Inappropriate Antibiotic Dispensing Research Articles

Implementing Community Antimicrobial Stewardship Model in Nigeria: Lessons Learned from AMS Outpatient Setting among Community Pharmacists/Patent and Proprietary Medicine

Antimicrobial resistance (AMR) is a growing global concern primarily driven by the overuse and inappropriate utilization of antimicrobials. In Nigeria, AMR is exacerbated by the routine sale of prescription-only medicines, including antimicrobials, without proper monitoring. The National Action Plan for Antimicrobial Resistance (2017-2022) highlighted widespread inappropriate antibiotic use, with significant proportions obtained without prescriptions. Antimicrobial stewardship (AMS) in outpatient settings is a novel concept in Nigeria. This interventional study sought to contribute to the reduction of inappropriate antibiotic dispensing and use in community/outpatient settings in Nigeria, focusing on enhancing the skills and capacity of improved rational antibiotic therapy among community pharmacists and Patent and Proprietary Medicine Vendors (PPMVs), with the sole aim of improving patient health outcomes. The CAMS interventional study involves education, quality improvement capacity building, patient empowerment, and a multifaceted AMS strategy. Results from the CFID’s CAMS model indicated a significant improvement in the rational dispensing and use of antimicrobials within the intervention group, emphasizing the effectiveness of CAMS. Notable variations in post-visit actions between the intervention and monitoring groups further support the positive impact of the intervention. Variation in attitudes towards sharing of antibiotic to friends and relatives was reduced among the intervention group, offering clear understanding into the potential impact of CFID AMS outpatient setting (CAMS) intervention. The study’s conclusion underscores the pivotal role of implementing AMS in outpatient and community settings such as the CAMS interventional model in improving antibiotic-related practices in both urban and rural communities in Nigeria, emphasizing its relevance and impact.

Effective Programmes to Reduce Inappropriate Dispensing of Antibiotics in Community Pharmacies Especially in Developing Countries

Effective Programmes to Reduce Inappropriate Dispensing of Antibiotics in Community Pharmacies Especially in Developing Countries

Antibiotic-Dispensing Patterns and Awareness of Anti-microbial Resistance Among the Community Pharmacists in South-Central India.

Background Anti-microbial resistance (AMR) is an ongoing epidemic contributing to extremely high healthcare costs and hospital admissions. Inappropriate dispensing of antibiotics is one of the root causes of AMR. Hence, our study aimed to assess antibiotic-dispensing patterns and AMR awareness among pharmacists from South-Central India. Methodology This cross-sectional observational study was conducted over a period of two months from June to July 2023. The pharmacies in urban and semi-urban areas of coastal and central districts of the Indian state of Andhra Pradesh were surveyed. Data were collected using a predesigned questionnaire for antibiotic-dispensing patterns and awareness of AMR, as approved by the Institutional Ethics Committee of Aster Ramesh Hospital, Vijayawada, India. The data were collected and analyzed descriptively by cross-tabulation. Results Among the 389 pharmacies that responded, 78% (n = 303) were dispensing antibiotics over the counter (OTC) and 22% (n = 86) were dispensing antibiotics only for valid prescriptions. It was found that antibiotics were dispensed OTC for common ailments such as the common cold, cough, sore throat, nasal congestion, fever, diarrhea, and urinary tract infections. As per the World Health Organization-recommended Access, Watch, and Reserve (AWaRe) criterion, antibiotics under the Watch group such as macrolides (azithromycin), fluoroquinolones (ciprofloxacin, norfloxacin, levofloxacin, and ofloxacin) and third-generation cephalosporins (cefixime and cefpodoxime) were found to be widely dispensed OTC. The most common antibiotics dispensed OTC were azithromycin (54.1%), amoxicillin (47.5%), cefixime (40%), amoxicillin + clavulanic acid (15.2%), ofloxacin (13.5%), ciprofloxacin (10%), and doxycycline (6.6%). Among the OTC dispensers, 82.5% (n = 250) were unaware of AMR and 17.5% were partially aware. However, 57% (n = 49) were unaware of AMR and its effects, in pharmacies dispensing antibiotics for valid prescriptions. Conclusion Our findings aggregateevidence on the alarming trend of inappropriate antibiotic-dispensing patterns that may further exacerbate AMR. Strict regulatory enforcement and periodical monitoring to regulate antibiotic dispensing to control unethical dispensing are inevitably necessary.

