anopenlearningprogrammepharmacists...

An open learning programme pharmacistsand pharmacy technicians

Avoidingantibiotic resistance:

the role of the pharmacy team

Educational solutions for the NHS pharmacy workforce

© Copyright controller HMSO 2007

Acknowledgements

Lead writer

SharonWarren, antibiotic pharmacist, Dudley Group of Hospitals NHSTrust

CPPE programme developer

Matthew Shaw, assistant director

Project team

Mazim Ali, community pharmacist, BirminghamKathryn Featherstone, PCT pharmacist, SouthTyneside PCTPaula Higginson, senior pharmacist, CPPEJyoti Saini, PCT advisor, East Birmingham PCTAmit Shah, community pharmacy adviser, Brent PCTSueWalton, learning and development co-ordinator, CPPE

Reviewers

Kevin Frost, antibiotic pharmacist, Airedale General Hospital

This learning programme was piloted nationally by the following pharmacists andpharmacy technicians:

Adedamola Folowosele, Linda MacDonald, Julie McCann, Chinjal Patel, SeemaPatel, JoanneTaylor

CPPE reviewers

Dr Chris CuttsPaula Higginson

Production

Outset Publishing Ltd, East Sussex

Published in November 2007 by the Centre for Pharmacy Postgraduate Education,School of Pharmacy and Pharmaceutical Sciences, University of Manchester, OxfordRoad, Manchester M13 9PT

http://www.cppe.ac.uk

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CPPE open learning programmes are printed on paper made only from sustainable forests, forest thinnings and sawmill residues. Chlorine-free pulp is used, and other raw materialsused in the manufacturing cycle are derived from natural products. All papers are also fully biodegradable (or recyclable) without harmful effect to the environment.

Contents

About CPPE open learning programmes vii

About this learning programme x

Supporting you, your practice and the NHS xii

Section 1 Resistance 1

1.1 Resistance – do you care? 1

1.2 How microbes acquire resistance 3

1.3 Mechanisms of resistance 4

Scope of the problem 4

1.4 Antibiotic prescriptions 5

1.5 The situation in the UK 6

1.6 What effect does the use of antimicrobials in animals have? 7

1.7 The role of the pharmacy team 8

How antibiotic prescribing and resistance is monitored 8

1.8 Antimicrobial resistance surveillance 9

Exercise 2

Practice points 5, 9, 10

Summary and intended outcomes 11

Section 2 Influencing and changing prescribing 12

2.1 Appropriate antimicrobial use 13

Examples of inappropriate antimicrobial usage 13

Factors that could influence the prescribing of 14inappropriate antimicrobials

2.2 Encouraging the prudent use of antimicrobials 15

Prescriber-focused strategies 15

Pharmacist-led initiatives 18

Patient-focused strategies 19

Case studies 1, 2, 3, 4 22, 23

Exercise 12

Practice points 13, 15, 16, 18


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C O N T E N T S

Section 3 Preventing infection: infection control 25

3.1 Infection control 26

Hand hygiene 26

Protective equipment 27

Handling and disposing of sharps 27

Handling and disposing of chemical waste 29

Cleaning, disinfecting and sterilisation 29

3.2 MRSA decolonisation 30

Dressings 31

3.3 Injections 31

Exercise 25

Practice points 27, 29, 31

Case studies 5, 6, 7 31, 32


Suggested answers 33

Section 4 Vaccination 34

4.1 How vaccines work 34

4.2 Immunisation schedule 35

Diphtheria 35

Haemophilus influenzae type b (Hib) 35

Measles 35

Mumps 36

Rubella 36

Meningococcus group C 36

Pertussis 36

Pneumococcus 36

Poliomyelitis 36

Tetanus 37

4.3 Other immunisation campaigns 37

Tuberculosis (TB) 37

Influenza 37

Developmental work 38

Exercise 39

Case studies 8, 9 38


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C O N T E N T S

Section 5 Completing the learning experience 40

5.1 Answers to exercises 40

5.2 Case study answers 43

5.3 Designing learning materials for your team and customers 47

5.4 Develop a protocol for infection control in your workplace 49

Your CPD 49

References and further reading 51

Index 54

Figures

Figure 1 Development of resistance 3

Figure 2 Typical recommended safety procedure following 28a needlestick injury

v

About CPPE open learning programmes

About CPPE

The Centre for Pharmacy Postgraduate Education (CPPE) is funded by theDepartment of Health to provide continuing education for practising pharmacistsand pharmacy technicians providing NHS services in England. We are based in theSchool of Pharmacy at the University of Manchester within the multidisciplinaryteaching environment of the Faculty of Medicine, Dentistry, Nursing and Pharmacy.

CPPE offers a wide range of learning opportunities for the pharmacy workforce.Our full learning portfolio is available on the internet at: http://www.cppe.ac.uk

Themes

We have allocated themes to all our learning programmes. There are 28 themes intotal and they allow you to navigate easily through our full learning portfolio. Eachtheme has been assigned a different colour, and this is used to identify the theme inthe annual prospectus, in CPPE news&events, on our website, and on the covers ofall the learning programmes.

This learning programme is part of the Infectious disease theme. You will findadditional learning programmes within this theme in our prospectus and on ourwebsite.

You can download this and other e-learning programmes from the CPPEwebsite.

We recognise that people have different learning needs and not every CPPE learningprogramme is suitable for every pharmacist or pharmacy technician. Some of ourprogrammes contain core learning while others deliver more complex learning thatis only required to support certain roles. So we have created three categories oflearning – CPPE 1 2 3 – and allocated each programme to an appropriate category.The categories are:

Core learning (limited expectation of prior knowledge).

Application of knowledge (assumes prior learning).

Supporting specialisms (CPPE may not be the provider and willsignpost you to other appropriate learning providers).

This is a learning programme.

Continuing professional development

You can use this learning programme to support your continuing professionaldevelopment (CPD). Consider what your learning needs are in this area. You mayfind it useful to work with the information and activities here in a way that iscompatible with the Royal Pharmaceutical Society of Great Britain’s approach to

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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

continuing professional development because you will be able to relate it to yourpersonal circumstances more closely. Use your CPD record sheets or go tohttp://www.uptodate.org.uk to plan and record the actions you have taken.

Activities

Exercises

We include exercises throughout this programme as a form of self-assessment. Usethem to test your knowledge and understanding of key learning points.

Practice points

Practice points are an opportunity for you to consider your practicalapproach to the effective care of patients or the provision of a service.They

are discrete activities designed to help you to identify good practice, to think throughthe steps required to implement new practice, and to consider the specific needs ofyour local population. Practice points are not essential learning; you must make yourown decision about whether to do them, and how long to spend on them.

The practice points in this programme have been designed to help you and yourteam to make links between the learning and your daily practice and to coordinatewith other healthcare professionals.

Case studies

Case studies are based on actual or simulated events and are a way ofhelping you to interpret protocols, deal with uncertainties and weigh up thebalance of judgments needed to arrive at a conclusion. Case studies are

designed to prepare you for similar or related cases that you may face in your ownpractice.

Assessment

The assessment for this programme can only be accessed through our website at:http://www.cppe.ac.uk You can complete the questions in your own time, but youmust submit your answers online. Instructions on how to do this are included at theend of this programme.

Reference sources and further reading

Reference sources for all the books, articles, reports and websites mentioned in thetext, together with a list of further reading to support your learning, can be found atthe end of the programme. References are indicated in the text by a ‘superscript’number (like this 3). For clarity, CPPE uses its own simplified format for references.

Programme guardians

CPPE has adopted a quality assurance process called ‘programme guardians’.A programme guardian is a recognised expert in an area relevant to the content of

E

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A B O U T C P P E O P E N L E A R N I N G P R O G R A M M E S

a learning programme who will review the programme every six months. Anycorrections, additions, deletions or further supporting materials that are needed willbe posted as an update to the programme on the CPPE website.

We recommend that you refer to these updates if you are using this (or any other)learning programme significantly after its initial publication date. A full list ofprogramme guardians is available on our website. You can e-mail your commentsabout this programme to them at: [email protected]

Brand names and trademarks

CPPE acknowledges the following brand names and registered trademarks whichare mentioned throughout the programme:

Actisorb Silver®, Allevyn®, DuoDERM®, Granuflex®, Iodoflex®, Iodosorb®.

External websites

CPPE is not responsible for the content of any non-CPPE websites mentioned inthis programme or for the accuracy of any information to be found there. The factthat a website or organisation is mentioned in the programme does not mean thatCPPE either approves of it or endorses it.

Disclaimer

CPPE recognises that local interpretation of national guidance may differ from theexamples used in this learning programme and you are advised to check with yourown relevant local guidelines.You are also advised to use this programme with otherestablished reference sources. If you are reading this programme significantly afterthe date of initial publication you should refer to current published evidence. CPPEdoes not accept responsibility for any errors or omissions.

Feedback

We hope you find this learning programme useful for your practice. Please help usto assess its value and effectiveness by completing the feedback form (if enclosed) andreturning it in the prepaid envelope. Otherwise, please e-mail us at:[email protected]

ix

x About this learning programme

Welcome to the CPPE open learning programme on avoiding antibiotic resistance –the role of the pharmacy team.This programme has been designed as a key elementof the Infectious disease theme.

The aim of this programme is to equip you with the knowledge that you need to:

� advise prescribers on the appropriate and inappropriate use of antimicrobialtherapy

� support public awareness campaigns on avoiding the use of antibiotics

� design learning materials for your team and your customers on avoiding antibioticresistance

� develop a protocol to support the introduction of infection control to yourworkplace

� demonstrate understanding of the importance of vaccination campaigns.

By the time you have worked through the material you should feel confident thatyour practice is supported by effective and current evidence-based guidelines.Your confidence will enable you to make effective interventions and to structureappropriate and relevant local activities.

The study time will depend on you, but we estimate that this programme will take youabout six to eight hours to complete, depending on your learning style and pace.The work-based exercises will take a little longer.

You should record the time it takes you in your own CPD record.

Target audience

This programme is aimed at pharmacists and pharmacy technicians working in anyarea of practice. This means that you will find some of our exercises more readilyapplicable than others.We do encourage you to try to apply them all to your own areaof practice.

Learning style adopted in this programme

This programme is split into five sections. Whilst you don’t need to work throughthese in order, we think that you do need to complete all of them in order to get themost benefit.

Learning objectives

CPPE has linked all its learning programmes to the Royal Pharmaceutical Society ofGreat Britain’s competences for pharmacists and pharmacy technicians. This willmake it easier for you to connect your professional practice to your learning needsand learning activities. We have selected only the competences for generalpharmacists and pharmacy technicians, but we are aware that others exist.

We have also linked the learning to the dimensions of the NHS Knowledge and SkillsFramework (KSF).

Learning objectives RPSGB competences KSF dimensions

Pharmacists Pharmacytechnicians

Advise prescribers on the G1 TG13 Health and well-being HWB7 Level 3appropriate and inappropriate useof antimicrobial therapy.

Support public awareness G1, G3 TG4 Communication Level 2campaigns on avoiding the use ofantibiotics.

Design learning materials for your G1, G6 TG5 Personal and people development Level 2 or 3team and your customers on Services and project management G5avoiding antibiotic resistance. Level 1 or 2

Develop a protocol to support the G1, G5 TG14 Quality Level 2introduction of infection control to Service improvement Level 2your workplace.

Demonstrate your understanding G1, G5 TG1 Health and well-being HWB7 Level 2of the importance of vaccinationcampaigns.

A B O U T T H I S L E A R N I N G P R O G R A M M E

The competences and dimensions relevant to this programme are:

You may also wish to order our open learning programme: Antibiotics and their rolein managing infections to help you expand your role in the management of infectiousdisease.

