The Role of Pharmacist in Encouraging Prudent Use of Antibiotics and Averting Antimicrobial Resistance A Review of Policy and Experience Eng

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DOCUMENT TITLE: THE ROLE OF PHARMACIST IN ENCOURAGING PRUDENT USE OF ANTIBIOTICS AND AVERTING
ANTIMICROBIAL RESISTANCE: A REVIEW OF POLICY AND EXPERIENCE IN EUROPE
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The role of pharmacist

in encouraging
prudent use of
antibiotics and
averting antimicrobial
resistance: a review of
policy and experience
World Health Organization

Regional Office for Europe
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Website: http://www.euro.who.int/en/health-topics/Health-systems/medicines
Health
Technologies
and
Pharmaceuticals
Programme
The role of pharmacist in encouraging

prudent use of antibiotics and averting
antimicrobial resistance: a review of
policy and experience in Europe
ABSTRACT
The good pharmacy practice (GPP) Joint FIP/WHO guidelines on GPP: standards for quality of pharmacy services
states, The mission of pharmacy practice is to contribute to health improvement and to help patients with health
problems to make the best use of their medicines. Based on the results of a literature review of the GPP roles
relating to AMR and a survey conducted in the WHO European Member States, this report outlines the roles of
pharmacists in this mission and, since they are often the first point of contact for patients, their potential as
important allies in the fight against antimicrobial resistance (AMR). The report illustrates that pharmacists already
have experience in treating patients with antibiotics, both responsibly and within an appropriate legal framework. It
also indicates, however, that in many countries the general public can still buy antibiotics over the counter without
a diagnosis or prescription and use them at will. According to the survey, pharmacists are among the best
positioned to influence the appropriate use of antibiotics and, therefore, have a crucial role to play in combating
AMR alongside policy-makers and general practitioners: every player is key.
KEYWORDS
Antimicrobial drug resistance
Medicine, evidence-based
Non-prescription drugs
Pharmaceutical services
Data collection
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World Health Organization 2014
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CONTENTS
Page
EXECUTIVE SUMMARY...............................................................................................................................................1
INTRODUCTION...........................................................................................................................................................3
BACKGROUND.............................................................................................................................................................3
OBJECTIVES................................................................................................................................................................4
METHODOLOGY...........................................................................................................................................................5
LITERATURE SEARCH...................................................................................................................................................5
GOOD PHARMACY PRACTICE.........................................................................................................................................6
GLOBAL - FIP............................................................................................................................................................7
SURVEY METHODOLOGY...............................................................................................................................................7
RESULTS.......................................................................................................................................................................8
AMRRELATED PHARMACY ROLES: MAPPING THE LITERATURE........................................................................................8
GlobalGPPguidelines.....................................................................................................................................11
SURVEY RESULTS.......................................................................................................................................................11
Characteristicsoftherespondents....................................................................................................................11
Viewsoftherespondentsonthepotentialofhealthprofessionaltoinfluencetheuseofantibiotics..............12
Accesstoantibiotics..........................................................................................................................................13
Monitoringconsumptionofantimicrobialmedicine.........................................................................................15
Antibioticstewardship.......................................................................................................................................17
Guidelinesonantibiotictreatment....................................................................................................................18
Otherfindings....................................................................................................................................................20
DISCUSSION...............................................................................................................................................................20
CONCLUSIONS.............................................................................................................................................................22
REFERENCES.............................................................................................................................................................1
ANNEXES......................................................................................................................................................................6
ANNEX 1. LIST OF DOCUMENTS WITH REFERENCE TO THE ROLE OF PHARMACIST IN RELATION TO AMR..............................6
ANNEX2.PHARMACYROLESINANTIMICROBIALRESISTANCELITERATUREMAP........................................................................9
ANNEX 3. ANTIBIOTICMEDICINESRELATED QUESTIONNAIRE FOR EUROPEAN PHARMACY/PHARMACIST ASSOCIATION.......21
ANNEX 4. COUNTRYSPECIFIC POLICY RECOMMENDATIONS...........................................................................................26
The role of pharmacist in encouraging prudent use of antibiotic medicines and averting antimicrobial resistance:
a review of current policies and experiences in Europe
page 1
Executive summary
Antimicrobial medicines play a major role in controlling infectious diseases. However, their
widespread use often overuse and misuse is seeing a growing resistance to their efficacy.
Therefore, one of the key challenges facing countries is to ensure the best use of antibiotics. In
this connection, it is important that any concerted action involve the examination and, where
necessary, improvement of the role of the pharmacist (including those working in clinics and
hospitals) as the main supplier and regulator of these medicines. This report provides an
independent assessment of the current policy and guidance on the role of the community
pharmacy/pharmacist, maps their key roles in relation to antimicrobial resistance (AMR), and
summarizes existing guidance for pharmacies/pharmacists and recent research on the
performance of pharmacy systems in Europe.
The findings presented in the report are the result of a combination of primary and secondary
research, namely a survey conducted in the 53 Member States of the WHO European Region
through a questionnaire addressed to pharmacy associations on current national pharmaceutical
services/initiatives linked to prudent use of antibiotic medicines. This was complemented by a
targeted literature review of academic articles, grey literature and guidance materials referring to
the role of the pharmacist. The literature identified has been categorized according to document
type: patient information material; focus on the pharmacists role; policy documents on tackling
AMR; and research articles (Annex 1).
Survey responses from 44 countries have been analysed and are presented in the report. The
findings show that access to antibiotics is regulated in most national contexts in Europe to a
greater or lesser degree. Therefore, while in some countries access to antibiotics without a
prescription is only possible in emergency situations, the regulations in others allow for a higher
level of over- the-counter (OTC) sales. Most countries reported pharmacy-level activities or
initiatives to foster the prudent use of antibiotics, such as educational campaigns and the
development of guidelines for consumers. Additionally, while the role and impact of the
pharmacist differ by country, an overwhelming majority of respondents were of the opinion that
pharmacists are best placed to help combat AMR given their positions of interface between the
health-care system and the patient. At the same time, it was reported that the doctors role vis-vis antibiotic guidance, in partnership with pharmacists, could be strengthened.
In taking the discussion on the specific role of the pharmacist forward, the report looks at the
survey results in detail and links these to the 4 pharmacist roles defined in the Joint FIP/WHO
guidelines on GPP: standards for quality of pharmacy services (the GPP guidelines) (1). Though
it clear that the pharmacists role is crucial, the GPP guidelines place it in a wider context.
Greater antibiotic stewardship and a strengthening of the medical and pharmacy curricula were
identified as important considerations for the future.
The report presents a number of issues, which policy-makers may wish to consider with a view
to strengthening their efforts to tackle AMR, such as enhancing the prudent use of antibiotics. In
this connection, the role of the pharmacist is seen as key and collaboration between pharmacists
and prescribers as particularly important.
The report was developed by the Health Technology and Pharmaceutical Programme in
collaboration with the Pharmaceutical Group of the European Union (PGEU), Europharm
page 2
Forum, and the WHO Collaborating Centre for Drug Development and Pharmacy Practice at
Pharmakon (Denmark).
page 3
INTRODUCTION
Background
As long as they have existed, antimicrobial medicines have played a major role in controlling
infectious diseases. However, their increasing widespread use has resulted in the development of
resistant microorganisms, which are causing disease in community and hospital settings,
resulting in increased morbidity and mortality, and higher health-care costs. The failure to
develop innovative antibiotic molecules over the last few decades has made the task of
combating resistant organisms more difficult (2).
The major cause of antimicrobial resistance (AMR) is the inappropriate use of antibiotics.
Various studies carried out in and outside Europe revealed that over 40% of prescriptions for
antibiotics were more or less inappropriate. This was found to be directly related to the tendency
towards self-medication and the unnecessary use of antibiotics for common sore throats and
colds that most frequently are caused by viral infections on which antibiotics have no effect.
(3,4). As well as self-medication by patients (including the use of left-over medicines), the
studies identified problems, such as the illegal dispensing of antimicrobials by pharmacists in
some European countries, as well as inappropriate prescribing by physicians (3,5,6,7).
The spread of AMR cannot be combated at the national level alone. It is a global problem that
requires a coordinated effort.
Both European Union (EU) and WHO strategies for the control of AMR have been applied in
countries of the WHO European Region
(7,8,9,10)).
The WHO health policy framework and
strategy, Health 2020: the European policy
for health and well-being (11), identifies
AMR as a major health challenge under
priority area 2, Tackling Europes major
health challenges: noncommunicable and
communicable diseases.
The European strategic action plan on
antibiotic resistance (8), adopted by the
WHO European Member States in
September 2011, was developed on the
basis of Health 2020 (11). It sets out 7 key
actions to address the problem of AMR
(Box 1) (8).
Box 1. The 7 key areas of action to address the

problem of AMR
1. Strengthen intersectoral coordination.
2. Strengthen surveillance of antibiotic resistance.
3. Promote rational use and strengthen surveillance
of antibiotic consumption.
4. Strengthen infection control and surveillance in
health-care settings.
5. Prevent emerging resistance in the veterinary and
food sectors.
6. Promote innovation and research on new drugs.
7. Improve awareness, patient safety, and
partnership.
Source: European strategic action plan on antibiotic
resistance (8)
The World Health Assembly, at its Sixtyseventh session in 2014, adopted resolution
WHA67.25 (12) requesting the Director-General to develop a draft global action plan to combat
AMR, including antibiotic resistance, for submission to the Sixty-eighth session of the World
Health Assembly in 2015. This plan is currently under development.
page 4
The overall goal must be to preserve our ability to treat serious infections. In some contexts,
preserving the effectiveness of antimicrobial medicines means to use them less. The appropriate
use of antibiotics is essential in the face of increasing AMR, and it is the collective responsibility
of all sectors of health care to cooperate on and tackle this issue. This is important in relation to
both human and animal health and action is required in both sectors; this report focuses on
human-related action.
Although multidrug-resistant strains of pathogens are increasing in hospital settings, an overall
reduction of AMR can only be obtained by addressing the outpatient use of antibiotics. Thus, the
role of the community pharmacist is key to reducing the threat of AMR (13). It is the pharmacist
who has the last contact with the patient before he or she receives an antibiotic medicine and,
thus, the pharmacist acts as the gatekeeper (14).
It is clear that a number of issues need to be addressed in the context of the pharmacists role in
combating AMR. These include:
dispensing antimicrobials without a prescription;

