Antimicrobial stewardship by Australian community pharmacists: Uptake, collaboration, challenges, and needs

Implementing a community-based antimicrobial stewardship intervention in Malaysia

Background

In Malaysia, the unregulated use of antibiotics and lack of awareness about antimicrobial resistance (AMR) among pharmacists pose significant challenges. Implementing community-based Antimicrobial Stewardship (AMS) initiatives is crucial to address the rising AMR.

Methods

We developed a bespoke AMS intervention, aligned with the World Health Organization's AMS modules, as a 2-day online educational seminar for community pharmacists. The effectiveness of the workshop was evaluated using pre- and post-seminar questionnaires, focusing on AMS knowledge and attitudes towards antimicrobial usage.

Results

Among 528 participants, 489 completed both questionnaires. Pre-seminar, only 59% correctly understood the concept of antibiotic resistance reversibility, which improved to 85.9% post-seminar (p = .002). The average AMS knowledge score increased from 5/10 to 8/10 post-intervention (p < .05). A significant improvement was also noted in pharmacists' ability to select appropriate antibiotic therapies, particularly for urinary tract infections, with an increase from 78% to 90% correct responses.

Conclusion

The AMS seminar was well-received and significantly improved the AMS knowledge of community pharmacists. The results underline the need for more AMS-focused interventions in this demographic in Malaysia, contributing to the development of formalized AMS programs. Such initiatives are expected to enhance antibiotic use awareness, encourage optimal antibiotic practices, and positively shift professional conduct in community settings.

Community pharmacists' knowledge and practices towards antimicrobial stewardship: findings and implications

BACKGROUND

Antimicrobial stewardship (AMS) programmes have been implemented around the world to optimally manage antimicrobial use to attenuate antimicrobial resistance (AMR). This study assessed the knowledge and practices of community pharmacists towards AMS strategies in the Lusaka District, Zambia.

METHODS

This cross-sectional study was conducted among 194 community pharmacists in the Lusaka district using a structured questionnaire from August 2022 to September 2022. Data analysis was done using Statistical Package for Social Science (SPSS) version 22.0.

RESULTS

Of the 194 participants, 86% of the community pharmacists had good knowledge of AMS. The present study found that 83.5% were aware of AMS strategies used in community pharmacy practice. Further, 83.5% of the CPs were familiar with the goals of AMS and 89.2% believed that AMS was necessary for their pharmacy practice. Furthermore, 66.7% of the participants exhibited good practice towards the AMS strategies. Finally, 61.3% frequently avoided the use of broad-spectrum antimicrobials that were not necessary.

CONCLUSIONS

According to the findings of this study, the majority of community pharmacists had good knowledge of the AMS strategies that were employed to combat AMR; nonetheless, some of them had poor practices. Therefore, there is a need for community pharmacists to have access to sufficient ongoing professional development programmes and educational activities through AMS programmes to address AMR.

Opportunities and Barriers to Pediatric Antimicrobial Stewardship by Community Pharmacists

Community Pharmacists (CPs) are easily accessible and can advocate for the appropriate use of antibiotics in children. Semi-structured interviews were conducted with 47 CPs and 46 parents/caregivers. Both groups expressed challenges to intervening when antibiotics have already been prescribed and highlighted the need for more support for CPs to make informed decisions.

Determining a future policy focus to support antimicrobial stewardship in community pharmacy: A modified Delphi study

Background

Over the past decade, the pharmacy sector's policy, academic and professional spheres have increasingly drawn attention to the opportunities to better leverage the untapped potential of the community pharmacy sector in contributing to global efforts to reduce antimicrobial resistance (AMR). While efforts are in train, progress is slow.

Objective

To draw insights from global experts in the field to identify a broad range of potential future policy directions to support community pharmacists' involvement in antimicrobial stewardship (AMS).

Methods

A modified Delphi technique, comprising two survey rounds to build consensus amongst global community pharmacy sector stakeholders and opinion leaders. In Round 1, participants rated their level of agreement with 28 statements across the three domains of policy design, implementation design, and monitoring and evaluation. Participants were also invited to contribute feedback in Round 1, which was reflected as new statements (n = 10) in Round 2. In Round 2, participants were asked to re-assess Round 1 statements in view of the group consensus and to rate the new statements.

