Antibiotic dispensing practices in community pharmacies: Implications for antimicrobial stewardship in resource-constrained settings
Abdullah Al Masud, Ramesh Walpola, Malabika Sarker, Muhammad Asaduzzaman, Md Saiful Islam, Ayesha Tasnim Mostafa, Zubair Akhtar, Alamgir Kabir, Holly Seale
Abstract
Background: Over-the-counter antibiotic sales in community-pharmacies significantly drive antimicrobial resistance (AMR) in low- and middle-income countries (LMICs) due to inappropriate use and early treatment discontinuation. In Bangladesh, community pharmacies, which dispense 56.6 % of antibiotics without prescriptions, serve as the first health-seeking touchpoint, yet conventional stewardship strategies often overlook these informal providers, heightening AMR risks. This study examines drug-sellers' understanding and practices towards antibiotic dispensing and compares their symptomatic-treatment practices with Bangladesh's Standard Treatment Guidelines (STGs) to understand the extent of antibiotic misuse. Methods: A cross-sectional survey in two urban and two rural areas of Bangladesh involved 120 drug-sellers from 30 randomly selected pharmacies per site. Knowledge was compared between drug-sellers with pharmacy-dispensing training and those without training, and their suggested treatments for two simulated health-symptoms-upper respiratory-tract and gastrointestinal infections-were evaluated against STGs to determine the extent of misuse. Results: = 0.008). Over half (57.5 %) were unaware of antibiotic dispensing policies, though most (75.8 %) acknowledged the link between AMR and antibiotic use. For simulated upper respiratory-tract infections, 54.2 % recommended single antibiotic-90.8 % Watch, 9.2 % Access (per WHO-AWaRe classification)-with 66.2 % of these prescriptions deviating from guidelines due to inappropriate selection or dosage. For gastrointestinal infections, 55.8 % recommended single antibiotic (40.3 % Watch, 59.7 % Access), with 82.1 % deviated from the guidelines. Additionally, 26.7 % recommended two antibiotics (51.6 % Watch, 48.4 % Access), all of which were inconsistent with guideline recommendations. For both simulated symptoms, no significant difference was observed in drug sellers' treatment practices based on their knowledge level. Conclusion: This study highlights the need for context-specific policies and regulatory measures in informal healthcare settings. While improving drug-sellers' knowledge is vital for antimicrobial stewardship in LMICs like Bangladesh, it alone is insufficient due to market competition, weak regulation, and patient-driven demand. Thus, curbing inappropriate antibiotic use at the community level requires stronger enforcement and multifaceted, context-tailored interventions-including public awareness, targeted training, and market-responsive strategies.