Researchers affiliated with the One Health Trust (OHT), the Population Council, GlaxoSmithKline, the University of Zurich, the University of Brussels, Johns Hopkins University, and the Harvard T.H. Chan School of Public Health analyzed pharmaceutical sales data from 67 countries from 2016-2023 for the effects of the COVID-19 pandemic and economic growth on human antibiotic consumption. The study provides a breakdown of global antibiotic sales in reported countries by national income level, antibiotic class, and antibiotic grouping according to the World Health Organization’s (WHO) AWaRe classification system for antibiotic stewardship and projects consumption through 2030. The study is published in the Proceedings of the National Academy of Sciences (PNAS).

The study found:

• Overall antibiotic sales increased in reporting countries from 2016-2023. Antibiotic sales in 67 reporting countries increased by 16.3 percent from 2016 to 2023, from 29.5 billion defined daily doses (DDDs) to 34.3 billion DDDs. This result reflected a 10.2 percent increase in the overall consumption rate in these countries from 13.7 to 15.2 DDDs per 1,000 inhabitants per day.
• Before the COVID-19 pandemic, antibiotic consumption rates in high-income countries were decreasing, and consumption rates in middle-income countries were increasing. From 2016-2019, antibiotic consumption rates (DDDs per 1,000 inhabitants per day) increased in middle-income countries (9.8 percent) while decreasing in high-income countries (-5.8 percent).
• The COVID-19 pandemic was significantly correlated with an overall reduction in antibiotic sales, most pronounced in high-income countries. An interrupted time series analysis showed that the onset of the COVID-19 pandemic in 2020 resulted in significantly decreased antibiotic consumption rates across income groups. The decrease was most pronounced in high-income countries, with the consumption rate falling 17.8 percent from 2019 to 2020. In 2021, lower-middle-income countries led high-income countries in antibiotic consumption rates as high-income countries experienced more sustained reductions.
• Middle-income countries experienced increased Watch antibiotic sales relative to Access antibiotic sales throughout the study period. High-income countries consumed consistently higher and overall increasing levels of Access antibiotics compared to Watch antibiotics as defined by the WHO’s AWaRe system. Middle-income countries consumed consistently higher and overall increasing Watch antibiotics relative to Access antibiotics.
• Middle-income countries experienced the largest increases in antibiotic consumption rates from 2016-2023. All five of the regions with the largest increases in their antibiotic consumption rate over the study period were made up of middle-income countries.
• By 2030, global consumption is expected to increase by 52.3 percent to 75.1 billion DDDs. Global projections based on the data from 67 countries show that by 2030, antibiotic consumption is expected to increase from 49.3 billion DDDs by 52.3 percent (uncertainty range [UR]: 22.1 to 82.6 percent) to a total of 75.1 (UR: 60.2 to 90.1) billion DDDs.

This study sheds light on recent trends in consumption across country income levels that can be used to help promote the careful use of antibiotics and other public health interventions that may reduce antibiotic consumption, such as improved infection prevention and control measures and increased childhood vaccination coverage. The study also has implications for future pandemic preparedness.

According to Dr. Eili Klein, lead author of the study and Senior Fellow at OHT, “The COVID-19 pandemic temporarily disrupted antibiotic use, but global consumption has rebounded quickly and continues to rise at an alarming rate. To address this escalating crisis, we must prioritize reducing inappropriate antibiotic use in high-income nations while making substantial investments in infrastructure in low- and middle-income countries to curb disease transmission effectively.”

“Global trends in antibiotic consumption during 2016–2023 and future projections through 2030” is available in PNAS (DOI: 10.1073/pnas.2411919121).

What is the Pharmacy First Scheme and how can pharmacies get started?

The Pharmacy First Service embraces several aspects including the emergency supply of medications after referral from NHS 111 and dealing with minor illness referrals from GPs. Probably the area that has attracted most attention is the management of seven common infections in accordance with clinical protocols and Patient Group Directions (PGDs). The PGDs now allow community pharmacists to supply antibiotics to certain patients so that uncomplicated minor infections can be treated promptly without the need to visit a GP. They represent a stepping stone towards a broader community pharmacy service, says Ms Barai.

Marketing of the new service to GPs and patients was a key element of the preparations for the Pharmacy First Service.

Practicalities – what worked well in Pharmacy First?

Ms Barai was in contact with her local GPs from an early stage.  “The fact that we’ve got good, open dialogue and good relationships with our general practice colleagues is really helping to implement the service”, she says. Her team has also made use of AccuRx software to create templates for the safety-netting information and leaflets that have to be given to patients treated under one of the seven clinical pathways. AccuRx has also been used (with patient’s permission) to look at health records when detailed medical information was required to satisfy exclusion criteria in PGDs.

