Practice of over-the-counter dispensary of antibiotics for childhood illnesses in Addis Ababa, Ethiopia: a simulated patient encounter study

Antibiotic prescription sources and use among under-5 children with fever/cough in sub-Saharan Africa

BACKGROUND

Childhood febrile illness is among the leading causes of hospital admission for children <5 y of age in sub-Saharan Africa (SSA). Antibiotics have played a pivotal role in enhancing health outcomes, especially for children <5 y of age. Antibiotics prescription pattern evidence exists for SSA, however, prescription sources (either from qualified or unqualified sources) and use among children with fever or cough have not been explored. Thus the present study assessed antibiotic prescription sources and use among children <5 y of age with fever and cough in SSA.

METHODS

We used Demographic and Health Survey data from 37 countries with a total of 18 866 children <5 y of age who had fever/cough. The surveys span from 2006 to 2021. The dependent variable was antibiotics taken for fever/cough based on prescriptions from qualified sources. The data were weighted using sampling weight, primary sampling unit and strata. A mixed-effects logistic regression model (both fixed and random effects) was fitted since the outcome variable was binary. Model comparison was made based on deviance (-2 log likelihood) and likelihood ratio tests were used for model comparison. Variables with p≤0.2 in the bivariable analysis were considered for the multivariable mixed-effects binary logistic regression model. In the final model, the adjusted odds ratio (AOR) with a 95% confidence interval (CI) and p<0.05 in the multivariable model were used to declare a significant association with taking antibiotics for fever/cough prescribed from qualified sources.

RESULTS

The percentage of unqualified antibiotic prescriptions among children <5 y of age who had a fever/cough and took antibiotics was 67.19% (95% CI 66.51 to 67.85), ranging from 40.34% in Chad to 92.67% in Sao Tome. The odds of taking antibiotics prescribed from unqualified sources for fever/cough among children <5 y of age living in rural areas were 1.23 times higher (AOR 1.23 [95% CI 1.13 to 1.33]) compared with urban children. The odds of taking antibiotics prescribed from qualified sources for fever/cough among children <5 y of age whose mothers had primary, secondary and higher education decreased by 14% (AOR=0.86 [95% CI 0.79 to 0.93]), 21% (AOR 0.79 [95% CI 0.72 to 0.86]) and 21% (AOR 0.79 [95% CI 0.65 to 0.95]) compared with those whose mother had no formal education, respectively.

CONCLUSIONS

The study showed that the majority of the children who received antibiotics obtained them from unqualified sources in the 37 SSA countries. Our findings underscore the significance of addressing healthcare disparities, improving access to qualified healthcare providers, promoting maternal education and empowering mothers in healthcare decision-making to ensure appropriate antibiotic use in this vulnerable population. Further research and interventions targeted at these factors are warranted to optimize antibiotic prescribing practices and promote responsible antibiotic use in the management of fever and cough in children <5 y of age.

Inappropriate antibiotic access practices at the community level in Eastern Ethiopia

Access to antibiotic medications is critical to achieving the Sustainable Development Goal for good health and well-being. However, non-prescribed and informal sources are implicated as the most common causes of inappropriate antibiotic access practices, resulting in untargeted therapy, which leads to antibiotic resistance. Hence, knowing antibiotic access practices at the community level is essential to target misuse sources. In this study, 2256 household representatives were surveyed between July and September 2023 to examine their antibiotic access practices. Of 1245 household members who received antibiotics, 45.6% did so inappropriately. Non-prescribed antibiotic access was more common among urban residents and individuals not enrolled in health insurance schemes. This means of antibiotic access was also more common among individuals concerned about distance, drug availability, and healthcare convenience at public facilities. In addition, women and rural individuals were more likely to get antibiotics from unauthorized sources. Unrestricted antibiotic dispensing practices in urban areas enabled their non-prescribed access, while unlicensed providers prevailed with this access practice in rural areas. In this regard, personal behaviors and healthcare-related gaps such as the lack of health insurance, inconvenience, and drug unavailability have led community members to seek antibiotics from unofficial and non-prescribed sources. Targeting the identified behavioral and institutional factors can enhance antibiotic access through prescriptions, hence reducing antibiotic resistance.

Qualitative enquiry on factors affecting antibiotic prescribing at primary healthcare facilities in Addis Ababa, Ethiopia

Background

The major driver of antibiotic resistance is the huge increase in antibiotic prescribing, especially in low- and middle-income countries.

Aim

This study aimed to explore factors affecting antibiotic prescribing at primary healthcare facilities in Addis Ababa, Ethiopia.