Working through this programme

We would advise you to work flexibly with the materials to suit your own style oflearning. There is no right or wrong approach, but remember that the aim of yourhard work is to enable you to feel confident to meet the challenges facing you whenyou advise on antibiotic therapy. Bear this in mind as you work through theprogramme – it will help you to decide if your approach to study is working!

We have designed the programme for self-study, but as you progress through thesections it will be essential for you to talk through some of the issues with your staffand colleagues.

Note. Some of the references in this programme are to material that is only availableonline, and it is assumed that you will have access to a computer connected to theinternet. If you do not wish to retype all the web addresses into your browser you mayfind it helpful to download this programme from the CPPE website as a PDFdocument containing ‘live’ web links. Log on to: http://www.cppe.ac.uk

We consider the current edition of the British national formulary to be an essentialreference for you to use and keep at hand as you work through this learningprogramme.

xi

Supporting you, your practice andthe NHS

When devising this programme we paid special attention to how it would contributeboth to your own professional development and to the overall improvement of NHSservices.We have illustrated some of these benefits in the diagram below (you will findmore detail as you progress through the programme).

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You,your practice

and this learningprogramme

Pharmacist prescribers

As pharmacists start to prescribe antibiotic therapy,

this programme can actas a reminder of how to

avoid their inappropriate use.

Primary care pharmacy

Primary care pharmacists and pharmacy technicians arewell placed to initiate local

schemes to reduce the use ofantibiotics when they are not

needed. This programme sharesapproaches that have workedin other parts of the country.

Policy drivers

This programme has been written to support

Department of Health guidelines on avoiding the use of

inappropriate antibiotics.

Community pharmacy

Community pharmacy teammembers have the opportunity

to talk to every person who brings in a prescription forantibiotic therapy and can

reduce the burden on the NHSby explaining to people the alternatives to antibiotics,

where appropriate. This programme suggests how

they can make more of an impact in this area

of healthcare.

Hospital pharmacy

Hospital pharmacists are in a unique position to advise

prescribers on the appropriateuse of antibiotics.

This programme encourages them and pharmacy technicians

to think about the ways that they could extend this to

working with patients andother members of the

healthcare team.

Section 1Resistance

Objectives

On completion of this section you should be able to:

� describe the main contributing factors leading to antimicrobialresistance

� list four mechanisms by which microbes become resistant toantibacterials

� list two main recommendations from the Department of HealthStanding Medical Advisory Committee report: The path of leastresistance1

� name three healthcare associated infections that require mandatorymonitoring

� discuss ways in which antimicrobials can be monitored in bothprimary and secondary care.

In this section we are going to explore antibiotic resistance. We are going to reviewhow resistance develops, consider why it is a problem, why more attention is beingfocused on avoiding resistance and what the role of the pharmacy team is.

1.1 Resistance – do you care?

Before you read any further in this section think about why resistance is such animportant public health issue. In particular, think about the effect it has on the patientand the health economy.

Make your notes below.

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S E C T I O N 1

xercise 1Here is a selection of ten prescriptions for antibiotic therapy. For each one we have

provided the drug name, together with its dose and course length. We also tell you

the noted indication and additional comments which may be useful for that person.

None of the patients have a stated allergy to the prescribed drug. Have a look at each

of these and note whether you think the prescription is appropriate.

Drug Dose Course Indication Comments Appropriate?

Amoxicillin 125 mg/5 mL 125 mg Five days Sore throat Five-year-old child with a temperatureSugar-free suspension three times a day and sore throat for two days

Trimethoprim tablets 200 mg Three days Urinary tract 72-year-old lady with infection duetwice a day infection to a catheter

Norfloxacin tablets 400 mg 14 days Urinary tract 41-year-old femaletwice a day infection

Erythromycin 125 mg/5 mL 125 mg Five days Otitis media Six-year-old child with earache,Sugar-free suspension four times a day no other symptoms

Cefuroxime tablets 250 mg Seven days Post-operative 52-year-old femaletwice a day prophylaxis

following eyesurgery

Metronidazole tablets 400 mg Ten days Diarrhoea 61-year-old male inpatienttwice a day

Ciprofloxacin tablets 250 mg Ten days Chest infection 24-year-old asthmatictwice a day

Sodium fusidate infusion 500 mg Five days Cellulitis 58-year-old femalethree times a day

Penicillin V tablets 500 mg Seven days Dental 38-year-old male with prostheticfour times a day prophylaxis heart valve

Metronidazole tablets 400 mg For four doses Bowel surgery 18-year-old male withat eight hour before surgery prophylaxis Crohn’s diseaseintervals

We will revisit this exercise at the end of this learning programme.

If you felt that you needed more information about any of these patients to be able

to complete this exercise, jot down what else you wanted to know about the cases

below.

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2

R E S I S TA N C E

Would you usually have this additional information for any antibiotic prescriptions

that you dispense?

1.2 How microbes acquire resistance

Let’s start this programme by looking at how resistance develops.We class resistanceas either clinical or microbiological.

Clinical resistance is due to an inadequate level of antimicrobial within the tissue orfluid. In other words, there is not enough of the agent present to kill the infectingorganism.

Microbiological resistance is when the microbe possesses a resistant mechanism andis divided into two main types. These are called acquired (secondary) or intrinsic(primary) and are determined genetically by their characteristics (cell wall, enzymes,biochemistry).

Primary resistance is what the microbe already possesses and is present regardless ofthe exposure to antimicrobials.

Secondary resistance is acquired by mutation. As the organism reproduces, mutationwill take place naturally – about one mutation in every one million generations.However, as micro-organisms reproduce morefrequently, then the appearance of mutationoccurs quickly.

If a mutation results in resistance developing,then this mutated organism will survive, whilethe other micro-organisms are killed.This resultsin the selection of resistant micro-organisms. Inturn these resistant micro-organisms can sharetheir DNA with other bacteria by:

� conjugation (the passage of a plasmidbetween cells),

� transduction (DNA transfer by abacteriophage), or

� transformation (uptake of ‘naked DNA’generated when cells breakdown).2

3

Resistance

Clinical Microbiological

Microbe possesses aresistant mechanism

IntrinsicPrimary

Microbe already possesses

AcquiredSecondary

From mutation

Inadequate level of antimicrobial within

the tissue or fluid

FIGURE 1 Development of resistance

S E C T I O N 1

1.3 Mechanisms of resistance

Microbes display a combination of methods to become resistant to antimicrobials.

1. Reducing drug accumulation

� Mutations in pump efflux mechanismsEfflux pumps on bacteria cell walls usually remove waste products. Mutationsoccur that allow the removal of antimicrobials from the cell, so that there areinsufficient concentrations of antimicrobials achieved within the cell to exert aneffect.

Resistance seen in gram-positive bacteria against macrolides is by this mechanism.

� Changes in cell permeabilityModifications in cell wall components can lead to decreased permeability andhence decreased sensitivity to antimicrobials.

2. Antimicrobial deactivation

Microbes produce enzymes that inactivate antimicrobials. The most well-knownenzyme is beta-lactamase. Beta-lactamase hydrolyses the beta-lactam ring ofpenicillins, cephalosporins, monobactams and carbapenems.

3. Alterations in target site

Mutations to the molecular target for an antimicrobial can lead to resistance. Anexample of this is an alteration in 50S ribosome, causing macrolide resistance.

4. Alteration of metabolic pathway

Some microbes develop an alternative metabolic pathway, so antimicrobials workingon the old metabolic pathway are no longer active. Resistance to trimethoprim andsulphonamides occurs via this mechanism.

Whichever method, or combination of methods, the microbe uses, the outcome isan antimicrobial agent which has reduced efficacy in managing infection.

Scope of the problem

Antimicrobial resistance is a major public health problem. Antimicrobial use isconsidered to be an important contributing factor in selecting for resistant microbes.

Penicillin was discovered in 1928 by Fleming. Adequate supplies of penicillin wereavailable by D-day (1944). At the end of the war penicillin was widely available. In1945 when Fleming gave his Nobel Prize lecture, he warned of the danger ofresistance.

‘It is not difficult to make microbes resistant to penicillin in the laboratory by exposingthem to concentrations not sufficient to kill them and the same thing has occasionallyhappened in the body.The time may come when penicillin may be bought by anyone in theshops.Then there is a danger that an ignorant man may easily underdose himself and byexposing his microbes to non-lethal quantities of the drug make them resistant.’ 3

We now know that within a couple of years from the launch of a new antimicrobial,resistance starts to develop in the target microbes. We also know that inappropriateuse of antibiotics affects the resistance pattern of microbes for a community as awhole.

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R E S I S TA N C E

Across Europe, many countries make antimicrobials available for purchase inpharmacies and shops, which allows uncontrolled, inappropriate use.

The European Surveillance of Antimicrobial Consumption (ESAC) project in 2005,found that there was a great variation in non-hospital antibiotic prescription useacross 26 different countries, and a significant correlation between antibiotic use andresistance.4They also noted that there was a trend to prescribe more broad-spectrumagents rather than narrow-spectrum agents.

They found that easier access to antibiotics results in a higher level of resistance.It also results in greater use of broad spectrum rather than narrow spectrum agents.

We know that the ideal way to treat an infection is with the narrowest spectrum agentpossible, if we want to avoid resistance. You can find out more about choosing theright antibiotic in the CPPE open learning programme: Antibiotics and their role inmanaging infections.

1.4 Antibiotic prescriptions

Let us consider how many times each day we supply antibiotics.

Practice pointIf your system allows you to do so, then print off a report showing the numberof antibiotics you have dispensed – you may find it easiest to select what youconsider to be the five most commonly-used antibiotics and report on those.

If your computer system doesn’t let you do this, then choose any day in theweek and keep a count of how many antibiotics you dispense that day.

What percentage of all prescribed items is this?

Why do think the antibiotics were prescribed?

Bacterial infection

Viral infection

No idea at all

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S E C T I O N 1

Whichever of these approaches you use, it is worth repeating this activity atdifferent times of the year.When you compare your results can you see any evidenceto show that the prescribing of antibiotics increases in your locality as the incidenceof coughs and colds increase?

Eighty percent of all antibiotics are prescribed in the community and of these 20 to50 percent are inappropriate.5

In UK hospitals about 35 percent of all inpatients are prescribed antibiotics.We knowthat often the duration is too long and the choice of antibiotic is inappropriate.

Resistant microbes are a problem both in hospitals and in the community and theyare often harder to treat. Resistant infections increase the severity and duration of anillness for patients, often causing an increase in healthcare costs by increasing thelength of hospital stay and the cost of treatment.

Whether in the community or hospital setting we have to ensure that antibiotics areused appropriately to help reduce the development of further resistant microbes andto obtain the best clinical outcome when treating patients.

No-one is saying that we should stop using antibiotics. We know that life-threatening infections such as neutropenic sepsis require urgent antibiotic therapy,but we see frequent inappropriate use for viral infections that adds to the burden ofresistance and provides no benefit to the patient.

1.5 The situation in the UK

In the United Kingdom a prescription is required for the supply of most antimicrobials.However, concern regarding the scale and implications of antibiotic resistance in theUK resulted in a comprehensive House of Lords review on antibiotic resistance thatreported in 1998.6 The review highlighted areas where resistance had emergedand indicated where it was threatening to occur next, ie, methicillin resistantStaphylococcus aureus (MRSA), gonorrhoea, tuberculosis, malaria and humanimmunodeficiency virus (HIV).

