The destructive properties of AMR are already demonstrating themselves across the globe. With the emergence of resistant strains of bacteria, non-prescribed antibiotic dispensing (NPAD) is also considered a relevant factor to deal with. It imparts a substantial role in the prevalence of AMR globally both in the community and hospital settings . Various studies all over the world presented NPAD with a significant proportion [17–22]. The different studies reported that a majority of pharmacies encountered claims of visitors with self-medication of antibiotics and about half of them dispensed antibiotics without any due requirements [23, 24]. A similar trend is observed in this study. The results of this study focus on the attributes that lead to NPAD at the community pharmacies.
Out of 336 respondents, most of them were pharmacy graduates (56.8%) and working either as a manager or staff pharmacist. The majority of the pharmacy staff had an experience of fewer than two years in community pharmacies. Not every pharmacy visited had a pharmacist at that very time, so the place was revisited. The unavailability of a licensed pharmacists in the pharmacy might contribute towards NPAD in a haphazard way and hence AMR.
As far as policy perspective in Pakistan is concerned, the Drug Act 1976/ Drug Regulatory Authority Act 2012 provides the legislative impetus for the sale of medicines only under the supervision of a registered pharmacist [25, 26]. Despite the act being in place, the sales of antibiotics are poorly regulated because of poor enforcement by the concerned authority. In the Punjab province of Pakistan, pertinent rules are formulated for the regulation of drug sales by way of retail; known as the Punjab Drug Rules 2007. These rules have barred the sale of certain drugs without any prescription and have categorized drugs into different schedules viz Schedules B, C, D, E, F, and G. The Schedule-D, permits the sales of drugs strictly on the prescription of a registered medical practitioner . All the antibiotics have been included in this schedule. Therefore, the increasing trend of antimicrobial dispensing without prescription can be attributed to poor enforcement of existing laws in our study setting with a subsequent high rate of AMR.
Knowledge of the participants was good on a marking scale but still, a fair portion (21.1%) depicted poor knowledge about antibiotic use and dispensing which adds to unnecessary and over-dispensing of antibiotics . Our study revealed that 75% of the pharmacy staff were well aware of the PoM status of antibiotics. The majority of the respondents (75.9%) in this study agreed that AMR is a serious public health problem. However, dispensers supply antibiotics as OTC even after knowing their PoM status. Our study also reveals the same scenario. It is, therefore, necessary that the ‘PoM’ status of antimicrobials is enforced especially concerning to the sales from community pharmacies, to create an enabling environment for health behavior. A coordinated approach amongst stakeholders, including healthcare workers, patients, and policy-makers on the issue of AMR is needed . The multipronged approach with intra- as well as inter-professional coordination can ensure compliance with the national action plan on AMR.
The difference of opinion is detected among respondents whether to use antibiotics for minor ailments or not. A good portion of participants stated that antibiotics dispensing without prescription renders ease to patients who visit pharmacies and for those who find it difficult to access healthcare facility either due to lack of time or affordability . Different studies across the globe evince a good perception of pharmacy staff regarding the use of antibiotics but still, they do dispense without physician's order without any reluctance . Our findings are found coherent with these facts. Results showed a prominent agreement of proper guidance of patients regarding disease state of the patient, drug interactions, and emphasis on the complete course of antibiotics treatment; which is contradictory to the findings of Asian countries as retrieved by the public opinion about practices of pharmacy staff, especially the pharmacists . About one-third of the respondents stated to dispense antibiotics even in self-limiting and viral infections which is irrational. On average, 60% of the respondents agreed to provide antibiotics in infectious diseases if the patient gives a direct visit to their pharmacy as soon as the symptoms appear where only symptomatic treatment can bring out relief. The view of respondents in our study coincided with the fact that there is a need for proper laboratory tests for pathogen identification and sensitivity analysis for initiating antibiotics, but their practice of NPAD doesn’t match with this. Such practice accounts for irrational use of antibiotics in the community as indicated by National Institute for Health & Care Excellence (NICE) guidelines . Moreover, guidelines suggest using diagnostic tools for assessing the severity of disease which will eventually reduce over-use of antibiotics and avoid the emergence of AMR [34–36].
Interventions are always a choice for improvement . Good pharmacy practice (GPP) is a landmark standard for achieving rational, cost-effective, and responsible use of medicines to counter abuse of antibiotics and halt AMR. In Pakistan, in regards to AMR, the Ministry of National Health Services Regulations & Coordination Government of Pakistan (MNHSRC) devised a National Action Plan in the year 2017; in which weak curricula of professional education and lack of AMR awareness among professionals are pinpointed as weaknesses of the system . Our findings are in line with the results presented in a study conducted in the physicians of Lahore which, iterate awareness about antibiotics to all the stakeholders of the healthcare profession . Another study in Lahore demonstrated that low-dose and extensive use of broad-spectrum antimicrobials due to ease of access from pharmacies is responsible for high rates of AMR in Pakistan . A study conducted by Saleem et al in Lahore demonstrated that co-amoxiclav, levofloxacin, ciprofloxacin, and third-generation cephalosporins were among the most widely consumed antimicrobials from private healthcare institutions and pharmacies . If the use of such antimicrobials goes unchecked, it results in more resistant strains of microorganisms such as the outbreak of extensively drug-resistant (XDR) Typhoid in Hyderabad, Pakistan in 2016 .
According to a broad brush estimate of the global economic cost of antimicrobial drug resistance by 2050, the continually escalated resistance by 2050 will contribute to the death of 10 million people per year. There will be a reduction of 2-3.5% in Gross Domestic Product (GDP) which would cost the world up to 100 trillion United States Dollar .
In this context, the role of health authorities is very important; the Government of Pakistan should prioritize the issue of escalating AMR and formulate its containment strategies, however, there have not been sufficient resources allocated so far for this . Efforts should be made to educate healthcare professionals who deal with drugs such as; pharmacists and physicians regarding the appropriate use of antibiotics to reduce the likelihoods of AMR . Moreover, the pharmacists should be present in the pharmacies and should educate the visitors about self-care and AMR as well. The patients or the public also need to be educated for the use of antibiotics upon prescription by the registered medical practitioner .