1. Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312 doi: 10.1111/j.1365-2710.2011.01293.x
Irrational use of antibiotics and role of the pharmacist: an insight from a
qualitative study in New Delhi, India
A. Kotwani* PhD, C. Wattal MD, P. C. Joshià PhD, K. Holloway§ MRCP, PhD
*Department of Pharmacology, V. P. Chest Institute, University of Delhi, Delhi, Department of Clinical Microbiology, Sir Ganga Ram Hospital, Rajinder
Nagar, New Delhi, àDepartment of Anthropology, University of Delhi, Delhi and §Essential Drugs and Other Medicines, World Health Organization,
Regional Office for South East Asia, New Delhi, India
Received 22 March 2011, Accepted 04 July 2011
Keywords: antibiotic resistance, antibiotic use, community pharmacists, dispensing practices, India, rational use of antibiotics
qualitative study. Community pharmacists were willing to
SUMMARY
participate in educational programme aimed at improving
What is known and Objective: The overall volume of antibiotic use of antibiotics. Such programmes should be initiated
consumption in the community is one of the foremost causes within a multidisciplinary framework including doctors, phar-
of antimicrobial resistance. In developing countries like India, macists, social scientists, government agencies and non-profit
pharmacists often dispense ‘prescription-only’ drugs, like anti- organizations.
biotics, to patients who do not have a prescription. Not much
data is available regarding detailed information on behaviour
WHAT IS KNOWN AND OBJECTIVE
of antibiotic use by community pharmacists which is of parti-
cular significance to develop a suitable and sustainable inter- Irrational use of antibiotics in the community is a major cause
vention programme to promote rational use of antibiotics. A of rising antibiotic resistance.1 In many developing countries,
qualitative study was conducted to understand the dispensing pharmacists who serve as drug retailers not only provide access
practices and behaviour of community pharmacists to develop to pharmaceutical products but also provide advice and pre-
policy interventions that would improve the use of antibiotics scribe medicines.2–4 The present study tries to gain an insight
at the community level. into the behaviour of pharmacists, and their knowledge and
Methods: Focus group discussions (FGDs) were held for five attitude regarding antibiotic dispensing and usage and antimi-
municipal wards of Delhi with retail pharmacists, public sec- crobial resistance. This study was carried out to inform the
tor pharmacists and the office bearers of pharmacists’ associa- development of a suitable intervention programme to promote
tions. Data on antibiotic use and resistance were collected the rational use of antibiotics by community pharmacists. There
earlier from these five wards. FGDs (n = 3 with 40 pharma- is evidence for the value and favourable cost–benefit ratio of
cists) were analysed through grounded theory. such health promotion activities.5
Results and Discussion: Four broad themes identified were as Pharmacists often serve as the first contact for the patient
follows: prescribing and dispensing behaviour; commercial in the healthcare seeking chain and the last before consump-
interests; advisory role; and intervention strategies for rational tion of the drugs dispensed. They are an important junction
use of antibiotics. FGDs with pharmacists working in the from where health promotion materials can be distributed.6,7
public sector revealed that, besides the factors listed above, Dispensing by pharmacists has not been given much impor-
overstock and near-expiry, and under-supply of antibiotics tance in studies of antibiotic usage, compared to other pro-
promoted antibiotic misuse. Suggestions for interventions cesses such as diagnosis, and drug procurement, inventory
from pharmacists were the following: (i) education to increase control and distribution. It is important to study dispensing
awareness of rational use and resistance to antibiotics; (ii) behaviour as in many developing countries antibiotics are
involving pharmacists as partners for creating awareness easily available without a prescription.8–12 Most of the studies
among communities for rational use and resistance to antibio- focusing on pharmacists highlight their dispensing practice
tics; (iii) developing an easy return policy for near-expiry anti- and their role in facilitating self-medication,3,13 but studies on
biotics in public sector facilities; and (iv) motivating and the perceptions and practices of dispensers are lacking.14 Any
showing appreciation for community pharmacists who partici- community intervention programme must involve consultation
pate in intervention programmes. with all the stakeholders and be grounded in the local
What is new and Conclusions: Inappropriate antibiotic dis- context.15
pensing and use owing to commercial interests and lack The present study was carried out as part of a phase II
of knowledge about the rational use of antibiotics and programme on surveillance of antimicrobial use and resistance
antibiotic resistance were the main findings of this in-depth in the community. Phase I of the study established the metho-
dology for surveillance of antimicrobial drug use and resistance
in the community.16,17 The results of the phase I study clearly
Correspondence: Dr A. Kotwani, Department of Pharmacology, V.