The House of Lords Committee reported that, at that time, the use of antibiotics inthe UK was equivalent to every member of the population receiving five days’ antibiotictreatment each, every year. Their three main recommendations were:

� to ensure more widespread recognition of antibiotic resistance as a major threat topublic health

� for primary care trusts to increase the emphasis on training of prescribers relatingto antibiotic prescribing (via continuing professional development)

� for the government and primary care trusts to heighten awareness of the relevantissues among the public through education campaigns, especially for mothers withyoung children.

6

In our pilot, 10-19 percent of

prescriptions in one day in the

community pharmacy were for

an antibiotic.

R E S I S TA N C E

The SMAC report in 1998:The path of least resistance recommended four key thingsthat community prescribers could do ‘to make a difference’:1

� ‘no prescribing of antibiotics for simple coughs and colds

� no prescribing of antibiotics for viral sore throats

� limit prescribing for uncomplicated cystitis to 3 days in otherwise fit women

� limit prescribing of antibiotics over the telephone to exceptional cases’

In response to the House of Lords and the SMAC report, the Department of Healthproduced the UK Antimicrobial resistance strategy and action plan in June 20007 andin 2001 announced the creation of a Specialist Advisory Committee on AntimicrobialResistance (SACAR) created specifically to make sure that work continued to combatantimicrobial resistance.

A further report published by the Department of Health in 2002:Getting ahead of thecurve addressed both the importance of antimicrobial resistance and the role ofhealthcare professionals in combating emerging resistance.8

The Winning ways document, published by the Department of Health in 2003,suggested that support for prudent antibiotic prescribing will be provided by clinicalpharmacists, medical microbiologists and infectious disease physicians.9

Due to the ever-increasing number of methicillin-resistant Staphylococcus aureus(MRSA), bacteraemias and Clostridium difficile infections in hospitals, theDepartment of Health have issued targets to trusts to achieve a reduction of thesecases and made recommendations that pharmacists should be involved in the writingof policies for antimicrobial prescribing.10

1.6 What effect does the use of antimicrobials in animals have?

It is estimated that 50 percent of the antimicrobials used worldwide are usedin animals. Animals that are used to produce food are often given the sameantimicrobials as humans and resistant bacteria can be transmitted to humans viafood.

The use of antimicrobials in animals has caused much debate over recent years.Antimicrobials are not only used for treating infections in animals, but are also usedas growth promoters. However, the European Union has banned the use of allantibiotics as growth promoters since 1 January 2006.11

When an animal that is part of a large group has an infection, individual treatmentis not always possible and treatment is given to the whole group via their water orfeed.

Let’s have a look at an example of this.

The fluoroquinolone, enrofloxacin is used to treat respiratory tract infections inpoultry and is given to the whole flock via their water.

However, using enrofloxacin in this way has resulted in the development of a drug-resistant Campylobacter. And this is a common cause of food poisoning in humans.

Humans get Campylobacter gastroenteritis when they eat undercooked poultry, or ifhygiene is lacking in the kitchen when preparing the raw poultry.

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S E C T I O N 1

The prevalence of fluoroquinolone-resistant Campylobacter in humans is increasing.Believing this increased prevalence to be a direct result of the use of enrofloxacin inpoultry, the United States Food and Drug Administration (FDA) banned the use itin July 2005.

Since this will result in more poultry being infected with Campylobacter, then morehumans will be exposed to Campylobacter and the number of infections will increase.However, these infections will not be fluoroquinolone resistant.

The evidence for this comes from Australia where enrofloxacin is not used in poultry.The rate of fluroquinolone-resistant organisms is lower, but the rate of infection isgreater.

Campylobacter gastroenteritis is not routinely treated with antimicrobials.

Of more concern perhaps is the illegal use of amantadine in poultry. This use in thesouth of China and other parts of south-east Asia, means that although the H5N1strain that appeared in Hong Kong in 1997 was amantadine-sensitive, the morerecent strains have all been amantadine-resistant.This seriously reduces the treatmentoptions available to doctors in the event of an influenza pandemic.

In November 1997 18 UK organisations banded together to create a set of guidelineson the use of antibiotics in farm animals, in order to address the concerns of thegeneral public. Members of this consortium, called Responsible use of Medicine inAgriculture Alliance (RUMA), include the British Poultry Council and variousindustrial and pharmaceutical firms.

The use of antimicrobials in humans can also affect animals. Methicillin-resistantStaphylococcus aureus (MRSA) is acknowledged to be a human commensal andpathogen. Pet owners can transfer MRSA to their pets, where it causes similarproblems to those in humans.

1.7 The role of the pharmacy team

We have already considered two ways in which the pharmacy team can becomeinvolved in reducing resistance:

� by checking that antibiotics are only prescribed when they are needed

� by taking steps to ensure people use their antibiotics properly.

Let’s look at these in a bit more detail.

How antibiotic prescribing and resistance is monitored

Prescribing

In primary care, figures on the use of antimicrobials are available through prescribinganalysis and cost (PACT) data.This provides a picture of how and what each practiceprescribes, and the specific drugs prescribed by each prescriber within the practice.

In secondary care, however, there is currently no routinely generated informationavailable on antimicrobial use. Gathering data from individual prescriptions wouldprovide an ideal method for monitoring antimicrobial usage, but this facility will notbe possible until electronic prescribing is routinely used in all hospital trusts.

8

Recent H5N1 strains have all

been amantadine resistant.

R E S I S TA N C E

The UK does not have a comprehensive way of monitoring antimicrobial use insecondary care. But many UK hospitals now have a designated antimicrobialpharmacist who will collect usage data. Analysis of cost does provide an indicationof usage, but this analysis can be misleading. For example, if cost was used to monitorusage, and an expensive antimicrobial came off patent, this would lead to a dramaticreduction in price, which could be misinterpreted as a reduction in antimicrobial use.

A more reliable method of analysing antimicrobial usage is by calculating ‘defineddaily doses’ (DDDs).The DDD is the total quantity of drug, divided by the averagedaily dose, as defined by theWorld Health Organization (WHO). The DDD can bethen divided by a population denominator; a commonly-used example is 1000 beddays.

The DDD/1000 bed days can be compared with other hospitals locally, regionallyand nationally. However, this method has limitations as it does not take into accountthe variation in case mix between trusts; the appropriateness of prescribing and thenature of individual cases.

NB. PCTs have a similar method for analysing usage by all primary care prescribers.

Another method for monitoring antimicrobial prescribing in secondary care is the useof serial point prevalence studies. These studies target every patient within thehospital on a specific day. The patients who are prescribed antimicrobials on thatday have details of their antimicrobial prescription recorded. These provide a‘snapshot’ look at prescribing once or twice a year and enables prescribing patternsto be studied. Areas where improvements in prescribing are needed can then beidentified and targeted.

Practice pointFind out who monitors the prescribing of antimicrobials in your area ofpractice and how the monitoring is done.

� In hospital you may have a designated pharmacist.

� In the community it may be a practice-based pharmacist or someone atthe PCT. You could contact the PCT medicines management team orpublic health department for further information.

1.8 Antimicrobial resistance surveillance

Since 1980 many hospital microbiology laboratories in England and Wales havesupplied data to the Health Protection Agency (HPA) from routinely-generatedsusceptibility tests, with an emphasis on isolates from patients with bacteraemia.Although initially this information was voluntarily submitted, surveillance of someinfections has now become mandatory due to the increasing focus on healthcare-associated infections (HCAIs).

In England, the HPA Centre for Infection is responsible for the surveillance ofhealthcare-associated infections; there are equivalent centres inWales, Scotland andNorthern Ireland.

9

S E C T I O N 1

The HPA publishes six-monthly reports on MRSA bacteraemia and yearly reportson other healthcare-associated infections which can be viewed on their website:http://www.hpa.org.uk

Practice pointFind out which healthcare-associated infections require mandatorysurveillance in Scotland, Northern Ireland, England andWales.

The Antibiotic Resistance Monitoring and Reference Laboratory (ARMRL)(part of HPA) is a national reference laboratory that is responsible for detecting,investigating and advising on antibiotic resistance in both hospital andcommunity pathogens.The European Antimicrobial Resistance SurveillanceSystem (EARSS) is a European-wide network of national surveillancesystems, providing reference data on antimicrobial resistance for publichealth purposes.

10

R E S I S TA N C E

Summary

� The following factors contribute to antimicrobial resistance:

� general availability of antibiotics without a prescription in some countries

� patient’s demand for antibiotics for inappropriate infections

� failure of patients to complete the prescribed course of antimicrobials

� overuse and misuse of antimicrobials in humans, animals and agriculture.

� Microbes develop resistance to antimicrobial agents as soon as they have beendeveloped.

� The apparent rapidity with which resistance develops is due to the rapid reproduc-tion of new generations of microbes.

� As antibiotics become used more commonly, the incidence of resistance increases.

� The pharmacy team can help to reduce resistance by advising prescribers andpatients appropriately.

� Some healthcare-associated infections are subject to mandatory reporting.

Intended outcomes

By the end of this section you should be able to:

11

Learning objective Well can you?

Describe the main contributing factors leading toantimicrobial resistance.

List four mechanisms by which microbes becomeresistant to antibacterials.

List two main recommendations from theDepartment of Health Standing Medical AdvisoryCommittee report: The path of least resistance.1

Name three healthcare associated infections thatrequire mandatory monitoring.

Discuss ways in which antimicrobials can bemonitored in both primary and secondary care.

Section 2Influencing and changing prescribing

Objectives


� list four factors that can influence the prescribing of antibiotics

� describe ways of influencing prescribers on appropriate use ofantibiotics

� suggest two ways of reducing inappropriate antibiotic prescribing

� discuss ways pharmacists can improve and influence prescribing ofantibiotics.

We know from the first section of this programme that one of the ways in which thepharmacy team can reduce resistance is by advising prescribers and educatingpatients on the appropriate use of antibiotics. In this section we are going to look atthe ways in which this can be done.

xercise 2

Before completing this section take a few moments to consider the following

questions. Then reflect on the questions again once you have completed this section.

What is appropriate antimicrobial use?

Write down the examples of inappropriate antimicrobial use that you seemost often.

E

12

I N F L U E N C I N G A N D C H A N G I N G P R E S C R I B I N G

What factors result in inappropriate antimicrobial use?

What can you and your team do to ensure antimicrobials are used appropriately?

2.1 Appropriate antimicrobial use

TheWorld Health Organization defines the appropriate use of antimicrobials as:

‘the cost-effective use of antimicrobials which maximises clinical therapeutic effect whileminimising both drug-related toxicity and the development of antimicrobial resistance’.12

Examples of inappropriate antimicrobial usage

Some examples of inappropriate antimicrobial use are:

� prescribing antibacterials for non-bacterial infections

� not prescribing antimicrobials for infections that require treatment

� use of a broad spectrum agent over the use of a narrow spectrum agent

� prescribing for too long or too short a duration

� prescribing incorrect doses

� prescribing via an inappropriate route.

Practice pointHow can pharmacy staff improve antimicrobial use?

Find out what is being done locally to improve antibiotic prescribing, contactyour local prescribing adviser or speak to your head of pharmacy services.

13

S E C T I O N 2

Factors that could influence the prescribing of inappropriate antimicrobials

There are many contributing factors that influence the prescribing of an antimicrobial;we have detailed some of them below.

What influences prescribing?

Antimicrobial prescribing has a lot to do with the relationship between the doctorand patient.

Patient expectation plays a big role in the decision to prescribe. Prescribers may feelthat patients want a prescription for an antimicrobial as it confirms they do have anillness, and there has been a diagnosis. Also if they feel they have a ‘cure’ for theircondition, they may feel reassured that their illness is not ‘serious’.13 Some patientsbelieve that newer antimicrobials are more effective than older agents and the pressureto prescribe newer agents increases both the spread of resistance and healthcare costs.