Some 41 patients were referred in the first month and 10 of those met the clinical pathway gateway, says Ms Barai. For seven of these, treatment was supplied using the PGD and the remaining three were provided with support for self-care.

Pharmacy First – where is it going next?

Reflecting on what has worked well and what is needed to carry the developments forward Ms Barai advises community pharmacists to think differently about how services are organised.  For example, in her pharmacy she is training an accredited checking dispenser and has set up an appointments system – measures that will allow better organisation of time and personnel for Pharmacy First consultations.

Another important step is preparation for the arrival of the 2026 cohort of pharmacy graduates, all of whom will be independent prescribers.  These people will look for places where they can use their prescribing skills in satisfying jobs and well-developed Pharmacy First Services will contribute to an attractive working environment, she predicts.

About Reena Barai

Reena Barai started her career as a hospital pharmacist 25 years ago and then took over her family (community pharmacy) business 20 years ago. She works in the pharmacy six days a week, running the pharmacy. In addition, she is a co-founder and co-host of the Female Pharmacy Leaders Network and until recently she was the co-chair of an Integrated Neighbourhood Team. Previously  she has worked in primary care and as a GP practice pharmacist and has been a CPP tutor. She has also served as a  board member of the National Pharmacy Association and as a Committee Member of what was the Pharmaceutical Services Negotiating Committee (PSNC),  now Community Pharmacy England (CPE).

Read and watch the full series on our website or on YouTube.

Beyond the pathways

“GPs can refer patients to us under the minor illness umbrella, which includes a lot more conditions than just those seven pathways[of Pharmacy First]. So, we are seeing more things actually in pharmacy than we’ve seen before, but to be honest since the Covid pandemic that’s been happening too because people just learn to use pharmacy in a different way”, says Ms Barai.

The PGDs and the training that Ms Barai and her team have undertaken have been helpful in developing further skills to help distinguish between common, simple conditions and complex or uncommon problems. “I think what we’re developing is our own kind of pharmacy ‘radar’ and our own kind of way of understanding – you know – which patients can I help, which patients can’t I help and actually which patients could I maybe help for a few days and then see if it works but actually give them support to know how to get back into the NHS if they need to if things don’t work out”, she explains.

During a consultation one patient had said to her, “Reena you’ve been my best-kept secret for a long, long time. Whenever I’ve got health problem I can just come and talk to you”. She added that she hoped the service did not get so busy that an appointment was needed. Ms Barai says “for patients who are ‘in the know’ pharmacies are the best kept secret because we really can help people – sometimes when they don’t know what to do or we can help signpost [them] to where they may need to go. And so I think ….. there is a really important role there for pharmacy in that primary care navigation”.

GP reaction

“On the whole, the majority of my GPs have been really, really supportive. Many have said come and come and spend some time in our clinics. We’ll help you look in people’s ears to get you more comfortable with doing things like that. They want to work with us so that we make sure that they send the right patients to us and then work with us in case we need to escalate a patient back”, explains Ms Barai. There will always be practices that do not wish to participate and some that struggle to adopt the referral mechanism, she acknowledges. However, “on the whole it’s been a really positive experience”, she says.

Tips for success

The introduction of Pharmacy First Services represents a considerable change and this comes on top of a day job that is already challenging. “My message to colleagues is – think differently about the team,  think differently about your day,  think differently about the services you offer and how many of those support the actual agenda of the business. So, I’m thinking about my team – in particular I have a dispenser who I’m training up to become an accredited checking dispenser which will allow us to have a bit more free time to be able to offer these consultations. I’m thinking about my pharmacy and my day and how can we make …. Pharmacy First consultations fit into our day. So, we’ve decided to do appointment systems between 10 and 12 and then two and four”, says Ms Barai.  Pharmacists might also need to think about whether one consultation room is sufficient and whether to invest in expanding the premises, she adds.

