Pharmacist Expertise Is Critical to Antimicrobial Stewardship

Pharmacy TimesMarch 2024
Volume 90
Issue 3

Antimicrobial stewardship is crucial for all health care professionals—not just those in a hospital setting

Antimicrobial stewardship programs (ASPs) are alive and well, but so is antimicrobial resistance (AMR). Annually, more than 2 million Americans contract infections resistant to customary treatment, and experts estimate that by 2050, these infections will cause 10 million deaths globally every year. In fact, AMR continues to significantly increase morbidity, mortality, and health care costs despite the growth of ASPs.1,2

Antimicrobial Resistance (AMR) occurs when bacteria change over time and no longer respond to medicines. Genetic mutation in bacteria can lead to antibiotic resistance - Image credit: nobeastsofierce |

Image credit: nobeastsofierce |

Misuse of antimicrobial medications is the primary culprit.1,2 Other causes include self-medication with antibiotics, agricultural and livestock antibiotic use, and pollution of water sources with sewage runoff or industry waste.3-5

About the Author

Jeannette Y. Wick, MBA, RPh, FASCP, is the director of pharmacy professional development in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.


ASPs strategize to optimize antimicrobial use, improve patient outcomes, and stop or delay the emergence of resistance.6,7 By definition, ASPs are multidisciplinary in nature, involving infectious disease physicians, infection control professionals, hospital epidemiologists, and pharmacists.7 Pharmacists on ASPs use their expertise to perform indispensable duties, and study findings indicate that pharmacist-led interventions significantly improve prescribing practices, reduce unnecessary antibiotic use, optimize antibiotic selection and therapy, and enhance patient clinical outcomes.7-9

Most ASPs are established in hospital or clinic settings, but there is also a great need for stewardship in the community. Community based pharmacists can conduct some of the activities listed in Table 1.8,10-12 Perhaps the most significant responsibilities in community settings are the education of both health care professionals and patients, prescription review for interactions and allergies, and occasionally recommending therapy de-escalation.


Community pharmacy staff may interact with patients who are unhappy with a prescriber’s refusal to write a prescription for an antimicrobial. Parents who want an antibiotic for a child’s ear infection (a practice that has fallen out of favor) are an example. Often patients need to understand situations on a personal level before they understand the problem’s urgency and embrace solutions. One way to bring home the message that antimicrobial overuse has repercussions is by raising awareness of antibiotic adverse events (AEs), emphasizing consequences of misuse, and explaining irreversible environmental effects.


Antibiotics are the drug class most likely to cause AEs. More than 30% of children who take antibiotics for 14 days or more experience an AE.13 Many adults do too. Most antibiotic effects are mild and self-limiting, but diarrhea and rash can be signals that more severe AEs are possible.13 Discussing the possibility—or the likelihood—of AEs can help patients understand personal risks.Table 214-23 shows several AEs.

Another area where community pharmacists can be stewards is in topical treatment.24-26 OTC topical antibiotics such as bacitracin are inappropriate for routine care due to risk of allergy and anaphylaxis. Pharmacists can let patients know that the best way to treat minor cuts or scrapes is to clean them with mild soap and water and apply plain petrolatum if they need an emollient.24-26


Many patients are highly motivated to protect the environment. Once consumed or applied, antibiotic metabolites and residue have to go someplace.27 That means they find their way down various drains and into our water supply. Most municipal sewage treatment plants were built decades ago, and few have the capacity to clean water as well as they should. Indirect effects of antibiotics in the environment include consequent development of multiresistant bacteria, death of aquatic environments, and harmful effects on birds and bees. Researchers indicate they have not yet identified all of antibiotics’ indirect long-term effects on the ecosystem.27 Educating patients on these concerns could help motivate them to improve their own antimicrobial stewardship.


Affixing appropriate auxiliary labels to prescription bottles is one way to remind patients that antibiotics have potential AEs. Spending a few minutes with a patient to explain why excessive antibiotic use poses a problem to individuals and the planet is another way to raise awareness. Although antibiotic stewardship is typically a multidisciplinary process, pharmacists can start that process.

