Exploring the role of community pharmacists in antimicrobial stewardship

Judicious use of the currently available antimicrobials is crucial as the rate of antimicrobial resistance (AMR) continues to exceed the rate of new drug development. Globally 700,000 people die annually due to infections caused by antimicrobial resistant organisms and this is expected to reach 10 million per year by 2050, causing a loss of up to USD100 trillion to the global economy. A significant force driving the development of AMR is the use and, in particular, the inappropriate use of antimicrobials. It is estimated that almost 50% of all antimicrobials given to humans are inappropriate. Antimicrobial stewardship (AMS) is defined as a set of coordinated strategies to improve antimicrobial use with the goal of enhancing patient health outcomes, reducing resistance to antimicrobials and decreasing unnecessary costs. There are two main approaches to AMS and these are usually applied in combination. One of the approaches is the front-end or prescription method, which restricts the use of certain antimicrobials by employing an approval process. This approach is usually applied broadly in national, regional and institutionalised settings. The second is the back end or post prescription approach, involving audit and feedback to guide appropriate prescribing and dispensing of antimicrobials. Other approaches or techniques include delayed antimicrobial prescribing, point-of-care testing, providing education and awareness to the public, patients and prescribers, as well as decision support systems integrated into clinical software. Recently, resistant organisms have been increasingly detected in the community and community prescribers are responsible for about 90% of all antimicrobial prescriptions globally, with respiratory tract infections (RTIs) being the most common indication for prescribing antimicrobials in the community. In Australia, AMS programs are mandatory in hospitals; however, they are not currently present in the community, despite the widespread use of antimicrobials in this setting. Within primary care, community pharmacists are the most accessible healthcare professionals and consequently, have the potential to play a major role in AMS. The overall aim of the thesis is to investigate the current role of community pharmacists in AMS. The methodology is an explanatory, sequential, mixed method for the overall project, comprising a literature review, two quantitative studies and one qualitative study (Table 1). The first chapter of the thesis provides background information related to the overall project. The second chapter is a narrative literature review which describes various AMS interventional studies in community settings. This review evolved and was updated regularly until December 2020. Studies that measured an outcome to optimise antimicrobial use through prescribing or dispensing, compared with usual care or other interventions in the community sector, were included in the review. Most AMS interventions in the community setting were successful in optimising antimicrobials use, although infections other than RTIs were less well studied. The studies that employed multi-faceted interventions showed marginal superiority over studies involving a single intervention. Educational interventions, which were supported with either computerised decision support, delayed prescribing, point-of-care diagnostics or prescriber feedback, were found to be successful in improving appropriate antimicrobial use. Most studies were conducted in GP practices or aged care facilities; only few studies involved community pharmacists. The first quantitative study, which constitutes the third chapter of the thesis, was the development and validation of a survey questionnaire to explore the knowledge and perceptions of community pharmacists regarding AMS. The questionnaire was piloted amongst Tasmanian community pharmacists and the study has been published in the International Journal of Clinical Pharmacy. The resulting questionnaire to measure pharmacists' perceptions of the enablers and barriers to AMS in community settings demonstrated acceptable reliability and validity. The pilot study found that Tasmanian pharmacists are willing to participate in AMS initiatives, if facilitated with proper training and access to standard antimicrobial guidelines and patient records. The fourth chapter of the thesis describes the next study in which the newly developed, tested and revised survey questionnaire was deployed nationwide. The objective of the study was to gain more insights into the perceptions and practices of community pharmacists regarding AMS. The additional data from across Australia adds further to the questionnaire's reliability and validity. The study has been published in the Journal of Global Antimicrobial Resistance. The majority of participants reported that they frequently contacted prescribers if they thought antimicrobial prescriptions needed to be changed with regard to allergies, drug interactions and dosage. However, less than half of participants said they frequently contacted prescribers when, in their opinion, the chosen antimicrobial was not appropriate. Major barriers to AMS identified by the participants were lack of access to patient data and lack of access to a standard antimicrobial guideline for all healthcare professionals. These results were consistent with the results of the earlier Tasmanian study presented in the third chapter. The result of the literature review found there were few qualitative studies regarding community pharmacists' involvement in AMS; therefore, a qualitative telephone study was conducted and this constitutes the fifth chapter of this thesis. The manuscript arising from this study is currently being prepared and will be submitted to a relevant journal. The qualitative study explores the in-depth experiences and views of Australian community pharmacists on AMS in primary care. One-on-one semi-structured telephone interviews were conducted with community pharmacists across Australia. Interviews were transcribed verbatim and analysed using the framework analysis method. Our findings discovered some system-wide and profession-specific issues that are currently limiting community pharmacists' participation in AMS. Pharmacists identified that the clinical needs of patients and policies regarding prescribing and dispensing of antimicrobials are not consistent; these issues were considered to be major barriers to AMS. Respondents also reported that fragmentation of the primary health care system in Australia is limiting information exchange between community pharmacists and general practitioners and, at times, encouraging inappropriate and potentially unsanctioned use of antimicrobials. The existing community pharmacy funding model was also reported as discouraging community pharmacists from participating in AMS, as refusal to dispense an inappropriate antimicrobial agent result in a financial loss for the pharmacy. Pharmacists suggested restricting default antimicrobial repeat supplies, reducing the legal period of antimicrobial prescription validity to less than 12 months and adopting a treatment duration-based approach to antimicrobial prescription, instead of the current quantity-based approach, in which the quantity prescribed is linked to the standard pack size of the antimicrobials. Overall, my PhD project has advanced our knowledge regarding the current role and potential barriers to the contribution of community pharmacists to AMS. Based on the available literature and the quantitative and qualitative studies undertaken, it is clear that community pharmacy is currently underutilised in the area of AMS. The findings of our studies might help inform changes to the healthcare landscape to facilitate more optimal use of antimicrobials. Use of antimicrobials can be optimised by utilising the skills and services of community pharmacists through development and implementation of community AMS frameworks. (Table1 not included in this metadata record).