The Role of Pharmacist in Encouraging Prudent Use of Antibiotics and Averting Antimicrobial Resistance a Review of Policy and Experience Eng

7/21/2019 The Role of Pharmacist in Encouraging Prudent Use of Antibiotics and Averting Antimicrobial Resistance a Review of Policy and Experience Eng

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The role of pharmacist

in encouragingprudent use ofantibiotics and

averting antimicrobialresistance: a review of

olic and ex erience

HealthTechnologies

andPharmaceuticalsProgramme


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The role of pharmacist in encou

prudent use of antibiotics and a

antimicrobial resistance: a rev

policy and experience in Eur


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ABSTRACT

The good pharmacy practice (GPP)Joint FIP/WHO guidelineson GPP: standards forstates, The mission of pharmacy practice is to contribute to health improvement and t

problems to make the best use of their medicines. Based on the results of a literature relating to AMR and a survey conducted in the WHO European Member States, this re

pharmacists in this mission and, since they are often the first point of contact for patienimportant allies in the fight against antimicrobial resistance (AMR). The report illustrahave experience in treating patients with antibiotics, both responsibly and within an apalso indicates, however, that in many countries the general public can still buy antibiot

a diagnosis or prescription and use them at will. According to the survey, pharmacists positioned to influence the appropriate use of antibiotics and, therefore, have a crucialAMR alongside policy-makers and general practitioners: every player is key.

KEYWORDS

Antimicrobial drug resistanceMedicine, evidence-basedNon-prescription drugsPharmaceutical servicesData collection

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Alternatively, complete an online request form for documentation, health information, or for permisRegional Office web site (http://www.euro.who.int/pubrequest ).

World Health Organization 2014All rights reserved. The Regional Office for Europe of the World Health Organization welcomreproduce or translate its publications, in part or in full.

The designations employed and the presentation of the material in this publication do not implywhatsoever on the part of the World Health Organization concerning the legal status of any coof its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines o


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CONTENTS

EXECUTIVE SUMMARY....................................................................................................

INTRODUCTION................................................................................................................

BACKGROUND..................................................................................................................

OBJECTIVES.....................................................................................................................

METHODOLOGY................................................................................................................

LITERATURE SEARCH........................................................................................................

GOOD PHARMACY PRACTICE..............................................................................................

GLOBAL - FIP.................................................................................................................

SURVEY METHODOLOGY....................................................................................................

RESULTS............................................................................................................................

AMRRELATED PHARMACY ROLES:MAPPING THE LITERATURE............................................

GlobalGPPguidelines............................................................................................

SURVEY RESULTS..............................................................................................................

Characteristicsoftherespondents...........................................................................

Viewsoftherespondentsonthepotentialofhealthprofessionaltoinfluencethe

Access

to

antibiotics

.................................................................................................Monitoringconsumptionofantimicrobialmedicine...............................................

Antibioticstewardship..............................................................................................

Guidelinesonantibiotictreatment...........................................................................

Otherfindings...........................................................................................................

DISCUSSION......................................................................................................................

CONCLUSIONS....................................................................................................................

REFERENCES..................................................................................................................

ANNEXES...........................................................................................................................

ANNEX 1.LIST OF DOCUMENTS WITH REFERENCE TO THE ROLE OF PHARMACIST IN RELATION

ANNEX2.PHARMACYROLESINANTIMICROBIALRESISTANCELITERATUREMAP............................

ANNEX 3.ANTIBIOTICMEDICINESRELATED QUESTIONNAIRE FOR EUROPEAN PHARMACY/PH

ANNEX 4.COUNTRYSPECIFIC POLICY RECOMMENDATIONS.................................................


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The role of pharmacist in encouraging prudent use of antibiotic medicines and avea review of current polic

Executivesummary

Antimicrobial medicines play a major role in controlling infectious diseawidespread use often overuse and misuse is seeing a growing resistanTherefore, one of the key challenges facing countries is to ensure the besthis connection, it is important that any concerted action involve the examnecessary, improvement of the role of the pharmacist (including those wohospitals) as the main supplier and regulator of these medicines. This repindependent assessment of the current policy and guidance on the role of

pharmacy/pharmacist, maps their key roles in relation to antimicrobial resummarizes existing guidance for pharmacies/pharmacists and recent rese

performance of pharmacy systems in Europe.

The findings presented in the report are the result of a combination of pri

research, namely a survey conducted in the 53 Member States of the WHthrough a questionnaire addressed to pharmacy associations on current naservices/initiatives linked to prudent use of antibiotic medicines. This watargeted literature review of academic articles, grey literature and guidanthe role of the pharmacist. The literature identified has been categorized atype: patient information material; focus on the pharmacists role; policy AMR; and research articles (Annex 1).

Survey responses from 44 countries have been analysed and are presentedfindings show that access to antibiotics is regulated in most national contgreater or lesser degree. Therefore, while in some countries access to anti

prescription is only possible in emergency situations, the regulations in olevel of over- the-counter (OTC) sales. Most countries reported pharmacyinitiatives to foster the prudent use of antibiotics, such as educational camdevelopment of guidelines for consumers. Additionally, while the role an

pharmacist differ by country, an overwhelming majority of respondents wpharmacists are best placed to help combat AMR given their positions ofhealth-care system and the patient. At the same time, it was reported that vis antibiotic guidance, in partnership with pharmacists, could be strength

In taking the discussion on the specific role of the pharmacist forward, th


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The role of pharmacist in encouraging prudent use of antibiotic medicines and averting aa review of current policies and experiences in Europepage 2

Forum, and the WHO Collaborating Centre for Drug Development and PPharmakon (Denmark).


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Box 1. The 7 key areas problem of AMR

1. Strengthen intersectora

2. Strengthen surveillanc3. Promote rational use a

of antibiotic consumpti4. Strengthen infection co

health-care settings.5 Prevent emerging resis

INTRODUCTION

Background

As long as they have existed, antimicrobial medicines have played a majoinfectious diseases. However, their increasing widespread use has resulteresistant microorganisms, which are causing disease in community and h

resulting in increased morbidity and mortality, and higher health-care cosdevelop innovative antibiotic molecules over the last few decades has macombating resistant organisms more difficult (2).

The major cause of antimicrobial resistance (AMR) is the inappropriate uVarious studies carried out in and outside Europe revealed that over 40%antibiotics were more or less inappropriate. This was found to be directlytowards self-medication and the unnecessary use of antibiotics for comm

colds that most frequently are caused by viral infections on which antibio(3,4). As well as self-medication by patients (including the use of left-ovestudies identified problems, such as the illegal dispensing of antimicrobiasome European countries, as well as inappropriate prescribing by physici

The spread of AMR cannot be combated at the national level alone. It is arequires a coordinated effort.

Both European Union (EU) and WHO strategies for the control of AMR countries of the WHO European Region(7,8,9,10)).

The WHO health policy framework andstrategy,Health 2020: the European policy

for health and well-being (11), identifies

AMR as a major health challenge underpriority area 2, Tackling Europes majorhealth challenges: noncommunicable andcommunicable diseases.

TheEuropean strategic action plan on


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The overall goal must be to preserve our ability to treat serious infectionspreserving the effectiveness of antimicrobial medicines means to use themuse of antibiotics is essential in the face of increasing AMR, and it is the of all sectors of health care to cooperate on and tackle this issue. This is i

both human and animal health and action is required in both sectors; this human-related action.