enforcing rules relevant to unauthorized dispensing;
developing appropriate regulations, where necessary;
using repeat prescriptions for antimicrobials;
adjusting quantity dispensed vs quantity prescribed;
managing waste (used antibiotics);
using pharmacies in campaigns to promote and conduct awareness on the use of
antimicrobials;
providing information (pharmacist to patient) on antimicrobials, AMR and AMR-related
issues;
training pharmacy students and pharmacists in AMR and AMR-related issues;
cooperating with prescribing physicians;
providing antibiotic stewardship in primary-care settings.
Many countries and organizations have developed strategies for and guidance on AMR (15,16).
However, most of the related policy documents do not include guidance on the role of
pharmacists and pharmacies, or do so only to a very limited extent.
With this background in mind, there was a need to create an overview of the roles and activities
of pharmacists, pharmacies and pharmacy systems that can contribute to the prudent use of
antimicrobial medicines (17).
Objectives
The objectives of this report are to present the outcome of a review of the policy and guidance
existing in Europe in relation to the role of the community pharmacy/pharmacist and the results
of a survey to investigate and map the current availability and consumption of antibiotics. The
report also maps the roles of the pharmacist described in the GPP guidelines (1) at both global
and country levels, and outlines potential AMR-related action or policy options that countries
may wish to consider in promoting the prudent use of antibiotics.
page 5
METHODOLOGY
A targeted literature review was undertaken to analyse the status quo regarding the use of
antibiotics and strategies to combat the growing AMR epidemic, as well as the role of the
pharmacist in this respect. In addition, relevant guidance documents of various European
countries and global organizations were collected and analysed. The results were categorized on
the basis of the GPP guidelines (1) and grouped according to the 4 key responsibilities of the
pharmacist outlined in their conceptual framework.
In addition, a survey was carried out in the 53 WHO European Member States with the aim of
capturing the perception of pharmacists, patients, policy-makers and prescribers regarding the
availability and consumption of antibiotics, as well as their views on how to tackle the growing
AMR crisis and ways in which stakeholders could contribute to doing so.
Literature search
A literature map was conducted in September 2014 to identify evidence of the roles of
pharmacists and pharmacies in the use of antibiotics. A search of the National Center for
Biotechnology Information Pubmed Central (NCBI-PMC) was carried out using the following
combinations of key words (the numbers of articles found are mentioned in brackets):
1. prudent use antibiotics pharmacist (9)
2. prudent use antibiotics pharmacy (42)
3. prudent use antimicrobials pharmacist (11)
4. prudent use antimicrobials pharmacy (47)
5. antibiotic resistance pharmacists role(40)
6. antimicrobial resistance pharmacists role (54)
7. antibiotics irrational use pharmacist (10)
8. antibiotics rational use pharmacist (49)
9. reasonable use of antibiotics pharmacist (7)
10. inappropriate use of antibiotics pharmacist (125)
11. unreasonable use of antibiotics pharmacist (0)
12. role of pharmacist antibiotics prescription (45).
A search using the term pharmacy instead of pharmacist gave less relevant results or results
that were also covered in the above-mentioned search.
Strict inclusion and exclusion criteria were set up for the document screening. Documents were
included if (judging from abstracts or summaries) they contained guidelines or recommendations
on AMR-related activities in community-pharmacy practice relevant to the European setting.
Documents related to hospital settings were not included. The language of the publications was
restricted to English but, since Russian-language publications were also found, these were
included because of their relevance to the European Region. The literature search focused only
on human antimicrobial resistance problems, although veterinary issues also have a great impact
on the overall problem. Material referring to resistance to certain types of antibiotics or certain
types of microorganisms was also excluded.
In order to include all policy documents relating to AMR in the European Region, in September
2014, a search was made in Google using the same key words as in the above-mentioned search.
page 6
This led to documents from organizations, such as the European Centre for Disease Prevention
and Control (ECDC), the International Pharmaceutical Federation (FIP), the Pharmaceutical
Group of the European Union (PGEU), and the WHO Regional Office for Europe, as well as to
country-specific strategies.
Good pharmacy practice

The GPP guidelines (1) were chosen as the framework for analysing the literature on pharmacy
roles and activities in relation to AMR. They describe the standards necessary to ensure the
quality of pharmacy services, stating that the mission of pharmacy practice is to contribute to
health improvement and to help patients with health problems to make the best use of their
medicines. They identify 4 main roles with underlying functions in connection with which the
involvement of or supervision by pharmacists is expected by society and the individuals they
serve (Fig. 1). In this report, the activities of pharmacists/pharmacies are described according to
these 4 roles.
Fig. 1. The roles of the pharmacist according to the GPP guidelines
Source: Joint FIP/WHO guidelines on good pharmacy practice: standards for quality of pharmacy services (1).
page 7
Global - FIP
In 2008, FIP published a revised statement on AMR entitled, FIP Statement of policy - control
of antimicrobial medicines resistance (AMR) (18), whereby FIP takes responsibility for the
professional leadership through a range of activities. It urges pharmacists to:
provide proper counselling and appropriate written information when dispensing
antimicrobials;
encourage patients to take the full prescribed regimen and, if not possible, to dispose of any
unused antimicrobial medicines appropriately;
work with prescribers so that dosages prescribed are sufficient for the completion or
continuation of a course of therapy;
recommend therapies other than antimicrobials for minor ailments;
provide updated information on antimicrobial medicines to prescribers as well as health-care
professionals who administer or otherwise influence the use of medicines;
be actively involved in matters of hygiene and infection control in all health-care settings;
effectively monitor the supply and use of antimicrobials by their patients.
At the health-system level, FIP urges governments and health authorities to take the following
action directly related to community pharmacy:
develop and implement measures for the appropriate use of antimicrobials and prohibit the
dispensing and sale or supply of these medicines without a prescription from or order of a
qualified health-care professional;
strengthen the legislative and regulatory control of authorizations to market, import, export,
prescribe, dispense and otherwise supply antimicrobial medicines, and enhance the
enforcement of statutes and regulations;
ensure that only authorized channels of distribution are used to minimize the availability of
counterfeit and substandard medicines, thus assuring that available antimicrobials meet the
required standards of safety, quality and efficacy;
conduct health-education campaigns that promote the appropriate use of antimicrobials;
collaborate with health-professional societies and associations to develop and facilitate the
implementation of educational and behavioural interventions that will assist prescribers in
appropriate antimicrobial prescribing.
Survey methodology
A survey questionnaire was developed for the collection of primary data and distributed to
pharmacy and pharmacist associations in all 53 Member States of the WHO European Region
(Annex 3). The questions related to:
the capacity (including human resources and funding) of the respondents to carry out
activities related to antibiotic medicines;
the opinion of the respondents as to whether antibiotic medicines are prescribed, dispensed
and used appropriately in their countries;
the opinion of the respondents regarding actors capable of improving the use of antibiotic
medicines in their countries;
the question of whether over-the-counter (OTC) antibiotics are legally available, whether
they are being sold or supplied to the public illegally, and whether antibiotic medicines are
available outside the pharmacy;
page 8
collaboration between the physician and the pharmacist on the appropriate use of medicines;
monitoring of consumption of antibiotic medicines;
educational activities relating to the prudent use of antibiotic medicines and the
availability/use of standard treatment guidelines;
country-specific activities on the prudent use of antibiotic medicines, which give the
pharmacist a specific role and responsibility;
patient information related to the prudent use of antimicrobial medicines.
The questionnaire was developed in English and translated into Russian. The data was collected
in the countries during the period June-September 2014, using an electronic collection
instrument. Europharm Forum and PGEU requested their members to complete the
questionnaire. In the case of the Republic of Serbia and countries where Europharm Forum and
PGEU are not represented, the Regional Office approached the ministries of health or the
national medicines regulatory agencies through its country offices in these countries. Responses
received in Russian were translated and entered into the electronic survey tool by the Regional
Office.
Descriptive analyses of the responses and frequency calculations were carried out.
RESULTS
AMRrelated pharmacy roles: mapping the literature
The relevant literature was read and listed in 4 categories chosen for their importance in
identifying and better understanding ways of strengthening the prudent use of antibiotics:
1.
2.
3.
4.
patient information;
the professional role of the pharmacist;
recommendations of organizations or institutions on how to handle the problem of AMR;
research articles describing and evaluating concrete activities or efforts in this area (Annex
1).
The results were further analysed and categorized according to the 4 four roles of the pharmacist
outlined in the GPP guidelines (Boxes 2-5) (Annex 2) (1).
page 9
Box 2. GPP role 1: prepare, obtain, store, secure, distribute, administer, dispense and dispose
The following activities were identified as relevant to role 1 of the GPP guidelines (1) :
establishment of internal quality procedures to prevent contamination whereby all antibiotics are properly labelled,
dated and stored;
ensuring the regular and fast supply of all antibiotics to avoid undertreatment, in connection with which the
pharmacy describes the best dispensing practice, including the non-sale of partial doses and antibiotics without a
prescription;
provision of information - verbally (in a patient-friendly message) and/or in writing (in a legible, understandable
message) - on the appropriate use of antibiotic medicines (for example, when and for how long), side effects,
adverse reactions and interactions, and resistance issues;
provision of facilities conducive to encouraging patients to ask for advice, such as a display of leaflets and posters
on AMR;
provision of a medicine-waste-collection service to avoid misuse of antimicrobials.
Sources: Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenter study (7); FIP Statement of Policy
Control of Antimicrobial Medicines Resistance (AMR) (18); Preventing antibiotic resistance we all have a role to play (19); EPSA
Statement of Support for ANEPF (20); Irrational use of antibiotics and role of the pharmacists: an insight from a qualitative study in
New Delhi, India (21); Foundation in pharmacy practice (22); Attitudes of community pharmacists to antibiotic dispensing and microbial
resistance: a qualitative study in Portugal (23); Self-medication with antibiotics in the Republic of Srpska community pharmacies:
pharmacy staff (24); ASHP statement on the pharmacists role in antimicrobial stewardship and infection prevention and control (25);
PGEU statement: community pharmacists contribution to the control of antibiotic resistance (26).
Box 3. GPP role 2: provide effective medication therapy management

The following activities were identified as relevant to role 2 of the GPP guidelines (1):
development of guidelines or a clinical decision-support system, including:

directions for pharmacists on prescribing and when to refer to the doctor;
recommendations on choice of drugs (one drug per bacteria, narrow-spectrum antibiotics) based on tests;
recommendations on choice of drugs, based on interactions;
recommendations on dosage, based on poharmacokinetic/pharmacodynamic (PK/PD) parameters and the
dynamics of the individual antibiotics (avoidance of overdosage)
avoidance of duplicate therapy;
development of a test system (bacterial culture), re-evaluation of the need for antibiotics after 48-72 hours and
discussion with the doctor;
follow-up with patients over the telephone to ensure adherence;
encouragement of vaccination to avoid infections;
avoidance of long-term antibiotic prophylaxis;
counselling patients on symptomatic therapy and OTC medicines;
educating and counselling patients and families about storage, handling devices and waste disposal.
Sources: The pharmacists role in promoting optimal antimicrobial use (13); FIP Statement of Policy Control of Antimicrobial
Medicines Resistance (AMR) (18); Preventing antibiotic resistance we all have a role to play (19); EPSA Statement of Support for
ANEPF (20); Irrational use of antibiotics and role of the pharmacists: an insight from a qualitative study in New Delhi, India (21);
Foundation in pharmacy practice (22); Self-medication with antibiotics in the Republic of Srpska community pharmacies: pharmacy
staff (24); ASHP statement on the pharmacists role in antimicrobial stewardship and infection prevention and control (25); PGEU
statement: community pharmacists contribution to the control of antibiotic resistance (26); ECDC corporate strategies for diseasespecific programmes (27); The pharmacist's role in preventing antibiotic resistance (28); The role of pharmacist in limiting the
spread of antibiotic resistance in India (29); Experience with a clinical decision support system in community pharmacies to
recommend narrow-spectrum antimicrobials, nonantimicrobial prescriptions and OTC products to decrease broad-spectrum
antimicrobial use (30); Antimicrobial stewardship: whats it all about? (31).
page 10
Box 4. GPP role 3: maintain and improve professional performance

