Table 1.
Examples of initiatives to reduce self-purchasing of antibiotics in pharmacies predominantly in LMICs
| Activity | Outcome |
|---|---|
| Educational and other activities including regulations | |
| Chile68,69 | • Chile was one of the first countries in Latin America to introduce greater enforcement of the law banning the purchasing of antibiotics without a prescription—enhanced by antibiotics being removed from the list of medicines having sales incentives in pharmacies |
| • Antimicrobial consumption decreased from 12.3 DID before the intervention to 8.5 DID just after the enforcement (in 2000)—helped by public information campaigns before and during the implementation of enhanced enforcement of the regulations | |
| • However, there has been a slow increase in antimicrobial utilization since 2002 suggesting the impact of introduced regulations diminish over time unless pharmacists’ activities are continually monitored and further initiatives are introduced when pertinent | |
| China33 | • Multiple initiatives in Shaanxi Province in China—including stricter regulations for dispensing antibiotics, improving pharmacists’ education, a qualified pharmacist being present to dispense antibiotics and increased frequency of unannounced pharmacy inspections and punishments for misuse—decreased antibiotic sales between 2011 and 2017 |
| • For SPs acting as caregivers for a 5-year-old child with diarrhoea, dispensing of antibiotics without a prescription was reduced from 72.3% to 50.2% (P < 0.0001) | |
| • For SPs acting as a friend of a 20-year-male college student with a URTI, dispensing without an antibiotic was down from 95.8% to 69.5% (P < 0.0001) | |
| • Three demand levels were used to try and encourage antibiotics to be dispensed with the second level being ‘can you give me some antibiotics’ and the third level being ‘I would like some amoxicillin or cephalosporins’ | |
| Kenya40,58 | • Among pharmacists linked to the University of Nairobi, 94.1% of antibiotics were dispensed with a valid prescription with limited dispensing without a prescription |
| • There was no dispensing of antibiotics for ARIs, with OTC medicines such as cold and cough syrups and lozenges typically dispensed | |
| • There was no dispensing of either antimalarials or antibiotics without a prescription during a recent study conducted during the COVID-19 pandemic | |
| Namibia43,64,70 | • In a survey involving 100 households in Namibia, typically cold/flu medication, paracetamol and decongestants were used to treat adults or their children with ARIs including for common colds and influenza—helped by education among pharmacists, regulations banning the self-purchasing of antibiotics and the regular monitoring of community pharmacy activities |
| • There was a similar situation during the COVID-19 pandemic with no change in the utilization of antimicrobials compared with other African countries including Nigeria. This was helped by proactivity among pharmacists, knowledge regarding the current regulations banning self-purchasing and regular monitoring of pharmacy activities | |
| Republic of Srpska41,71 | • Education of pharmacists together with the production of guidelines including those for ARIs |
| • This coupled with greater enforcement of the regulations of guidelines banning the dispensing of antibiotics without a prescription resulted in the purchasing of antibiotics without a prescription for self-diagnosed URTIs significantly decreasing from 58% of requests to 18.5% for SPs | |
| • Encouragingly, the most common reason for not dispensing to SPs was that antibiotics cannot be dispensed without a prescription | |
| India, Malaysia and Vietnam36,72,73 | • There have been ongoing educational and other initiatives in recent years in India, Malaysia and Vietnam to try and reduce unnecessary dispensing of antimicrobials without a prescription |
| • These initiatives seem to be working, with no change or a decrease in the dispensing of antimicrobials among 83.3% to 100% of pharmacies surveyed in Malaysia and Vietnam in the initial months following the start of the COVID-19 pandemic despite the hype and concerns generally with increasing use of antibiotics. However, this may not always be the case | |
| • In India—no change in up to 57.7% of pharmacists surveyed | |
| Thailand74 | • Principally education involving a multidisciplinary intervention among grocery stores in a rural province in Thailand using trained community leaders |
| • There were 87% fewer antibiotics available postintervention compared with preintervention | |
| • Grocery stores in the control group saw only an 8% reduction in antibiotic availability between the two time periods | |
| Regulations/enforcement | |
| Brazil—private and public pharmacies75–77 | • In their study, Moura et al. (2015)75 found no difference in antibiotic utilization among public pharmacies between 2008 and 2012 where there had always been restrictions on the dispensing of antibiotics with a prescription and it is generally impossible for pharmacists to sell antibiotics without a prescription |
| • With respect to private pharmacists, Moura et al. (2015)75 showed a decrease in antibiotic use of 1.87 DID (P < 0.001) immediately after restrictions banning the sales of antibiotics without a prescription (2008 to 2012), with a greater decrease in the more developed regions as well as in the State Capitals | |
| • Lopes-Junior et al. (2015)76 also found that sales of amoxicillin (commonly sold antibiotic) among private pharmacies fell by approximately 30% post-legislation despite a general growth in the pharmaceutical market, with decreased sales of other popular antibiotics including tetracyclines (30.5% decrease), sulphonamides (28.5% decrease) and macrolides (25% decrease) | |
| • Mattos et al. (2017)77 also documented a decrease in the dispensing of cephalosporins (−19.4%), quinolones (−12.7%) and aminopenicillins (−11.1%) following restrictions in private pharmacies | |
| Colombia69,78 | • The initial enforcement of the law in 2005 had a modest impact on overall sales in the first three years (−1.00 DID) |
| • However, a follow-up study five years after implementation found a high number of pharmacies (80.3%) were still not complying with the law due to lax monitoring. This prompted calls for greater enforcement of the law | |
| Mexico68,79 | • The government implemented policies in 2010 to enforce existing laws whereby antibiotics could only be dispensed to patients presenting with a prescription. As part of this, the regulations require antibiotic prescriptions to be retained and registered in pharmacies, with fines imposed for non-compliance |
| • Antibiotic utilization decreased by 22.9% between 2007 and 2012, with the trend accelerating after greater enforcement of the legislation | |
| • There was also an appreciable seasonal reduction in the use of penicillins in Mexico after greater enforcement of the legislation | |
| Saudi Arabia42 | • The regulations and law concerning the purchasing of antibiotics without a prescription were enforced from May 2018 onwards alongside fines in Saudi Arabia |
| • 70.7% of pharmacies taking part in the study reported that purchasing of antibiotics without a prescription was common before the updated regulations and fines, with 96.6% and 87.7% of participating pharmacies dispensing antibiotics to SPs for pharyngitis and UTIs respectively | |
| • Following law enforcement and fines, only 12.9% of community pharmacists reported that the purchasing of antibiotics without a prescription was still a common practice | |
| • In addition, only 12.1% of pharmacies dispensed an antibiotic to SPs—and typically only at the third level of demand (57.1%), i.e. the SP directly asking for an antibiotic. This compares with 85.7% at the first level, i.e. just asking for something to relieve the symptoms, prior to the changes in regulations and fines | |
| • Similarly for UTIs, only 5.2% dispensed antibiotics without a prescription and typically only at the third level (66.7%). This compared with 74% at the first level prior to the changes | |
| Venezuela69 | • The government implemented policies to try and limit the dispensing of three antibiotic groups without a prescription |
| • However, there were no public awareness campaigns, and the ‘enforcement’ was only via government publications with no follow-up of the regulations | |
| • This resulted in no decrease of antibiotic utilization levels—in fact the opposite with an increase | |