identified high use of antibiotics and high resistance level in
P. Chest Institute, University of Delhi, Delhi 110007, India. Tel.: the community, with newer members from each class of antibio-
+91 11 27402404; fax: +91 11 27666549; e-mail: anitakotwani@gmail. tics being used more than the older members of the same
com class.18
ª 2011 Blackwell Publishing Ltd 308

2. Antibiotic dispensing practices of pharmacists in New Delhi A. Kotwani et al.
Codes were applied to the broad themes that emerged from the
METHODOLOGY
sub-themes already identified. Agreement on themes, sub-themes
To explore the behaviour of pharmacists on the use of antibio- and coding was sought. The method of ‘constant comparison’
tics and to identify suitable intervention strategies, qualitative was central to the process generating various themes and codes.19
focus group discussions (FGDs) were undertaken. This method
provides an in-depth knowledge of perceptions and attitudes of
Ethical approval
the population being studied. In India, medicines prescribed by
doctors in the public sector are provided free of charge to Ethical approval for the study was obtained from V. P. Chest
patients. At private retail pharmacies, patients pay for medi- Institute, Sir Ganga Ram Hospital, and also from WHO Ethics
cines. Three focus group discussions (FGDs) were planned, one Review Committee. Informed consent was obtained from all
each for public and private sector pharmacists and one for the participants involved in the study.
leaders of their associations. FGDs were held in February–
August 2008 with the help of two chief investigators of the
RESULTS
study (AK and CW) and a social scientist. One of the chief
investigators was an expert on the surveillance of antibiotic use, The focus group discussions (FGDs) with community pharma-
and the second was a clinical microbiologist and expert on anti- cists supported our earlier findings of high antibiotic use in the
microbial resistance patterns in the study area. The FGDs were community.16 Four broad themes were identified: prescribing
facilitated by the former. The study was conducted in New and dispensing behaviour; commercial interests; advisory role;
Delhi, India, and covered five municipal wards (residential and intervention strategies for rational use of antibiotics, which
areas) from where the antibiotic use and resistance data were were further divided into sub-themes.
collected in 2004 and later in 2008–2009. Retail pharmacists
invited for FGDs were from the same five municipal wards.
Prescribing and dispensing behaviour
Public sector pharmacists were invited from the 10 public health
facilities from which data on antibiotic drug use were collected. Pharmacists identified contexts in which they either honoured
For public sector meetings, zonal incharges were contacted, and prescriptions or prescribed antibiotics without a prescription:
for private sector meetings, office bearers of pharmacists’ asso-
ciations were contacted for permission and cooperation. Honouring old prescriptions. Private sector pharmacists frequently
One group was comprised exclusively of retail pharmacists14 honoured old prescriptions. Old prescriptions are referred to
who ran their own private retail pharmacies, commonly called those prescriptions that were written in the past by a doctor for
chemist shops in New Delhi. The second FGD was for public certain symptoms. Prescriptions are kept back by the patients in
sector pharmacists8 but a few private pharmacists5 who had India. Patients bring back the previous prescription and ask for
been unable to attend the first meeting joined the group. The the same antibiotic for similar symptoms may be for self or for
third FGD was made up of leaders3 and office bearers4 of phar- a different patient. Although it is not permissible legally, phar-
macists’ organizations and six6 enthusiastic retail pharmacist macists generally dispense antibiotics on old prescriptions. This
members from those organizations. For the public sector, 8 of 10 argument was given by a retail pharmacist:
pharmacists invited participated in the FGD. For the private sec- Pharmacist- He (pharmacist) does not give (prescribe) from his
tor, 35 retail pharmacists were contacted and invited, 14 came side… in the sense that, doctor had prescribed medicine(antibiotic)
and 5 joined the FGD with the public sector pharmacists. Forty earlier, patient either did not take full course and came for refill or
pharmacists participated with only one female pharmacist from after some days or may be after months patient wants the same
the public sector. medicine for similar symptoms. Second time he (patient) did not
The FGDs were conducted with the help of a topic guide, and take doctor’s advice and came to the pharmacist directly......
