Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312                                            doi: 10.1111/j...
Antibiotic dispensing practices of pharmacists in New Delhi                                                               ...
Antibiotic dispensing practices of pharmacists in New Delhi                                                               ...
Antibiotic dispensing practices of pharmacists in New Delhi                                                               ...
Antibiotic dispensing practices of pharmacists in New Delhi                                                               ...
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  1. 1. Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312 doi: 10.1111/j.1365-2710.2011.01293.xIrrational use of antibiotics and role of the pharmacist: an insight from aqualitative study in New Delhi, IndiaA. 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, RajinderNagar, 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, IndiaReceived 22 March 2011, Accepted 04 July 2011Keywords: antibiotic resistance, antibiotic use, community pharmacists, dispensing practices, India, rational use of antibiotics qualitative study. Community pharmacists were willing toSUMMARY participate in educational programme aimed at improvingWhat is known and Objective: The overall volume of antibiotic use of antibiotics. Such programmes should be initiatedconsumption 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-profitpharmacists often dispense ‘prescription-only’ drugs, like anti- organizations.biotics, to patients who do not have a prescription. Not muchdata is available regarding detailed information on behaviour WHAT IS KNOWN AND OBJECTIVEof 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 causevention 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 accesspractices 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 insightat the community level. into the behaviour of pharmacists, and their knowledge andMethods: 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 thetor pharmacists and the office bearers of pharmacists’ associa- development of a suitable intervention programme to promotetions. Data on antibiotic use and resistance were collected the rational use of antibiotics by community pharmacists. Thereearlier from these five wards. FGDs (n = 3 with 40 pharma- is evidence for the value and favourable cost–benefit ratio ofcists) were analysed through grounded theory. such health promotion activities.5Results and Discussion: Four broad themes identified were as Pharmacists often serve as the first contact for the patientfollows: 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 junctionuse of antibiotics. FGDs with pharmacists working in the from where health promotion materials can be distributed.6,7public 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, inventoryfrom pharmacists were the following: (i) education to increase control and distribution. It is important to study dispensingawareness of rational use and resistance to antibiotics; (ii) behaviour as in many developing countries antibiotics areinvolving pharmacists as partners for creating awareness easily available without a prescription.8–12 Most of the studiesamong communities for rational use and resistance to antibio- focusing on pharmacists highlight their dispensing practicetics; (iii) developing an easy return policy for near-expiry anti- and their role in facilitating self-medication,3,13 but studies onbiotics in public sector facilities; and (iv) motivating and the perceptions and practices of dispensers are lacking.14 Anyshowing appreciation for community pharmacists who partici- community intervention programme must involve consultationpate in intervention programmes. with all the stakeholders and be grounded in the localWhat is new and Conclusions: Inappropriate antibiotic dis- context.15pensing and use owing to commercial interests and lack The present study was carried out as part of a phase IIof knowledge about the rational use of antibiotics and programme on surveillance of antimicrobial use and resistanceantibiotic 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 clearlyCorrespondence: Dr A. Kotwani, Department of Pharmacology, V. identified high use of antibiotics and high resistance level inP. 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 samecom class.18ª 2011 Blackwell Publishing Ltd 308
  2. 2. Antibiotic dispensing practices of pharmacists in New Delhi A. Kotwani et al. Codes were applied to the broad themes that emerged from theMETHODOLOGY sub-themes already identified. Agreement on themes, sub-themesTo 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.19focus group discussions (FGDs) were undertaken. This methodprovides an in-depth knowledge of perceptions and attitudes of Ethical approvalthe population being studied. In India, medicines prescribed bydoctors in the public sector are provided free of charge to Ethical approval for the study was obtained from V. P. Chestpatients. At private retail pharmacies, patients pay for medi- Institute, Sir Ganga Ram Hospital, and also from WHO Ethicscines. Three focus group discussions (FGDs) were planned, one Review Committee. Informed consent was obtained from alleach 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 RESULTSstudy (AK and CW) and a social scientist. One of the chiefinvestigators 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 themicrobial resistance patterns in the study area. The FGDs were community.16 Four broad themes were identified: prescribingfacilitated 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, whichareas) from where the antibiotic use and resistance data were were further divided into sub-themes.collected in 2004 and later in 2008–2009. Retail