ORIGINAL ARTICLE
Pharmacists Views and Practices in Regard to Sales of Antibiotics Without a Prescription in Madinah, Saudi Arabia Anas Bahnassi, PhD Objective: The aim of this study was to investigate pharmacists views and practices in Madinah, Saudi Arabia, through conducting direct interviews including direct questions and hypothetical scenarios. Methods: A purposeful sample of 150 community pharmacists of different ethnic and educational backgrounds were approached to participate in the study. Semistructured interviews including general questions and 5 hypothetical scenarios were used for the investigation. Complete transcripts of the interviews were prepared. All transcripts were coded and categorized into main themes using a computer software. Results: Fifty-four pharmacists agreed to participate (response rate, 36%). Sale of antibiotics without prescription is commonly practiced in Saudi Arabia. Lack of legislation enforcement has exacerbated this practice. Economic hardship, patient’s age, emotional factors, and pharmacists’ self confidence in diagnosing and prescribing medications in general and antibiotics in particular were the themes included in the interviews and influenced pharmacists’decision to sell antibiotics without a prescription. Many pharmacists did not see the practice as a problem and felt capable of continuing to dispense antibiotics without a prescription. Pharmacists who saw the practice as a problem sees legislation enforcement to be the solution of the problem. Conclusions: Pharmacist views and practices are alarming. The results of this study show that this practice will continue to spread unless strict enforcement is put in place, Lack of clear understanding of the limitations of pharmacist’s scope of practice. Results of these studies can be extrapolated to other countries in the region and other countries of the similar social and professional development status. Key Words: antibiotic resistance, pharmacist’s practice, community pharmacy, unauthorized dispensing, qualitative analysis (J Patient Saf 2014;00: 00Y00)
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any recent studies have shown increased antibiotic resistance by different bacterial species over the last decades in Saudi Arabia.1Y6 Antibiotic resistance is directly related to the increased use of antibiotics among human communities.7Y15 Although antibiotic resistance has been studied in developed countries, these studies are limited in developing countries where the threat of antibiotic resistance is alarming.8,9 Antibiotic resistance rates are high in communities where the sale of antibiotics without a prescription is commonly practiced.16,18 Until now, no studies have shown that the nonprescription antibiotic use is worse in developing antibiotic resistance than equally frequent prescription antibiotic use.13Y15 Nonprescription use, however, is associated with short treatment courses16Y18 and inappropriate drug and dose selection.16,18,19 Antibiotics have From the Taibah University, Al Madinah Al Munawwarah, Saudi Arabia. Correspondence: Anas Bahnassi, PhD, Taibah University, PO Box 344, Al Madinah Al Munawwarah, Saudi Arabia (email: [email protected]). The author discloses no conflict of interest. Copyright * 2014 by Lippincott Williams & Wilkins
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been openly sold by community pharmacists without a prescription in many developing countries including the majority of the Arab states.16,20,21 This practice has increased the burden of antibiotic resistance and hospitalization on the health systems in different countries around the world.12,16,22 Legal provisions exist in Saudi Arabia to govern the licensing and prescribing practices of prescribers. Saudi laws restrict the dispensing of medications by prescribers or the sale of antibiotics without a prescription,23 yet these regulations are not strictly enforced.9 A recent study has addressed the problem in one region of Saudi Arabia, focusing on specific clinical scenarios related to major concerns that need to be addressed by pharmacists. The study used patients simulated by actors and showed overwhelming practice of inappropriate antibiotic dispensing by pharmacists without a prescription but did not collect pharmacists’ views and attitudes towards the practice.24 Because no clear evidence that dispensing antibiotics without a prescription result in less appropriate use than prescribed ones, studies suggest that physicians, pharmacists, and patients might be equally participating in the spread of antibiotic resistance through the overuse of antibiotics.25,26 Dispensing antibiotics in still an alarming practice in many countries especially developing countries,9,19 many factors contribute to the spread of this practice including: lack of pharmacists’ knowledge, pressure from customers, financial incentives from the pharmaceutical industry, and the business nature of pharmacies.27,28 In this study, we directly approached the participating pharmacists for interviews providing them with hypothetical clinical scenarios with no preset answers to explore their views, attitudes, and practices. The goal was to investigate the magnitude and the aspects of this practice from the pharmacist perspective and suggest approaches to tackle the problem from the pharmacist’s point of view.
MATERIALS AND METHODS Sample Selection A purposeful sample of 150 registered community pharmacists was selected. All the pharmacists were based in the metropolitan city of Al Madinah Al Munawwarah, Saudi Arabia, a culturally and ethnically diverse city with a huge percentage of expats and visitors from all over the world. The selected pharmacists represented most ethnic backgrounds working in retail pharmacy in Saudi Arabia, including Middle Eastern, Indian, and African. Most participating pharmacists were Egyptians of Middleastern/African background. The selection of the pharmacies was based on the type of clients they served. Some of the selected pharmacies, located in the downtown area, primarily serve visitors to Al Madinah (Pilgrims), whereas other pharmacies located in residential areas and primarily served citizens and expats in the city.
Interview Structure Qualitative analysis was used to conduct this study. Pharmacists were asked for participation through individual visits www.journalpatientsafety.com
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during down times. The participation in the interview process was voluntary, All Pharmacists were assured not be penalized for expressing their honest opinions and were reassured anonymity and confidentiality of their personal data by applying a coding ID system that does not include the pharmacist’s name or personal information. A semistructured interview guide was developed and used during the interview process; it included general practice questions and 5 hypothetical scenarios adapted from studies conducted earlier.29Y31 Part of the general questions was pharmacist’s background including pharmacists’ age, socio-ethnic background, school and year of graduation, and working experience. The other part was related to the dispensing practice of antibiotics without a prescription. Questions included; the frequency of customers asking for antibiotics without a prescription, if the pharmacist question the reason for customer’s request for antibiotics, Most common indications for antibiotics sold without a prescription, side-effects related to the use of antibiotics, and the steps of counseling provided when dispensing antibiotics without a prescription all questions are listed in Table 1. All steps of the interview’s protocol were reviewed and approved by the clinical pharmacy department at the faculty of pharmacy at Taibah University for ethical conduct and participants’ rights and confidentiality protecti on.32
Hypothetical Scenarios Five hypothetical scenarios based on realistic incidents have been adapted to make them relevant to the practice of our interviewed pharmacists. Our scenarios were structured similarly to other scenarios used in previous studies.29Y31 The themes of the hypothetical scenarios are listed in Table 2. The scenarios explored pharmacists’ views regarding the use and supply of antibiotics in different situations. All scenarios where
TABLE 1. Questions Related to Pharmacists Views and Practices Regarding Selling Antibiotics Without a Prescription Question 1 2
3 4 5 6 7 8 9 10
2
Please answer the following questions to the best of your ability reflecting your real everyday practice: How many customers ask for an antibiotic everyday without providing a valid prescription? Do you always ask for the indication of using the antibiotic? € Yes € No What is the reason that patients provide when they ask for the antibiotic? What is the antibiotic mostly sold without a prescription in your pharmacy? What are the most important points that you cover when you counsel your patient about antibiotics sold without a prescription? What are the most side effects that patient returns to your pharmacy and complains about? How do you manage the side effects if your patient returns complaining about them? How often do you suggest a change to the antibiotic that the patient has asked for? In your opinion, what is the impact of selling antibiotics without a prescription on the health system in Saudi Arabia? If you think that the sale of antibiotics without a prescription is a problem, what are the steps that need to be taken to stop this practice?
