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A recent report by NHS England highlights “the essential clinical role that community pharmacy staff have in AMS activities and collaborative working with other primary care colleagues as well as ongoing and continued public education to ensure the safe and appropriate use of antibiotics”.1
These AMS findings form a solid foundation of knowledge and experience for community pharmacy to build on as the Pharmacy First service in England is introduced, the report says.
Community Pharmacy Quality Scheme 2020-22: Findings and Recommendations from the Antimicrobial Stewardship Initiatives1 summarises the results from the Pharmacy Quality Scheme (PQS) AMS initiatives in England up until and including 2021/22.
Key findings
- In 2020/2021, 10,488 (>90 per cent) of community pharmacies declared that 54,399 registered pharmacy professionals had completed the AMS and infection management e-learning
- The introduction of the Antibiotic Guardian pledge as part of the PQS in 2020/21 led to a vast increase in pledges from community pharmacy teams in 2020 (28,369), which was sustained in 2021 (27,334)
- In 2021/22, 9,950 (89 per cent) of community pharmacy teams throughout England engaged in AMS activity using the TARGET Antibiotic Checklist. They provided indication-specific education to patients and positively impacted flu vaccine uptake. During the four-week data collection period, 8,374 pharmacies submitted information from 213,105 checklists
- In total, 69,861 patient information leaflets were provided to patients to support knowledge about their condition and treatment. Some 62,544 (30 per cent) checklists were completed for patients with a respiratory tract infection; 43,093 (21 per cent) for a urinary tract infection; and 30,764 (15 per cent) for tooth/dental infections
- Prompted by discussions while using the antibiotic checklist, an additional 16,625 (8 per cent of all checklists) influenza vaccinations were delivered by community pharmacies
- Forty-four per cent of pharmacies submitting data surpassed the required number (25 checklists) to qualify for the PQS incentive
- Community pharmacy teams reported checking duration, dose, appropriateness of antibiotic and patient allergies and medicine interactions (94-95 per cent); antibiotic prescribing guideline adherence (89 per cent); and checking the patient’s previous use of antibiotics (81 per cent)
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The prescriber was contacted for 2,741 (1.3 per cent) of the antibiotic checklists; the most common reasons were around dose, duration and possible patient allergy.
The story so far...
The UK’s 2019-2024 national action plan for tackling antimicrobial resistance (AMR) has three overarching aims2:
- To reduce the need for, and the unintentional exposure to, antimicrobials
- To optimise the use of antimicrobials
- To invest in innovation, supply and access.
According to the UK Health Security Agency (UKHSA), in 2020 around 80 per cent of antibiotic prescribing happened in primary care in England, making it a key setting for antimicrobial stewardship (AMS).3
Since 2020, the Pharmacy Quality Scheme (PQS)4 has incentivised activity related to AMS in community pharmacy, including the use of the TARGET Antibiotic Checklist.5 The checklist is designed for patients to complete while waiting for their prescription to be dispensed, enabling the pharmacy team to initiate AMS conversations and actions.
Recommendations
The report makes several recommendations for community pharmacy. These include ensuring that community pharmacy teams act as antimicrobial stewards and promote antimicrobial stewardship, and infection prevention and control.
Community pharmacists are advised to encourage patients to complete the TARGET antibiotic checklist and to use TARGET toolkit resources to support awareness and education. Pharmacy teams should also continue to promote vaccinations to protect patients, while simultaneously contributing to reducing the prevalence of antimicrobial resistance (AMR).
The report also recommends that integrated care boards (ICBs) should ensure community pharmacy is “effectively integrated with multi-disciplinary teams to promote optimum care and antimicrobial stewardship”.
The report concludes that the PQS has “effectively promoted AMS activities in community pharmacy”. There was high engagement with the AMS criteria first introduced in 2020/21 and built upon in 2021/22. “These findings have demonstrated that the TARGET Antibiotic Checklist can support community pharmacy teams to play a crucial role in AMS, by tailoring patient education and addressing patients’ concerns about antibiotic use,” the report says.
The data show how the use of the antibiotic checklist has “allowed patients and pharmacists to discuss antibiotic-specific queries such as side-effects, how to take their antibiotics and how long their symptoms would last”.
Community pharmacy teams have also shown “collaboration with their general practice colleagues and should continue to do this to optimise patient care”. This may further reduce patient expectation to receive antibiotics for self-limiting infections and reduce pressure on prescribers to prescribe antibiotics, the report says.
While engaging with patients in conversations about their antibiotic prescriptions, “community pharmacy teams have provided additional indication-specific education materials to reinforce their counselling and increased influenza vaccinations uptake”, the report says.
These findings “add to the evidence that community pharmacy can play a vital role in AMS and support the NHS in England to tackle the significant threat of AMR to public health”.
