Over-the-counter sales of high-priority antibiotics are common: results of a global survey

Abstract

Background

Antimicrobial resistance (AMR) is a critical public health threat exacerbated by the sales of antibiotics without prescriptions. Despite national action plans, data on global over-the-counter (OTC) availability remains limited.

Methods

We surveyed members of the AMR Insights Ambassador Network across 37 countries using a web-based instrument. Data analysis was conducted by the survey programme and verified by two authors (X.Y. and N.M.M.).

Results

Despite regulations, 65% of respondents reported antibiotics were available OTC in their countries. Pharmacies were the primary source (85.9%), followed by internet vendors (23.4%). Notably, carbapenems and glycopeptides were reported to be available without prescriptions by 36.7% and 26.7% of respondents, respectively.

Conclusions

These findings highlight a significant gap between policy and practice. The availability of high-priority antimicrobials without prescriptions demands urgent regulatory enforcement and improved surveillance of both physical pharmacies and digital marketplaces.

Introduction

Antimicrobial resistance (AMR) undermines medical care and public health responses to infectious diseases. To address this, member states at the 2015 World Health Assembly pledged to implement national AMR action plans that include legal frameworks for monitoring antibiotic sales and infrastructure for antimicrobial stewardship.¹ Building on this foundation, the 2024 United Nations General Assembly High-Level Meeting on AMR culminated in a political declaration with ambitious global targets, including a 10% reduction in human deaths associated with bacterial AMR by 2030.² To increase the engagement with the public, the AMR Awareness Week is observed globally in the same week in November annually, and individual countries either develop their own antimicrobial stewardship or use those available on the World Health Organization (WHO) website.³

The acquisition and use of antibiotics without a prescription remains a significant barrier to addressing the global burden of AMR. While all antimicrobial use contributes to the development of resistance, such use when unwarranted can lead to significant harm to both the individual and society.⁴ Furthermore, dispensing antibiotics without healthcare provider evaluation and prescription may prolong illness severity, increase the likelihood of adverse outcomes, and have other unknown consequences.⁵

Despite regulatory efforts, use of over-the-counter (OTC) antibiotics for humans is ubiquitous. A systematic review of community pharmacies found the highest rates of non-prescription supply in South America followed by Africa and Asia.⁶ Yet, this issue is not limited to lower-income regions. In the United States, a 2023 multisite survey revealed that 43.6% of respondents reported prior use of non-prescription antibiotics, often obtained from local markets or relatives.⁷ Similarly, in Europe, a study in Spain found that antibiotics were sold without a prescription in 54.1% of pharmacies surveyed, an increase from previous years.⁸ This trend is global: a 2025 scoping review covering 93 countries estimated that ∼30% of global antibiotic consumption is inappropriate. Although such misuse is prevalent across all income levels, it is exacerbated in regions with limited healthcare infrastructure, where patients often bypass clinical evaluation due to high out-of-pocket costs and a lack of available prescribers.⁹

Recognizing this as a universal failure of stewardship, the WHO recently convened stakeholders to develop a global campaign specifically aimed at phasing out OTC antibiotic sales.¹⁰ Here, we report findings from a global survey on OTC antibiotic sales conducted among an international network of AMR experts to further illuminate the determinants and prevalence of this practice.

Methods

Study population and data collection

We surveyed members of the AMR Insights Ambassador Network (www.amr-insights.eu). At the time of the study, the network comprised ∼600 individuals from 60 countries representing diverse backgrounds in biomedical sciences and clinical backgrounds. Data collection was conducted using an electronic questionnaire developed and deployed via Zoho Survey (Zoho Corporation, Chennai, India). This platform was selected to ensure a standardized and secure interface for respondents across the participating countries. In December 2023, the system administrator emailed a unique link for a self-administered web-based survey (to participants. Responses were anonymous, and two reminders were sent at two-week intervals to maximize participation.

Survey instrument

The survey instrument was developed based on the WHO list of critically important antimicrobials for human medicine and prior studies.¹¹ Questions assessed demographic characteristics, the existence of national regulations, and the availability of specific antibiotics (grouped by WHO classification) for purchase without a prescription.

Data analysis

Data were collected via the Zoho survey platform. The primary analysis was conducted by the survey program software and verified manually by two authors (XY and NMM) to ensure accuracy and consistency. Data were analysed using Microsoft Excel.