Inappropriate antibiotic dispensing and use: A public health threat in the Philippines

Inappropriate antibiotic dispensing and use: A public health threat in the Philippines

Barriers and facilitators to adherence to national drug policies on antibiotic prescribing and dispensing in Bangladesh

BackgroundThe National Drug Policy in Bangladesh prohibits the sale and distribution of antibiotics without prescription from a registered physician. Compliance with this policy is poor; prescribing antibiotics by unqualified practitioners is common and over-the-counter dispensing widespread. In Bangladesh, unqualified practitioners such as drug shop operators are a major source of healthcare for the poor and disadvantaged. This paper reports on policy awareness among drug shop operators and their customers and identifies current dispensing practices, barriers and facilitators to policy adherence.MethodsWe conducted a qualitative study in rural and urban Bangladesh from June 2019 to August 2020. This included co-design workshops (n = 4) and in-depth interviews (n = 24) with drug shop operators and customers/household members, key informant interviews (n = 12) with key personnel involved in aspects of the antibiotic supply chain including pharmaceutical company representatives, and model drug shop operators; and a group discussion with stakeholders representing key actors in informal market systems namely: representatives from the government, private sector, not-for-profit sector and membership organizations.ResultsBarriers to policy compliance among drug shop operators included limited knowledge of government drug policies, or the government-led Bangladesh Pharmacy Model Initiative (BPMI), a national guideline piloted to regulate drug sales. Drug shop operators had no clear knowledge of different antibiotic generations, how and for what diseases antibiotics work contributing to inappropriate antibiotic dispensing. Nonetheless, drug shop operators wanted the right to prescribe antibiotics based on having completed related training. Drug shop customers cited poor healthcare facilities and inadequate numbers of attending physician as a barrier to obtaining prescriptions and they described difficulties differentiating between qualified and unqualified providers.ConclusionAwareness of the National Drug Policy and the BPMI was limited among urban and rural drug shop operators. Poor antibiotic prescribing practice is additionally hampered by a shortage of qualified physicians; cultural and economic barriers to accessing qualified physicians, and poor implementation of regulations. Increasing qualified physician access and increasing training and certification of drug shop operators could improve the alignment of practices with national policy.

Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study

IntroductionThe aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia.MethodsStandardised patients (SPs) made a...

Community Pharmacy Personnel Understanding of Antibiotic Dispensing in Eastern Nepal.

BackgroundCommunity pharmacies are easily accessible outlets providing medicines to the general public in Nepal, but it is known that irrational dispensing of antibiotics from such outlets contributes to antimicrobial resistance.ObjectiveTo assess the understanding of community pharmacy personnel around antibiotic-dispensing in Eastern Nepal and the relationship between this understanding and their personal characteristics.MethodsA cross-sectional survey was conducted on 312 pharmacy personnel working in community pharmacies of three districts within Eastern Nepal using a self-administered questionnaire. Descriptive statistics were used to analyze participants’ characteristics and their understanding of antibiotic dispensing. The relationships between their understanding of antibiotic dispensing and their characteristics were determined using Chi-square tests.ResultsMost of the pharmacy personnel considered that dispensing antibiotics without a valid prescription is a problem (76.9%), and that it would not be legal to do so (86.9%). In the survey, 34.9% of participants agreed that they had dispensed antibiotics without prescription, and 26.9% disagreed with the assertion that inappropriate dispensing of antibiotics could promote antimicrobial resistance. Most (94.5%) reported that they would advise patients to follow their antibiotic dosage regimen, but 34.3% reported that they believed antibiotics to reduce pain and inflammation. Bivariate analysis showed that the level of understanding about antibiotic indication was significantly associated with age (p<0.001), work experience (p<0.001) and qualifications (p=0.017) of the pharmacy personnel. Work experience and qualifications also had significant but independent relationships with the level of understanding that irrational dispensing of antibiotics promotes antimicrobial resistance (p=0.018 and p=0.004) and is on the need for patient follow-up after dispensing antibiotics (p<0.001 and p=0.042).ConclusionThe understanding of community pharmacy personnel about antibiotic dispensing in Eastern Nepal requires significant improvement. Degree of understanding of some aspects of antibiotic dispensing was influenced by age, work experience and qualifications.

