Antimicrobial resistance and pharmacy students in Sri Lanka and Australia

Abstract

This thesis opens with background information about the research presented in this thesis focussing on antimicrobial resistance (AMR) as a global challenge, contributing factors for the development and spread of AMR, the World Health Organization (WHO) Global Action Plan on AMR, the pharmacists’ role in guiding the appropriate use of antibiotics and the importance of education in addressing AMR. Furthermore, this introduction chapter describes the aims of the research presented in this thesis and provides an overview of this thesis (Chapter 1). The next chapter presents a systematic review of studies investigating the non-prescription sales of antimicrobial agents in developing countries. The review found that antimicrobials were able to be purchased without a prescription in 28 developing countries across Asia, Africa, South America, Europe and the Middle East. Contributing factors for non-prescription sales of antimicrobials were poor medicines regulations, lack of available suitably qualified pharmacists, commercial pressures on pharmacy staff, consumer demand, inappropriate prescribing practices and a lack of awareness of AMR. Together, these factors contribute to the development and spread of AMR. Importantly, this review identified the paucity of qualified and trained pharmacy staff at community pharmacies as an important contributing factor for these inappropriate sales (Chapter 2). The next chapter presents a narrative review that explores the pharmacists’ role in the appropriate use of antibiotics and how this role can be enhanced to help address the challenge of AMR in developing countries. Studies from developed countries have demonstrated that improved patient outcomes are achieved when pharmacists’ roles are enhanced within the healthcare system, when they are recognised as part of the healthcare team to provide advice on the rational and safe use of medicines, and university curricula and continuing professional education provide theoretical and practical knowledge and skills regarding the quality use of medicines. In addition, antimicrobial stewardship involving pharmacists should be established in hospitals to ensure judicious and appropriate antimicrobial use (Chapter 3). Both these reviews highlight the importance of relevant education and training to produce effective pharmacists who support and promote appropriate antibiotic use in the community and hospital settings. Chapter 4 investigates antibiotic use, knowledge of antibiotics and AMR among undergraduate pharmacy students at Sri Lankan universities and compares junior and senior pharmacy student groups. This study found that pharmacy students in Sri Lankan universities commonly report using antibiotics and entry-level students hold some misconceptions about antibiotics. A comparison between junior and senior pharmacy students suggests that pharmacy education is associated with improved understanding of appropriate antibiotic use and AMR among undergraduate pharmacy students in Sri Lanka (Chapter 4). Chapter 5 describes knowledge about antibiotics and AMR among Sri Lankan undergraduate students of various healthcare fields: pharmacy and the Allied Health Sciences (AHS) of nursing, radiography and medical laboratory sciences. In this study pharmacy students demonstrated better knowledge and understanding regarding antibiotics utilisation than AHS students (Chapter 5). The next chapter describes antibiotic use, knowledge of antibiotics and AMR among pharmacy students at Australian universities. This chapter also discusses comparative data regarding antibiotic knowledge between junior and senior pharmacy student groups. Moreover, this study found that pharmacy students of Australian universities commonly report using antibiotics and some inappropriate antibiotic use was identified among junior pharmacy students. In line with other studies in this thesis, pharmacy education was associated with an improved understanding of appropriate antibiotic use and AMR among pharmacy students in Australia (Chapter 6). Chapter 7 compared usage and knowledge regarding antibiotics and AMR among undergraduate pharmacy students in a developing country, Sri Lanka and a developed country, Australia. Antibiotic use was highly prevalent among undergraduate pharmacy students in both countries and some misconceptions about antibiotics and a lower level of knowledge of AMR was observed among Sri Lankan undergraduate pharmacy students. These results are useful to identify gaps in pharmacy education and to inform interventions to improve pharmacists’ education and training on antibiotics and AMR (Chapter 7). As an extension of the previous studies, the next chapter proposes an optimal AMR curriculum for pharmacy students and practicing pharmacists in Sri Lanka to improve knowledge regarding antibiotics and AMR. This has the potential to increase the appropriate use of antibiotics in Sri Lanka and we recommend that this module to be incorporated into the pharmacy curriculum in Sri Lankan universities. Furthermore, this module can be used as a continuous professional development programme for practicing pharmacists in Sri Lanka (Chapter 8). Chapter 9 presents a narrative review describing strategies that need to be implemented to improve appropriate antibiotic dispensing practices in Sri Lanka. This review identified that multi-faceted approach incorporating enforcement of existing medicines regulations, education and training of pharmacy staff, consumer awareness of appropriate antibiotic use and implementation of antimicrobial stewardship program are required to improve appropriate dispensing practices in Sri Lanka (Chapter 9). Chapter 10 describes the need to strengthen the role of pharmacists in Sri Lanka. This chapter emphasises the crucial need for the qualified trained pharmacist to become more integrated member of Sri Lankan healthcare team in order to achieve greater improvement in antibiotics usage and AMR and more positive health outcomes in all Sri Lankans (Chapter 10). The next chapter describes some insights regarding the need to reinforce AMR education in pharmacists of developing countries (Chapter 11). The last chapter summarises research presented in this thesis and provides recommendations for future research (Chapter 12).