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Elementor #40089

In course 2, we introduced the role and importance of pharmacists in promoting AMS. We also highlighted why good stewardship is essential to keep antimicrobials working for the future. Inappropriate prescribing of antimicrobials contributes to AMR and poorer patient outcomes; pharmacists are key players in reducing this.

Did you know? According to the ESPAUR report, in the UK over 80% of antimicrobial prescribing happens in the community setting. Therefore, community teams are especially well-placed to help promote and support AMS. Furthermore, there are a number of hospital and clinic-based interventions that pharmacists are involved in that can improve stewardship as part of the multi-disciplinary team (MDT).

This module aims to build upon concepts that were introduced in previous courses. We will explain the importance of reviewing the appropriateness of antimicrobial prescriptions, explore strategies for this, and explain how you can challenge inappropriate prescriptions. By the end of this module, you should be able to:

This module aims to build upon concepts that were introduced in previous courses. We will explain the importance of reviewing the appropriateness of antimicrobial prescriptions, explore strategies for this, and explain how you can challenge inappropriate prescriptions. By the end of this module, you should be able to:

    • Review antibiotic prescriptions for safety and appropriateness

    • Describe some strategies to reduce the inappropriate prescription of antimicrobials

    • Communicate effectively when challenging inappropriate prescribing and use the opportunity to educate prescribers

Reviewing the Appropriateness of Antimicrobial prescriptions

What is an appropriate prescription?

First, we must consider what is meant by an appropriate antimicrobial prescription.

An appropriate prescription is one that adheres to the relevant antimicrobial prescribing guidelines and is the right choice of agent, right dose, right frequency, right duration and right route. Below, we explain the specific criteria you should check.

When an antimicrobial prescription is received, regardless of the clinical setting (community or hospital), pharmacists should check:

A helpful antibiotic checklist tool designed for use by community pharmacists can be downloaded from the TARGET website in a number of different languages here.

Case Study

Below is an example of a situation in which a pharmacist would have to review a prescription. Using the TARGET checklist, select the appropriate course of action.

A 30-year-old female patient brings her prescription into the pharmacy. It is for doxycycline 100mg daily for 7 days.

You ask her about the condition for which this is to treat, and she tells you it is for a chest infection. Local guidelines state that amoxicillin is the first line treatment for respiratory tract infection.

In addition, when you check the patient’s allergies, interactions, and other relevant medical conditions, you find that she has no allergies, takes no other medicines and has no history of kidney or liver problems but is approximately 10 weeks pregnant.

Which of the following are the appropriate courses of action? Click or tap the correct answer. Green means you were correct, red means you need to try again!

Dispense the prescription for doxycycline.

Contact the prescriber to explain that doxycycline is not safe for the patient as they are pregnant, however, the antibiotic recommended in the local guidance, amoxicillin, is safe, and ask if they would be happy to supply a new prescription for this instead.

Discuss flu vaccination with the patient (if applicable in your country).  

Provide information to the patient including how to take her prescription, any side effects, when to seek further help if symptoms do not improve, and how to dispose of any unused antibiotics. 

Answer explained (click to reveal)

Contact the prescriber to explain that doxycycline is not safe for the patient as they are pregnant, however, the antibiotic recommended in the local guidance, amoxicillin, is safe, and ask if they would be happy to supply a new prescription for this instead.

Once you have reviewed the prescription, contacting the prescriber with a clear problem and suggesting a solution is the best course of action. We will discuss the best approach to take in more detail later in the module.

It is also important to discuss the correct use of antimicrobials with any patient as well as alternatives that would be appropriate depending on any extenuating factors, such as pregnancy.

For more information on the safety of antimicrobials during pregnancy, please use the resources below (guidelines may vary based on location):

You should also take this opportunity to discuss flu vaccination with the patient (if applicable in your country).

Delayed prescribing

In an effort to reduce inappropriate antimicrobial usage, some healthcare systems have introduced back-up or delayed prescribing for antimicrobials where the diagnosis of infection versus self-limiting condition is uncertain.

This initially encourages self-care for these conditions, but still allows the patient access to antimicrobials if their symptoms fail to improve after a defined period. This has been shown to reduce antimicrobial usage whilst not compromising patient safety and satisfaction.

This article has more information on how delayed prescribing is a stewardship strategy.