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TABLE 2. Outlines of the 5 Hypothetical Scenarios Scenario Explain your reasons for supplying or not supplying antibiotics in the following situations without a prescription. 1 A pilgrim (visitor) requesting an antibiotic to treat his sore throat with no travel insurance to see a physician. 2 A pregnant woman with severe and obvious sinusitis. 3 A previously diagnosed urinary tract infection that was treated with a course of antibiotics by a physician and you personally dispensed the medication the patient. 4 A usual customer who is requesting an antibiotic to treat his 5-year-old son’s ear infection. 5 A pharmacist-diagnosed skin infection. (diagnosed by the interviewed pharmacist)
provided to the interviewed pharmacist with no extra details, translation to Arabic was provided to certain pharmacists when needed without any extra details to the scenario. The interview questions and hypothetical scenarios were piloted with three pharmacists. All interviews were conducted by the primary investigator the interviews were recorded using detailed handwritten notes. Pharmacists were encouraged to read the written notes taken and explain their views freely in detail and any ambiguities were clarified at the time of the interviews.
Scenario Analysis Complete transcripts of the interviews were prepared. All transcripts were coded and categorized into main themes using ATLAS.ti,7 software for managing qualitative data. All results were presented according to a certain theme with an indication of the numbers of pharmacists’ responses to the hypothetical scenarios (Table 3).
RESULTS One-hundred fifty pharmacists were approached to participate in our study; only 54 consented to participate (36% response rate). All pharmacists interviewed were male subjects because it is very uncommon for female pharmacists to practice in community pharmacies in Saudi Arabia. The age of all pharmacists interviewed ranged between 32 and 49 years old. They were overwhelmingly Egyptian expatriates (98%) except for a one Pakistani pharmacist interviewed. Community practice experience ranged between 2 and 5 years (35%), 5 to 10 years (42%), and the rest had more than 10 years of community practice experience (33%). All pharmacists had their pharmacy qualification from their country of origin except for one pharmacist who had a master degree from the UK. Antibiotic dispensing behavior questions provided us with an understanding of the pharmacists’ opinions and behavior when dispensing antibiotics without proper prescriptions, the results are listed in Table 2. On average, the interviews took about 15 to 20 minutes. Pharmacists’ responses to the hypothetical scenarios show that all of them would supply antibiotics without prescription. Pharmacists were more likely to provide the antibiotics when the patient was prescribed them before for the same symptoms (Scenario 3) or when the infection can easily be identified by the pharmacist (Scenario 5). Responses to the first scenario showed that pharmacists’ sympathy with religious visitors (pilgrims) with no insurance can easily affect their professional judgment. A * 2014 Lippincott Williams & Wilkins
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Pharmacists Views and Practices in Saudi Arabia
TABLE 3. Pharmacists’ Opinions and Behavior When Dispensing Antibiotics Without Prescriptions Questions Trend Frequency of unauthorized antibiotic dispensing The most common dispensed antibiotic without a prescription Use Indication
Pharmacist involvement in choosing the antibiotic type Percentage of patients returned due to ineffective/insufficient treatment Adverse reactions resulted from the antibiotics dispensed Pharmacists recommendation of managing adverse reactions Points stressed when the pharmacist dispensed antibiotics without a prescription (out of 100%) Pharmacists stand on unauthorized dispensing of antibiotics
Pharmacists suggestions to limit unauthorized dispensing of antibiotics (out of 100%)
Pharmacists Feedback Very Often 63% First Amoxicillin Pharmacist does not ask for reason
Often 21% Second Amoxicillin + Clavaulinate Obvious infection that can be diagnosed by the pharmacist 36% 42% Pharmacist is involved 43% 23%
Diarrhea 36% Stopping the antibiotic
Itching/Rash 18% Treat the reaction
33% 41% Finish the antibiotic Discuss interactions even when symptoms with other medications are relieved 28% 32% A serious problem Required in most cases due to high physicians’ fee 9% Enforce regulations by health authorities 70%
Interview Themes Five key themes relating to pharmacists’ views and practices regarding the use of nonprescription antibiotics emerged while analyzing the data; these are as follows: 1. Economic hardship, 2. Concurrent physiological state, 3. Reuse of an antibiotic, 4. Patient’s age category, and 5. Pharmacist’s knowledge and experience. These themes are discussed in detail below. Exact quotes of participating pharmacists are used to clarify each theme that developed from the interviews conducted.
Economic Hardship The first theme to emerge was pharmacists’ awareness of the economic hardship that the patient endures. Sympathy with religious visitor and patients with no medical insurance were decisive factors on whether or not to supply the antibiotics. ‘‘A pilgrim is a visitor of God we need to make life easier to him/her.’’ The sympathy with the pilgrim’s visit and all the hardship they endure, highly affected the pharmacist’s decision to provide antibiotics without a prescription. ‘‘Pilgrims already suffer a lot, this is the least we can do to help them.’’
Unusually 2%
Third Azithromycin Reuse an antibiotic they have used before 22% Pharmacist is not involved 57%
Severe Allergic Reaction 1% Replace with another antibiotic 12% Discuss possible adverse reactions
58% Required in most cases due to limited physicians’ accessibility 24% 21% Stop pharmacists’ dispensing Educational programs of antibiotics without to the public authorization 21%
summary of the pharmacists’ responses to the five hypothetical scenarios is presented in Table 3.
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Usually 14%
None Reported 45% Refer to the physician 14% Discusses dose and dosing regimens 82% Not a problem
47%
26%
In most cases, pharmacists felt that they have moral and may be ‘‘religious’’ obligation to provide antibiotics to pilgrims, especially the elderly. ‘‘Most pilgrims are poor and old and cannot afford the long lines in hospitals or the high costs of private clinics.’’ Some pharmacists stated that in times of pilgrimage, where health professionals are scarce, clinics are overcrowded, and people are in real need for antibiotics; pharmacists ethically should use their judgment and supply patients with the proper antibiotics when antibiotic treatment is required.
Concurrent Physiological State Pharmacists were more reluctant to dispense antibiotics to pregnant women. The coexistence of a physiological state ‘‘pregnancy’’ provided a warning for many of them to seek a physician’s opinion. In Scenario 2, when a pregnant woman asked for an antibiotic for her sinusitis, pharmacists provided answers like: ‘‘Pregnant women need to consult their gynecologists first unless they had the antibiotic before.’’ Scenario 2 was by far the situation with the highest percentage of pharmacists’ decline to provide antibiotics without a prescription. ‘‘I am not sure if I do it since there may be a risk to the fetus.’’ Pharmacists considered being ethical and professional very important. They felt they have a moral responsibility to report these cases to a physician. Many reasons were behind this decision; however, the main drive for their denial to provide the www.journalpatientsafety.com
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antibiotic was their concerns about the well-being of the mother and more importantly of the coming baby.