The following were identified as relevant to role 3 of the GPP guidelines (1).
education of the pharmacy profession:

symposia, self-study, e-learning, congresses, articles in professional journals, national campaigns;
undergraduate education (include AMR awareness);
postgraduate education (for example, therapeutic drug monitoring).
focus on inappropriate dispensing through:

financial incentives to dispense only according to prescription and standards/procedures;
professional attitude (recognition of pharmacists responsibility).
Collaboration between:
pharmacists and doctors in the interpretation of culture results and compliance with standards/procedures;
primary care and hospitals on follow-up of prescriptions.
Sources: The pharmacists role in promoting optimal antimicrobial use (13); UK five year antimicrobial resistance strategy 2013 to
2018 (15); Strategy for tackling antimicrobial resistance (STAR) 2012-2017 (16); FIP Statement of Policy Control of Antimicrobial
Medicines Resistance (AMR) (18); EPSA statement of support for ANEPF (20); Irrational use of antibiotics and role of the
pharmacists: an insight from a qualitative study in New Delhi, India (21); Foundation in pharmacy practice (22); Attitudes of
community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Portugal (23); ASHP statement on the
pharmacists role in antimicrobial stewardship and infection prevention and control (25); The pharmacist's role in preventing antibiotic
resistance (28); The role of pharmacist in limiting the spread of antibiotic resistance in India (29); Antimicrobial stewardship: whats it
all about? (31); Sale of regulated antibiotics without prescription. Research on the pharmacists attitudes and patterns of economic
behaviour (32); Antibiotic resistance (33); Impact of a program to reduce the dispensing of antibiotics without a prescription in Spain
(34); Availability and dispensing practices for antimalarials and antimicrobials in western Kenyan pharmacies (35).
Box 5. GPP role 4: contribute to improving effectiveness of the health-care system and public health
The following were identified as relevant to role 4 of the GPP guidelines (1):
public campaigns focusing on:

the problem of AMR;
prevention (for example, hand hygiene in schools);
action by the individual (for example, in connection with antibiotic waste).
development and innovation (related mainly to pharmacists working in research):

new treatments that meet the required standards;
better diagnostic tools;
collection of data on consumption and interventions;
development of national policy with the involvement of pharmacists:

legislative action (for example, to prevent dispensing without prescription, or prescribing and dispensing at the
same time by doctors);
implementation of surveillance systems and development of indicators;
ensuring safety of medicines;
minimizing the drug industrys influence on prescribing and dispensing;
implementation of policies on and programmes for the marketing authorization process;
professional stewardship:
development of national policy with the involvement of pharmacists and other health-care professionals;
monitoring and providing feedback to government and payers (for example, health-insurance funds).
Sources: The pharmacists role in promoting optimal antimicrobial use (13); Strategy for tackling antimicrobial resistance (STAR)
2012-2017 (16); FIP Statement of Policy Control of Antimicrobial Medicines Resistance (AMR) (18); EPSA Statement of Support for
ANEPF (20); Irrational use of antibiotics and role of the pharmacists: an insight from a qualitative study in New Delhi, India (21);
Attitudes of community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Portugal (23); ASHP
statement on the pharmacists role in antimicrobial stewardship and infection prevention and control (25); PGEU statement:
community pharmacists contribution to the control of antibiotic resistance (26); The pharmacist's role in preventing antibiotic
resistance (28); The role of pharmacist in limiting the spread of antibiotic resistance in India (29); Sale of regulated antibiotics without
prescription. Research on the pharmacists attitudes and patterns of economic behaviour (32); Impact of a program to reduce the
dispensing of antibiotics without a prescription in Spain (34); A survey of public knowledge and awareness related to antibiotic use
and resistance in Sweden (36); Examining influences of pharmacists communication with consumers about antibiotics (37); Fact
sheet. Fighting antibiotic resistance by ensuring the rational use of medicines (38).
page 11
The literature search also revealed policy documents by global and country-specific players,
which include reference to the key roles and responsibilities of the pharmacist in relation to
AMR.
Global GPP guidelines

The GPP guidelines (1) provide some guidance to pharmacies regarding AMR.
The focus on AMR is expressed in role 1, for example, in the mention of safe storage of
medicines, dispensing and counselling according to national guidelines, and the safe disposal
of unused medicines. Function 1.D Administration of medicines, vaccines and other
injectable medications specifies that pharmacists should have an educator, facilitator and
immunizer role, thus contributing to the prevention of diseases through participation in
vaccination programmes, by ensuring vaccination coverage and by also ensuring vaccine
safety.
Role 2 relates to pharmacist support to patients and prescribers in the appropriate use or nonuse of medicines, according to the patients individual situation. Function 2.D Provide
information about medicines and health-related issues specifies that pharmacists should
be proactive in reducing antimicrobial resistance by providing information about the
appropriate use of antimicrobials to consumers and prescribers.
Role 3 focuses on the importance of pharmacists maintaining a high level of knowledge,

skills and performance through continuing education and is generally relevant to all
professional tasks. There is no specific mention of functions relating to AMR in connection
with role 3.
The focus of role 4 is on improving the effectiveness of health-care systems and public
health. Function 4.B Engage in preventive care activities and services specifies that
pharmacists should engage in preventive-care activities that promote public health and
prevent disease, for example, in areas, such as smoking cessation, infectious diseases and
sexually transmitted diseases.
Country-specific examples, the organizations involved and policy recommendations on the role
of the pharmacist in relation to AMR are listed in Annex 4.
Survey results
The survey response rate was 83% (44 countries out of 53), the majority of respondents
representing pharmacist associations or pharmacy associations (Fig 2), and the majority of
organizations having a national impact (82% (36 out of 44)).
Characteristics of the respondents

Fig. 2 shows the proportions of the respondents (total = 44) to the survey.
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Fig. 2. Proportions of respondents to the survey (total = 44)
Views of the respondents on the potential of health professionals to

influence the use of antibiotics
Most of the respondents felt that policy-makers, pharmacists and prescribers are in the best
position to improve the situation related to the appropriate use of antibiotics in their countries
followed by professional associations and patient communities (Fig. 3). It is thus evident that,
along with the policy-makers, there were pharmacists who felt they had played a leading role in
making a difference in the use and consumption of antibiotics. In fact, 93% of the respondents
agreed that pharmacists, as a health-professional group, are in one of the best positions to help
combat AMR and highlighted the key role pharmacists can play through their direct and frequent
contact with consumers and patients.
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Fig. 3. Views of respondents on those in the best position to influence use of antibiotics, by
professional body/organization (total = 44)
Access to antibiotics
As discussed earlier in the report, there is a strong connection between the availability and use of
antibiotics and resistance to them. Therefore, the survey included questions on the availability of
antibiotics with or without a prescription and over the counter. It was found that in 43% of the
responding countries (19 out of 44), it was legally possible to buy antibiotics over the counter
(Fig. 4) and, therefore, pharmacists already have experience in treating patients with these
medicines both responsibly and within an appropriate legal framework.
A number of respondents reported restrictions in OTC sales in their countries in that only a few
antibiotics are legally available over the counter. These include erythromycin gel 3% (30gram)
(Albania), fusafungin (Czech Republic), bacomycin (Norway), 24-hour dosage of any antibiotic
medicines in emergency situations (Romania), antibiotics with local effect (eye and topical
preparations) (Serbia and Slovakia), and chloramphenicol eye drops for the treatment of
conjunctivitis and azithromycin for the treatment of chlamydia (United Kingdom). Some of the
respondents who reported that OTC sale of antibiotics was legal in their countries did not
mention any OTC sales restrictions.
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Fig. 4. Countries where OTC sales of antibiotics are legal
At the same time, only 12% of the respondents (5 out of 44 countries) reported that it was
possible to buy antibiotics without a prescription over the Internet (Fig. 5), indicating a potential
difference between the regulation of Internet pharmacy sales and sales at physical pharmacies. It
is not clear whether the online pharmacies in question are legal.
Fig. 5. Countries where it is possible to buy antibiotics online without prescription
In 27% (12 out of 44) of the responding countries it is possible to buy antibiotics outside the
pharmacy, such as on the black market or in veterinary clinics and/or pharmacies (Fig. 6) though
page 15
purchase from the latter is likely to be through a legitimate source with a veterinary prescription
or directly from a veterinarian.
Fig. 6. Countries where it is possible to buy antibiotics outside the pharmacy
Monitoring consumption of antimicrobial medicine

Activities with great potential for reducing AMR include monitoring and mapping the
consumption of antimicrobial medicine through the regular collection of data on sales,
prescriptions and use. The data on antibiotic use (based on the collection of wholesale data) are
monitored through ECDC and the European Surveillance of Antimicrobial Consumption
Network (ESAC-net) (for European Union (EU) countries) and through the WHO Regional
Office for Europe (for non-EU countries) (Fig. 7).
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Fig 7. Countries monitoring antmicrobial consumption, 2014 (total = 53)
The authority responsible for the collection of data on antibiotic consumption varies from one
European country to another and an array of institutions is responsible (Fig. 8). However, ESACnet methodology is used in all countries (39).
page 17
Fig. 8. Authority responsible for collection of data on antimicrobial consumption (total = 53)
2%
Drugagencyaloneorwithministry
ofhealthandpublichealthinstitute
2%
2% 2%
Academiaaloneorwithministryof
healthandpublichealthinstitute
31%
21%
Ministryofhealthaloneorwith
drugagencyandpublichealth
institute
Nationalpublichealthinstitute
and/orepidemiologicalinstitute
Civilsociety
Researchinstitute
Nationalantibioticcommittee
19%
22%
Instituteofhygiene
Antibiotic stewardship
Antibiotic stewardship is an effective way of ensuring the prudent use of antibiotics. The
pharmacist plays a very important role in the antibiotic stewardship programme: this includes
conducting therapeutic drug monitoring, consulting physicians and counselling patients, all of
which contributes to the prudent use of antibiotics (40).
According to the results of the survey, antibiotic stewardship is included in the medical and
pharmaceutical curricula in most of the responding countries (Fig. 9). In approximately 58% of
them, pharmacists and medical professionals have been educated in antibiotic stewardship from
the time of their undergraduate training and are, therefore, well equipped to collaborate on
reducing AMR from the start of their careers.
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Fig. 9. Responses on inclusion of antibiotic stewardship in medical/pharmaceutical

undergraduate and postgraduate curricula (total = 44)
Guidelines on antibiotic treatment