Results

Demographics and regulations

We received 75 responses from AMR Network Ambassadors across 37 countries. The participants were predominantly male (n = 49, 65.3%) and primarily within the 25- to 50-year age bracket (n = 42, 56.0%). A total of 62.7% of respondents (n = 47) were located in lower-middle income countries, whereas 21.3% (n = 16) were from high-income countries. Table S1 (available as Supplementary data at JAC-AMR Online) shows the countries in the category based on the World-Bank income class in 2025–26.¹²

Professionally, physicians and healthcare workers constituted 45.3% (n = 34) of the respondents, with the remaining participants identifying as pharmacists (n = 8, 10.7%), veterinarians (n = 8 10.7%) or other professionals (n = 25, 33.3%). Detailed socio-demographic and professional characteristics are summarized in Table 1.

Table 1.

Socio-demographic and Professional Characteristics of Respondents (n = 75)

Variable	Number (n)	Percentage (%)
Sex
Male	49	65.3%
Female	25	33.3%
Prefer not to mention	1	1.3%
Age group (years)a
<25	14	18.7%
25–50	42	56.0%
51–60	10	13.3%
61–70	6	8.0%
>70	2	2.7%
Not reported	1	1.3%
Country income levelb
High-income	16	21.3%
Upper-middle income	3	4.0%
Lower-middle income	47	62.7%
Low-income	9	12.0%
Professionc
Qualified physician (prescribe to third parties and self)	13	17.3%
Qualified physician (prescribe to third parties only)	6	8.0%
Healthcare worker (not a qualified physician)	15	20.0%
Pharmacist	8	10.7%
Veterinarian	8	10.7%
Other	25	33.3%

This table provides a comprehensive overview of the study's participants, categorized by gender, age, economic context and professional background.

^aOne respondent skipped this item (n = 74).

^bCountry income level is based on world-bank classification for 2024–25 available at: https://blogs.worldbank.org/en/opendata/world-bank-country-classifications-by-income-level-for-2024-2025.

^cProfession was based on self-identification.

Access to antimicrobials

Of the 75 respondents, 49 (65.3%) indicated that antibiotics could be purchased OTC in their countries without a prescription. In contrast, only eight participants (10.7%) reported that antibiotic sales were strictly limited to individuals with a valid medical prescription.

A total of 64 participants responded to the items regarding points of sale for non-prescription antimicrobials. Community pharmacies were identified as the primary point of sale for non-prescription antibiotics by 85.9% of respondents (n = 55). Additionally, respondents identified other sources including retail stores (n = 22, 34.5%), internet vendors (n = 15, 23.4%) and grocery stores (n = 8, 12.5%).

Penicillins (n = 26, 86.7%) and tetracyclines (n = 25, 83.3%) were the most frequently reported classes available without a prescription, but respondents also indicated the availability of critical antimicrobial classes (Figure 1). Specifically, fluoroquinolones (n = 14, 46.7%) and macrolides (n = 10, 33.3%) were identified, while 36.7% of respondents (n = 11) reported the availability of carbapenems, and 26.7% (n = 8) reported that glycopeptides could be obtained without a prescription.

Figure 1.

Percentage of respondents who reported that a given WHO antibiotic class could be acquired without a prescription in their country (n = 30). While penicillins and tetracyclines were most frequently reported, respondents also identified the availability of highest priority critically important antimicrobials (HPCIA), specifically cephalosporins (n = 21, 70.0%), quinolones (n = 20, 66.7%) and macrolides (n = 18, 60.0%). Access to other critical classes included carbapenems (n = 11, 36.7%) and glycopeptides (n = 8, 26.7%). As respondents could select multiple options, the total percentage exceeds 100%.

Discussion

Although the use of antibiotics without a prescription is potentially harmful and exacerbates AMR, the practice remains inadequately described on a global scale. The present study investigated the sale of antibiotics without prescriptions in 37 countries using an online survey among professionals in the AMR Insights Ambassador Network. Significantly, most respondents (65%) reported that antibiotics could be purchased in their countries without a prescription. Although procurement methods varied, respondents indicated that 86% of OTC purchases were made in community pharmacies. The finding that antibiotics are readily available in 37 countries—representing nearly 19% of the 194 WHO Member States—is concerning and highlights a critical gap in global stewardship.

Our results align with prior evidence demonstrating the widespread sale of non-prescription antimicrobials across nearly all global regions.¹³ Recent surveys confirm that this practice is deeply entrenched in Africa and Asia. In sub-Saharan Africa, for instance, a systematic review found that non-prescription dispensing occurred in 69% of requests.¹⁴ Country-specific data further corroborate this: In Ghana, 88.3% of community pharmacies and drug outlets sold antibiotics without a prescription¹⁵ and rates in Ethiopia ranged from 45.6% to nearly 88%, depending on the region.¹⁶ Similarly, studies in Asian countries have documented unprescribed antimicrobial purchases in stand-alone pharmacies in Tamil Nadu, India,¹⁷ and in China, where such sales persisted despite regulatory shifts.¹⁸ This trend extends to South America. Muri-Gama et al. reported that a majority of surveyed residents (66.2%) in the Brazilian Amazon Basin had self-medicated with antibiotics obtained without a prescription.¹⁹

