Good morning, everyone, and thank you for the opportunity to be here today.
My name is Shelita Dattani, and I am the director of practice development and knowledge translation at the Canadian Pharmacists Association, which is the national voice of Canada's 42,000 pharmacists. I am also a practising hospital and community pharmacist and have significant experience leading and participating in antimicrobial stewardship initiatives in the hospital setting.
Since the discovery of penicillin by Sir Alexander Fleming in 1945, as my colleague described, antibiotics have made an enormous contribution to the treatment of infectious disease, and they have made so many other treatments and procedures, such as surgeries and transplants, possible for us.
It is worth echoing my colleagues here today that AMR has been described as a “slow moving disaster”. As others have said, it is a very serious threat to health and public safety. If left unchallenged, it could lead to 10 million deaths a year by 2050, and with few new antibiotics in current drug development, it's frightening. It's everyone's problem, and everyone must be part of the solution.
I want to talk to you today about antimicrobial stewardship and the role of the pharmacist.
As others have said, stewardship is a team sport, and our collective goal in antimicrobial stewardship is ensuring that patients get the right antibiotics when they need them, and only when they need them. As the medication experts, pharmacists are fundamental to antimicrobial stewardship. Hospital pharmacists throughout this country have demonstrated leadership in antimicrobial stewardship activities and programs for several years now. Just as I spent much of my time in hospital practice ensuring that patients were receiving the right antibiotics, and only if they needed them, I work with my primary care colleagues now to do the same when I practise at the neighbourhood pharmacy. Pharmacists can act as stewards throughout the continuum of care, as other professions can. We work in hospital settings, long-term care settings, primary care teams, public health, and the area that I will predominantly focus on today, which is community pharmacy.
Hospitals and long-term care environments have either established or evolving stewardship programs, but over 80% of antibiotics are prescribed in the community, where few formal antimicrobial stewardship programs currently exist. One large study published last year in the Journal of the American Medical Association demonstrated that 30% of antibiotic use in non-hospitalized patients is unnecessary.
Antibiotic prescribing in the community is driven by the tendencies of individual prescribers and consumer demand. Community pharmacists have the skills and knowledge to make a real difference. Pharmacists like me, in communities across this country, have established relationships with their patients and their prescriber colleagues. Pharmacists can effect real change in community-based antibiotic prescribing.
There are five key areas in which pharmacists are demonstrating leadership as antimicrobial stewards in the community. These include public education, immunization, prescribing for minor ailments, counselling patients, and optimizing prescribing by other health care providers.
Many Canadians are unaware of the impact and the risks of inappropriate antibiotic use compared with the benefits. Pharmacies are the hubs of their local communities, and pharmacists can play a big role in health promotion and transforming patients into stewards. As others have mentioned, educational campaigns in Canada, such as the community-based education program Do Bugs Need Drugs? and the Choosing Wisely campaign, include antibiotic-related information. Pharmacists have participated in the development of these campaigns. They are developing their own lists for these campaigns, and they are relaying the messages to their patients each and every day in the hubs of their communities.
For several years, Canadians have been able to go to their community pharmacy to get their flu shots. One of the best opportunities I have to talk to my patients about infection prevention, symptomatic management of viral infections, or their hesitancy in getting vaccinated in the first place is during flu shot season. I tell my patients that vaccinations don't just prevent primary infections, but they can also prevent secondary infections from antibiotic-resistant bacteria, for example, pneumonias that can follow flu infections. I use these opportunities around flu season to talk about the importance of all vaccinations.
Beyond this, pharmacists are also taking on more active, targeted, and patient-specific interventions that you may not be aware of, which include assessment, treatment, and follow-up of their patients. Because pharmacists see their patients on average 14 times a year—sometimes at nine o'clock on a Thursday night, or maybe at 4 p.m. on a Sunday—they are very well placed to provide direct care to patients.
In one province in this country, pharmacists can independently prescribe broadly, and in a few others, can prescribe more specifically for minor ailments like uncomplicated urinary tract infections or strep throat. Pharmacists are guideline-oriented practitioners, and they are very invested, as I mentioned, in campaigns like Choosing Wisely's “More is not always better”. As drug experts, prescribers, and antimicrobial stewards, we pharmacists are very conscious of responsible prescribing—and more importantly, not prescribing if not needed.