Factors associated with inappropriate dispensing of antibiotics among non-pharmacist pharmacy workers.

Pharmacies are a primary source of healthcare services in low and middle income countries, especially where patient to physician ratio is low. Due to the wide variability in the training of pharmacy workers, inappropriate antibiotic dispensing is common, which increases the risk of poor therapeutic outcomes and antibiotic resistance. This study aims to understand the factors that drive the inappropriate dispensing of antibiotics among pharmacy workers in Bahawalpur, Pakistan. In this qualitative study, the data were collected from the pharmacy workers through semi-structured interviews. A two-step sampling procedure, including purposive and convenient sampling techniques, was adopted to recruit the study participants. The sample size was determined by applying the saturation point criteria. All interviews were audio recorded and transcribed verbatim. The data were analysed to draw conclusions using the inductive thematic analysis approach. A total of 16 in-depth interviews were conducted. Data analysis yielded four themes and 18 subthemes. Under-dispensing and dispensing of antibiotics without need were reported. Lack of knowledge of dispensers, false feeling of being qualified, social acceptance, customer demands, public beliefs, high consultation fees of doctors, expensive diagnostic tests, economic influences and profit maximization were the main factors associated with the inappropriate dispensing of antibiotics. Multiple pharmacy worker (non-pharmacist) level factors that may lead to the inappropriate dispensing of antibiotics were identified in this study. There is a dire need for the training of pharmacy workers and supervision of their dispensing practices. Strict enforcement of legislation is required to restrict the irrational use of antibiotics in Pakistan.

Invisible medicine sellers and their use of antibiotics: a qualitative study in Cambodia

BackgroundGlobal attention to antimicrobial resistance has increased interest in tackling the widespread inappropriate dispensing of antibiotics by informal, for-profit healthcare providers (HCPs). We provide new evidence on an understudied group...

Antibiotic dispensing following pediatric visits in the US emergency departments and outpatient settings from 2006 to 2016.

This study measured rates and trends in antibiotic dispensing for emergency department (ED) and outpatient visits by age groups. This retrospective analysis used data from the National Institutes of Health Collaboratory Distributed Research Network. The analysis included children (aged > 3 months to <12 years) and adolescents (aged 12 to <19 years) with or without an antibiotic dispensed within 3 days following visits for infectious diagnoses occurring from 2006 to 2016, with no antibiotic fills 90 days prior. Diagnoses were classified as: 1) respiratory tract infections (RTIs) for which antibiotics are mostly indicated; 2) RTIs for which antibiotics are mostly not indicated; 3) respiratory conditions for which antibiotics are never indicated; 4) infectious conditions beyond RTIs regardless of antibiotic indication. The largest annual decrease in any dispensed antibiotics (5% per year) was seen in ED visits for not indicated RTIs and never indicated respiratory conditions (incidence rate ratio [IRR] 0.95, 95% confidence interval [CI] 0.95‐0.96). In outpatient settings, a 2% per year decrease was seen for not indicated RTIs and never indicated respiratory conditions (IRR 0.98, 95% CI 0.98‐0.98). Broad‐spectrum antibiotics had a 1% per year increase in outpatient settings for mostly indicated RTIs (IRR 1.01, 95% CI 1.01‐1.01). Compared with adolescents, broad‐spectrum antibiotic dispensing rates and trends were consistently higher for children regardless of diagnosis or care setting. Using national claims data, this real‐world analysis found uneven decreases in potentially inappropriate antibiotic dispensing, suggesting the need for antibiotic stewardship interventions to become more common in outpatient settings.

