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Antimicrobial Stewardship Initiatives Need to Focus on More Than Reducing Resistance Rates

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Contagion, October 2016, Volume 1, Issue 1

Strategic Alliance Partners | <b>Society of Infectious Diseases Pharmacists</b>

Antimicrobial use without a pre&shy;scription is a global issue that is not limited to developing countries. Taking antibiotics without a pre&shy;scription, or as not originally in&shy;tended, has been associated with shorter treatment durations than prescribed, inappropriate dosing, and the use of expired medications that may have decreased in potency.

1

Any use of antimicrobials selects for bacterial resis&shy;tance, and so controlling overuse and misuse of these drugs is paramount.

2

National and global efforts have targeted the medical community and the general public in an attempt to reduce inappropriate antimicrobial pre&shy;scribing and provide education. However, these efforts are most immature in the area of greatest antimicrobial use in humans—the outpatient setting.

2,3

Zoorob and colleagues conducted a survey study to estimate the prevalence of nonprescription antibiotic use, with a focus on the sources of nonprescription an&shy;timicrobials and the willingness of respondents to take antibiotics without a prescription. In their study, “non&shy;prescription use” referred to use of an antibiotic without the guidance of a medical professional. This included the use of antibiotics prescribed previously that had been stored by patients for future use. Patients were recruit&shy;ed from both public- and private-sector health clinics to ensure both economic and ethnic diversity, which was successful.

Over half of the respondents reported having some college education or greater. Thirty-eight percent report&shy;ed an annual income <$20,000 and 23% were uninsured. Nonprescription antibiotic use in the prior 12 months was reported in 5% of respondents.

A pharmacy or store in the United States was the most common source of these antimicrobials, followed by ac&shy;quisition from another country, a friend or relative, and using a remaining supply from a past prescription. Al&shy;though only 5% of respondents reported taking a non&shy;prescription antibiotic within the past 12 months, 25.4% reported they were willing to use antibiotics without a prescription and 74% reported having antibiotics stored at home.

4

Therefore, the population “at risk” of self-guid&shy;ed, nonprescription antimicrobials is significantly high&shy;er than that which actually reported using them.

Perhaps the most concerning finding from this study is that the majority of respondents were willing to use antimicrobials without guidance from a medical pro&shy;fessional. In a study of the Latino immigrant population in and outside the United States, it was discovered that antimicrobials were commonly acquired without a pre&shy;scription, presumably to be used for self-treatment.

5

Pre&shy;viously, it was thought this practice may be most com&shy;mon in Latino communities, a finding suggested by the dispensing practices of pharmacies and stores in New York City, which found that stores in Hispanic commu&shy;nities were more likely to sell antibiotics without a pre&shy;scription.6 The study by Zoorob and colleagues helps to establish the framework that inappropriate antimicro&shy;bial use may extend to all communities and, aside from where they were acquired, the greater impact may be that many people do not think they need medical guid&shy;ance to take antibiotics.

4

The results of this study are supported by studies con&shy;ducted in Spain, which found an increase in pharmacist dispensing of antimicrobials without a prescription from 2008 to 2014, a practice that is also considered illegal in Spain.

7,8

This finding may be indicative from increased patient requests to self-medicate rather than seek medi&shy;cal guidance. Having a greater understanding of the rea&shy;soning for using antimicrobials without a prescription may be helpful in developing ways to educate the public and change common attitudes and beliefs.

In countries with high rates of resistance and nonpre&shy;scription antibiotic use, a correlation between antimi&shy;crobial use and multidrug-resistant organisms has been shown. In those countries that developed initiatives to curb antimicrobial misuse, the result was a decrease in rates of resistance.

1

Zapata-Cahafiero and colleagues found that even when pharmacists identified antimi&shy;crobial resistance as a problem, they were still likely to dispense antimicrobials without a prescription.