Methods

The study was part of a three-phased explanatory sequential mixed method design. The study was conducted in five primary healthcare facilities through in-depth interviews of 20 prescribers and 22 key informants using pre-prepared interview guides. The data were analysed through thematic content analysis by applying ATLAS.ti 9 software.

Results

The antibiotic prescribing decision of prescribers was shown to be affected by various factors. The factors related to prescribers include not updating oneself on antibiotic use and antibiotic resistance, not reviewing patient history, not considering the concerns related to antibiotic resistance during prescribing, and competency problems. The patient-related factors were low awareness about antibiotics, lack of respect for prescribers, and pressure on prescribers. The shortage of antibiotics and laboratory reagents, a lack of updated antimicrobial resistance information, patient load, inadequate capacity, private sector practice, inadequate follow-up and support, and health insurance membership were the system-related factors. Appropriate interventions should be designed and implemented to address the identified factors and improve the prescribing practice.

"Handing out non-prescribed antibiotics is storing up trouble for the next generation!" Unpacking multistakeholder views of drivers and potential solutions in Ethiopia

BACKGROUND

Antibiotic resistance is a global health crisis, with inappropriate antibiotic use often being linked to non-prescribed antibiotic dispensing practices. This study aimed to examine the perspectives of multiple stakeholders on the drivers and potential solutions for non-prescribed antibiotic dispensing in Ethiopian community drug retail outlets (CDROs). Despite the prescription only use policies, the practice remains prevalent in Ethiopia. Many factors are thought to contribute to this issue, although little research is available for non-urban settings.

METHODS

A phenomenological qualitative study was conducted. Pharmacy professionals (owners or employees) working in non-urban towns CDROs were selected through a simulated client study, which identified CDROs that had dispensed antibiotics without a prescription. Some high-level decision makers in the Ethiopian health system were also purposively selected. Interviews were conducted in-person and over the phone or via Zoom. The interview data were transcribed verbatim, translated to English, and thematically analysed. NVivo 12 software was used to assist with coding.

RESULTS

CDRO pharmacy professionals (n = 18) and five decision makers were interviewed. Most professionals (61%) were pharmacists working in drug stores, with one to 11 years of work experience. Several contributing factors were identified at the level of patients, CDRO staff, and the healthcare system. These included economic interests, inadequate knowledge and inappropriate attitudes about antibiotic use or supply, and issues within the healthcare system included inaccessibility and insufficient capacity, absence of or a weak enforcement of prescription-only regulations or service supervision. Additionally, patient-related factors included a lack of knowledge and inappropriate attitudes about antibiotics use and their supply, previous successful treatment experience and a culture of seeking out antibiotics.

CONCLUSIONS

A complex set of modifiable factors related to patients, CDRO staff and healthcare system were identified that contribute to the non-prescribed supply of antibiotics. Due to this complexity, a single solution will not resolve the issues. Therefore, a range of multifaceted solutions have been suggested, including stricter regulation, increasing availability and accessibility of healthcare services, collaboration, and local consensus-building among CDROs, regular training for CDRO staff, and using community social events to educate the public about responsible use of antibiotics.

Magnitude of non-prescribed antibiotic dispensing in Ethiopia: a multicentre simulated client study with a focus on non-urban towns

OBJECTIVES

Non-prescription dispensing of antibiotics significantly contributes to widespread antibiotic misuse, which in turn hastens the occurrence of antibiotic resistance. It is believed to be common in Ethiopia despite prescription-only regulations. We aimed to quantify non-prescription dispensing of antibiotics in community drug retail outlets (CDROs) with a focus on non-urban towns in the Amhara region of Ethiopia.

METHODS

A multicentre simulated client (SC) study was conducted to measure the non-prescription provision of antibiotics in 225 consenting CDROs. Each CDRO was visited twice by two trained SCs, one to present pre-prepared clinical case scenarios and the other to directly request specific antibiotics. Descriptive statistical analysis was performed to report the findings.

RESULTS

The study had 450 interactions across the two visits. Non-prescribed antibiotics were obtained in 198 (88%) of the 225 clinical case scenarios-based visits and in 205 (91%) of the 225 direct antibiotic request visits. Most of the supply was at the first level of demand: 84% of the 198 clinical case scenario visits and 95% of the 205 direct antibiotic request visits. CDRO staff requested further information about the patient or the case in 40% of the clinical case scenarios-based visits and 30% of the direct antibiotic request visits.

