Coughs & Colds: Fighting resistance and flu

The time of year has come again when our pharmacy counters are dominated by cough, cold and flu queries. With the public being urged to visit their local community pharmacist as opposed to their GP and patients demanding faster more effective treatments, we are likely to be under more pressure than ever. However, with this predicted increase in footfall, it also presents an opportunity to focus on an issue which, if not addressed, will have major consequences: the ever growing and ever present matter of antibiotic resistance.

While the majority of coughs, colds and seasonal illnesses are caused by viruses; results published in a recent report by the World Health Organization (WHO) show that an alarming 64 per cent of those involved in the study believe that they will have a faster resolution of their illness with antibiotic treatment, despite the fact that antibiotics have no effect on viral infections. Thus, gaps in understanding, misconceptions (32 per cent of those interviewed in the WHO survey believe that when they feel better, they should stop the taking the prescribed antibiotic, as opposed to completing the course of treatment), and inappropriate prescribing have unfortunately contributed to the two thirds of the population believing this idea, leading to increased demand for treatment for even the slightest sign of symptoms, and therefore the inappropriate and overuse of antibiotics in practice has amassed to something with great implications, potentially life threatening in our near future.

Antibiotic resistance occurs when a microorganism (in most cases bacteria) becomes resistant to an antibiotic to which it was originally sensitive. The rise of antibiotic resistance is now recognised as a global health crisis, and has become one of the greatest challenges for public health today, reaching dangerously high levels across the world. It is compromising the ability to treat infectious diseases, causing them to persist for longer periods of time, increasing the risk of spread to others and additionally stalling medical advancements (despite the fact that a disturbing 64 per cent of those involved in the WHO study believed that experts in the industry would solve the problem before it becomes ‘too serious’). If antibiotics are lost, then even the simplest of infections could become life threatening once again, and as a recent report in 2014 displayed, if resistant infections are not tackled now, they could kill an extra ten million people across the world annually by 2050.

While recently there has been a push to increase the discovery of novel antibiotics, until now the focus has been on prevention rather than cure, as no new class of antibiotic has been discovered in the past 30 years. With cold and flu season imminent, it is a priority to reduce the inappropriate use of antibiotics in practice (74 per cent of antibiotics used in the UK are prescribed in general practice), and, as pharmacists, we have an important role not only in this aspect but also in patient education; as 76 per cent of WHO  study respondents believed that antibiotic resistance occurs when the body becomes resistant to antibiotics as opposed to the bacteria causing the infection, while more than 57 per cent of those involved in the survey felt that there was not much they could do to stop antibiotic resistance.

Pharmacists therefore have an important role in reducing antibiotic resistance in many aspects. Some measures in community practice include improving patient understanding and education, reducing infection incidence and optimising the use of the prescribed antibiotic treatments. Monitoring antibiotic use is also vital for common conditions such as coughs, throat, sinus or throat infections; and we need to assess is the antibiotic that has been prescribed the most appropriate for the infection according to local guidelines, is the dose, route, frequency and duration appropriate for that patient. We, as pharmacists, also need to consider that, if a patient presents a prescription that is post-dated or is presented several days or weeks after the date of issue, is the antibiotic that has been prescribed still required, or is it clinically relevant for the condition at all? Counselling is just as crucial with acute antibiotic treatment as that of chronic condition medications, such as completion of the course of prescribed treatment in order to maximise its therapeutic effect, or counselling on drug-drug interactions, particularly that of the fluoroquinolones and macrolide classes of antibiotics. Additionally, pharmacy teams alongside the pharmacist, also play a role in reducing antibiotic resistance in practice and therefore upon receipt of antibiotics prescription.

We should therefore ask three questions:

• What has the antibiotic been prescribed for?
• Are there any known allergies?
• If applicable has the patient had their flu vaccine?

Reassurance surrounding the self-limiting nature of many viral infections is of the highest importance, as is the reinforcement that antibiotics are not usually required, but that self help with over-the-counter medication, closely managing fluid intake and body temperature and bed rest are most commonly first line as these conditions resolve on their own. Some durations of the conditions commonly seen in practice are shown below, generally only if a patient’s infection persists beyond these time frames would they require referral for further examination and possibly antibiotic treatment.