Although multidrug-resistant strains of pathogens are increasing in hospireduction of AMR can only be obtained by addressing the outpatient use role of the community pharmacist is key to reducing the threat of AMR (who has the last contact with the patient before he or she receives an antithus, the pharmacist acts as the gatekeeper (14).

It is clear that a number of issues need to be addressed in the context of thcombating AMR. These include:

dispensing antimicrobials without a prescription; enforcing rules relevant to unauthorized dispensing; developing appropriate regulations, where necessary; using repeat prescriptions for antimicrobials; adjusting quantity dispensed vs quantity prescribed; managing waste (used antibiotics);

using pharmacies in campaigns to promote and conduct awareness onantimicrobials; providing information (pharmacist to patient) on antimicrobials, AMR

issues;

training pharmacy students and pharmacists in AMR and AMR-relate cooperating with prescribing physicians; providing antibiotic stewardship in primary-care settings.

Many countries and organizations have developed strategies for and guidHowever, most of the related policy documents do not include guidance o

pharmacists and pharmacies, or do so only to a very limited extent.

With this background in mind, there was a need to create an overview of


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METHODOLOGY

A targeted literature review was undertaken to analyse the status quo regaantibiotics and strategies to combat the growing AMR epidemic, as well

pharmacist in this respect. In addition, relevant guidance documents of vcountries and global organizations were collected and analysed. The resuthe basis of the GPP guidelines (1)and grouped according to the 4 key re

pharmacist outlined in their conceptual framework.

In addition, a survey was carried out in the 53 WHO European Member Scapturing the perception of pharmacists, patients, policy-makers and presavailability and consumption of antibiotics, as well as their views on howAMR crisis and ways in which stakeholders could contribute to doing so.

Literature

search

A literature map was conducted in September 2014 to identify evidence opharmacists and pharmacies in the use of antibiotics. A search of the NatBiotechnology Information Pubmed Central (NCBI- PMC) was carried ocombinations of key words (the numbers of articles found are mentioned

1. prudent use antibiotics pharmacist (9)

2. prudent use antibiotics pharmacy (42)3. prudent use antimicrobials pharmacist (11)4. prudent use antimicrobials pharmacy (47)5. antibiotic resistance pharmacists role(40)6. antimicrobial resistance pharmacists role (54)7. antibiotics irrational use pharmacist (10)8. antibiotics rational use pharmacist (49)9. reasonable use of antibiotics pharmacist (7)

10.inappropriate use of antibiotics pharmacist (125)11.unreasonable use of antibiotics pharmacist (0)12.role of pharmacist antibiotics prescription (45).

A search using the term pharmacy instead of pharmacist gave less rethat were also covered in the above-mentioned search


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This led to documents from organizations, such as the European Centre fand Control (ECDC), the International Pharmaceutical Federation (FIP), Group of the European Union (PGEU), and the WHO Regional Office focountry-specific strategies.

Goodpharmacypractice

The GPP guidelines (1)were chosen as the framework for analysing the lroles and activities in relation to AMR. They describe the standards necequality of pharmacy services, stating that the mission of pharmacy practhealth improvement and to help patients with health problems to make thmedicines. They identify 4 main roles with underlying functions in conninvolvement of or supervision by pharmacists is expected by society and serve (Fig. 1). In this report, the activities of pharmacists/pharmacies are

these 4 roles.Fig. 1. The roles of the pharmacist according to the GPP guidelines


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Global-FIP

In 2008, FIP published a revised statement on AMR entitled, FIP Statemof antimicrobial medicines resistance (AMR)(18), whereby FIP takes res

professional leadership through a range of activities. It urges pharmacists

provide proper counselling and appropriate written information when antimicrobials;

encourage patients to take the full prescribed regimen and, if not possiunused antimicrobial medicines appropriately;

work with prescribers so that dosages prescribed are sufficient for the continuation of a course of therapy;

recommend therapies other than antimicrobials for minor ailments; provide updated information on antimicrobial medicines to prescribers

professionals who administer or otherwise influence the use of medici be actively involved in matters of hygiene and infection control in all effectively monitor the supply and use of antimicrobials by their patien

At the health-system level, FIP urges governments and health authorities action directly related to community pharmacy:

develop and implement measures for the appropriate use of antimicrobdispensing and sale or supply of these medicines without a prescriptioqualified health-care professional;

strengthen the legislative and regulatory control of authorizations to mprescribe, dispense and otherwise supply antimicrobial medicines, andenforcement of statutes and regulations;

ensure that only authorized channels of distribution are used to minimcounterfeit and substandard medicines, thus assuring that available antrequired standards of safety, quality and efficacy;

conduct health-education campaigns that promote the appropriate use

collaborate with health-professional societies and associations to deveimplementation of educational and behavioural interventions that will appropriate antimicrobial prescribing.

Surveymethodology


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collaboration between the physician and the pharmacist on the approp monitoring of consumption of antibiotic medicines; educational activities relating to the prudent use of antibiotic medicin

availability/use of standard treatment guidelines; country-specific activities on the prudent use of antibiotic medicines,

pharmacist a specific role and responsibility; patient information related to the prudent use of antimicrobial medici

The questionnaire was developed in English and translated into Russian. in the countries during the period June- September 2014, using an electroinstrument. Europharm Forum and PGEU requested their members to comquestionnaire. In the case of the Republic of Serbia and countries where EPGEU are not represented, the Regional Office approached the ministriesnational medicines regulatory agencies through its country offices in thesreceived in Russian were translated and entered into the electronic survey

Office.

Descriptive analyses of the responses and frequency calculations were ca

RESULTS

AMRrelated

pharmacy

roles:

mapping

the

literature

The relevant literature was read and listed in 4 categories chosen for theiridentifying and better understanding ways of strengthening the prudent us

1. patient information;2. the professional role of the pharmacist;3. recommendations of organizations or institutions on how to handle th4. research articles describing and evaluating concrete activities or effor

1).

The results were further analysed and categorized according to the 4 fouroutlined in the GPP guidelines (Boxes 2-5) (Annex 2) (1).


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Box 2. GPP role 1: prepare, obtain, store, secure, distribute, administer, dispens

The following activities were identified as relevant to role 1 of the GPP guidelines (1):

establishment of internal quality procedures to prevent contamination whereby all antdated and stored;

ensuring the regular and fast supply of all antibiotics to avoid undertreatment, in connpharmacy describes the best dispensing practice, including the non-sale of partial doprescription;

provision of information - verbally (in a patient-friendly message) and/or in writing (inmessage) - on the appropriate use of antibiotic medicines (for example, when and foadverse reactions and interactions, and resistance issues;

provision of facilities conducive to encouraging patients to ask for advice, such as a don AMR;

provision of a medicine-waste-collection service to avoid misuse of antimicrobials.

Sources: Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenterControl of Antimicrobial Medicines Resistance (AMR) (18); Preventing antibiotic resistance we all Statement of Support for ANEPF(20); Irrational use of antibiotics and role of the pharmacists: an inNew Delhi, India (21); Foundation in pharmacy practice (22);Attitudes of community pharmacists toresistance: a qualitative study in Portugal (23); Self-medication with antibiotics in the Republic of Srpharmacy staff (24);ASHP statement on the pharmacists role in antimicrobial stewardship and infePGEU statement: community pharmacists contribution to the control of antibiotic resistance (26).