CONCLUSIONS

It was possible to obtain antibiotics without prescription from a high proportion of CDROs, both in clinical scenario-based and direct antibiotic request interactions. Multifaceted interventions including stringent regulatory enforcement, frequent CDRO practice surveillance, CDRO staff training and community health education are needed with greater emphasis on rural areas.

Non-prescribed antibiotic use for children at community levels in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Non-prescribed antibiotic use is an emerging risky practice around the globe. An inappropriate use involving nonprescription access is one cause of the rapid increase in antibiotic resistance. Children commonly encounter many self-limiting illnesses for which they frequently use antibiotics without prescription. However, no specific and conclusive evidence exists to inform actions against this unsafe practice. We thus aimed to estimate the pooled proportion of non-prescribed antibiotic use for children at community levels in low- and middle-income countries.

METHODS

A systematic search of records was conducted from PubMed/Medline, Embase, Scopus, CINAHL, and Google scholar. Eligible English-language publications were original articles which reported on community-based non-prescribed antibiotic use for children and conducted in low- and middle-income countries. Study features and the number of antibiotics used without prescriptions were extracted and pooled for effect sizes employing a random-effects model. The pooled proportion of non-prescribed antibiotic use was estimated as a percentage.

RESULTS

In this analysis, we included a total of 39 articles consisting of 40,450 participants. Of these, 16,315 participants used non-prescribed antibiotics. The pooled percentage for this use of non-prescribed antibiotics was 45% (95% CI: 40-50%). The estimate was considerably higher in studies involving simulated patient methods (56%; 95% CI: 49-62%) than those studies with community surveys (40%; 95% CI: 34-46%) (P = 0.001). It was also varied by the recall period of antibiotics use-56% (95% CI: 50-62%) for instantly observed practice, 36% (95% CI: 22-50%) for within two week recall, 35% (95% CI: 26-45%) for 1-6 months recall, and 46% (95% CI: 37-54%) for more than six months recall (P = 0.001). Primary access points for the non-prescribed antibiotic uses were retail drug outlets.

CONCLUSIONS

We found that nearly half of the antibiotics used for children in community settings were without prescriptions. For these unsafe practices, caregivers accessed antibiotics mainly from drug outlets. Hence, context-specific educational and regulatory interventions at these outlets and the community levels are the first steps to improving antibiotic usage for children in low- and middle-income countries.

TRIAL REGISTRATION NUMBER

CRD42021288971 (PROSPERO).  https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021288971 .

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.

A scoping review of global aminoglycoside antibiotic overuse: A potential opportunity for primary ototoxicity prevention

BACKGROUND

Aminoglycosides are widely used, broad-spectrum antibiotics with significant potential for ototoxicity. Global efforts to prevent ototoxicity must account for aminoglycoside overuse and non-prescription use.

OBJECTIVES

The goals of this study were to a) estimate the prevalence of aminoglycoside overuse by synthesizing evidence on self-medication, over the counter (OTC) availability, and household antibiotic storage for later use, and to report the specific aminoglycosides used and the predictors of overuse, and b) leverage this information to comment on potential risk of ototoxicity.

METHODS

Two systematic search strings were conducted to extract peer-reviewed articles published from 2005 to 2020. The first focused on overuse of aminoglycoside antibiotics. The second focused on potentially ototoxic effects of aminoglycosides related to drug overuse.

RESULTS

A total of 26 articles were included (first search string: n = 21; second search string: n = 5). The prevalence of aminoglycoside self-medication was high and household storage and OTC availability of aminoglycosides was common. Gentamicin was the most commonly overused aminoglycoside. No studies provided information on antibiotic dosing or resultant toxicities, including ototoxicity.

CONCLUSIONS

The limited available evidence indicates that antibiotic overuse (self-medication, home storage, and non-prescription availability) is relatively common, especially in low resource settings, and that aminoglycoside antibiotics comprise a variable, but concerning, proportion of non-prescribed antibiotics. Additional evidence is needed to evaluate the relationship between these dispensing patterns and ototoxicity.

Community drug retail outlet staff's knowledge, attitudes and practices towards non-prescription antibiotics use and antibiotic resistance in the Amhara region, Ethiopia with a focus on non-urban towns

INTRODUCTION

Some evidence suggests that knowledge and attitudes towards rational antibiotic use influences dispensing practice in community drug retail outlets. However, there is limited evidence in resource limited countries, including Ethiopia. We aimed to assess the knowledge and attitudes surrounding antibiotic use or supply and antibiotic resistance, and the non-prescribed antibiotic dispensing practices in community drug retail outlets in non-urban Ethiopia.

