A multifaceted strategy is needed to limit the over-the-counter sale of antimicrobials

KEYWORDS:

• Over-the-counter
• antimicrobials
• dispensing
• community pharmacy
• quality

We read with interest the paper on the sale of antimicrobials without prescriptions among Ghanaian community pharmacies [1]. The authors highlight that pharmacists admit to dispensing antibiotics based on the desire to help patients presenting with symptoms of infections. However, this is not the sole explanation for the extensive practice observed in many parts of the world. The issue of over-the-counter sale is deeply rooted, and it results from various factors. Therefore, multifaceted interventions are needed to address this problem. Qualitative studies are required to gain a better understanding of why this problem is so highly perpetuated [2]. However, not all sales of antimicrobials without medical prescriptions may be considered negative practices. There are instances in which dispensing antimicrobial agents, such as for recurrent infections – uncomplicated urinary tract infections, genital herpes, for example – where patients clearly recognize the symptoms, might be justified.

To address the problem of the indiscriminate use of antimicrobials, particularly for respiratory tract infections, multifaceted strategies are needed, extending beyond administrative or regulatory measures [3]. We believe there is an urgent need to foster a proactive attitude among pharmacists through a combination of educational interventions within the community pharmacy sector and increased awareness campaigns targeting proper antimicrobial use among the general population. Implementing education that promotes changes in cultural practices and reinforces information aimed at educating the general population about the risks associated with the indiscriminate use of this class of medicines is crucial for curbing the perpetuation of the over-the-counter sale of antibiotics [4].

For many patients and parents, bypassing the general practitioner or the pediatrician due to the lack of time or long waiting times for getting an appointment is an easy solution. Community pharmacists also report that patients who have previously benefited from any antibiotic and considered it a solution are more prone to request and obtain an antibiotic. Complacency of patients is an important factor reported in studies as the motivational factor to dispense without a prescription. Moreover, certain pharmacists, particularly in smaller pharmacies, are hesitant to deny customer requests, as they fear losing their loyal clientele. Furthermore, community pharmacists dispense antibiotics to their clients because they understand that doctors would prescribe antibiotics in clinical situations similar to the ones presented in the pharmacy [5].

Despite the high percentage of pharmacies in Ghana selling antimicrobial agents without an official prescription, some positive findings can be drawn from the presented results. The observation that an Access antibiotic for pediatric diarrhea accounted for the most sold antibiotic is, at least, promising. A common finding observed in European community pharmacies is the use of first-line Access antibiotics for suspected urinary tract infections in adult women. However, the issue with respiratory tract infections is similar in middle- and low-income countries as well as high-income countries, where Watch and broad-spectrum Access antibiotics are commonly sold without a prescription. The sale of macrolides in sub-Saharan countries is worrisome, as it is prone to spreading antimicrobial resistance more easily. Despite being Access antibiotics, the use of amoxicillin and the combination of amoxicillin and clavulanate observed in Europe, being broad-spectrum antibiotics, should be also limited.

Moreover, dispensing practices should be better regulated, at least limiting the use of antibiotics to those belonging to the Access group and dispensing only small boxes. This is clearly seen in our latest study conducted in Catalonia, where the majority of boxes of beta-lactams sold corresponded to standard antibiotic durations, primarily for self-limiting respiratory tract infections [6]. The availability of very small boxes of antibiotics should be ensured in pharmacies. This trend, promoting a more widespread use of short courses of antibiotics for many common community-acquired infections, should be implemented as a regulatory measure to curb patients’ exposure to antibiotics, particularly in cases of suspected viral and self-limiting infections.

In conclusion, it is necessary to implement educational, regulatory, or administrative strategies, as well as cultural changes, not only in low- and middle-income countries but also in Western countries, to reduce the indiscriminate use of antimicrobials. The over-the-counter sale is not always negative, but qualifying the antimicrobial dispensing process is a fundamental factor for improving the rational use of antimicrobials and reducing microbial resistance.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

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