In 81% of the responding countries (36 out of 44), guidelines on antibiotics are issued centrally
(mainly) and/or separately by various institutions (Fig. 10). Most of the guidelines are developed
by professional associations, policy-makers, prescribers and pharmacists (Fig. 11). Professional
associations are a significant stakeholder group in the development of such guidelines and
pharmacists have an opportunity here to become more involved, as has been demonstrated by
responses indicating that pharmacists are in one of the best positions to combat AMR.
page 19
Fig. 10. Distribution of guidelines on antibiotic treatment in responding countries (total = 44)
Fig 11: Authorities responsible for the development of guidelines on antibiotic treatment (total=
44)
page 20
Other findings
The survey also revealed the following information.
In 31 of the 44 responding countries (70%), there are some activities related to, or initiatives
to foster, the prudent use of antibiotics at the pharmacy level, such as campaigns to increase
awareness (including Antibiotic Awareness Day), AMR working groups and educational
campaigns.In approximately half of the responding countries (21 out of 44 (49%)), the
number of doses to be dispensed is adjusted for each patient in the pharmacy based on the
quantity requested and the duration of treatment stated on the prescription. This avoids
dispensing excess medication, which could potentially be used for self-medication later on.
Close collaboration between pharmacists and doctors regarding medicines prescribed for
patients was reported by 15 of the 44 responding countries; 20 respondents believed that, in
their countries, doctors can be influenced by pharmacists to change prescriptions if the latter
do not consider them appropriate.
13 respondents agreed that feedback from pharmacists to doctors is influential.
36 respondents agreed that pharmacists in their countries are in a position to provide patients
with relevant advice on the use of antibiotics; 30 agreed that pharmacists provide patients
with detailed information on the use of antibiotics; and only 25 respondents agreed that
doctors provide patients with detailed information on this issue.
DISCUSSION
The survey shows that regulations on access to antibiotics at the pharmacy, including OTC and
Internet-based sales, are in place in most European countries. Wide access to antibiotics should
not be allowed and in countries where there are no restrictions to OTC and Internet-based sales
of antibiotics, regulations need to be introduced, particularly in view of the growing popularity
of purchasing medicine online. Lack of regulations pertaining to the availability, dispensing of
and access to antibiotics can lead to excessive consumption and an increase in AMR. In
countries where antibiotics are provided over the counter in emergencies, as well as in topical
forms, ways should be considered of avoiding the negative effects of the overuse of these options
in terms of AMR. Strict government policy and law enforcement related to the sale of antibiotics
in pharmacies are, along with public-awareness campaigns, essential to addressing the crisis
linked to AMR.
In terms of global and European guidance, this is available in the form of the GPP guidelines (1)
and the FIP statement on AMR (18), which outline the contributions pharmacists can make to
combating AMR and ways in which governments and health authorities can enhance the use of
the community pharmacy to this end. These include using the pharmacist in the roles of educator,
facilitator and immunizer, and as a resource in ensuring the appropriate use or non-use of
medicines and providing support to patients and prescribers alike. However, using the
pharmacists in these roles could be pursued further at the national level (41). In particular, how
best to motivate their providing proper counselling and information on the appropriate use of
medicines to consumers and other health professionals, as well as their active engagement in
matters of hygiene and infections control in all health-care settings which would promote the use
of pharmaceutical services in the area of antibiotics rather than sales.
Point-of-care testing (PoCT) is now possible in many areas of clinical medicine, including
screening for bacterial infections. Many new forms of PoCT are being developed that will
page 21
provide inexpensive and simple-to-use methods of deoxyribonucleic acid/ribonucleic acid

(DNA/RNA)-based identification of potentially multiple pathogens from a single sample. When
they become available, these new forms of PoCT will make it possible to start correct treatment
immediately. A new activity is being piloted in the United Kingdom1 whereby certain
pharmacies in the London area are carrying out PoCT linked to sore throat and, if bacterial
tonsillitis infection is detected, are supplying penicillin-V (or in case of allergy, clarithromycin).
This is made possible though pharmacy-based patient group direction (PGD). PGDs provide a
legal framework that allows certain registered health professionals to supply and/or administer
specified medicine(s) to a predefined group of patients, without their having to see a doctor.
However, supplying and/or administering medicines under PGD should be reserved for
situations in which doing so offers the advantage of patient care without compromising patient
safety. This pilot project is an example of how the role of the community pharmacist in the
appropriate use of antibiotics for bacterial tonsillitis infection is being explored. In the United
States, a similar pharmaceutical service is in use (42).
Evaluations on the role of rapid diagnostics/PoCT in other countries where these methods are
used would be welcome. The usefulness of novel diagnostic tests is clearly that they offer the
opportunity of swiftly distinguishing cases for which antibiotics are not needed and, therefore,
can safely be withheld. Information about new patient-centred models for the prudent use of
antibiotics, including the use of PoCT in a variety of relevant settings, is also of interest. They
could pave the way to a more efficient, targeted use of antibiotics and would likely contribute to
reversing the AMR trend. Better diagnoses would lead to an important reduction in the use of
antibiotics.
To tackle the issue of AMR, multiple interventions are needed, also by pharmacists. The
community pharmacist must engage in various public-health initiatives relating, for example, to
the appropriate dispensing of antibiotics, the restriction of irrational dispensing, and bringing
about greater patient awareness of the importance of avoiding self-medication without correct
diagnosis and of the increasing problem of AMR (43-45).
Surveillance of the use of antibiotics can be strengthened. There is a long tradition of monitoring
the use of medicines in most EU countries but efforts to this end should be increased in parts of
eastern Europe. WHO has supported related activities in non-EU countries: a network was
created in 2011 to complement ECDC activities to monitor the use of antimicrobial medicines
through wholesale data (46). Data from 42 countries and regions in the WHO European Region
on wholesale of antimicrobial medicines in 2011 indicate an almost fourfold difference between
the lowest and highest numbers of antibiotic users. Mapping consumption is the first step
towards identifying and tackling the growing public problem of AMR. Action to gain a clearer
overview of the online prescription and use of antibiotics should also be considered, as well as
ways to support follow-up of the data gathered (47).
The increased use of antibiotics is related to the socioeconomic situation, which explains the
status quo as regards the use of antibiotics in some eastern European countries. Furthermore, the
lack of stringent government policies and regulations and their enforcement, for example,
through efficient decentralization, is also accountable for the increase in AMR in some of these
countries (48).
The survey results indicate that more effort is needed in encouraging the prudent use of
antibiotics and that the role of the pharmacist needs to be clearly recognized and enhanced. In
this connection, while the survey revealed that efforts are being made to include courses on
antibiotic stewardship in the medical and pharmaceutical undergraduate and postgraduate
1
Accordingtopersonalcommunicationon28October2014withtheDirectorofthecompanypilotingtheproject.
page 22
curricula, it is crucial that the information provided in these courses is timely and stresses the
importance of the roles of the medical and pharmaceutical professions in promoting the prudent
use of antibiotics. Also, as 8 countries did not respond to the questionnaire, the current situation
for the whole Region in this respect is not yet clear. The Regional Office is endeavouring to
complete the mapping exercise through follow up with the countries in question.
National and local efforts are needed to enhance the antibiotic stewardship programme in
Europe. With reference to research on undergraduate and postgraduate medical education, a wide
variation was found among the countries with respect to the principles of prudent prescribing of
antibiotics (40,47). There is a need to optimize knowledge about choice of antibiotics, dosage
regimens, monitoring adverse effects, and limiting collateral damage in the use of antibiotics.
With AMR increasing worldwide, the role of the pharmacist is manifold in terms of influencing
the choice of antibiotics administered, ensuring access, and carrying out therapeutic drug
monitoring. If practised effectively, pharmacists in antibiotic stewardship programmes can go far
to ensure the rational use of antibiotics.
Shaping the behaviour of all health professionals as has been done, for example, in the
Netherlands - could be useful in all countries. Generally, this is most easily achieved by starting
at an early stage, hence the importance of updating undergraduate curricula. This should be done
in combination with postgraduate educational strategies and interventions on behavioural change
aimed at all health professionals and through awareness-raising campaigns and communication
with the public on the importance of the prudent use of antimicrobials.
CONCLUSIONS
This report identifies multiple activities related to the prevention of AMR in the Region in which
community pharmacists could be involved and indicates that pharmacists have many relevant
suggestions and initiatives regarding the prudent use of antibiotics and the reduction of AMR.
Based on the examples identified, the potential of the pharmacist in this respect has not been
explored to a great extent. However, pharmacy organizations have developed basic guidance
documents. At the policy level (EU or national), the pharmacist is seen as an essential player in
the health system which, in many countries, provides the funding for pharmacist-led
pharmaceutical-care services.
In some countries, there is scope at the national level to address adherence to current regulations
and guidance on the use of antibiotic medicines from the perspectives of the prescriber and the
community pharmacist. Pharmacists have taken on the role of providing relevant information to
patients, which includes ensuring their compliance with a prescribed course of medicine (for
example, through the Treat Yourself Better with Pharmacist Advice campaign and the New
Medicines Service in the United Kingdom (England and Wales), Medisinstart in Norway, the
Belgian Asthma Service, the French Therapeutic Patient Education service and Adhirete in
Spain). Thus, there is scope to increase the level and quality of information being provided to
patients on the use of medicines and, in this case, the use of antibiotics (10,45). In addition,
quantity dispensed vs quantity prescribed and the responsible disposal of unused antibiotics
could be investigated at the European level.
The time is opportune to address the need to increase collaboration between pharmacists and
prescribers and, thus, decrease the level of inappropriate prescribing, building - at the same
time- stronger relations, respect and mutual trust between the two groups. In the process of
encouraging the prudent use of antibiotics, full advantage must be taken of the position of the
page 23
pharmacist as an effective liaison between prescriber and patient. Improved communication

