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Antibiotic pharmacists in the ascendancy
Kieran Hand*
Pharmacy Department, Southampton University Hospitals NHS Trust, Southampton General Hospital,
Tremona Road, Southampton SO16 6YD, UK
Specialist pharmacists have become an established feature of the antibiotic stewardship landscape in
hospitals throughout the UK over the last decade. This review examines the origins of the specialist
antibiotic pharmacist and how the role has developed in recent years. Antibiotic pharmacists fulfil a
vital function in modern National Health Service hospitals as key members of the infection control
team with overall responsibility for initiatives to promote rational antibiotic prescribing. Evidence of
the impact of antibiotic pharmacists on clinical, microbiological and financial outcomes is presented
along with examples of innovative practice. Finally, a vision for the future of the antibiotic pharmacist
role is outlined.
Keywords: antimicrobial prescribing, pharmacy, microbiology, hospital
Introduction
The model of pharmacy services adopted by British hospitals
has evolved considerably over the last 30 years. While retaining
the core functions of efficient procurement, distribution and safe
and secure handling of medicines, clinical services provided by
pharmacists have become an established part of hospital health-
care.
1
Evidence is accumulating to show that clinical pharmacy
activities lead to improved patient care, with better use of medi-
cines that in many cases is more cost-effective.
2
Analysis of US
hospital data examining four health outcome measures—mortality,
length of stay, drug costs and total cost of care—revealed the ratio
of clinical pharmacists to occupied beds as the only pharmacy
variable associated with positive outcomes for all four measures
and similar data are becoming available for the UK.
3,4
Modern-day clinical pharmacists in UK hospitals spend a
substantial proportion of their time on wards, reviewing drug
therapy and tailoring optimal treatment regimens for individual
patients, often as members of collaborative multi-disciplinary
healthcare teams. Pharmacists are increasingly available on ward
rounds to provide advice at the point of prescribing or alterna-
tively, they will be in a position to intervene and influence pre-
scribing before therapy commences by triaging requests for new
medications. Clinical pharmacists with the appropriate training
and support are therefore ideally placed to promote responsible
and effective antibiotic prescribing.
The majority of UK clinical pharmacists undertake formal
postgraduate training in clinical pharmacology and therapeutics,
often with an element of specialist instruction in the field of anti-
microbial therapeutics. Traditionally viewed as generalists, with
knowledge of a broad range of therapy areas, UK hospital
pharmacists have broken the mould in recent years as the concept
of specialization has emerged in hospital pharmacy practice.
Pharmacists with an interest in a particular area of therapeutics
such as cardiology, critical care or mental health, have sought and
undertaken specialty training and now pursue successful careers
as specialist clinical pharmacists and consultant pharmacists.
5
Antibiotic pharmacists
Specialist antibiotic pharmacist posts were established in a small
number of UK hospitals in the early 1990s, however, it was not
until 2003 that the potential of the antibiotic pharmacist became
embedded in the collective conscience of Chief Pharmacists in
national health service (NHS) hospitals acro ss England and W ales.
Several national and international reports on the subject of
antimicrobial resistance since 1998 ha d acknowledged the
important role hospital pharmacists have to play in influencing
antibiotic prescribing and identified the potential to build on this
promising foundation to promote responsible use of antibiotics.
6–9
The value of pharmacists was highlighted by the Standing
Medical Advisory Committee who contended that pharmacists,
particularly in hospitals, have an important role in controlling,
prescribing and identifying inappropriate prescribing.
8
A role for
hospital pharmacists was also advocated in the ‘Winning Ways’
report from the UK Chief Medical Officer on healthcare associ-
ated infection in England, which stipulates that support for
prudent antibiotic prescribing in hospitals will be provided by
clinical pharmacists, along with medical microbiologists and
infectious diseases physicians.
7
This requirement has been incor-
porated into performance indicators for NHS acute trusts and is
currently subject to audit by the Healthcare Commission.
.....................................................................................................................................................................................................................................................................................................................................................................................................................................
*Tel: þ44-2380795117; Fax: þ44-2380798780; E-mail: kieran.hand@suht.swest.nhs.uk
Journal of Antimicrobial Chemotherapy (2007) 60, Suppl. 1, i73 –i76
doi:10.1093/jac/dkm163
.....................................................................................................................................................................................................................................................................................................................................................................................................................................
i73
# The Author 2007. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.
For Permissions, please e-mail: journals.permissions@oxfordjournals.org
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Responding to a recommendation from its Specialist
Advisory Committee on Antimicrobial Resistance, the
Department of Health (DH) announced an investment of £12M
over 3 years to support clinical pharmacy activities around the
promotion of prudent antimicrobial prescribing.