Patients and prescribers overemphasise the importance of purulent secretions indeciding to prescribe antimicrobials. Doctors frequently assume a patient with anacute respiratory infection, or their parents, will not be satisfied unless they receivea prescription for an antimicrobial. Whereas studies show that patients are oftenhappier if they receive accurate explanations and reassurance, rather thaninappropriate antimicrobial therapy.14 Once an antimicrobial has been prescribedfor a patient, they are more likely to return for another antimicrobial prescription, forthe same condition, in the future.15

Ethnic origin may have an effect on patient’s/parent’s perceived need for anantimicrobial but this is not reflected in prescribing data.16 One American studyfound that Asian and Latino parents were both 17 percent more likely than non-Hispanic white parents to report that antimicrobials were either definitely or probablynecessary.17 This research highlights the need for public health campaigns to reachall ethnic groups equally.

Prescribing of antibacterials may be affected by the country in which the prescribertrained and previously practised, although one study raised doubts about thisassumption.18 Prescribers who have trained overseas may need to be updated onantibiotic policies in the UK, including the need to minimise unnecessary antibioticprescribing.

Studies indicate that as a doctor’s age and number of years in practice increases, sodoes the level of antimicrobial prescribing.19 However, this increase may relate to thedemographics of the patients that they see.

Antimicrobials are more likely to be prescribed in urban and non-teachingpractices.20This may relate to doctors’ lack of knowledge, their difficulty with select-ing appropriate agents and their tendency to make insufficient use of microbiologicalinformation. This lack of knowledge can lead to a fear of possible litigation andtherefore they may prescribe ‘just to be on the safe side’.

A GP practice with a high number of locum doctors will often have a higher level ofantibiotic prescribing than other local practices, often due to the difficulty in followup, hence prescribing ‘just to be on the safe side’ and possibly because they are notable to develop a long-term prescriber/patient relationship where explanation andreassurance may result in long-term benefits.21

Prescribing may also be influenced by the input of pharmaceutical drug representatives.22

14

Some patients believe that

newer antimicrobials are

more effective.


2.2 Encouraging the prudent use of antimicrobials

Prescriber-focused strategies

Earlier on we briefly discussed how you can use PACT data, DDDs and audit toidentify those doctors, practices and hospital wards who are high prescribers ofantibiotics.

Once you have identified the prescribers, you can arrange to meet to discuss theirprescribing. It is often useful to be able to show prescribers how they compare toother prescribers working in the same area by presenting the results of any audit ormonitoring data. They may be able to explain why their prescribing is so high, butyou can then work together to put a plan in place to help to rationalise their prescribing.

Practice pointYou find from monitoring data that a local practice is using four times theamount of co-amoxiclav, than another local practice of the same size. Howwould you approach the local practice about your findings?

Developing guidelines

Guidelines are important in helping prescribers make an informed decision onappropriate antimicrobial therapy. A pharmacist should be involved in the writingand updating of any local guidelines which should be evidence-based and take intoaccount local resistance patterns.

The following resources should prove useful when writing or reviewing guidelines:

� The Specialist Advisory Committee on Antimicrobial Resistance (SACAR)*produced a UK template for hospital antimicrobial guidelines which can be usedwhen guidelines are written or reviewed.You can find these at:http://www.bsac.org.uk/_db/_documents/Template_for_hospital_antimicrobial_guidelines_May_2005.doc

*Note:The final meeting of SACAR took place on 24th April 2007.

The committee has been officially stood down and will be replaced by ARHAI (anAdvisory Non Departmental Public Body (ANDPB) on Antimicrobial Resistanceand Healthcare Associated Infections). Details of this new committee will be madeavailable shortly.

You can still access the publications of the committee using the menu from this webaddress: http://www.advisorybodies.doh.gov.uk/sacar/

� The Health Protection Agency has also produced guidance for primary care on themanagement of infection which can be adapted to suit local needs. Wheneverpossible you should involve the local consultant microbiologist in this process, toensure co-ordination with local secondary care guidelines.The guidance is availableonline at:http://www.hpa.org.uk/infections/topics_az/antimicrobial_resistance/guidance.htm

15

S E C T I O N 2

� The British Association of Antimicrobial Chemotherapy has a website whichprovides empirical treatment guidelines for hospital infections, together with otherhelpful information. Visit their website at: http://www.bsac.org.uk/pyxis/

� The National Prescribing Centre (NPC) has produced a MeReC bulletin thatmakes recommendations for the management of common infections in primarycare. The infections discussed are: common colds, acute sinusitis, acute otitismedia, acute uncomplicated urinary tract infections in women, sore throat andacute bronchitis.This is a useful resource to use and will help educate prescriberswho are unsure of when an antibiotic is indicated. The bulletin: The managementof common infections in primary care. 17(3) 2006 is available online at:http://www.npc.co.uk/MeReC_Bulletins/MeReC_Bulletin_Vol17_No3_Intro.htm

� Clinical knowledge summaries, available online at:http://www.cks.library.nhs.uk may also provide useful up-to-date information.

Practice pointOf course, guidelines are only useful if they are known about and used.

Think about your own area of practice.What techniques have you seen usedto remind prescribers of antibiotic prescribing guidelines?

16


Some of the different approaches that we are aware of are:

� mouse mats

� stickers (that can be used in the British national formulary)

� laminated cards (to carry with your staff ID card), and

� posters.

Training may be necessary when new guidelines are published to highlight any keychanges; workshops have been found to be more effective in changing practice thanlecture-style sessions.23 Training should include alternative strategies and copingstrategies for dealing with potential patient pressure. All healthcare staff should beconsidered when planning any training, including GP reception staff.

During hospital ward rounds ward nurses can remind doctors of the importance ofappropriate antimicrobial use. An audit on adherence to guidelines, such as a localantimicrobial policy in either secondary or primary care, will highlight any problemareas. The results of these audits, whether good or bad, can be fed back to doctorsand the situation can be re-audited at a later date. The NPC have published ahandbook on audit, which discusses key elements that professionals need to be awareof when undertaking an audit. The Pharmacy audit handbook from the NationalPrescribing Centre focuses on clinical governance in primary care and managingantibiotic prescribing. It also addresses how audit can be used to change behaviour.It is available online at:http://www.npc.co.uk/publications/auditHandbook/contents.htm

It is easier for pharmacists to check that guidelines are being followed in secondarycare than it is in primary care. When electronic prescribing is available in bothsecondary and primary care, monitoring antibiotic prescribing is going to be madeeasier.

Approaches for prescribers

Delayed prescriptions

Providing a ‘delayed prescription’ is an approach used by prescribers to reduceantimicrobial use.

The patient is given a prescription and told to only have it dispensed if symptomspersist or get worse; often they are given a set time frame for this.

There are concerns with this method as some patients could keep the prescriptionand misuse it at a later date. Also, some patients may perceive that the prescriber hasa lack of knowledge and is uncertain about what is needed and when. To reduce thechance of abusing this system some GPs ask the patient to collect the prescriptionfrom the surgery within a set time frame. The benefits of giving a delayed prescrip-tion are that the patient learns that antimicrobials are not always necessary and itpreserves the prescriber/patient relationship. Also patients who are given a delayedprescription are less likely to revisit with similar illnesses in the future.24

17

S E C T I O N 2

No prescription – just information

Patients sometimes feel better if they leave the consultation with some paper in theirhand; not necessarily a prescription. Some practices use a non-prescription padwhich contains healthcare advice and information for the patient to take away withthem. Examples are shown below.

PCT-produced information for patients.

Practice pointFind out whether your area has a minor ailment scheme in place and, if so,how this could be used to help prescribers provide support to patientswithout giving a prescription.

Pharmacist-led initiatives

Intravenous to oral switch

It is now possible for an appropriately trained pharmacist, ie, a supplementary orindependent prescriber, to modify drug treatment under strict procedures. Sometrusts have a policy in place for specific antimicrobials and certain medical conditionsor infections, where pharmacists can switch antimicrobials automatically fromintravenous to oral therapy after a specific length of time (usually 48 hours).

Automatic stop

Some trusts have automatic stop policies, where the ward pharmacist will stopantibiotics after a specific length of time. This type of policy will have specific

18


inclusion and exclusion criteria and will be used if the duration of treatment has notbeen stated on the drug chart. If the clinician still wants the patient to continue onthe antibiotic, it has to be re-prescribed. This forces clinicians to review theirprescriptions and think about duration of therapy. The policy would apply to bothoral and intravenous therapy and can be used as a means of getting the prescribersto switch to oral therapy from intravenous.

With the introduction of more senior roles for pharmacists in NHS trustsantimicrobial pharmacists will have a greater opportunity to become independentprescribers or consultant pharmacists, allowing their careers to progress along a moreclinical path.This development should also mean that there will be an increased focuson antimicrobial use and the pharmacist will be able to independently changeprescribing.

Patient-focused strategies

As well as supporting prescribers, we know that it is important to manage theexpectations and understanding of patients.

In 1999 the Government launched a national public education campaign onantibiotic resistance to help educate patients about the correct use of antimicrobialsand reduce their expectation of antimicrobial prescriptions for common colds.

The campaign was run in two parts. The first part ran in autumn 1999, focusing onproviding support to healthcare professionals who were treating patients with acuteupper respiratory tract infections. The aim of this part of the campaign was toeducate patients on the correct use of antibiotics, thereby reducing the pressure forantibiotic prescriptions.

The second part of this campaign ran in January 2002, reinforcing the message aboutthe importance of correct usage and also looked at the harmful effects of antibiotics.School children and their parents were targeted through an education campaignwhich was available for teachers/school health workers to use in their classroom,which tied in with the curriculum. The education material available for use inschools is called: The Bug investigators, and is available to download at:http://www.buginvestigators.co.uk It is fun to use and worth a look. Posters andleaflets to support the campaign can be ordered from the Department of Health.There are Bengali, Urdu and Gujarati versions of the leaflets also available.

In November 2006 to support the activities of ‘Ask about medicines week’, the RoyalPharmaceutical Society of Great Britain (RPSGB), in association with the HPA andSACAR, launched a public awareness campaign called: ‘Ask about antibiotics’. Thecampaign highlighted key messages about antibiotics, including how to take themcorrectly, and explained the importance of only using antibiotics to treat bacterialinfections. Campaign material including leaflets and posters are still available to orderfrom the RPSGB’s website: http://www.rpsgb.org – or you can download a PDFversion.

The antibiotic resistance website, which is part of the National electronic Library ofInfection, has links to many more patient education materials.http://www.antibioticresistance.org.uk/

19

Resources are available to help

you educate patients on the

correct use of antibiotics.

S E C T I O N 2

Taking your role a step further

When we were writing this programme, we considered what the pharmacy teamcould do to extend their role in reducing resistance. We have detailed some of theideas below; we have arranged them from the easiest, but most reactive approaches,to the more time-consuming, proactive and possibly more rewarding approaches.

� Patient information provision

Take a look at the patient information literature regarding antibiotics that is availablewithin the pharmacy where you work.

What do you think of it?

Select one of the leaflets to give out each time you dispense an antibiotic.

If there are none available, or on display, why not order some?

You can get leaflets and posters from the Department of Health or your local PCT.

Examples of patient information leaflets.

� Supporting local campaigns

Find out if there are any antimicrobial campaigns running locally.

What are the key messages?

Have a chat with the rest of your pharmacy team and talk about what you can all doto support the campaign. Plan your roles and how you will measure the impact ofwhat you do.

20


� Raising awareness

Why not create a window display?

Have a chat with your team and design a professional and eye-catching windowdisplay that encourages people to use antibiotics only when they are needed. Youcould link this with travel health – or winter ailments.