Reuse of an Antibiotic Pharmacists felt comfortable repeating an antibiotic course for a patient who had that antibiotic prescribed for the same indication before. In Scenario 3, pharmacists stated that a course of antibiotic for a recurrent episode of urinary tract infection is a very common practice in women while they believed that it may require more professional attention in men. ‘‘Honestly? I usually do. I know I shouldn’t, but if it is a woman I would.’’ Few pharmacists were reluctant especially when the gender of the patient is not identified. ‘‘What if I was wrong? I am not sure’’ or ‘‘It depends on the type of antibiotic, the gender of the patient, and the type of the infection.’’ For the majority of the pharmacists interviewed, it was common practice to provide a renewal on antibiotic prescribed before; they believed that because the medication was used and worked before for the patient, there was no reason to hold it. ‘‘Yes, it’s OK. I’d sell it to the patient again and if anything wrong happens then the patient can check with the doctor.’’
Patient’s Age Category When it came to dispensing antibiotics to children, pharmacists were a little reluctant, but not as much as they were for pregnant women. They did not believe for the most part that antibiotics are harmful for children. ‘‘Antibiotics are approved for children.’’ In scenario 4, Pharmacists did not want to turn down their usual customers and lose the business, however, none of them stated this clearly, instead, they justified their decision to provide the antibiotic to the father. ‘‘I do not think the antibiotic will hurt the child if does not do him/her any good.’’ The few pharmacists who declined the sale of antibiotics without a prescription to children had concerns about side effects including dehydration related to diarrhea or the dose suitability to the child. ‘‘No, not for a child. There are many safety issues involved like dehydration.’’
Pharmacist’s Knowledge and Experience All of the pharmacists interviewed finished their pharmacy degree in countries other than Saudi Arabia. No differences in pharmacists’ responses to the hypothetical scenarios appeared based on the country where the pharmacist obtained his pharmacy qualification. Most pharmacists said that they would apply their professional judgment to supply antibiotics without prescription. Some felt that they were well trained and knowledgeable to treat and diagnose various infections. ‘‘I believe I am well trained and qualified to provide antibiotics to patients.’’ Most Pharmacists who felt that they had the training and the knowledge, stated that they would only feel confident to manage certain cases of infection, like wound infection, urinary tract infections, and throat infection. They stated that physician’s involvement is only necessary when the infection is complex and requires regular follow-up. Only few of the pharmacists interviewed showed adequate awareness of antibiotic resistance as a driving factor sell antibiotics without prescription.
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‘‘I do not abuse antibiotics we need to be careful about resistance.’’ Pharmacists’ responses were collected and categorized in Table 4; most pharmacists provided an antibiotic without asking for the indication. When patients asked the pharmacist to suggest an antibiotic, amoxicillin containing antibiotics topped the list of antibiotics requested by patients, recommended by pharmacists and sold without a prescription. Most pharmacists did not address dispensing of antibiotics without a prescription as a problem as they felt it is required because of limited physician’s accessibility in public health centers and the high fee required in private clinics. More than 50% of pharmacists have dispensed the antibiotic according to patient’s preference with very little or no pharmacist’s involvement in making the decision. The majority of pharmacists did not emphasize the importance of completing the antibiotic regimen; for the most part, patient’s counseling was limited to explaining the frequency of dosing and listing the expected side effects with limited individualized pharmaceutical care plan. None of the answers we had included asking patients about allergies, although some pharmacists asked if the patient had used the antibiotic before. When side effects appeared in patients, most pharmacists chose to treat the side effect; others stopped the antibiotic without providing any alternative, which can highly contribute to the spread of antibiotic resistance. Pharmacists who recognized sale of antibiotic as a problem or kind of a problem that is required in some or many cases agreed that this can only be stopped by enforcing regulations already exist by health authorities. Others felt that pharmacists should refuse such practice; many suggested improving public awareness through educational programs.
DISCUSSION This study confirms that the sale of antibiotics without prescription is a very common practice in Saudi Arabia. Laws regulating the sale of antibiotics in this country are basic and not enforced. All pharmacists interviewed were willing to sell antibiotics without a prescription. This agreed with a study conducted in Kathmandu, Nepal, where all pharmacists contacted by simulated patients engaged in diagnostic and therapeutic behavior beyond their scope of practice or legal mandate.17 Obtaining antibiotic without a prescription in the developed countries is limited. In the United States, several studies found considerable use of leftover antibiotics,32Y35 drugs obtained from a friend or family member, a pharmacy, or from outside the US36,37 This happened at larger scales in developing countries.38,39 The majority of interviewed pharmacists did not ask for possible allergies, pregnancy status, the usage indication, the duration of therapy, nor they cautioned for side effects when they dispensed the antibiotic, which agrees with results from other parts of the country.24 This sacrifices one of the pharmacist’s most basic duties to ensure the patient’s safety.40
TABLE 4. Pharmacists Feedback to the Hypothetical Scenarios Scenario No. (N = 54) 1 2 3 4 5
Yes (%)
No (%)
47 (87%) 2 (3.7%) 24 (44.4%) 11 (20.4%) 50 (92.6%) 0 (0%) 43 (79.6%) 6 (11.1%) 49 (90.7) 1 (1.9%)
Not Sure (%) 5 (9.3%) 19 (35.2%) 4 (7.4%) 5 (9.3%) 4 (7.4%)
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In this study, the majority of pharmacists did not have any consideration to the legislation in their decision to sell antibiotics without a prescription. The most driving factors that seemed to affect pharmacists’ views, decisions, and practices regarding the sale of antibiotics without prescription were sympathy with the economic hardship the patient may endure, followed by the concurrent physiological states that the patient may have, patient’s age, patient’s previous exposure to the antibiotic, and pharmacist’s knowledge and experience. These factors were different from those stated in studies conducted in other places.17Y19,24,29 This was clearly evident in the all scenarios presented to the participating pharmacists.
Study Limitations Our study relied mainly on hypothetical scenarios and pharmacists’ self reporting. The scenarios were brief, and addressed specific states, therefore pharmacists might not have fully immersed in them. Also, this may have limited the quality and depth of this practice assessment. Pharmacists were suspicious of the implications surrounding the study in general and the scenarios in particular, this might have affected their responses to reflect what they think is the best possible practice in comparison to their actual practice. Our interviews were relatively short, and were conducted during working hours. The interviews were interrupted by customers and technicians quite a few times, which may have affected the quality of the interview and the time the pharmacists could afford to complete the interview. The study response rate was small (54/150), pharmacists were either busy, suspicious, or not interested in participating in the study. Future studies can overcome these limitations by conducting the interviews in continuous education setting, where pharmacists have designated duration of time to answer the scenarios anonymously with no customers’ pressure.