Results

289 participants were invited to participate. 48/289 (17% response rate) completed Round 1, and 25/42 (60% response rate) completed Round 2. Consensus (defined as >70% agreement) was achieved for 79% (n = 30) of the statements across the three domains.

Conclusion

Pharmacy sector experts agreed that acknowledging community pharmacists in AMS national action plans is an important component, signalling a recognition of the sector's contribution to whole-of-nation AMS efforts. Implementation components that achieved consensus reflect the profession's evolution to a professional service driven model, particularly in complementary AMS initiatives including infection prevention and control measures. Context-specific adjustments to support implementing these AMS measures will be required, in addition to striking the appropriate balance to support the pace of increased community pharmacists'involvement in AMS with building whole-of-profession buy-in.

Knowledge and attitude of healthcare prescribers and pharmacists toward antimicrobial stewardship program and the barriers for its implementation

BACKGROUND

Antimicrobial stewardship (ASP) is considered a key prevention strategy in addressing the worldwide concern of accelerating antimicrobial resistance. Limited research is available regarding healthcare providers' knowledge and attitude toward antimicrobial stewardship and the barriers for its implementation.

METHODS

The present cross-sectional study was conducted on pharmacists and healthcare prescribers (HCPs) in different hospital sites across Jordan. A validated survey was used to evaluate HCPs and pharmacists' knowledge, and attitudes towards ASP and the barriers for its implementation. Logistic and linear regression were conducted to identify the factors associated with knowledge and attitude toward ASP, respectively.

RESULTS

A total of 603 participants, 69 (11.4%) pharmacists and 534 (88.6%) HCPs completed the study questionnaire, with a response rate of 80.4%. The overall mean knowledge about ASP was 7.16 out of 10, ranging from 0 to 10 (SD 2.22). Being a pharmacist and increased awareness/familiarity about ASP were associated with improved ASP knowledge. The overall average attitude score was = 3.8 ± 0.49 (range: 1.8-4.8). Results revealed that being a pharmacist and improved knowledge were associated with improved attitude toward ASP. Lack of specialized staff with expertise in ASP and lack of access to education and training programs were the major barriers hinder ASP implementation.

CONCLUSION

Despite the reasonable knowledge and the positive attitude toward the ASP, several barriers were reported, particularly by the pharmacists. Therefore, promoting the presence of adequately skilled healthcare personnel, creating easily accessible online courses, and establishing a comprehensive database of ASP resources are all suggested approaches to improve the application of ASP in healthcare settings.

The National Implementation of a Community Pharmacy Antimicrobial Stewardship Intervention (PAMSI) through the English Pharmacy Quality Scheme 2020 to 2022

Since 2020, England's Pharmacy Quality Scheme (PQS) has incentivised increased antimicrobial stewardship (AMS) activities in community pharmacy. In 2020/21, this included the requirement for staff to complete an AMS e-Learning module, pledge to be an Antibiotic Guardian and develop an AMS Action plan. To build and embed these initiatives, in 2021/22, the PQS required the use of the TARGET Antibiotic Checklist (an AMS tool for use when patients present with a prescription for antibiotics to support conducting and recording of a series of safety and appropriateness checks against each prescribed antibiotic). This paper describes the implementation of the national PQS criteria from 2020 to 2022, and details community pharmacies' AMS activities and barriers to implementation of the 2021/22 criteria. A total of 8374 community pharmacies submitted data collected using the TARGET Antibiotic Checklist for 213,105 prescriptions; 44% surpassed the required number for the PQS. Pharmacy teams reported checking the following: duration, dose, and appropriateness of antibiotics; patient allergies and medicine interactions (94-95%); antibiotic prescribing guideline adherence (89%); and the patient's previous use of antibiotics (81%). The prescriber was contacted for 1.3% of TARGET Antibiotic Checklists (2741), and the most common reasons for such contacts were related to dose, duration, and possible patient allergy. A total of 105 pharmacy staff responded to a follow-up questionnaire, which suggested that some AMS principles had been embedded into daily practice; however, the necessary time commitment was a barrier. The PQS was able to incentivise mass AMS activities at pace over consecutive years for England's community pharmacies simultaneously. Future research should monitor the continuation of activities and the wider impacts on primary care.