between the two in relation to diagnosis, type of antibiotics prescribed and dosage is one way
to ensure appropriate prescribing. In addition, patients should be well counselled on the need
for and use of antibiotics, adverse effects, consequences of incomplete dosage and the growing
problem of AMR. Thus, a team-based approach to patient care is needed.
We must recognize the ability of pharmacist feedback (especially within the framework of
national/regional guidelines) to influence prescribing positively and, thus, combat AMR (49).
The search for information on AMR and action taken in community pharmacy to combat it
revealed many examples of antimicrobial stewardship programmes for hospitals. However, it is
in primary care that the greatest proportion of antibiotics is prescribed and, therefore,
antimicrobial stewardship programmes need to be extended to and integrated with primary care.
The analysis of the role of the pharmacist on the basis of the 4 GPP roles and the assessment of
pharmacy systems show that countries could utilize their pharmacy systems much more to
combat AMR and improve the health of their populations.
The capacity of the pharmacist is underestimated. Pharmacists are key health professionals with
the skills and training required to contribute to the reduction of AMR. It is important to
recognize and use their potential. While, in many countries of Europe, pharmacists already have
the capacity to take on additional roles and responsibilities to foster the prudent use of antibiotic
medicine, in some, a special effort will be necessary to update the pharmacist curriculum and
ensure that it includes antibiotic stewardship.
In terms of next steps, the results of the survey point to the need to:
1. ensure pharmacist input in the development of national plans on AMR;
2. develop a catalogue describing recommended action at the different levels (national, local
and pharmacist-led);
3. encourage the sharing and adoption of good practices;
4. establish the community pharmacists role (and value) in general strategies for fighting
AMR, thereby making it visible to health authorities, other health-care professionals and
professional organizations;
5. increase efforts to tackle illegal online pharmacies and the illegal trade of pharmaceuticals on
the black market, in pharmacies or from other outlets;
6. foster better collaboration between pharmacists and prescribers.
Improvements in these areas should be shared across and between countries of the Region to the
extent possible. The Regional Office could facilitate this action.
page 1
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Amsterdam: Health Action International (HAI) Europe; 2011 (http://haieurope.org/wpcontent/uploads/2012/02/HAI-EUROPE-Fact-Sheet-Antibotic-Resistance.pdf, accessed 21
October 2014).
39. European Surveillance of Antimicrobial Consumption Network (ESAC-Net) [website].
Stockholm: European Centre for Disease Prevention and Control; 2014
(http://www.ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx).
40. Pulcini C, Gyssens IC. How to educate prescribers in antimicrobial stewardship practices.
Virulence. 2013;4(2)192-202 ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654620/).
41. Yagudina RI, Kondratieva B.B. (GPP)
. .. , .. .
[Standard of good pharmacy practice (GPP) and the future of the pharmaceutical profession.
Collection of materials]. Moscow: Russian Congress of Pharmaceutical Workers; 2014.
42. Klepser DG, Bisanz SE, Klepser ME. Cost-effectiveness of pharmacist-provided treatment of
adult pharyngitis. The Americal Journal of Managed Care. 2012;18(4):e145-54.
43. Yagudina RI. .. :
[The role of pharmacies in the modern health care system:
achievements and challenges]. [New
Pharmaceutical Effective Management]. 2012;7:(22-7).
44. Porseva NY, Soloninina AV, Krupnova IV.
:
[On the professional competency of pharmaceutical
profile: delineation of functional responsibilities of pharmacists].
[Quality of Management in Health and
Social development]. 2011;1:143-9.
45. Ashiru-Oredope D. Community pharmacist must help conserve antibiotics. The
Pharmaceutical Journal. 2014(24 September) (http://www.pharmaceuticaljournal.com/opinion/comment/community-pharmacists-must-help-conserveantibiotics/20066496.article).
46. Versporten A, Bolokhovets G, Ghazaryan L, Abilova V, Pyshnik G, Spasojevic T et al.
Antibiotic use in eastern Europe: a cross-national database study in coordination with the
WHO Regional Office for Europe, The Lancet. Infectious Diseases. 2014;14(5):381-7
(http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70071-4/abstract).
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47. Ohl CA, Luther VP. Health care provider education as a tool to enhance antibiotic
stewardship practices. Infectious Diseases Clinics of North America. 2014;28(2):177-93
(http://www.sciencedirect.com/science/article/pii/S0891552014000142).
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[Role of the pharmacist and its implementation through
legislation, regulation and training]. [Moscow Pharmacies]. 2006;9:1213.
49. Soloninina AV.
/ .. // [Pharmacist role as a consultant on the use of
drugs should be strengthened]. [Pharmaceutical Bulletin].
2008;36:34.
page 6
ANNEXES
Annex 1. List of documents with reference to the role of pharmacist in
relation to AMR
Category1
and no.
of
document
Document reference
1.1
Andr M, Vernby , Berg J, Lundborg C. A survey of public knowledge and awareness

related to antibiotic use and resistance in Sweden. Journal of Antimicrobial
Chemotherapy. 2010;65(6):1292-6 (http://jac.oxfordjournals.org/content/65/6/1292.long,
1.2
Preventing antibiotic resistance we all have a role to play. Dehli: Indian Pharmacist
Association (IPA); 2011 (http://ipa.medlineindia.com/2011/11/25/preventing-antibioticresistance-%E2%80%93-we-all-have-a-role-to-play/, accessed 20 October 2014).
2.1
Survey on activities related to antibiotic awareness, internal note from PGEU. Ref
13,03,21E 008FS. 2013.
2.2
EPSA Statement of support for ANEPF. Brussels: European Pharmaceutical Students

Association; 2013 (http://www.epsaonline.org/doc/epsa%20doc/EPSA%20statement%20of%20support%20for%20ANEPF%2
0France.pdf, accessed 20 October 2014).
2.4
ECDC corporate strategies for disease-specific programmes. Stockholm: European

Centre for Disease Prevention and Control; 2010
(http://www.ecdc.europa.eu/en/publications/Publications/100714_COR_Strategies_for_dis
ease-specific_programmes_2010-2013.pdf, accessed 26 October 2014).
2.5
Stoyanova R, Dimova R, Raycheva R. Sale of regulated antibiotics without prescription.

Research on the pharmacists attitudes and patterns of economic behavior. Trakia Journal
of Sciences. 2012;10(4):71-5 (http://tru.unisz.bg/tsj/Vol.10,%20N%204,%202012/R.Stoyanova_2.pdf, accessed 20 October 2014).
2.6
McCoy D, Toussaint K, Gallagher JC. The pharmacist's role in preventing antibiotic

resistance. US Pharmacist. 2011;36(7):42-9
(http://www.uspharmacist.com/content/d/feature/c/29137/ accessed 21 October 2014).
Category1:patientinformation;Category2:theprofessionalroleofthepharmacist;
Category3:recommendationsoforganizationsorinstitutionsonhowtohandletheproblemofAMR;
Category4:researcharticlesdescribingandevaluatingconcreteactivitiesoreffortsinthisarea.
page 7
2.7
Rahman AU. The role of pharmacist in limiting the spread of antibiotic resistance in India.
International Journal of Pharmaceutical Research and Bio-Science. 2013;2(5):237-45
(http://www.ijprbs.com/issuedocs/2013/10/IJPRBS%20447.pdf, accessed 21 October
2014).
2.8
Dickerson L, Mainous A, Carek P. The pharmacists role in promoting optimal antimicrobial

use. Pharmacotherapy. 2000;20(6):711-23.
2.9
Kotwani A, Wattal C, Joshi P, Holloways K. Irrational use of antibiotics and role of the
pharmacists: an insight from a qualitative study in New Delhi, India. Journal of Clinical
Pharmacy and Therapeutics. 2012;37:308-12.
2.10
Whalley B, Fletcher K, Weston S, Howard R, Fawlinson C. Foundation in pharmacy

practice. London: Pharmaceutical Press; 2008.
2.11
Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, Herdeiro MT. Attitudes

of community pharmacists to antibiotic dispensing and microbial resistance: a
qualitative study in Portugal. International Journal of Clinical Pharmacy. 2013;35:41724.
2.12
Coleman CL. Examining influences of pharmacists communication with consumers about

antibiotics. Health Communication. 2003;15:1:79-99.
2.13
Markovic-Perkovi V, Grubia N. Self-medication with antibiotics in the Republic of Srpska

community pharmacies: pharmacy staff. Pharmacoepidemiology and Drug Safety.
2012;21(10):1130-33.
2.14
Madaras-Kelly K, Hannah E, Bateman K, Samora M. Experience with a clinical decision support

system in community pharmacies to recommend narrow-spectrum antimicrobials, nonantimicrobial
prescriptions and OTC products to decrease broad-spectrum antimicrobial use. Journal of
Managed Care Pharmacy. 2006;12(5):390-7.
2.15
McKenzie D, Rawlins M, Mar CD. Antimicrobial stewardship: whats it all about? Australian
Prescriber. 2013;36:116-20 (http://www.australianprescriber.com/magazine/36/4/116/20,
3.1
ASHP statement on the pharmacists role in antimicrobial stewardship and infection prevention
and control. American Journal of Health-System Pharmacy. 2010;67:5757.
(http://www.ashp.org/DocLibrary/BestPractices/SpecificStAntimicrob.aspx, accessed 21 October
2014).
3.2
PGEU statement: community pharmacists contribution to the control of antibiotic resistance.

Approved by the General Assembly on 17 November 2009. Brussels: Pharmaceutical Group of
the European Union; 2009
3.3
Fact sheet. Fighting antibiotic resistance by ensuring the rational use of medicines. Amsterdam:
Health Action International (HAI) Europe; 2011 (http://haieurope.org/wpcontent/uploads/2012/02/HAI-EUROPE-Fact-Sheet-Antibotic-Resistance.pdf, accessed 21
October 2014).
3.4
Department of Health, Department for Environment, Food and Rural Affairs. UK five year
antimicrobial resistance strategy 2013 to 2018. London: Department of Health; 2013
(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_
UK_5_year_AMR_strategy.pdf, accessed 21 October 2014).
3.5
Antibiotic resistance. Brussels: European Parliament; 2006

(http://www.itas.kit.edu/downloads/etag_hoho06a.pdf, accessed 21 October 2014).
3.6
Strategy for tackling antimicrobial resistance (STAR) 2012-2017. Belfast: Department of Health,
Social Services and Public Safety; 2012 (http://www.dhsspsni.gov.uk/star-doc.pdf, accessed 21
October 2014).
page 8
3.7
FIP Statement of Policy Control of Antimicrobial Medicines Resistance (AMR). The Hague:
International Pharmaceuticals Federation (FIP); 2008.
http://www.fip.org/www/uploads/database_file.php?id=289&table_id=, accessed 21 October
2014).
4.1
Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernandez-Llimos F. Impact of a program

to reduce the dispensing of antibiotics without a prescription in Spain. Pharmacy Practice.
2013;11(4):185-90 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869633/, accessed 21 October
2014).
4.2
Roque F, Soares S, Breitenfeld L, Lpez-Durn A, Figueiras A, Herdeiro MT. Attitudes of

community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in
Portugal. International Journal of Clinical Pharmacology. 2013;35(3):417-24.
4.3
Wafula, F. Availability and dispensing practices for antimalarials and antimicrobials in western
Kenyan pharmacies. Pharmaceutical Regulatory Affairs. 2013:2(106)
(http://www.omicsgroup.org/journals/availability-and-dispensing-practices-for-antimalarials-andantimicrobials-in-western-kenyan-pharmacies-2167-7689.1000106.pdf, accessed 21 October
2014).
4.4
Skliros et al. Self-medication with antibiotics in rural population in Greece: a cross-sectional

multicenter study. BMC Family Practice. 2010;11:58 (http://www.biomedcentral.com/14712296/11/58, accessed 21 October 2014).
4.5
Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernandez-Llimos F. Impact of a program

to reduce the dispensing of antibiotics without a prescription in Spain. Pharmacy Practice.
2013;11(4):185-90 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869633/, accessed 21 October
2014).
4.6
Tonna, AP, Stewart, DC, West, B. and McCaig, D. J. Exploring pharmacists' perceptions of the
feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland.
International Journal of Pharmacy Practice. 2010;18:31219
(http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7174.2010.00059.x/abstract, accessed 25
October 2014).
4.7
L Ecker, Ochoa TJ, Vargas M, Del Valle MJ, Ruiz J. Factors affecting caregivers' use of antibiotics
available without a prescription in Peru. Pediatrics. 2013;131(6):1771-9
(http://www.ncbi.nlm.nih.gov/pubmed/23690517, accessed 22 October 2014).
page 9
Annex 2. Pharmacy roles in antimicrobial resistance literature map