Study External Validity Pharmacists in Saudi Arabia are mostly from other developing countries (Not Saudis), these pharmacists brought the same practices they had in their home countries to Saudi Arabia. Lack of law enforcement and customers’ insistence on getting the medication helped this practice to be predominant.41 Thus, the results of this study can be extrapolated to other regions within Saudi Arabia and other similar developing countries who share the same social and legislative situations.9Y11
CONCLUSIONS The interviews revealed some unexpected views and practices in regard to unauthorized antibiotic dispensing without prescription in community pharmacists that could jeopardize patient’s safety and welfare. In addition to being unprofessional and illegal, this practice may result in overdose, treatment failure (especially if inappropriate antibiotics or treatment regimen were selected), unnecessary costs and increased potential for developing antibiotic resistance. Unexpectedly, most pharmacists did not recognize this practice as a problem and could not identify the limitations of their scope of practice. They felt comfortable to diagnose, prescribe, and dispense antibiotics which confirms previous study performed in another region of Saudi Arabia24 but not in other developing countries.17 Although sales of antibiotics without a prescription are illegal in Saudi Arabia, this does not hold pharmacists from selling antibiotics without a prescription. Many of the pharmacists who see this practice as a problem agree that law enforcement will make other pharmacists fear the consequences of these practices. Pharmacists need to regularly update their * 2014 Lippincott Williams & Wilkins
Pharmacists Views and Practices in Saudi Arabia
legal and professional knowledge, as many are not clear about the scope of practice for pharmacists and its limitations. Additional studies are required to study the impact of this practice on the overall health system in Saudi Arabia, including the prescribing behavior of antibiotics by local physicians, the impact of the unnecessary antibiotic side effects on the patient’s quality of life and the overall antibiotic resistance in the country. REFERENCES 1. Zowawi HM, Balkhy HH, Walsh TR, et al. A-lactamase production in key gram-negative pathogen isolates from the Arabian peninsula. Clin Microbiol Rev. 2013;26:361Y380. 2. Aly M, Balkhy HH. The prevalence of antimicrobial resistance in clinical isolates from Gulf Cooperation Council Countries. Antimicrob Resist Infect Control. 2012;19:26. 3. Yezli S, Shibl AM, Livermore DM, et al. Antimicrobial resistance among gram-positive pathogens in Saudi Arabia. J Chemother. 2012;33:750Y755. 4. Ellis ME, al-Hajjar S, Bokhari H, et al. High proportion of multi-drug resistant mycobacterium tuberculosis in Saudi Arabia. Scand J Infect Dis. 1996;28:591Y595. 5. Al-Tawfiq JA. Increasing antibiotic resistance among isolates of Escherichia coli recovered from inpatients and outpatients in a Saudi Arabian hospital. Infect Control Hosp Epidemiol. 2006;27:748Y753. 6. Bilal NE, Gedebou M. Clinical and community strains of Klebsiella pneumoniae: multiple and increasing rates of antibiotic resistance in Abha, Saudi Arabia. Br J Biomed Sci. 2000;57:185Y191. 7. Goossens H. Antibiotic consumption and link to resistance. Clin Microbiol Infect 2009;15:12Y15. 8. Okeke IN, Laxminarayan R, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect Dis. 2005;5:481Y493. 9. Okeke IN, Klugman KP, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect Dis. 2005;5:568Y580. 10. Okeke IN, Lamikanra A, Edelman R. Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerg Infect Dis. 1999;5:18Y27. 11. Kunin CM. Use of antimicrobial drugs in developing countries. Int J Antimicrob Agents. 1995;5:107Y113. 12. Kunin CM, Johansen KS, Worning AM, et al. Report of a symposium in use and abuse of antibiotics worldwide. Rev Infect Dis. 1990;12:12Y19. 13. Col NF, O’Connor RW. Estimating worldwide current antibiotic usage: report of task force 1. Rev Infect Dis. 1987;9(suppl 3):232Y243. 14. Finley RL, Collingnon P, Joakim Larsson DG, et al. The scourge of antibiotic resistance: the important role of the environment. Clin Infect Dis. 2013;57:704Y710. 15. Ashbolt NJ, Amezquita A, Backhaus T, et al. Human health risk assessment (HHRA) for environmental development and transfer of antibiotic resistance. Environ Health Perspect. 2013. Available at: http://dx.doi.org/10.1289/ehp.1206316. Accessed August 20, 2013. 16. Awad A, Eltayeb I, Matowe L, et al. Self-medication with antibiotics and antimalarials in the community of Khartoum State, Sudan. J Pharm Pharm Sci. 2005;8:326Y331. 17. Wachter DA, Joshi MP, Rimal B. Antibiotic dispensing by drug retailers in Kathmandu, Nepal. Trop Med Int Health. 1999;4:782Y788. 18. Van Duong D, Binns CW, Van Le T. Availability of antibiotics as over-the-counter drugs in pharmacies: a threat to public health in Vietnam. Trop Med Int Health. 1997;2:1133Y1139.
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19. Bartoloni A, Cutts F, Leoni S, et al. Patterns of antimicrobial use of antimicrobial resistance in Bolivia. Trop Med Int Health. 1998;3:116Y123.
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31. Medow MA, Wilt TJ, Dysken S, et al. Effect of written and computerized decision support aids for the U.S. Agency for Health Care Policy and Research depression guidelines on the evaluation of hypothetical clinical scenarios. Medical Decision Making. 2001;21:344Y356.
21. Amidi S, Ajamee G, Sadeghi Hr, et al. Dispensing drugs without prescription and treating patients by pharmacy attendants in Shiraz, Iran. Am J Public Health. 1978;68:395Y497. 22. Liss RH, Batchelor FR. Economic evaluations of antibiotic use and resistanceVa perspective: report of task force 6. Rev Infect Dis. 1987;9(suppl 3):297Y312. 23. Saleh I. Licensing and registration of drugs in Saudi Arabia: appropriate use of medicines. Proceedings of the First Drug Symposium in Saudi Arabia, College of Pharmacy, King Saud University, 1979; 18Y20.
32. Grigoryan L, Haaijer-Rysjamp FM, Burgerhof JG, et al. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis. 2006;12:452Y45. 33. Vanden Eng J, Marcus R, Hadler JL, et al. Consumer attitudes and use of antimicrobial drugs. Emerg Infect Dis. 2003;9:1128Y1135. 34. Larson E, Lin SX, Gomez-Duarte C Antibiotic use in Hispanic households, New York City. Emerg Infect Dis. 2003;9:1096Y1102.
24. Bin Abdulhak AA, Altannir MA, Almansor MA, et al. Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: a cross sectional study. BMC Public Health. 2011;11:538.
35. McKee MD, Mills L, Mainous AG III. Antibiotic use for the treatment of upper respiratory infections in a diverse community. J Fam Pract. 1999;48:993Y996.