10,11
A survey of
183 NHS Trusts in England was undertaken in 2005 to investi-
gate the involvement of pharmacy staff in anti-infective medi-
cines management and the impact of the DH funding. Of the
130 Trusts who responded, 125 employed at least one specialist
member of pharmacy staff with responsibility for anti-infectives,
89% of whom were pharmacists.
12
The role of the antibiotic pharmacist
A number of reviews of the role of the antibiotic pharmacist
have been published in recent years.
13 – 19
A tradition of collabor-
ation between pharmacists and microbiologists is well estab-
lished.
20,21
Typical responsibilities of the hospital antibiotic
pharmacist are discussed below.
Expert advice
The antibiotic pharmacist is expected to provide expert advice
on the management of antibiotic therapy in individual cases
referred by ward pharmacist colleagues and to act as a triage for
cases requiring input from staff in microbiology or infectious
diseases. Advice may be provided over the telephone in response
to radio page or in person on ward rounds, often in conjunction
with microbiology or infectious diseases clinicians.
Education and training
Antibiotic pharmacists are frequently called upon to provide
education and training for pharmacists, doctors, nurses and other
healthcare professionals on prudent antibiotic prescribing and to
raise awareness of hospital guidelines and policies. This may
include presentations at induction sessions for new hospital staff.
Liaison role
The antibiotic pharmacist acts as a liaison between microbiology
and pharmacy departments with regard to such issues as the
antibiotic formulary, managed entry of new antibiotics, labora-
tory susceptibility testing and monitoring of antibiotic levels.
Formulary enforcement
Many hospitals operate an antibiotic formulary restricting choice
of available agents and requiring microbiologist or infectious
diseases physician authorization for prescribing of certain broad-
spectrum agents. The antibiotic pharmacist typically plays an
important role in supporting ward pharmacists in enforcement of
antibiotic formularies and monitoring compliance of prescribers.
Antibiotic guidelines
Developing and maintaining an tibiotic guidelines is one of the
fundamental roles of the antibiotic pharmacist and he/she will
often act as ca talyst between a number of stakeholders, working to
achieve consensus and endorsement by key opinion leaders in the
hospital. It is recognized, however, that clinical practice guidelines
have had a limited effect on changing physician beha v iour and
numerous studies have explored the underlying reasons.
22,23
The
critical task of implementing prescribing policies and encouragin g
compliance with antibiotic guidelines has fallen largely to ward
pharmacists, without whom many of these initiatives would be
largely ineffectual. The successful implementa tion of clinical
guidelines is beholden to efficient communication and antibiotic
pharmacists ar e ideally placed to conduct educational campaigns
and to engage pharmacist and doctor colleagues.
Antibiotic policy
A wide variety of policies designed to control antibiotic pre-
scribing have been described in the published literature and
introduced to varying degrees in UK hospitals, often initiated
and implemented by antibiotic pharmacists. Examples of issues
addressed include:
† Intravenous-to-oral switch or sequential therapy
† Mandatory antibiotic order forms
† Therapeutic substitution of antibiotics
† Automatic stop orders
Antibiotic serum level monitoring and dosing
A recent review of aminoglycoside and glycopeptide serum
level monitoring in the US demonstrated that there were signifi-
cantly fewer numbers of related deaths when pharmacists pro-
vided this service in comparison with other healthcare
professionals.
24
Antibiotic pharmacists are responsible for devel-
oping policy for serum level monitoring of these agents and for
training pharmacists in safe and effective dosing practices.
Monitoring and feedback
Antibiotic pharmacists invariably undertake or facilitate moni-
toring of antibiotic use and prescribing by means of electronic
stock control systems or through dedicated prescribing
audits.
25,26
The value of regular feedback to prescribers includ-
ing trend analysis and benchmarking with peers is inc reasingly
recognized as a tool for effectively influencing prescribing and
antibiotic pharmacists are working towards providing this feed-
back routinely in UK hospitals.
27
Research and development
Antibiotic pharmacists are also active in practice research and a
Cochrane Review of interventions to improve antibiotic prescrib-
ing practices for hospital inpatients identified 22 robust studies
where the interventions were delivered by pharmacists, predomi-
nately educational and exclusively aimed at decreasing antibiotic
treatment.
28
Antibiotic pharmacists are expected to coordinate
research and practice development in th is area and to share best
practice with colleagues in peer-reviewed publications.
Evidence and outcomes
The quality of published research into the effectiveness of
interventions to improve the quality of antibiotic prescribing in
Hand
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hospitals is relatively weak.
29
However, there are a number of
robust studies in the literature describing positive clinical, micro-
biological and economic outcomes of clinical pharmacy activity
in the area of antibiotic prescribing. Although specialist anti-
biotic pharmacists are not mentioned specifically in the follow-
ing reports, they are likely to be instrumental in the successful
local implementation of similar initiatives.
