Pharmacists dispensing antibiotics without a prescription: A qualitative pilot study

OBJECTIVES: One of the primary causes of the rise in antibiotic resistance, which can travel the globe, is the inappropriate use of antibiotics. Unlike the United States, pharmacies in Africa, Asia, Europe and South America frequently dispense antibiotics without a prescription (WP). There has been little research, however, about why pharmacists dispense antibiotics WP. This study aimed to identify factors influencing pharmacists' decisions to dispense antibiotics WP in Alexandria, Egypt. METHODS: In January 2010, the primary investigator conducted semi-structured one-to-one face-to-face interviews with open-ended questions using a convenience sample of 7 community pharmacists. Purposive and saturation sampling techniques were applied to identify participants and determine sample size, respectively. Interviews were recorded, translated, transcribed and then analysed independently by the 2 authors. Emerging themes were extracted and analysed using the grounded theory approach. RESULTS: Financial, patron and pharmacist related factors influenced the decision to dispense antibiotics WP. We identified 4 reasons that facilitated dispensing antibiotics WP: (1) profit from selling antibiotics (2) ease of obtaining antibiotic WP from other pharmacies, (3) patron's insistence on getting an antibiotic and (4) patron's inability to access a doctor. On the other hand, pharmacists reported that they would not dispense an antibiotic WP if: (1) the complexity of the patron's condition exceeds a pharmacist's expertise and needs the involvement of a doctor, (2) the requested antibiotic is hazardous or (3) the patron's condition is not worthy of an antibiotic. We identified 5 factors influencing antibiotic product selection. Pharmacists reported that they are more likely to pick a specific antibiotic that is: (1) safe, (2) suitable for the patron's condition, (3) taken in a small number of doses or produces a quick improvement, (4) matched to the patron's financial status,i.e., expensive for rich patrons and cheap for poor patrons and (5) familiar to the pharmacist. Pharmacists' belief that patrons will perceive them as incompetent or unwilling to help if they refuse to dispense an antibiotic WP was cited as a challenge in handling patrons insisting on getting an antibiotic when a pharmacist thinks that antibiotic use is not warranted. CONCLUSIONS: A heterogeneous set of factors influence pharmacists' decisions to dispense antibiotics WP as well as the antibiotic product selection. These factors compromise pharmacists' role in safeguarding the community from inappropriate antibiotic use. Policy makers need to involve pharmacists and patients when promoting the judicious use of antibiotics.