Box 3. GPP role 2: provide effective medication therapy management

The following activities were identified as relevant to role 2 of the GPP guidelines (1):

development of guidelines or a clinical decision-support system, including: directions for pharmacists on prescribing and when to refer to the doctor; recommendations on choice of drugs (one drug per bacteria, narrow-spectrum a recommendations on choice of drugs, based on interactions; recommendations on dosage, based on poharmacokinetic/pharmacodynamic (P

dynamics of the individual antibiotics (avoidance of overdosage) avoidance of duplicate therapy;

development of a test system (bacterial culture), re-evaluation of the need for antib

discussion with the doctor; follow-up with patients over the telephone to ensure adherence; encouragement of vaccination to avoid infections; avoidance of long-term antibiotic prophylaxis; counselling patients on symptomatic therapy and OTC medicines; educating and counselling patients and families about storage, handling devices a


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Box 4. GPP role 3: maintain and improve professional performance

The following were identified as relevant to role 3 of the GPP guidelines (1).

education of the pharmacy profession: symposia, self-study, e-learning, congresses, articles in professional journals, n undergraduate education (include AMR awareness); postgraduate education (for example, therapeutic drug monitoring).

focus on inappropriate dispensing through: financial incentives to dispense only according to prescription and standards/pro professional attitude (recognition of pharmacists responsibility).

Collaboration between: pharmacists and doctors in the interpretation of culture results and compliance w primary care and hospitals on follow-up of prescriptions.

Sources: The pharmacists role in promoting optimal antimicrobial use (13); UK five year antimicro

2018 (15); Strategy for tackling antimicrobial resistance (STAR) 2012-2017 (16);FIP Statement oMedicines Resistance (AMR) (18); EPSA statement of support for ANEPF (20); Irrational use of apharmacists: an insight from a qualitative study in New Delhi, India (21) ; Foundation in pharmacycommunity pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Popharmacists role in antimicrobial stewardship and infection prevention and control (25); The pharresistance (28); The role of pharmacist in limiting the spread of antibiotic resistance in India (29) ;all about? (31); Sale of regulated antibiotics without prescription. Research on the pharmacists atbehaviour(32);Antibiotic resistance (33); Impact of a program to reduce the dispensing of antibio(34);Availability and dispensing practices for antimalarials and antimicrobials in western Kenyan

Box 5. GPP role 4: contribute to improving effectiveness of the health-care sys

The following were identified as relevant to role 4 of the GPP guidelines (1):

public campaigns focusing on: the problem of AMR; prevention (for example, hand hygiene in schools); action by the individual (for example, in connection with antibiotic waste).

development and innovation (related mainly to pharmacists working in research): new treatments that meet the required standards; better diagnostic tools; collection of data on consumption and interventions;

development of national policywith the involvement of pharmacists: legislative action (for example, to prevent dispensing without prescription, or pre

same time by doctors);


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The literature search also revealed policy documents by global and countwhich include reference to the key roles and responsibilities of the pharmAMR.

Global GPP guidelines

The GPP guidelines (1)provide some guidance to pharmacies regarding The focus on AMR is expressed in role 1, for example, in the mention

medicines, dispensing and counselling according to national guidelinof unused medicines. Function 1.D Administration of medicines, vinjectable medications specifies that pharmacists should have an eimmunizer role, thus contributing to the prevention of diseases througvaccination programmes, by ensuring vaccination coverage and by alsafety.

Role 2 relates to pharmacist support to patients and prescribers in the use of medicines, according to the patients individual situation. Funcinformation about medicines and health-related issues specifies tha

be proactive in reducing antimicrobial resistance by providing informappropriate use of antimicrobials to consumers and prescribers.

Role 3 focuses on the importance of pharmacists maintaining a high l

skills and performance through continuing education and is generallyprofessional tasks. There is no specific mention of functions relating with role 3.

The focus of role 4 is on improving the effectiveness of health-care syhealth. Function 4.B Engage in preventive care activities and servi

pharmacists should engage in preventive-care activities that promote prevent disease, for example, in areas, such as smoking cessation, inf

sexually transmitted diseases.Country-specific examples, the organizations involved and policy recomm

of the pharmacist in relation to AMR are listed in Annex 4.

l


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Fig. 2. Proportions of respondents to the survey (total = 44)

Views of the respondents on the potential of health profesinfluence the use of antibiotics

Most of the respondents felt that policy-makers, pharmacists and prescribposition to improve the situation related to the appropriate use of antibiot

followed by professional associations and patient communities (Fig. 3). Ialong with the policy-makers, there were pharmacists who felt they had pmaking a difference in the use and consumption of antibiotics. In fact, 93agreed that pharmacists, as a health-professional group, are in one of the combat AMR and highlighted the key role pharmacists can play through

t t ith d ti t


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Fig. 3. Views of respondents on those in the best position to influence us

professional body/organization (total = 44)

Access to antibiotics

As discussed earlier in the report, there is a strong connection between th

antibiotics and resistance to them. Therefore, the survey included questioantibiotics with or without a prescription and over the counter. It was fouresponding countries (19 out of 44), it was legally possible to buy antibio(Fig. 4) and, therefore, pharmacists already have experience in treating pamedicines both responsibly and within an appropriate legal framework.

A number of respondents reported restrictions in OTC sales in their counantibiotics are legally available over the counter. These include erythrom

(Albania), fusafungin (Czech Republic), bacomycin (Norway), 24-hour dmedicines in emergency situations (Romania), antibiotics with local effecpreparations) (Serbia and Slovakia), and chloramphenicol eye drops for tconjunctivitis and azithromycin for the treatment of chlamydia (United Krespondents who reported that OTC sale of antibiotics was legal in their cmention any OTC sales restrictions.


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Fig. 4. Countries where OTC sales of antibiotics are legal

At the same time, only 12% of the respondents (5 out of 44 countries) reppossible to buy antibiotics without a prescription over the Internet (Fig. 5

difference between the regulation of Internet pharmacy sales and sales at is not clear whether the online pharmacies in question are legal.

Fig. 5. Countries where it is possible to buy antibiotics online without pre


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purchase from the latter is likely to be through a legitimate source with a

or directly from a veterinarian.

Fig. 6. Countries where it is possible to buy antibiotics outside the pharm

Monitoring consumption of antimicrobial medicine

Activities with great potential for reducing AMR include monitoring andconsumption of antimicrobial medicine through the regular collection of

prescriptions and use. The data on antibiotic use (based on the collection monitored through ECDC and the European Surveillance of Antimicrobi

Network (ESAC-net) (for European Union (EU) countries) and through tOffice for Europe (for non-EU countries) (Fig. 7).


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Fig 7. Countries monitoring antmicrobial consumption, 2014 (total = 53)

The authority responsible for the collection of data on antibiotic consumpEuropean country to another and an array of institutions is responsible (Fnet methodology is used in all countries (39).


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Fig. 8. Authority responsible for collection of data on antimicrobial consu

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21%

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Antibiotic stewardship

Antibiotic stewardship is an effective way of ensuring the prudent use of pharmacist plays a very important role in the antibiotic stewardship progrconducting therapeutic drug monitoring, consulting physicians and counswhich contributes to the prudent use of antibiotics (40).

According to the results of the survey, antibiotic stewardship is included h ti l i l i t f th di t i (Fi 9) I


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Fig. 9. Responses on inclusion of antibiotic stewardship in medical/pharmundergraduate and postgraduate curricula (total = 44)

Guidelines on antibiotic treatment

In 81% of the responding countries (36 out of 44), guidelines on antibioti(mainly) and/or separately by various institutions (Fig. 10). Most of the g

by professional associations, policy-makers, prescribers and pharmacists associations are a significant stakeholder group in the development of suc

pharmacists have an opportunity here to become more involved, as has bresponses indicating that pharmacists are in one of the best positions to c


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Fig. 10. Distribution of guidelines on antibiotic treatment in responding co

Fig 11: Authorities responsible for the development of guidelines on antib44)


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Other findings

The survey also revealed the following information.

