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With the winter cold and flu season approaching, pharmacy customers need to be made aware that the inappropriate use of antibiotics could have disastrous implications for us all. 

In April 2014, the World Health Organization (WHO) published its first global report on the issue of antibiotic resistance, looking at data from 114 countries. The report revealed that resistance to common bacteria has reached alarming levels in many parts of the world, with some areas already out of treatment options for bacterial infections like sepsis, diarrhoea, urinary tract infections and pneumonia.

In July, prime minister David Cameron warned that resistance to antibiotics was a €very real and worrying threat€ and could send medicine €back to the dark ages€, where everyday infections and injuries could kill again. The WHO report revealed that no new antibiotics are in development and research into replacement medicines is still in its early stages. Developing new antibiotics is one way to combat resistance, but this isn't the definitive solution. According to the WHO, there must be a drastic change in the way antibiotics are prescribed by doctors and used by patients.

Antibiotic prescribing

There is evidence that frequent and long courses of antibiotics are related to the rise in bacterial resistance. Since the late 1990s, the Department of Health (DH) has been recommending that there should be no prescribing of antibiotics for simple coughs and colds or viral sore throats. Yet researchers from Public Health England (PHE) and University College London revealed in August that the number of patients given antibiotics for minor ailments has soared in recent years. The study, published in the Journal of Antimicrobial Chemotherapy, showed a 40 per cent rise in antibiotic prescriptions by GPs for colds and flu from 1999 to 2011.

€Antibiotics are very effective drugs, as long as they are used appropriately,€ says Dr Maureen Baker, chair of the Royal College of GPs (RCGP). €But we have developed a worrying reliance on them and GPs face enormous pressure to prescribe them, even for minor symptoms which will get better on their own or can be treated effectively with other forms of medication. Our patients and the public need to be aware of the risks associated with the inappropriate use of antibiotics and how to use them responsibly.€

A new winter health campaign from PAGB and Pharmacy Voice, called 'Treat Yourself Better with Pharmacist Advice', backed by the DH and PHE, was launched in September and will continue through to the end of February. The aim of the campaign is to encourage people to treat winter ailments themselves and to seek advice from their pharmacist before going to their GP. Research carried out to support the campaign found that only one in five adults make use of their local pharmacist for winter ailments.

The survey revealed that people were most likely to visit their GP or A&E about their flu symptoms (24 per cent), followed by nasal congestion (20 per cent), sore throat (13 per cent) or cold (11 per cent). Nearly half of those who visit their GP for common winter ailments do so because they want antibiotics, with the younger generation being the biggest culprits. Nearly one in four of 18 to 34-year-olds admit they have visited a GP as a first port of call for winter ailments compared to only one in 10 of those aged over 35. Furthermore, almost half of GPs admitted to prescribing antibiotics even though they know they won't treat the patient's condition.

Lack of knowledge

The 'Treat Yourself Better' survey highlighted that many people underestimate the normal duration of winter ailments and there-fore visit their GP too early in the infection. Nine in 10 expect a cough to last on average for only eight days, when in fact it can last for up to three weeks, and eight in 10 expect flu symptoms to last only 10 days, when two weeks is the normal duration.

€There is an enormous amount of work to be done, particularly in delivering messages to the public that viral infections are self-limiting and can't be treated with antibiotics,€ says Neal Patel, head of corporate communications at the Royal Pharmaceutical Society (RPS). €People need to know how long these viral infections should last and what to do if their symptoms last longer or are more severe. They should be encouraged to return to the pharmacy if their symptoms don't resolve, before going to their GP.€

In June, the public voted for antibiotic resistance to be the focus of the £10m Longitude Prize, which has set the challenge of creating a cost-effective, accurate, rapid and easy-to-use test for bacterial infections. Seventy per cent of GPs surveyed by the Longitude Prize in July said they prescribed antibiotics because they weren't sure whether the patient had a viral or bacterial infection, while nearly a quarter cited a lack of diagnostic tools.