a theoretical sampling procedure was adopted to enrich the con-
tent. The topic guide had five main key areas that were enriched Irregularities in supply of antibiotics in public sector. Public sector
with each successive FGD. The five key areas of the topic guide pharmacists mentioned two contexts where irrational use of
were as follows: antibiotic dispensing behaviour of pharmacists; antibiotic is seen: when medicines are unavailable or over-
antibiotic prescribing by pharmacists to patients; knowledge stocked. In government-run dispensaries (primary health care),
about antimicrobial resistance; understanding about antibiotic the pharmacist is able to dispense only part of the full course
misuse; and suggestions for suitable interventions. A brief intro- prescribed when there is insufficient stock. Poor patients are
duction and results from the completed antibiotic use and resis- usually unable to afford buying the rest from private retail
tance study were given in the beginning of focus group pharmacies. Some pharmacists in the government sector stated
discussions. The facilitator focused the discussion on the motiva- that surplus stock whose expiry was nearing was usually
tions and behaviours that lead to antibiotic misuse. After the dis- cleared by over-prescribing, even for antibiotics. The pharma-
cussion regarding antibiotic dispensing practices as well as cists and doctors did not return the stock because to do so
prescribing behaviours, pharmacists were asked to suggest suita- would have involved lengthy procedures and they were pres-
ble interventions to decrease the misuse of antibiotics and anti- sured by higher officials to exhaust remaining stock.
biotic resistance. All FGDs were videotaped, transcribed and
translated where required. There was continuous analysis of Self-medication. Private retail pharmacists defined self-medication
FGDs throughout the study from the first to the last FGD. The as instances where they did not advise patient about a medicine
data were subjected to grounded theory, which is inductive and but the patient asked for the medicines without prescription.
iterative. In the first FGD, discrete themes were identified, which Patients came to them with the names of antibiotics that at some
were then used in subsequent FGDs and tested for reality. Tran- point had given relief, with empty strips of used medicine,
scripts were closely examined to identify themes and categories. diaries maintained for different symptoms and drugs to be
ª 2011 Blackwell Publishing Ltd Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312
309

3. Antibiotic dispensing practices of pharmacists in New Delhi A. Kotwani et al.
used. None said that they refused selling prescription-only anti- Public sector pharmacist said they did not have enough time
biotics. to advise or educate patients on the use of antibiotics.
Pharmacists’ prescribing behaviour. Most of the private retail phar-
Suggestions by pharmacists for intervention strategies for
macists initially denied prescribing themselves, as they were
rational use of antibiotics
neither qualified nor allowed to do so. Initially, they insisted that
they rarely prescribed for patients directly. Most later admitted After realizing that antibiotic resistance is indeed a serious pro-
prescribing antibiotics for diseases or symptoms like diarrhoea, blem for which interventions are required especially to change
common cold, mild fever, sore throat and cough. For such condi- behaviour, many suggestions were put forth. The actions sug-
tions, they mimicked the prescriptions given by neighbourhood gested by pharmacists were the following:
doctors of good standing for patients with similar complaints.
The following statement reveals their justification: Increasing awareness among consumers. Many pharmacists
Pharmacist-Usually we do not prescribe. We usually give six believed that if a patient was aware of the importance of taking
tablets…Septran (co-trimoxazole). Only when a poor patient comes a full course, this would have significant effect on use of anti-
who cannot afford doctor’s fees, we treat with simple medicine like biotics. They gave an example of how an aware foreigner asking
Septran…If he goes to a doctor, he (patient) will have to pay the for an anti-diarrhoeal would specifically mention not wanting
fees any antibiotics. However, some pharmacists mentioned that in
Pharmacists used the context of prescribing to poor patients their respective areas even ‘educated’ patients demanded anti-
as doing social work. Most prescribed antibiotics for 2–3 days. biotics to speed up recovery. Therefore, it was suggested that
Some private retail pharmacists even mentioned giving just television and newspapers advice about the appropriate usage
three to six tablets. Antibiotics like cotrimoxazole, erythromycin of antibiotics should be given. Pharmacists of both the sectors
and clarithromycin were said to be used commonly. For diar- readily agreed to take part in the distribution of educational
rhoea, metrodinazole and norfloxacin were used. They pre- material and help in the campaign to promote the rational use
scribed according to the economic status of the patient. They of antibiotics. They also expected recognition and incentives to
did not think that this practice could lead to an increase in be given to pharmacists involved in such campaigns.
resistance as they were giving antibiotics for only a few days.