If delayed prescribing is something that your local prescribers do, you can provide further self-care advice and ensure the patient knows when to start taking the antimicrobial prescription should they need it. Some key points to communicate to your patients if delayed prescribing is in use include the following:

Below is an example script to use to communicate delayed prescriptions to a patient with a viral cough.

“Your cough is most likely caused by a viral infection. Viral infections don’t respond to antibiotics, and whilst unpleasant, your body’s immune system will be able to clear the infection in a few days. You can help by resting, drinking plenty of fluids, and you can take paracetamol for fevers or sore throat. Antibiotics are unlikely to help and will expose you to potential side effects that you could avoid. Antibiotics should be used carefully to make sure they still work when you need them as we know that overuse of antibiotics can make them ineffective in fighting bacteria in the future.”

“Whilst I’m sure your symptoms will clear up shortly, sometimes bacterial infections can have similar symptoms or may even present as a secondary infection to the viral infection. In this case, your symptoms won’t improve by themselves. Since we cannot be certain, you have been given a prescription for antibiotics to take after 2 days if your symptoms get worse, or if they don’t improve within the 48 hours. If you feel you are starting to get better within the 48 hour period please do not take the antibiotics and return them to us for safe disposal”.

See the TARGET toolkit hub for more information on discussing back up or delayed prescriptions with a patient.

Note
Some caution needs to be exercised with this strategy for very vulnerable groups, especially young babies who may not have completed their scheduled vaccinations yet.

Strategies to reduce inappropriate Prescriptions for antimicrobials

As well as the use of delayed prescriptions, as described previously, there are several strategies that can be implemented to reduce inappropriate prescriptions for antimicrobials and improve AMS practices.

These include:

  • IV to Oral Switch (IVOS)
  • Changing prescriptions based on microbiology results
  • Appropriate source control

Click through the drop down sections below to learn more about them.

Note
The following strategies mainly take place in a hospital or clinic setting where pharmacists can access clinical notes, laboratory data, clinical observations, and assess the patient themselves where possible.

IV to Oral Switch

The majority of patients presenting with a severe infection who require IV therapy initially can be switched to oral therapy provided that they are improving clinically and are able to tolerate an oral formulation.

IVOS has major advantages for the patient and the hospital and moreover has been recognised as an easy-to-accomplish antibiotic stewardship intervention, resulting in a more efficient antimicrobial use.

The infographic below summarises the potential advantages to IVOS.

IVOS criteria may be covered in local, regional or national guidelines. Where available local guidelines should be followed as they will be most specific to your area and reflect local laboratory testing and the availability of antimicrobials.

Task

We would like you to explore IVOS and find out the following:

 

If IVOS is promoted/included in your local/regional/national antibiotic guidelines?

 

If so, is there a decision-aid tool available with criteria to help guide on the suitability of IVOS?

 

If no tool is available, would you consider developing a local tool, using the examples below, that can be approved via relevant committees and used in practice to promote IVOS?

Decision aid tools

There are a number of decision aid tools available for clinicians to decide on a patient’s suitability for IVOS, for example:

ACED Criteria

The ACED criteria are outlined in the infographic below. There should ideally be a daily review of IV therapy against these criteria until there is a finalised infection management plan. 

Note
On specialist advice, some of the above infections may still be suitable for an IV to oral switch following careful assessment.

For more information and guidance, download the flowchart on IVOS here.

Antibiotic availability

There is a common misconception that IV antimicrobials are “stronger” and so better for serious infections, however this is not necessarily the case. When determining the appropriateness of an IV or an oral agent, you need to consider its bioavailability and how well the drug penetrates the site of infection. Take a look at the image below, which highlights the difference between oral and IV agents.

Oral drugs with high bioavailability have been shown to be just as effective as IV drugs for certain infection types, provided they penetrate the infection site at an adequate concentration. This is a particularly important consideration for bone and joint and nervous system infections. 

Pharmacokinetic information, including bioavailability, is usually available in the manufacturer’s datasheets or Summary of Product Characteristics (SPC) for the individual drug.

The UK database of SPCs can be found here. Datasheets from other countries will usually give similar information.

Use of oral agents for deep-seated infections- Oral Versus Intravenous Antibiotics for Bone and Joint Infection (OVIVA) trial

The IVOS criteria above talks about deep-seated infections and the need to use IV antimicrobials – although on specialist assessment, sometimes an oral stepdown may still be appropriate. As an example, the OVIVA trial published in 2019 demonstrated non-inferiority of oral antimicrobials compared to IV antimicrobials for a range of bone and joint infections, including diabetic foot associated osteomyelitis and prosthetic joint infection.