In May 2014, a study published in BMC Family Practice found that the use of a quick blood test for C-reactive protein (CRP) levels led to a 30 per cent fall in antibiotic prescriptions in patients with acute cough/respiratory tract infections (RTIs). CRP levels rise in response to infections, but testing is currently controversial. It can't fully distinguish between bacterial and viral infections, although higher levels correlate with the presence of pneumonia.

According to the researchers, avoiding antibiotic prescribing in patients with lower CRP levels may limit the unnecessary use of these agents. The researchers hope the findings will encourage the use of the test in primary care €“ something that has been recommended in the latest European guidelines for the treatment of lower RTIs and is routinely used in Nordic countries for both upper and lower RTIs.

Pharmacy advice

The 'Treat Yourself Better with Pharmacist Advice' campaign hopes people will think twice before making a GP appointment unless they display 'warning signs' or are advised to do so by their pharmacist. To support the campaign in pharmacies, Pharmacy Voice and PAGB have revised the series of condition-specific Self Care Advice guides, which were launched last year to help the pharmacy team deliver consistent advice and care to patients.

The www.treatyourselfbetter.co.uk website includes a symptom checker and warning sign support material, videos by pharmacist Raj Patel and Dr Rob Hicks providing advice on self-care and symptom duration and a section for healthcare professionals, including a downloadable consumer leaflet and poster.

€With over 1.2 million people visiting community pharmacies every day for health-related reasons, community pharmacists and their teams have lots of opportunities to engage with customers and provide advice to manage their cold and flu symptoms themselves,€ says Rob Darracott, chief executive of Pharmacy Voice. They have an ideal opportunity to explain how long the symptoms may take to resolve, and reinforce the message that antibiotics have no impact on cold and flu symptoms caused by viruses, he adds.

If pharmacy customers are prescribed antibiotics, it is essential that they know how to take them properly. WHO guidelines stress that patients should only use antibiotics when the medicines are prescribed by a doctor and should take the full course, even if feeling better, and never share antibiotics with others or use leftover antibiotics.

Research commissioned by Pharmacy Voice, which was published in July, found that a quarter of those surveyed admitted to deliberately not following instructions about a course of medicines prescribed by a doctor, while only a fifth always complete a course. One in seven said they have used out-of-date medicines and one in 20 use medicines that have been prescribed for family and friends. While not taking a full course of antibiotics can have an impact on the individual, such as delaying their recovery, there is particular concern that this also makes bacteria resistant, presenting a danger to the patient and wider community.

€It is important to recognise that combatting resistance is not only about reducing inappropriate prescribing, but is also about ensuring that when prescribed correctly, courses are completed,€ says Rob Darracott. €Failing to hit bacteria hard can lead to resistance as much as inappropriate use in the first place.€

Challenging attitudes

In July 2014, a Joint Statement on Antimicrobial Resistance was published by the RCGP, the Royal College of Physicians (RCP), the Royal Pharmaceutical Society (RPS), the Royal College of Nursing (RCN) and the UK Faculty of Public Health (FPH). It sets out how healthcare professionals can challenge current attitudes that antibiotics are a 'cure all' and how to educate patients and the public about the dangers of the over-use or misuse of antibiotics. It also calls on patients to take some responsibility by considering alternatives to antibiotics or allowing minor viral infections to clear up in their own time.

€It is imperative that doctors, nurses and pharmacists
start talking about the alternatives available to patients who ask for antibiotics to treat minor illnesses,€ says Dr Maureen Baker. €We need to do everything we can to prevent bacteria building up a resistance to antibiotics, so patients can use them in the future, when they might really need them.€

The 'Treat Yourself Better' website offers the following advice to consumers with a cold or flu:

• Get plenty of rest, preferably in bed, and drink plenty of fluids
• Take paracetamol or ibuprofen to lower a fever and ease aches and pains
• Speak to your pharmacist about effective medicines to help relieve the commonest cold and flu symptoms, such as nasal congestion, sore throat and/or cough.

More information at www.treatyourselfbetter.co.uk