Encourage local surgery staff to provide ideas and get involved; it will help to spreadawareness and understanding.

� Link with local schools

Consider extending these approaches by working with local schools. Perhaps youcould host a session at the school addressing the use of antibiotics – and get them todesign the window display for you!

� Running a campaign

Could you be involved in the designing and running of a new campaign?

The PCT or trust may be keen to get a new campaign up and running. By linking itin with a national event such as ‘Ask about medicines’ week, you may be able to accessmaterials more easily and get a co-ordinated approach across the PCT or trust area.

Find out about any plans your Local Pharmaceutical Committee has for aneducational campaign.

� Educating patients/parents and prescribers

Children are a good target audience for any education campaign on antibiotics.Thebenefits of educating children on the appropriate use of antibiotics is that they ofteneducate their parents – parents are reported to be a high pressure group, when itcomes to expecting antibiotics for their children. It also means that the children willgrow up with greater knowledge and understanding of the consequences of misuse.

Consider the following as ways of educating parents/patients:

� holding educational events at mother and toddler groups and nurseries� linking in with a Sure Start scheme� providing stickers for children when advice is requested regarding coughs and

colds.

Examples of ways of educating local school children include:

� holding a competition, asking them to design a poster on antibiotic use for thelocal surgery or hospital waiting room

� devising relevant crosswords or wordsearches for them to complete� putting on plays, involving theatre groups and local drama students.

� Getting team support

Gather your pharmacy team together to discuss antimicrobial use and ways you canwork as a group to deliver the same messages to patients and customers.

Think about using the situation that has developed nationally with MRSA as a wayto explain to patients the importance of appropriate use.

If you were designing a leaflet on antibiotic use think about the key messages youwould want it to contain?

21

Which approach would work

best in your practice?

S E C T I O N 2

Case studies

To help you answer the following cases, read through the MeReC Bulletin: Themanagement of common infections in primary care. 17(3) 2006 available online at:http://www.npc.co.uk/MeReC_Bulletins/MeReC_Bulletin_Vol17_No3_Intro.htm

Mary Sutton has just taken her six-year-old son Jamie to the GP, forsome antibiotics to clear his chest. He has had a cold for a week andhe is still sniffling and coughing. The GP wouldn’t prescribe anyantibiotics for Jamie and Mary has come in to complain about thesituation, as she is furious. How would you respond to her?

Turn to page 43 for suggested answers.

Claire Green asks your advice; her four-year-old daughter, Chloe, hasearache,which started this morning. On questioning her you discoverthat Chloe has severe ear pain, especially when eating. She also hasitching and hearing loss in both her ears. She swims regularly andhas not had a cold recently.What advice would you give Claire?

Turn to page 44 for suggested answers.A

A

2

1

22


Nicky Killion has had a cold and has now got a headache, nasaldischarge and facial pain. Nicky has had these symptoms for threedays now and has just visited her GP who has issued her aprescription for amoxicillin 500 mg, three times daily for seven days,and told to get it dispensed in a week if her symptoms do not improve,or at any time if the symptoms get worse. Nicky said she’s going to

take it now as she wants to feel better sooner rather than later. What advicewould you give?


Jane Green, a 34-year-old mother of two has had a cold for four daysand is coughing up green ‘phlegm’. She comes to see you to ask if sheneeds an antibiotic.What advice would you give?


A

4

3

23

S E C T I O N 2

Reflection

Take a moment now to return to the questions that we set you on pages 12 and 13at the start of this section.

Summary

� Change is needed on the part of both the prescriber and the patient in order toaffect the prescribing of antibiotics.

� The pharmacy team have a key role in advising prescribers and managingexpectations of patients.

� A range of methods have been used and shown to work in reducing inappropri-ate antibiotic usage.

� You can make your own decisions about the amount of support your team offersto patients and customers.

Intended outcomes


24


List four factors that can influence the prescribingof antibiotics.

Describe ways of influencing prescribers onappropriate use of antibiotics.

Suggest two ways of reducing inappropriateantibiotic prescribing.

Discuss ways pharmacists can improve andinfluence prescribing of antibiotics.

Section 3Preventing infection: infection control

Objectives

By the time you have completed this section you should be able to:

� discuss the purpose of infection control

� explain to all staff the importance of hand hygiene

� demonstrate the correct handwashing technique to a colleague

� list five ways of reducing infection spread

� give correct advice to concerned patients who are colonised withMRSA.

We have looked at how resistance develops and how you can support prescribers andpatients in reducing the inappropriate use of antibiotics. In this section we are goingright back to basics to consider the importance of prevention.

xercise 3

Before you read this section think about what infection control measures you

undertake on a daily basis:

� as part of your daily home life

� as part of your role within the healthcare team.

E

25

S E C T I O N 3

3.1 Infection control

Infection control is particularly important for community pharmacists and pharmacytechnicians who handle any bodily fluids; whether this is urine for pregnancy testingor chlamydia testing, blood samples for diabetes tests or sharps handling for syringeand needle exchange. It also has an impact on the hospital pharmacist and pharmacytechnicians who visit wards, as well as those involved in the preparation ofchemotherapy and total parenteral nutrition.

Infection control involves the development of preventative measures to protectpatients, healthcare workers and visitors in the healthcare setting. The measures areput in place to try to minimise the chances of acquiring an infection, which may bebacterial, eg, MRSA; viral, eg, norovirus; or parasitic, eg, malaria, from other peopleor from a contaminated environment or equipment.

In primary and secondary care there are infection control teams that work alongsidethe microbiologist or infection control doctor, to advise and train staff on infectioncontrol, monitor outbreaks and police the infection control policy.

Hand hygiene

Hand hygiene is the most important activity for reducing the spread of infection.The National Patient Safety Agency (NPSA) rolled out a ‘cleanyourhands’ campaignin 2004/2005 to all acute trusts in England and Wales. The campaign introducedeasily-accessible alcohol hand rub.The practical benefits of alcohol-based rubs are:25

� they are quick and easy to use

� they reduce bacteria at a greater rate than soap and water, and do not need to belocated by a sink

� they cause less skin irritation than soap.

Many healthcare professionals do not decontaminate their hands with alcohol gels asoften as they should, or use the correct handwashing technique.

Hands should be decontaminated before direct contact with patients and after anyactivity or contact that contaminates the hands, including after the removal of gloves.

Hands should be decontaminated between each patient. Hands that are visibly dirtymust be washed with soap and water and dried thoroughly.26 It is very important todry your hands thoroughly as wet surfaces transfer organisms more effectively thandry hands. Alcohol hand gels and rubs are an alternative to soap but they are not asubstitute for soap when you have dirty hands.

Adequate handwashing facilities must be available and easily accessible in all patientareas, treatment rooms, sluices and kitchens.The sinks in clinical areas should have tapsthat can be turned off without touching them with your hands and should be providedwith liquid soap dispensers, paper handtowels and foot-operated bins. Alcohol handgels must be available at the point of care in all primary and secondary care settings.

All healthcare staff, have a responsibility to their patients and must use the facilitiesavailable to prevent cross-infection. Any lack of facilities must be highlighted to theappropriate person in charge.

26

Hand hygiene is the most

important activity for reducing

the spread of infection.

P R E V E N T I N G I N F E C T I O N : I N F E C T I O N C O N T R O L

Practice pointYour local trust is trying to raise the awareness of hand hygiene.The trust islooking for strategies to improve compliance with the policy. List below anysuggestions you could put forward to improve this compliance.

Some ideas that we came up with include:

� a school competition to design a poster on handwashing – this educates childrenand their parents on hand hygiene and the winning poster can be displayed in allclinical areas

� training of all staff in infection control on an annual basis

� ensure alcohol gel is freely available in all clinical areas alongside posters to remindstaff and patients.

Protective equipment

It is important to protecting yourself and the patient, and prevent the risk of cross-infection by wearing personal protective equipment, ie, gloves, aprons and masks.Disposable gloves must be worn whenever there might be contact with blood andbodily fluids, mucous membranes or broken skin. Handwashing is still requiredbefore putting the gloves on and again on removal. When handling high risksubstances nitrile or latex gloves should be used, rather than polythene. Apronsshould be worn whenever there is a risk of contaminating clothing with blood andbodily fluids and when a patient has a known infection. Eye protection and masks areneeded if there is a risk of blood or bodily fluids splashing in the eye or on the face.Masks are also necessary if an infection is spread via an airborne route.

Most hospitals have an infection control policy which advises on the appropriateprecautions for any particular infection. In a hospital the ward area is likely to havean information sheet displayed.

Handling and disposing of sharps

The main health risk when handling sharps is a needlestick injury resulting in infectionwith hepatitis B, hepatitis C and HIV. Handling of sharps should be kept to aminimum and needles should not be re-sheathed. Sharps should be disposed of in aspecial container, at the point of use, away from children and the public. All staffshould be aware of the appropriate safety procedure in the case of a needlestick injury.

27

S E C T I O N 3

A flow chart showing an example of the procedure to follow after a needlestick injuryis shown below. The risk of infection depends on a number of factors:

� patient risk factors� HIV� hepatitis B� hepatitis C� injecting drug user

� staff immunity to hepatitis B

� the type of injury.

All source patients (ie, the source of the potentially contaminated blood) should beasked if they are willing to provide a sample of blood to test for blood-borne viruses.If there is a high risk of HIV transmission, then post-exposure prophylaxis (PEP) isrecommended.The Department of Health issue guidance on PEP:HIV Post-exposureprophylaxis: guidance from the UK Chief Medical Officers’ Expert Advisory Group onAIDS.27

FIGURE 2 Typical recommended safety procedure following aneedlestick injury

28

Encourage bleeding of the wound

Do not suck

Wash under running water

Do not scrub the wound

Report to your manager andoccupational health department

or local A&E

Fill in an accident form and assessthe risk

Injury from used needle –assessment of risk needs to becarried out by microbiologist,

or consultant for communicabledisease control

Clean/unused needle – no further action required


Handling and disposing of chemical waste

Disposal of unwanted medicines is listed as an essential service under the pharmacycontract in England andWales. Your place of work should have a procedure on thedisposal of waste, that should include cytotoxic, pharmaceutical and clinical waste.Clinical waste such as used sharps and swabs for finger-prick blood tests can bestored in the pharmacy, until collection for safe disposal. Sharps that are not collectedby the local authority (the preferred method) or part of a needle exchange scheme(enhanced service) can be disposed of by pharmacies. Further information on wastedisposal can be found from the Pharmaceutical Services Negotiating Committee(PSNC) or RPSGB websites:

PSNC – available online at: http://www.psnc.org.uk/

RPSGB – available online at: http://www.rpsgb.org.uk

All staff should have training on the correct way to handle waste and what to do incase of spillages.

Practice pointList the infection control measures you need to consider before providing aneedle exchange service.

Cleaning, disinfecting and sterilisation

It is important that all equipment is decontaminated between each patient use. Singleuse equipment should not be re-used. Devices designated for single patient use areclearly marked with the symbol shown below.

The Medicines and Healthcare products Regulatory Agency have received reportsof hepatitis B outbreaks in nursing and care homes following the use of the wrong

29

2

S E C T I O N 3

type of lancing device. For blood glucose monitoring, nursing and care homes mustuse either disposable single-use lancing devices (used once and then discarded) or anon-disposable lancing device which is intended for use on multiple patients, usedwith a disposable single-use lancet.28

Disinfectants are classified generically and their biocidal capacities are all different.Most disinfectants are capable of inactivating bacteria and enveloped viruses, butonly some have sufficient activity against non-enveloped viruses. Efficacy dependson choosing the correct disinfectant and using it correctly. Each trust will have theirown policy for the use of appropriate disinfectants and the infection control teamwill be able to give advice on appropriate agents. All staff using disinfectants shouldhave sufficient training.

