How good are pharmacists at antimicrobial stewardship?

According to this QLD study, they’re doing quite well at delaying ‘wait and see’ prescriptions – but improvements can be made

A number of strategies have been trialled in primary healthcare to address inappropriate use of antibiotics.

One of the most successful has been delayed prescribing – i.e. ‘wait and see’ or ‘watchful waiting’.

This prescribing model includes generation of a script by the doctor, while advising the patient not to fill the prescription immediately, unless they feel worse or develop specific symptoms.

Queensland pharmacy researchers have looked at community pharmacists’ perceptions of this antibiotic stewardship strategy, with their findings published in the International Journal of Pharmacy Practice.

In a survey of 103 staff working in community pharmacy, from owners and managers to employees and interns, 60% of respondents said they would not dispense the delayed antibiotic prescription if a patient presented to the pharmacy within 24 hours of seeing a doctor.

Instead, they would advise the patient to wait 2-3 days and if they are not improving or if symptoms are worsening to then have the prescription filled.

Eleven per cent said they would dispense the prescription immediately, regardless of its ‘wait and see’ status.

An additional 29% would also dispense the script without waiting the recommended time; however, counselling would be provided to the patient about the rationale behind the ‘wait and see’ approach.

The explanation for not waiting was that it may not be practical for some patients to return to the pharmacy, depending on their circumstances or geographical location.

Other participants commented that the ‘wait and see’ initiative was a “great idea” and potentially decreased unnecessary use of antibiotics while saving the patient from having to repeatedly visit the doctor.

Carefully considering each patient individually as part of an individualised treatment protocol developed by the GP was preferred, said one pharmacist.

Doctors, patients and the wider community would benefit from increased awareness of the benefits of delayed prescribing, said respondents.

Delayed prescribing has been found by a Cochrane review to be a successful strategy resulting in significantly fewer antibiotic used, with 32% of patients using antibiotics in the delayed prescribing group compared to 93% of patients in the immediate prescription group.

The researchers say the success of ‘wait and see’ approaches depends on effective partnerships between GPs and pharmacists.

The lead author of a US study on the topic says watchful waiting is an effective way to reduce unnecessary antibiotic use, without affecting patient safety.

However patient compliance with watchful waiting advice could be increased by enhancing instructions from doctors, the study found.

“When we use antibiotics, the strongest bacteria still survive even though we feel well again,” says Associate Professor Erina MacGeorge from Pennsylvania State University.

“Over time, these bacteria adapt to become resistant ‘superbugs’ that even very strong antibiotics with dangerous side effects cannot kill.

“Our best defence is to avoid antibiotics whenever possible, with guidance from health professionals.”

NPS MedicineWise states that clinicians should discuss ‘wait and see’ prescribing with parents who prefer antibiotic treatment.

“Provision of a script for an antibiotic along with advice only to use it if the pain persists for 48 hours will reduce antibiotic use by two-thirds (with no negative impact on family satisfaction),” says NPS MedicineWise.

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  1. Nicholas Logan

    Even more successful than delayed prescribing – i.e. ‘wait and see’ or ‘watchful waiting’ is for the doctor to not give them a prescription for antibiotics until they present with a bacterial infection.

    • Michael Post

      If you have the secret to discriminating early bacterial infection from other infections in the community setting please share Nick.

      • Jarrod McMaugh

        That’s not really relevant since therapeutic guidelines don’t recommend treating an early infection that can’t be clearly differentiated with the presenting clinical picture.

        • Michael Post

          It is very relevant Jarrod. GP is providing a ‘watch and wait ‘ script for a ‘possible’ bacterial infection. Failure to provide a ‘watch and wait’ script when presenting symptoms are equivocal and early may delay treatment with secondary complications should a bacterial infection develop further. Comorbid patients are especially vulnerable if a plan is not in place to deal with bacterial infection. Same day access to medicos is limited by geography and infrastructure.over much of our land mass.

          • Jarrod McMaugh

            Ok so that’s a philosophical debate more than a medical one.

            If a patient presents with symptoms that are not clearly bacterial, is there a benefit in providing a prescription at that point for an antibiotic that may not be needed, which can lead to harm to the patient directly (side effects), financially (paying for something not needed), and indirectly (antibiotic resistance with future potential infections unable to be treated)?

            Is there a benefit in not providing the prescription at that point, leading to delayed treatment of an actual infection, with subsequent complications?

            I bring this back to the guidelines on treatment, since these are based on evidence of benefit vs complications/side effects. On the balance, not providing a prescription when there is not a clear bacterial infection, is the best way to proceed.

            Further weight is added to this point of view when you consider that for some infections, even when it is clearly bacterial, it is recommended to not use antibiotics immediately and await spontaneous resolution thanks to the way many infections resolve on their own.

            Agreed on the limitations on rural access, but while this affects much of our land mass, it affects a relatively small part of our population. While it is important that those in this situation have access and a method of practice in place that takes this in to account, it isn’t a reason to accept this as standard practice for the majority.

  2. Karl Staben

    What percentage of patients that are told to ‘wait and see’ actually do? That would be an interesting statistic to see..

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