Perceptions and practices of community pharmacists toward antimicrobial resistance and antimicrobial stewardship: A cross-sectional study

INTRODUCTION

Over the past decades, the world has faced a devastating crisis due to remarkable increase in multidrug-resistant microorganisms, which has led to a significant increase in illness and death rates.[1] By 2050, antimicrobial resistance (AMR) may cause 10 million deaths annually.[2] These alarming statistics emphasize several potential causes due to improper antimicrobial drug handling practices and the absence of regulations prohibiting the over-the-counter dispensing of antibiotics in some countries.

Antimicrobial Stewardship (AMS) Program guidelines have been successfully implemented in hospitals; however, it faces many challenges in community pharmacies. Community pharmacists’ limited AMS awareness and improper practices worsen antibiotic misuse and resistance, risking global spread of resistance patterns.

Therefore, the current study aims to assess the perceptions and practices of community pharmacists toward the use of antibiotics, antibiotic resistance, and AMS to provide solutions and strategies for promoting more responsible antibiotic use in community settings.

METHODS

A cross-sectional survey was conducted in Egyptian community pharmacies from April to July 2023. Using Raosoft, a sample size of 367 was calculated for a population of 75,165 pharmacies. The study protocol and questionnaire were approved by Ahram Canadian University’s IRB (ACU-REC1523).

A 40-item questionnaire adapted from Al-Shami et al. covered demographics, AMR and AMS perceptions, antibiotic practices, and strategies for improved antibiotic use and the barriers to participation in AMS.[3] Responses used a 5-point Likert scale. The survey, conducted anonymously via Google Forms, targeted 1800 licensed community pharmacists. Data analysis was performed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp with ANOVA to examine relationships between perceptions, practices, and demographics.

RESULTS

An online survey of 746 Egyptian community pharmacists (41.4% response rate) found 52.4% male, 74% under 30 years, 67% with under 5 years’ experience, and 61% holding only a bachelor’s degree.

The survey highlighted pharmacists’ strong support for combating antibiotic resistance, with 88.8% recognizing their role in reducing antibiotic resistance and 85.6% rejecting the idea that resistance is solely a hospital concern. Over 80% linked over-the-counter antibiotics to resistance and supported AMS programs to boost public trust and reduce resistance. While 76.8% opposed antibiotic use in uncertain cases and 75% rejected home storage, 39.1% would dispense smaller amounts for patients unable to afford a full course. Restricted access to patient records was a barrier for 77.8% to AMS participation. Additionally, 87% supported updated clinical guidelines for infectious disease treatment, over 80% emphasized public and professional education, and 70% supported stricter antibiotic regulations including reclassifying antibiotics as prescription only.

DISCUSSION

Community pharmacists in Egypt demonstrate good awareness and practices regarding AMR and AMS, yet Egypt ranked among the top three low-income countries for antibiotic consumption. While overdispensing by pharmacists is a concern, studies showed overprescribing by physicians is more prevalent. Thus, developing context-specific guidelines easily accessible for appropriate antibiotic use is crucial.[4]

Consistent with earlier findings, community pharmacists are more likely to recommend antibiotics for upper respiratory tract infections than gastroenteritis, even though such infections are typically viral.[5]

Cultural beliefs also influence antibiotic utilization, with some traditions viewing antibiotics as preventive measures against diseases, posing challenges for pharmacists to influence self-medication behaviors. Alarmingly, half of the pharmacists in this study admitted to dispensing shorter courses of antibiotics when patients could not afford the full course, a practice that may lead to treatment failure and increased resistance.

Most participants (87%) strongly agreed that providing community pharmacies with updated clinical practice guidelines for treating infectious diseases is an effective strategy for improving antibiotic use. With their accessibility, community pharmacists are ideally positioned to play a crucial role in implementing AMS programs and controlling microbial resistance. However, barriers such as restricted access to patient records hinder their participation in AMS initiatives.[6]

In the current study, pharmacists with bachelor’s degrees showed better antimicrobial practices and AMS perceptions due to recent education and exposure to innovative learning methods. On the other hand, the study limitations include limited regional coverage and potential social desirability bias in self-reported responses.

CONCLUSION

Community pharmacists in Egypt acknowledge their responsibility for mitigating the widespread development of antimicrobial resistance, however a gap exists between their understanding of AMR and AMS and the implementation of best practices. Barriers such as limited access to patient records hinder effective AMS in community pharmacies, providing critical insights for policymakers and healthcare systems aiming to strengthen AMS programs.

The consensus among community pharmacists was strong towards the effectiveness of raising awareness among pharmacy students, community pharmacists, and the general public about the rationale for the use of antibiotics as an optimal strategic approach. In conclusion, the study highlights the potential impact of community pharmacists in reducing AMR and the necessity of enabling environments and policies to support their role effectively. Further research is recommended to explore the impact of specific interventions in community pharmacy settings on AMR and AMS outcomes.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.