Low sale of antibiotics without prescription: a cross-sectional study in Zimbabwean private pharmacies

The Extent of Antibiotic Dispensing in Self-Medication Encounters in Sudan: A Simulated Patient Study Focusing on Cefixime Sale

Background

Antibiotics play an important role in decreasing morbidity and mortality worldwide. However, inappropriate use of them by patients or healthcare professionals contributes to their resistance rendering them less efficacious. Community pharmacists (CPs) have a significant part in reducing antibiotic resistance. Therefore, this study aimed to investigate the dispensing of antibiotics without prescription in community pharmacies with an emphasis on cefixime dispensing.

Methods

A cross-sectional, simulated patient (SP) study was conducted in the Khartoum locality. A total of 238 community pharmacies were randomly chosen using simple random sampling. One scenario of uncomplicated urinary tract infection was designed, and six female pharmacy students who were trained to act as SPs presented the scenario. Descriptive statistics were applied to report the study outcomes.

Results

In the 238 pharmacy visits, at least one antibiotic was dispensed without a prescription in 69.3% of the simulated visits. Among the dispensed antibiotics, ciprofloxacin was the most dispensed antibiotic followed by cefixime representing 51.5% and 41.8%, respectively, of total dispensed antibiotics. Cefixime was dispensed as a first choice by CPs in 29% of the visits, and in the rest of the visits, only 37.3% of CPs refused to dispense cefixime after SP demand.

Conclusion

The findings revealed a high rate of antibiotics dispensing without prescription by CPs in Khartoum state, and cefixime was obtained with ease before and after the patient's demand. Urgent corrective actions such as imposing strict regulations, monitoring pharmacists' practice, and endorsing educational programs for pharmacists are needed to prevent inappropriate antibiotic dispensing practices.

The effect of a comprehensive typhoid conjugate vaccine campaign on antimicrobial prescribing in children in Harare, Zimbabwe: a mixed methods study

BACKGROUND

Vaccines prevent infections and could subsequently reduce antimicrobial use. A 1-week mass vaccination campaign was done with Typbar-TCV (Bharat Biotech, Hyderabad, India) between Feb 25 and March 4, 2019. We investigated whether this typhoid conjugate vaccine campaign could affect antimicrobial prescribing in children presenting to primary care in Harare, Zimbabwe.

METHODS

In this mixed methods study, data for acute paediatric outpatient consultations between Jan 1, 2018, and March 31, 2020, were collected from five clinics in Harare. Interrupted time series analysis was done to compare prescription data before and after the campaign. To contextualise findings, qualitative data were collected between April 20, 2021, and July 20, 2022, comprising ethnographic research (ie, workshops, surveys, observations, and interviews) in 14 clinics. Ethnographic data were used for thematic analysis. The primary outcome was monthly antimicrobial prescriptions in children aged 6 months to 15 years, normalised by the number of trauma events in all age groups.

FINDINGS

In the data collection period, 27 107 paediatric consultations were recorded. 17 951 (66·2%) of 27 107 children were prescribed antimicrobials. Despite the perceived reduction in typhoid cases and a decreasing trend in the prescription of antimicrobials commonly used to treat typhoid (ie, ciprofloxacin and azithromycin), mass vaccination with Typbar-TCV did not affect the total rate of antimicrobials (adjusted rate ratio, 1·20, 95% CI 0·70-2·05, p=0·51) or the rate of typhoid antimicrobials prescribed (0·93, 0·44-1·96, p=0·85). Unsafe water sources and insufficient diagnostic services were reported to contribute to the continued disease burden and antimicrobial prescription.

INTERPRETATION

Non-specific febrile illness caused by confirmed or suspected typhoid is a common cause of antimicrobial use in endemic areas. Although effective in preventing typhoid fever, we were unable to identify any effect of Typbar-TCV on antimicrobial prescribing. Ethnographic research showed the effect of contextual factors on antimicrobial prescribing, including concerns regarding safe water access, appropriate sewage disposal, health-care and diagnostic availability. To realise effects beyond disease burden reduction, holistic approaches addressing these concerns are needed so that the value of vaccines mitigating the effects of antimicrobial use as a driver of antimicrobial resistance is fully achieved.

FUNDING

Wellcome Trust.

TRANSLATION

For the Shona translation of the abstract see Supplementary Materials section.

Current rates of purchasing of antibiotics without a prescription across sub-Saharan Africa; rationale and potential programmes to reduce inappropriate dispensing and resistance

INTRODUCTION

Antimicrobial resistance (AMR) is a global concern. Currently, the greatest mortality due to AMR is in Africa. A key driver continues to be high levels of dispensing of antibiotics without a prescription.

AREAS COVERED

A need to document current rates of dispensing, their rationale and potential ways forward including antimicrobial stewardship programmes (ASPs). A narrative review was undertaken. The highest rates of antibiotic purchasing were in Eritrea (up to 89.2% of antibiotics dispensed), Ethiopia (up to 87.9%), Nigeria (up to 86.5%), Tanzania (up to 92.3%) and Zambia (up to 100% of pharmacies dispensing antibiotics without a prescription). However, considerable variation was seen with no dispensing in a minority of countries and situations. Key drivers of self-purchasing included high co-payment levels for physician consultations and antibiotic costs, travel costs, convenience of pharmacies, patient requests, limited knowledge of antibiotics and AMR and weak enforcement. ASPs have been introduced in some African countries along with quality targets to reduce inappropriate dispensing, centering on educating pharmacists and patients.

EXPERT OPINION

ASP activities need accelerating among community pharmacies alongside quality targets, with greater monitoring of pharmacists' activities to reduce inappropriate dispensing. Such activities, alongside educating patients and healthcare professionals, should enhance appropriate dispensing of antibiotics and reduce AMR.

Antibiotic Prescribing Practices for Treating COVID-19 Patients in Bangladesh

Although national and international guidelines have strongly discouraged use of antibiotics to treat COVID-19 patients with mild or moderate symptoms, antibiotics are frequently being used. This study aimed to determine antibiotics-prescribing practices among Bangladeshi physicians in treating COVID-19 patients. We conducted a cross-sectional survey among physicians involved in treating COVID-19 patients. During September-November 2021, data were collected from 511 respondents through an online Google Form and hardcopies of self-administered questionnaires. We used descriptive statistics and a regression model to identify the prevalence of prescribing antibiotics among physicians and associated factors influencing their decision making. Out of 511 enrolled physicians, 94.13% prescribed antibiotics to COVID-19 patients irrespective of disease severity. All physicians working in COVID-19-dedicated hospitals and 87% for those working in outpatient wards used antibiotics to treat COVID-19 patients. The majority (90%) of physicians reported that antibiotics should be given to COVID-19 patients with underlying respiratory conditions. The most prescribed antibiotics were meropenem, moxifloxacin, and azithromycin. Our study demonstrated high use of antibiotics for treatment of COVID-19 patients irrespective of disease severity and the duty ward of study physicians. Evidence-based interventions to promote judicious use of antibiotics for treating COVID-19 patients in Bangladesh may help in reducing an overuse of antibiotics.