Next steps

Pharmacy services in Scotland, Northern Ireland and Wales already deal with a wider range of conditions and Ms Barai believes that parallel developments should now take place in England.  She identifies three key considerations for ongoing development: first, there needs to be a fully integrated IT system that supports smooth working for community pharmacists and their general practice colleagues. Second, the community pharmacy sector needs time for the changes to bed in. “We need to make sure that everybody’s on board and everyone’s doing a good job and providing a good service before we …. bolt on more”, she says. Third, is preparation for the arrival of the 2026 cohort of pharmacy graduates, all of whom will be independent prescribers.  Ms Barai explains, “My biggest concern is that they’re going to come out and work in community pharmacy and they may not be able to use their skills – and if they’re not using their skills in community pharmacy …. they’re going to go [and] work somewhere else where it’s sexier and possibly easier.”  The 2026 graduates will look for places where they can use their skills in satisfying jobs “and so actually it’s in our interest to do well with Pharmacy First. It’s in our interest to do well with all the services and to really show how we can safely supply using PGDs so that we can hopefully move that to independent prescribing and support a clinical decision-making model in Community Pharmacy……. I think that would be the future because of our future workforce. We can’t afford to lose those people. ….. and if we start to lose [them] because we’re not able to offer services that match the skills of our future workforce then we’re in trouble”.

About Reena Barai

Reena Barai started her career as a hospital pharmacist 25 years ago and then took over her family (community pharmacy) business 20 years ago. She works in the pharmacy six days a week, running the pharmacy. In addition, she is a co-founder and co-host of the Female Pharmacy Leaders Network and until recently she was the co-chair of an Integrated Neighbourhood Team. Previously  she has worked in primary care and as a GP practice pharmacist and has been a CPP tutor. She has also served as a  board member of the National Pharmacy Association and as a Committee Member of what was the Pharmaceutical Services Negotiating Committee (PSNC),  now Community Pharmacy England (CPE).

Read and watch the full series on our website or on YouTube.

Briefing GPs

“This was probably the first time in my career where the GP practices were asking to talk to me. Normally I’m the one with my hand up saying, ‘Please can I come and talk to you about something?’ and this is the first time they’ve actually said, ‘Reena can you come and talk to us about Pharmacy First?’. So, that’s been really positive, really, really, encouraging”, says Ms Barai.  “I can see that general practice really want Pharmacy First to work”, she adds. If, as envisaged, the Pharmacy First Service frees up millions of GP appointments then GPs will be able to concentrate on the patients who really need their expertise. “The fact that we’ve got good, open dialogue and good relationships with our general practice colleagues is really helping to implement the service”, she says.

AccuRx

“When we were implementing this new service, we wanted to look for solutions that can make things a little bit easier for us and one of the IT softwares that we’ve been using for a long time is called AccuRx.  What we were using it for was a messaging system to our patients to tell them that their prescriptions ready or to invite them for a blood pressure check or remind them of a covid vaccine appointment and what we realised is that actually there’s more to AccuRx than we first thought”, she explains.  In fact, using AccuRx has enabled the pharmacy to do several things that underpin and enhance the services that are now being provided. For example, the team has been able to create templates for the safety-netting information and leaflets that have to be given to patients treated under one of the seven clinical pathways. This could be given during the consultation but sometimes it is helpful for patients to receive the information a few hours later when they have more time to digest it. In addition, “we’re able to use AccuRx, with the patient’s permission, to look at their health record  – and that’s really important when we’re taking important decisions to supply prescription-only medicines via Patient Group Directions”, she says. Some PGDs have long lists of exclusion criteria that require detailed medical information  and patients do not aways know the answers to these questions, so it is helpful to have access to the records in this way, she explains.

“The third thing that we’re really hoping to trial out is video consultations – that we’re able to do using AccuRx – and we feel this will be a game-changer because many pharmacies like mine only have one consultation room and actually, while we’re busy doing flu, Covid [vaccinations], hypertension, contraception and other local services plus Pharmacy First that one room is really being utilised quite a bit!”, says Ms Barai. If they were able to set up an area for video consultations that could be helpful for some patients. “We realise we can’t keep doing the things we’ve always done with the change that’s coming. We need to think differently and kind of bring [in] some digital tools to support us”, she says.

First experiences

“We saw 41 patients in the first month who were referred to us and 10 of those patients met the clinical pathway gateway”, says Ms Barai. For seven of these, treatment was supplied using the PGD but the remaining three were provided with support for self-care. This was important she says because she was able to explain that the illness was not so severe as to require antibiotic treatment but that the patient could return if symptoms worsened. Moreover, she points out, “the route to get back into pharmacy is really, really simple you just turn up or you ring. It’s not like you have to ring the next day at 8:30 in the morning try to get an appointment then they say ‘sorry we have to wait three days’ and so actually what Pharmacy First is going to create, I think, is an absolutely great way of supporting the self-care agenda.”

Ms Barai also believes that a reduction in overall prescribing of antibiotics might occur because of the Pharmacy First scheme. This could happen “because of the ease with which patients can come back if their symptoms deteriorate”. Currently this option rarely exists in general practice so patients may pressure prescribers for antibiotics or prescribers may err on the side of caution and prescribe antibiotics, for example, for young children.

