launch of the group in 2001. Three years later matters do not seem to
have improved.
Resistance to vancomycin used for treatment of methicillin resistant
Staphylococcus aureus (MRSA) infections is now emerging, as has been
reported in a paper recently published in Emerging Infectious Diseases.
Widespread and often inappropriate use of existing drugs are thought
to have contributed to the current problem of antimicrobial drug resistance.
So what can be done to halt further increases in resistance, if not actually
reverse the trends?
The Government has recognised that antimicrobial drug resistance is a
significant public health issue, and is looking to clinical pharmacists
to help provide a solution. “Getting ahead of the curve”,
a report by the Chief Medical Officer in 2002, proposed a strategy for
combating infectious diseases, and drew attention to the role pharmacists
should play. In June 2003, a letter from the Chief Medical Officer and
Chief Pharmaceutical Officer alerted chief pharmacists in England that
the Department of Health was investing £12m over three years in
a hospital pharmacy initiative for promoting prudent use of antibiotics
in hospitals. The initiative will be overseen by the prescribing sub-group
of SACAR, co-chaired by Jonathan Cooke, director of pharmacy, South Manchester
University Hospitals.
Chief pharmacists have been asked to plan developments in clinical pharmacy
services to improve the prudent use and monitoring of antibiotics in
their hospital. Strategic health authorities will monitor the results
for performance management.
According to Dr Cooke, the first goal of this initiative is to see clinical
pharmacy input at all acute trusts in England, and to establish close
working with microbiologists and specialists. Networks are being formed
in different regions in the country to support this work.
Pharmacists from around the country are attending a conference in London
next week, organised by SACAR, in conjunction with the National Prescribing
Centre and the Royal Pharmaceutical Society, to discuss promoting the
rational use of antimicrobials in acute hospitals. There is clearly a
great deal that clinical pharmacists can do to promote effective use
of antimicrobials and contribute to tackling the global problem of antimicrobial
resistance, and the hope is that examples of good practice already in
existence will be spread more widely.
Clinical pharmacy activities
The key to successful clinical pharmacy intervention to promote effective
antibiotic prescribing is a close working relationship with senior
clinicians and microbiologists, according to Steve Williams, principal
pharmacist clinical services, South Manchester University Hospitals
NHS Trust. “A restricted antibiotic policy is important to the
overall strategy of appropriate antibiotic use and, as pharmacists,
we monitor adherence to this as gatekeeper of the drugs. Prudent antibiotic
use can be best supported by a combination of educating the junior
doctors about empirical treatment and maintaining a restricted list,” he
said. Mr Williams attends clinical meetings for directorates in his
trust, with consultant microbiologists, to provide guidance on antimicrobial
prescribing issues in those areas.
A patient group direction (PGD) at South Manchester University Hospitals
to allow pharmacists to prescribe oral antibiotics has also been developed.
The PGD permits pharmacists to switch patients with respiratory infections
from intravenous to oral therapy, when the strict clinical inclusion
criteria of the PGD have been met. All consultants in the trust were
informed about the proposed PGD and with no opposition it was introduced.
This practice reduces drug costs, allows earlier discharge from hospital
and improves patient comfort by stopping unnecessary antibiotic therapy
earlier.
The importance of multidisciplinary working is also recognised by Wendy
Lawson, senior pharmacist, infectious diseases, Hammersmith Hospitals
NHS Trust. “It is imperative that you are able to work in a multidisciplinary
group. It is important to have support from microbiology/infectious diseases,
and work closely with infection control and prescribers,” she said.
She also commented on the increasing call for pharmacists with responsibility
for prudent antimicrobial use — she helped establish the United
Kingdom Clinical Pharmacy Association infection management pharmacists
group and membership has increased from 25 a few years ago to over 110.
And Dr Cooke suggested that those responsible for the undergraduate education
of pharmacists should increase the content devoted to antimicrobials,
so that pharmacists are prepared to fill these roles.
Another initiative at Hammersmith Hospitals NHS Trust is the introduction
of mandatory order forms for newer anti-infective agents such as linezolid.
There are few new anti-infective agents reaching the market and Ms Lawson
explained that it is therefore important to control the use of these
drugs to minimise potential for development of resistance. Pharmacists
at the trust do not dispense linezolid until the prescribing doctor has
confirmed the indication of the drug and approval has been obtained from
a microbiologist for its use.
Ultimately, the Government’s pharmacy initiative was setup to stem
the increase in antimicrobial drug resistance, and tests of resistance
(eg, levels of MRSA and Clostridium difficile) will indicate if it is
effective. According to Dr Cooke, hospitals may decide to use other measures
locally, such as antimicrobial usage, intravenous to oral switch rates
and infection rates. With the SACAR meeting next week, pharmacists have
an opportunity to demonstrate what clinical pharmacy can achieve.
Data collection is first step to rational use of antibiotics
Wendy Lawson, Hammersmith Hospitals NHS Trust, emphasised that
it is important to have knowledge of antibiotic prescribing practice
in a trust to identify areas that need targeting. She described
an initiative by pharmacy, infection control and a hospital epidemiology
consultant at the Hammersmith Hospitals NHS Trust which involves
serial point-prevalence studies on anti-infective use. Clinical
pharmacists have collected, every six months since 1999, details
of anti-infectives that all inpatients are receiving on the specific
day determined for data collection. Information collected includes
whether antibiotics are being administered orally or intravenously,
whether they are for surgical prophylaxis, duration of treatment,
drug combinations and, if the drug was on the reserved list, whether
its had been approved by a microbiologist. This data is also used
as a proxy marker for hospital acquired infection. This initiative
has proved to be one practical method of monitoring anti-infective
use, and provides data for benchmarking which can be compared with
previous studies or other trusts. This initiative has recently
been extended to other trusts in west London.
Although figures on the use of antimicrobials in primary care are
available through prescribing analysis and cost (PACT) data, this
sort of information is not generated in secondary care. “The
UK is behind most of the rest of Europe with regards to producing
antimicrobial usage data, and this is an area where pharmacists
can work to provide improvements,” said Jonathan Cooke, South
Manchester University Hospitals. One of the most useful ways to
collect this information is to present it as defined daily doses
(the total quantity of the drug used divided by the average daily
dose). When this figure is divided by a population demoninator,
such as 100 bed days, the resulting figure can be compared across
different institutions and countries where the drug price may differ. |
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The
Pharmaceutical Journal