Maintaining a clean clinical environment is important for reducing the spread ofinfections in all healthcare settings.

3.2 MRSA decolonisation

Patients who are admitted to hospital for elective surgery and those patients who aremoved into high-risk areas, ie, intensive care, are usually swabbed to see if they arecolonised with MRSA. Patients who are found to have MRSA, or on admission areknown to be previously positive for MRSA, are isolated in a side room. MRSAeradication is usually given to patients prior to surgery (as an outpatient) or while theyare inpatients. Eradication therapy usually consists of topical/nasal antibiotic ointments(mupirocin) and washes and shampoos (chlorhexidine).

Certain sites are more likely to act as carriage sites for MRSA. When a patient hasbeen found to be colonised or infected at one site, the remaining sites should beswabbed to assess the extent of carriage. The same sites are screened for clearanceafter a course of eradication therapy.

Sites more likely to be colonised/infected include:

� nose

� groin

� broken skin

� pressure sores

� wounds

� stoma sites

� entry sites of invasive devices

� sputum if intubated.

PatientswithMRSAcolonisation in the communitydonot normally require eradication.

The Joint Working Party of the British Society for Antimicrobial Chemotherapy,Hospital Infection Society and Infection Control Nurses Association have producedguidelines for the prophylaxis and treatment of MRSA infections in the UK. Theyare available online at:http://jac.oxfordjournals.org/cgi/content/full/57/4/589#SEC11

30


Dressings

Dressings can help eradicate MRSA and protect against MRSA. For patients withinfected or colonised ulcers or wounds, certain dressings can be used that are activeagainst MRSA, for example, Iodoflex, Iodosorb, Actisorb Silver 220. If a patient iscolonised with MRSA at another site, and has an open wound that is negative forMRSA, a dressing that protects against MRSA can be used to cover the wound, forexample, Allevyn, Granuflex or Duoderm.

3.3 Injections

Aseptic technique is important when drawing up injectable drugs. Pharmacists andpharmacy technicians should have their technique assessed regularly if they work inan aseptic unit drawing up chemotherapy or making total parenteral nutrition.

Injections should be prepared in a clean designated area, where contamination fromblood or bodily fluids is unlikely. Single use vials or pre-filled syringes should be usedif available.

Practice pointAfter reading this section have you identified any further measures youshould be taking to prevent infection within your area of practice?

Highlight any important points to the rest of your healthcare team.

If you work in secondary care consider organising a training session.Ask amember of your infection control team to run a lunchtime session to coverwhat is expected of pharmacy staff when visiting wards.

If you work in the community, consider organising a training session for anycare homes that you visit.

Case studies

JaneWhite, a local care assistant, asks your advice regarding one ofher residents. One of the ladies has just returned to the care homefrom hospital and she is having ‘eradication therapy’ for MRSA. Janewants to know if the other residents are at risk and if any specialprecautions are needed.5

31

S E C T I O N 3


Whilst visiting one of your regular wards, you come across a newpatient in a side roomwithClostridium difficile-associated diarrhoea.You need to enter the side room to assess the patient’s ownmedication and take a drug history. What infection control issuesshould you be aware of?


What infection control issues do you need to consider before settingup a diabetes testing service in your pharmacy?


A

7

A

6

32


Summary

� Avoiding inappropriate antibiotic usage includes avoiding infection and infectioncontrol is a key strategy for this.

� Simple measures, such as handwashing and the use of alcohol hand gels, havebeen shown to have a positive impact on reducing infections.

Intended outcomes


Suggested answer to Practice point (page 29)

Things to consider include:

� hepatitis B vaccinations for all staff

� gloves

� the procedure in case of a needlestick injury.

Note: Staff should not normally handle the sharps, they should be placed in the sharps

bin by the client. All staff must be trained in the risks associated with sharps injuries and

ways to avoid them.

A

33


Discuss the purpose of infection control.

Explain to all staff the importance of hand hygiene.

Demonstrate the correct handwashing techniqueto a colleague.

List five ways of reducing infection spread.

Give correct advice to concerned patients who arecolonised with MRSA.

34 Section 4Vaccination

Objectives


� describe the principles of vaccination

� advise parents on childhood immunisation

� name three live attenuated vaccines.

In this section we are going to review the other key method of preventing infection(other than infection control), ie, vaccination.

The best way to deal with infectious diseases is to prevent them. Vaccines and theiruse as part of national immunisation programmes continue to be among the mostimportant elements of public health in the UK.

4.1 How vaccines work

Vaccines contain either:

� a live attenuated form of the organism

� inactivated (killed) preparations of the organism, or

� extracts of or detoxified exotoxins produced by the organism.

When the vaccine is given it induces active immunity. So, if a vaccinated individualcomes across the natural infection at a later date their immune system will recognisethe infection and mount an immediate and appropriate response, thereby preventinginfection.

Live attenuated vaccines usually produce a long-term immunity, but this may notalways last as long as natural immunity. Where multiple doses of live vaccinationsare needed, they should either be given at the same time (at different sites, if not acombined preparation) or separated by an interval of four weeks or greater.

Inactivated vaccines often require a primary series of injections and boosters, toprovide a sufficient immune response.

V A C C I N AT I O N

4.2 Immunisation schedule

In the UK we have an active programme of childhood immunisation to prevent keydiseases.

The diseases that are prevented with childhood immunisations are:

� diphtheria

� Haemophilus influenzae type b (Hib)

� measles

� mumps

� rubella

� meningococcus group C

� pertussis

� pneumococcus

� poliomyelitis

� tetanus.

Let’s have a brief look at these infections and their complications. Remember, thesuccess of the immunisation schedule in preventing these infections is one of themost important factors in public health in the UK.

Diphtheria

Diphtheria causes serious upper respiratory tract infections. Diphtheria is caused bythe action of diphtheria toxin, produced by toxigenic Corynebacterium diptheriae orCorynebacterium ulcerans.

Since the introduction of the vaccine in the 1940s, diphtheria has now becomeinfrequent in the UK, but it is still prevalent in south-east Asia, South America,Africaand India.

High immunisation rates need to be maintained to prevent the re-emergence ofdisease which can result from the introduction of cases or carriers of toxigenic strainsfrom overseas.

Haemophilus influenzae type b (Hib)

Haemophilus influenzae type b is a bacterium which most commonly presents asmeningitis in children. Other presentations of Hib include epiglottitis, bacteraemia,septic arthritis, cellulites, pneumonia and pericarditis.

Hib disease is now rare, but before the introduction of the vaccine in 1992, one in 600children developed some form of Hib disease before their fifth birthday.

Measles

Measles is an acute viral illness, causing fever with a erythematous, maculopapularrash. Complications such as convulsions, pneumonia and encephalitis can occur.

Before the introduction of the vaccine in 1968 there were 100 deaths per year frommeasles.

35

S E C T I O N 4

Mumps

Mumps is caused by a paramyxovirus. The parotid glands (salivary glands betweenthe ear and the jaw) are usually both swollen, although sometimes only one may beaffected. Complications that can occur include pancreatitis, oophoritis (inflammationof the ovaries) orchitis (inflammation of the testes), deafness, meningitis andencephalitis.

Rubella

Rubella is caused by a togavirus, and the symptoms are a mild illness and rash.However, if a pregnant woman has rubella it can cause foetal loss or damage. If the childis born they are likely to have multiple defects; known as Congenital Rubella Syndrome.

The rubella vaccination was introduced in the UK in 1970 and given to girls priorto puberty, as well as women of childbearing age without immunity. As a result of thevaccination there has been a fall in the number of babies born with CongenitalRubella Syndrome.

Since 1988, immunisation against rubella has been as part of the measles, mumps andrubella vaccine.

Meningococcus group C

Meningococcal disease in the UK is usually a result of Neisseria meningitidis groupB or C. Meningococcal infection commonly presents as meningitis and septicaemia.To date there is no vaccine available against group B organisms.

Pertussis

Pertussis (whooping cough) is usually caused by Bordetella pertussis.Whooping coughis highly infectious and causes a prolonged and distressing cough. Major complicationsinclude pneumonia and brain damage.

In the UK, the pertussis vaccine was introduced in the 1950s and now the disease israre. However, even though only a small number of cases of pertussis are seen in theUK, it still remains a significant cause of illness and death in children under six months.

Pneumococcus

Pneumococcus is a bacterium which can cause a number of infections, includingbacteraemia, meningitis and pneumonia. Pneumococcus particularly affects the veryyoung, elderly, those with an absent or non-functioning spleen or immunosuppressedpatients. Pneumococcal antibiotic resistance has risen worldwide.

The pneumococcal conjugate vaccine was added to the routine childhood immunisationprogramme in 2006; prior to this it was only available to patients at high risk ofinfection.

Poliomyelitis

The polio virus infects the gastrointestinal tract and replicates; it then travels to thenervous system where it can cause a meningitis-like illness. Headache, gastrointestinaldisturbances, malaise, stiffness of the neck and back, with or without paralysis mayoccur.

In the UK, the first polio vaccine was introduced in 1956, as a result polio is now rare.

36


Tetanus

Tetanus is caused by the tetanus toxin released from a bacterium,Clostridium tetaniwhich is often found in soil. It causes severe rigidity and spasms of skeletal muscle.Tetanus is not spread from person to person and can not be eradicated, as spores arecommonly present in the environment.

Tetanus vaccination was introduced in the UK in 1961. Deaths from tetanus in theUK are largely in adults over 65 years of age.

For information on the current recommendations for childhood immunisations visit:http://www.immunisation.nhs.uk

4.3 Other immunisation campaigns

Tuberculosis (TB)

Prior to 2005 the Bacillus Calmette-Guerin (BCG) vaccine was given to all school-children in the UK. However, since 2005 vaccination has been targeted at ‘at-risk’individuals. The BCG vaccine is now recommended in the following populations:

� all infants in areas within the UK, where the incidence of tuberculosis is greaterthan 40 per 100,000 population per year

� infants, wherever they live, with one or more parent or grandparent born in acountry with a tuberculosis incidence of greater than 40 per 100,000

� previously unvaccinated new immigrants from countries with a high incidence oftuberculosis.

The protection given by the BCG vaccine has been shown to last between 10 to 15years. There is limited data on the effect of the vaccine in children over 16 years ofage. The vaccine is more effective at preventing more serious forms of the disease(TB meningitis in children), but is not as effective at preventing respiratory TB,which is the most common presentation in adults. The BCG vaccine is notrecommended for people over 16 years of age, unless the risk of exposure is high(eg, occupational contact or travel).

Influenza

The influenza virus is easily passed between individuals and is a major cause ofmorbidity and mortality each year in the UK.The influenza vaccine was first availablein the UK in the 1960s. It is now available annually to patients aged 65 years andolder, and to all patients aged six months or over in at-risk groups, health and socialcare staff directly involved in patient care, and people living in long-stay residentialcare homes and their carers.

Influenza strains change over time and the World Health Organization monitorsviruses throughout the world and recommends which strains are to be included in theannual vaccine.The changes that occur are classed as antigenic shift (minor changes)or antigenic drift (major changes) in the haemagglutinins (H) and neuraminidases(N) on the surface of the viruses.

Antigenic drift can lead to a new subtype with a different haemagglutinin protein,antigenic drift is seen more commonly in A rather than B strains.These new subtypescan result in a pandemic. Antigenic drifts can sometimes occur in animal species.The

37

S E C T I O N 4

CPPE open learning programme: Influenza provides further information and isavailable to download from the CPPE website.