Category
and no.4
of
document
Document reference
Country/region
(year)
1.1
Andr M, Vernby , Berg J, Lundborg C. A

survey of public knowledge and awareness
related to antibiotic use and resistance in
Sweden. Journal of Antimicrobial
Chemotherapy. 2010;65(6):1292-6
(http://jac.oxfordjournals.org/content/65/6/1
292.long, accessed 20 October 2014).
Preventing antibiotic resistance we all
have a role to play. Dehli: Indian
Pharmacist Association (IPA); 2011
(http://ipa.medlineindia.com/2011/11/25/pre
venting-antibiotic-resistance-%E2%80%93we-all-have-a-role-to-play/, accessed 20
October 2014).
Sweden (2010)
1.2
India (2011)
Action, practices, recommendations described relating to the four roles of

pharmacists described in Joint FIP/WHO guidelines on GPP: standards for quality of
pharmacy services5
Role 4: contribute
Role 1: prepare,
Role 2: provide
Role 3: maintain
to improving the
obtain, store,
effective
and improve
effectiveness of
secure, distribute,
medication therapy professional
management
performance
the health-care
administer,
dispense and
system and public
health
dispose of medical
products
Campaign
messages: keep total
antibiotic prescribing
on a low level; be
aware of resistance;
trust health
professionals.
Counselling on
appropriate use,
resistance and
adverse effects.
Only one antibiotic

per bacteria.
The references are categorized according to the main focus of the documents in question: (1) patient information materials; (2) the professional role of the pharmacist; (3) policy
related to handling the problem; (4) research articles.
5
International Pharmaceutical Organization, WHO.Good pharmacy practice. Joint FIP/WHO guidelines on GPP: standards for quality of pharmacy services. The Hague: International
Pharmaceutical Federation; 2012(http://www.fip.org/files/fip/WHO/GPP%20guidelines%20FIP%20publication_final.pdf,accessed6November2014).
page 10
2.1
Survey on activities related to antibiotic

awareness, internal note from PGEU. Ref
13,03,21E 008FS. 2013.
Europe (2013)
Over-the-counter
information to
patients on proper
use.
Leaflets and posters
on antimicrobial
resistance.
Phone app for

guidelines on
prescribing
antibiotics.
2.2
EPSA Statement of support for ANEPF.

Brussels: European Pharmaceutical
Students Association; 2013
(http://www.epsaonline.org/doc/epsa%20doc/EPSA%20stat
ement%20of%20support%20for%20ANEP
F%20France.pdf, accessed 20 October
2014).
Europe (2013)
Ensure a regular
quick supply of all
types of antibiotics in
pharmacies to
maximize access.
Provide complete
information about
drug treatment.
Collect and dispose
of unused antibiotics.
Ensure patient
compliance
(counselling; followup assistance for
disabled).
2.4
ECDC corporate strategies for diseasespecific programmes. Stockholm:

European Centre for Disease Prevention
and Control; 2010
(http://www.ecdc.europa.eu/en/publications
/Publications/100714_COR_Strategies_for
_disease-specific_programmes_20102013.pdf, accessed 26 October 2014).
Europe (2010)
Antibiotics prescribed
by pharmacists
according to
guidelines.
Enhancing the
awareness of
patients about AMR
and hygiene.
Symposium on
antibiotic awareness.
Articles in national
professional journals.
Self-study
educational
materials.
Pharmacist congress
on antimicrobial
resistance.
Postgraduate
education.
Include antimicrobial
resistance in higher
education and postgraduate education
programmes.
Develop prescriptiononly guidelines
according to
standards.
Strive for better
collaboration among
stakeholders.
Pharmacists support
national campaigns
by discouraging
patients from keeping
left-over antibiotics.
Public debate
broadcast on national
TV.
Need for:
innovative treatments
capable of tackling
antimicrobial
resistance;
development of new
effective antibiotics;
better diagnosis;
avoidance of doctors
prescribing and
dispensing at the
same time;
regulation and
surveillance systems;
public campaigns;
basic level of
microbiology and
hygiene in schools.
page 11
2.5
2.6
Stoyanova R, Dimova R, Raycheva R. Sale

of regulated antibiotics without prescription.
Research on the pharmacists attitudes and
patterns of economic behavior. Trakia
Journal of Sciences. 2012;10(4):71-5
(http://tru.unisz.bg/tsj/Vol.10,%20N%204,%202012/R.St
oyanova_2.pdf, accessed 20 October
2014).
McCoy D, Toussaint K, Gallagher JC. The
pharmacist's role in preventing antibiotic
resistance. US Pharmacist. 2011;36(7):429
(http://www.uspharmacist.com/content/d/fe
ature/c/29137/ accessed 21 October 2014).
Bulgaria (2012)
USA (2011)
Re-evaluate
continued need for
antibiotics after 48
72 hours.
Stop antibiotics
stopped if cultures
are negative or if
infection unlikely or
resolved.
Screen for drugdrug
interactions or
duplicate therapy
maximizing
pharmacokinetic/phar
macodynamic
(PK/PD) parameters
for dose optimization
of antibiotics.
Switch therapy to
most appropriate
antibiotic on basis of
results.
Minimize use of
broad-spectrum
antibiotics.
Avoid chronic or longterm antibiotic
prophylaxis.
Provide poper overthe-counter (OTC)
counselling of
Pharmacists
prescribing antibiotics
can be influenced by
economic incentives
of pharmaceutical
companies and
consumers.
Enhanced control
and penalties are the
solutions to ensuring
that the aim of
pharmacists is
improvement of
public health rather
than monetary gain.
Assisting in the
interpretation of
results from
diagnostic tests or
cultures (colonization
vs. contamination vs.
infection).
Working in
conjunction with the
microbiology
laboratory to aid in
the selection of
diagnostic tools or
tailoring susceptibility
reports based on
available formulary
antibiotics and
susceptibility
patterns.
Educating the public
regarding: general
hygiene, hand
hygiene, coughs
etiquette, immunizations, and importance
of staying home
when sick.
page 12
2.7
Rahman AU. The role of pharmacist in

limiting the spread of antibiotic resistance
in India. International Journal of
Pharmaceutical Research and BioScience. 2013;2(5):237-45
(http://www.ijprbs.com/issuedocs/2013/10/I
JPRBS%20447.pdf, accessed 21 October
2014).
India (2013)
patients on viral
treatments.
Refer in case of
bacterial infection.
Encourage
vaccinations.
Provide guidelines or
pathways for
appropriate empiric
use of antibiotics.
Re-evaluate antibiotic
prescription after 4872 hours.
Advise clinicians to
stop antibiotics on
basis of negative
culture or resolved
infection.
Screen for
interactions.
Suggest appropriate
treatment on basis of
results, PK/PD
parameters and
dynamics.
Provide proper OCT
counselling to
patients on viral
treatment.
Provide guidelines on
empiric and
prophylactic use of
antibiotics.
Assist physician in
interpreting results of
diagnostic tests.
Advise physician on
minimal use of broadspectrum antibiotics.
Assist development
of policy and
guidelines.
Identify diagnostic
tools.
Collect and report
data about
antibiotics-related
intervention.
page 13
2.8
Dickerson L, Mainous A, Carek P. The

pharmacists role in promoting optimal
antimicrobial use. Pharmacotherapy.
2000;20(6):711-23.
USA (2000)
2.9
Kotwani A, Wattal C, Joshi P, Holloways K.

Irrational use of antibiotics and role of the
pharmacists: an insight from a qualitative
study in New Delhi, India. Journal of
Clinical Pharmacy and Therapeutics.
2012;37:308-12.
India (2012)
2.10
Whalley B, Fletcher K, Weston S, Howard

R, Fawlinson C. Foundation in pharmacy
practice. London: Pharmaceutical Press;
2008.
United Kingdom
(2008)
2.11
Roque F, Soares S, Breitenfeld L, LopezDuran A, Figueiras A, Herdeiro MT.

Attitudes of community pharmacists to
antibiotic dispensing and microbial
resistance: a qualitative study in Portugal.
International Journal of Clinical Pharmacy.
2013;35:417-24.
Portugal (2013)
Return outdated
antibiotics without
financial
repercussion.
Secure the supply of
antibiotics to avoid
undertreatment.
Advise patients about
proper treatment.
Counsel patients and
provide them with
written information.
Pharmacists urge
patients to comply
with antibiotics.
Develop clinical
guidelines.
Establish an
antibiotic control
programme (order
forms, stop dates,
restrictions for
specific indications or
classes of infectious
bacteria, improved
diagnostic tests).
Prescribe only on the
basis of guidelines.
Pharmacy refuses
claims for
inappropriate use of
antibiotics.
Provide education to
colleagues.
Provide audit and

feedback to healthcare team,
government, tax
payers, etc.
Pharmacists should
refuse financial
incentives for the
promotion of products
if it is not in
compliance with
standards,
Secure inexpensive
medicines.
Remind patients by
telephone to take
their medicine.
Prevent inappropriate
prescription.
More interaction
encouraged between
pharmacists and
physicians and
between primary care
and hospitals.
Patients lack
knowledge about
antibiotics.
Patients
socioeconomic
situations can result
in their avoiding
medical expenses.
page 14
2.12
Coleman CL. Examining influences of

pharmacists communication with
consumers about antibiotics. Health
Communication. 2003;15:1:79-99.
USA (2003)
2.13
Markovic-Perkovi V, Grubia N. Selfmedication with antibiotics in the Republic

of Srpska community pharmacies:
pharmacy staff. Pharmacoepidemiology
and Drug Safety. 2012;21(10):1130-33.
Madaras-Kelly K, Hannah E, Bateman K,
Samora M. Experience with a clinical
decision support system in community
pharmacies to recommend narrowspectrum antimicrobials, nonantimicrobial
prescriptions and OTC products to
decrease broad-spectrum antimicrobial
use. Journal of Managed Care Pharmacy.
2006;12(5):390-7.
Bosnia and
Herzegovina
(2012)
2.14
2.15
McKenzie D, Rawlins M, Mar CD.