Some pharmacists said they resorted to such practices for fear Awareness and education of pharmacists. Many pharmacists were
of losing patients and lack of awareness about the importance ignorant of the rational use of antibiotics and factors that lead
of rational use of antibiotics. to the development of antibiotic resistance and asked for semi-
nars and educational courses to help them.
Commercial interests
Changing prescription habits of doctors. Most of the pharmacists
Honouring inappropriate prescriptions. Pharmacists said they hon- were unanimous in their opinion that, first of all, doctors should
oured all kinds of prescriptions for economic reasons even if change their prescribing habits. Most of the private retail phar-
they thought they were inappropriate. A few of the private macists modelled their prescriptions on those of a neighbour-
retail pharmacists considered themselves as mere ‘traders’. Most hood doctors:
of the pharmacists felt such dispensing was necessary for their Pharmacist- If we see different trends…like antibiotics are not pre-
commercial establishment. scribed for diarrhoea…. whatever trend the doctor is creating that
is the norm of that region. Which we chemist also follow.
Push factor of pharmaceutical companies. Pharmaceutical compa-
nies run their own drug promotion programmes to maximize Easy return policy for nearly expired antibiotics. Public sector phar-
profits. Generic drugs are not marketed as they are cheaper and macists stressed that for near-expiry and over-supplied antibio-
are usually not stocked in chemist shops. Generally, doctors tics, an easy return policy would help.
prescribe new antibiotics that are costly and have larger profit
margins for pharmacists. Changing pharmacists’ dispensing. Few pharmacists felt that it was
Pharmacist-There is pressure from industry to doctors. We will get their moral responsibility to stop the misuse of antibiotics in the
your clinic renovated…arrange foreign trip for family… Company community. However, a majority of them stated that the respon-
gives them (doctors) such offers. Whatever trend is going on we sibility rested with patients and doctors. Regulatory authorities
start stocking antibiotics according to that. They (doctors) are the should implement and enforce laws against honouring old pre-
ones who start prescribing new antibiotics. It is good for us as well scriptions for antibiotics and dispensing smaller quantities of
since our profit is also more antibiotics than prescribed by the doctor.
Redefining the role of pharmacists. Many pharmacists felt that they
Advisory role of pharmacist
were occupying the second rung in the medical hierarchy. All
Pharmacists from both sectors said they refrained from making agreed that intervention should be organized through big and
remarks on the inappropriateness of prescriptions. They said respected organizations.
that if they point it out to a doctor, he will rebuke them for
challenging his authority. If an inappropriate prescription is
DISCUSSION
pointed out to a patient, the patient has more faith in the doctor
than the pharmacist’s advice. Although patients may take This is one of the first comprehensive studies in developing
advice and buy medicines directly from pharmacists, they do countries of antibiotic dispensing and prescribing practices of
not want them to advise or comment on doctors’ prescription. community pharmacists. Our study revealed that pharmacists
ª 2011 Blackwell Publishing Ltd Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312
310

4. Antibiotic dispensing practices of pharmacists in New Delhi A. Kotwani et al.
dispensed antibiotics inappropriately in different contexts. Self- skills.26 Interventions targeted at pharmacists should be
medication with antibiotics has been reported.3,20 A study con- embedded in the local health context and take into account their
ducted in Manila showed that 66% of the purchases were with- existing perception, beliefs and attitudes.27 To stop the misuse
out prescription21 and the most common perceived indications of antibiotics, a multifaceted strategy including education, based
were respiratory tract infections, ‘prophylaxis’ and gastrointest- on an understanding of existing beliefs, replacement of perverse
inal infections. Almost 90% of purchases were for 10 or less cap- incentives with those promoting best practices through persua-
sules or tablets. The median number of units purchased was sion, and investment in improved surveillance is required.28 At
three. Customers with written prescriptions purchased a mean the pharmacists’ level, education and motivation are more
of eight capsules whereas those who self-prescribed purchased important. Apart from educational intervention with pharma-
a mean of four units. Pharmacists in our study sold 4–6 cap- cists, written information, brochures and posters can be dis-
sules of inexpensive antibiotics for respiratory tract infections, played in pharmacies.29 Much work is needed to foster a sense
diarrhoea, sore throat and fever. Often patients purchased fewer of responsibility among the pharmacists themselves. This is
than the units prescribed by the doctors. likely to require intervention from the professional bodies – the
Pharmacists also revealed that doctors tended to prescribe Drug and Chemists Association and the Medical Association.