Developmental work

Vaccines that are currently in development include ones that will protect against HIVand Helicobacter pylori.

Case studies

What advice would you give to a mother of a two-month-old baby,who is worried about the side-effects of the childhood immunisations?


Which vaccine would be required for a 35-year-old builder whopresents in the emergency department with a clean wound, but whocan’t remember previously receiving any tetanus vaccinations?


A

9

8

38


Describe the principles of vaccination.

Advise parents on childhood immunisation.

Name three live attenuated vaccines.


xercise 4

Which of the following are live attenuated vaccines?

Yes NoMeasles, mumps and rubella (MMR)

Pertussis

Polio

Tetanus

Diphtheria

Yellow fever


Summary

� The vaccination campaign is one of the most important components of publichealth in the UK.

� National vaccination programmes have reduced the occurrence of some infectiousdiseases almost to extinction.

� Some people may have concerns about the safety of vaccination campaigns andthe pharmacy team need to be prepared to offer accurate and professional adviceto parents who are concerned about the potential risk to their children.

Intended outcomes


E

A

39


Trimethoprim tablets 200 mg Three days Urinary tract 72-year-old lady with infection duetwice a day infection to a catheter

What we thought

No. Is the lady symptomatic? Patients with a catheter and asymptomatic bacteriuria

should not receive antibiotic treatment. If symptomatic then co-amoxiclav or

ciprofloxacin is usually given (for seven days).

A

Section 5Completing the learning experience

In this section we are going to review some of the learning points that we shared withyou during this learning programme.We are sharing our responses to the case studiesthat we included during the text, asking you to complete your CPD entries for thislearning programme and returning to the ten prescriptions that we included at thestart of Section 1.

5.1 Answers to exercises

Exercise 1

At the start of this learning programme (see page 2) we gave you a set of ten prescrip-tions and asked you to jot down whether you thought they were appropriate.

Have a go at the exercise again – we suggest that you redo the exercise without lookingback at your original answers. One of the reasons for repeating this exercise is to seewhether your thinking has changed as a result of the information you have acquiredwhile working through this learning programme.

These are our suggested answers. How do they compare with yours? For each one,we have provided a brief explanation for our choice.

A

40


Amoxicillin 125 mg/5 mL 125 mg Five days Sore throat Five-year-old child with a temperatureSugar-free suspension three times a day and sore throat for two days

What we thought

No. Most sore throats are viral and self-limiting. The child has only had symptoms for

two days. Paracetamol could be given to relieve temperature and pain. If antibiotics are

indicated, penicillin is usually the first choice.

A


Norfloxacin tablets 400 mg 14 days Urinary tract 41-year-old femaletwice a day infection

What we thought

Don’t know. Is this an upper urinary tract infection (UUTI) or an uncomplicated lower

urinary tract infection (LUTI)? If uncomplicated LUTI this prescription would be inappro-

priate. If UUTI then it is appropriate.

A


Erythromycin 125 mg/5 mL 125 mg Five days Otitis media Six-year-old child with earache,Sugar-free suspension four times a day no other symptoms

What we thought

No. Child just has earache and no other symptoms. We don’t know how long the child

has had symptoms for, but as there are no systemic symptoms this prescription is likely

to be inappropriate. Also, the dose is normally 250 mg four times daily for a six-year-

old.

A


Metronidazole tablets 400 mg Ten days Diarrhoea 61-year-old male inpatienttwice a day

What we thought

No. Metronidazole should be given three times a day. What is the cause of the

diarrhoea? If it is C.difficile then three times daily dosing would be appropriate.

A


Cefuroxime tablets 250 mg Seven days Post-operative 52-year-old femaletwice a day prophylaxis

following eyesurgery

What we thought

No. This is a treatment course not prophylaxis.

A

C O M P L E T I N G T H E L E A R N I N G E X P E R I E N C E 41


Ciprofloxacin tablets 250 mg Ten days Chest infection 24-year-old asthmatictwice a day

What we thought

Don’t know. Is the infection community or hospital acquired? If it is community-acquired

then the patient should be treated with amoxicillin first line.

A


Penicillin V tablets 500 mg Seven days Dental 38-year-old male with prostheticfour times a day prophylaxis heart valve

What we thought

No. This length of therapy would be a treatment course rather than the required

prophylaxis.

A


Metronidazole tablets 400 mg For four doses Bowel surgery 18-year-old male withat eight hour before surgery prophylaxis Crohn’s diseaseintervals

What we thought

No. Usually a single intravenous dose before surgery (500mg) cefuroxime or gentamicin

will also need to be prescribed.

A


Sodium fusidate infusion 500 mg Five days Cellulitis 58-year-old femalethree times a day

What we thought

No. Sodium fusidate should be administered with another antistaphylococcal antibiotic

to prevent resistance. Flucloxacillin and penicillin are usually first choice treatment for

cellulitis. If the patient has an MRSA infection, tetracyclines are normally used but if

sensitivities are known then sodium fucidate may be indicated, together with a

glycopeptide or rifampicin.

A

S E C T I O N 542

C O M P L E T I N G T H E L E A R N I N G E X P E R I E N C E

nswer to Exercise 4 (page 39)

Which of the following are live attenuated vaccines?

These are both live attenuated vaccines:

Measles, Mumps and Rubella (MMR)

Yellow fever

These three are not!

Pertussis

Tetanus

Diphtheria

And this one might be!

Polio

5.2 Case study answers

As you worked through the learning programme you were presented with a series ofcase studies to help you put things in to context. These are our suggested solutionsto them.

Mary Sutton has just taken her six-year-old son Jamie to the GP, forsome antibiotics to clear his chest. He has had a cold for a week andhe is still sniffling and coughing. The GP wouldn’t prescribe anyantibiotics for Jamie and Mary has come in to complain about thesituation, as she is furious. How would you respond to her?

Some important points that should come out in the discussion with Mary to

reinforce the GP include:

� Jamie has a viral infection that will not respond to antibiotic treatment

� coughs and runny noses can persist for two to three weeks following a cold

� coughs and colds will resolve without treatment

� she can purchase a decongestant to ease Jamie’s symptoms (decongestants are

considered as drugs of limited clinical value and are not usually included in minor

ailment scheme formularies. Should pharmacies still be recommending them?)

� she can purchase a soothing cough syrup, eg, simple linctus paediatric, as there is

some evidence to show that soothing syrups may reduce the frequency of coughing

� Jamie should get plenty of rest and drink plenty of fluid

� inappropriate antibiotic use leads to unnecessary side-effects and resistance.

A

1

A

43

S E C T I O N 5

Claire Green asks your advice; her four-year-old daughter, Chloe, hasearache,which started this morning. On questioning her you discoverthat Chloe has severe ear pain, especially when eating. She also hasitching and hearing loss in both her ears. She swims regularly andhas not had a cold recently.What advice would you give Claire?

From the information, it would seem that Chloe has otitis externa, which is five

times more common in regular swimmers. Other factors that can lead to otitis externa

are chemicals (hairspray), skin conditions and ear trauma. Otitis externa in swimmers

is due to any water remaining in the ear after swimming, becoming infected. Otitis

externa will need treatment with ear drops containing antibiotic and corticosteroid.

Claire should take Chloe to the GP. Advice should be given on keeping the ear dry whilst

swimming (swimming cap) or applying drops after swimming to dry the ear. The corner

of a towel should not be used to dry the ear as this can damage the ear, pushing any

alien bodies further into the ear. Painkillers, ibuprofen or paracetamol will help relieve

the pain. Acetic acid spray would be a suitable treatment also, but is not available over-

the-counter for children under 12 years.

Acute otitis media on the other hand is a self-limiting infection in 80 percent of cases.

Antibiotics are usually only required in children under two years old, with bilateral

infection, when there is discharge from the ear, the patient is systemically unwell, or has

recurrent infections. Acute otitis media is often associated with a recent cold and can

be managed initially with ibuprofen or paracetamol. If the child does not improve after

two to three days or is systemically unwell, referral to the GP would be advisable.

Nicky Killion has had a cold and has now got a headache, nasaldischarge and facial pain. Nicky has had these symptoms for threedays now and has just visited her GP who has issued her aprescription for amoxicillin 500 mg, three times daily for seven days,and told to get it dispensed in a week if her symptoms do not improve,or at any time if the symptoms get worse. Nicky said she’s going to

take it now as she wants to feel better sooner rather than later. What advicewould you give?

Sinusitis is usually a self-limiting condition. Antibiotics are not routinely needed.

Only 30-40 percent of patients with suspected sinusitis have a bacterial infection.

Antibiotics are recommended for patients with systemic illness, or those who have

several severe signs and symptoms that have lasted longer than seven to ten days or

worsen after five to seven days. Paracetamol or ibuprofen could be taken to relieve

pain. It can take up to two to three weeks for all symptoms to resolve – regardless of

whether antibiotics are being taken.

A

3

A

2

44


Jane Green, a 34-year-old mother of two has had a cold for four daysand is coughing up green ‘phlegm’. She comes to see you to ask if sheneeds an antibiotic.What advice would you give?

Nasty as it is, coughing up sputum (even if it is green) is often an indication the

cold is coming to an end (although antibiotics would not have helped her cold). She

should however see her GP if the cough persists over three or four weeks, if she becomes

short of breath, develops chest pains or if she already has an existing chest condition.

On the other hand, older patients with chronic obstructive pulmonary disease should

take antibiotics when they have a chest infection and start to cough up purulent sputum

(green and lumpy, with streaks of brown / blood) as they are at a higher risk of develop-

ing bacterial infections.

JaneWhite, a local care assistant, asks your advice regarding one ofher residents. One of the ladies has just returned to the care homefrom hospital and she is having ‘eradication therapy’ for MRSA. Janewants to know if the other residents are at risk and if any specialprecautions are needed.

The same infection control standards should be used for this lady as the other

residents of the care home. If good basic infection control measures are followedMRSA

carriers are not a risk to other residents, staff, visitors or family members. The lady can

still share a room with another resident as long as the person they are sharing with

does not have open wounds or invasive devices. She can sit in the communal areas

provided open wounds are covered by an impermeable dressing. She can still visit family

and friends outside the home.

A

5

A

4

45

S E C T I O N 546

Whilst visiting one of your regular wards, you come across a newpatient in a side roomwithClostridium difficile-associated diarrhoea.You need to enter the side room to assess the patient’s ownmedication and take a drug history. What infection control issuesshould you be aware of?

An infection control isolation notice should be posted on the entrance to the side

room indicating the infection and measures needed to take before entering, which

should then be followed.

Generally, before entering you should use alcoholic hand gel and put on an apron and

gloves. On exiting the room the apron and gloves need to be discarded in yellow bags

provided outside the side room. Afterwards wash hands with soap and water as alcohol

gel does not kill Clostridium difficile spores.

What infection control issues do you need to consider before settingup a diabetes testing service in your pharmacy?

Staff will need training on the risks of handling body fluids and a consultation

area must be used for the testing. Staff should wear gloves when handling body fluids

and all staff involved in testing will need to be vaccinated against hepatitis B and have

their blood titre checked regularly. Standing operating procedures should be in place

on needlestick injury, spillage of bodily fluids and disposal of clinical waste and sharps.

What advice would you give to a mother of a two-month-old baby,who is worried about the side-effects of the childhood immunisations?

You should emphasise the importance of the vaccinations by informing her how

serious these infections are. Without continued vaccination any of the diseases we

vaccinate against could return. Vaccines not only protect the individual, but also create

what is known as ‘herd immunity’. The side-effects from vaccines are generally mild

and self-limiting.

A

8

A

7

A

6


Which vaccine would be required for a 35-year-old builder whopresents in the emergency department with a clean wound, but whocan’t remember previously receiving any tetanus vaccinations?