In 31 of the 44 responding countries (70%), there are some activities to foster, the prudent use of antibiotics at the pharmacy level, such asawareness (including Antibiotic Awareness Day), AMR working groucampaigns.In approximately half of the responding countries (21 out

number of doses to be dispensed is adjusted for each patient in the phquantity requested and the duration of treatment stated on the prescripdispensing excess medication, which could potentially be used for sel

Close collaboration between pharmacists and doctors regarding medipatients was reported by 15 of the 44 responding countries; 20 respontheir countries, doctors can be influenced by pharmacists to change prdo not consider them appropriate.

13 respondents agreed that feedback from pharmacists to doctors is in 36 respondents agreed that pharmacists in their countries are in a posi

with relevant advice on the use of antibiotics; 30 agreed that pharmacwith detailed information on the use of antibiotics; and only 25 respodoctors provide patients with detailed information on this issue.

DISCUSSION

The survey shows that regulations on access to antibiotics at the pharmacInternet-based sales, are in place in most European countries. Wide accesnot be allowed and in countries where there are no restrictions to OTC anof antibiotics, regulations need to be introduced, particularly in view of thof purchasing medicine online. Lack of regulations pertaining to the avaiand access to antibiotics can lead to excessive consumption and an increa

countries where antibiotics are provided over the counter in emergenciesforms, ways should be considered of avoiding the negative effects of the in terms of AMR. Strict government policy and law enforcement related in pharmacies are, along with public-awareness campaigns, essential to alinked to AMR.


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provide inexpensive and simple-to-use methods of deoxyribonucleic acid

(DNA/RNA)-based identification of potentially multiple pathogens from they become available, these new forms of PoCT will make it possible toimmediately. A new activity is being piloted in the United Kingdom1whe

pharmacies in the London area are carrying out PoCT linked to sore throtonsillitis infection is detected, are supplying penicillin-V (or in case of aThis is made possible though pharmacy-based patient group direction (PGlegal framework that allows certain registered health professionals to supspecified medicine(s) to a predefined group of patients, without their havHowever, supplying and/or administering medicines under PGD should bsituations in which doing so offers the advantage of patient care without csafety. This pilot project is an example of how the role of the communityappropriate use of antibiotics for bacterial tonsillitis infection is being expStates, a similar pharmaceutical service is in use (42).

Evaluations on the role of rapid diagnostics/PoCT in other countries wheused would be welcome. The usefulness of novel diagnostic tests is clearopportunity of swiftly distinguishing cases for which antibiotics are not ncan safely be withheld. Information about new patient-centred models forantibiotics, including the use of PoCT in a variety of relevant settings, is could pave the way to a more efficient, targeted use of antibiotics and woreversing the AMR trend. Better diagnoses would lead to an important reantibiotics.

To tackle the issue of AMR, multiple interventions are needed, also by ph

community pharmacist must engage in various public-health initiatives rethe appropriate dispensing of antibiotics, the restriction of irrational dispeabout greater patient awareness of the importance of avoiding self-medicdiagnosis and of the increasing problem of AMR (43-45).

Surveillance of the use of antibiotics can be strengthened. There is a longthe use of medicines in most EU countries but efforts to this end should beastern Europe. WHO has supported related activities in non-EU countrie

created in 2011 to complement ECDC activities to monitor the use of antthrough wholesale data (46). Data from 42 countries and regions in the Won wholesale of antimicrobial medicines in 2011 indicate an almost fourfthe lowest and highest numbers of antibiotic users. Mapping consumptiontowards identifying and tackling the growing public problem of AMR. A

i f h li i i d f ibi i h ld l b


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curricula, it is crucial that the information provided in these courses is timimportance of the roles of the medical and pharmaceutical professions in use of antibiotics. Also, as 8 countries did not respond to the questionnaifor the whole Region in this respect is not yet clear. The Regional Office complete the mapping exercise through follow up with the countries in qu

National and local efforts are needed to enhance the antibiotic stewardshEurope. With reference to research on undergraduate and postgraduate m

variation was found among the countries with respect to the principles ofantibiotics (40,47). There is a need to optimize knowledge about choice oregimens, monitoring adverse effects, and limiting collateral damage in thWith AMR increasing worldwide, the role of the pharmacist is manifold the choice of antibiotics administered, ensuring access, and carrying out tmonitoring. If practised effectively, pharmacists in antibiotic stewardshipto ensure the rational use of antibiotics.

Shaping the behaviour of all health professionals as has been done, for Netherlands - could be useful in all countries. Generally, this is most easat an early stage, hence the importance of updating undergraduate curricuin combination with postgraduate educational strategies and interventionsaimed at all health professionals and through awareness-raising campaignwith the public on the importance of the prudent use of antimicrobials.

CONCLUSIONS

This report identifies multiple activities related to the prevention of AMRcommunity pharmacists could be involved and indicates that pharmacistssuggestions and initiatives regarding the prudent use of antibiotics and thBased on the examples identified, the potential of the pharmacist in this rexplored to a great extent. However, pharmacy organizations have develo

documents. At the policy level (EU or national), the pharmacist is seen asthe health system which, in many countries, provides the funding for phapharmaceutical-care services.

In some countries, there is scope at the national level to address adherencand guidance on the use of antibiotic medicines from the perspectives of

Th l f h i t i i d t f tibi ti di i d


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pharmacist as an effective liaison between prescriber and patient. Improv

between the two in relation to diagnosis, type of antibiotics prescribed anto ensure appropriate prescribing. In addition, patients should be well coufor and use of antibiotics, adverse effects, consequences of incomplete do

problem of AMR. Thus, a team-based approach to patient care is needed.

We must recognize the ability of pharmacist feedback (especially within national/regional guidelines) to influence prescribing positively and, thus

The search for information on AMR and action taken in community pharrevealed many examples of antimicrobial stewardship programmes for hoin primary care that the greatest proportion of antibiotics is prescribed anantimicrobial stewardship programmes need to be extended to and integrThe analysis of the role of the pharmacist on the basis of the 4 GPP roles

pharmacy systems show that countries could utilize their pharmacy systecombat AMR and improve the health of their populations.

The capacity of the pharmacist is underestimated. Pharmacists are key hethe skills and training required to contribute to the reduction of AMR. It irecognize and use their potential. While, in many countries of Europe, phthe capacity to take on additional roles and responsibilities to foster the pmedicine, in some, a special effort will be necessary to update the pharmensure that it includes antibiotic stewardship.

In terms of next steps, the results of the survey point to the need to:

1. ensure pharmacist input in the development of national plans on AM2. develop a catalogue describing recommended action at the different leand pharmacist-led);

3. encourage the sharing and adoption of good practices;4. establish the community pharmacists role (and value) in general strat

AMR, thereby making it visible to health authorities, other health-car

professional organizations;

5. increase efforts to tackle illegal online pharmacies and the illegal tradthe black market, in pharmacies or from other outlets;

6. foster better collaboration between pharmacists and prescribers.