Antimicrobial stewardship: whats it all
about? Australian Prescriber.
2013;36:116-20
(http://www.australianprescriber.com/maga
zine/36/4/116/20, accessed 21 October
2014).
USA (2006)
Australia (2013)
Participation in
campaigns depends
on availability of
pamphlets,
supportive managers,
physicians and
professional groups/
organizations, and of
education on AMR.
Provide legible
instructions for use
on labels and
understandable oral
messages.
Offer symptomatic
therapy with various
OCT medicines.
Refer to doctors
when necessary.
Provide a clinicaldecision support
system for
recommending
narrow-spectrum
antimicrobials, nonantimicrobial
prescriptions and
OTC products to
decrease broadspectrum
antimicrobial use.
Prescriber and
patient education
programme.
Restrict antibiotics via

pharmaceutical
benefits scheme.
Provide feedback on
patterns of antibiotics
consumption to track
use.
page 15
3.1
ASHP statement on the pharmacists role

in antimicrobial stewardship and infection
prevention and control. American Journal
of Health-System Pharmacy. 2010;67:575
7.
(http://www.ashp.org/DocLibrary/BestPracti
ces/SpecificStAntimicrob.aspx, accessed
21 October 2014).
USA (2010)
Establish qualitycontrol procedures

for pharmacies to
prevent
contamination of
products.
Secure proper
labelling, dating and
storage.
Educate and counsel

patients and families
on adherence,
storage, handling
devices and waste
disposal.
Encourage
immunization.
3.2
PGEU statement: community pharmacists

contribution to the control of antibiotic
resistance. Approved by the General
Assembly on 17 November 2009. Brussels:
Pharmaceutical Group of the European
Union; 2009
Europe (2009)
Information on:
best dispensing
practice;
use (when, how
long), side effects,
adverse reactions
and interactions;
waste-collection
services.
Identify nonadherence.
Treat minor ailments.
Refer to doctors
when necessary.
3.3
Fact sheet. Fighting antibiotic resistance by

ensuring the rational use of medicines.
Amsterdam: Health Action International
(HAI) Europe; 2011
(http://haieurope.org/wpcontent/uploads/2012/02/HAI-EUROPEFact-Sheet-Antibotic-Resistance.pdf,
Europe (2011)
Provide knowledge
about AMR to
colleagues via
antimicrobial
stewardship
programmes
Provide conferences,
newsletters for health
professionals.
Encouraging
multidisciplinary
collaboration to
ensure optimal
patient outcomes.
Generate and
analyse data on drug
use.
Be involved in the
development of
guidelines on risk
assessment,
treatment and
monitoring of patients
exposed to bacteria.
Promoting prudent
use.
Promote measures to
prevent and control
infection.
Health campaign;
health promotion in
schools and the
community.
Minimize the drug

industrys influence
on decisions related
to prescribing and
dispensing.
page 16
3.4
Department of Health, Department for

Environment, Food and Rural Affairs. UK
five year antimicrobial resistance strategy
2013 to 2018. London: Department of
Health; 2013
(https://www.gov.uk/government/uploads/s
ystem/uploads/attachment_data/file/24405
8/20130902_UK_5_year_AMR_strategy.pd
f, accessed 21 October 2014).
United Kingdom
(2012)
3.5
Antibiotic resistance. Brussels: European

Parliament; 2006
(http://www.itas.kit.edu/downloads/etag_ho
ho06a.pdf, accessed 21 October 2014).
Europe (2006)
3.6
Strategy for tackling antimicrobial

resistance (STAR) 2012-2017. Belfast:
Department of Health, Social Services and
Public Safety; 2012
(http://www.dhsspsni.gov.uk/star-doc.pdf,
United Kingdom
(Northern
Ireland) (2010)
Encourage patients
seeking advice to use
community
pharmacies.
Include antimicrobial
resistance
awareness,
responsible
prescribing,
dispensing and
administration
practice, and
effective prevention,
management and
control of infection in
undergraduate and
postgraduate
curricula for
pharmacy.
Remove economic
incentives to
dispense without
prescription.
Neglect of
pharmacists as a
group in national
educational
campaigns.
Therapeutic Drug
Monitoring (TDM)
training provided
through the Trust is
available to
pharmacy staff.
E-learning course for
pharmacists on
antimicrobials
(www.nicpld.org).
Introduce
antimicrobial
resistance at the
undergraduate level.
National primary-care
guidelines distributed
to community
pharmacies for
information.
Participation in
writing Therapeutic
Notes reflecting local,
national and
international
guidelines and
standards.
page 17
3.7
FIP Statement of Policy Control of

Antimicrobial Medicines Resistance (AMR).
The Hague: International Pharmaceuticals
Federation (FIP); 2008.
http://www.fip.org/www/uploads/database_f
ile.php?id=289&table_id=, accessed 21
October 2014).
Global (2008)
Give proper
counselling advice
and provide
appropriate written
information when
dispensing
antimicrobials.
Encourage patients
to dispose of any
unused antimicrobial
medicines.
Effectively monitor
the supply
antimicrobials and
patients use of them.
Recommend
therapies other than
antimicrobials for
minor ailments.
Work with prescribers
to order sufficient
doses to complete or
continue a course of
therapy.
Provide updated
information on
antimicrobials to
prescribers, as well
as to health-care
professionals who
administer or
otherwise influence
the use of medicines.
Professional
organizations are
working to:
promote surveillance
systems and the
development and use
of indicators;
establish policies and
programmes for the
market authorization
process;
support educational
campaigns aimed at
the public and healthcare professionals;
promote the
discovery and
development of new
cost-effective
antimicrobial agents
and alternative
treatments and
vaccines;
support the
development of rapid
and reliable
diagnostic and
susceptibility tests;
promote the role of
the pharmacist in the
selection,
procurement,
distribution and use
of antimicrobials;
impose restrictions
on prescribing
antimicrobial
medicines;
strengthen the
legislative and
page 18
regulatory control of
authorizations to
market, import,
export, prescribe,
dispense and
otherwise supply
antimicrobial
medicines;
ensure that the
available
antimicrobials meet
the required
standards of safety,
quality and efficacy;
develop appropriate
adult and child
vaccination
programmes;
be actively involved
in matters of hygiene
and infection control
in all health-care
settings.
4.1
4.2
Gastelurrutia MA, Larraaga B, Garay A,

Echeveste FA, Fernandez-Llimos F. Impact
of a program to reduce the dispensing of
antibiotics without a prescription in Spain.
Pharmacy Practice. 2013;11(4):185-90
(http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC3869633/, accessed 21 October 2014).
Roque F, Soares S, Breitenfeld L, LpezDurn A, Figueiras A, Herdeiro MT.
Attitudes of community pharmacists to
antibiotic dispensing and microbial
resistance: a qualitative study in Portugal.
International Journal of Clinical
Pharmacology. 2013;35(3):417-24.
Spain (2013)
Portugal (2013)
Pharmacists should
provide patients with
a better
understanding of
prescriptions and not
merely treat their
symptoms.
Campaigns to reduce
the number of
pharmacists
prescribing
antibiotics.
Attitudes that lead to

dispensing antibiotics
without prescription
are complacency and
precaution.
page 19
4.3
4.4
4.5
Wafula, F. Availability and dispensing

practices for antimalarials and
antimicrobials in western Kenyan
pharmacies. Pharmaceutical Regulatory
Affairs. 2013:2(106)
(http://www.omicsgroup.org/journals/availa
bility-and-dispensing-practices-forantimalarials-and-antimicrobials-inwestern-kenyan-pharmacies-21677689.1000106.pdf, accessed 21 October
2014).
Skliros et al. Self-medication with
antibiotics in rural population in Greece: a
cross-sectional multicenter study. BMC
Family Practice. 2010;11:58
(http://www.biomedcentral.com/14712296/11/58, accessed 21 October 2014).
Kenya (2013)
Gastelurrutia MA, Larraaga B, Garay A,

Echeveste FA, Fernandez-Llimos F. Impact
of a program to reduce the dispensing of
antibiotics without a prescription in Spain.
Pharmacy Practice. 2013;11(4):185-90
(http://www.ncbi.nlm.nih.gov/pmc/articles/P
MC3869633/, accessed 21 October 2014).
Spain (2013)
Medicines missing in
stocks.
Dispensing without
prescription.
Selling partial doses.
Greece (2010)
Legislative ban on
unregulated sale of
antibiotics without
prescription.
Irrational use of
antibiotics is mainly
due to a high degree
of self-medication
and the absence of
government
regulatory policy on
the prescription and
sale of antibiotics.
Pharmacists should
provide therapy to
patients by providing
better understanding
of prescriptions and
not merely by treating
their symptoms.
page 20
4.6
4.7
Tonna, AP, Stewart, DC, West, B. and

McCaig, D. J. Exploring pharmacists'
perceptions of the feasibility and value of
pharmacist prescribing of antimicrobials in
secondary care in Scotland. International
Journal of Pharmacy Practice.
2010;18:31219
(http://onlinelibrary.wiley.com/doi/10.1111/j.
2042-7174.2010.00059.x/abstract,
L Ecker, Ochoa TJ, Vargas M, Del Valle
MJ, Ruiz J. Factors affecting caregivers'
use of antibiotics available without a
prescription in Peru. Pediatrics.
2013;131(6):1771-9
(http://www.ncbi.nlm.nih.gov/pubmed/2369
0517, accessed 22 October 2014).
United Kingdom
(Scotland)
(2010)
Peru (2013)
Easy access to and

the practicality of
prescriptions for
antibiotics by
pharmacists on the
basis of the patients
clinical condition is
preferable to
patients.
Pharmacists identify
the potential for
evidence-based
medicine.
Pharmacists feel the

need for a better
understanding of
antimicrobial
treatment and of
identifying possible
ways of reducing the
risk of resistance.
Parents and care
givers are likely to
follow the physicians
advice in cases
where antibiotics are
not prescribed.
Improving the
prescription and
dispensing habits of
physicians and
pharmacists and
educating the whole
community,
especially in settings
where antibiotic
regulations are
limited, would be
beneficial in
encouraging the
prudent use of
antibiotics in children.
page 21
Annex 3. Antibioticmedicinesrelated questionnaire for European

pharmacy/pharmacist association
Section 1: General information

Name:

Name of Authority/Department/institution/Organization:

City/State/Country/ Email address/Phone/Website

Type of organization:

Pharmacist association
Pharmacy association
Other

Funding :

Public

Private

Fees from members

Both

Yearly budget for rational use of medicines/ prudent use of AB medicines related activities___________________

Impact :

International
National
State/regional
County councils/lands/municipalities

Size of organizations related activities:

No. of professional staff
No. of support staff

Annual budget for the organizations related activities: _____________________

Section2:Situationoverview
page 22
1. Do you think antibiotics in your country are:

a) Prescribedappropriately?

Yes

No

b) Dispensedappropriatelywithavalidprescription?

Yes

No

c) Usedcorrectlybypatients?
Yes

No

2. If yes, who do you feel is in a position to improve the situation with the use of antibiotics (check
as many boxes as needed)?

