Clinical Pharmacist led antimicrobial stewardship

Clinical pharmacists in all settings play important roles in antimicrobial stewardship. They are uniquely placed to provide medicines advice to both prescribers and patients, spreading the message of appropriate and safe antimicrobial use.

While pharmacists in hospital may have access to local antimicrobial guidelines, Australian community pharmacists all have access to the national Therapeutic Guidelines: Antibiotic. Pharmacists who pack dose administration aids for nursing homes are well placed to identify inappropriate antimicrobials that may have been continued long term by mistake along with inappropriately prescribed antimicrobials, particularly for asymptomatic bacteriuria.

Pharmacists in the community can identify patients who have found an old script or repeat in the cupboard and are planning to use the medication for the wrong indication or at the wrong dose. By discussing the prescription with the patients the pharmacist may be able to provide a more appropriate therapy or refer the patient to their GP for appropriate antibiotics.

Hospital pharmacists can put systems in place to alert them to review patients when certain antibiotics are prescribed. Timely post-prescription review can determine whether the antibiotics are prescribed according to best practice guidelines and if necessary prompt a discussion with the clinician.

If you work in a setting without on-site microbiology or infectious diseases specialists there are still ways to ensure antimicrobial stewardship occurs:

  • Establish which guidelines and policies to follow. In community practice this will be the Therapeutic Guideline: Antibiotic while in hospitals there may be area or state guidelines. Where no local guideline is available the Therapeutic Guideline: Antibiotic is always available. Ensuring antibiotics are prescribed according to appropriate guidelines will reduce the risk of antibiotic resistance.
  • Identify which antibiotics/ conditions require the most attention. Some antibiotics, such as fluoroquinolones, carry a higher risk of causing resistance than others and should be restricted to conditions where they are the only option. Broad spectrum agents, such as third generation cephalosporins (ceftriaxone), carry similar risks. Identifying inappropriate antibiotic prescribing in nursing home patients is particularly important. Nursing home patients are often unnecessarily treated for asymptomatic bacteriuria and antibiotics packed into dose administration aids need to have a cease date included to ensure they are not packed indefinitely.
  • The pharmacist can intervene before the drug is supplied. In community practice this can involve discussing the prescription with the patient and/or prescriber before dispensing. In hospital this can involve removing the drugs from general ward stock and requiring a pharmacist or other clinician to be involved in the supply process.
  • If an antibiotic prescription is identified as inappropriate it is important to address the situation. If an old prescription or repeat has been presented by a patient this is a great time provide education on the appropriate use of antibiotics and why antibiotics are not always appropriate. There are many patient resources available. If a prescriber has prescribed an antibiotic which not does not match best practice guidelines this should be discussed to determine their therapeutic intent.

See also this Approach to restricted anti-infective stewardship.

Ongoing Education

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