Background:
In Ireland, national community antimicrobial consumption surveillance is based on purchased antibiotic sales data from a pharmaceutical market research company. This data was deemed unsuitable by the Antibiotic Consumption Surveillance Working Group (WG) recommendations to the Strategy for the control of Antimicrobial Resistance in Ireland (SARI) in 2003, as the data is not based on actual pharmaceutical dispensing or direct sales from manufacturers to pharmacies.
Objectives:
This minor thesis aimed to demonstrate the feasibility of implementing SARI’s recommendations for a sentinel antimicrobial consumption surveillance system in Ireland, utilising the community pharmacy setting. This data would be used to identify local antimicrobial consumption trends, detect areas needing local intervention and inform local prescribers by providing feed-back on trends observed.
Methodology:
A mixed-method study was undertaken: a systematic literature review, repeated cross-sectional study and feed-back questionnaires on study findings for local GPs and pharmacists.
The repeated, cross- sectional study was undertaken across 2 study periods in 2010 and 2011 comparing prospective, point-prevalent antimicrobial consumption data. A novel surveillance tool was developed using the WG recommendations and piloted by local pharmacists. The tool was designed to adapt into the patient-pharmacist interaction, collecting anonymous prescription data. A complete sampling of the community was obtained with the four local pharmacies partaking in one geographical region. The Influenza-like Illness GP consultation rate was identical for both study periods, as this has been shown to affect antimicrobial prescribing trends.
Standardised methodology was used including the WHO’s ATC Classification system and List of Critically Important Antimicrobials for each antimicrobial prescription. Published national sales data was used as an audit tool to compare local and national prescribing trends, as recommended by the WG. National methodology for broad spectrum antibiotics and narrow spectrum antibiotics was used.
Results:
Outcomes and impacts:
Study findings were fed-back to local prescribers and pharmacists as a printed and bound report, highlighting areas needing intervention, and emphasising the public health impact of individual patient prescribing;
70% of antimicrobials prescribed in the local community were listed as WHO Critically Important Antimicrobials.
For every narrow-spectrum antibiotic dispensed in the community, 10.3 broad-spectrum antibiotics were dispensed in 2010, which increased to 10.8 in 2011.
Local cephalosporin use was almost three times the national level in both study periods.
The burden of community antimicrobial consumption is highest in public patients; public patient antimicrobial usage was high locally accounting for 64% of total prescriptions in 2010 and 55% in 2011, despite representing 38.1% of the Irish population at that time.
Only 4-5% of antimicrobials were prescribed by dentists, therefore interventions focusing on GP prescribing would have the most impact.
Key findings from the novel questionnaires on local prescribing knowledge, behaviour and attitudes reveal that 100% of local GPs feel pressurised by patients to prescribe and write antimicrobial prescriptions that aren’t necessary due to this patient pressure. Local pharmacists gave feedback that they could be used as a resource for antimicrobial selection by prescribers in the community and that they perform health education to patients on the ineffective use of antibiotics for viral infections.
1. Findings were presented nationally to Irish GPs by oral presentation at the Association of University Departments of General Practice in Ireland (AUDGPI) conference 2013. After my presentation, the HSE's Quality and Patient Safety Directorate requested my permission to circulate my research on the national healthcare associated infection (HCAI) implementation group.
2. Findings were presented to professionals from the national health protection centres in Ireland, Scotland, England, Wales, Northern Ireland by poster presentation at the 5 Nations Health Protection conference 2013.
Future developments:
This project demonstrated that implementing national recommendations is feasible if investment is made. Sharing findings from this MPH minor thesis at national level to GPs, national health protection centres in the 5 nations, and with the national healthcare associated infection implementation group may provide evidence to change national policy, leading to the funding of an antimicrobial consumption surveillance system in the community.