Antimicrobial dispensing process in community pharmacies: a scoping review

Background

Antimicrobial resistance remains a major global public health concern, and antimicrobial dispensing in community pharmacies is an important factor in preventing this damage. However, the current literature focuses on the technical and attitudinal aspects related to antimicrobial dispensing, with little emphasis on the interventions provided in this service. Thus, this study aimed to determine the antimicrobial dispensing process in community pharmacies.

Methods

A scoping review was performed in September 2020 using the PubMed, EMBASE, LILACS, Web of Science, and Cochrane databases. The search terms included words related to dispensing, antibacterial agents, and pharmacies in various combinations. Two reviewers screened the titles, abstracts, and full-text articles according to the eligibility criteria, and extracted the data. The findings were presented in a descriptive form.

Results

Of the 7713 studies screened, 35 were included, of which 22 (63%) were published in Asia. Most studies followed a cross-sectional design (n = 27), and the simulated patient was the most often used method to assess the antimicrobial dispensing process (n = 22). Moreover, 31 (89%) studies investigated antimicrobial dispensing without prescription, and only four (11%) studies evaluated antimicrobial dispensing with prescription. In the 35 studies, the most frequently asked questions were about drug allergies (n = 19) and patient symptoms (n = 18), and counseling mainly focused on the side effects (n = 14), precautions (n = 14), how to take the medication (n = 12), and duration of medication use (n = 11). Another common intervention was referral (n = 15). Among clinical cases, counseling on medication use occurred often in cases of urinary tract infection (51%) and otitis media (50%).

Conclusions

Antimicrobial dispensing processes have been primarily investigated in low- and middle-income countries, with a focus on dispensing antimicrobials without prescriptions. During the dispensing process, pharmacists mostly posed minimal questions and counseling, highlighting the deficiencies that persist in this practice. Our results indicate the need for multifaceted strategies, such as implementing educational, regulatory or administrative strategies and changes in cultural background, especially in low- and middle-income countries, that aim to reduce indiscriminate use of antimicrobials. Therefore, qualifying the antimicrobial dispensing process is a fundamental factor for improving the rational use of antimicrobials and reducing microbial resistance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01157-0.

Knowledge, attitudes and practices relating to antibiotic use and resistance among prescribers from public primary healthcare facilities in Harare, Zimbabwe

Background Overuse of antibiotics is one of the main drivers for antimicrobial resistance (AMR). Globally, most antibiotics are prescribed in the outpatient setting. This survey aimed to explore attitudes and practices with regards to microbiology tests, AMR and antibiotic prescribing among healthcare providers at public primary health clinics in Harare, Zimbabwe. Methods This cross-sectional survey was conducted in nine primary health clinics located in low-income suburbs of Harare between October and December 2020. In Zimbabwe, primary health clinics provide nurse-led outpatient care for acute and chronic illnesses. Healthcare providers who independently prescribe antibiotics and order diagnostic tests were invited to participate. The survey used self-administered questionnaires. A five-point Likert scale was used to determine attitudes and beliefs. Results A total of 91 healthcare providers agreed to participate in the survey. The majority of participants (62/91, 68%) had more than 10 years of work experience. Most participants reported that they consider AMR as a global (75/91, 82%) and/or national (81/91, 89%) problem, while 52/91 (57%) considered AMR to be a problem in their healthcare facilities. A fifth of participants (20/91, 22%) were unsure if AMR was a problem in their clinics. Participants felt that availability of national guidelines (89/89, 100%), training sessions on antibiotic prescribing (89/89, 100%) and regular audit and feedback on prescribing (82/88, 93%) were helpful interventions to improve prescribing. Conclusions These findings support the need for increased availability of data on AMR and antibiotic use in primary care. Educational interventions, regular audit and feedback, and access to practice guidelines may be useful to limit overuse of antibiotics.

No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies

BACKGROUND

Non-prescription dispensing of antibiotics, one of the main sources of antibiotic misuse or over use, is a global challenge with detrimental public health consequences including acceleration of the development of antimicrobial resistance, and is facilitated by various intrinsic and extrinsic drivers. The current review aimed to systematically summarise and synthesise the qualitative literature regarding drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries.

METHODS

Four electronic databases (PubMed, CINAHL, Scopus and Google Scholar) and reference lists of the relevant articles were searched. The Joanna Briggs Institute's Critical Appraisal Checklist for qualitative studies was used to assess the quality of included studies. The enhancing transparency in reporting the synthesis of qualitative research statement was used to guide reporting of results. Data were coded using NVivo 12 software and analysed using both inductive and deductive thematic analysis.

RESULTS

A total of 23 articles underwent full text review and 12 of these met the inclusion criteria. Four main themes were identified in relation to facilitators of non-prescribed sale of antibiotics among community drug retail outlets: i) the business orientation of community drug retail outlets and tension between professionalism and commercialism; ii) customers' demand pressure and expectation; iii); absence of or a lax enforcement of regulations; and iv) community drug retail outlet staff's lack of knowledge and poor attitudes about antibiotics use and scope of practice regarding provision.

CONCLUSIONS

This review identified several potentially amendable reasons in relation to over the counter dispensing of antibiotics. To contain the rise of antibiotic misuse or over use by targeting the primary drivers, this review suggests the need for strict law enforcement or enacting new strong regulation to control antibiotic dispensing, continuous and overarching refresher training for community drug retail outlet staff about antibiotic stewardship, and holding public awareness campaigns regarding rational antibiotic use.

Community pharmacists' management of self-limiting infections: a simulation study in Akwa Ibom State, South-South Nigeria

BACKGROUND

Inappropriate use of antibiotics, especially for treatment of self-limiting infections remains one of the major drivers of antibiotic resistance (ABR). Community pharmacists can contribute to reducing ABR by ensuring antibiotics are dispensed only when necessary.

OBJECTIVE

To assess community pharmacists' management of self-limiting infections.

METHODS

A purposive sample of 75 pharmacies participated in the study. Each pharmacy was visited by an investigator and a trained simulated patient who mimicked symptoms of common cold and acute diarrhoea, respectively. Interactions between the simulated patient and pharmacist were recorded by the investigator in a data collection form after each visit. Descriptive statistical analysis was carried out. Ethics approval was obtained from the state Ministry of Health Research Ethics Committee.

RESULTS

For common cold, 68% (51/75) of pharmacists recommended an antibiotic. Azithromycin, amoxicillin/clavulanic acid, and sulphamethoxazole/trimethoprim (43%, 24%, 20%, respectively) were the most frequently dispensed agents. For acute diarrhoea, 72% (54/75) of pharmacists dispensed one antibiotic, while 15% dispensed more than one antibiotic. The most frequently dispensed agent was metronidazole (82%), which was dispensed in addition to amoxicillin or tetracycline among pharmacists who dispensed more than one agent. In both infection scenarios, advice on dispensed antibiotics was ofered in 73% and 87% of the interactions, respectively.

CONCLUSION

This study shows high rate of inappropriate antibiotics dispensing among community pharmacists. There is need for improved awareness of antibiotic resistance through continuing education and training of community pharmacists. Furthermore, the inclusion of antibiotic resistance and stewardship in undergraduate pharmacy curriculum is needed.

Non-prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African countries: a systematic review and meta-analysis

BACKGROUND

The development of antimicrobial resistance, which is partially attributable to the overuse and/or misuse of antibiotics in health care, is one of the greatest global public health challenges. In Sub-Saharan African (SSA) countries, non-prescribed dispensing of antibiotics in community drug retail outlets (CDROs) has been flagged as one of the contributing factors for the widespread misuse of antibiotics in the community.

OBJECTIVE

The current review aimed to estimate the proportion of non-prescription antibiotics requests or consultations that resulted in provision of antibiotics without a valid prescription among CDROs in SSA region, and describe the type of antibiotics dispensed.

METHODS

A literature search was conducted using PubMed, CINAHL, Scopus and Google Scholar. We also searched reference lists of relevant articles. Random effect model meta-analysis was employed to determine the pooled proportion of over the counter sale of antibiotics. Subgroup and meta-regression was undertaken to explore the potential cause of heterogeneity in effect size across studies.

RESULTS

Of 671 total citations retrieved, 23 met the inclusion criteria (seven cross-sectional questionnaire-based surveys and 16 cross-sectional client-based studies). The overall pooled proportion of non-prescription antibiotics requests or consultations that resulted in supply of antibiotics without prescription was 69% (95% CI 58-80). Upper respiratory tract infections and/or acute diarrhoea were the most frequently presented case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed antibiotics to treat those symptoms.

CONCLUSIONS

Non-prescribed dispensing of antibiotics was found to be a common practice among CDROs in several SSA countries. Ease of access to and overuse of antibiotics can potentially accelerate the emergence of resistance to antibiotics available in the region. Our review highlights the need for a stringent enforcement of existing policies and/or enacting new regulatory frameworks that would regulate antibiotic supply, and training and educational support for pharmacy personnel (e.g. pharmacists, pharmacy assistants) regarding judicious use of antibiotics and the importance of antimicrobial stewardship.

Assessment of community pharmacy management towards self-medication requests of tetracyclines for pregnant women: a simulated client study in Upper Egypt

Background Self-medication is a worldwide phenomenon of using medications without medical supervision. It is even more prevalent in low-income countries, where individuals seek community pharmacies because of accessibility and affordability. Although self-medication is associated with an increased risk of medication errors, few studies have been conducted to examine the quality of community pharmacy management towards self-medicating individuals of at-risk populations such as pregnant women. Objective We sought to investigate the quality of community pharmacies management of self-medication requests of tetracyclines for pregnant women. Setting The study was conducted in community pharmacies in Minya, Egypt. Methods A random sample of 150 community pharmacies was chosen from the urban areas of five districts of Minya, Egypt. To evaluate the actual practice, a simulated client was trained to visit pharmacies and purchase doxycycline for a pregnant woman. In a random subset of the sampled pharmacies (n = 100), interviews were conducted to evaluate pharmacy staff knowledge and attitudes regarding information gathering and dispensing practice. Main outcome measure Dispensing rate of doxycycline for pregnant women. Results From simulated client visits, almost all pharmacy staff (99.1%) dispensed doxycycline without requesting a prescription or collecting any information. About 25% of staff members did not abstain from dispensing even after knowing about pregnancy. On the other hand, most interviewed pharmacy staff (91.5%) reported that they ask about pregnancy before dispensing. Conclusion Our findings show that the current community pharmacy practice puts pregnant women at high risk of experiencing harmful self-medication outcomes. Therefore, strict legislative measures and pharmacy education programs should be considered in Egypt to lessen inappropriate dispensing rates in community pharmacies.

Rodrigues D, Figueiras A, Zapata-Cachafeiro M, Roque F, Herdeiro MT. Antibiotic Dispensation without a Prescription Worldwide: A Systematic Review

Antibiotic resistance still remains a major global public health problem and the dispensing of antibiotics without a prescription at community pharmacies is an important driver of this. MEDLINE, Pubmed and EMBASE databases were used to search and identify studies reporting the dispensing of non-prescribed antibiotics in community pharmacies or drugstores that sell drugs for human use, by applying pharmacy interviews/questionnaires methods and/or simulated patient methods. Of the 4683 studies retrieved, 85 were included, of which 59 (69.4%) were published in low-and middle-income countries. Most of the papers (83.3%) presented a percentage of antibiotic dispensing without a prescription above 60.0%. Sixty-one studies evaluated the active substance and the most sold antibiotics without a prescription were amoxicillin (86.9%), azithromycin (39.3%), ciprofloxacin (39.3%), and amoxicillin-clavulanic acid (39.3%). Among the 65 articles referencing the diseases/symptoms, this practice was shown to be mostly associated with respiratory system problems (100.0%), diarrhea (40.0%), and Urinary Tract Infections (30.8%). In sum, antibiotics are frequently dispensed without a prescription in many countries and can thus have an important impact on the development of resistance at a global level. Our results indicate the high need to implement educational and/or regulatory/administrative strategies in most countries, aiming to reduce this practice.

Sale of WHO AWaRe groups antibiotics without a prescription in Pakistan: a simulated client study

Introduction

Resistant strains of bacteria are rapidly emerging with increasing inappropriate use of antibiotics rendering them less efficacious. Self-purchasing of antibiotics particularly for viral infections is a key driver of inappropriate use, especially in lower- and middle-income countries. There is a particular issue in countries such as Pakistan. Consequently, there is a need to assess current rates of self-purchasing especially for reserve antibiotics to guide future policies.

Aims

Assess the extent of current antibiotic sales without a prescription in urban areas of Pakistan.

Methodology

A multicenter cross-sectional study was conducted in different areas of Punjab, Pakistan using Simulated Client technique. The investigators demanded different predefined antibiotics from WHO AWaRe groups without prescription. Three levels of demand were used to convince the pharmacy staff in order to dispense the antibiotic without a prescription. A data collection form was completed by simulated clients within 15 min of each visit.

Results

Overall 353 pharmacies and medical stores were visited out of which 96.9% pharmacies and medical stores dispensed antibiotics without demanding a prescription (82.7% at demand level 1 and 14.2% at demand level 2), with only 3.1% of pharmacies refusing to dispense antibiotics. The most frequently dispensed antibiotic was ciprofloxacin (22.1%). Surprisingly, even the reserve group antibiotics were also dispensed without a prescription. In only 25.2% visits, pharmacy staff guided patients about the use of antibiotics, and in only 11.0% pharmacists enquired about other medication history.

Conclusion

Currently, antibiotics are easily acquired without a legitimate prescription in Pakistan. There is a need for strict adherence to regulations combined with a multi-dimensional approach to enhance appropriate dispensing of antibiotics and limit any dispensing of WHO restricted antibiotics without a prescription.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

Antibiotic prescribing for acute uncomplicated cystitis in Lebanese community pharmacies using a simulated patient

BACKGROUND

Urinary tract infections are considered as one of the most frequent bacterial infections in the community and hospital settings. In this era of increasing antimicrobial resistance, antimicrobial stewardship has become highly important in the struggle to preserve the effectiveness of available drugs. One the main causes of antibiotic resistance is the inappropriate prescribing of antibiotics; which evidence show that community pharmacists contribute to.

OBJECTIVE

This study aims to evaluate antibiotic prescribing rate and responses of the contact persons in community pharmacies and to assess the conformity of the prescribed antibiotics with international guidelines. It also aims to evaluate the responses with sociodemographic characteristics.

METHODS

A cross-sectional, nationwide study conducted between February and May 2017 using a simulated patient case of acute uncomplicated cystitis. Two hundred fifty pharmacies were included. Descriptive data was reported for the medications prescribed, conformity, questions asked and counseling. Bivariate analysis using the Pearson chi-squared, Fisher's exact and Student's t-tests were used to identify possible factors affecting the prescribing rates and responses in community pharmacies.

RESULTS

The prescribing rate of antibiotics was 83.6% (n=209) with ciprofloxacin being the most prescribed (50.2%, n=105). The global conformity to international guidelines was 3.8% (n=8) with the highest conformity rate for the antibiotic choice (91.4%, n=191). Counseling about what to do in case symptoms persist was 12.8% (n=32) and that of non-pharmacological management was 53.6% (n=134). Male participants (88.1%) had a higher prescribing rate than female participants (77.6%) (p<0.05). The number of questions asked was higher in pharmacists and in female participants (p<0.05). Other results showed non-significant differences in diagnosis, antibiotic prescribing, conformity rates, referral rates and counseling points between the pharmacists and assistants.

CONCLUSIONS

The high antibiotic prescribing rate in Lebanese community pharmacies is alarming and calls for action. This should be tackled by legislative bodies, which should enforce laws that restrict such practices.

Exposure assessment of the consumers living in Mount Lebanon directorate to antibiotics through medication and red meat intake: A cross-sectional study

Background and Aim

The misuse and abuse of antibiotics by human and in animal production are leading to serious threats to global health. This study aimed to assess the dietary exposure of Lebanese consumers to antibiotic residues from the consumption of meat and compare it to that from medication intake.

Materials and Methods

Beef samples (n=61) were collected and analyzed for penicillin residues using enzyme-linked immunosorbent assay and high-performance liquid chromatography. A cross-sectional study recruited 500 participants living in Mount Lebanon, using an interviewer-based questionnaire. The dietary exposure assessment was calculated following the tiered assessment approach.

Results

The results showed that only 44% of the participants reported using antibiotic on doctor's prescription. Participants with good antibiotic knowledge (6-7/7) are significantly less likely to change antibiotic during treatment and would better use them as compared to those with lower knowledge (p=0.000). Those with lower education and monthly household income are more likely to improperly use antibiotics as compared to those with higher education and income. Penicillin -containing antibiotics were among the most used medications. On the other hand, the prevalence of penicillin residues in the meat samples was 21.3%, though none was above the maximum residue level. The dietary exposure to penicillin through meat consumption was equivalent to 88.3%, 31.9%, and 5.7% of the acceptable daily intake, using Tier 1, 2, and 3 approaches, respectively. Males, single, obese participants, and those with household income below 999,000 Lebanese pound were significantly more exposed to penicillin as compared to other participants due to their high meat consumption.

Conclusion

These findings will provide insight into designing future targeted awareness interventions and adapted policies as efforts toward improving rational use and intake of antibiotics for preventing the development of antibiotic resistance.

A systematic review of the use of simulated patient methodology in pharmacy practice research from 2006 to 2016

OBJECTIVES

Simulated patient (SP) methodology (mystery shopping) is used increasingly to assess quality of pharmacy services, and evaluate impact of interventions. Our objective was to review papers reporting on the use of SP methodology in pharmacy practice research 2006-2016 in community pharmacies worldwide.

METHODS

We searched EMBASE and MEDLINE for papers reporting on the use of mystery shopping in pharmacy settings, using a wide range of terms for SPs, based on previous review. We removed irrelevant papers, duplicates, papers not written in English, and review papers and reviewed remaining papers. Two reviewers carried out data abstraction, using the same tool as the previous review and inserting data into Excel, focusing on how the SP methodology is used.

KEY FINDINGS

A total of 148 papers from 52 countries from all regions of the world were included in the review. A wide range of terms described the method, and simulated patient was the most common (49 papers). Most studies were cross-sectional (124), and most investigated only community pharmacies (115). The most common aim was to evaluate some aspect of pharmacists' or other staff's advice and counselling (94). Number of visits is 2-7785. Many papers did not cover details, such as number of visits planned, and carried out, scenario used, training and background of SPs, and ethical approval for the study.

CONCLUSIONS

The use of SP methodology has increased substantially in the field of pharmacy over the past decade. This is a useful method in a wide range of countries and settings. Greater detail is required in reporting.

Knowledge, attitude, and practice of self-medication with antibiotics among community residents in Addis Ababa, Ethiopia

Background: Self-medication with antibiotics, which may cause significant antibiotic resistance, is predominant in developing countries. The aim of this study is to assess the knowledge, attitude, and practice of self-medication with antibiotics among community residents in Ethiopia. Methods: A cross-sectional study design was conducted from June to August 2017. Knowledge-Attitude-Practice questionnaire was developed and distributed to eligible household respondents in Addis Ababa and its surrounding area. Logistic regression analysis was used to identify factors associated with self-medication with antibiotics. Results: Among the 605 invited participants, 595 respondents were participated in this study (response rate = 98.3%) and 67.3% of the respondents had reported self-medication with antibiotics in the past 6 months. The median score of knowledge about antibiotics was 3 (Inter quarter range: 2-4) of a maximum possible score of 6 and the median score of attitude was 19 (Inter quarter range: 16-22) from a maximum of 29. Self-medication with antibiotics was significantly associated with age, educational status, and average monthly income of the communities. Conclusions: Respondents have inadequate knowledge and inappropriate practice toward rational use of antibiotics. Policies such as restricting the purchase of antibiotics without a medical prescription and educating appropriate use of antibiotics are urgently needed.

Quality of Community Pharmacy Practice in Antibiotic Self-Medication Encounters: A Simulated Patient Study in Upper Egypt

Antibiotic misuse, either by patients or healthcare professionals, is one of the major contributing factors to antimicrobial resistance. In many Middle Eastern countries including Egypt, there are no strict regulations regarding antibiotic dispensing by community pharmacies. In this study, we examined antibiotic dispensing patterns in Egyptian community pharmacies. About 150 community pharmacies were randomly chosen using convenience sampling from the five most populous urban districts of Minia Governorate in Egypt. Two simulated patient (SP) scenarios of viral respiratory tract infection requiring no antibiotic treatment were used to assess the actual antibiotics dispensing practice of. Face-to-face interviews were then conducted to assess the intended dispensing practice. Descriptive statistics were calculated to report the main study outcomes. In 238 visits of both scenarios, 98.3% of service providers dispensed amoxicillin. Although stated otherwise in interviews, most pharmacy providers (63%) dispensed amoxicillin without collecting relevant information from presenting SPs. Findings showed high rates of antibiotic misuse in community pharmacies. Discrepancies between interviews and patient simulation results also suggest a practice‒knowledge gap. Corrective actions, whether legislation, enforcement, education, or awareness campaigns about antibiotic misuse, are urgently needed to improve antibiotic dispensing practices in Egyptian community pharmacies.

"You could lose when you misuse" - factors affecting over-the-counter sale of antibiotics in community pharmacies in Saudi Arabia: a qualitative study

Background

The sale of antibiotics without a prescription poses a global public health concern. Antibiotics dispensed without a prescription are largely recognised as a cause of antibiotic misuse and overuse which may result in antibiotic resistance, recurrent infection, increased cost and adverse effects of treatment. There have been no qualitative studies to explore the reasons for over-the-counter (OTC) sale of antibiotics, despite the fact that non-prescription sale of antibiotics are increasing in Saudi Arabia.

Methods

Qualitative interviews were conducted with community pharmacists living in the Eastern Province of Saudi Arabia using face-to-face, open-ended questions. Interviews were audio-recorded and transcribed verbatim. The interview transcripts were analysed using thematic analysis and NVivo 10 software.

Results

All participants declared that antibiotics were frequently sold without a medical prescription on an OTC basis. The main reasons for OTC sale of antibiotics were found to be related to the ease of access to community pharmacies compared to other healthcare services, expertise and knowledge of pharmacists and patients’ trust, misconceptions and inappropriate practices of the public towards antibiotic use, customer pressure, pharmacists’ need to ensure business survival and weak regulatory enforcement mechanism. These are presented in more detail below by using illustrative quotes from participants’ transcripts.

Conclusions

The non-prescribed sale of antibiotics is still a common practice in Saudi Arabia, despite being a problem. The results of this study highlight the need to design interventions to promote rational use of antibiotics.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3753-y) contains supplementary material, which is available to authorized users.

Investigating knowledge regarding antibiotics and antimicrobial resistance among pharmacy students in Sri Lankan universities

Background

Antimicrobial resistance (AMR) is a major challenge for global health care. Pharmacists play a key role in the health care setting to help support the quality use of medicines. The education, training, and experiences of pharmacy students have the potential to impact on patterns of antibiotic use in community and hospital settings. The aim of this study was to investigate antibiotic use, knowledge of antibiotics and AMR among undergraduate pharmacy students at Sri Lankan universities and to compare this between junior and senior pharmacy student groups.

Methods

A cross-sectional study was conducted at the six universities in Sri Lanka that offer pharmacy undergraduate programmes. All pharmacy students in each university were invited to participate in this study using a self-administered questionnaire with ethics approval. The study instrument comprised five major sections: demographic information, self-reported antibiotic use, knowledge of antibiotic uses in human health, knowledge of AMR and antibiotic use in agriculture. Descriptive data analyses were conducted and Chi-squared analysis was used to explore associations between different variables and level of pharmacy education.

Results

Four hundred sixty-six pharmacy students completed the questionnaire. A majority of participants (76%) reported antibiotic use in the past year. More than half (57%) of the junior pharmacy students incorrectly indicated that antibiotic use is appropriate for the management of cold and flu conditions. Senior pharmacy students (n = 206) reported significantly better antibiotic knowledge than junior students (n = 260), p < 0.05. Overall pharmacy students showed good understanding of AMR and their knowledge level increased as the year of pharmacy study increased.

Conclusions

This study found that pharmacy students commonly report using antibiotics. Junior students report some misconceptions about antimicrobials. 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.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3107-8) contains supplementary material, which is available to authorized users.

Pattern of medication selling and self-medication practices: A study from Punjab, Pakistan

BACKGROUND

Access to medicines without prescription is a major contributing factor for self-medication practices. This study was designed to examine the ratio of non-prescribed medicines sales and self-medication practices in Punjab, Pakistan. This study also evaluates the reasons for self-medication within its communities.

METHODS

An observational study was conducted in 272 systemically selected pharmacies to analyze medicines-related sales, with or without prescription. A cross-sectional survey was performed between June 2015 and November 2016. Consumers were interviewed about their self-medication practices.

RESULTS

Of the pharmacies surveyed, 65.3% participated in the study. A total of 4348 medicines were purchased for self-medication by 3037 consumers (15.2% of all study participants), of which 873 (28.7%) participated in an interview. Majority (81.2%) medicine purchaser, (90.9%) interview participants, and (59.4%) drug users were male. On average, each community pharmacy sold 7.9 medicines without prescription each day, to an average of 5.5 customers. Many participants (28.9%) had matriculation in their formal education. The medicines most often sold for self-medication were analgesics and antipyretics(39.4%). More than 25% of participants reported fever symptoms and 47.8% assumed their illness was too trivial to consult a doctor. Media advertisements were the most common source of information for participants (46.7%).

CONCLUSION

Many types of medicines were often sold without prescription from community pharmacies. Self-medication was common practice for a wide range of illnesses. Pakistan also needs effective implementation of policies to monitor medication sales. Public education about rational medication and limits to advertising medicine are very necessary.

Non-prescription sale and dispensing of antibiotics in community pharmacies in Zambia

BACKGROUND

In Zambia, antibiotics are categorized as prescription-only medicines. Antibiotics dispensed without a prescription pose a public health threat, which is a concern. Consequently, the aim is to ascertain the extent of non-prescription sales and dispensing of antibiotics in community pharmacies in Zambia.

METHODS

The practice of non-prescription sale and dispensing were assessed in 73 randomly selected community retail pharmacies, using a structured interviewer-administered questionnaire with simulated case scenarios.

RESULTS

Majority (97%) stated that clients frequently requested non-prescribed antibiotics. Interviewees usually asked clients' indications (94%), counselled on dosing (96%) and suggested changes to antibiotic choices (97%). All (100%) dispensed non-prescribed antibiotics. Commonly dispensed antibiotics included amoxicillin (52%), cotrimoxazole (25%) and metronidazole (23%). Non-prescription sale and dispensing of antibiotics was significantly associated with interviewees' professional qualification in four out of five simulations.

CONCLUSION

Non-prescription sale and dispensing of antibiotics is widespread in Zambia. Concerted public and professional interventions are needed coupled with stronger regulatory enforcement to reduce this.

Prevalence and Predictors of Self-Medication with Antibiotics in Al Wazarat Health Center, Riyadh City, KSA

Background. Antibiotics are responsible for most dramatic improvement in medical therapy in history. These medications contributed significantly to the decreasing mortality and morbidity when prescribed based on evidence of microbial infection. Objective. The aim of this study was to determine the prevalence and predictors of self-prescription with antibiotics in Al Wazarat Health Center, Riyadh City, Kingdom of Saudi Arabia. Material and Methods. Cross-sectional study was conducted in Al Wazarat Health Center between February 2014 and November 2014. Respondents were randomly selected using a multistage clustered random sampling technique. Data was entered into SPSS version 21 and analyzed. Descriptive statistics and multiple logistic regression models were applied. Results. A total of 681 patients have participated in this study with a response rate of 92%. The prevalence of self-prescription with antibiotics in Al Wazarat Health Center was 78.7%. Amoxicillin was the most used self-prescribed antibiotic with prevalence of (22.3%). Friend advice on self-prescription of antibiotics use (p = 0.000) and pharmacy near to the participants (p = 0.002) were the most common predictors for self-prescription with antibiotics. Conclusion. The level of self-prescribing antibiotics is relatively high among participants. Health education on the appropriate use of antibiotics is highly recommended. The proper use of treatment guidelines for antibiotic therapy will significantly reduce self-prescription with antibiotics.

Inappropriate Use of Antibiotics and Its Associated Factors among Urban and Rural Communities of Bahir Dar City Administration, Northwest Ethiopia

Background

Inappropriate use of antibiotics in the community plays a role in the emergence and spread of bacteria resistant to antibiotics which threatens human health significantly. The present study was designed to determine inappropriate use of antibiotics and its associated factors among urban and rural communities of Bahir Dar city administration.

Methods

A comparative cross sectional study design was conducted in urban and rural kebeles of Bahir Dar city administration from February 1 to March 28, 2014. A total of 1082 participants included in the study using a systematic random sampling technique. Data was collected using pre-tested and structured questionnaire. Data was coded and entered into SPSSS version 16 for statistical analysis. Bivariate and multivariate logistic regression model were used to identify factors associated with inappropriate use of antibiotics.

Results

Inappropriate use of antibiotics was 30.9% without significant difference between urban (33.1%) and rural (29.2%) communities. From the inappropriate antibiotic use practice, self-medication was 18.0% and the remaining (12.9%) was for family member medication. Respiratory tract symptoms (74.6%), diarrhea (74.4%), and physical injury/wound (64.3%) were the three main reasons that the communities had used antibiotics inappropriately. Factors associated with inappropriate use of antibiotics were low educational status, younger age, unsatisfaction with the health care services, engagement with a job, and low knowledge on the use of antibiotic preparations of human to animals.

Conclusions

Inappropriate use of antibiotic exists in the study area with no significant difference between urban and rural communities. The study indicated an insight on what factors that intervention should be made to reduce inappropriate use of antibiotics in the community. Interventions that consider age groups, educational status, common health problems and their jobs together with improvement of health care services should be areas of focus to reduce inappropriate use of antibiotics.

A review of the provision of appropriate advice by pharmacy staff for self-medication in developing countries

BACKGROUND

Patients in developing countries often prefer to self-medicate via community pharmacies. Pharmacy staff are therefore in a strategic position to optimize the health of the public by providing appropriate advice to patients who self-medicate.

OBJECTIVE

To determine the proportion of pharmacy staff who provide appropriate advice when handling self-medication requests in developing countries.

METHOD

A literature search was undertaken via MEDLINE, EMBASE, CINAHL Plus, Web of Science and International Pharmaceutical Abstracts. Studies that reported on the proportion of pharmacy staff providing appropriate advice when handling self-medication requests in developing countries were included. The appropriateness of advice was determined by each author's definition in the original studies.

RESULTS

Twenty-eight studies met the inclusion criteria. There were variations in methods, scenarios, how the authors reported and defined appropriate advice, and study populations. The proportion of pharmacy staff providing appropriate advice varied widely from 0% to 96%, with a minority providing appropriate advice in 83% of the scenarios performed.

CONCLUSION

There was considerable variation in results, with the majority of studies reporting that inappropriate advice was provided by pharmacy staff when handling self-medication requests in developing countries. Consistent and robust methods are required to provide comparisons across practice settings. There is also a need to identify contributing factors to poor provision of advice for developing intervention strategies for practice improvement.

Antibiotic sales in rural and urban pharmacies in northern Vietnam: an observational study

Background

The irrational overuse of antibiotics should be minimized as it drives the development of antibiotic resistance, but changing these practices is challenging. A better understanding is needed of practices and economic incentives for antibiotic dispensing in order to design effective interventions to reduce inappropriate antibiotic use. Here we report on both quantitative and qualitative aspects of antibiotic sales in private pharmacies in northern Vietnam.

Method

A cross-sectional study was conducted in which all drug sales were observed and recorded for three consecutive days at thirty private pharmacies, 15 urban and 15 rural, in the Hanoi region in 2010. The proportion of antibiotics to total drug sales was assessed and the revenue was calculated for rural and urban settings. Pharmacists and drug sellers were interviewed by a semi-structured questionnaire and in-depth interviews to understand the incentive structure of antibiotic dispensing.

Results

In total 2953 drug sale transactions (2083 urban and 870 rural) were observed. Antibiotics contributed 24% and 18% to the total revenue of pharmacies in urban and rural, respectively. Most antibiotics were sold without a prescription: 88% in urban and 91% in rural pharmacies. The most frequent reported reason for buying antibiotics was cough in the urban setting (32%) and fever in the rural area (22%). Consumers commonly requested antibiotics without having a prescription: 50% in urban and 28% in rural area. The qualitative data revealed that drug sellers and customer’s knowledge of antibiotics and antibiotic resistance were low, particularly in rural area.

Conclusion

Over the counter sales of antibiotic without a prescription remains a major problem in Vietnam. Suggested areas of improvement are enforcement of regulations and pricing policies and educational programs to increase the knowledge of drug sellers as well as to increase community awareness to reduce demand-side pressure for drug sellers to dispense antibiotics inappropriately.

Improving pharmacy staff knowledge and practice on childhood diarrhea management in Vietnam: are educational interventions effective?

BACKGROUND

In many developing countries, private pharmacies play an important role in providing health information and services to local communities for common health issues. The aim of this study was to ascertain medium-term impact of educational interventions on knowledge and practice of pharmacy staff regarding management of childhood diarrhea in Vietnam.

METHODS

This was a pre- and post-intervention study with 32 and 44 months difference from the time of the baseline survey to the conclusion of trainings and the time of the end-line survey, respectively. Interventions included in-class training for pharmacy staff, printed materials at the pharmacy, and supportive supervision. Knowledge/reported practice and actual practice of pharmacy staff were measured before and after interventions.

RESULTS

After interventions, significant improvements (p<0.01) were observed for all indexes related to pharmacy staff's knowledge about childhood diarrhea; for instance, 31% and 60% of surveyed staff asked about weight of the child and accompanying symptoms of childhood diarrhea, respectively, an increase from 11% and 45% at the baseline. Oral rehydration solution (ORS) was the most frequently reported product recommended (97% to 99%), but probiotics and antidiarrheals were the products most frequently prescribed at pharmacies. Public health facilities remained the preferred choice for referrals from pharmacies, but the use of private clinics was increasing. Consultations and advice provided to caregivers also improved, but considerable gaps between knowledge and actual practice of staff in real pharmacy settings remained.

CONCLUSIONS

Educational interventions were effective in improving pharmacy staff knowledge and practice regarding management of childhood diarrhea. Knowledge and actual practice of staff in real pharmacy settings did not always correlate; there is need for a stronger regulatory and law enforcement system. Interventions to improve pharmacy practice in developing countries should be focused, comprehensive, and evidence-based.

A review of the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries

BACKGROUND

Currently, no review has been completed regarding the information-gathering process for the provision of medicines for self-medication in community pharmacies in developing countries.

OBJECTIVE

To review the rate of information gathering and the types of information gathered when patients present for self-medication requests.

METHODS

Six databases were searched for studies that described the rate of information gathering and/or the types of information gathered in the provision of medicines for self-medication in community pharmacies in developing countries. The types of information reported were classified as: signs and symptoms, patient identity, action taken, medications, medical history, and others.

RESULTS

Twenty-two studies met the inclusion criteria. Variations in the study populations, types of scenarios, research methods, and data reporting were observed. The reported rate of information gathering varied from 18% to 97%, depending on the research methods used. Information on signs and symptoms and patient identity was more frequently reported to be gathered compared with information on action taken, medications, and medical history.

CONCLUSION

Evidence showed that the information-gathering process for the provision of medicines for self-medication via community pharmacies in developing countries is inconsistent. There is a need to determine the barriers to appropriate information-gathering practice as well as to develop strategies to implement effective information-gathering processes. It is also recommended that international and national pharmacy organizations, including pharmacy academics and pharmacy researchers, develop a consensus on the types of information that should be reported in the original studies. This will facilitate comparison across studies so that areas that need improvement can be identified.

Examining characteristics, knowledge and regulatory practices of specialized drug shops in Sub-Saharan Africa: a systematic review of the literature

BACKGROUND

Specialized drug shops such as pharmacies and drug shops are increasingly becoming important sources of treatment. However, knowledge on their regulatory performance is scarce. We set out to systematically review literature on the characteristics, knowledge and practices of specialized drug shops in Sub-Saharan Africa.

METHODS

We searched PubMed, EMBASE, WEB of Science, CAB Abstracts, PsycINFO and websites for organizations that support medicine policies and usage. We also conducted open searches using Google Scholar, and searched manually through references of retrieved articles. Our search included studies of all designs that described characteristics, knowledge and practices of specialized drug shops. Information was abstracted on authors, publication year, country and location, study design, sample size, outcomes investigated, and primary findings using a uniform checklist. Finally, we conducted a structured narrative synthesis of the main findings.

RESULTS

We obtained 61 studies, mostly from Eastern Africa, majority of which were conducted between 2006 and 2011. Outcome measures were heterogeneous and included knowledge, characteristics, and dispensing and regulatory practices. Shop location and client demand were found to strongly influence dispensing practices. Whereas shops located in urban and affluent areas were more likely to provide correct treatments, those in rural areas provided credit facilities more readily. However, the latter also charged higher prices for medicines. A vast majority of shops simply sold whatever medicines clients requested, with little history taking and counseling. Most shops also stocked popular medicines at the expense of policy recommended treatments. Treatment policies were poorly communicated overall, which partly explained why staff had poor knowledge on key aspects of treatment such as medicine dosage and side effects. Overall, very little is known on the link between regulatory enforcement and practices of specialized drug shops.

CONCLUSIONS

Evidence suggests that characteristics and practices of specialized drug shops differ across rural and urban locations, and that these providers are highly responsive to client demand. However, there is a dearth in knowledge on how regulatory enforcement influences their characteristics and practices, and what strategies can be employed to strengthen the governance of the retail pharmaceutical sector.

Non-prescription antimicrobial use worldwide: a systematic review

In much of the world antimicrobial drugs are sold without prescription or oversight by health-care professionals. The scale and effect of this practice is unknown. We systematically reviewed published works about non-prescription antimicrobials from 1970-2009, identifying 117 relevant articles. 35 community surveys from five continents showed that non-prescription use occurred worldwide and accounted for 19-100% of antimicrobial use outside of northern Europe and North America. Safety issues associated with non-prescription use included adverse drug reactions and masking of underlying infectious processes. Non-prescription use was common for non-bacterial disease, and antituberculosis drugs were available in many areas. Antimicrobial-resistant bacteria are common in communities with frequent non-prescription use. In a few settings, control efforts that included regulation decreased antimicrobial use and resistance. Non-prescription antimicrobial and antituberculosis use is common outside of North America and northern Europe and must be accounted for in public health efforts to reduce antimicrobial resistance.

Do Indonesian community pharmacy workers respond to antibiotics requests appropriately?

OBJECTIVE

To quantify antibiotics sales without a prescription and to explore provision of patient assessment and medicine information related to antibiotics requested with or without a prescription in Surabaya community pharmacies.

METHODS

Scenarios of specific product requests (ciprofloxacin tablets and tetracycline capsules) and a request of amoxicillin dry syrups based on a new prescription were presented by simulated patients to 105 purposively selected pharmacies. Data were recorded by simulated patients after their purchase of each product. They documented the questions asked in patient assessment, the content of information given, recommendations provided and pharmacy workers' characteristics.

RESULTS

Antibiotics requested without a prescription were sold in 80 (91%) pharmacies. Information related to ciprofloxacin tablets and tetracycline capsules was only provided when requested by the simulated patient in 69% and 68% of pharmacies for the two scenarios, respectively. Very few pharmacies assessed patients. Medicine information on indication, dosing, duration and direction for use was provided more frequently in all cases. Medicine information was more likely to be given when a new prescription of amoxicillin dry syrups being presented. Overall, the majority of sampled pharmacies responded antibiotics requests inappropriately.

CONCLUSION

Inappropriate responses to antibiotic requests with or without a prescription remain an issue in Indonesia with pharmacy workers often failing to adequately assess patients. The illegality of delivering antibiotics without a prescription is of a considerable concern. Therefore, strategies to control antibiotics dispensing in community pharmacies should be seriously considered.

"Practical knowledge" and perceptions of antibiotics and antibiotic resistance among drugsellers in Tanzanian private drugstores

Background

Studies indicate that antibiotics are sold against regulation and without prescription in private drugstores in rural Tanzania. The objective of the study was to explore and describe antibiotics sale and dispensing practices and link it to drugseller knowledge and perceptions of antibiotics and antibiotic resistance.

Methods

Exit customers of private drugstores in eight districts were interviewed about the drugstore encounter and drugs bought. Drugsellers filled in a questionnaire with closed- and open-ended questions about antibiotics and resistance. Data were analyzed using mixed quantitative and qualitative methods.

Results

Of 350 interviewed exit customers, 24% had bought antibiotics. Thirty percent had seen a health worker before coming and almost all of these had a prescription. Antibiotics were dispensed mainly for cough, stomachache, genital complaints and diarrhea but not for malaria or headache. Dispensed drugs were assessed as relevant for the symptoms or disease presented in 83% of all cases and 51% for antibiotics specifically. Non-prescribed drugs were assessed as more relevant than the prescribed. The knowledge level of the drugseller was ranked as high or very high by 75% of the respondents. Seventy-five drugsellers from three districts participated. Seventy-nine percent stated that diseases caused by bacteria can be treated with antibiotics but 24% of these also said that antibiotics can be used for treating viral disease. Most (85%) said that STI can be treated with antibiotics while 1% said the same about headache, 4% general weakness and 3% 'all diseases'. Seventy-two percent had heard of antibiotic resistance. When describing what an antibiotic is, the respondents used six different kinds of keywords. Descriptions of what antibiotic resistance is and how it occurs were quite rational from a biomedical point of view with some exceptions. They gave rise to five categories and one theme: Perceiving antibiotic resistance based on practical experience.

Conclusions

The drugsellers have considerable "practical knowledge" of antibiotics and a perception of antibiotic resistance based on practical experience. In the process of upgrading private drugstores and formalizing the sale of antibiotics from these outlets in resource-constrained settings, their "practical knowledge" as well as their perceptions must be taken into account in order to attain rational dispensing practices.

Survey of non-prescribed use of antibiotics for children in an urban community in Mongolia

OBJECTIVE

to estimate the prevalence and identify the determinants of non-prescription use of antibiotics for children in Mongolia.