Improvements in these areas should be shared across and between countribl h i l Offi ld f ili hi i


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The role of pharmacist in encouraging prudent use of antibiotic medicines and ave


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antibiotic prescribing in primary care for clinical syndromes subject trecommendations to reduce antibiotic resistance, UK 1995- 2011. JouChemotehrapy. 2014;doi:10.1093/jac/dku291(http://jac.oxfordjournals.org/content/early/2014/08/01/jac.dku291.fu

5. Vnnen MH, Pietil K, Airaksinen M. Self-medication with antibiohappen in Europe? Health Policy. 2006;77(2):166- 71(http://www.ncbi.nlm.nih.gov/pubmed/16095749).

6. Reeves DS, Finch RG, Bax RP, Davey PG, Li Wan Po A, Lingam G antibacterials without prescription (also called over-the-counter usAntimicrobial Chemotherapy. 1999;44:163- 77(http://jac.oxfordjournals.org/content/44/2/163.full.pdf+html).

7. Skliros E, Merkouris P, Papazafiropoulou A, Gikas A, Matzouranis GSelf-medication with antibiotics in rural population in Greece: a crossstudy. BMC Family Practice. 2010;11:58 ( http://www.biomedcentra2296/11/58).

8. European strategic action plan on antibiotic resistance. Copenhagen: Wfor Europe; 2011 (EUR/RC61/14 + EUR/RC61(Conf.Doc./7);http://www.euro.who.int/en/about-us/governance/regional-committee

i / i t fi t i /d t ti / ki d t / d14

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11.Health 2020: a European policy framework and strategy for the 21st

cWHO Regional Office for Europe; 2013(http://www.euro.who.int/__data/assets/pdf_file/0011/199532/Health

12.Resolution WHA67.25 on antimicrobial resistance. Geneva: World H2014 (http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_R25-en.p

13.Dickerson LM, Carek PJ. The pharmacists role in promoting optimaPharmacotherapy: The Journal of Human Pharmacology and Drug Th

23(http://onlinelibrary.wiley.com/doi/10.1592/phco.20.7.711.35171/absD5AF670DEFDA488C2D220CE2DD.f04t04?systemMessage=Wiley+be+disrupted+on+the+18th+October+from+10%3A00+BST+%280+essential+maintenance+for+approximately+two+hours+as+we+make+our+services+to+you).

14.Strategies to minimize antibiotic resistance. International Journal of E

and Public Health. 2013;10(9):4274-

305 (http://www.ncbi.nlm.nih.g15.Department of Health, Department for Envoironment, Food and Rura

antimicrobial resistance strategy 2013 to 2018. London: Department o(https://www.gov.uk/government/publications/uk-5-year-antimicrobi2013-to-2018).

16.Strategy for tackling antimicrobial resistance (STAR) 2012-2017. BeHealth, Social Services and Public Safety; 2012 (http://www.dhsspsn

17.Aagard Thomsen, Frkjr B, Rossing C, Herborg H. Assessment of pselected countries. Identification of literature and experiences. DecemPharmakon; 2011(http://www.google.dk/url?sa=t&rct=j&q=&esrc=s&source=web&cd&url=http%3A%2F%2Fwww.pharmakon.dk%2Fdata%2Ffiles%2FAssessment%2520of%2520pharmacy%2520systems_WEB_samlet.pdfOO-VgZgH&usg=AFQjCNF9EZ4CJT54nP8HlYTa_yrK7cJavw&sig

YaM00PSW2Lim7g&bvm=bv.77880786,d.ZWU).

18.FIP Statement of policy control of antimicrobial medicines resistanceInternational Pharmaceuticals Federation (FIP); 2008(http://www.fip.org/www/uploads/database_file.php?id=289&table_i



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p g g pa review of current polic

23.Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, Herd

community pharmacists to antibiotic dispensing and microbial resistain Portugal. International Journal of Clinical Pharmacy. 2013;35:417-

24.Markovic-PerkoviV, Grubia N. Self-medication with antibiotics incommunity pharmacies: pharmacy staff. Pharmacoepidemiology and 2012;21(10):1130- 33.

25.ASHP statement on the pharmacists role in antimicrobial stewardshiprevention and control. American Journal of Health-System Pharmac(http://www.ashp.org/DocLibrary/BestPractices/SpecificStAntimicroOctober 2014).

26.PGEU statement: community pharmacists contribution to the controlApproved by the General Assembly on 17 November 2009. Brussels:of the European Union; 2009(http://europharm.pbworks.com/f/09.11.17E+PGEU+Statement+on+AAPPROVED+GA.pdf, accessed 11 November 2014).

27.ECDC corporate strategies for disease-specific programmes. StockhoDisease Prevention and Control; 2010(http://www.ecdc.europa.eu/en/publications/Publications/100714_COse-specific_programmes_2010-2013.pdf, accessed 26 October 2014).

28.McCoy D, Toussaint K, Gallagher JC. The pharmacist's role in prevenresistance. US Pharmacist.2011;36(7):42- 9

(http://www.uspharmacist.com/content/d/feature/c/29137/accessed 229.Rahman AU. The role of pharmacist in limiting the spread of antibiot

International Journal of Pharmaceutical Research and Bio-Science. 20(http://www.ijprbs.com/issuedocs/2013/10/IJPRBS%20447.pdf, acce

30.Madaras-Kelly K, Hannah E, Bateman K, Samora M. Experience witsupport system in community pharmacies to recommend narrow-specnonantimicrobial prescriptions and OTC products to decrease broad-s

use. Journal of Managed Care Pharmacy. 2006;12(5):390-

7.31.Antimicrobial stewardship: whats it all about? Australian Prescriber.

(http://www.australianprescriber.com/magazine/36/4/116/20, accesse

32.Stoyanova R, Dimova R, Raycheva R. Sale of regulated antibiotics wR h h h i i d d f i b h

The role of pharmacist in encouraging prudent use of antibiotic medicines and averting a


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p g g p ga review of current policies and experiences in Europepage 4

and-antimicrobials-in-western-kenyan-pharmacies-2167-7689.100010October 2014).

36.Andr M, Vernby , Berg J, Lundborg C. A survey of public knowlerelated to antibiotic use and resistance in Sweden. Journal of Antimic2010;65(6):1292- 6 (http://jac.oxfordjournals.org/content/65/6/1292.October 2014).

37.Coleman CL. Examining influences of pharmacists communication w

antibiotics. Health Communication. 2003;15:1:79-

99.38.Fact sheet. Fighting antibiotic resistance by ensuring the rational use

Amsterdam: Health Action International (HAI) Europe; 2011 (http://hcontent/uploads/2012/02/HAI-EUROPE-Fact-Sheet-Antibotic-ResistOctober 2014).

39.European Surveillance of Antimicrobial Consumption Network (ESAStockholm: European Centre for Disease Prevention and Control; 201(http://www.ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pag

40.Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stVirulence. 2013;4(2)192- 202 ( http://www.ncbi.nlm.nih.gov/pmc/art

41.Yagudina RI, Kondratieva B.B. . .. , .. . [Standard of good pharmacy practice (GPP) and the future of the phar

Collection of materials]. Moscow: Russian Congress of Pharmaceutic42.Klepser DG, Bisanz SE, Klepser ME. Cost-effectiveness of pharmaci

adult pharyngitis. The Americal Journal of Managed Care. 2012;18(4

43.Yagudina RI. .. [The role of pharmacies in the modern health cachievements and challenges]. Pharmaceutical Effective Management]. 2012;7:(22-7).