25. Holloway KA, Mathai E, Sorensen T, et al. A Community-Based Surveillance of Antimicrobial Use and Resistance in Source-Constrained Settings. Report of Five Pilot Projects. Geneva, Switzerland: World Health Organization; 2009.
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37. Ceaser S, Wurtz R. ‘‘Leftover’’ antimicrobial drugs in the medicine cabinet. Ann Intern Med. 2000;133:74. 38. Emeka PM, Al-Omar MJ, Khan TM. A qualitative study exploring role of community pharmacy in the irrational use and purchase of nonprescription antibiotics In Al Ahsa. Eur J Gen Med. 2012;9:230Y234. 39. Kardas P, Pechere JC, Hughes DA, et al. A global survey of antibiotic leftovers in the outpatient setting. Int J Antimicrob Agents. 2007;30:530Y536. 40. Deuster S, Roten I, Muehlebach S. Implementation of treatment guidelines to support judicious use of antibiotic therapy. J Clin Pharm Ther. 2010;35:71Y78. 41. Bawazir SA. Prescribing pattern at community pharmacies in Saudi Arabia. Int Pharm J. 1992;6:222Y224.
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Pharmacists Views and Practices in Regard to Sales of Antibiotics Without a Prescription in Madinah, Saudi Arabia Anas Bahnassi, PhD Objective: The aim of this study was to investigate pharmacists views and practices in Madinah, Saudi Arabia, through conducting direct interviews including direct questions and hypothetical scenarios. Methods: A purposeful sample of 150 community pharmacists of different ethnic and educational backgrounds were approached to participate in the study. Semistructured interviews including general questions and 5 hypothetical scenarios were used for the investigation. Complete transcripts of the interviews were prepared. All transcripts were coded and categorized into main themes using a computer software. Results: Fifty-four pharmacists agreed to participate (response rate, 36%). Sale of antibiotics without prescription is commonly practiced in Saudi Arabia. Lack of legislation enforcement has exacerbated this practice. Economic hardship, patient’s age, emotional factors, and pharmacists’ self confidence in diagnosing and prescribing medications in general and antibiotics in particular were the themes included in the interviews and influenced pharmacists’decision to sell antibiotics without a prescription. Many pharmacists did not see the practice as a problem and felt capable of continuing to dispense antibiotics without a prescription. Pharmacists who saw the practice as a problem sees legislation enforcement to be the solution of the problem. Conclusions: Pharmacist views and practices are alarming. The results of this study show that this practice will continue to spread unless strict enforcement is put in place, Lack of clear understanding of the limitations of pharmacist’s scope of practice. Results of these studies can be extrapolated to other countries in the region and other countries of the similar social and professional development status. Key Words: antibiotic resistance, pharmacist’s practice, community pharmacy, unauthorized dispensing, qualitative analysis (J Patient Saf 2014;00: 00Y00)
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any recent studies have shown increased antibiotic resistance by different bacterial species over the last decades in Saudi Arabia.1Y6 Antibiotic resistance is directly related to the increased use of antibiotics among human communities.7Y15 Although antibiotic resistance has been studied in developed countries, these studies are limited in developing countries where the threat of antibiotic resistance is alarming.8,9 Antibiotic resistance rates are high in communities where the sale of antibiotics without a prescription is commonly practiced.16,18 Until now, no studies have shown that the nonprescription antibiotic use is worse in developing antibiotic resistance than equally frequent prescription antibiotic use.13Y15 Nonprescription use, however, is associated with short treatment courses16Y18 and inappropriate drug and dose selection.16,18,19 Antibiotics have From the Taibah University, Al Madinah Al Munawwarah, Saudi Arabia. Correspondence: Anas Bahnassi, PhD, Taibah University, PO Box 344, Al Madinah Al Munawwarah, Saudi Arabia (email: [email protected]). The author discloses no conflict of interest. Copyright * 2014 by Lippincott Williams & Wilkins
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been openly sold by community pharmacists without a prescription in many developing countries including the majority of the Arab states.16,20,21 This practice has increased the burden of antibiotic resistance and hospitalization on the health systems in different countries around the world.12,16,22 Legal provisions exist in Saudi Arabia to govern the licensing and prescribing practices of prescribers. Saudi laws restrict the dispensing of medications by prescribers or the sale of antibiotics without a prescription,23 yet these regulations are not strictly enforced.9 A recent study has addressed the problem in one region of Saudi Arabia, focusing on specific clinical scenarios related to major concerns that need to be addressed by pharmacists. The study used patients simulated by actors and showed overwhelming practice of inappropriate antibiotic dispensing by pharmacists without a prescription but did not collect pharmacists’ views and attitudes towards the practice.24 Because no clear evidence that dispensing antibiotics without a prescription result in less appropriate use than prescribed ones, studies suggest that physicians, pharmacists, and patients might be equally participating in the spread of antibiotic resistance through the overuse of antibiotics.25,26 Dispensing antibiotics in still an alarming practice in many countries especially developing countries,9,19 many factors contribute to the spread of this practice including: lack of pharmacists’ knowledge, pressure from customers, financial incentives from the pharmaceutical industry, and the business nature of pharmacies.27,28 In this study, we directly approached the participating pharmacists for interviews providing them with hypothetical clinical scenarios with no preset answers to explore their views, attitudes, and practices. The goal was to investigate the magnitude and the aspects of this practice from the pharmacist perspective and suggest approaches to tackle the problem from the pharmacist’s point of view.
MATERIALS AND METHODS Sample Selection A purposeful sample of 150 registered community pharmacists was selected. All the pharmacists were based in the metropolitan city of Al Madinah Al Munawwarah, Saudi Arabia, a culturally and ethnically diverse city with a huge percentage of expats and visitors from all over the world. The selected pharmacists represented most ethnic backgrounds working in retail pharmacy in Saudi Arabia, including Middle Eastern, Indian, and African. Most participating pharmacists were Egyptians of Middleastern/African background. The selection of the pharmacies was based on the type of clients they served. Some of the selected pharmacies, located in the downtown area, primarily serve visitors to Al Madinah (Pilgrims), whereas other pharmacies located in residential areas and primarily served citizens and expats in the city.