METHODS

We conducted a cross-sectional survey of community drug retail outlet staff in the Amhara region, Ethiopia with a focus on non-urban towns. An expert validated self-administered questionnaire was used. Following exploratory factor analysis and best items selection, we summarised our findings and assessed factors associated with non-prescribed antibiotic dispensing. The data were analysed using Stata Statistical Software version 17. P-values < 0.05 were considered significant.

RESULTS

A total of 276 participants from 270 drug outlets completed the questionnaire. The participants median age was 30 (Interquartile range (IQR) = 25-35) years and 79.7% were pharmacy assistants. The majority demonstrated good levels of knowledge about antibiotic use or supply and antibiotic resistance (77.9% and 76% of the participants responded correctly to more than half of the items, respectively). We identified four attitude domains: the role of antibiotics in recovering from diseases regardless of their cause (median score = 2 (IQR = 2-4), beliefs inconsistent with good practice); professional competency to supply non-prescribed antibiotics, and the non-prescribed antibiotics supply (median score for each domain = 4 (IQR = 4-5), attitudes consistent with good practice); and positive attitudes towards actions to prevent antibiotic resistance and promote appropriate antibiotic use (median score = 4 (IQR = 4-5). Fifty eight percent of the participants reported that they had dispensed antibiotics without a prescription. Participants who did not perceive that they were competent to supply non-prescribed antibiotics (adjusted odds ratio = 0.86, 95% confidence interval = 0.78-0.93) were less likely to report non-prescribed antibiotics dispensing.

CONCLUSION

While most of the participants had appropriate knowledge about and attitudes to antibiotic use and antibiotic resistance, basic knowledge and attitude gaps remain. Despite Ethiopia's regulatory restrictions, the non-prescribed antibiotic provision continues to be a common practice. Our study highlights the need for multifaceted interventions that may include a strict regulatory system, staff training and public education.

Assessment of medicine use among outpatients at healthcare facilities in Ethiopia using the WHO's prescribing indicators with a focus on antibiotics: a systematic review and meta-analysis

OBJECTIVES

To summarize studies on prescribing medicine to general outpatients through the WHO/International Network for Rational Use of Drugs (INRUD) prescribing indicators with a focus on antibiotic prescription.

METHODS

A systematic review and random-effects meta-analysis of studies on the WHO prescribing indicators with a focus on the percentage of encounters with antibiotics prescribed (PEAP) was performed. The databases PubMed, Web of Science, EMBASE and Global Index Medicus were searched.

RESULTS

Twenty-six studies with a total of over 34 000 prescription encounters were included in the systematic review, showing a mean of two medicines per encounter. In each meta-analysis, a range of 19 to 25 studies was included. The percentages of medicines prescribed with an international non-proprietary name (INN) and from the essential medicines list (EML) were 91% and 96% of the total number of medicines, respectively, while 19% of encounters contained injections. Studies with over 25 000 prescription encounters reported an average PEAP of 58% and PEAP showed an increasing trend over the years included in this review. Multivariable meta-regression showed that PEAP increased with the average number of medicines per encounter (estimate = 0.83, P value = 0.0005). The number of medicines, study design and year of prescription explained over 40% of the variation in PEAP across studies.

CONCLUSIONS

Patterns of medicine use within and close to the WHO reference values were reported for the number of medicines, INN prescribing, prescription of injections and compliance with the EML, on average. Prescription of antibiotics requires attention as amounts much higher than the reference values were prescribed, which were even higher with polypharmacy and increasing over the years included in this review.

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.

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.

Are We Making the Most of Community Pharmacies? Implementation of Antimicrobial Stewardship Measures in Community Pharmacies: A Narrative Review

Community pharmacists recognize the need to implement antimicrobial stewardship activities in community pharmacies. They are in a unique position to provide triage for common primary care indications and to lower the burden of patients at general practitioners’ offices. However, research shows that, in some areas, dispensing of antimicrobials without valid prescription is still highly prevalent. Regardless of training, every community pharmacist can give his contribution to antimicrobial stewardship. One of the basic elements should be antimicrobial dispensing according to regulations, either prescription only, or according to guidelines where pharmacists have prescribing authority. Patient consultation supported with educational materials, such as leaflets, may reduce patients’ expectations to receive antibiotics for self-limiting infections and reduce pressure on general practitioners to prescribe antibiotics on patients’ demand. Treatment optimization may be achieved in collaboration with the prescribing general practitioners or by providing feedback. At last, pharmacists provided with additional training may be encouraged to provide consultation services to long-term care facilities, to introduce point-of-care testing for infectious diseases in their pharmacies or prescribe antimicrobials for uncomplicated infections. These services are welcomed by patients and communities. Expanding pharmacy services and pharmacists’ prescribing autonomy have shown a positive impact by reducing antibiotics consumption, thus ensuring better compliance with treatment guidelines.

