Community pharmacists are often the first healthcare professional a patient will visit to seek advice and treatment of symptoms of cold or flu. Consumer research shows that 78 per cent of patients are likely to visit a pharmacist, and quite quickly after symptom onset. While there is a vast range of over-the-counter medicines to treat symptoms, studies have shown that viral infections such as colds and flus are among the most common reasons for patients self-using antibiotics.

Cold and flu symptoms are most likely caused by viral infections on which antibiotics have no effect. They can usually be self-managed, without seeing a doctor for prescribed medicines, if the patient has no other underlying health issues. The pharmacy team has an essential role to discourage inappropriate use of antibiotics that could contribute to antimicrobial resistance (AMR) by promoting prevention and self-care and delivering important health advice and information. Providing this information helps to manage the patient’s expectations of the normal symptom duration for self-limiting infections.

Pharmacists and their teams have a huge role to play in antimicrobial stewardship (AMS) in the area of cold and flu. A lot of patients expect an antibiotic for treatment of their symptoms and perceived respiratory tract infection. Some of the most common reasons for using antibiotics are sore throat, flu and colds.  AMS not only looks at challenging inappropriate prescribing of antimicrobials but also plays a role in the prevention of infection and promoting self-care for cold and flu, right from the initial contact with the patient.

Pharmacists are ideally placed to educate patients about the indications for use of antibiotics and the importance of avoiding their misuse and overuse. Patients should be educated on the difference between bacterial and viral infections as well as the reasons why antibiotics are not effective against viruses, which are the primary cause of the common cold and flu. Pharmacy teams can help reshape the patient’s perception of managing cold and flu symptoms. Pharmacists must encourage their teams to reinforce public health messaging around prevention of infection and self-care for cold and flu, and they must strongly discourage patients from automatically seeking antibiotics.

This message needs to begin at the start of the patient journey — at first presentation, when initiating the consultation. This can be achieved through an effective consultation, with appropriate treatment recommendations resulting in successful symptom relief.

Antimicrobial resistance

Antimicrobial resistance occurs when an antimicrobial that was previously effective, is no longer effective to treat an infection or disease caused by a microorganism. This makes infections harder to treat and increases the risk of disease spread, severe illness and death. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of it spreading to others.

Antibiotic resistance is caused by:

• Overuse of antibiotics — the more times bacteria come into contact with an antibiotic the more likely it is that the bacteria will find ways to change itself and survive;
• Bacteria growing, changing and spreading very fast — this means some antibiotics will no longer work properly for certain infections; and
• Antibiotics killing our ‘good’ bacteria as well as our ‘bad’ bacteria — this means superbugs can grow and take over.

Antimicrobial stewardship

As pharmacists we have an important role in tackling antimicrobial resistance and supporting the principles of good antimicrobial stewardship. Antimicrobial stewardship refers to a set of interventions designed to improve and measure the appropriate use of antimicrobials. Pharmacists can contribute to antimicrobial stewardship by incorporating relevant principles into their day-to-day practice to help limit the development of antimicrobial resistance.

Some examples of antimicrobial stewardship activities by pharmacists include:

• Providing advice to patients so that they have a better understanding of appropriate antimicrobial use and antimicrobial resistance;
• Providing advice to patients when they present with a self-limiting or a likely viral infection;
• Promoting vaccination for vaccine preventable diseases such as flu, COVID-19, and pneumococcal infections;
• Participating in the vaccination of preventable diseases for vaccines authorised for supply and administration by pharmacists;
• Engaging in continuing professional development relating to antimicrobial resistance, infection prevention and control and antimicrobial stewardship, including the vaccination of preventable diseases;
• Keeping up to date with current antimicrobial guidelines and advice relating to antimicrobial stewardship; and
• Checking, where possible, if antimicrobial prescriptions align with HSE antimicrobial prescribing

Educating the patient

Pharmacists are ideally placed in the community setting to help support patients to gain a better understanding of appropriate antimicrobial use and antimicrobial resistance. It is important that pharmacists provide advice when a patient presents with a self-limiting or viral infection. They can also contribute by raising awareness and maximising the uptake of vaccinations by providing the public with accurate, factual information and reassurance about vaccinations.