Crucially, this challenge is not solely limited to low- and middle-income countries. Data from high-income nations indicates that regulatory frameworks do not guarantee compliance. In the United States, a 2020–21 multisite survey revealed that 43.6% of the 564 respondents indicated prior use of non-prescription antibiotics, often obtained from local markets or relatives.⁷ Similarly, despite stricter regulatory frameworks in Europe, OTC sales persist. For example, Guinovart found that in 2013–14 antibiotics were sold without a prescription in 54.1% of 220 Spanish pharmacies surveyed, an increase from previous years.⁸ These findings suggest that the demand for self-medication often bypasses legal restrictions, regardless of the region's economic status.

A particularly concerning finding from our study is that high-priority and ‘last-resort’ drugs can be purchased without a prescription (10). Respondents reported that penicillins (86.7%), cephalosporins (70.0%) and fluoroquinolones were frequently sold OTC. More critically, 36.7% reported that carbapenems and 26.7% reported that glycopeptides can be dispensed without a prescription.

In this global survey, nearly a quarter (23.4%) of respondents reported that antibiotics were sold via the internet without restriction, highlighting an expanding, unregulated frontier that bypasses traditional pharmacy controls. This ease of access suggests severe shortcomings in the implementation of national action plans (NAPs), which specifically call for the optimal use of antimicrobial medicines. While these plans provide a necessary framework, first-generation NAPs often focused on institutional stewardship and frequently failed to incorporate community pharmacies or the informal retail sector.

Recent systematic evidence highlights that the mere existence of an NAP is not enough to ensure robust surveillance or optimized use. There remains a critical need to address the behavioural factors and sociocultural drivers—including health-seeking and health-providing behaviours—that facilitate the unwarranted use of antimicrobials.²⁰ Moving forward, stewardship strategies need to be tailored to these real-world contextual needs to bridge the gap between policy and practice.

This study has limitations. The data are derived from a self-administered survey of a professional network (n = 75), which may introduce selection bias and may not be fully representative of all 37 countries included. Significantly, the data reflect the professional observations of the respondents rather than objective sales data. However, the study population comprised individuals who voluntarily joined an association dedicated to addressing AMR. As members of the AMR Insights Ambassador Network, these professionals are highly aware of the complexities of antimicrobial stewardship. Their shared commitment to mitigating AMR ensures they possess deep systemic knowledge of their respective local health infrastructures and the practical realities of antibiotic acquisition in their countries. We also acknowledge that the survey instrument did not distinguish between pharmacies dedicated solely to human medicine and ‘mixed’ pharmacies that serve both human and veterinary needs. While this study is anchored in human health, field observations in Kenya indicate that retail outlets may stock antimicrobials for both populations; however, the extent of this overlapping availability across all 37 participating countries was not measured. Nevertheless, the use of the AMR Insights Ambassador Network ensured that respondents know their local health systems and how antibiotics are purchased in their countries. Additionally, this study focused primarily on documenting the prevalence and scope of OTC antibiotic sales rather than evaluating specific interventions or enforcement mechanisms. Future research should explore context-specific solutions, including regulatory frameworks, pharmacist training programmes, digital surveillance systems for online sales and behavioural interventions to reduce consumer demand for non-prescribed antibiotics.

In summary, the widespread availability of antibiotics without a prescription severely undermines global efforts to address AMR. While NAPs provide a foundational framework, their mere existence does not guarantee optimized use. Impactful change demands robust governance, political accountability, and an understanding of the cultural and behavioural drivers of unwarranted use.

Innovative visual strategies, such as the red-marked packaging implemented in Bangladesh to signal professional oversight, represent vital regulatory efforts. However, as noted in recent global reviews, these interventions must be coupled with expanded healthcare access and diagnostic support to effectively reduce global demand without removing essential points of care in resource-limited settings.^21,22

Funding

This work was conducted as a voluntary contribution to the World Health Organization Antimicrobial Resistance response. The first author received travel support from the International Society for Pharmacoepidemiology (ISPE).

Transparency declarations

All authors declare that they have no conflict of interest.

Declaration of generative AI and AI-assisted technologies

Gemini Advanced was used for retrieval of references and streamlining texts. Analysis was conducted by the survey programme and verified by two authors: X.Y. and N.M.M. All references from AI were manually validated against original sources, as was the streamlined text, and the authors take full responsibility for the content.

Ethics approval

This study was reviewed and approved by the Penn State College of Medicine Institutional Review Board (Nicole Hackman, MD, Principal Investigator).

Supplementary data

Table S1 is available as Supplementary data at JAC-AMR Online.