However, the oral antimicrobial of choice must have excellent bioavailability in addition to good penetration into bone and joint tissues. This limits the oral options, and the available antimicrobials tend to have a higher incidence of side effects or interactions compared with many other agents, hence caution must be exercised and additional monitoring may be required. These agents should be used under infection specialist supervision for longer courses.

Examples of oral agents that may be used for bone and joint infections include linezolid, co-trimoxazole, ciprofloxacin, doxycycline and clindamycin.

The OVIVA trial publication can be found here.

OPAT (Home IV Antimicrobials)

Outpatient Parenteral Antimicrobial Therapy (OPAT) involves the administration of IV antibiotics in patients who need IV therapy and are well enough not to require hospital admission. This may include IV antibiotic administration in outpatient clinics, home-based settings, or community healthcare facilities. Pharmacists play a large role in IVOS and OPAT strategies as they can assist in decisions on whether it is appropriate for the patient to receive IV therapy or proceed to oral therapy.

OPAT is frequently being integrated into AMS programs as it reduces length of stay or even the need for hospital admission, and therefore decreases the risk of healthcare-associated infections (HAIs) and recurring infections.

The infographic below summarises the main advantages and disadvantages of OPAT:

Note
Note: It is much easier logistically to give an antimicrobial once a day in the community setting. However, in principle, the convenience of a once daily antimicrobial should not be prioritised over stewardship. The agents that have standard once daily dosing (for example, ceftriaxone) may be unnecessarily broad spectrum, or may not cover all likely pathogens.

What is the role of the pharmacist?

The pharmacist, working in conjunction with the wider healthcare team, is well placed to offer suggestions for suitable IV or even oral alternatives that are best targeted for the infection.

Pharmacists checking prescriptions for home IV antimicrobials should check:

The majority of antimicrobials are prescribed empirically and will tend to be broad-spectrum to cover the most likely range of organisms. Empirical prescribing makes assumptions about the likely infective pathogen and its susceptibility to antimicrobials. However, it may not always be correct, especially given the increasing rates of AMR. AMR can result in greater rates of empirical treatment failure which is associated with increased morbidity and mortality.

Where microbiology laboratory resources are available, culture and sensitivity testing should be encouraged in line with local policies to allow therapy to be targeted to the infection. In many cases, this will allow a de-escalation to a narrow-spectrum antimicrobial, but may also alert the team to a resistant organism that needs a change in therapy.

Negative culture results do not necessarily mean the absence of infection, especially if the tests were done after the patient started antimicrobials but may contribute to an overall clinical picture of an alternative cause for symptoms – in which case consideration should be given to stopping antimicrobials.

This process is known as diagnostic stewardship.  Not only is it beneficial to AMS, but also to infection prevention & control (IPC) practices and AMR surveillance as it allows teams to identify and control the transmission of pathogens and informs prescribing guidelines based on local data.

Adapted from: WHO Diagnostic stewardship: A guide to implementation in antimicrobial resistance surveillance sites.

The diagnostic pathway covers the events from the patient presenting at the health facility to the clinical re-evaluation of their treatment.

The pathway involves clinical and laboratory teams working in collaboration to ensure that the patient receives the most appropriate targeted agent. Pharmacists have an essential role to play in the MDT, ensuring appropriate and optimised treatment.

What is the role of pharmacists?

Pharmacists will have a role in ensuring that an appropriate targeted agent is selected where a particular pathogen is identified.

With all these factors in mind, the narrowest spectrum antimicrobial that is appropriatefor the individual patient should be selected.

The term “source control” encompasses all possible physical measures used to identify and eliminate the source of infection. It is an important AMS strategy to reduce the need for prolonged courses of antimicrobial therapy, a known driver of AMR, but can also have adverse effects on the patient, increase the chance of Clostridium difficileinfection, and increase healthcare costs.

For deep-seated or complex infections such as abscesses or deep diabetic foot ulcers, antimicrobials alone are often not enough as treatment. Physical or surgical interventions to remove, drain or debride infected material is the most effective management strategy. Implanted or prosthetic devices, such as pacemakers, prosthetic heart valves or prosthetic knee or hip joints, are especially prone to bacterial colonisation and antibiotics alone will rarely clear biofilms on these surfaces entirely, even when a long course is prescribed.