A study carried out to examine the impact of an antimicrobial
prescribing protocol for management of community-acquired
lower respiratory tract infection reported both clinical and econ-
omic outcomes.
30
Clinical pharmacists were involved with the
development and encouraged day-to-day implementation of the
protocol on hospital wards. Patients treated using the protocol had
significant reductions in length of stay, intravenous drug adminis-
tration, duration of intravenous therapy and number of treatment
failures. A multicentre study of guideline implementation for
pneumonia was carried out at 23 hospitals and 60 outpatient
clinics in the US.
31
Pharmacists were part of the multidisciplinary
group that developed and implemented the guidelines and the
study reported a significant reduction in 30 day mortality (odds
ratio 0.69, 95% CI 0.49–0.97) for hospitalized patients treated by
physicians who participated in the guideline programme.
A study reporting microbiological outcomes following
implementation of a multidisciplinary antimicrobial management
team, including pharmacists, reported significant and sustained
reductions in Clostridium difficile-associated diarrhoea and
resistant Enterobacteriaceae.
32
Researchers at a tertiary university hospital in Scotland evalu-
ated the impact of a restricted antimicrobial policy implemented
by ward pharmacists and reported a significant and sustained
reduction on the use and cost of the restricted agents in the 2
years following introduction of the policy.
33
The cost of develop-
ment, dissemination and implementation of the policy was fully
evaluated and found to be ,20% of the cost savings generated.
Information about the cost-effectiveness of employing special-
ist pharmacy staff in this role is lacking but savings of £10 per
patient reviewed on multi-disciplinary ward rounds per day have
been attributed to the antibiotic pharmacist.
34
Some hospitals
have reported annual cost savings associated with antibiotic man-
agement activities of between £23 000 and £500 000.
12
Innovative practice
Antibiot ic pharm acists have been exploring innovative sol-
utions to common problems in antimicrobial medicines man-
agement and sharing the fruits of their labours with colleagues
in the NHS.
Wickens et al.
35
in St Mary’s hospital, London, have success-
fully deployed a web-based referral system used by ward phar-
macists to alert the microbiology pharmacist to patients with
antimicrobial-related problems for triaging and subsequent dis-
cussion with microbiology or infectious diseases clinicians as
well as recording outcomes.
Hills, a microbiology pharmacist at Nottingham has collabo-
rated with microbiology colleagues to design and implement a
hospital web site for infection management.
36
The web site
leads users through an interactive process to local recommen-
dations for investigation and treatment of common infections as
well as information about monitoring antibiotic serum levels and
local susceptibility patterns.
Weeks et al .
37
at Southampton University Hospitals NHS
Trust have reported on the cost-effective implementation of anti-
microbial management teams with regular review of patients
referred by ward pharmacists on ward rounds with microbiolo-
gists and clinical pharmacists.
The future for antibiotic pharmacists
Continuing concerns over inappropriate antibiotic prescribing and
the menace of hospital-acquired infection with multiresistant
microorganisms, combined with the incorporation of antibiotic
prescribing data into key performance indicators for hospitals,
will mean that the skills of the antibiotic pharmacist remain in
demand for the foreseeable future. The Infectious Diseases
Society of America has recently endorsed the role of the pharma-
cist with specialist infectious diseases training as a core member
of the hospital antimicrobial stewardship team and many UK hos-
pitals have opted to continue to fund antibiotic pharmacist posts
following the expiration of DH dedicated funding in 2006.
38
Antibiotic pharmacists have a vital role to play in the forth-
coming implementation of electronic prescribing and will be
instrumental in harnessing the potential of computerized
decision support for improving the quality of antibiotic prescrib-
ing and for monitoring prescribing trends and associated health-
care outcomes.
39
The challenges that lie ahead will include the development of
an accredited training programme and competency asses sment
for specialist antibiotic pharmacists in order to ensure that they
are fit-for-purpose. Computer-assisted learning packages and
web-based accreditation and competency assessment are already
in the advanced stages of development.
Weller and Jamieson
17
outlined the implications of sup-
plementary prescribing by antibiotic pharmacists and the import-
ance of clear role delineation between microbiologists,
infectious diseases physicians and antibiotic pharmacists. The
need for clarification of responsibilities will become even more
acute with the advent of in dependent pharmacist prescribing and
the appointment of consultant antibiotic pharmacists over the
coming years. Successful antibiotic pharmacists are likely to be
those who can play to their strengths and differentiate the
service they provide from their colleagues in microbiology and
infectious diseases, adding demonstrable value to their local
healthcare economy in the process.
Antibiotic pharmacists are here to stay but further investment
in practice research is of paramount importance to identify the
most efficient and effective means of deploying this valuable
pharmacy resource.
Transparency declarations
None to declare.
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