Lupine Publishers | LOJ Pharmacology & Clinical Research
Short Communication
The value of critical care pharmacists
has been well documented. Various studies have shown that critical care
pharmacists reduce medication errors, improve patient outcomes, reduce costs
and waste, and decrease mortality rates among patients with thromboembolic
diseases or infections [1,2]. Antimicrobial resistance (AMR) causes prolonged
illness, greater risk of infection spread, increased morbidity, and higher
mortality rates, which result in increased expenses to the government,
healthcare services, and individuals. It is estimated that around 700,000
people die annually from drug-resistant infections, with experts predicting an
alarming possible increase to 10 million deaths each year by 2050 and major
future challenges to the way we practice medicine and surgery. Resistance has
been associated with increasing mortality, treatment failure and healthcare
costs [3,4]. This alarming rate exceeds the annual number of deaths caused by
cancer (8.2 million) and is almost ten times that of motor vehicle accidents
(1.2 million) [5]. In the United States, in addition to significant mortality,
antimicrobial resistance adds $20 billion in excess direct health care costs
and up to $35 billion in annual societal costs as a result of lost productivity
[6]. Antibiotic stewardship was established to combat this trend and was
recognized in 1996 to draw attention to the rising incidents in mortality and
morbidity associated with inappropriate use of antibiotics [7]. Antibiotic
stewardship is a core part of critical care, and many times, the physician will
rely on the pharmacist’s recommendations and expertise. Antibiotic Stewardship
Recommendations include constituting a team, close coordination between teams,
audit, formulary restriction, deescalation, optimizing dosing, active use of
information technology among other measure [8].
The Infectious Diseases Society of
America guidelines on antimicrobial stewardship recommend that the core
multidisciplinary stewardship team include an infectious diseases (ID)
physician and a clinical pharmacist with ID training [9]. Antibiotic
prescribing in outpatient settings exceeds that of inpatient prescribing, with
more than 150 million antibiotic prescriptions annually; of these
prescriptions, more than 30% are either unnecessary or inappropriately
prescribed [10-12]. Orally administered antimicrobials accounted for
approximately 90% of total consumption: oral third generation cephalosporins,
macrolides, and fluoroquinolones accounted for approximately 77% of oral
consumption. Therefore, pharmacists must extend their support for the
appropriate use of antimicrobials prescribed by attending physicians to not
only hospitalized patients but also outpatients [13]. As the regulations for
antibiotic stewardship in outpatient settings continue to evolve and optimal
stewardship strategies are defined, pharmacists must be leaders in the
implementation of these programs [14]. Stewardship programs can help, reduce
inappropriate prescription and broad-spectrum use of antimicrobials, improve,
clinical outcomes for the population as a whole, slow down the emergence of
antimicrobial resistance and conserve healthcare resources [3]. The WHO Global
Action Plan on Antimicrobial Resistance recommends countries work together to
improve awareness and understanding of antimicrobial resistance, including
through social media.
The 2018 World Antibiotic Awareness Week
campaign used Twitter to tailor media messages about the Global Action Plan
[15]. Social media have become important information channels but may not reach
people with low knowledge and/or low interest in the subject. Within the EU,
countries with low use of antibiotics, such as Sweden and The Netherlands, show
a higher population knowledge level [16]. The use of community antibiotic
stewardship programs (ASPs) is rising. ASPs involving pharmacists are effective
in decreasing antibiotic prescribing and increasing guidelineadherent
antibiotic prescribing by GPs [17]. Evidence in China and Netherlands showed
that antibiotic stewardship program was associated with more less 80% and more
than 25% decrease in cost of antibiotic prophylaxis per procedure respectively
[18]. The issue of antimicrobial resistance is worse in low and middleincome
countries (LMIC), as the incidence of infectious diseases is high compared to
high-income countries. In low and middleincome countries, the mortality rates
due to antimicrobialresistant bacteria are under-reported, however, available
data in India, Nigeria, Pakistan, and Congo indicate that a huge number of
neonatal deaths resulted from drug-resistant sepsis [19]. Annually, more than
50,000 newborns are estimated to die from sepsis due to pathogens resistant to
first-line antibiotics [20]. In European countries, antimicrobial resistance is
also on the rise and considered to be responsible for about 25,000 deaths
annually [21]. Pharmacists are core AMS team members where there is an ongoing
need to align continuing education for health professionals with realities of
practice. However, antimicrobial stewardship (AMS) is not comprehensively and
fully taught in medical or pharmacy curricula and little is known about the
relevance of pharmacist training to meet AMS needs [22]. Critically, there is a
need for establishing sustainable funding for AMS teams working beyond hospital
settings that is not solely derived from cost savings through reduced drug
expenditure.