Interview Structure Qualitative analysis was used to conduct this study. Pharmacists were asked for participation through individual visits www.journalpatientsafety.com
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during down times. The participation in the interview process was voluntary, All Pharmacists were assured not be penalized for expressing their honest opinions and were reassured anonymity and confidentiality of their personal data by applying a coding ID system that does not include the pharmacist’s name or personal information. A semistructured interview guide was developed and used during the interview process; it included general practice questions and 5 hypothetical scenarios adapted from studies conducted earlier.29Y31 Part of the general questions was pharmacist’s background including pharmacists’ age, socio-ethnic background, school and year of graduation, and working experience. The other part was related to the dispensing practice of antibiotics without a prescription. Questions included; the frequency of customers asking for antibiotics without a prescription, if the pharmacist question the reason for customer’s request for antibiotics, Most common indications for antibiotics sold without a prescription, side-effects related to the use of antibiotics, and the steps of counseling provided when dispensing antibiotics without a prescription all questions are listed in Table 1. All steps of the interview’s protocol were reviewed and approved by the clinical pharmacy department at the faculty of pharmacy at Taibah University for ethical conduct and participants’ rights and confidentiality protecti on.32
Hypothetical Scenarios Five hypothetical scenarios based on realistic incidents have been adapted to make them relevant to the practice of our interviewed pharmacists. Our scenarios were structured similarly to other scenarios used in previous studies.29Y31 The themes of the hypothetical scenarios are listed in Table 2. The scenarios explored pharmacists’ views regarding the use and supply of antibiotics in different situations. All scenarios where
TABLE 1. Questions Related to Pharmacists Views and Practices Regarding Selling Antibiotics Without a Prescription Question 1 2
3 4 5 6 7 8 9 10
2
Please answer the following questions to the best of your ability reflecting your real everyday practice: How many customers ask for an antibiotic everyday without providing a valid prescription? Do you always ask for the indication of using the antibiotic? € Yes € No What is the reason that patients provide when they ask for the antibiotic? What is the antibiotic mostly sold without a prescription in your pharmacy? What are the most important points that you cover when you counsel your patient about antibiotics sold without a prescription? What are the most side effects that patient returns to your pharmacy and complains about? How do you manage the side effects if your patient returns complaining about them? How often do you suggest a change to the antibiotic that the patient has asked for? In your opinion, what is the impact of selling antibiotics without a prescription on the health system in Saudi Arabia? If you think that the sale of antibiotics without a prescription is a problem, what are the steps that need to be taken to stop this practice?
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TABLE 2. Outlines of the 5 Hypothetical Scenarios Scenario Explain your reasons for supplying or not supplying antibiotics in the following situations without a prescription. 1 A pilgrim (visitor) requesting an antibiotic to treat his sore throat with no travel insurance to see a physician. 2 A pregnant woman with severe and obvious sinusitis. 3 A previously diagnosed urinary tract infection that was treated with a course of antibiotics by a physician and you personally dispensed the medication the patient. 4 A usual customer who is requesting an antibiotic to treat his 5-year-old son’s ear infection. 5 A pharmacist-diagnosed skin infection. (diagnosed by the interviewed pharmacist)
provided to the interviewed pharmacist with no extra details, translation to Arabic was provided to certain pharmacists when needed without any extra details to the scenario. The interview questions and hypothetical scenarios were piloted with three pharmacists. All interviews were conducted by the primary investigator the interviews were recorded using detailed handwritten notes. Pharmacists were encouraged to read the written notes taken and explain their views freely in detail and any ambiguities were clarified at the time of the interviews.
Scenario Analysis Complete transcripts of the interviews were prepared. All transcripts were coded and categorized into main themes using ATLAS.ti,7 software for managing qualitative data. All results were presented according to a certain theme with an indication of the numbers of pharmacists’ responses to the hypothetical scenarios (Table 3).
RESULTS One-hundred fifty pharmacists were approached to participate in our study; only 54 consented to participate (36% response rate). All pharmacists interviewed were male subjects because it is very uncommon for female pharmacists to practice in community pharmacies in Saudi Arabia. The age of all pharmacists interviewed ranged between 32 and 49 years old. They were overwhelmingly Egyptian expatriates (98%) except for a one Pakistani pharmacist interviewed. Community practice experience ranged between 2 and 5 years (35%), 5 to 10 years (42%), and the rest had more than 10 years of community practice experience (33%). All pharmacists had their pharmacy qualification from their country of origin except for one pharmacist who had a master degree from the UK. Antibiotic dispensing behavior questions provided us with an understanding of the pharmacists’ opinions and behavior when dispensing antibiotics without proper prescriptions, the results are listed in Table 2. On average, the interviews took about 15 to 20 minutes. Pharmacists’ responses to the hypothetical scenarios show that all of them would supply antibiotics without prescription. Pharmacists were more likely to provide the antibiotics when the patient was prescribed them before for the same symptoms (Scenario 3) or when the infection can easily be identified by the pharmacist (Scenario 5). Responses to the first scenario showed that pharmacists’ sympathy with religious visitors (pilgrims) with no insurance can easily affect their professional judgment. A * 2014 Lippincott Williams & Wilkins
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TABLE 3. Pharmacists’ Opinions and Behavior When Dispensing Antibiotics Without Prescriptions Questions Trend Frequency of unauthorized antibiotic dispensing The most common dispensed antibiotic without a prescription Use Indication
Pharmacist involvement in choosing the antibiotic type Percentage of patients returned due to ineffective/insufficient treatment Adverse reactions resulted from the antibiotics dispensed Pharmacists recommendation of managing adverse reactions Points stressed when the pharmacist dispensed antibiotics without a prescription (out of 100%) Pharmacists stand on unauthorized dispensing of antibiotics
Pharmacists suggestions to limit unauthorized dispensing of antibiotics (out of 100%)
Pharmacists Feedback Very Often 63% First Amoxicillin Pharmacist does not ask for reason
Often 21% Second Amoxicillin + Clavaulinate Obvious infection that can be diagnosed by the pharmacist 36% 42% Pharmacist is involved 43% 23%
Diarrhea 36% Stopping the antibiotic
Itching/Rash 18% Treat the reaction
33% 41% Finish the antibiotic Discuss interactions even when symptoms with other medications are relieved 28% 32% A serious problem Required in most cases due to high physicians’ fee 9% Enforce regulations by health authorities 70%
Interview Themes Five key themes relating to pharmacists’ views and practices regarding the use of nonprescription antibiotics emerged while analyzing the data; these are as follows: 1. Economic hardship, 2. Concurrent physiological state, 3. Reuse of an antibiotic, 4. Patient’s age category, and 5. Pharmacist’s knowledge and experience. These themes are discussed in detail below. Exact quotes of participating pharmacists are used to clarify each theme that developed from the interviews conducted.
Economic Hardship The first theme to emerge was pharmacists’ awareness of the economic hardship that the patient endures. Sympathy with religious visitor and patients with no medical insurance were decisive factors on whether or not to supply the antibiotics. ‘‘A pilgrim is a visitor of God we need to make life easier to him/her.’’ The sympathy with the pilgrim’s visit and all the hardship they endure, highly affected the pharmacist’s decision to provide antibiotics without a prescription. ‘‘Pilgrims already suffer a lot, this is the least we can do to help them.’’
Unusually 2%
Third Azithromycin Reuse an antibiotic they have used before 22% Pharmacist is not involved 57%
Severe Allergic Reaction 1% Replace with another antibiotic 12% Discuss possible adverse reactions
58% Required in most cases due to limited physicians’ accessibility 24% 21% Stop pharmacists’ dispensing Educational programs of antibiotics without to the public authorization 21%
summary of the pharmacists’ responses to the five hypothetical scenarios is presented in Table 3.