About Reena Barai

Reena Barai started her career as a hospital pharmacist 25 years ago and then took over her family (community pharmacy) business 20 years ago. She works in the pharmacy six days a week, running the pharmacy. In addition, she is a co-founder and co-host of the Female Pharmacy Leaders Network and until recently she was the co-chair of an Integrated Neighbourhood Team. Previously  she has worked in primary care and as a GP practice pharmacist and has been a CPP tutor. She has also served as a  board member of the National Pharmacy Association and as a Committee Member of what was the Pharmaceutical Services Negotiating Committee (PSNC),  now Community Pharmacy England (CPE).

Read and watch the full series on our website or on YouTube.

The Pharmacy First Service embraces several aspects including the emergency supply of medications after referral from NHS 111 and dealing with minor illness referrals from GPs. Probably the area that has attracted most attention is the management of seven common infections in accordance with clinical protocols and Patient Group Directions (PGDs). The seven conditions are: acute otitis media, impetigo, infected insect bites, shingles, sinusitis, sore throat and uncomplicated urinary tract infection. Patients can be referred to the pharmacy by their GP or can self-refer and simply walk into the pharmacy.

For some years patients with minor illnesses have been encouraged to consult a pharmacist in the first instance but “there was a limit to what we could do and what we could supply to treat these patients”, says Ms Barai. It was frustrating for pharmacists to be unable to supply the required treatment and complete the episode of care, she explains. “What was actually happening was we were ….. sometimes able to offer some self-care advice, sometimes able to offer something they could buy over the counter to help relieve their symptoms but sometimes having to refer them back to the general practice to see somebody to get something prescribed”, she says.  The Pharmacy First Service was born partly in response to the problems with access to GP services post-Covid and, in particular, recognition of the need to  reduce the workload in primary care so that general practice only sees the patients that it really needs to see. Patients with simple, minor conditions or common conditions that are included in the Pharmacy First seven clinical pathways can then be seen by a community pharmacist – often closer to home and with no appointment necessary – so it’s more convenient for patients too, she explains.

Patient Group Directions (PGDs)

“The PGDs are legislation that allows the safe supply of a prescription-only medication (POM) by certain healthcare professionals and within all PGDs you’ve got inclusion criteria and exclusion criteria”, explains Ms Barai. Many community pharmacists also have independent prescribing qualifications, she notes. “I think PGDs are a great stepping stone towards what I’d love to see in community pharmacy – that …. there is an independent prescriber in every pharmacy” Such individuals should have a scope of practice that would allow them to support patients more effectively than in the past. Furthermore, integrated IT will be essential  “so that when we’re prescribing, everybody knows what we’re doing and [that] we’re doing things safely and that to me is the ultimate goal and I think that’s why Pharmacy First and the clinical pathways are really exciting. We’ve had PGDs before with vaccines and things like that but this is the first time [that] we’re really getting them at a national level for antibiotics and products like that. So, I really hope the sector embraces it. …. I’d love to see pharmacy technicians being able to use Patient Group Directions in the future as well”, she says.

Getting started

“The preparation for Pharmacy First has been quite intense”, recalls Ms Barai. Her team spent the whole of January looking at the protocols and clinical pathways, understanding the PGDs and working out how to operationalise the service. Training was high on the list “because we all felt that there were some skill gaps in our knowledge and we wanted to make sure that we were able to safely look inside somebody’s ear, for example, and feel confident of what we’re looking at”, she says. It was also important to ensure that the day-to-day running of the pharmacy was under control because “we didn’t know whether we’re going to have a queue out the door on the first day” or whether demand would be steady. “The third element was the marketing – talking to our GP colleagues, talking to our patients about this new service and making sure that they were aware of the ins and outs and …. how the service works and how people can be referred or how they can walk in to see us”, she explains.

About Reena Barai

Reena Barai started her career as a hospital pharmacist 25 years ago and then took over her family (community pharmacy) business 20 years ago. She works in the pharmacy six days a week, running the pharmacy. In addition, she is a co-founder and co-host of the Female Pharmacy Leaders Network and until recently she was the co-chair of an Integrated Neighbourhood Team. Previously  she has worked in primary care and as a GP practice pharmacist and has been a CPP tutor. She has also served as a  board member of the National Pharmacy Association and as a Committee Member of what was the Pharmaceutical Services Negotiating Committee (PSNC),  now Community Pharmacy England (CPE).

Read and watch the full series on our website or on YouTube.