Community pharmacy staff\u2019s response to symptoms of common infections: a pseudo-patient study

BackgroundInappropriate over-the-counter supply of antibiotics in pharmacies for common infections is recognised as a source of antibiotic misuse that can worsen the global burden of antibiotic resistance.ObjectivesTo assess responses of community pharmacy staff to pseudo-patients presenting with symptoms of common infections and factors associated with such behaviour.MethodsA cross-sectional pseudo-patient study was conducted from Jan-Sept 2017 among 242 community pharmacies in Sri Lanka. Each pharmacy was visited by one trained pseudo-patient who pretended to have a relative with clinical symptoms of one of four randomly selected clinical scenarios of common infections (three viral infections: acute sore throat, common cold, acute diarrhoea) and a bacterial uncomplicated urinary tract infection. Pseudo-patients requested an unspecified medicine for their condition. Interactions between the attending pharmacy staff and the pseudo-patients were audio recorded (with prior permission). Interaction data were also entered into a data collection form immediately after each visit.ResultsIn 41% (99/242) of the interactions, an antibiotic was supplied illegally without a prescription. Of these, 66% (n = 65) were inappropriately given for the viral infections. Antibiotics were provided for 55% of the urinary tract infections, 50% of the acute diarrhoea, 42% of the sore throat and 15% of the common cold cases. Patient history was obtained in less than a quarter of the interactions. In 18% (44/242) of the interactions staff recommended the pseudo-patient to visit a physician, however, in 25% (11/44) of these interactions an antibiotic was still dispensed. Pharmacy staff advised the pseudo-patient on how to take (in 60% of the interactions where an antibiotic was supplied), when to take (47%) and when to stop (22%) the antibiotics supplied. Availability of a pharmacist reduced the likelihood of unlawful antibiotic supply (OR = 0.53, 95% CI: 0.31–0.89; P = 0.016) but not appropriate practice.ConclusionsIllegal and inappropriate dispensing of antibiotics was evident in the participating community pharmacies. This may be a public health threat to Sri Lanka and beyond. Strategies to improve the appropriate dispensing practice of antibiotics among community pharmacies should be considered seriously.

Community Pharmacists’ Knowledge, Practices and Perceptions on Antibiotic Use and Resistance: A Cross-Sectional, Self-Administered Questionnaire Survey, in Guediawaye and Pikine, Senegal

Background: Antibiotic resistance is a threat to global health. Community pharmacists are among the most accessible health professionals. Therefore, their role in improving antibiotic use and subsequently in fighting resistance is crucial. The objective of this study was to evaluate community pharmacists’ knowledge, practices and perceptions on antibiotic use and resistance. Methods: We conducted a cross-sectional study in community pharmacies located in the departments of Guediawaye and Pikine, Senegal. The study took place between November 2017 and February 2018. A total of 121 community pharmacies were located. In each of them, we planned to include one pharmacist. A self-administered questionnaire was used. The data were analyzed using Epi Info 7. The analysis was descriptive. Variables were expressed as number (n) and percentage (%). Results: The response rate was 75.2%. The majority mistakenly thought that antibiotics are always effective against sore throat (64.8%), bronchitis (51.6%), paronychia (72.5%) and dental caries (65.9%). Most respondents knew that self-medication (96.7%), poor treatment compliance (94.5%), inappropriate antibiotic dispensing (79.1%), inappropriate antibiotic prescribing (85.7%) were causes of resistance. Further, causes such as poor hand hygiene and lack of immunization were cited by 9.9% and 6.6% of participants. Moreover, 25.2% knew that third-generation cephalosporins, macrolides and quinolones are critically important antibiotics. In addition, 96.7% and 90.2% said to dispense antibiotics without a prescription and to contact prescribers in case of doubt about the reliability of an antibiotic prescription, respectively. The majority was of the opinion that some antibiotic prescriptions were inadequate (29.7%) and that the consumption of antibiotics was high (92.3%). Conclusion: This study showed a lack of knowledge among community pharmacists practicing in Guediawaye and Pikine towards antibiotic use and resistance. Therefore, it is necessary to sensitize them. Further studies should be conducted to better understand the beliefs and behavior of community pharmacists regarding antibiotic use and resistance.

What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India

ObjectivesThere are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings....

Determinants of antibiotic dispensing without a medical prescription: a cross-sectional study in the north of Spain.