Perceptions of community pharmacists regarding their role in antimicrobial stewardship in Pakistan: A way forward

BACKGROUND

Antimicrobial resistance is one of the biggest challenges to healthcare resulting in increased morbidity and mortality, and associated with drug resistant infections. Community pharmacists (CPs) can play a key role in antimicrobial stewardship (AMS) programs to aid the prudent use of antibiotics, and in infection prevention and control.

OBJECTIVE

The aim of this study was to assess perceptions of CPs regarding their role, awareness, collaboration, facilitators and barriers towards effective AMS practices in Pakistan.

METHOD

ology: A descriptive, cross-sectional study design was adopted, where convenience and snowball sampling methods were applied to enroll respondents (pharmacists working at these community pharmacies in different cities of Pakistan) of the study. After sample size determination, n = 386 CPs were enrolled. A pre-validated questionnaire was used regarding CPs roles and perceptions in association with AMS. Statistical analysis was performed using SPSS v. 21.

RESULTS

The results of the study reported that 57.3% (n = 221) of CPs had strong familiarity with term AMS. 52.1% (n = 201) of CPs agreed that they require adequate training to undertake activities in AMS programmes in their setting. The results of the study showed that 92.7% (n = 358) of the pharmacists thought real time feedback would be helpful. Significant association was observed in AMS awareness, approach, collaboration and barriers with regards to the respondents' gender, age groups and levels of experience in a community pharmacy.

CONCLUSIONS

The study concluded that CPs were aware of AMS programmes, their relevance and necessity of AMS in their everyday practice, but had inadequate training and resources to implement it in Pakistan.

Improving access to quality contraceptive counselling in community pharmacy: examining the knowledge, attitudes and practices of community pharmacists in Australia

BACKGROUND

Across most of Australia, the role of community pharmacists in contraceptive care has been unchanged since 2004. To understand their current scope of practice and potential for practice advancements, we examined community pharmacists' contraceptive knowledge and their attitudes, practices and perceived barriers to and benefits of contraceptive counselling provision.

METHODS

A nationwide postal survey was conducted between September and December 2020. We contacted a state/territory-stratified sample of 2149 community pharmacies and limited eligibility to one pharmacist per pharmacy. Summary statistics of respondent characteristics and parametric (χ², linear regression) and non-parametric (Mann-Whitney, logistic regression) tests were computed for the outcomes: practices, knowledge (reported and tested), confidence, attitudes, barriers and benefits.

RESULTS

Eligible responses were received from 366 pharmacies (19%). Pharmacists' median age was 34. Most (85% of) pharmacists agreed that contraceptive counselling fits within their current professional activities and emphasised benefits to their patients, including improved access to contraceptive decision support (80%), as being key motivators of counselling. A lack of payment mechanisms (66%), training opportunities (55%) and technical assistance tools (54%) were the most important barriers. Self-rated knowledge and confidence were highest for combined oral contraceptive pills and lowest for the copper intrauterine device (IUD). When tested, pharmacists were very knowledgeable about method, dosage, frequencies and costs, and relatively less knowledgeable about side-effects and IUD suitability for adolescents.

CONCLUSIONS

Community pharmacists provide contraceptive information and counselling but lack the necessary resources and support to be able to consistently provide quality, person-centred care. Remuneration mechanisms, training opportunities and pharmacy-specific professional resources need to be explored.

Community pharmacists as antimicrobial guardians and gatekeepers - A qualitative study of the perspectives of pharmacy sector stakeholders

Background

Community pharmacists, as primary care providers, are an underutilised resource in antimicrobial stewardship (AMS). Primary care plays an important role in tackling antimicrobial resistance (AMR) as the principle of balancing access to antimicrobials while ensuring optimal use is agnostic to health setting. Understanding the sector's perceptions and practices towards AMS involvement is a continuing focus area of research. However, there is an opportunity to understand the sociological factors which influence the profession's contribution to stewardship practice, particularly across a broader spectrum of sector stakeholders at the individual, practice, system, and policy levels.