1. Dadgostar P. Antimicrobial resistance: implications and costs. Infect Drug Resist. 2019;12:3903-3910. doi:10.2147/IDR.S234610
2. Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global multifaceted phenomenon. Pathog Glob Health. 2015;109(7):309-318. doi:10.1179/2047773215Y.0000000030
3. Antimicrobial resistance. World Health Organization. November 21, 2023. Accessed January 20, 2024.
4. Rather IA, Kim BC, Bajpai VK, Park YH. Self-medication and antibiotic resistance: crisis, current challenges, and prevention. Saudi J Biol Sci. 2017;24(4):808-812. doi:10.1016/j.sjbs.2017.01.004
5. Hashemi S, Nasrollah A, Rajabi M. Irrational antibiotic prescribing: a local issue or global concern? EXCLI J. 2013;12:384-395.
6. Timbrook TT, Hurst JM, Bosso JA. Impact of an antimicrobial stewardship program on antimicrobial utilization, bacterial susceptibilities, and financial expenditures at an academic medical center. Hosp Pharm. 2016;51(9):703-711. doi:10.1310/hpj5109-703
7. Zay Ya K, Win PTN, Bielicki J, Lambiris M, Fink G. Association between antimicrobial stewardship programs and antibiotic use globally: a systematic review and meta-analysis. JAMA Netw Open. 2023;6(2):e2253806. doi:10.1001/jamanetworkopen.2022.53806
8. Dighriri IM, Alnomci BA, Aljahdali MM, et al. The role of clinical pharmacists in antimicrobial stewardship programs (ASPs): a systematic review. Cureus. 2023;15(12):e50151. doi:10.7759/cureus.50151
9. Otieno PA, Campbell S, Maley S, Obinju Arunga T, Otieno Okumo M. A systematic review of pharmacist-led antimicrobial stewardship programs in sub-Saharan Africa. Int J Clin Pract. 2022;2022:3639943. doi:10.1155/2022/3639943
10. Suh Y, Ah YM, Chun HJ, et al. Potential impact of the involvement of clinical pharmacists in antimicrobial stewardship programs on the incidence of antimicrobial-related adverse events in hospitalized patients: a multicenter retrospective study. Antibiotics (Basel). 2021;10(7):853. doi:10.3390/antibiotics10070853
11. Hammond KM, Kabbani D, Doucette KE, et al. How does the antimicrobial stewardship provider role affect prospective audit and feedback acceptance for restricted antibiotics in a Canadian tertiary-care center? Infect Control Hosp Epidemiol. Published online August 18, 2023. doi:10.1017/ice.2023.152
12. Palanisamy PR. Stop antibiotic resistance – a roller coaster ride through “antibiotic stewardship,” “prescription auditing” and “AWaRe” assessment tool. J Family Med Prim Care. 2023;12(9):1796-1801. doi:10.4103/jfmpc.jfmpc_296_23
13. Olson SC, Smith S, Weissman SJ, Kronman MP. Adverse events in pediatric patients receiving long-term outpatient antimicrobials. J Pediatric Infect Dis Soc. 2015;4(2):119-125. doi:10.1093/jpids/piu037
14. Baggio D, Ananda-Rajah MR. Fluoroquinolone antibiotics and adverse events. Aust Prescr. 2021;44(5):161-164. doi:10.18773/austprescr.2021.035
15. Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003;36(11):1404-1410. doi:10.1086/375078
16. Barbut F, Meynard JL. Managing antibiotic-associated diarrhoea. BMJ. 2002;324(7350):1345-1346. doi:10.1136/bmj.324.7350.1345
17. Bartlett JG. Clinical practice: antibiotic-associated diarrhea. N Engl J Med. 2002;346(5):334-339. doi:10.1056/NEJMcp011603
18. Hempel S, Newberry SJ, Maher AR, et al. Probiotics for the prevention and treatment of antibiotic-associated diarrhea: a systematic review and meta-analysis. JAMA. 2012;307(18):1959-1969. doi:10.1001/jama.2012.3507
19. Morales-Alvarez MC. Nephrotoxicity of antimicrobials and antibiotics. Adv Chronic Kidney Dis. 2020;27(1):31-37. doi:10.1053/j.ackd.2019.08.001
20. Kim SY, Moon A. Drug-induced nephrotoxicity and its biomarkers. Biomol Ther (Seoul). 2012;20(3):268-272. doi:10.4062/biomolther.2012.20.3.268
21. Perazella MA, Rosner MH. Drug-induced acute kidney injury. Clin J Am Soc Nephrol. 2022;17(8):1220-1233. doi:10.2215/CJN.11290821
22. Smith CA. Trimethoprim-sulfamethoxazole and hyperkalemia. Nephrol Nurs J. 2021;48(2):177-180.
23. Alappan R, Buller GK, Perazella MA. Trimethoprim-sulfamethoxazole therapy in outpatients: is hyperkalemia a significant problem? Am J Nephrol. 1999;19(3):389-394. doi:10.1159/000013483
24. Mowad CM. Contact allergens of the year. Adv Dermatol. 2004;20:237-255.
25. Sood A, Taylor JS. Bacitracin: allergen of the year. Am J Contact Dermat. 2003;14(1):3-4. doi:10.2310/6620.2003.38621
26. Spring S, Pratt M, Chaplin A. Contact dermatitis to topical medicaments: a retrospective chart review from the Ottawa Hospital Patch Test Clinic. Dermatitis. 2012;23(5):210-213. doi:10.1097/DER.0b013e31826e443c
27. Wang K, Zhuang T, Su Z, Chi M, Wang H. Antibiotic residues in wastewaters from sewage treatment plants and pharmaceutical industries: occurrence, removal and environmental impacts. Sci Total Environ. 2021;788:147811. doi:10.1016/j.scitotenv.2021.147811
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