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Usually 14%
None Reported 45% Refer to the physician 14% Discusses dose and dosing regimens 82% Not a problem
47%
26%
In most cases, pharmacists felt that they have moral and may be ‘‘religious’’ obligation to provide antibiotics to pilgrims, especially the elderly. ‘‘Most pilgrims are poor and old and cannot afford the long lines in hospitals or the high costs of private clinics.’’ Some pharmacists stated that in times of pilgrimage, where health professionals are scarce, clinics are overcrowded, and people are in real need for antibiotics; pharmacists ethically should use their judgment and supply patients with the proper antibiotics when antibiotic treatment is required.
Concurrent Physiological State Pharmacists were more reluctant to dispense antibiotics to pregnant women. The coexistence of a physiological state ‘‘pregnancy’’ provided a warning for many of them to seek a physician’s opinion. In Scenario 2, when a pregnant woman asked for an antibiotic for her sinusitis, pharmacists provided answers like: ‘‘Pregnant women need to consult their gynecologists first unless they had the antibiotic before.’’ Scenario 2 was by far the situation with the highest percentage of pharmacists’ decline to provide antibiotics without a prescription. ‘‘I am not sure if I do it since there may be a risk to the fetus.’’ Pharmacists considered being ethical and professional very important. They felt they have a moral responsibility to report these cases to a physician. Many reasons were behind this decision; however, the main drive for their denial to provide the www.journalpatientsafety.com
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antibiotic was their concerns about the well-being of the mother and more importantly of the coming baby.
Reuse of an Antibiotic Pharmacists felt comfortable repeating an antibiotic course for a patient who had that antibiotic prescribed for the same indication before. In Scenario 3, pharmacists stated that a course of antibiotic for a recurrent episode of urinary tract infection is a very common practice in women while they believed that it may require more professional attention in men. ‘‘Honestly? I usually do. I know I shouldn’t, but if it is a woman I would.’’ Few pharmacists were reluctant especially when the gender of the patient is not identified. ‘‘What if I was wrong? I am not sure’’ or ‘‘It depends on the type of antibiotic, the gender of the patient, and the type of the infection.’’ For the majority of the pharmacists interviewed, it was common practice to provide a renewal on antibiotic prescribed before; they believed that because the medication was used and worked before for the patient, there was no reason to hold it. ‘‘Yes, it’s OK. I’d sell it to the patient again and if anything wrong happens then the patient can check with the doctor.’’
Patient’s Age Category When it came to dispensing antibiotics to children, pharmacists were a little reluctant, but not as much as they were for pregnant women. They did not believe for the most part that antibiotics are harmful for children. ‘‘Antibiotics are approved for children.’’ In scenario 4, Pharmacists did not want to turn down their usual customers and lose the business, however, none of them stated this clearly, instead, they justified their decision to provide the antibiotic to the father. ‘‘I do not think the antibiotic will hurt the child if does not do him/her any good.’’ The few pharmacists who declined the sale of antibiotics without a prescription to children had concerns about side effects including dehydration related to diarrhea or the dose suitability to the child. ‘‘No, not for a child. There are many safety issues involved like dehydration.’’
Pharmacist’s Knowledge and Experience All of the pharmacists interviewed finished their pharmacy degree in countries other than Saudi Arabia. No differences in pharmacists’ responses to the hypothetical scenarios appeared based on the country where the pharmacist obtained his pharmacy qualification. Most pharmacists said that they would apply their professional judgment to supply antibiotics without prescription. Some felt that they were well trained and knowledgeable to treat and diagnose various infections. ‘‘I believe I am well trained and qualified to provide antibiotics to patients.’’ Most Pharmacists who felt that they had the training and the knowledge, stated that they would only feel confident to manage certain cases of infection, like wound infection, urinary tract infections, and throat infection. They stated that physician’s involvement is only necessary when the infection is complex and requires regular follow-up. Only few of the pharmacists interviewed showed adequate awareness of antibiotic resistance as a driving factor sell antibiotics without prescription.
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‘‘I do not abuse antibiotics we need to be careful about resistance.’’ Pharmacists’ responses were collected and categorized in Table 4; most pharmacists provided an antibiotic without asking for the indication. When patients asked the pharmacist to suggest an antibiotic, amoxicillin containing antibiotics topped the list of antibiotics requested by patients, recommended by pharmacists and sold without a prescription. Most pharmacists did not address dispensing of antibiotics without a prescription as a problem as they felt it is required because of limited physician’s accessibility in public health centers and the high fee required in private clinics. More than 50% of pharmacists have dispensed the antibiotic according to patient’s preference with very little or no pharmacist’s involvement in making the decision. The majority of pharmacists did not emphasize the importance of completing the antibiotic regimen; for the most part, patient’s counseling was limited to explaining the frequency of dosing and listing the expected side effects with limited individualized pharmaceutical care plan. None of the answers we had included asking patients about allergies, although some pharmacists asked if the patient had used the antibiotic before. When side effects appeared in patients, most pharmacists chose to treat the side effect; others stopped the antibiotic without providing any alternative, which can highly contribute to the spread of antibiotic resistance. Pharmacists who recognized sale of antibiotic as a problem or kind of a problem that is required in some or many cases agreed that this can only be stopped by enforcing regulations already exist by health authorities. Others felt that pharmacists should refuse such practice; many suggested improving public awareness through educational programs.
DISCUSSION This study confirms that the sale of antibiotics without prescription is a very common practice in Saudi Arabia. Laws regulating the sale of antibiotics in this country are basic and not enforced. All pharmacists interviewed were willing to sell antibiotics without a prescription. This agreed with a study conducted in Kathmandu, Nepal, where all pharmacists contacted by simulated patients engaged in diagnostic and therapeutic behavior beyond their scope of practice or legal mandate.17 Obtaining antibiotic without a prescription in the developed countries is limited. In the United States, several studies found considerable use of leftover antibiotics,32Y35 drugs obtained from a friend or family member, a pharmacy, or from outside the US36,37 This happened at larger scales in developing countries.38,39 The majority of interviewed pharmacists did not ask for possible allergies, pregnancy status, the usage indication, the duration of therapy, nor they cautioned for side effects when they dispensed the antibiotic, which agrees with results from other parts of the country.24 This sacrifices one of the pharmacist’s most basic duties to ensure the patient’s safety.40
TABLE 4. Pharmacists Feedback to the Hypothetical Scenarios Scenario No. (N = 54) 1 2 3 4 5
Yes (%)
No (%)
47 (87%) 2 (3.7%) 24 (44.4%) 11 (20.4%) 50 (92.6%) 0 (0%) 43 (79.6%) 6 (11.1%) 49 (90.7) 1 (1.9%)
Not Sure (%) 5 (9.3%) 19 (35.2%) 4 (7.4%) 5 (9.3%) 4 (7.4%)
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In this study, the majority of pharmacists did not have any consideration to the legislation in their decision to sell antibiotics without a prescription. The most driving factors that seemed to affect pharmacists’ views, decisions, and practices regarding the sale of antibiotics without prescription were sympathy with the economic hardship the patient may endure, followed by the concurrent physiological states that the patient may have, patient’s age, patient’s previous exposure to the antibiotic, and pharmacist’s knowledge and experience. These factors were different from those stated in studies conducted in other places.17Y19,24,29 This was clearly evident in the all scenarios presented to the participating pharmacists.