Objective

To explore stakeholders' perceptions of the Australian community pharmacy sector's AMS involvement.

Methods

Semi-structured interviews were conducted with fifteen key informants from the Australian community pharmacy sector. Participants' insights were invited across three broad areas: (1) understanding of AMR and AMS; and the (2) current and (3) future state of community pharmacy's AMS involvement. Interviews were audio-recorded, transcribed verbatim and analyzed using a combined method of inductive (informed by the Theoretical Domains Framework) and deductive thematic analysis.

Results

Perceptions on promoting community pharmacists' AMS involvement within their existing role in promoting the quality use of medicines were heard. Adopting an antimicrobial guardian or gatekeeper role was perceived as influenced by the timing of their interaction with a patient either prior to, or post-consultation with a general practitioner (GP). Suggestions that the profession's potential and actual role in AMS could be challenged or even delimited due to lack of access to completeness of clinical information, and perceived consequences from a clinical and professional engagement perspective were also heard.

Conclusion

Collaborative partnerships between GPs and community pharmacists, framing stewardship within a quality use of medicines agenda, and highlighting connections between pharmacists' professional services such as minor ailments are key elements enabling community pharmacist's antimicrobial gatekeeper and guardian role.

Improving diagnostic antimicrobial stewardship in respiratory tract infections: a protocol for a scoping review investigating point-of-care testing programmes in community pharmacy

INTRODUCTION

Diagnostic uncertainty regarding the cause of respiratory tract infections (RTIs) multiplies the problem of unnecessary use of antibiotics and antimicrobial resistance in primary care. Point-of-care testing (POCT) programmes have been recognised as a potential stewardship strategy to optimise antimicrobial use in primary care. There is a need for greater understanding of community pharmacy-based POCT programmes in reducing the unnecessary use of antimicrobials in patients with RTIs. This review systematically maps out evidence around the effectiveness, feasibility and implementation challenges of POCT programmes in community pharmacy to improve safe antimicrobial use in RTIs.

METHODS AND ANALYSIS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist and the Arksey and O'Malley methodology framework will guide the reporting of this review. We will systematically review studies with either randomised controlled trial, non-randomised controlled trial, before-after study, observational study or pilot feasibility study design. Medline, Emcare, PubMed, Health Technology Assessment, Cochrane Central Register of Controlled Trials and Google Scholar databases will be used to search for articles. Three reviewers will independently screen, review and select studies with POCT programmes involving community pharmacists for antimicrobial stewardship in RTIs. Summary statistics and random effects model, if data permit, will be used to summarise the effectiveness, feasibility and cost-effectiveness of the POCT programme. The Consolidated Framework for Implementation Research will capture POCT implementation drivers.

ETHICS AND DISSEMINATION

This review study does not require research ethics approval. Findings will be disseminated through national and international conferences, seminars and publication in a peer-reviewed journal.

A Novel GPPAS Model: Guiding the Implementation of Antimicrobial Stewardship in Primary Care Utilising Collaboration between General Practitioners and Community Pharmacists

Interprofessional collaboration between general practitioners (GPs) and community pharmacists (CPs) is central to implement antimicrobial stewardship (AMS) programmes in primary care. This study aimed to design a GP/pharmacist antimicrobial stewardship (GPPAS) model for primary care in Australia. An exploratory study design was followed that included seven studies conducted from 2017 to 2021 for the development of the GPPAS model. We generated secondary and primary evidence through a systematic review, a scoping review, a rapid review, nationwide surveys of Australian GPs and CPs including qualitative components, and a pilot study of a GPPAS submodel. All study evidence was synthesised, reviewed, merged, and triangulated to design the prototype GPPAS model using a Systems Engineering Initiative for Patient Safety theoretical framework. The secondary evidence provided effective GPPAS interventions, and the primary evidence identified GP/CP interprofessional issues, challenges, and future needs for implementing GPPAS interventions. The framework of the GPPAS model informed five GPPAS implementation submodels to foster implementation of AMS education program, antimicrobial audits, diagnostic stewardship, delayed prescribing, and routine review of antimicrobial prescriptions, through improved GP-CP collaboration. The GPPAS model could be used globally as a guide for GPs and CPs to collaboratively optimise antimicrobial use in primary care. Implementation studies on the GPPAS model and submodels are required to integrate the GPPAS model into GP/pharmacist interprofessional care models in Australia for improving AMS in routine primary care.

