As the world steers in the direction of sustainable development in all spheres of life, the human race is facing significant sustainability problems regarding antimicrobial resistance. Antimicrobial resistance poses a significant threat to the world with economic and health consequences. In this commentary, we highlight the gaps in the battle against antimicrobial resistance that increase the call for concerted efforts to promote the role of pharmacists in addressing the threats. Hospital and community pharmacists are the nearest health care practitioners to the patient. As medication custodians, pharmacists can promote antimicrobial stewardship strategies by optimizing prescribing behavior, monitoring antimicrobial use, preventing infection, educating, training, and engaging the public among others.
Antimicrobial resistance (AMR) is a global health threat.1 The development of AMR is a natural process; however, the indiscriminate use of antimicrobials contributes immensely to this growing menace, as it is the single most important factor fueling the development of highly resistant pathogens in many settings including hospitals and in the community.2 The rising threat of AMR has also brought to the forefront the need to strengthen antimicrobial stewardship (AMS) globally. According to the Global Research on Antimicrobial Resistance (GRAM), 1.2 million people died as a direct result of antibiotic-resistant infections in 2019 alone.3 The number of deaths is projected to reach 10 million annually by 2050, greater than the annual deaths from cancer.1 AMR can increase health care costs and treatment in the near future; according to several analyses, AMR is expected to cost between $300 billion to more than $1 trillion per year by 2050.4 The immediate monetary impacts of AMR on health care include high expenses associated with expensive and extensive treatments and an increase in resource consumption.4 The growing antibiotic-seeking behavior and injudicious use of antimicrobials are likely to further accelerate the predicted burden of AMR if urgent care is not taken. Antimicrobial stewardship has been defined as “the optimal selection, dosage and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance2 .” The core elements of antibiotics stewardship are shown in Figure 1.
Antimicrobials have enabled clinical and medical improvement over several decades. However, the emergence of resistance to antimicrobials restricts our ability to deal with diseases and curbs efforts to achieve universal health coverage and health-associated sustainable development goals. Without sustainable and effective infection treatment, quality health care for all would be impossible to provide, and managing AMR will make long-term funding of universal health coverage challenging. AMR is a complex problem and often-ignored global health crisis that needs urgent interest and action. A major contributor to the rising trend of resistance is the misuse and overuse of antibiotics in hospitals and outpatient settings.5 Antibiotics are often used in animals for prophylaxis and/or growth enhancement as well as in agriculture and aquaculture.5 Crucially, this demonstrate the urgent need to set up and implement a multidisciplinary AMS that cut across all aspects of resistance development.
It is important to note that AMR is not always nosocomial; some resistant organisms come from the community, especially through the food chain.6 Researchers have frequently identified aquatic animals, soils and wastewater treatment plants as reservoirs of antibiotic-resistant pathogens.5 Food animals are considered key reservoirs of antibiotic-resistant bacteria, and the use of antibiotics in the food production industry has contributed to the global challenge of AMR.5 This also highlighted a competence through which pharmacists’ efforts can improve antimicrobial stewardship.2 Pharmacists as custodians of medication are in a good position to educate communities, particularly livestock farmers on the devastating effects of having antimicrobials in feeds, on the community and the larger society.
Hospital and community pharmacists play an important role to contain the spread of AMR. They strive to continuously maintain improved medication management and pharmaceutical care of patients to the best standards through optimization of therapeutic outcomes by improving patients’ adherence and reducing antimicrobial-related abuse and misuse. Community pharmacists are the health professionals most accessible to the general public: They are visited by the sick, apparently healthy and also healthy people, making them invaluable health care professionals in disease prevention and antimicrobial stewardship (Figure 1). It is therefore essential that the pharmacists, together with physicians, play a professional role in recognizing and distinguishing those symptoms that can be an indication of bacterial or viral disease requiring medical attention from those of minor illnesses e.g., those that can be managed with over-the-counter medications.
There is no doubt that there are great benefits from the establishment of multidisciplinary AMS teams. A collaborative approach is important to develop and implement effective AMS strategies among health care professionals (including pharmacists), health care commissioning bodies, providers and the public at large. Pharmacists, however, being drug experts, are the core members of antimicrobial stewardship and champions for appropriate antimicrobial use.7 The role of pharmacists in antimicrobial stewardship cannot be overemphasized, as pharmacists’ involvement in antimicrobial management in hospital and community settings has been proven to improve antimicrobial usage and reduce their misuse. There has been an increase in the use of antibiotics in the hospital setting as empirical treatment and also in the communities as self-medication.7 Pharmacists can promote AMS strategies by optimizing prescribing behavior, monitoring antimicrobial use, infection prevention and education, training and public engagement among others. AMS requires pharmacists to be able to distinguish between symptoms and ask questions about the use of antibiotics should symptoms be more consistent with a viral infection or when microbiology results do not indicate a bacterial cause.7 Pharmacists, for example, provide guidance on limiting the use of broad-spectrum antibiotics and promoting the overall judicious use of antibiotics, and are thus important in promoting AMS in hospitals and in community at large.
Recommendations and Conclusion
For antimicrobial stewardship to be successful, several factors need to be addressed and integrated. Clinical competence of pharmacists and other health care providers must be improved through targeted training. Key areas include the ability to distinguish signs and symptoms of superimposed bacterial or fungal diseases prevent unnecessary antibiotic use, evaluation of the need for clinical devices that increase the possibility of health care-related infections and antibiotic use and enforce strict infection prevention and control measures. Physicians need to be aware of the necessity to request microbiological susceptibility test before prescribing broad-spectrum antibiotics for healthy people. Immediate de-escalation to a suitable narrow-spectrum antibiotic is necessary if susceptibilities are established for a patient with life-threatening conditions.8
A national antibiotic policy could be developed to guide the employment of antibiotics for the prophylaxis of disease in food-producing animals. The antimicrobial stewardship project will be supported by the national antibiotic policy, which will mainly rely on monitoring antimicrobial resistance and antibiotic usage. The antibiotic policy will also offer guidelines and recommendations for streamlining procedures and reducing antimicrobial drug misuse Community education regarding consumption of animals that were slaughtered before antibiotics had cleared the animal’s system would be beneficial.9 An antibiotic restraining policy should be developed to convert open-market sales of antibiotics, for example non-prescription sale and dispensing of antibiotics is widespread especially in developing nations.9 Antibiotics’ restraining policy would ensure that concerted effort on the part of the public and professional sectors as well as stronger enforcement by regulatory agencies are put together to tackle this issue. Furthermore, the use of biocidal agents for environmental and private disinfection should be done with utmost caution, and agents with low selections of antibiotic-resistant strains should be prioritized. Also, more studies should be conducted to ensure that antimicrobial stewardship activities turn out to be a fundamental part of patient care. The studies agenda would include differential diagnosis to distinguish bacterial and viral respiratory tract infections with fast and affordable methods; a long-term and short-term analysis of the effects of the extensive use of biocides for environmental and private disinfection along with links to cross-resistance with antimicrobial agents; and options for a sustainable environment.12 Therefore, the role of pharmacists in curbing AMR and promoting antimicrobial stewardship should not be overlooked to address the emergence of untreatable drug-resistant infections and diseases that might potentially result in serious public health emergencies in the nearest future.
Role of Authors
UAH and YAA conceptualized and wrote the first draft with significant contribution from DEL, EF and LGI. All authors read and approved the manuscript.