During consultations with the public, pharmacists and their teams should take the time to educate their patients on:

• Preventing illness;
• Explaining why antibiotics are not always prescribed;
• Show patients how to effectively manage self-limiting infections that do not require antibiotics such as cold and flu;
• Advise when to contact a doctor;
• Not asking for antibiotics to treat viral infections, including colds and flu;
• Only taking antibiotics when your GP or prescriber thinks you need them; and
• Explain the importance of antibiotic adherence and not sharing prescribed antibiotics with others.

Vaccination

Vaccines are an important tool in the fight against antimicrobial resistance. A vaccine directly blocks the transmission of pathogens that cause infections. Decreasing this transmission decreases the number of infections and reduces the chance of a pathogen mutating to a drug-resistant form. Pharmacists have an important role to play in advising and educating the public about health protection measures such as immunisation, as well as an important role in implementing the national immunisation programme and providing vaccination services. Flu vaccination is one of the most effective methods of preventing flu infection. Vaccination has been associated with reduction of risk of flu infection and transmission, hospitalisation, and risk of flu-related death in at-risk patients. As pharmacists we can help to ensure the annual flu vaccination is strongly recommended to those aged 60 and older, those at risk and children aged 2-17 years.  At-risk patients include:

• Pregnant women;
• Healthcare workers;
• Residents of nursing homes, old people’s homes, and other long-stay facilities where rapid spread is likely to follow introduction of infection;
• Carers;
• Patients with long-term health conditions such as chronic heart disease, chronic liver disease, chronic renal failure, chronic respiratory disease including COPD, Cystic fibrosis and asthma, chronic neurological disease, diabetes mellitus, Down Syndrome, morbid obesity, Haemoglobinopathies, immunosuppression due to disease or treatment; and
• People with regular contact with pigs, poultry or waterfowl.

Cold and flu treatment options

Most cold and flus can be treated at home. Patients will get better by themselves without any specific treatment. They can be advised to drink plenty of liquids, get lots of rest and eat healthily. Normal activities can be resumed once they feel well enough.

Consumer research shows that the majority of patients look to treat a cold or flu within three days and will also look for a cure all medicine for all symptoms. [insert image 2]  There are many over-the-counter medicines to help relieve cold and flu symptoms. Products range from: pain relief such as paracetamol and ibuprofen to relieve headaches and fever; decongestants containing pseudoephedrine and antihistamines to stop sneezing and a runny nose; phenylephrine to reduce swelling and pressure to alleviate sneezing and blocked, runny noses; cough suppressants such as dextromethorphan; and expectorants like guaifenesin — all can help treat cough symptoms. There is little evidence that supplements such as vitamin C, zinc, echinacea or garlic prevent colds or speed up recovery, but patients can find these helpful.

Non-pharmacological treatments can help manage symptoms, and are great for patient groups such as babies, children and pregnant women:

• Saline: Use over-the-counter saline drops, sprays and rinses to loosen up the mucus in the nostrils;
• Humidifiers: Moisten the air in the home with a humidifier. The clean, cool mist will help moisten the air and decrease the drying of nasal passages and throat; and
• Steam inhalation: The steam may help ease congestion by loosening mucus and making it easier to clear by blowing your nose.

“Consumer research shows that the majority of patients look to treat a cold or flu within three days and will also look for a cure all medicine for all symptoms.”

Identifying need for referral

Some patients may present and require referral to a GP for assessment and possible antimicrobial treatment. Pharmacists can easily determine if more serious infection is suspected, or involvement of the lower airways, which would indicate referral. When assessing patients’ presenting symptoms, pharmacists can identify red-flag symptoms:

Patients may require referral with the following:

• Sudden chest pain, shortness of breath, or difficulty breathing;
• Blood in the sputum;
• Cold, clammy, or pale and mottled skin, or the lips turn blue;
• Cold or flu symptoms worsen or do not improve within three weeks; or
• Patients with long-term conditions or with weakened immune systems.

Infection control and self-care measures

1. Washing your hands: Wash your hands frequently, especially before eating or preparing food. Also, wash your hands after using the bathroom, wiping your nose or coming into contact with someone who has a cold;
2. Avoiding touching your face: Cold viruses spread from your hands to your eyes, nose and mouth;
3. Cleaning frequently used surfaces: Viruses can live on doorknobs and other places people often touch;
4. Using hand sanitizers: When you can’t wash your hands with soap and water, use alcohol-based hand sanitizer;
5. Strengthening your immune system: Get enough sleep, eat a healthy diet and exercise so your body is ready to fight off germs; and
6. Staying home: To make sure you don’t spread the cold to others, stay home when you’re sick.