A systems thinking approach for antimicrobial stewardship in primary care

INTRODUCTION

The establishment of antimicrobial stewardship (AMS) in primary care is central to substantially reduce the antimicrobial use and the associated risk of resistance. This perspective piece highlights the importance of systems thinking to set up and facilitate AMS programs in primary care.

AREAS COVERED

The challenges that primary care faces to incorporate AMS programmes is multifactorial: an implementation framework, relevant resources, team composition, and system structures remain under-researched, and these issues are often overlooked and/or neglected in most parts of the world. Progress in the field remains slow in developed countries but potentially limited in low- and middle-income countries.

EXPERT OPINION

The key AMS strategies to optimize antimicrobial use in primary care are increasingly known; however, health system components that impact effective implementation of AMS programs remain unclear. We highlight the importance of systems thinking to identify and understand the resource arrangements, system structures, dynamic system behaviors, and intra- and interprofessional connections to optimally design and implement AMS programs in primary care. An AMS systems thinking systemigram (i.e. a visual representation of overall architecture of a system) could be a useful tool to foster AMS implementation in primary care.

Human factors and ergonomics methods for pharmacy research and clinical practice

BACKGROUND

Human factors and ergonomics (HFE) is a scientific and practical human-centered discipline that studies and improves human performance in sociotechnical systems. HFE in pharmacy promotes the human-centered design of systems to support individuals and teams performing medication-related work.

OBJECTIVE

To review select HFE methods well suited to address pharmacy challenges, with examples of their application in pharmacy.

METHODS

We define the scope of HFE methods in pharmacy as applications to pharmacy settings, such as inpatient or community pharmacies, as well as medication-related phenomena such as medication safety, adherence, or deprescribing. We identify and present seven categories of HFE methods suited to widespread use for pharmacy research and clinical practice.

RESULTS

Categories of HFE methods applicable to pharmacy include work system analysis; task analysis; workload assessment; medication safety and error analysis; user-centered and participatory design; usability evaluation; and physical ergonomics. HFE methods are used in three broad phases of human-centered design and evaluation: study; design; and evaluation. The most robust applications of HFE methods involve the combination of HFE methods across all three phases. Two cases illustrate such a comprehensive application of HFE: one case of medication package, label, and information design and a second case of human-centered design of a digital decision aid for medication safety.

CONCLUSIONS

Pharmacy, including the places where pharmacy professionals work and the multistep process of medication use across people and settings, can benefit from HFE. This is because pharmacy is a human-centered sociotechnical system with an existing tradition of studying and analyzing the present state, designing solutions to problems, and evaluating those solutions in laboratory or practice settings. We conclude by addressing common concerns about the implementation of HFE methods and urge the adoption of HFE methods in pharmacy.

Antimicrobial stewardship in Australia: the role of qualitative research in programme development

Antimicrobial stewardship (AMS) in Australia is supported by a number of factors, including enabling national policies, sectoral clinical governance frameworks and surveillance programmes, clinician-led educational initiatives and health services research. A One Health research programme undertaken by the National Centre for Antimicrobial Stewardship (NCAS) in Australia has combined antimicrobial prescribing surveillance with qualitative research focused on developing antimicrobial use-related situational analyses and scoping AMS implementation options across healthcare settings, including metropolitan hospitals, regional and rural hospitals, aged care homes, general practice clinics and companion animal and agricultural veterinary practices. Qualitative research involving clinicians across these diverse settings in Australia has contributed to improved understanding of contextual factors that influence antimicrobial prescribing, and barriers and facilitators of AMS implementation. This body of research has been underpinned by a commitment to supplementing 'big data' on antimicrobial prescribing practices, where available, with knowledge of the sociocultural, technical, environmental and other factors that shape prescribing behaviours. NCAS provided a unique opportunity for exchange and cross-pollination across the human and animal health programme domains. It has facilitated synergistic approaches to AMS research and education, and implementation of resources and stewardship activities. The NCAS programme aimed to synergistically combine quantitative and qualitative approaches to AMS research. In this article, we describe the qualitative findings of the first 5 years.