44.Porseva NY, Soloninina AV, Krupnova IV. : [On the professional compe

profile: delineation of functional responsibilities of pharmacists]. [Quality of Manag



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a review of current polic

47.Ohl CA, Luther VP. Health care provider education as a tool to enhan

stewardship practices. Infectious Diseases Clinics of North America. (http://www.sciencedirect.com/science/article/pii/S089155201400014

48.Soloninina AV. , [Role of the pharmacist and its implemelegislation, regulation and training]. [Moscow P13.

49.Soloninina AV. / .. // [Pharmacist role as a

drugs should be strengthened]. [Ph

2008;36:34.

The role of pharmacist in encouraging prudent use of antibiotic medicines and averting ai f t li i d i i E


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a review of current policies and experiences in Europepage 6

ANNEXES

Annex1.Listofdocumentswithreferencetotheroleo

relationtoAMR

Category1

and no.ofdocument

Document reference

1.1 Andr M, Vernby , Berg J, Lundborg C. A survey of public knowrelated to antibiotic use and resistance in Sweden. Journal of AntChemotherapy. 2010;65(6):1292- 6 (http://jac.oxfordjournals.org/caccessed 20 October 2014).

1.2 Preventing antibiotic resistance we all have a role to play. Dehli

Association (IPA); 2011 (http://ipa.medlineindia.com/2011/11/25/presistance-%E2%80%93-we-all-have-a-role-to-play/ , accessed 20

2.1 Survey on activities related to antibiotic awareness, internal note 13,03,21E 008FS. 2013.

2.2 EPSA Statement of support for ANEPF. Brussels: European PharAssociation; 2013 (http://www.epsa-online.org/doc/epsa%20doc/EPSA%20statement%20of%20suppo0France.pdf, accessed 20 October 2014).

2.4 ECDC corporate strategies for disease-specific programmes. StocCentre for Disease Prevention and Control; 2010(http://www.ecdc.europa.eu/en/publications/Publications/100714_Cease-specific_programmes_2010-2013.pdf, accessed 26 Octobe

2.5 Stoyanova R, Dimova R, Raycheva R. Sale of regulated antibioticResearch on the pharmacists attitudes and patterns of economicof Sciences. 2012;10(4):71- 5 (http://tru.uni-

sz.bg/tsj/Vol.10,%20N%204,%202012/R.Stoyanova_2.pdf, acces2.6 McCoy D, Toussaint K, Gallagher JC. The pharmacist's role in pre

resistance. US Pharmacist.2011;36(7):42- 9(http://www.uspharmacist.com/content/d/feature/c/29137/accesse



36/57

a review of current polic

2.7 Rahman AU. The role of pharmacist in limiting the spread of antib

International Journal of Pharmaceutical Research and Bio-Scienc(http://www.ijprbs.com/issuedocs/2013/10/IJPRBS%20447.pdf, ac2014).

2.8 Dickerson L, Mainous A, Carek P. The pharmacists role in promouse. Pharmacotherapy. 2000;20(6):711- 23.

2.9 Kotwani A, Wattal C, Joshi P, Holloways K. Irrational use of antibpharmacists: an insight from a qualitative study in New Delhi, IndiPharmacy and Therapeutics. 2012;37:308- 12.

2.10 Whalley B, Fletcher K, Weston S, Howard R, Fawlinson C. Foundpractice. London: Pharmaceutical Press; 2008.

2.11 Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, of community pharmacists to antibiotic dispensing and microbiaqualitative study in Portugal. International Journal of Clinical Pha24.

2.12 Coleman CL. Examining influences of pharmacists communicatantibiotics. Health Communication. 2003;15:1:79- 99.

2.13 Markovic-PerkoviV, Grubia N. Self-medication with antibioticscommunity pharmacies: pharmacy staff. Pharmacoepidemiology2012;21(10):1130- 33.

2.14 Madaras-Kelly K, Hannah E, Bateman K, Samora M. Experiencesystem in community pharmacies to recommend narrow-spectruprescriptions and OTC products to decrease broad-spectrum anManaged Care Pharmacy. 2006;12(5):390- 7.

2.15 McKenzie D, Rawlins M, Mar CD. Antimicrobial stewardship: whPrescriber. 2013;36:116- 20 (http://www.australianprescriber.coaccessed 21 October 2014).

3.1 ASHP statement on the pharmacists role in antimicrobial stewaand control. American Journal of Health-System Pharmacy. 201(http://www.ashp.org/DocLibrary/BestPractices/SpecificStAntim

2014).

3.2 PGEU statement: community pharmacists contribution to the coApproved by the General Assembly on 17 November 2009. Bruthe European Union; 2009

3 3 Fact sheet Fighting antibiotic resistance by ensuring the rationa

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3.7 FIP Statement of Policy Control of Antimicrobial Medicines ResiInternational Pharmaceuticals Federation (FIP); 2008.http://www.fip.org/www/uploads/database_file.php?id=289&tabl2014).

4.1 Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernanto reduce the dispensing of antibiotics without a prescription in S2013;11(4):185- 90 (http://www.ncbi.nlm.nih.gov/pmc/articles/PM2014).

4.2 Roque F, Soares S, Breitenfeld L, Lpez-Durn A, Figueiras A, community pharmacists to antibiotic dispensing and microbial rePortugal. International Journal of Clinical Pharmacology.2013;3

4.3 Wafula, F. Availability and dispensing practices for antimalarialsKenyan pharmacies. Pharmaceutical Regulatory Affairs. 2013:2(http://www.omicsgroup.org/journals/availability-and-dispensing-antimicrobials-in-western-kenyan-pharmacies-2167-7689.100012014).

4.4 Skliros et al. Self-medication with antibiotics in rural population imulticenter study. BMC Family Practice. 2010;11:58 (http://www2296/11/58, accessed 21 October 2014).

4.5 Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernanto reduce the dispensing of antibiotics without a prescription in S2013;11(4):185- 90 (http://www.ncbi.nlm.nih.gov/pmc/articles/PM2014).

4.6 Tonna, AP, Stewart, DC, West, B. and McCaig, D. J. Exploring pfeasibility and value of pharmacist prescribing of antimicrobials iInternational Journal of Pharmacy Practice. 2010;18:31219(http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7174.2010.000October 2014).

4.7 L Ecker, Ochoa TJ, Vargas M, Del Valle MJ, Ruiz J. Factors affeavailable without a prescription in Peru. Pediatrics. 2013;131(6)(http://www.ncbi.nlm.nih.gov/pubmed/23690517, accessed 22 O

The role of pharmac


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Annex 2. Pharmacy roles in antimicrobial resistance lit

Categoryand no.4ofdocument

Document reference Country/region(year)

Action, prapharmacistpharmacy

Role 1: preobtain, stosecure, disadministerdispense a

dispose of products1.1 Andr M, Vernby , Berg J, Lundborg C. A

survey of public knowledge and awarenessrelated to antibiotic use and resistance inSweden. Journal of AntimicrobialChemotherapy. 2010;65(6):1292- 6(http://jac.oxfordjournals.org/content/65/6/1292.long, accessed 20 October 2014).

Sweden (2010)

1.2 Preventing antibiotic resistance we all

have a role to play. Dehli: IndianPharmacist Association (IPA); 2011(http://ipa.medlineindia.com/2011/11/25/preventing-antibiotic-resistance-%E2%80%93-we-all-have-a-role-to-play/, accessed 20October 2014).

