Manjiri Gharat, Vice-Principal, KMK Pharmacy Polytechnic, Ulhasnagar, MH and VP and Chairperson, Indian Pharmaceutical Association-Community Pharmacy Division (IPA CPD)
“Mirror, mirror on the wall, do I need antibiotics at all?” was the slogan seen in some pharmacies across Thailand. What was it all about? The Community Pharmacists Association of Thailand developed an innovative campaign to convince patients not to insist on antibiotics for viral infections, and prevent unnecessary use of antibiotics for non-bacterial infections. People were encouraged to check their throats in a mirror placed in the Pharmacy. Pharmacist explained the differences in the symptoms of bacterial infections and other conditions. Involvement of the patients themselves in the decision making process and the right education did have its positive impact and unnecessary antibiotic usage did decrease in the campaign areas. Pharmacists in Spain launched a communication campaign with the slogan: “Do not ask us for antibiotics but for information”. The aim was to discourage patients from using antimicrobials without prescription and to improve responsible use of antimicrobials. In parts of the US, pharmacists carry out strep throat test using rapid diagnostic toolkit in the pharmacy and refer patients to physicians as per the need. Such point of care testing (POCT) gives immediate diagnosis, avoids any unnecessary use of antibiotics and patients get quicker relief. In some countries pharmacists are legally allowed to prescribe antimicrobials in clearly specified cases. For example, in Canada pharmacists are given the authority to prescribe antimicrobials for certain minor fungal and bacterial infections. Thus pharmacists can facilitate quick and appropriate use of antimicrobials for their patients. In New Zealand, pharmacists can prescribe and dispense trimethoprim for short-term treatment of an uncomplicated urinary tract infection. In several countries, pharmacists are involved in vaccine administration and there is growing evidence that vaccination by pharmacists increases vaccination rates and this subsequently reduces the prevalence of infections and use of antibiotics.
These are just a few examples of pharmacists’ work from around the globe. Publication from International Pharmaceutical Federation (FIP) “Fighting Antimicrobial Resistance: Contribution of Pharmacists” gives several such examples. All over the world, as the problem of Antimicrobial Resistance (AMR) becomes more serious, there is increasing importance gained by the role of community pharmacists. Community pharmacists are often the first point of contact for the public. They are often the entry gate to the health system on account of their easy accessibility. Patient with symptoms first approach the pharmacist rather than visiting the doctor and patients coming from doctors’ clinics come to the pharmacy with prescription before going home. Thus, pharmacists are in the most strategic position to advise patients on minor ailments, refer them to physicians when needed and to provide counsel about medications prescribed by the doctor. Thus, the pharmacist has ample opportunity and wide scope to impact patient behaviour. With regards to responsible use of antibiotics and to combat AMR, the WHO has defined roles for every stakeholder, from patients to policymakers. As per www.who.org/waaw , a poster saying “What Can Pharmacists Do?” summarises key roles of pharmacists by asking them the following questions:
- Do you only dispense antibiotics when they are needed, according to current guidelines (e.g. does the patient have a valid prescription, is it for the right drug/dose/duration)?
- When patients are seeking treatment for cold or flu, do you explain that antibiotics are not needed? Do you talk to patients about how to take antibiotics correctly, antibiotic resistance & the dangers of misuse?
- Do you remind patients to contact their health professional if symptoms persist?
- Do you talk to patients about preventing infections (e.g. vaccination, hand washing, safer sex, covering nose & mouth when sneezing)?
Above is an excellent summary of what pharmacist should do and many countries have policies, education, regulations and overall ecosystem to nurture such antibiotic guardian role of the pharmacists.
In India, the situation is very different. Pharmacists are still more or less traders/ shop keepers rather than health care professionals. In approximately 6.5 lac pharmacies across the country, the presence of pharmacist during all working hours of the pharmacy is often a big question. Needless to say that the role of a pharmacist as patient counsellor, as medication expert, is still far away. Neither is pharmacy practice well developed nor are health and medicine literacy established among consumers. This creates a dangerous situation with regards to use of antibiotics. Overuse, underuse and wrong use of antibiotics is common. On the one hand, consumers are keen on self-medication and on the other, they won’t complete the course of antibiotics when prescribed by the doctor. Easy availability of antibiotics over the counter encourages self-medication. Irrational prescribing and irrational Fixed Dose Combinations (FDCs) further complicate the situation. Antibiotics are special drugs which don’t act on a particular cell of the body but on the bacteria which can fight back, so the enemy is strong, smart and dynamic. By overuse, underuse or misuse of these medicines, we are making antibiotics weaker and making the enemy much stronger. This basic understanding has been lost by most stakeholders.
Pharmacists Making the Difference
Case one: A pharmacy on the busy street of Mumbai! A patient walks in, tells the pharmacist that he has an upset stomach and had loose motions since last night. He has no other complaints like fever etc. Patient insists on being given a known common brand of Ofloxacin. The pharmacist listens to him with patience, and then explains to him that what is most needed is to replace the lost water and electrolytes from the body, not an antibiotic. The pharmacist explains in simple language that an antibiotic cannot be given without doctor’s prescription. He explains to patient politely that if he goes to a doctor and the doctor does write prescription for ofloxacin or any other antibiotic, he will be most happy to dispense it. But at the moment, he can give what is known as Oral Rehydration Salts (ORS) which would treat the dehydration and will take care of situation. He tells patient that patient should see the doctor if he doesn’t feel better in a day.