Study Limitations Our study relied mainly on hypothetical scenarios and pharmacists’ self reporting. The scenarios were brief, and addressed specific states, therefore pharmacists might not have fully immersed in them. Also, this may have limited the quality and depth of this practice assessment. Pharmacists were suspicious of the implications surrounding the study in general and the scenarios in particular, this might have affected their responses to reflect what they think is the best possible practice in comparison to their actual practice. Our interviews were relatively short, and were conducted during working hours. The interviews were interrupted by customers and technicians quite a few times, which may have affected the quality of the interview and the time the pharmacists could afford to complete the interview. The study response rate was small (54/150), pharmacists were either busy, suspicious, or not interested in participating in the study. Future studies can overcome these limitations by conducting the interviews in continuous education setting, where pharmacists have designated duration of time to answer the scenarios anonymously with no customers’ pressure.
Study External Validity Pharmacists in Saudi Arabia are mostly from other developing countries (Not Saudis), these pharmacists brought the same practices they had in their home countries to Saudi Arabia. Lack of law enforcement and customers’ insistence on getting the medication helped this practice to be predominant.41 Thus, the results of this study can be extrapolated to other regions within Saudi Arabia and other similar developing countries who share the same social and legislative situations.9Y11
CONCLUSIONS The interviews revealed some unexpected views and practices in regard to unauthorized antibiotic dispensing without prescription in community pharmacists that could jeopardize patient’s safety and welfare. In addition to being unprofessional and illegal, this practice may result in overdose, treatment failure (especially if inappropriate antibiotics or treatment regimen were selected), unnecessary costs and increased potential for developing antibiotic resistance. Unexpectedly, most pharmacists did not recognize this practice as a problem and could not identify the limitations of their scope of practice. They felt comfortable to diagnose, prescribe, and dispense antibiotics which confirms previous study performed in another region of Saudi Arabia24 but not in other developing countries.17 Although sales of antibiotics without a prescription are illegal in Saudi Arabia, this does not hold pharmacists from selling antibiotics without a prescription. Many of the pharmacists who see this practice as a problem agree that law enforcement will make other pharmacists fear the consequences of these practices. Pharmacists need to regularly update their * 2014 Lippincott Williams & Wilkins
Pharmacists Views and Practices in Saudi Arabia
legal and professional knowledge, as many are not clear about the scope of practice for pharmacists and its limitations. Additional studies are required to study the impact of this practice on the overall health system in Saudi Arabia, including the prescribing behavior of antibiotics by local physicians, the impact of the unnecessary antibiotic side effects on the patient’s quality of life and the overall antibiotic resistance in the country. REFERENCES 1. Zowawi HM, Balkhy HH, Walsh TR, et al. A-lactamase production in key gram-negative pathogen isolates from the Arabian peninsula. Clin Microbiol Rev. 2013;26:361Y380. 2. Aly M, Balkhy HH. The prevalence of antimicrobial resistance in clinical isolates from Gulf Cooperation Council Countries. Antimicrob Resist Infect Control. 2012;19:26. 3. Yezli S, Shibl AM, Livermore DM, et al. Antimicrobial resistance among gram-positive pathogens in Saudi Arabia. J Chemother. 2012;33:750Y755. 4. Ellis ME, al-Hajjar S, Bokhari H, et al. High proportion of multi-drug resistant mycobacterium tuberculosis in Saudi Arabia. Scand J Infect Dis. 1996;28:591Y595. 5. Al-Tawfiq JA. Increasing antibiotic resistance among isolates of Escherichia coli recovered from inpatients and outpatients in a Saudi Arabian hospital. Infect Control Hosp Epidemiol. 2006;27:748Y753. 6. Bilal NE, Gedebou M. Clinical and community strains of Klebsiella pneumoniae: multiple and increasing rates of antibiotic resistance in Abha, Saudi Arabia. Br J Biomed Sci. 2000;57:185Y191. 7. Goossens H. Antibiotic consumption and link to resistance. Clin Microbiol Infect 2009;15:12Y15. 8. Okeke IN, Laxminarayan R, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part I: recent trends and current status. Lancet Infect Dis. 2005;5:481Y493. 9. Okeke IN, Klugman KP, Bhutta ZA, et al. Antimicrobial resistance in developing countries. Part II: strategies for containment. Lancet Infect Dis. 2005;5:568Y580. 10. Okeke IN, Lamikanra A, Edelman R. Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerg Infect Dis. 1999;5:18Y27. 11. Kunin CM. Use of antimicrobial drugs in developing countries. Int J Antimicrob Agents. 1995;5:107Y113. 12. Kunin CM, Johansen KS, Worning AM, et al. Report of a symposium in use and abuse of antibiotics worldwide. Rev Infect Dis. 1990;12:12Y19. 13. Col NF, O’Connor RW. Estimating worldwide current antibiotic usage: report of task force 1. Rev Infect Dis. 1987;9(suppl 3):232Y243. 14. Finley RL, Collingnon P, Joakim Larsson DG, et al. The scourge of antibiotic resistance: the important role of the environment. Clin Infect Dis. 2013;57:704Y710. 15. Ashbolt NJ, Amezquita A, Backhaus T, et al. Human health risk assessment (HHRA) for environmental development and transfer of antibiotic resistance. Environ Health Perspect. 2013. Available at: http://dx.doi.org/10.1289/ehp.1206316. Accessed August 20, 2013. 16. Awad A, Eltayeb I, Matowe L, et al. Self-medication with antibiotics and antimalarials in the community of Khartoum State, Sudan. J Pharm Pharm Sci. 2005;8:326Y331. 17. Wachter DA, Joshi MP, Rimal B. Antibiotic dispensing by drug retailers in Kathmandu, Nepal. Trop Med Int Health. 1999;4:782Y788. 18. Van Duong D, Binns CW, Van Le T. Availability of antibiotics as over-the-counter drugs in pharmacies: a threat to public health in Vietnam. Trop Med Int Health. 1997;2:1133Y1139.
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37. Ceaser S, Wurtz R. ‘‘Leftover’’ antimicrobial drugs in the medicine cabinet. Ann Intern Med. 2000;133:74. 38. Emeka PM, Al-Omar MJ, Khan TM. A qualitative study exploring role of community pharmacy in the irrational use and purchase of nonprescription antibiotics In Al Ahsa. Eur J Gen Med. 2012;9:230Y234. 39. Kardas P, Pechere JC, Hughes DA, et al. A global survey of antibiotic leftovers in the outpatient setting. Int J Antimicrob Agents. 2007;30:530Y536. 40. Deuster S, Roten I, Muehlebach S. Implementation of treatment guidelines to support judicious use of antibiotic therapy. J Clin Pharm Ther. 2010;35:71Y78. 41. Bawazir SA. Prescribing pattern at community pharmacies in Saudi Arabia. Int Pharm J. 1992;6:222Y224.
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