Effective
Commenting on the report and its findings, Professor Diane Ashiru-Oredope, lead pharmacist for antimicrobial resistance at UKHSA, says: “The work from the PQS demonstrates how effective community pharmacy has been in promoting AMS, and the importance of ongoing training and education. The impact
that these activities have had also included promoting the uptake of flu vaccinations, which prevents infections and contributes to tackling antimicrobial resistance.”
Sejal Parekh is senior policy manager, Primary Care Strategy and NHS Contracts Group, Primary, Community and Personalised Care Directorate, NHS England. The work from the PQS “supports the development of a critical foundation for community pharmacy on which to build the sector’s future role described in our delivery plan for improving access to primary care”, she says.
This includes the launch of the Pharmacy First service, which is an extra £645m investment in the sector over the next two years.6 The service covers seven conditions: uncomplicated UTIs in women, shingles, impetigo, infected insect bites, sinusitis, sore throat and acute otitis media in under-18s.
Parekh says pharmacists will be expected to use a clinical pathway to assess patients who are suspected to have any of the seven conditions, and offer appropriate management of each of these conditions comprising self-care and supply of certain OTC medicines via protocol or POMs, such as antibiotics via patient group directions, where clinically appropriate.
“The PQS initiatives have demonstrated that community pharmacy has a sound foundation in antimicrobial stewardship. It is important that community pharmacy utilises this opportunity effectively,” says Professor Ashiru-Oredope.
- All AMS initiatives have been renewed for the 2023/24 PQS with the addition of advice on the safe disposal of unused or expired antibiotics. Full details are also provided in Part VIIA of the Drug Tariff. Contractors are advised to follow the details listed in the Drug Tariff and use the guidance to complete this year’s PQS.
Community pharmacists and AMS
The NHS England report highlights “the importance of pharmacists in promoting antimicrobial stewardship initiatives”, says Lila Thakerar, superintendent pharmacist at Shaftesbury Pharmacy in Harrow. “Pharmacy teams can practise very effective antimicrobial stewardship and can promote it when talking to patients,” she adds.
Thakerar says the report highlights “what pharmacy teams have known all along – the seriousness of antibiotic resistance; that antibiotics are abused, may not be correctly used, not prescribed for the correct reasons and over prescribed; and are requested when not required”.
Ade Williams, lead pharmacist at Bedminster Pharmacy in Bristol, says the report “really shows the commitment of pharmacy teams to helping address the global trend of AMR. The report demonstrates that across our teams we are able to embed the evidence-based use of antibiotics. This bodes well for the more clinical future of community pharmacy.”
He says the report also “acknowledges the work community pharmacy does in supporting the uptake
of vaccinations, which sits comfortably alongside AMS. And it recognises that we need to proactively take action to keep people healthy.”
However, some key questions remain, he says. Will current measures to tackle AMR be enough to address what is a global trend? What more needs doing? What is the role of community pharmacists in all of this and what more support can be given to pharmacy to tackle the issue?
Lila Thakerar says the sector has “always played a very important role in preventing resistance to antibiotics, and needs to continue with self-education and updating its knowledge in this area”.
"Pharmacy is in the front line of face-to-face contact with patients, so it is important that teams are trained in AMS and aware of any AMR initiatives,” she says. “This training isn’t something we should do once in a lifetime and then forget about it. It has to be updated on a regular basis.”
Thakerar ensures her team is up to date with AMR knowledge and guidance, and is given regular training. Her team also gives advice to patients about antibiotics, including the importance of completing a course rather than splitting it and of not sharing antibiotics. “Giving [consistent]advice to patients with antibiotic prescriptions is very important,” she says.
Pharmacists need to pick up on any issues with an antibiotic prescription – checking if the patient is allergic to penicillin, say, or if they have been given the correct dose and the correct treatment period.
Ade Williams says practising effective AMS is also about building “active partnerships that involve community pharmacists, prescribing clinicians and their local community”. Pharmacy needs to be “part of a collective effort, delivering the right treatments and consistent messages, and being proactive”, he says.
Practising effective AMS is also about managing patients’ expectations. “There is a public expectation about being given antibiotics,” says Williams, but patients need to understand why antibiotics may not be suitable to treat their condition. “We want them not to feel that they’ve been refused a course of antibiotics, but that they don’t need a course of antibiotics,” he says.
The trend for AMR “cannot be underestimated and is one we as pharmacy professionals should be acutely aware of”, he says. “We have an opportunity to mitigate that trend and must see this as part of our role.”
“We want patients not to feel that they've been refused a course of antibiotics - but that they don't need a course of antibiotics”
Useful resources
How to use pharmacy resources (containing a community pharmacy flowchart).
Community pharmacy counselling checklist.
UTI Women Under 65 leaflet for community pharmacies.
RTI leaflet for community pharmacies.
Other TARGET leaflets that can be used in community pharmacy.
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