The patient, though a bit irritated and in a mood to go to another nearby chemist whom he believes would have given anything and everything over the counter, feels there is some logic in what this pharmacist says and accepts the advice and buys ORS packets. Two days later he returns to the pharmacy to thank the pharmacist for timely and useful advice and a word of wisdom. Pharmacist feels happy to help the patient and is glad that he could avoid misuse of antibiotics in this case.
Case two: A patient is diagnosed with TB by a physician from the private sector and has just started anti-TB treatment. He purchases his medicines from a chemist shop near the physician’s clinic. Few days later the patient happens to walk into another pharmacy where he reads a board that anti-TB medicines are available free, and that it is a Government DOTS centre. The patient feels curious and asks the pharmacist for more details. The pharmacist explains that the patient can also get benefit of free treatment, provided that he gets diagnosed by the government hospital and directs him for the same. The patient follows these instructions and his TB is confirmed. His DOTS medicine box reaches the pharmacy and patient completes the treatment under direct observation of the pharmacist.
What exactly is the significance of above intervention by the pharmacist? TB Treatment lasts for a minimum of 6 to 8 months and the full course needs to be completed for complete cure. The patient in this case was poor with very meagre monthly income and if he had stayed with paid treatment, he would have most likely stopped taking the medicine once his condition visibly improved in a month or two. Thus, the default might have led to development of Drug Resistant TB (DR TB) later on in life. The pharmacist’s guidance brought the patient to free and supervised treatment ensuring complete adherence and avoiding probable case of DR TB.
Some discussion with pharmacists brings out interesting facts about the consumer demands and expectations:
1) Some patients who had taken antibiotics previously, walk into the pharmacy asking for the same old antibiotics, with old prescription or left-over medicine or by just describing how the medicine looked like.
2) Some people, even though not much educated somehow know names of antibiotics, especially commonly known are amoxicillin, erythromycin, ofloxacin, penicillin. Cold and cough, stomach upset, sore throat, fever, skin infections are common complaints for which consumers ask antibiotics.
3) Some don’t know the exact names but know the term antibiotic. They don’t know what are antibiotics, how they act etc but know that these are the medicines which are like magic bullets and will make them feel better very soon.
4) Some walk into the pharmacy and tell the pharmacy attendant to give them “strong medicine” for their symptoms.
5) Some walk in with valid prescription, but won’t buy full course of antibiotics due to insufficient money or due to lack of faith in the treatment and so will end up buying the course halfway. In contrast, some may buy full course, but would stop it halfway as soon as they start feeling better.
6) Some patients buy the antibiotics with valid prescription and would also comply fully to the prescribed treatment.
Pharmacist can and need to play a very proactive role to improve the situation of antibiotic usage.
- Counselling patients when antibiotics are not needed, pharmacists can reassure patients and correct any misunderstandings.
- Infection control and prevention: It’s important to educate patients about hygiene, cleanliness and self-care. Importance of proper handwashing, cough etiquettes, use of condoms are some of the important preventive measures for infection control. Health day such as Global Handwashing Day 15th October can be observed, and it can be turned into a big campaign to create awareness in the society.
- Information about vaccinations: In India, vaccination rates are still not satisfactory. Pharmacists, especially in rural areas, and those who are near urban slums, have a great opportunity to check with patients if the vaccination schedule is being followed for their children. Immunisation chart also can be displayed in the pharmacy.
- Adherence: Whenever there is an antibiotic in the prescription, pharmacist needs to counsel the patient regarding need for completion of the course and should emphasise completing course even if patient starts feeling better with few days of the treatment. Tuberculosis patients need to be paid special attention for adherence. Patients can be followed up by phone calls/sms/whatsapp messages for treatment adherence. All TB patients should be informed at the very beginning of treatment about the free anti-TB drug treatment from the Government sector.
- Medication Counselling: Patients need to be told about purpose of an antibiotic, how to take it, when to take, before or after food, common side effects and importance of following the dosage schedule, antibiotic resistance etc
- Timely referrals: Patient with minor symptoms can be handled by the pharmacists with OTC medicines but those with any serious symptoms should be immediately referred to the physician.
- Written Counselling tools: Pharmacists can use auxiliary labels, patient information leaflets as a supplementary method to support verbal counselling.
It is not easy to perform the above tasks. It is very challenging for even knowledgeable and responsible pharmacists. Today if a pharmacist refuses to dispense an antibiotic and starts counselling the patients not to self-medicate with antibiotic, patient may simply just go to another shop and buy the antibiotic there. Thus, it is not only a financial loss for the pharmacy but is demotivating as well. Some employed knowledgeable pharmacists may be discouraged by pharmacy owners to offer any patient care services as they may consider it as waste of time. After working closely with community pharmacists across India for more than a decade, I have found “true” pharmacists but this number is still very low. The cases described here under Pharmacists Making The Difference are real-life cases from the field. But such pharmacists face massive struggles because of the unfavourable ecosystem. To develop and get the full benefit of this healthcare team member’s potential, various enabling factors are required such as appropriate policies, law implementation, patient oriented education, continuing pharmaceutical education and consumer sensitisation. IPA’s DOTS TB Pharmacist project (a public private partnership project) and few other pilot projects have demonstrated the value of pharmacists’ service in public health. It is a very big missed opportunity not to have developed the role of pharmacist as a healthcare professional. Policymakers and all other stakeholders need to urgently look into it to rectify this state. And the catastrophic problem of AMR should itself trigger the actions in this direction. If not, then the pharmacists will continue to be untapped potential human resources.