Non-prescription sale of antibiotics and service quality in community pharmacies in Guangzhou, China: A simulated client method

OBJECTIVE

To measure the situation of the non-prescription sale of antibiotics and the service quality of community pharmacies in Guangzhou, China.

METHODS

A simulated client method was conducted to estimate the non-prescription sale of antibiotics and service quality based on scenarios about adult acute upper respiratory tract infection in 2019. A total of 595 community pharmacies from 11 districts were investigated in Guangzhou, China. We used binary logistic regression to evaluate the factors associated with the non-prescription sale of antibiotics.

RESULTS

The proportion of non-prescription dispensing of antibiotics was 63.1% in Guangzhou, China, with a higher incidence of antibiotic dispensing without prescription in outer districts (69.3%). Cephalosporin (44.1%) and Amoxicillin (39.0%) were sold more often than other antibiotics. Chain pharmacies had better performance on the prescription sale of antibiotics and service quality. Traditional Chinese medicine was commonly recommended by pharmacy staff.

CONCLUSION

Since the non-prescription sale of antibiotics is prevalent in Guangzhou, effective solutions should be determined. Strengthened public awareness and regulatory system innovation are needed.

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.

Factors influencing non-prescription sales of antibiotics among patent and proprietary medicine vendors in Kano, Nigeria: a cross-sectional study

Patent and proprietary medicine vendors (PPMVs) increase access to antibiotics through non-prescription sales in their drug retail outlets. This fosters irrational antibiotic use among people, thus contributing to the growing burden of resistance. Although training programmes on antibiotic use and resistance exist, they have disproportionately targeted health workers in hospital settings. It's unclear if there is a relationship between such trainings and non-prescription sales of antibiotics among PPMVs which are more embedded in communities. Therefore, a cross-sectional study was conducted to elicit the determinants of non-prescription antibiotic sales among PPMVs in Kano metropolis, Nigeria. Through brainstorming, causal loop diagrams (CLDs) were used to illustrate the dynamics of factors that are responsible for non-prescription antibiotic sales. Multilevel logistic regression model was used to determine the relationship between training on antibiotic use and resistance and non-prescription antibiotic sales, after controlling for potential confounders. We found that two-third (66.70%) of the PPMVs reported that they have sold non-prescribed antibiotics. A total of three CLDs were constructed to illustrate the complex dynamics of the factors that are related to non-prescription antibiotic sales. After controlling for all factors, PPMVs who reported that they had never received any training on antibiotic use and resistance were twice as more likely to sell antibiotic without prescription compared with those who reported that they have ever received such training (OR = 2.07, 95% CI: 1.27-3.37). This finding suggests that there is an association between training on antibiotic use and resistance and non-prescription sales of antibiotics. However, the complex dynamics of the factors should not be ignored as it can have implications for the development of intervention programmes. Multifaceted and multicomponent intervention packages (incorporating trainings on antibiotic use and resistance) that account for the inherent complexity within the system are likely to be more effective for this setting.

Knowledge, Attitude and Practice of Community Pharmacists Regarding Antibiotic Use and Infectious Diseases: A Cross-Sectional Survey in Hungary (KAPPhA-HU)

One of the key drivers for the emergence and spread of antimicrobial resistance (AMR) is non-prudent antibiotic (AB) use, which results in selection pressure towards relevant bacteria. Community pharmacists have pivotal roles in facilitating the prudent use of ABs that have been demonstrated by several studies worldwide. The aim of our present study was to evaluate the knowledge, attitude and practice of community pharmacists related to AB use and infectious diseases in Hungary. A descriptive cross-sectional survey was performed among community pharmacists in Hungary with the use of an anonymous, structured and pilot-tested questionnaire. Data collection ran between January 2016 and January 2018; n = 339 community pharmacists nationwide were approached with our questionnaire, out of which 192 filled out our survey. Hungarian pharmacists have appropriate knowledge regarding ABs and antimicrobial therapy, and they realize the public health impact of the growing AMR. Twenty-five percent of participants admitted to giving out non-prescription ABs at least once in the last year. The age and presence of board-certified specializations were shown to be significant factors of self-perceived knowledge and professional attitudes. Educational strategies and interventions specifically aimed at focusing on identified shortcomings and changing certain attitudes could substantially improve AB dispensing and AB use, in addition to minimizing resistance.