India (2011) Counselling

appropriate resistance aadverse effe

4The references are categorized according to the main focus of the documents in question:

related to handling the problem; (4) research articles.5International Pharmaceutical Organization, WHO.Good pharmacy practice. Joint FIP/WHOPharmaceutical Federation; 2012(http://www.fip.org/files/fip/WHO/GPP%20guidelines%2

The role of pharmacist in encouraging prudent use of antibiotic medicines and averting antia review of current policies and experiences in Europe


39/57


2.1 Survey on activities related to antibioticawareness, internal note from PGEU. Ref13,03,21E 008FS. 2013.

Europe (2013) Over-the-coinformation patients on use.Leaflets andon antimicroresistance.

2.2 EPSA Statement of support for ANEPF.Brussels: European PharmaceuticalStudents Association; 2013(http://www.epsa-online.org/doc/epsa%20doc/EPSA%20statement%20of%20support%20for%20ANEPF%20France.pdf, accessed 20 October2014).

Europe (2013) Ensure a requick supplytypes of antpharmaciesmaximize acProvide cominformation drug treatmeCollect and of unused a

2.4 ECDC corporate strategies for disease-specific programmes. Stockholm:European Centre for Disease Preventionand Control; 2010(http://www.ecdc.europa.eu/en/publications/Publications/100714_COR_Strategies_for_disease-specific_programmes_2010-2013.pdf, accessed 26 October 2014).

Europe (2010)

The role of pharmac


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2.5 Stoyanova R, Dimova R, Raycheva R. Saleof regulated antibiotics without prescription.Research on the pharmacists attitudes andpatterns of economic behavior. TrakiaJournal of Sciences. 2012;10(4):71-5(http://tru.uni-sz.bg/tsj/Vol.10,%20N%204,%202012/R.Stoyanova_2.pdf, accessed 20 October2014).

Bulgaria (2012)

2.6 McCoy D, Toussaint K, Gallagher JC. Thepharmacist's role in preventing antibioticresistance. US Pharmacist.2011;36(7):42-9(http://www.uspharmacist.com/content/d/feature/c/29137/accessed 21 October 2014).

USA (2011)

The role of pharmacist in encouraging prudent use of antibiotic medicines and averting antia review of current policies and experiences in Europe


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page 12

2.7 Rahman AU. The role of pharmacist in

limiting the spread of antibiotic resistancein India. International Journal ofPharmaceutical Research and Bio-Science. 2013;2(5):237- 45(http://www.ijprbs.com/issuedocs/2013/10/IJPRBS%20447.pdf, accessed 21 October2014).

India (2013)

The role of pharmac


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2.8 Dickerson L, Mainous A, Carek P. Thepharmacists role in promoting optimalantimicrobial use. Pharmacotherapy.2000;20(6):711- 23.

USA (2000)

2.9 Kotwani A, Wattal C, Joshi P, Holloways K.Irrational use of antibiotics and role of thepharmacists: an insight from a qualitativestudy in New Delhi, India. Journal ofClinical Pharmacy and Therapeutics.2012;37:308- 12.

India (2012) Return outdantibiotics wfinancialrepercussioSecure the santibiotics toundertreatmAdvise patieproper treat

2.10 Whalley B, Fletcher K, Weston S, HowardR, Fawlinson C. Foundation in pharmacypractice. London: Pharmaceutical Press;2008.

United Kingdom(2008)

Counsel patprovide themwritten infor

2.11 Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, Herdeiro MT.Attitudes of community pharmacists toantibiotic dispensing and microbialresistance: a qualitative study in Portugal.International Journal of Clinical Pharmacy.2013;35:417

-24.

Portugal (2013) Pharmacistspatients to cwith antibiot

The role of pharmacist in encouraging prudent use of antibiotic medicines and averting antia review of current policies and experiences in Europepage 14


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page 14

2.12 Coleman CL. Examining influences ofpharmacists communication withconsumers about antibiotics. HealthCommunication. 2003;15:1:79- 99.

USA (2003)

2.13 Markovic-PerkoviV, Grubia N. Self-medication with antibiotics in the Republicof Srpska community pharmacies:pharmacy staff. Pharmacoepidemiologyand Drug Safety. 2012;21(10):1130- 33.

Bosnia andHerzegovina(2012)

Provide legiinstructions on labels anunderstandamessages.

2.14 Madaras-Kelly K, Hannah E, Bateman K,Samora M. Experience with a clinicaldecision support system in communitypharmacies to recommend narrow-spectrum antimicrobials, nonantimicrobialprescriptions and OTC products todecrease broad-spectrum antimicrobialuse. Journal of Managed Care Pharmacy.2006;12(5):390- 7.

USA (2006)

2.15 McKenzie D, Rawlins M, Mar CD.Antimicrobial stewardship: whats it allabout? Australian Prescriber.2013;36:116- 20(http://www.australianprescriber.com/magazine/36/4/116/20, accessed 21 October2014).

Australia (2013)

The role of pharmac


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3.1 ASHP statement on the pharmacists rolein antimicrobial stewardship and infectionprevention and control. American Journalof Health-System Pharmacy. 2010;67:5757.(http://www.ashp.org/DocLibrary/BestPractices/SpecificStAntimicrob.aspx, accessed21 October 2014).

USA (2010) Establish qucontrol procfor pharmacpreventcontaminatioproducts.Secure proplabelling, dastorage.

3.2 PGEU statement: community pharmacistscontribution to the control of antibioticresistance. Approved by the GeneralAssembly on 17 November 2009. Brussels:Pharmaceutical Group of the EuropeanUnion; 2009

Europe (2009) Information best dispenspractice;use (when, long), side eadverse reaand interactwaste-collecservices.

3.3 Fact sheet. Fighting antibiotic resistance byensuring the rational use of medicines.

Amsterdam: Health Action International(HAI) Europe; 2011(http://haieurope.org/wp-content/uploads/2012/02/HAI-EUROPE-Fact-Sheet-Antibotic-Resistance.pdf,accessed 21 October 2014).

Europe (2011)



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page 16

3.4 Department of Health, Department forEnvironment, Food and Rural Affairs. UKfive year antimicrobial resistance strategy2013 to 2018. London: Department ofHealth; 2013(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_UK_5_year_AMR_strategy.pdf, accessed 21 October 2014).

United Kingdom(2012)

Encourage pseeking advcommunitypharmacies

3.5 Antibiotic resistance. Brussels: EuropeanParliament; 2006(http://www.itas.kit.edu/downloads/etag_hoho06a.pdf, accessed 21 October 2014).

Europe (2006)

3.6 Strategy for tackling antimicrobialresistance (STAR) 2012- 2017. Belfast:Department of Health, Social Services andPublic Safety; 2012(http://www.dhsspsni.gov.uk/star-doc.pdf,accessed 21 October 2014).

United Kingdom(NorthernIreland) (2010)

The role of pharmac


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3.7 FIP Statement of Policy Control ofAntimicrobial Medicines Resistance (AMR).The Hague: International PharmaceuticalsFederation (FIP); 2008.http://www.fip.org/www/uploads/database_file.php?id=289&table_id=, accessed 21October 2014).

Global (2008) Give propercounselling and provideappropriate information dispensingantimicrobiaEncourage pto dispose ounused antimedicines.



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p g

4.1 Gastelurrutia MA, Larraaga B, Garay A,Echeveste FA, Fernandez-Llimos F. Impactof a program to reduce the dispensing ofantibiotics without a prescription in Spain.Pharmacy Practice. 2013;11(4):185- 90(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869633/, accessed 21 October 2014).