Policy makers

Pharmacists
Prescribers

Patient community
Professional associations e.g. medical microbiologists or infectious disease
specialists

Other (please specify)_________________

3. Are antibiotics legitimately available overthecounter in your country?

Yes
No
Yes
No

4. Are antibiotics available without a prescription in your country?

5. Are antibiotics available without a prescription, by any other means in your country?

Yes

No
6. If Yes, please describe by which other means antibiotics are available without a prescription?

For
example: in eye-drops, etc.

page 23
7. Do you feel that antibiotics are mostly prescribed appropriately in your country?

Yes

No

8. Is it possible to buy antibiotics:

a)Onlinewithaprescriptionfromyourcountry?
Yes

No
b) Online without a prescription from your country?
Yes

No
c) Onlinewithaprescriptionfromanothercountry?
Yes
No
d) Onlinewithoutaprescriptionfromanothercountry?

Yes

No
e) Somewhereelsethanapharmacyinyourcountry?

Yes

No

9. Is there close collaboration (feedback) between pharmacists and doctors in your country?

Yes
10.
11.
12.
13.
No

Can the pharmacist in your country influence the doctor to change the prescription if he/she
does not consider it appropriate?

Yes

No

Are data on antibiotics use monitored in your country?

Yes

No

If yes, who is responsible for data collection and monitoring?
Please describe:
Isprudentuseofantibioticsapartofundergraduatecurriculainyourcountry?
For medical staff

For pharmaceutical staff
No Dont know
page 24
14. Isprudentuseofantibioticsapartofpostgraduatecurriculainyourcountry?
For medical staff

No

For pharmaceutical staff

Dont know

15. Are there any guidelines on antibiotic treatment in your country?
Yes

No
Dont know

16. If yes, are they issued

Centrally

Separately by various institutions for own use

17. Who is involved in the development of these guidelines?

Policy makers

Pharmacists

Prescribers

Patient community
Professional associations e.g. medical microbiologists or infectious disease
Specialists

Other (please specify)_________________

18. If issued centrally, have the guidelines on antibiotic treatment in your country been updated in
the last 5 years?
Yes
No
Dont know
Section3:Theroleofpharmacists
19. Are you aware of any activities or initiatives in your country to foster prudent use of antibiotics
at the pharmacy level?
Yes

No
20. If yes, please describe the activities and the institutions responsible for them?
21. Are you aware of any collaboration between pharmacists and health professional societies/
associations to develop and facilitate the implementation of educational and behavioural
interventions that will assist prescribers in appropriate antimicrobial prescribing?

page 25
22. If yes, please describe the activities and the institutions responsible for them?

23. Are the number of pills dispensed in pharmacy adjusted for every patient based on the quantity
requested/duration of treatment stated on their prescription?
Yes

No

24. Are waste collection services provided by pharmacies in your countries?

Yes

Other___________
No
Dont know

25. Do you think pharmacists in your country are in a good position (in terms of skills and
knowledge) to provide advice on the use of antibiotics to patients?
Yes
No

26. Detailed information on the use of antibiotics provided by pharmacists to patients

Strongly agree
Agree Neither agree nor disagree

Disagree Strongly disagree

27. Detailed information on the use of antibiotics provided by doctors to patients

Strongly agree
Agree Neither agree nor disagree

Disagree Strongly disagree

page 26
Annex 4. Countryspecific policy recommendations

Country / Region
Organization
Policy
Europe
PGEU
The following pharmacy tasks

are identified:
informing patients how to take
the medicines correctly and
for how long, as well as on
possible side effects, adverse
reactions and drug
interactions;
advising patients on minor
ailments and referring them,
when required, to their doctor;
providing waste-collection
services to avoid selftreatment;
promoting health campaigns
in local communities, schools
and other community
organizations.
At the national level, pharmacists
were also identified as
contributors, which can be seen
from the following examples.
Belgium
Belgian Antibiotic Policy

Coordination Committee (Babcoc)
Includes a multidisciplinary work

group, including pharmacists, to
handle identified activities. One
of these activities is a campaign
to facilitate discussion between
patients, doctors and
pharmacists on the need for the
appropriate use of antibiotics.
Germany
Bundesministerium fr Ernhrung
und Landwirtscharft
Mentions education and post

education relating to antibiotic
resistance and patient
communication.
Latvia
ECDC
The report on a country mission

to Latvia describes the situation
vis--vis antimicrobial resistance
in 2011and the action taken in
the country in this area. No
activity at community pharmacy
level is mentioned. According to
websites of the pharmacy chains,
they provide information on
preventive measures of avoiding
infections.
page 27
The Netherlands
ECDC
Guidelines on prescribing
antibiotics exist and pharmacists
react to prescriptions that do not
adhere to them. This is linked to
a bonus agreement. The
dispensing data is collected by
foundations, such as the Dutch
Foundation for Pharmaceutical
Statistics . When GPs prescribe
according to the guidelines (a
certain percentage of them), they
receive a bonus paid by
insurance companies.
Accordingly, when pharmacists
dispense according to the
guidelines, they also receive a
bonus and this motivates them to
help GPs who do not respect the
guidelines to prescribe better.
Sweden
Swedish National Board of Health

and Welfare (Socialstyrelsen)
The pharmacy is identified in the

Forslag til Svensk handlingsplan
mot antibiotikaresistens
[Proposed Swedish Action Plan
against antimicrobial resistance]
as a source of public information
on the AMR problem.
United Kingdom
Department of Health
In the UK 5 year antimicrobial

resistance strategy 2013 to 2018,
the focus is on education and
post education to improve the
knowledge and understanding of
AMR by incorporating
antimicrobial resistance
awareness, responsible
prescribing, dispensing and
administration practice, as well
as effective prevention,
management and control of
infection. The strategy also
mentions the need for exploring
how to encourage patients to use
community pharmacies for
advice is needed.
The WHO Regional

Office for Europe
The World Health
Organization (WHO) is a
specialized agency of the
United Nations created in
1948 with the primary
responsibility for international
health matters and public
health. The WHO Regional
Office for Europe is one of six
regional offices throughout
the world, each with its own
programme geared to the
particular health conditions of
the countries it serves.
DOCUMENT TITLE: THE ROLE OF PHARMACIST IN ENCOURAGING PRUDENT USE OF ANTIBIOTICS AND AVERTING
ANTIMICROBIAL RESISTANCE: A REVIEW OF POLICY AND EXPERIENCE IN EUROPE
Member States
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Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The former Yugoslav Republic
of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom
Uzbekistan
The role of pharmacist

in encouraging
prudent use of
antibiotics and
averting antimicrobial
resistance: a review of
policy and experience
World Health Organization

Regional Office for Europe
UN City, Marmorvej 51, DK-2100 Copenhagen , Denmark
Tel.: +45 45 33 70 00
Fax: +45 45 33 70 01
Email: contact@euro.who.int
Website: http://www.euro.who.int/en/health-topics/Health-systems/medicines
Health
Technologies
and
Pharmaceuticals
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The Role of Pharmacist in Encouraging Prudent Use of Antibiotics and Averting Antimicrobial Resistance A Review of Policy and Experience Eng

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The WHO Regional

Office for Europe

The role of pharmacist

World Health Organization

The role of pharmacist in encouraging

Box 1. The 7 key areas of action to address the

dispensing antimicrobials without a prescription;

Good pharmacy practice

provision of a medicine-waste-collection service to avoid misuse of antimicrobials.

Box 3. GPP role 2: provide effective medication therapy management

development of guidelines or a clinical decision-support system, including:

Box 4. GPP role 3: maintain and improve professional performance

education of the pharmacy profession:

focus on inappropriate dispensing through:

public campaigns focusing on:

development and innovation (related mainly to pharmacists working in research):

development of national policy with the involvement of pharmacists:

Global GPP guidelines

Role 3 focuses on the importance of pharmacists maintaining a high level of knowledge,

Characteristics of the respondents

Fig. 2. Proportions of respondents to the survey (total = 44)

Views of the respondents on the potential of health professionals to

Fig. 4. Countries where OTC sales of antibiotics are legal

Monitoring consumption of antimicrobial medicine

Fig 7. Countries monitoring antmicrobial consumption, 2014 (total = 53)

Fig. 9. Responses on inclusion of antibiotic stewardship in medical/pharmaceutical

Guidelines on antibiotic treatment

13 respondents agreed that feedback from pharmacists to doctors is influential.

provide inexpensive and simple-to-use methods of deoxyribonucleic acid/ribonucleic acid

pharmacist as an effective liaison between prescriber and patient. Improved communication

23. Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, Herdeiro MT. Attitudes of

Andr M, Vernby , Berg J, Lundborg C. A survey of public knowledge and awareness

EPSA Statement of support for ANEPF. Brussels: European Pharmaceutical Students

ECDC corporate strategies for disease-specific programmes. Stockholm: European

Stoyanova R, Dimova R, Raycheva R. Sale of regulated antibiotics without prescription.

McCoy D, Toussaint K, Gallagher JC. The pharmacist's role in preventing antibiotic

Dickerson L, Mainous A, Carek P. The pharmacists role in promoting optimal antimicrobial

Whalley B, Fletcher K, Weston S, Howard R, Fawlinson C. Foundation in pharmacy

Roque F, Soares S, Breitenfeld L, Lopez-Duran A, Figueiras A, Herdeiro MT. Attitudes

Coleman CL. Examining influences of pharmacists communication with consumers about

Markovic-Perkovi V, Grubia N. Self-medication with antibiotics in the Republic of Srpska

Madaras-Kelly K, Hannah E, Bateman K, Samora M. Experience with a clinical decision support

PGEU statement: community pharmacists contribution to the control of antibiotic resistance.

Antibiotic resistance. Brussels: European Parliament; 2006

Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernandez-Llimos F. Impact of a program

Roque F, Soares S, Breitenfeld L, Lpez-Durn A, Figueiras A, Herdeiro MT. Attitudes of

Skliros et al. Self-medication with antibiotics in rural population in Greece: a cross-sectional

Gastelurrutia MA, Larraaga B, Garay A, Echeveste FA, Fernandez-Llimos F. Impact of a program

Annex 2. Pharmacy roles in antimicrobial resistance literature map

Andr M, Vernby , Berg J, Lundborg C. A

Action, practices, recommendations described relating to the four roles of

Only one antibiotic

Survey on activities related to antibiotic

Phone app for

EPSA Statement of support for ANEPF.

ECDC corporate strategies for diseasespecific programmes. Stockholm:

Stoyanova R, Dimova R, Raycheva R. Sale

Rahman AU. The role of pharmacist in

Dickerson L, Mainous A, Carek P. The

Kotwani A, Wattal C, Joshi P, Holloways K.

Whalley B, Fletcher K, Weston S, Howard

Roque F, Soares S, Breitenfeld L, LopezDuran A, Figueiras A, Herdeiro MT.

Provide audit and