ObjectivesAntibiotic resistance is a major public health concern and is greatly exacerbated by inappropriate antibiotic use at a community level. The aim of this study was to ascertain which attitudes of community pharmacists were related to inappropriate antibiotic dispensing.MethodsWe conducted a cross-sectional study of community pharmacists in a region situated in northern Spain (n = 393). Personal interviews were conducted using a self-administered questionnaire. The degree of agreement with each item of knowledge and attitude was measured using an unnumbered, horizontal visual analogue scale, with replies being scored from 0 (total disagreement) to 10 (total agreement). The data were analysed using logistic regression.ResultsOf the total of 286 pharmacists (72.8%) who completed the questionnaire, 185 (64.7%) acknowledged having undertaken dispensing of antibiotics without a medical prescription (DAwMP). Attitudes such as patient complacency, external responsibility, indifference and insufficient knowledge were shown to be related to DAwMP. In contrast, no association was found with any of the pharmacists' personal or professional traits.ConclusionsThis study confirms that, albeit unlawful, DAwMP is a common practice in Spanish pharmacies. DAwMP was seen to be usually associated with some of the attitudes evaluated.

Irrational use of antibiotics and role of the pharmacist: an insight from a qualitative study in New Delhi, India

The overall volume of antibiotic consumption in the community is one of the foremost causes of antimicrobial resistance. In developing countries like India, pharmacists often dispense 'prescription-only' drugs, like antibiotics, to patients who do not have a prescription. Not much data is available regarding detailed information on behaviour of antibiotic use by community pharmacists which is of particular significance to develop a suitable and sustainable intervention programme to promote rational use of antibiotics. A qualitative study was conducted to understand the dispensing practices and behaviour of community pharmacists to develop policy interventions that would improve the use of antibiotics at the community level. Focus group discussions (FGDs) were held for five municipal wards of Delhi with retail pharmacists, public sector pharmacists and the office bearers of pharmacists' associations. Data on antibiotic use and resistance were collected earlier from these five wards. FGDs (n = 3 with 40 pharmacists) were analysed through grounded theory. Four broad themes identified were as follows: prescribing and dispensing behaviour; commercial interests; advisory role; and intervention strategies for rational use of antibiotics. FGDs with pharmacists working in the public sector revealed that, besides the factors listed above, overstock and near-expiry, and under-supply of antibiotics promoted antibiotic misuse. Suggestions for interventions from pharmacists were the following: (i) education to increase awareness of rational use and resistance to antibiotics; (ii) involving pharmacists as partners for creating awareness among communities for rational use and resistance to antibiotics; (iii) developing an easy return policy for near-expiry antibiotics in public sector facilities; and (iv) motivating and showing appreciation for community pharmacists who participate in intervention programmes. Inappropriate antibiotic dispensing and use owing to commercial interests and lack of knowledge about the rational use of antibiotics and antibiotic resistance were the main findings of this in-depth qualitative study. Community pharmacists were willing to participate in educational programme aimed at improving use of antibiotics. Such programmes should be initiated within a multidisciplinary framework including doctors, pharmacists, social scientists, government agencies and non-profit organizations.

Pathways for Inappropriate Dispensing of Antibiotics for Rhinosinusitis: A Randomized Trial

We evaluated the extent of and factors that determine the inappropriate use of antibiotics that are obtained without a physician's prescription. Ninety-eight Greek pharmacists were visited by actress-researchers who played clients requesting antibiotics without a physician's prescription. Pharmacists were randomly challenged in a scenario that involved simulated cases of acute uncomplicated rhinosinusitis with either low fever (38.5 degrees C) or high fever (40 degrees C). Antibiotics were offered by 34 (69%) of 49 pharmacists who were presented with the high-fever scenario and by 42 (86%) of 49 pharmacists who were presented with the low-fever scenario (risk difference, 16.3%; P = .05). Thirty-two (65%) and 35 (71%) pharmacists in the high- and low-fever study arms, respectively, agreed to sell the actress-researchers broad-spectrum antibiotics. Only 28 (57%) and 17 (35%) pharmacists, respectively, recommended that the patient visit a physician (P = .03). Inappropriate recommendations regarding antibiotic use were very common in the studied setting. Antibiotics were more likely to be offered to persons who did not have a prescription when they were less likely to be clinically indicated.