newer antibiotics, probably because of pharmaceutical industry As suggested by pharmacists themselves, a pharmacy week
pressure and pharmacists themselves followed the prescribing could be used as an intervention programme. Pharmacy week is
practices of neighbourhood doctors. The influence of the phar- celebrated throughout India in November by various pharma-
maceutical industry is well known.22 A New Zealand study23 cists associations to upgrade their members’ knowledge about
showed that a majority of nurses recommended treatments to new developments through workshops, seminars and continu-
the prescribing doctor and provided advice to patients about ing medical education. The medical fraternity must take com-
over-the-counter medications. In India, pharmacists dispense all munity pharmacists with them in this endeavour. Without this,
antibiotics without a prescription.24 In public sector pharmacies, educational strategies are unlikely to surmount the barriers pre-
the antibiotics were prescribed to use up surplus stock and sented by commercial interests.
smaller quantities of antibiotics were dispensed when in short
supply. Underuse of antibiotics is as dangerous as overuse.
STRENGTHS AND LIMITATIONS
Deficiencies in the provision of drugs in primary health care are
attributable to inadequacies within the drug distribution chain Our study was undertaken in West Delhi and pharmacists from
in less affluent settings, a problem recognized by WHO.25 The five municipal wards participated. This may not be representa-
results observed in our study are troubling from a public health tive of general practice as a whole. Although common themes
standpoint because of their implications on the emergence of emerged and thematic saturation was satisfactorily achieved,
antibiotic resistance. caution is still required in generalizing the findings. One of the
Pharmacists reported prescribing fluoroquinolones or metro- main strengths of this study was the participation of both public
nidazole for diarrhoea because they have seen prescriptions and private sector pharmacists. It was encouraging that most of
from doctors commonly prescribing these two antimicrobials the pharmacists were concerned about antibiotic resistance and
for diarrhoea. Pharmacists described their own prescribing were willing to participate in educational programmes.
habits as necessary for economic survival and as a response to
patient pressure and pressure from doctors. They also above
WHAT IS NEW AND CONCLUSIONS
all attributed their poor prescribing to their own lack of
awareness of rational use of antibiotics and antimicrobial Inappropriate antibiotic dispensing and use owing to commer-
resistance. cial interests and lack of knowledge about the rational use of
This study adds to the growing body of knowledge about the antibiotics and antibiotic resistance were the main findings of
need to devise effective interventions to improve prescribing of this in-depth qualitative study. Community pharmacists were
antibiotic by pharmacists in low-income countries. There are no willing to participate in educational programme aimed at
published results of such interventions. Important feedback improving use of antibiotics. Such programmes should be
obtained from pharmacists was their readiness to learn about initiated within a multidisciplinary framework including doc-
rational use of antibiotics and to disseminate good practice. tors, pharmacists, social scientists, government agencies and
Some of the pharmacists and leaders of their associations were non-profit organizations.
optimistic on this issue. Education of patients is important too.
Community pharmacists believed those participating in promo-
ACKNOWLEDGEMENTS
tion of rational use of antibiotics should be recognized by rele-
vant authorities and organizations. Recognition can be in the We would like to thank Dayanand Yumnam for helping in
form of a certificate and/or award to display in their pharma- arrangements and conduct of FGDs. We thank Shashi Katewa
cies. The pharmacists also stressed that enforced regulatory for helping in transcribing the videotapes of FGDs and helping
action from concerned authorities is needed. in analysis. We thank Alice Easton for reading and checking
The minimum qualification required in India for a pharmacist our draft manuscript. We would also thank all the participants
to practice is a Diploma in Pharmacy which is a 2-year course and Zonal incharge, West Zone, Central & New Delhi Zone and
followed by 3 months’ training at an approved hospital. There Directorate Health Services, Government of NCT, Delhi.
is no obligation for continuing education. Our results are similar
to those of a study in Karnataka, India, where respondents
FUNDING
declared themselves ready to accept pharmacists’ extended roles
if they improved their knowledge base and communication The study was funded by WHO, Geneva (OD/TS-07-00163).
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311

5. Antibiotic dispensing practices of pharmacists in New Delhi A. Kotwani et al.
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