“The role of clinical pharmacist in combating antibiotic resistance”.

Antibiotic: Since the discovery of penicillin in 1928, antimicrobials have enabled many of the greatest
medical advances. Penicillin, with its excellent safety and efficacy profile, saved the lives of many
people during the Second World War. Without antibiotics, procedures such as surgery would carry a
much higher risk owing to an increased likelihood of sepsis.

Antimicrobials are chemicals that kill or inhibit the growth of microorganisms and are used to treat
microbial infections. Some are produced naturally by microbes but many are synthetic.
Antimicrobials include antibiotics, antivirals, antifungals and other drugs such as antimalarial.

Antibiotic usage
Antibiotic use in hospitalized patients in Indonesia, as in many other countries, is high and often
inappropriate. We surveyed two hospitals in Surabaya and Semarang and showed that depending on
the type of department between 67% (Internal Medicine) and 90% (Surgery and Paediatrics) of
patients who are hospitalized for at least 5 days are treated with antibiotics during their stay in
hospital. Only 21% of prescriptions were considered appropriate, for 42% there was no indication for
treatment and 15% were inappropriate regarding choice, dosage or duration. Fever was often the
trigger for starting antimicrobial therapy, even when no obvious signs or symptoms of bacterial
infection were present or even a viral infection was likely. The presumed diagnosis in a patient with
fever without a focal infection was often sepsis, without applying strict criteria for this diagnosis.

Antibiotic resistance

Antimicrobial resistance (AMR)

is a natural process. It occurs
when microorganisms evolve
to be able to resist the
medicine that has been used to
combat them. (5) Resistant
microorganisms can survive or
even grow in the presence of a
concentration of antimicrobial
that is usually sufficient to
inhibit or kill non-resistant
microorganisms of the same
species. (4) This important
feature was foreseen by
Alexander Fleming who, in his speech when receiving the Nobel Prize in Medicine for the discovery
of penicillin, issued a warning about the possibility of creating resistant organisms if antibiotics were
used irresponsibly. (6) It is likely that AMR began as soon as mass use of antimicrobials by the
population began, soon after industrialised production became possible.

Bacterial resistance has evolved with the increased number,volume and diversity of antimicrobial
applications. As new drugs were introduced clinically, resistant strains were identified relatively soon
after. Many of these resistant bacteria are not obligate pathogens, being part of the indigenous
microflora. However given the right associations, such as immunocompromised patients and the use
of antibiotics, these organisms have the potential to cause life-threatening disease.

Reasons for antibiotic resistance

1)Overuse of Antibiotics:

Bacteria are living organisms, and like most other living organisms, they will tend to evolve to
survive. The constant exposure of bacteria to broad-spectrum antibiotics will give the bacteria the
ability to adapt to the new threat. Once resistant, the strain may continue to spread among
individuals of a population. One reason for the increase in resistant strains of bacteria is that doctors
sometimes will prescribe
antibiotics to treat even a minor
bacterial infection that could be
easily dealt with by the patient's
immune system over the course of
time. This unnecessary use of
antibiotics is one of the main
causes to the recent rise in
antibiotic resistant bacteria

2) Natural Selection and Resource

Abundance

Natural Selection also plays a key

role in the emergence of antibiotic
resistant bacteria. Many resistant antibiotic resistant strains of bacteria emerge in hospitals and
healthcare facilities where sterile environments are plentiful. The sterility of the facility limits
competition among bacteria by killing weaker bacteria and leaving the tougher ones alive through
natural selection. The removal of the competing weaker bacteria allows the resistant and stronger
bacteria to have access to an excess of resources allowing for the bacteria to thrive and reproduce
quickly. The main reason in which bacteria can survive in these harsh sterile environment is the
ability of bacteria to form biofilms. These films are made of polymers secreted by aggregates of
microbes, fungi, and other bacteria that form a large coating or film that forms to help protect the
bacteria from the stress of their environment. Biofilms are extremely difficult for antibiotics and
common antiseptics to kill.

3) Failure to Complete Prescription Duration

Another instance that contributes to the formation of antibiotic resistant bacteria is that patients
sometimes fail to completely eliminate a bacterial infection from their bodies by failing to complete
the required amount of antibiotics over a prescribed period of time. This failure to eliminate the
infection completely allows some of the remaining bacteria to have a higher tendency to develop
resistance to the antibiotic since they were exposed to the drug but not eliminated by it.

4)Plasmid Expression:

Once the superbugs are free to interact with other bacteria, antibiotic resistance can be acquired by
other bacteria through plasmid expression in which resistant bacteria cells will exchange DNA and
genetic information that enables antibiotic resistance. A plasmid is a mobile bundle of DNA that is
copied and exchanged between different species of bacteria. New genetic information may
eventually be integrated into the chromosomes of the recipient cell. This allows strains to achieve
resistance immediately and possibly spread the genetic trait to even more bacteria causing
widespread antibiotic resistance

Lack of Antibiotic Variation

No new types of antibiotics have been introduced since the 1980s, and overuse of the ones currently
used today is leading to a buildup of resistant bacteria. Without cycling between antibiotics, bacteria
will adjust and evolve to develop multiple resistances. The constant exposure of bacteria to one
antibiotic will greatly increase the possibility of resistance. As seen with penicillin, resistant strains
emerged relatively quickly after mass application of penicillin. Without newer ways to treat bacterial
infections, it is possible that resistance will catch up with the latest and strongest antibiotics and will
no longer be able to be stopped without the introduction of new technology and medicine.

