Pharmacy and Antimicrobial Stewardship: Addressing the Global Challenge of Resistance

Clinical pharmacy has always been committed to managing and enhancing patients' health in all aspects of medication management. From controlling adverse drug reactions (ADRs), drug–drug interactions, pharmacovigilance, therapeutic drug monitoring (TDM), medication therapy management (MTM), and drug use evaluations to antimicrobial stewardship, it plays a crucial role in direct patient care involving total health care team. In infectious disease prevalence, clinical pharmacy joins a multidisciplinary approach with microbiology and public health to combat antibiotic misuse.

Clinical pharmacists are establishing activities which are continuously improving patient care. These involve the implementation of Antimicrobial stewardship programs in hospital settings, conducting surveys on antibiotic prescribing patterns, addressing physicians and nursing staff on the effective use of antibiotics, approaching the community for public awareness of antibiotic adverse effects and organizing seminars and conferences on infectious diseases-antimicrobial stewardship to communicate and share recent research updates on resistance patterns and novel drugs. These activities have produced exceptional results in terms of patient health.

Antimicrobial stewardship programs are specialized clinical initiatives that evaluate and improve antibiotic prescribing, dosing, administration, and patterns of use. It uses the before-after study for data collection, assessment is done in two to three different phases which finally executes in the interventions to a therapy. Interventions are changes in drug regimen on behalf of dose, dosage form, frequency, route of administration, spectrum of microbial and contraindications to the subject. The more interventions are made, the more benefit to the patient in terms of therapeutic decision making.

Clinical pharmacists play a pivotal role in medication management and drug use evaluation of antimicrobial stewardship programs. A clinical pharmacist establishes a performance according to WHO guidelines to review the antimicrobial therapy of patients. They assess dosing, prescribing, selection and microbiology patterns by applying the 5D’s Formula; right drug, correct dose, right drug route, suitable duration and timely de-escalation to pathogen-directed therapy.

Rigorous reviewing is done in the first 24 to 48 hours respectively, and results and interventions are further discussed with other professionals e.g. infectious diseases physicians, nurses, clinical microbiologists and clinical pathologists to go for therapeutic decision-making.

According to a Report of the Global Research on Antimicrobial Resistance (GRAM) Project, covering 204 countries from 2000 to 2018, the consumption of antibiotics has increased by 46 percent.¹ Statistics show that these rates are still increasing significantly worldwide. Asian countries especially Indo-Pak regions have always been in a pandemic crisis eg miss use and common use of antibiotics. Although technological advances are promoting patient health such statistics are making patient care vulnerable.

In a case study, a microbiology report of a boy observed multidrug resistance to ceftriaxone, tazobactum-piperacillin, colistin, vancomycin, meropenem and several others which clearly explains possible threats of Resistant patterns. It can be justified by using optimal therapy like the aid of culture sensitivity tests, choosing the least resistant drugs and optimizing doses. Microbial infections are becoming multidrug resistant due to drug and food patterns, environmental influences, lifestyle adaptations, and trending opportunities.

Multidrug-Resistant Organisms (MDRO) like MRSA (methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Staphylococcus aureus (VRSA), Clostridium spp., Neisseria spp., Pseudomonas aeruginosa, skin and soft tissue infections (SSTIs), and others are increasing regularly and are difficult to treat. Hence, it contributes to a worldwide resistant environment, which is devastating. Currently, antimicrobial resistance is the greatest issue to address, irrespective of warfare.

Fishman demonstrated that infections subject to the guidance of an antimicrobial stewardship program exhibited a remarkable 70% improvement in successful treatment outcomes and an impressive 80% reduction in instances of treatment failure.²

"It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them…there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant," said Alexander Fleming on receiving the Nobel Prize in 1945.

Regrettably, the issue of antimicrobial resistance persists, and it will be devastatingly increased in the upcoming decades. The most viable option may be to learn to live with MDROs, not to fight, but this approach could potentially jeopardize herbal and traditional medicine.

One Country's Emerging Stewardship Programs

In Pakistan, the situation regarding the management of multifaceted infections is concerning. According to a study published in BMC Infectious Diseases, the most reported clinical diagnosis is urinary tract infections (UTIs) at 16%, with E coli displaying 30% resistance to first-line antibiotics and 49 per cent resistance to MRSA.³

The state of the artwork of clinical pharmacists is exceptional in Pakistan but no doubt, the changing pharmaceutical landscape presents enormous opportunities for clinical pharmacists to direct patient health. Institutions like Agha Khan Hospital, Shaukat Khanum Cancer Hospital, Shifa International, Indus Hospital, Pakistan Kidney and Liver Institute, Ghurki Trust Hospital, and Rehman Medical Institute, are a few among many which are conducting rigorous antimicrobial stewardship programs. It is a highly encouraging move towards a well-constructed and managed healthcare system.

In this realm, MDRO has become a global pandemic, it is hard to minimize this tragedy but it can be controlled or frozen in order to reduce the resistant statistics that are predicted for 2050. However, the execution of such programs can be an effective step toward a healthier world.

References

1. Global antibiotic consumption. Oxford News. University of Oxford. Accessed September 29, 2023, https://www.ox.ac.uk/news/2021-11-16-global-antibiotic-consumption-rates-increased-46-percent-2000

2. Fishman N. Antimicrobial stewardship. Am J Med. 2006;119(6 Suppl 1):S53-S70. doi:10.1016/j.amjmed.2006.04.003 https://pubmed.ncbi.nlm.nih.gov/16735152/

3.Bilal, H. Antibiotic resistance in Pakistan: a systematic review of the past decade. BMC Infectious Diseases. Accessed September 29, 2023. https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-05906-1#auth-Hazrat-Bilal-Aff1