Dispensing of Non-Prescribed Antibiotics from Community Pharmacies of Pakistan: A Cross-Sectional Survey of Pharmacy Staff's Opinion

Community pharmacies are the main channel of antibiotics distribution. We aimed to analyze the dispensing of non-prescribed antibiotics and knowledge of pharmacy staff. We conducted a cross-sectional study in Punjab, Pakistan between December 2017 and March 2018. A self-administered, structured, pretested, and validated bilingual questionnaire was used, and we used chi-square tests in the statistical analysis. A total of 573 (91.7%) pharmacy retailers responded to the survey; 44.0% were aged 31-40 years and all were men. Approximately 81.5% of participants declared that dispensing non-prescribed antibiotics is a common practice in community pharmacies, and 51.1% considered themselves to be authorized to dispense these drugs; 69.3% believed this a contributing factor to antimicrobial resistance. Most (79.1%) respondents believed that this practice promotes irrational antibiotics use, and half (52.2%) considered antimicrobial resistance to be a public health issue. Only 34.5% of respondents reported recommending that patients consult with a doctor prior to using antibiotics, and 61.8% perceived that their dispensing practices reduce patients' economic burden. Approximately 44.9% of pharmacy retailers stated that they have proper knowledge about antibiotics use. Nitroimidazole was the main class of antibiotic dispensed without a prescription. Dispensing of injectable and broad-spectrum antibiotics can be potential threat for infection cure. Poor knowledge of staff is associated with dispensing of non-prescribed antibiotics. This inappropriate practice must be addressed immediately.

Divergent and Convergent Attitudes and Views of General Practitioners and Community Pharmacists to Collaboratively Implement Antimicrobial Stewardship Programs in Australia: A Nationwide Study

Setting up an interprofessional team for antimicrobial stewardship (AMS) to improve the quality and safety of antimicrobial use in primary care is essential but challenging. This study aimed to investigate the convergent and divergent attitudes and views of general practitioners (GPs) and community pharmacists (CPs) about AMS implementation and their perceived challenges of collaboration to design a GP–pharmacist collaborative AMS (GPPAS) model. Nationwide surveys of GPs and CPs across Australia were conducted January-October 2019. Chi square statistics and a theoretical framework were used for comparative analyses of quantitative and qualitative data, respectively. In total, 999 participants responded to the surveys with 15.4% (n = 386) response rates for GPs and 30.7% (n = 613) for CPs. GPs and CPs were aware about AMS however their interprofessional perceptions varied to the benefits of AMS programs. CPs indicated that they would need AMS training; significantly higher than GPs (GP vs. CP; 46.4% vs. 76.5%; p < 0.0001). GPs’ use of the Therapeutic Guideline Antibiotic was much higher than CPs (83.2% vs. 45.5%; p < 0.0001). No interprofessional difference was found in the very-limited use of patient information leaflets (p < 0.1162) and point-of-care tests (p < 0.7848). While CPs were more willing (p < 0.0001) to collaborate with GPs, both groups were convergent in views that policies that support GP–CP collaboration are needed to implement GPPAS strategies. GP–pharmacist collaborative group meetings (54.9% vs. 82.5%) and antimicrobial audit (46.1% vs. 86.5%) models were inter-professionally supported to optimise antimicrobial therapy, but an attitudinal divergence was significant (p < 0.001). The challenges towards GP–CP collaboration in AMS were identified by both at personal, logistical and organisational environment level. There are opportunities for GP–CP collaboration to improve AMS in Australian primary care. However, strengthening GP–pharmacy collaborative system structure and practice agreements is a priority to improve interprofessional trust, competencies, and communications for AMS and to establish a GPPAS model in future.