Role of Community pharmacists in combating resistance:

Community pharmacists are often the first point of contact for the public and they have a pivotal
role in advising patients on minor ailments and referring them to their physician when required.
They are often the entry gate to the health system on account of their easy accessibility.

Health promotion

Health promotion events and campaigns that are having a positive impact on population immunity,
resilience to infections and overall community health are indirectly helping to reduce the need for
use of antimicrobials. In this regard, pharmacists as communicators on healthy lifestyles have taken
part in health promotion campaigns on a wide range of topics, including encouraging the choices
that help to keep the immune system healthy, e.g., smoking cessation and healthy eating (getting
enough vitamins, etc).

Infection prevention and control

a) Educating on infection prevention

Infection prevention and control is an essential strategy to reduce infection and the subsequent
increased use of antimicrobials. It supports a broader public health and infection minimisation
agenda, with educating the community on hand washing and hygiene practices, correct
sneezing/coughing protocols, isolation of infected patients etc. Pharmacists are involved in such
strategies.

b) Infection control via immunisation

Immunisation is an important part of any infection control strategy. It helps reduce the misuse of
antimicrobials. In the case of viral vaccines, protection from a virus will reduce the number of viral
infections (and, consequently, bacterial superinfections), which in some cases are mistakenly
diagnosed as a bacterial infection and so treated with antimicrobials. For example, there is a
common misuse of antibiotics against influenza.

Triage

Triage is a process of assessing whether patients in a community pharmacy can be successfully

treated by the pharmacist or whether they need to be referred to another health care professional.
The stages of triage are described below:

a) Appropriate treatment of symptoms without antimicrobials: People suffering from influenza or

other respiratory problems may think treatment with antibiotics is needed. Pharmacists can give
proper counselling for symptoms and ensure that patients have a good understanding of their illness
and realistic expectations of its progression.

b) Direct supply of antimicrobials by pharmacists: In some countries pharmacists are legally allowed
to prescribe antimicrobials in clearly specified cases. Some provinces in Canada have given
pharmacists the authority to prescribe antimicrobials for certain minor ailments. Although the list of
approved minor aliments varies among provinces, the treatment of certain fungal and bacterial
infections are often included.

c)Referral to appropriate health professionals: After an accurate assessment, pharmacists can offer
to treat minor health problems or infections with an over-the-counter medicine. If a serious health
problem is identified and the person needs to see a physician or specialist, pharmacists refer the
patient to an appropriate professional.

Ensuring quality of medicines

Quality of medicines is a crucial factor in the prevention of AMR (antimicrobial resistance).

Counterfeit medicines are a major threat to public health and antibiotics are one of the most
counterfeited groups. Counterfeit medicines may have no therapeutic effect or may even be toxic.
Moreover, if the medicine has the correct active antimicrobial ingredient but it is not in sufficient
quantity, this can increase AMR.

Pharmacist-led stewardship programmes: Antimicrobial stewardship programmes in hospitals seek

to optimise antimicrobial prescribing in order to improve individual patient care and slow the spread
of antimicrobial resistance. Pharmacists in the UK, Australia and the USA have been integral to the
development of antimicrobial stewardship guidance for both primary and secondary care and
hospitals and the development of antimicrobial prescribing standards.

Sterilisation: Many hospital sterilisation services are not provided by a fully-fledged department but
by a sub-department under the hospital’s surgical or nursing services. However, pharmacists, with
their training in microbiology and aseptic technique, are competent in the functions sterilisation
services are expected to perform. Hospital pharmacists may also have the responsibility of
implementing training programmes for hygiene personnel.

Conclusion

Overexposure and overuse will allow bacteria to continue to exchange genetic resistance to other
species of bacteria if not contained and isolated from other environmental bacteria. In order to deal
with this emerging global health crisis, world governments must collaborate with health
organizations to educate the public and to put in place regulations and guidelines on antibiotics and
antimicrobials, so the emergence of new superbugs is slowed and future growth of existing
superbugs is hindered. This is a global issue that cannot be tackled by one party alone; many of the
solutions require active participation and intense supervision from a multitude of different
populations, governments, and organizations. There are many different factors, but if antibiotic
usage is closely monitored, then many of the resultant factors will be controlled. Controlling over
usage through a variety of public campaigns, regulations, and monitoring will have the largest and
most immediate impact on the growth and spread of superbugs. Many of the proposed solutions
that were outlined are practical in execution, but unfortunately, it is unlikely that all parties will
cooperate to the extent needed to see a definite change until the matter worsens.