Spain (2013)

4.2 Roque F, Soares S, Breitenfeld L, Lpez-

Durn A, Figueiras A, Herdeiro MT.Attitudes of community pharmacists toantibiotic dispensing and microbialresistance: a qualitative study in Portugal.International Journal of ClinicalPharmacology.2013;35(3):417-24.

Portugal (2013)

The role of pharmac


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4.3 Wafula, F. Availability and dispensingpractices for antimalarials andantimicrobials in western Kenyanpharmacies. Pharmaceutical RegulatoryAffairs. 2013:2(106)(http://www.omicsgroup.org/journals/availability-and-dispensing-practices-for-antimalarials-and-antimicrobials-in-western-kenyan-pharmacies-2167-7689.1000106.pdf, accessed 21 October2014).

Kenya (2013) Medicines mstocks.Dispensing prescriptionSelling parti

4.4 Skliros et al. Self-medication withantibiotics in rural population in Greece: across-sectional multicenter study. BMCFamily Practice. 2010;11:58(http://www.biomedcentral.com/1471-2296/11/58, accessed 21 October 2014).

Greece (2010)

4.5 Gastelurrutia MA, Larraaga B, Garay A,Echeveste FA, Fernandez-Llimos F. Impactof a program to reduce the dispensing ofantibiotics without a prescription in Spain.Pharmacy Practice. 2013;11(4):185- 90(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869633/, accessed 21 October 2014).

Spain (2013)



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4.6 Tonna, AP, Stewart, DC, West, B. andMcCaig, D. J. Exploring pharmacists'perceptions of the feasibility and value ofpharmacist prescribing of antimicrobials insecondary care in Scotland. InternationalJournal of Pharmacy Practice.2010;18:31219(http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7174.2010.00059.x/abstract,accessed 25 October 2014).

United Kingdom(Scotland)(2010)

4.7 L Ecker, Ochoa TJ, Vargas M, Del ValleMJ, Ruiz J. Factors affecting caregivers'use of antibiotics available without aprescription in Peru. Pediatrics.2013;131(6):1771- 9(http://www.ncbi.nlm.nih.gov/pubmed/23690517, accessed 22 October 2014).

Peru (2013)



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Annex3.Antibioticmedicinesrelatedquestionnairefo

pharmacy/pharmacistassociation

Section 1:General information

Name:

NameofAuthority/Department/institution/Organization:

City/State/Country/Emailaddress/Phone/Website

Typeoforganization:

Pharmacist association

Pharmacy association

Other

Funding:

Public

Private

Fees from members

Both

Yearly budget for rational use of medicines/ prudent use of AB medicin

Impact:

International

National



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1. Do you think antibiotics in your country are:a) Prescribedappropriately?

Yes No

b) Dispensedappropriatelywithavalidprescription?

Yes No

c) Usedcorrectlybypatients?

Yes No

2. If yes, who do you feel is in a position to improve the situation with the

as many boxes as needed)?

Policy makers

Pharmacists

Prescribers

Patient community

Professional associations e.g. medical microbiologists or infectiospecialists

Other (please specify)_________________

3. Are antibiotics legitimately available overthecounter in your country?

Yes No

4. Are antibiotics available without a prescription in your country?

Yes No



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7. Do you feel that antibiotics are mostly prescribed appropriately in your

Yes No

8. Is it possible to buy antibiotics:

a)Onlinewithaprescriptionfromyourcountry?

Yes No

b) Online without a prescription from your country?Yes No

c)Onlinewithaprescriptionfromanothercountry?

Yes Nod)Onlinewithoutaprescriptionfromanothercountry?

Yes No

e)Somewhereelsethanapharmacyinyourcountry?

Yes No

9. Is there close collaboration (feedback) between pharmacists and docto

Yes No

10.Can the pharmacist in your country influence the doctor to change the p

does not consider it appropriate?

Yes No

11.Are data on antibiotics use monitored in your country?

Yes No



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14.Isprudentuseofantibioticsapartofpostgraduatecurriculainyourcountr

For medical staff For pharmaceutical staff

No Dont know

15.Are there any guidelines on antibiotic treatment in your country?

Yes No Dont know

16.If yes, are they issued

Centrally Separately by various institutions for ow

17.Who is involved in the development of these guidelines?

Policy makers

Pharmacists

Prescribers

Patient community

Professional associations e.g. medical microbiologists or infectio

Specialists

Other (please specify)_________________

18.If issued centrally, have the guidelines on antibiotic treatment in your cthe last 5 years?

Yes No Dont know

Section3:

The

role

of

pharmacists

19.Are you aware of any activities or initiativesin your country to foster pr

at the pharmacy level?



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22.If yes, please describe the activities and the institutions responsible for

23.Are the number of pills dispensed in pharmacy adjusted for every patierequested/duration of treatment stated on their prescription?

Yes No

24.Are waste collection services provided by pharmacies in your countries

Yes No Dont know

Other___________

25.Do you think pharmacists in your country are in a good position (in termknowledge) to provide advice on the use of antibiotics to patients?

Yes No

26.Detailed information on the use of antibiotics provided by pharmacists

Strongly agree Agree Neither agree nor d

Disagree Strongly disagree

27.Detailed information on the use of antibiotics provided by doctors to pa

Strongly agree Agree Neither agree nor dDisagree Strongly disagree



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Annex4.Countryspecificpolicyrecommendations

Country / Region Organization Policy

Europe PGEU The folare ide

infothe

for hposreacinte

advailmwhe

prov

servtrea

promin loandorga

At the nwere a

contribfrom th

Belgium Belgian Antibiotic PolicyCoordination Committee (Babcoc)

Includegroup, handleof theseto facilipatientpharma

approp

Germany Bundesministerium fr Ernhrungund Landwirtscharft

Mentioneducatresista



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The Netherlands ECDC Guideli

antibiotreact toadherea bonudispensfoundaFoundaStatistiaccordicertain receiveinsuranAccorddispensguidelinbonus help GPguidelin

Sweden Swedish National Board of Healthand Welfare (Socialstyrelsen)

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The WHO RegionalOffice for Europe

The World HealthOrganization (WHO) is aspecialized agency of theUnited Nations created in1948 with the primaryresponsibility for internationalhealth matters and publichealth. The WHO RegionalOffice for Europe is one of six

DOCUMENT TITLE: THE ROLE OF PHARMACIST IN ENCOURAGING PRUDENT USE OF ANTIBIOTICS AND AVERTINGANTIMICROBIAL RESISTANCE:A REVIEW OF POLICY AND EXPERIENCE IN EUROPE


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Office for Europe is one of sixregional offices throughoutthe world, each with its ownprogramme geared to theparticular health conditions ofthe countries it serves.

Member States

AlbaniaAndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia and HerzegovinaBulgariaCroatiaCyprusCzech Republic

DenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIcelandIrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuania

LuxembourgMaltaMonacoMontenegroNetherlandsNorwayPolandPortugalRepublic of MoldovaRomaniaRussian FederationSan MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe former Yugoslav Republicof Macedonia

TurkeyTurkmenistanUkraineUnited KingdomUzbekistan

World Health OrganizationRegional Office for Europe

UN City, Marmorvej 51, DK-2100 Copenhagen , Denmark

Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: [email protected]

Website: http://www.euro.who.int/en/health-topics/Health-systems/medicines

Documents

The Role of Pharmacist in Encouraging Prudent Use of Antibiotics and Averting Antimicrobial Resistance a Review of Policy and Experience Eng