Instead, funding for developing and
supporting AMS teams should be considered within the patient safety and
healthcarequality-related spending [23]. More recently, the introduction of
national stewardship guidelines, and an increased focus on stewardship as part
of the UK five-year antimicrobial resistance strategy, have accelerated and
embedded developments. Antimicrobial pharmacists have been instrumental in
effecting changes at an organizational and national level [24]. A pharmacist
dispensing antimicrobials without a prescription is 83-100% of the time unaware
of a patient’s allergies status [19]. Inaccurate allergy labelling results in
inappropriate antimicrobial management of the patient, which may affect
clinical outcome, increase the risk of adverse events and increase costs.
Inappropriate use of alternative antibiotics has implications for antimicrobial
stewardship programs and microbial resistance. 2019 recommended that a
pharmacistled allergy management service is a safe option to promote
antimicrobial stewardship and appropriate allergy labelling [25]. 2018
suggested broader adoption for the role of pharmacists in the provision of
penicillin skin testing. This would help expand the service and maximize the
potential benefits of penicillin skin testing [26]. Pharmacists may be tasked
to lead ASP development and implementation with little or no support from an
infectious diseases (ID) physician and other hospital personnel whose
involvement on ASP teams is recommended (e.g., clinical microbiologists,
infection control specialists, hospital epidemiologists) [27]. Pharmacists and
other health care professionals should collaborate within multidisciplinary
teams (MDTs) to reduce the risk of antimicrobial resistance, thereby reducing
the economic burden, improving patients’ quality of life, and reducing
hospitalization due to infections [19]. In a UK study, almost 60% of
pharmacist’s contributions are made during the MDT round [28]. Research has
shown that pharmacists play an important role in the (Emergency Department) ED,
but there is a need for data supporting this in specific patient outcomes as
the majority of the literature addresses adverse drug event prevention and cost-containment
[29]. Critical care pharmacists are recognized in the guidelines from the
Society of Critical Care Medicine (SCCM) as essential team members for the
delivery of care for critically ill patients. In fact, the return on investment
of an ICU pharmacist’s salary approached in multiple studies of critically ill
patients with infection [30]. Including critical care pharmacists in the
multidisciplinary ICU team improved patient outcomes including mortality, ICU
length of stay in mixed ICUs, and preventable/nonpreventable adverse drug
events [31].
Although factors, such as a lack of
financial resources, may be beyond the control of the pharmacy profession,
other factors, such as increased documentation in patient records and increased
scholarly work demonstrating pharmacists’ contributions, can and should be
addressed more consistently by all critical care pharmacists [32]. The critical
care pharmacist ensures the discontinuation of these medications in patients
who no longer have an indication. Unfortunately, these medications are
sometimes started by the ward team and continued on discharge. Additionally,
home maintenance medications are often not resumed on hospital admission and/or
subsequent discharge, increasing the risk of death, emergency department visit,
or hospitalization. A critical care pharmacist integrated into the ICU-Recovery
Center (ICU-RC) may take attempt to identify and treat the types of medication
errors found in a population of high-risk ICU [33]. In addition, pharmacists
who are often the first point of care, dispense antibiotics without a physician
prescription, offer alternative antibiotics even when patients present with a
prescription. Within the hospitals lack of monitoring of antibiotic use is one
of the major factors driving the spread of resistance [34]. The implementation
of antimicrobial stewardship programs in primary health care is suboptimal.
This negatively affects the global efforts to control antimicrobial resistance.
There is a need to institutionalize national guidelines for AMS in primary
health care [35]. Multiple randomized controlled trials (RCTs) have found that
shorter courses of antibiotic therapy result in similar cure rates as
traditional courses for many types of infections, including UTIs, SSTIs, and
pneumonia. Unfortunately, familiarity with short-course therapy as a
stewardship tool is limited. A recent study found that only one-third of
infectious diseases practitioners from 58 countries recommended short-course
therapies [36]. Consequently, some countries have recommended shortening the
duration of antibiotic treatment of communityacquired pneumonia (CAP). No
significant differences in adverse events were reported. However, none of the
trials reported on the impact on the development of resistant bacteria [37]. As
with the cost of climate change, estimates of total AMR costs are fraught with
uncertainty and may be far too low. This cost depends on various factors: which
drug and pathogen are involved, the mechanism of antibiotic resistance, the
prevalence of that pathogen, the types of infections it causes and their level
of transmissibility, the health burden of those infections, and whether
alternative treatments are available [38]. AMS can help pharmacists improve the
quality of patient care and improve patient safety through increased infection
cure rates, reduced treatment failures, and increased frequency of correct
prescribing for therapy and prophylaxis. The cost of employing a pharmacist at
the recommended minimum staffing level is approximately £20 per patient per
day. Several studies find that the role reduces overall expenditure through
more efficient use of medicines and the avoidance of direct costs of iatrogenic
harm, with additional savings made from avoiding payouts arising from damages
claims [19,27].
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