Further misconceptions about coughs and colds surround the production of coloured mucus or phlegm. Many patients – and even some healthcare workers – believe that any colour other than clear would indicate an infection. However, mucus and phlegm of any colour is produced by the body as a defence mechanism against dirt, pollen or microbes and, as such, is not always a definite sign of infection. If the body is actually under attack from microbes, the immune system is capable of fighting infections and does not always need antibiotics to do so.

Despite many infections being self limiting, in a lot of circumstances antibiotics are deemed clinically appropriate and are required for therapy. One of the main reasons why patients visit their GP is at the point when their day-to-day activities or sleeping are affected by their seasonal illness or if their illness goes on longer than anticipated. This, in turn, costs GPs valuable time and NHS expenditure, and, while pharmacists are equipped with the clinical understanding surrounding these common conditions, there is very little we can do if an infection is thought bacterial, other than refer to a medical practitioner to prescribe the required course of antibiotics or treatment. This costs both GPs and patients valuable time and NHS spending; therefore, a recent pilot scheme was trialled across pharmacies in England in order to address these various issues, focusing on bacterial throat infections, and, based on the findings, it could yield an important change for the future of antibiotic prescribing within the UK.

The walk-in service encouraged sore throat sufferers to visit their pharmacist instead of their doctor for an on-the-spot test to decide if they needed antibiotics, so called ‘The Sore Throat Test and Treat Service’. The service was trialled in 35 Boots pharmacies across England and determined if the illness was caused by viral or bacterial origin. This was performed using a throat swab, which measured the sugar levels on the tongue and provided results within five minutes. If a threshold level was reached, the pharmacist was permitted to prescribe antibiotics on the spot for the patient without the need to contact the GP to make an appointment. Of the 360 patients who took part in the scheme, 36 were provided with a prescription for antibiotics: a massive reduction on what is commonly seen in practice, thus reducing GP time, inappropriate antibiotic use and also provides insight into what the future could hold for the pharmacy sector. The throat test is one of eight medical interventions being introduced to help the NHS modernise in the face of demand.

While coughs, colds and other seasonal viral or bacterial infections are general self limiting and have small risk of further complications, the same, however, cannot be said for the flu. The influenza virus is prevalent in Northern Ireland in the colder months (October to May) and in a normal flu season approximately five-ten per cent of the population can suffer from the infection. In otherwise healthy individuals, influenza is unpleasant, and generally self-limiting resolving around two to seven days; however in at-risk patients – such as those who have co-morbidities, pregnant women, infants and the elderly – the risk of serious complications as a result of the flu increases up to 18 times that of a healthy individual.

As with coughs and colds, prevention is better than the cure, so the role of the pharmacist is again education about avoidance and the most effective method to do is vaccination against the flu itself. WHO recommends that a target of 75 per cent vaccination rates should be achieved in the groups identified for administration.

Flu vaccination services have been provided for many years for patients who are over 65 or those that fall at risk from further complications. There has been an increase in the number of flu vaccinations delivered in the province in recent years, largely due to the introduction of the pharmacy flu vaccination PGD in 2013 which allows for the administration of influenza vaccines without the need for a prescription for each patient. This increased access to the flu vaccine, saving GP time, but it also extends the role of pharmacists and other healthcare professionals. However, even with the recent introduction of this PGD, there still needs to be more done in order to meet the target set out by WHO, as currently legislation within Northern Ireland permits only “medical practitioners” to provide the flu vaccination on the NHS, a definition which unfortunately does not include pharmacists.

Despite many of Northern Ireland’s community pharmacies already providing private flu vaccination services via PGD outside of the NHS, the health service within the region needs to increase public choice and capacity by offering an NHS flu vaccination service which utilises general practice surgeries and community pharmacies working together to achieve the WHO target. Legislation should be amended to facilitate the NHS to extend the scope of its vaccination services. NHS England are already developing their community pharmacy network as part of a national NHS flu vaccination service. Previous research has shown that vaccinations conducted through the community pharmacy sector actually increases vaccination uptake, and is associated with a high level of patient satisfaction. Online networks and platforms should also be utilised to allow the liaison of GPs with pharmacists in order to update medical records as to which patients have been vaccinated accordingly to optimise the service.