Summer 2018

Antimicrobial Stewardship: An Action Plan for Ontario Community Pharmacists

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In the Spring 2017 issue of Pharmacy Connection we shared with readers information about the role of pharmacy professionals in antimicrobial stewardship (AMS). This remains an important topic for all pharmacy professionals, in any practice environment, and is becoming increasingly so for those in community practice settings. Pharmacy Connection welcomes contributors from the Antimicrobial Stewardship Program team at the Sinai Health System and University Health Network in Toronto to share their insights and perspectives with pharmacy professionals across the province.

This is the first in their series of articles about the role of community pharmacy professionals in AMS which reinforces important information for practitioners while providing practical tips and access to resources to support ongoing AMS efforts within our health system.

Mark McIntyre, Pharm.D., ACPR
Pharmacotherapy Specialist, Antimicrobial Stewardship
Sinai Health System-University Health Network, Toronto Ontario

Antimicrobial Stat 92 percent

How many prescriptions for antimicrobials do you encounter every day? In Canada, we fill more than 22 million prescriptions for antimicrobials each year.1 In Ontario, this equates to an annual average of more than one antimicrobial prescription for every two people.

Antimicrobials are a lifesaving component of medical care. Without effective antimicrobial therapy, many minor infections turn serious or deadly and many routine procedures such as joint replacement and chemotherapy become nearly impossible to achieve optimum patient outcomes.

With antimicrobial use, however, comes the inevitable risk of antimicrobial resistance (AMR). AMR is a growing threat to modern healthcare and is compounded by inappropriate or unnecessary prescribing of antimicrobial agents.3,4

Antimicrobial Statistics

As pharmacists, we have a duty to get the right patient the right drug at the right dose via the right route at the right time. Antimicrobial stewardship (AMS) takes this central tenet of pharmacy practice and applies it to antimicrobial agents. Remember that stewardship aims to get optimal therapy for each patient and to preserve antibiotics for everyone. Pharmacists encounter nearly every dose of antimicrobial therapy prior to the patient receiving the medication, making pharmacists – as clinicians and medication experts – antimicrobial stewards.

This and subsequent submissions to Pharmacy Connection will focus on stewardship for pharmacists in community practice, specifically syndromes that drive the majority of adult antimicrobial prescribing in community practice – uncomplicated cystitis, sinusitis, pharyngitis and bronchitis. The goal of our submissions is to highlight the importance of effective infectious disease assessment and to ensure optimal antimicrobial use for the discussed conditions. In this issue, we review general strategies to incorporate AMS into your current practice.


Many antimicrobial stewardship interventions are already widespread in practice.5,6 From administration of influenza vaccine, to counselling on the expected duration of viral illness-related symptoms, we are reducing the human antimicrobial footprint every day. However, we can do more.

Through the Antimicrobial Stewardship Program at Sinai-UHN, we classify AMS interventions as proactive or reactive. Proactive interventions are those that occur in the absence of an ill patient presenting to your pharmacy counter. These interventions are targeted at prescribers or patients and serve to either prevent the need for antimicrobials or optimize use if they are prescribed. Many of these interventions take training and time to pull together but serve to facilitate a collegial relationship with your prescribers and extensive collaboration may be well worth the effort.

Interventions occurring at the time of an encounter with an ill patient are termed reactive . In the busy reality of daily practice, these types of interventions are likely to represent the majority of stewardship actions. Be it recommending self-care measures for bronchitis or optimizing antimicrobial duration for a urinary tract infection, many opportunities are well within the reach of pharmacists in the community.

The exact mix of strategies employed in your pharmacy will depend on various factors including workflow, experience and prescriber relationships. Whichever mix of strategies you choose, the goal of all interventions is to facilitate valuable, lasting behavior change and improve patient outcomes.

Examples of Proactive AMS Interventions


• Academic detailing on decision aids/optimal treatment for specified syndromes
• Promoting dated watchful waiting prescriptions
• Shared speaking engagements with clinicians (schools, community groups)


• Vaccination clinics
• Cold and flu education days
• Engagement posters supporting reasonable antimicrobial use

Examples of Reactive AMS Interventions

Patients without prescriptions for antimicrobials

• Assessment and counselling on self-management of viral/self-limited conditions
• Counselling on expectation of symptom duration and when to seek further care
• Education on viral vs. bacterial infections
• Pharmacist follow-up for symptom resolution

Patients with prescriptions for antimicrobials

• Confirming indication with patient or agent (optimally at drop-off)
• Counselling on expectation of antimicrobial benefits and risks
• Adaptation and/or follow-up with prescriber for questions regarding duration of, or indication for, antimicrobial therapy

Where to start? Pharmacists should know the indication for every antimicrobials they dispense.7 Though not always available, this information can transform the pharmacist’s understanding of antimicrobial therapy as well as his/her ability to plan and apply stewardship interventions successfully. As stated in NAPRA’s Model Standards Of Practice for Canadian pharmacists, “…each new prescription should be reviewed to ensure that it is the most appropriate for the specific patient.”8 Fundamental to appropriateness is knowledge of why the medication is prescribed. Engaging pharmacy technician colleagues and ensuring optimized pharmacy workflow to gather indication information, as an example, may prove an impactful and practical way to start or expand stewardship activities in your pharmacy.

Knowledge is only part of the intervention. Communication to prescribers and patients about reactive stewardship interventions can be challenging. Time pressure to get patients antibiotics and difficulties discussing patient care issues with prescribers are barriers to successful interventions. To facilitate better communication with patients and prescribers, examples of scripting for patient interactions and fax templates for prescribers will be provided in subsequent submissions to Pharmacy Connection.

In the meantime, see the links to some practical web-based resources below to help support effective antimicrobial stewardship in your community pharmacy. Keep antibiotics working; we can’t do it without you!

  1. Public Health Agency of Canada. Canadian Antimicrobial Resistance Surveillance System: – report 2017. Her Majesty the Queen in Right of Canada, as represented by the Minister of Health; 2017.
  2. Shively NR, Buehrle DJ, Clancy CJ, Decker BK. Prevalence of Inappropriate Antibiotic Prescribing in Primary Care Clinics within a Veterans Affairs Health Care System. Antimicrob Agents Chemother. 2018;62(8).
  3. Goossens H, Ferech M, Vander Stichele R, Elseviers M, Group EP. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365(9459):579-587.
  4. Review on Antimicrobial Resistance, Tackling Drug Resistant Infections Globally: Final Report and Recommendations [Internet].]; 2016.
  5. Blanchette L, Gauthier T, Heil E, et al. The essential role of pharmacists in antibiotic stewardship in outpatient care: an official position statement of the Society of Infectious Diseases Pharmacists. J Am Pharm Assoc (2003). 2018.
  6. Leung V, Langford B. Antimicrobial Stewardship in Ontario: What’s Your Role?. Pharmacy Connection: Ontario College of Pharmacists; Spring 2017:25-27.
  7. Schiff GD, Seoane-Vazquez E, Wright A. Incorporating Indications into Medication Ordering–Time to Enter the Age of Reason. N Engl J Med. 2016;375(4):306-309.
  8. Model Standards of Practice for Canadian Pharmacists. The National Asssociation of Pharmacy Regulatory Authorities; 2016.

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