Pharmacists play an important role in increasing the awareness of antimicrobial resistance (AMR) and supporting AMR mitigating interventions such as implementation of antimicrobial stewardship (AMS) interventions and vaccination programmes. They are also involved in research and development of new antimicrobials. They have a vital role in monitoring the choice and use of antimicrobials and ensuring appropriateness; that is adherence to clinical guidelines, monitoring the duration and frequency of antimicrobial use, correct indication of use, reconciliation with biomarkers and patient clinical picture and diagnosis.

Pharmacists’ expertise and clinical knowledge must be fully utilized to ensure appropriate use of antimicrobials and improve stewardship especially now; with the knowledge we have, that misuse and overuse of antimicrobials such as antibiotics are major drivers of AMR. Pharmacists practicing in clinical and community settings thus, play a critical role in supporting the efforts towards AMR mitigation by ensuring that antimicrobials are dispensed in a safe and rational manner while also monitoring effectiveness and cost.

In low- and middle-income countries (LMICs) such as those sub-Saharan Africa (SSA), pharmacists still face major challenges and barriers. These include limited knowledge on AMR and stewardship, poor public awareness, inadequate physician-pharmacist collaboration, misaligned salary structures, organizational obstacles, inadequate staffing and lack of adequate technology. Other factors include perverse financial incentives to make more money by selling antimicrobials without prescriptions, lack of accountability and a lack of understanding of how their practices impacts public health. The adoption of pharmacist-led antimicrobial stewardship programs (ASPs) could be effective in lowering antimicrobial consumption in SSA as has been shown in most high-income countries and some LMICs. Dispensing of antibiotics without a prescription among community drug retail outlets in SSA is a common practice. This unregulated access to antimicrobials is one of the major contributors to the spread of AMR in the community.

The majority of SSA countries lack AMR surveillance systems and only few countries conduct effective routine surveillance.  Through the activities supported by SEDRIC, efforts are being made to support AMR surveillance at the country and regional levels to enable improvements in routine AMR surveillance activities that would complement AMS efforts.

The pharmacist role is evolving in SSA countries in relation to services they can provide such as being able to offer vaccines like in South Africa and health screening tests . The services provided by most pharmacists in the region are mainly, distribution, acquisition, delivery and dispensing of medications. They are not routinely involved in activities relevant to patient care, such as attending and providing their expertise during clinical rounds, supporting precision medicine innovations through understanding and using pharmacokinetics and pharmacodynamics knowledge, their critical role in immunisation programs (that would lower the need for antimicrobials by preventing certain diseases), infection control nor collecting useful data through prospective chart audits and providing feedback to clinicians. Thus, there is suboptimal professional involvement in programmes that promote the judicial use of antibiotics. The inadequate availability and accessibility of primary healthcare institutions in the SSA region is one of the reasons why individuals still approach community drug retail outlets and obtain antibiotics without a prescription.  This behaviour which is driven by poor health systems in LMICs is also compounded by weak laboratory infrastructure, limited staff capacity and training, limited or lack of availability of consumables, diagnostics and reagents, questionable quality assurance and inadequate funding.  Overall, these shortcomings limit the capacity of countries to capture AMR surveillance data which can be used to guide antimicrobial stewardship activities.

Proposed solutions: 

• Raising awareness and knowledge of pharmacy staff on AMR and their critical role in AMR containment especially through stewardship should be prioritized.
• Engaging pharmacy personnel in AMS interventions to improve antimicrobial prescribing in hospitals and curbing unregulated dispensing of antimicrobials in community pharmacies.
• Providing technical support in developing and implementation of evidence-based guidelines, delivering education and training, reviewing antimicrobial regimens for individual patients, and providing advice, and auditing antimicrobial prescribing outcomes and providing data feedback for prescribers.   
• Adopting a One-health approach that looks at the interconnectedness of human, animal and environmental ecosystems and antimicrobial use. Many of the same antibiotics are used for human and animal health.
• Integrating AMS with robust AMR surveillance systems and effective implementation of IPC will be key cost-effective strategies in combating AMR. 
• Pharmacy professional bodies getting involved in shaping and promoting best practices of pharmacists as it relates to their role in AMS, surveillance and infection control?

AMR provides a great opportunity for pharmacists in SSA and other LMICs to get more involved in clinical and public health roles. Pharmacists could play a key role in minimizing unnecessary prescribing of antimicrobials and developing local prescribing guidelines according to resistance profiles, diagnoses, and local antibiotic susceptibility patterns, working closely with clinicians and other health-care workers. Part of this can be achieved through provision of high quality and increased pharmacy education especially in clinical and community dimensions. There should be increased emphasis on inclusion of and teaching about infectious diseases, epidemics and pandemics, their management, and AMR in pharmacy curricula. Hospitals should engage pharmacists in implementing antimicrobial stewardship programmes to ensure prudent and sensible antibiotic use. The use of these approaches will add to better patient outcomes, public health and slow the emergency of AMR. It is encouraging to see a few countries in the region moving in this direction.

Dr Mirfin Mpundu is the Director of ReAct Africa and SEDRIC board member. Twitter: @MirfinM