7

This may suggest that community antimicrobial stewardship initiatives directed toward pharmacists should not focus solely on reducing resistance rates.

Nonprescription antimicrobial use in the United States is not limited to a certain race or ethnicity, and many pa&shy;tients may still be willing to use antimicrobials without medical guidance. The study by Zoorob and colleagues differs from past studies conducted in the United States, as it is more applicable to the general population.

1,5

The actual number of patients who used, were willing to use, or who have antibiotics stored at home may actually be higher than reported in this study, as surveys may un&shy;derestimate the problem. Patients may want to answer what they believe is correct when they are in the pres&shy;ence of medical professionals, and respondents may be subject to recall bias.

It is evident that there is a need for greater commu&shy;nity antimicrobial stewardship. Typically, these move&shy;ments have targeted changing prescribing practices of the medical community and educating the public.

2,3

The findings from Zoorob and colleagues indicate that community stewardship initiatives should include em&shy;phasis on preventing self-medication with antimicro&shy;bials and reducing dispensing without a prescription. Community antimicrobial stewardship initiatives for pharmacists should not just focus on the importance of reducing resistance rates, given that some pharmacists may be aware of this and do not see it is a discouraging factor.

7

Important educational points for pharmacists should focus on patient safety and the legal aspects of dispensing without prescriptions. Education for the public should emphasize safe antimicrobial practices and focus on changing current attitudes and beliefs re&shy;garding the use of nonprescription antimicrobials.

Alexandra Hanretty, PharmD, is a PGY2 resident in infectious diseases pharmacy at Temple University. She completed a pharmacy practice residency at the University of San Francisco Medical Center. She received her PharmD from Temple University School of Pharmacy and bachelor of science degree from Syracuse University.

Jason C. Gallagher, PharmD, FCCP, FIDSA, BCPS, is clinical professor at Temple University School of Pharmacy and clinical pharmacy specialist in infectious diseases at Temple University Hospital, both in Philadelphia. He also is the director of the PGY2 Residency in Infectious Diseases Pharmacy at Temple.

REFERENCES

1. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisen&shy;berg S. Non-prescription antimicrobial use worldwide: A systematic review. Lancet Infect Dis. 2011;11(9):692-701. doi: 10.1016/S1473- 3099(11)70054-8.

2. Harbarth S, Samore MH. Antimicrobial resistance determinants and future control. Emerg Infect Dis. 2005;11(6):794-801.

3. Spellberg B, Guidos R, Gilbert D, et al. The epidemic of antibiot&shy;ic-resistant infections: a call to action for the medical communi&shy;ty from the Infectious Diseases Society of America. Clin Infect Dis. 2008;46(2):155-164. doi: 10.1086/524891.

4. Zoorob R, Grigoryan L, Nash S, Trautner BW. Non-prescription an&shy;timicrobial use in a primary care population in the united states: Evi&shy;dence for action. Antimicrob Agents Chemother. 2016.

5. Mainous AG, Cheng AY, Garr RC, Tilley BC, Everett CJ, McKee MD. Nonprescribed antimicrobial drugs in Latino community, South Caro&shy;lina. Emerg Infect Dis. 2005;11(6):883-888. doi:10.3201/eid1106.040960.

6. Larson E, Grullon-Figueroa L. Availability of antibiotics without prescription in New York City. J Urban Health. 2004;81(3):498-504.

7. Zapata-Cachafeiro M, González-González C, Váquez-Lago JM, et al. Determinants of antibiotic dispensing without a medical pre&shy;scription: A cross-sectional study in the north of Spain. J Antimicrob Chemother. 2014;69(11):3156-3160. doi: 10.1093/jac/dku229.

8. Guinovart MC, Figueras A, Llop JC, Llor C. Obtaining antibiotics without prescription in Spain in 2014: even easier now than 6 years ago. J Antimicrob Chemother. 2015;70(4):1270-1271. doi: 10.1093/jac/ dku526.