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VIEWPOINT


aS wORld aNtIBIOtIc awaRENESS wEEk aPPROachES (14-20 NOVEmBER 2016), tERRy magUIRE talkS aBOUt thE thREat POSEd By aNtImIcROBIal RESIStaNcE aNd thE challENgES facEd By hEalthcaRE PROfESSIONalS...


by terry maguire


RESIStaNt BUgS: NO jOkINg mattER


m


y first joke flopped - which was an embarrassing start to my talk on antimicrobial


Stewardship. I was unaware that the pharmacists attending the Pharmacy Show in Birmingham did not know Owen Smith - or that he used to be a Pfizer rep.


So, when I said that I had just popped over to the Pfizer stand to see if Owen Smith was there begging for his old job back, my audience did not register a flicker of recognition, never mind a controlled giggle, I was panicked. after all it was the day jeremy beat Owen in the labour leadership election at the Party’s conference and I was sure pharmacists, at least, would know something about contemporary British politics.


my task at the Pharmacy Show was to get pharmacists thinking about ways in which they might make a difference to the global threat that is antimicrobial resistance. It’s a big problem and more dangerous than a donald trump presidency – no, didn’t get it – with some 700,000 deaths annually due to bugs resistant to the best of our antibiotics - and this rising to ten million deaths by 2050 if nothing is done.


the good news, I told my audience, was that a few weeks ago in New york, the United Nations agreed a landmark declaration on antimicrobial Resistance (amR), of which antibiotic resistance is by far the biggest threat. the UN declaration, signed by all 193 member states, compels members to improve surveillance on resistant bugs, binds them to regulate systems for sale and supply of antibiotics, raises public awareness of the dangers of resistance and supports innovation.


26 - PhaRmacy IN fOcUS


commenting on the declaration, the Uk health Secretary, jeremy hunt, said that failure to remedy amR would ‘nullify the progress of over a century of modern medicine and kill millions’.


this quote, I quipped to my audience, could equally be from junior doctors about jeremy hunt. Nothing.


Since antibiotics underpin most of current medical practice, we will have to do medicine very differently if we fail to tackle the problem of resistance. Patients will die of what are currently common conditions. there will be poorer clinical outcomes from infectious diseases, such as pneumonia and meningitis. cancer chemotherapy will become too risky as we cannot reduce immune systems. this also applies to all forms of transplants, and surgical procedures, such as cardiac bypass, hip replacement and caesareans.


Such medical interventions that are today routine practice will be impossible in a post-antibiotic era. the Uk has done most to highlight the matter. chief medical Officer, dame Sally davis, has been instrumental in driving the Uk agenda and Big (lord) jim O’Neill – the economist better known for naming the BRIc nations – chaired an amR working group whose report was highly influential, indeed fundamental, in shaping the UN landmark declaration.


the ten recommendations from jim O’Neill’s report identify what we need to do. Rapid diagnostics would be an important innovation where a simple near-patient test would identify the bug, and more importantly its antibiotic sensitivity, before prescribing. this is a research and development project that will now be


fast tracked - as will new drugs and the partnership with Big Pharma - to deliver with sufficient incentives to do so. It came as a shock to me to learn that there has not been a new antibiotic class for over 30 years.


the recommendations most relevant to community pharmacy practice are in raising public awareness through campaigns. we can do that. also we could better support care for self- limiting infections such as upper respiratory infection (URtI). But we already do that I hear you cry... well I’m not sure we actually do.


focusing on URtI allows for a major reduction in inappropriate prescribing of antibiotics since 50 per cent of prescribing of broad spectrum antibiotics in general practice is for this condition. URtI is a very common condition and most of us get one bout a year. It accounts for about ten per cent of all doctors' consultations, which add up to a fantastic waste of medical time and resources. Since as much as 95 per cent of URtIs are viral - and of those that are bacterial there is no evidence that use of broad spectrum antibiotics reduces the number of symptom days compared to no-treatment - there is good reason to completely stop prescribing antibiotics for this condition in normally healthy adults.


In practice this will be difficult. take alex, a 45 year old who is as fit as a butcher’s dog, and who has the sniffles - possibly man flu - and feels near death. he comes to me last Saturday morning and asks for a 'lend' of an antibiotic. I refuse his request and advise that he doesn't need antibiotics, but that I can offer symptomatic relief. he insists, however, and goes to Out Of hours (OOh), where he gets a course prescribed with little problem.


Back in the pharmacy he complains that he had wanted a liquid so he is unlikely to be compliant with the 'horse tablets' he has been prescribed. with the perverse incentive for me to dispense even though I know this is inappropriate prescribing, I fully appreciate how difficult it will be for community pharmacists to reduce inappropriate antibiotic prescribing in our current system.


Ninety per cent of gPs feel under pressure to prescribe antibiotics and 97 per cent of patients requesting them get them. this is a behavioural issue: on alex’s part; on the OOh's, the gP’s part and on my part. what influence needs to come to bear to change these behaviours?


what must be changed is the false cultural hierarchy for treatment of URtI in healthy adults. there is nothing. then there is symptom relief: sore throat, chesty cough, runny and congested nose. But if you really want the best treatment, use an antibiotic. this story is totally false, yet pharmacists do little to counter it, even when to do so would be to their business advantage.


I finished my talk at the Pharmacy Show with a quip that I hoped we would make Brad Pitt and angelina jolie’s marriage break-up a bigger threat to global public health than amR. Nothing. Perhaps they were right; the threat of amR is just not funny. •


thESE VIEwS aRE ENtIREly thOSE Of thE aUthOR aNd dO NOt NEcESSaRIly REflEct thE OPINIONS Of EIthER PROfIlE PUBlIShINg & dESIgN ltd. OR thE UlStER chEmIStS’ aSSOcIatION.


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