In certain provinces, pharmacists can substitute one antibiotic for another. For example, if you come into your pharmacy and you have allergies to the antibiotic prescribed, or if the initial antibiotic prescribed does not resolve your infection, I can substitute a more appropriate antibiotic. I have a relationship with you; I can do that.
These expanded scopes mean that pharmacists have a very direct opportunity to lead in antimicrobial stewardship. There is currently research under way in the province of New Brunswick to capture outcomes in patients assessed and treated by their pharmacists for uncomplicated urinary tract infections.
Pharmacists can also help support their physician colleagues who use delayed prescribing, which is a debatable practice. If a patient gets a prescription from their doctor and is instructed to start antibiotics if symptoms do not improve after a specified time, I can reinforce symptom management with my patient to ensure that we don't jump to antibiotics too quickly. I can counsel my patient on when to follow up with her prescriber. If my patient ends up needing antibiotics, I will talk to her in detail about benefits but also the other things she may not be thinking about, such as the adverse effects and other unintended consequences that have been described here today.
Rapid strep tests are also now offered in some pharmacies. Pharmacists can administer these tests and intervene immediately, either through prescribing or recommending antibiotics or over-the-counter treatments for viral illnesses, as appropriate. Expanding these services would further relieve pressure on the health care system if patients were able to avoid emergency departments or urgent care clinics. A U.K. demonstration study showed that 49% of patients would have sought care from their family doctor if strep tests were not accessible and available in community pharmacies, which are the health care hubs of their communities.
Pharmacists, as evidence-based practitioners, play a huge role in educating prescribers to support them in optimal prescribing for their patients. Pharmacists educate prescribers informally on a regular basis, and they have formal roles where they lead in individual educational outreach.
Pharmacists also have established roles in integrated primary care teams, and they collaborate every day with their colleagues to ensure optimal prescribing of antibiotics through direct and individual feedback on prescribing. This practice has met with much success in the hospital environment.
CPhA participates in the interdisciplinary AMS Canada steering committee and the Canadian Roundtable on AMS. We have demonstrated leadership in increasing the awareness and importance of antimicrobial stewardship for all pharmacists in Canada. We are engaged in continuing to shape the significant role of pharmacists as part of the team in the fight against AMR.
Pharmacists are doing a lot, but we want to do more and we could be doing more to help as primary care providers. We need to have the authority to act to make an more impactful difference. Our skills, scope, and access have enabled us to improve outcomes in chronic disease, and evidence is now building in other areas.
We also need enabling tools to be even more effective antimicrobial stewards. It doesn't make sense to me that a 32-year-old woman in New Brunswick can be treated by a pharmacist for a simple urinary tract infection, but a similar patient in Ontario can't and might have to wait longer to access treatment.
We recommend action in four specific areas. First, and most critically, we recommend that all jurisdictions, including the federal government as a provider of health services, promote harmonization of pharmacists' expanded scope of practice and associated remuneration for these services across the country. This should include prescribing for minor ailments, as well as therapeutic substitution of antibiotics.
Second, the implementation of a fully integrated drug information system and electronic health record in every province and territory would ensure that pharmacists have access to the information they need, such as patients' medication profiles and culture and sensitivity reports, to help us care for patients and work more effectively with our colleagues to ensure safe and effective antibiotic use.
Third, the Canadian Pharmacists Association, through our work with the AMS steering committee, supports the development of national prescribing guidelines. We also commit to leading the development of knowledge mobilization tools and mentorship networks for pharmacists, to ensure they are armed with the most current knowledge and skills to act as antimicrobial stewards in the interests of public safety.
Finally, we recommend that all antibiotic prescriptions include the indication for the medication—why the medication was prescribed to that patient—on the prescription. This information would help us promote optimal and safe antibiotic use, ensuring that the patient receives the correct drug, the correct dose, and the correct duration of therapy for that particular indication.
Every interaction I have with a patient or a prescriber is an opportunity to get my patient the right antibiotic, if needed, and an opportunity for all pharmacists to embrace their role as antimicrobial stewards. We need to continue to work together to solve this problem.
Pharmacists are committed to being a major part of the solution in this shared responsibility of stewardship, and we ask for the committee's support in advancing the role of the pharmacist as antimicrobial steward, as described today.
Thank you very much.