Addressing the Antibiotic Resistance Crisis through Community Pharmacy Interventions
Non-prescription antibiotic dispensing is a significant contributor to the global threat of antimicrobial resistance (AMR). In many low- and middle-income countries, community pharmacies remain a primary source of antibiotics, often dispensing these medications without a valid prescription. This practice not only undermines efforts to promote appropriate antibiotic use, but also increases the risk of adverse health outcomes and the emergence of resistant pathogens.
To tackle this challenge, a team of researchers in Indonesia conducted a comprehensive, multi-faceted intervention targeting community pharmacies in the city of Semarang. By addressing both provider and consumer behavior, this innovative approach yielded promising results in reducing non-prescription antibiotic dispensing.
Designing a Tailored Intervention
The researchers leveraged insights from previous studies that had identified key barriers to prescription-based antibiotic dispensing among Indonesian community pharmacists. These barriers included:
-
Fear of losing customers: Pharmacists were hesitant to refuse non-prescription antibiotic requests, fearing they would lose business to other pharmacies more willing to dispense antibiotics without a prescription.
-
Customer demand: Customers often pressured pharmacists to provide antibiotics, even when a prescription was not available.
-
Lack of oversight: In many pharmacies, a supervising pharmacist was not consistently present, allowing non-prescription dispensing to occur.
-
Knowledge gaps: Some pharmacy staff had limited understanding of regulations and guidelines surrounding appropriate antibiotic use.
To address these barriers, the researchers designed a multi-faceted intervention consisting of the following components:
-
Online educational sessions for pharmacists: These sessions focused on improving pharmacists’ knowledge of antibiotic resistance, appropriate antibiotic use, and effective communication strategies to manage customer expectations.
-
Awareness campaign targeting customers: Waiting room materials, such as posters and brochures, educated customers on the importance of obtaining a prescription before receiving antibiotics.
-
Peer visits and supervision: Experienced pharmacists conducted virtual and in-person visits to provide mentorship, support, and accountability to participating pharmacies.
-
Pharmacy branding and pharmacist certification: Participating pharmacies were recognized for their commitment to responsible antibiotic dispensing, and pharmacists were awarded continuing education credits.
Measuring the Impact
The researchers used a pre-post quasi-experimental design to evaluate the impact of this multi-faceted intervention. They recruited 80 community pharmacies in Semarang, with half assigned to the intervention group and the other half serving as a non-participating control group.
To assess the primary outcome of non-prescription antibiotic dispensing, the researchers employed standardized patients (SPs) who visited the pharmacies and presented with symptoms of upper respiratory tract infection, urinary tract infection, or childhood diarrhea. The SPs would first request medication without specifying antibiotics, and then, if needed, would directly ask for an antibiotic.
At baseline, the rate of non-prescription antibiotic dispensing was high in both groups, with 76.3% in the intervention group and 84.6% in the control group. However, after the 7-month intervention period, the rate of non-prescription antibiotic dispensing in the intervention group had significantly decreased to 55.4%, compared to 82.3% in the control group.
The researchers also found that non-prescription antibiotics were less likely to be dispensed in the intervention group (OR=0.19, 95% CI 0.09-0.43) and more likely to be dispensed for the urinary tract infection scenario (OR=3.29, 95% CI 1.56-6.94).
Overcoming Persistent Barriers
Despite the overall success of the intervention, the researchers identified several persistent barriers that continued to drive non-prescription antibiotic dispensing, even among participating pharmacies. These included:
- Fear of losing customers: Some pharmacists remained reluctant to refuse non-prescription antibiotic requests, fearing they would lose business to more lenient competitors.
- Customer demand: Customers often insisted on receiving antibiotics, even when a prescription was not available.
- Lack of supervising pharmacist: In some pharmacies, a qualified pharmacist was not consistently present to oversee antibiotic dispensing practices.
To address these lingering challenges, the researchers recommend strengthening regulatory enforcement, enhancing customer education campaigns, and exploring strategies to incentivize pharmacists to adhere to prescription-based antibiotic dispensing policies.
Sustaining the Impact through Collaborative Efforts
The findings of this study demonstrate the potential of multi-faceted interventions to significantly reduce non-prescription antibiotic dispensing in community pharmacies. By simultaneously addressing provider knowledge, attitudes, and behaviors, as well as consumer awareness, this approach was able to achieve a meaningful and measurable impact.
However, the researchers emphasize that sustained progress will require ongoing collaboration between community pharmacists, local health authorities, and national policymakers. An antimicrobial stewardship program led by community pharmacists, in partnership with the broader health system, is crucial to promote the responsible use of antibiotics and curb the rising tide of antimicrobial resistance.
As the global community works to address this pressing public health challenge, the lessons learned from the PINTAR (Protecting Indonesia from the Threat of Antibiotic Resistance) study offer valuable insights into the design and implementation of effective, multi-faceted interventions targeting community pharmacies. By empowering pharmacists as frontline agents of change and engaging with consumers, these types of comprehensive approaches hold the promise of making a lasting impact on antibiotic use and resistance in low- and middle-income countries.
Key Takeaways
- Non-prescription antibiotic dispensing in community pharmacies is a significant contributor to the global AMR crisis, particularly in low- and middle-income countries.
- A multi-faceted intervention in Indonesia, involving educational sessions, awareness campaigns, peer supervision, and pharmacist certification, was able to significantly reduce non-prescription antibiotic dispensing in participating community pharmacies.
- Persistent barriers, such as fear of losing customers, customer demand, and lack of supervising pharmacists, continue to hinder progress and require ongoing efforts to address.
- Sustained impact will depend on collaborative efforts between community pharmacists, local health authorities, and national policymakers to implement comprehensive antimicrobial stewardship programs.
- The lessons from the PINTAR study offer valuable insights for designing effective, multi-faceted interventions to promote responsible antibiotic use in community pharmacy settings.
Conclusion
The global threat of antimicrobial resistance demands a multifaceted, collaborative response that engages all stakeholders, including community pharmacists who play a crucial role in antibiotic stewardship. The PINTAR study in Indonesia demonstrates the potential of comprehensive interventions to drive positive change in antibiotic dispensing practices, paving the way for more sustainable, equitable, and resilient health systems. By empowering community pharmacists as partners in the fight against AMR, we can make meaningful progress towards safeguarding the effectiveness of these essential medicines for generations to come.