As he has not received tetanus vaccinations previously he will need to be

vaccinated immediately with adsorbed diphtheria (low dose), tetanus and inactivated

poliomyelitis, followed by the completion of the course.

The final two activities in this section will help you to assess if you have met thelearning outcomes for this programme.

Two of the aims of the programme were to equip you with the knowledge to:

� design learning materials for your team and customers on avoiding antibioticresistance, and

� develop a protocol to support the introduction of infection control to yourworkplace.

Let’s look at how we have helped you meet those objectives.

5.3 Designing learning materials for your team and customers

We think that the key messages you need to put across in any learning materials aboutavoiding antibiotic resistance are relevant to both your team and your customers.The messages, or information, can be grouped under the following headings:

� why avoiding antibiotic resistance is important

� what is being done in your area

� how to recognise those occasions when antibiotics are needed.

Using these as headings, jot down the messages or information that you are going topass on to help your team and customers learn about avoiding antibiotic resistance.

Why avoiding antibiotic resistance is important.

A

9

47

S E C T I O N 5

What is being done in your area?

How do you recognise when antibiotics are needed?

Now make a note of when you plan to run through these issues with your team.

Think about the way you would you like them to approach your customers to passthe information on to them, and make a note of it here.

48


Consider what checks you may need to put in place to be sure that the relevantinformation is being passed on to customers.

Remember that you can also offer your team an opportunity to work through thislearning programme.

5.4 Develop a protocol for infection control in your workplace

In Section 3 we provided the information that you need to develop an infectioncontrol protocol.

Jot down the activities that you undertake in your workplace which involve any bodilyfluids (these could include needle and syringe exchange, urine testing, blood testingor other types of testing).

Use each of these activities as a separate heading and note the infection controlmeasures that your staff need to take.This will include considering where the activityshould take place, whether gloves need to be worn and what action needs to be takenif anything goes wrong.

Your protocol is likely to address:

� hand hygiene

� the use of protective equipment

� sharps handling

� the disposal of chemical waste

� other areas specific to where you practice.

Your CPD

Evaluation point

Now that you have reached the end of our learning programme, take a moment togo back to your reasons for starting it.

Have you met your personal objective(s)?

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S E C T I O N 5

What methods did you use to do that?

How can you show that you have met your objective(s)?

What difference will this make to the way that you practice as a pharmacist?

You can transfer your answers to these questions to your CPD record.

50

References and further reading

1. Department of Health Standing Medical Advisory Committee, Sub-group onAntimicrobial Resistance Occasional Report (1998). The path of least resistance.(London: Department of Health)

2. Wickens H andWade P (2005). Understanding antibiotic resistance. PharmaceuticalJournal 274: 501-504

3. Fleming A (1945). Penicillin. Nobel Lecture. December 11 1945. Availableonline at: http://nobelprize.org/nobel_prizes/medicine/laureates/1945/fleming-lecture.pdf (accessed 29.10.2007)

4. Goossens H, Ferech M,Vander Stichele R, Elseviers M for the ESAC Projectgroup (2005). Outpatient antibiotic use in Europe and association with resistance:a cross-national database study. The Lancet 365: 579-587

5. Wise R, Haut T, Cars O (1998). Antimicrobial resistance: is a major threat topublic health. British Medical Journal 317: 609-10

6. House of Lords Committee on Science and Technology (1998). Resistance toantibiotics (London:The Stationery Office)

7. Department of Health (2000). UKAntimicrobial resistance strategy and action plan(London: Department of Health)

8. Department of Health (2002). Getting ahead of the curve. A strategy for combatinginfectious diseases. (London: Department of Health)

9. Department of Health (2003). Winning ways:working together to reduce healthcareassociated infection in England. (London: Department of Health)

10. Department of Health (2006). Healthcare associated infections, in particular infectioncaused by Clostridium difficile. Dear Colleague letter. Available online at:http://www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/DearColleagueLetters/DearColleagueLettersArticle/fs/en?CONTENT_ID=4141036&chk=XLVabx (accessed 10.12.06)

11. Lord Soulsby of Swaffham Prior (2005). Resistance to antimicrobials in humansand animals. British Medical Journal 331: 1219–20

12. World Health Organization (2001). WHO Global strategy for containment ofantimicrobial resistance. (Geneva:WHO). Available online at:http://www.who.int/drugresistance/WHO_Global_Strategy_English.pdf(accessed 29.10.2007)

13. Avorn J, Solomon DH (2000). Cultural and economic factors that (mis)shapeantibiotic use: the non pharmacological basis of therapeutics. Annals of InternalMedicine 133:128-35

14. Britten N (1995). Patients’ demand for prescriptions in primary care – Patientscannot take all the blame for over prescribing. British Medical Journal 310: 1084-1085

15. HimmelW, Lippert-Urbanke E, Kochen MM (1997). Are patients more satisfiedwhen they receive a prescription? The effect of patients expectations in generalpractice. Scandinavian Journal of Primary Health Care 15: 188-122

16. Gill P, Scrivener G, Lloyd D, Dowell T (1995). The effect of patient’s ethnicityon prescribing rates. HealthTrends 27: 111-114

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17. Bauchner H, Pelton SI, Klein JO (1999). Parents, physicians, and antibioticuse. Pediatrics 103: 395–401

18. Gill PS, Dowell A, Harris CM (1997). Effect of doctors’ ethnicity and countryof qualification on prescribing patterns in single handed general practices: linkageof information collected by questionnaire and from routine data. British MedicalJournal 315: 1590-1594

19. Stolley PD, Becker MH, Lasagna L, McEvilla JD, Sloane LM (1972). Therelationship between physician characteristics and prescribing appropriateness.Medical Care 10(1): 17-28

20. Mangione-Smith R, Elliott M, Stivers T, McDonald L, Heritage J, McGlynn E(2004). Racial/ethical variation in parent expectations for antibiotics: implicationsfor public health campaigns. Pediatrics 113: e385-394

21. Hart AM, Pepper, GA, Gonzales R (2006). Balancing acts: Deciding for oragainst antibiotics in acute respiratory infections. Journal of Family Practice 55:320-335

22. CaudillTS, Lurie N, Rich ED (1992).The influence of pharmaceutical industryadvertising on physician prescribing. Journal of Drug Issues 22: 331-338

23. O’Brien MA, Freemantle N, Oxman AD,Wolf F, Davis DA, Herrin J (2001).Continuing education meetings and workshops: effects on professional practice andhealth care outcomes (Cochrane Review).Cochrane Database Systematic Reviews.CD003030.http://www.cochrane.org/reviews/index.htm (accessed 15.12.2006)

24. Little P, Gould C, Williamson I, Moore M, Warner G, Dunleavey J (2001).Pragmatic randomized controlled trial of two prescribing strategies in forchildhood acute otitis media. British Medical Journal 322: 336-42

25. National Patient Safety Agency (2004). Clean hands help save lives. Patient safetyalert 04. (London: NPSA)

26. National Institute of Clinical Excellence (2003). Infection control, prevention ofhealthcare-associated in primary care. (London: NICE) Available online at:www.nice.org.uk/pdf/Infection_control_fullguideline.pdf (accessed 19.12.2006)

27. Department of Health (2004). HIV Post-exposure prophylaxis: guidance from theUK Chief Medical Officers’Expert Advisory Group on AIDS. (London: Departmentof Health)

28. Medicines and Healthcare products Regulatory Agency (2006). Press release:MHRA issues safety warning over the use of lancing devices in nursing and care homes.6 December 2006. (London: MHRA)Available online at:http://www.mhra.gov.uk/home/idcplg?IdcService=SS_GET_PAGE&useSecondary=true&ssDocName=CON2025422&ssTargetNodeId=389(accessed 19.12.2006)

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R E F E R E N C E S A N D F U R T H E R R E A D I N G

Further reading

Bugs and Drugs on the web: http://www.antibioticresistance.org.uk/A UK website aimed at the public, which discusses issues of antibiotic resistance.Thewebsite is written by members of the Institute of Health Sciences, City University,London. The website has useful links to other resources.

Department of Health key documents

Department of Health Standing Medical Advisory Committee, Sub-group onAntimicrobial Resistance Occasional Report (1998). The path of least resistance.(London: Department of Health)

Department of Health (2000). UK Antimicrobial resistance strategy and action plan(London: Department of Health)

Department of Health (2002). Getting ahead of the curve. A strategy for combatinginfectious diseases. (London: Department of Health)

Department of Health (2003). Winning ways: working together to reduce health careassociated infection in England. (London: Department of Health)

Department of Health (2004). Towards cleaner hospitals and lower rates of infection: asummary of action. (London: Department of Health)

Department of Health (2005). Pandemic flu: key facts. (London: Department ofHealth)

Department of Health (2006). The Health Act 2006:Code of practice for the preventionand control of healthcare associated infections. (London: Department of Health)

Department of Health (2006). Immunisation against infectious disease:‘The green book’.3rd edition (London: Department of Health)This document provides further information on the individual vaccines and isavailable to download via the Department of Health website (http://www.dh.gov.uk).

Health Protection Agency

For information on antimicrobial resistance on the HPA website visit:http://www.hpa.org.uk/infections/topics_az/antimicrobial_resistance/menu.htm

National Institute of Clinical Excellence

National Institute of Clinical Excellence (2001). Standard principles for preventinghospital acquired infections. (London: NICE)

National Institute of Clinical Excellence (2003). Infection control, prevention ofhealthcare-associated in primary and community care. (London: NICE)

For more information on resistance and drug-resistant pathogens:

Wickens H andWade P (2005). Understanding antibiotic resistance. PharmaceuticalJournal. 274: 501-504

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Index

Aalcohol-based rubs, use of 26amantadine, use of 8animals and antimicrobials 7antimicrobials and animals 7automatic stop policy 18awareness raising 21

BCampylobacter gastroenteritis 7chemical waste 29children, involving 20, 21cleaning equipment 29clinical resistance 3conjugation 3

Ddefined daily doses 9delayed prescriptions 17diphtheria 35disinfectants, use of 30disinfecting equipment 29dressings, use of 31

Eenrofloxacin, use of 7

Gguidelines, use of 15

HHaemophilus influenzae type b (Hib) 35hand hygiene 26healthcare-associated infections monitoring 9Helicobacter pylori 38HIV 38

Iimmunisation Section 4, 34, 35inactivated vaccines 34infection control Section 3, 25, 26infection control protocol 49

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I N D E X

influences on prescribing 14influenza 37injecting technique 31intravenous to oral switch 18

Llancing devices, use of 30latex gloves, use of 27live attenuated vaccines 34local campaigns 20

Mmacrolide resistance 4measles 35mechanisms of resistance 4meningococcus group C 36methicillin-resistant Staphylococcus aureus (MRSA) 8microbiological resistance 3MRSA decolonisation 30mumps 36

Nneedlestick injury 27, 28nitrile gloves, use of 27

Pparent education 21patient expectation 14patient information 18, 19, 20patient-focused strategies 19, 20penicillin 4pertussis 36pharmacist-led initiatives 18pneumococcus 36poliomyelitis 36prescriber-focused strategies 15prescribing antimicrobials 8prescribing influences 14prescriptions, delayed 17preventing infection Section 3, 25primary resistance 3protective equipment 27

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I N D E X

Rresistance Section 1resistance surveillance 9rubella 36

Sschools, working with 20, 21secondary resistance 3serial point prevalence studies 9sharps, handling 27sterilisation equipment 29

Ttetanus 37training 17transduction 3transformation 3tuberculosis 37

Vvaccination Section 4, 34

Wwhooping cough 36

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