Antimicrobials will have a role alongside some of these interventions to prevent further spread or seeding of infection. Although in some cases where physical source control is achieved, a prolonged course of antimicrobials isn’t always necessary. For example, if an abscess or collection is drained, there may only be a need for a few days of antimicrobial therapy to clear any last residual pathogens, rather than several weeks of treatment.

What is the role of pharmacists?

When presented with prescriptions for a long course of antimicrobials for such infections, pharmacists should establish what infection is being treated and, where applicable, ask what source control measures have been considered as part of the wider MDT discussion. If a prolonged course of antimicrobials can be avoided, it lessens the risk of side effects and antibiotic-related infections such as C. difficile, as well as the risk of the infection becoming resistant. 

Challenging Inappropriate prescribing

Pharmacists are an essential safeguard between the prescriber and the patient, ensuring the appropriateness of prescriptions. Pharmacists will frequently need to contact prescribers to query individual prescriptions and it is important that, during these conversations, all key points are covered in enough detail and presented clearly with a suggested solution. This will usually result in a good outcome.  

The SBAR approach (Situation Background Assessment Recommendation), originally designed by the US Navy, is used to facilitate efficient communications between healthcare teams. This approach can be used to structure your conversations when you raise queries with prescribers.

Example: when you would challenge a prescription

A patient presents to your pharmacy with a prescription for amoxicillin 500mg PO 8 hourly. Upon questioning, you determine it is prescribed for a moderately severe pneumonia. You ask further questions and determine that the patient has had a previous severe allergic reaction to penicillin that required hospital treatment.

Before you contact the prescriber, anticipate that they may ask you for the alternatives you recommend – so offering a solution to the problem presented. You consult your local guidelines and find doxycycline 100mg twice a day for 7 days is recommended, and your questioning of the patient has found no contraindication to this option.

Task

How would you present the above situation to a prescriber using the SBAR approach?

Answer explained (click to reveal)

Here is the example presented in the SBAR format

 

S

 

Patient X has been prescribed Amoxicillin and has a history of a severe allergy to penicillin.

 

B

 

Patient X was prescribed Amoxicillin 500mg PO three times a day for moderate to severe pneumonia. Whilst checking for drug allergies, patient X reported he previously had a reaction to penicillin that required hospital admission.

 

A

 

I consulted the local guidelines and found that doxycycline 100mg twice a day for 7 days is recommended, and your questioning of the patient has found no contraindication to this option.

 

R

 

I recommend changing the prescription to doxycycline 100mg twice daily for 7 days. I would also recommend that the patient’s records be updated to include a history of severe penicillin allergy to prevent further prescriptions for penicillin.

This a straightforward situation, however what do you do when there is a pattern of inappropriate antimicrobial prescribing?

The SBAR approach (Situation Background Assessment Recommendation), originally designed by the US Navy, is used to facilitate efficient communications between healthcare teams. This approach can be used to structure your conversations when you raise queries with prescribers.

When challenging inappropriate prescriptions, pharmacists should take it as an opportunity to educate the prescriber on appropriate prescribing, such as checking the patient’s allergy status before prescribing and referring to guidelines and microbiology results where applicable. This may include pointing out to the prescriber how to access the most up-to-date guidelines.

It can be significantly more challenging when there is a pattern of inappropriate prescribing as it presents a risk of conflict between prescriber and pharmacist. However, using the SBAR approach and having clear and open communication will usually lead to the best outcome.

Collaborative working is an essential element of AMS and a recurring theme in the WHO Health Workers Curriculum on Antimicrobial Stewardship. Pharmacists have an essential role in educating the MDT and the public on the safe use of antimicrobials, as well as participating in audit, feedback and quality improvement projects to improve stewardship. Building relationships and understanding the factors and systems that influence prescribing decisions is key to enabling change. 

Summary

Pharmacists are a crucial line of defense in recognising inappropriate antimicrobial prescriptions. In this module, we described what an appropriate antimicrobial prescription is, how to review prescriptions and approaches that can reduce inappropriate prescribing. There are a number of strategies that can reduce the number of inappropriate prescriptions and improve antimicrobial use, including delayed prescribing and IV to oral switch (IVOS). Finally, we provided the SBAR framework to follow for situations when you need to raise queries with prescribers.

Resources/references

Below you’ll find the list of resources mentioned in this module: