Economic and social drivers of antibiotic dispensing practices among community pharmacies in Nepal

Drivers of antimicrobial resistance within the communities of Nepal from One Health perspective: a scoping review

Background

A major driver of antimicrobial resistance (AMR) is the inappropriate use of antimicrobials. At the community level, people are often engaged in behaviors that drive AMR within human, animal, and environmental (One Health) impacts. This scoping review consolidates research to determine (a) the community's knowledge, attitudes, and practices around AMR; (b) existing community-based interventions; and (c) barriers and enablers to addressing AMR in Nepal.

Methods

This scoping review follows the Joanna Briggs Institute scoping review methodology. Literature indexed in PubMed, Scopus, CINAHL, Global Index Medicus, HINARI-SUMMON, Embase (Ovid), Global Health (Ovid), CAB Abstracts (Ovid), Web of Science, and Google Scholar between January 2000 and January 2023 were reviewed for inclusion. Articles were included in the review if they considered the issues of AMR at the community level in Nepal; this excluded clinical and laboratory-based studies. A total of 47 studies met these criteria, were extracted, and analyzed to consolidate the key themes.

Results

A total of 31 (66%) articles exclusively included human health; five (11%) concentrated only on animal health; no studies solely focused on environmental aspects of AMR; and the remaining studies jointly presented human, animal, and environmental aspects. Findings revealed inadequate knowledge accompanied by inappropriate practice in both the human and animal health sectors. Four community interventions improved knowledge and practices on the appropriate use of antimicrobials among community people. However, various social and economic factors were found as barriers to the appropriate use of antimicrobials in the community.

Conclusion

Community engagement and One Health approaches could be key tools to improve awareness of AMR and promote behavioral change related to AM use in communities, as current studies have revealed inadequate knowledge alongside inappropriate practices shared in both human and animal health sectors.

Systematic review registration

DOI: 10.17605/OSF.IO/FV326.

Trends and seasonal variation of antibiotic consumption by community residents in Hefei, China, 2012-2016

OBJECTIVES

The aim of this study was to evaluate the trends and seasonal variations of antibiotic consumption by community residents in Hefei, China, over a 5-year period.

STUDY DESIGN

This was an ecological study.

METHODS

Data on antibiotic consumption by community residents in Hefei between 2012 and 2016 were collected from the Hefei Center for Disease Control and Prevention. Statistical analysis was carried out using Microsoft Excel 2021, SPSS 26.0 and R4.1.3. An interrupted time series (ITS) analysis was modelled to assess the impact of policies on antibiotic consumption trends.

RESULTS

Amoxicillin and cephalosporins accounted for 63.64% and 30.48%, respectively, of the total defined daily dose per 1000 inhabitant-days (DID) of antibiotics in 2016. The total consumption of antibiotics decreased from 6.92 DID in 2012 to 5.61 DID in 2016 (P_trend = 0.017). Seasonal analysis showed an average of 34.24% antibiotic consumption in the winter over the 5 years. The equation constructed by the ITS analysis was Y = 5.530 + 0.323X1 - 7.574X2 - 0.323X3 + ε.

CONCLUSION

Between 2012 and 2016, overall antibiotic consumption by community residents in Hefei decreased significantly. The impact of antibiotic policies, implemented between 2011 and 2013, started to appear in 2014 when the consumption of antibiotics decreased. This study has important policy implications for the use of antibiotics at the community level. Further studies on the trends of antibiotic consumption are required, and strategies should be designed to promote appropriate use of antibiotics.

A Formative Assessment of Antibiotic Dispensing/Prescribing Practices and Knowledge and Perceptions of Antimicrobial Resistance (AMR) among Healthcare Workers in Lahore Pakistan

(1) Background: Antimicrobial resistance causes significant disease burden in low- and middle-income countries. The objective of this paper is to describe antibiotic dispensing/prescribing practices and underlying factors associated with these practices among community-based healthcare workers. (2) Methods: Cross-sectional survey data were collected from private and public health facilities in 14 union councils, Lahore Pakistan. Respondents included physicians, nurses, lady health workers/volunteers, midwives, pharmacy and medicine shop employees, and medical technicians. Descriptive and bivariate analysis are used to present the data; (3) Results: 177 respondents completed the survey. In terms of weekly dispensing of antibiotics, the most common were Amoxicillin/Augmentin (2.3 [SD 1.5]), Cefixine (2.4 [SD 1.6]), and Azithromycin (2.5 [SD 2.1]). For children, antibiotics were more likely to be prescribed/dispensed for sore throat (54.3%/95) and diarrhea (48.9%/86). For adults, antibiotics were more likely to be prescribed/dispensed for sore throat (67.0%/118), diarrhea (59.7%/105) and burning sensation when urinating (55.7%/176). In total, 55.4% of respondents stated that they have sold partial antibiotic courses to patients/customers. A total of 44.6% of respondents incorrectly answered that antibiotics could be used for viral infections; (4) Conclusions: Data from this study and similar research emphasize the urgent need to implement community-based stewardship programs for all healthcare workers.

Antimicrobial Use and Management of Childhood Diarrhea at Community Drug Retail Outlets in Eastern Ethiopia: A Matched Questionnaire-Based and Simulated Patient-Case Study

Introduction

Antimicrobial agents have saved millions of lives worldwide. However, inappropriate use has become a global concern leading to the emergence and spread of antimicrobial resistance (AMR). In this regard, the dispensing practices of pharmacy professionals in the community drug retail outlets (CDROs) plays a central role. Therefore, this study was aimed to assess the knowledge and dispensing practices of pharmacy professionals in the management of childhood diarrhea in CDROs of Eastern Ethiopia.

Methods

A community based cross-sectional study was conducted in 100 randomly selected CDROs in Eastern Ethiopia from 1 August to 30 September 2020. Data were collected with a structured questionnaire matched with a simulated patient case. Descriptive statistics were employed to summarize variables. Cohen's Kappa was analyzed to measure the degree of agreement between questionnaire-based and simulated patient-based methods. Binary logistic regression analysis was conducted to determine factors associated with inappropriate dispensing practice.

Results

Majority of the participants were aged 25-34 years (median: 29 years). High proportion of them were male (65%) and had work experiences of two or more years. Majority (61%) of the professionals were knowledgeable about AMR. Out of 2886 scores, 745 scores were agreed on Cohen's Kappa interrater agreement scale with the overall percent agreement between the two methods being 26.0%. Besides, about 67% of dispensing practices to the simulated patient case was found inappropriate. On the multivariate analysis, insufficient knowledge of retailers on AMR was significantly associated with the inappropriate dispensing of antimicrobial agents.

Conclusion

A considerable proportion of retailers had insufficient knowledge regarding the emergence and spread of AMR. Only a quarter of their questionnaire-based knowledge response agreed with simulated-patient-based actual practice, indicating weak agreement between the two methods and high level of inappropriate practice. Besides, insufficient knowledge of retailers was significantly associated with their inappropriate dispensing of antimicrobials.

Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers' Perspectives across Two States

India has one of the highest rates of antimicrobial resistance (AMR) worldwide. Despite being prescription drugs, antibiotics are commonly available over-the-counter (OTC) at retail pharmacies. We aimed to gain insight into the OTC sale of antibiotics at retail pharmacies and to elucidate its underlying drivers. We conducted face-to-face, in-depth interviews using convenience sampling with 22 pharmacists and 14 informal dispensers from 36 retail pharmacies across two Indian states (Haryana and Telangana). Thematic analysis revealed that antibiotics were often dispensed OTC for conditions e.g., fever, cough and cold, and acute diarrhea, which are typically viral and self-limiting. Both Access and Watch groups of antibiotics were dispensed for 1-2 days. Respondents had poor knowledge regarding AMR and shifted the blame for OTC practices for antibiotics onto the government, prescribers, informal providers, cross practice by alternative medicine practitioners, and consumer demand. Pharmacists suggested the main drivers for underlying OTC dispensing were commercial interests, poor access to public healthcare, economic and time constraints among consumers, lack of stringent regulations, and scanty inspections. Therefore, a comprehensive strategy which is well aligned with activities under the National Action Plan-AMR, including stewardship efforts targeting pharmacists and evidence-based targeted awareness campaigns for all stakeholders, is required to curb the inappropriate use of antibiotics.