METHODS

a community-based cross-sectional survey was undertaken in 10 subdistricts in Ulaanbaatar, Mongolia's capital. We used a structured questionnaire to collect data from a random sample of 540 households with at least one child aged < 5 years. Logistic regression was used to identify factors associated with antibiotic misuse.

FINDINGS

of 503 participating caregivers, 71% were mothers; 42.3% (95% confidence interval, CI: 37.8-46.9) of caregivers had used non-prescribed antibiotics to treat symptoms in their child during the previous 6 months. Symptoms commonly treated were cough (84%), fever (66%), nasal discharge (65%) and sore throat (60%). Amoxicillin was the most commonly used antibiotic (58%). Pharmacies were the main source (86%) of non-prescribed antibiotics. Non-prescribed use by mothers was significantly associated with keeping antibiotics at home (odds ratio, OR: 1.7; 95% CI: 1.04-2.79), caregiver self-medication (OR: 6.3; 95% CI: 3.8-10.5) and older child's age (OR: 1.02; 95% CI: 1.01-1.04). Caregivers with a better knowledge of antibiotics were less likely to give children non-prescribed antibiotics (OR: 0.7; 95% CI: 0.6-0.8).

CONCLUSION

the prevalence of non-prescribed antibiotic use for young children was high in Ulaanbaatar. Because such use leads to the spread of bacterial resistance to antibiotics and related health problems, our findings have important implications for public education and the enforcement of regulations regarding the sale of antibiotics in Mongolia.

Informal sector providers in Bangladesh: how equipped are they to provide rational health care?

In Bangladesh, there is a lack of knowledge about the large body of informal sector practitioners, who are the major providers of health care to the poor, especially in rural areas, knowledge which is essential for designing a need-based, pro-poor health system. This paper addresses this gap by presenting descriptive data on their professional background including knowledge and practices on common illnesses and conditions from a nationwide, population-based health-care provider survey undertaken in 2007. The traditional healers (43%), traditional birth attendants (TBAs, 22%), and unqualified allopathic providers (village doctors and drug sellers, 16%) emerged as major providers in the health care scenario of Bangladesh. Community health workers (CHWs) comprised about 7% of the providers. The TBAs/traditional healers had <5 years of schooling on average compared with 10 years for the others. The TBAs/traditional healers were professionally more experienced (average 18 years) than the unqualified allopaths (average 12 years) and CHWs (average 8 years). Their main routes of entry into the profession were apprenticeship and inheritance (traditional healers, TBAs, drug sellers), and short training (village doctors) of few weeks to a few months from semi-formal, unregulated private institutions. Their professional knowledge base was not at a level necessary for providing basic curative services with minimum acceptable quality of care. The CHWs trained by the NGOs (46%) were relatively better in the rational use of drugs (e.g. use of antibiotics) than the unqualified allopathic providers. It is essential that the public sector, instead of ignoring, recognize the importance of the informal providers for the health care of the poor. Consequently, their capacity should be developed through training, supportive supervision and regulatory measures so as to accommodate them in the mainstream health system until constraints on the supply of qualified and motivated health care providers into the system can be alleviated.

The quality of private pharmacy services in low and middle-income countries: a systematic review

AIM OF THE REVIEW

In low and middle income countries private pharmacies are considered a valuable resource for health advice and medicines in many communities. However the quality of the service they provide has often been questioned and is unclear. This paper reviews the evidence regarding the quality of professional services from private pharmacies in low and middle-income countries.

METHOD

A literature search (computer and hand searches) was undertaken to identify all studies which included an assessment of the quality of some aspect of private pharmacy services in low and middle income countries.

RESULTS

30 studies were identified which spanned all regions in the developing world. These included 9 which examined the scope and/or quality of a range of professional services, 14 which assessed the quality of advice provided in response to specific symptoms and 7 which investigated the supply of medicines without a prescription. A range of methods were employed, in particular, questionnaire surveys with staff and/or clients and assessment of practice using simulated client methodology. Whilst many authors identified a potential for pharmacies to contribute more effectively to primary health care, virtually all studies identified deficiencies in the quality of current professional practice. In particular authors highlighted the lack of presence of pharmacists or other trained personnel, the provision of advice for common symptoms which was not in accordance with guidelines and the inappropriate supply of medicines.

CONCLUSION

The evidence-base regarding the quality of professional services from pharmacies in low and middle income countries is limited, but indicates that standards are often deficient. If pharmacists are to contribute effectively to health care, the barriers to the provision of higher quality care and ways in which these might be overcome must be identified and examined.

Antimicrobial resistance: international control strategies, with a focus on limited-resource settings

Microorganisms resistant to multiple anti-infective agents have increased worldwide. These organisms threaten both optimal care of patients with infection as well as the viability of current healthcare systems. In addition, antimicrobials are valuable resources that enhance both prevention and treatment of infections. As resistance diminishes this resource, it is a societal goal to minimise resistance and therefore to reduce forces that produce resistance. This review considers strategies for minimising resistance that are needed at several different levels of responsibility, ranging from the patient care provider to international agencies. It then describes responses that might be appropriate according to the resources available for control, focusing on limited-resource settings. Antimicrobial resistance represents an international concern. Response to this problem demands concerted efforts from multiple sectors both in developed and developing countries, as well as the strengthening of multinational/international partnerships and regulations. Both medical and public health agencies should be in the forefront of these efforts.

Malaria treatment in the retail sector: knowledge and practices of drug sellers in rural Tanzania

BACKGROUND

Throughout Africa, the private retail sector has been recognised as an important source of antimalarial treatment, complementing formal health services. However, the quality of advice and treatment at private outlets is a widespread concern, especially with the introduction of artemisinin-based combination therapies (ACTs). As a result, ACTs are often deployed exclusively through public health facilities, potentially leading to poorer access among parts of the population. This research aimed at assessing the performance of the retail sector in rural Tanzania. Such information is urgently required to improve and broaden delivery channels for life-saving drugs.

METHODS

During a comprehensive shop census in the districts of Kilombero and Ulanga, Tanzania, we interviewed 489 shopkeepers about their knowledge of malaria and malaria treatment. A complementary mystery shoppers study was conducted in 118 retail outlets in order to assess the vendors' drug selling practices. Both studies included drug stores as well as general shops.

RESULTS

Shopkeepers in drug stores were able to name more malaria symptoms and were more knowledgeable about malaria treatment than their peers in general shops. In drug stores, 52% mentioned the correct child-dosage of sulphadoxine-pyrimethamine (SP) compared to only 3% in general shops. In drug stores, mystery shoppers were more likely to receive an appropriate treatment (OR = 9.6), but at an approximately seven times higher price. Overall, adults were more often sold an antimalarial than children (OR = 11.3). On the other hand, general shopkeepers were often ready to refer especially children to a higher level if they felt unable to manage the case.

CONCLUSION

The quality of malaria case-management in the retail sector is not satisfactory. Drug stores should be supported and empowered to provide correct malaria-treatment with drugs they are allowed to dispense. At the same time, the role of general shops as first contact points for malaria patients needs to be re-considered. Interventions to improve availability of ACTs in the retail sector are urgently required within the given legal framework.