pharmacistsinvited for FGDs were from the same five municipal wards. Prescribing and dispensing behaviourPublic sector pharmacists were invited from the 10 public healthfacilities from which data on antibiotic drug use were collected. Pharmacists identified contexts in which they either honouredFor 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 towho ran their own private retail pharmacies, commonly called those prescriptions that were written in the past by a doctor forchemist shops in New Delhi. The second FGD was for public certain symptoms. Prescriptions are kept back by the patients insector pharmacists8 but a few private pharmacists5 who had India. Patients bring back the previous prescription and ask forbeen unable to attend the first meeting joined the group. The the same antibiotic for similar symptoms may be for self or forthird 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. Thismembers 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 histor, 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 orpharmacists participated with only one female pharmacist from after some days or may be after months patient wants the samethe 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 sectorwith each successive FGD. The five key areas of the topic guide pharmacists mentioned two contexts where irrational use ofwere 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 coursemisuse; and suggestions for suitable interventions. A brief intro- prescribed when there is insufficient stock. Poor patients areduction and results from the completed antibiotic use and resis- usually unable to afford buying the rest from private retailtance study were given in the beginning of focus group pharmacies. Some pharmacists in the government sector stateddiscussions. The facilitator focused the discussion on the motiva- that surplus stock whose expiry was nearing was usuallytions 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 soprescribing 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 andtranslated where required. There was continuous analysis of Self-medication. Private retail pharmacists defined self-medicationFGDs throughout the study from the first to the last FGD. The as instances where they did not advise patient about a medicinedata 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 somewere 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 beª 2011 Blackwell Publishing Ltd Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312 309
  3. 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 timebiotics. 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 formacists initially denied prescribing themselves, as they were rational use of antibioticsneither qualified nor allowed to do so. Initially, they insisted thatthey 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 changecommon 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 thatSome private retail pharmacists even mentioned giving just television and newspapers advice about the appropriate usagethree to six tablets. Antibiotics like cotrimoxazole, erythromycin of antibiotics should be given. Pharmacists of both the sectorsand clarithromycin were said to be used commonly. For diar- readily agreed to take part in the distribution of educationalrhoea, metrodinazole and norfloxacin were used. They pre- material and help in the campaign to promote the rational usescribed according to the economic status of the patient. They of antibiotics. They also expected recognition and incentives todid 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 wereof losing patients and lack of awareness about the importance ignorant of the rational use of antibiotics and factors that leadof 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 pharmacistsHonouring inappropriate prescriptions. Pharmacists said they hon- were unanimous in their opinion that, first of all, doctors shouldoured 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 profitmargins 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 theyAdvisory role of pharmacist were occupying the second rung in the medical hierarchy. AllPharmacists from both sectors said they refrained from making agreed that intervention should be organized through big andremarks on the inappropriateness of prescriptions. They said respected organizations.that if they point it out to a doctor, he will rebuke them forchallenging his authority. If an inappropriate prescription is DISCUSSIONpointed out to a patient, the patient has more faith in the doctorthan the pharmacist’s advice. Although patients may take This is one of the first comprehensive studies in developingadvice and buy medicines directly from pharmacists, they do countries of antibiotic dispensing and prescribing practices ofnot want them to advise or comment on doctors’ prescription. community pharmacists. Our study revealed that pharmacistsª 2011 Blackwell Publishing Ltd Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312 310
  4. 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 bemedication with antibiotics has been reported.3,20 A study con- embedded in the local health context and take into account theirducted in Manila showed that 66% of the purchases were with- existing perception, beliefs and attitudes.27 To stop the misuseout prescription21 and the most common perceived indications of antibiotics, a multifaceted strategy including education, basedwere respiratory tract infections, ‘prophylaxis’ and gastrointest- on an understanding of existing beliefs, replacement of perverseinal 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 Atthree. Customers with written prescriptions purchased a mean the pharmacists’ level, education and motivation are moreof 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 sensediarrhoea, sore throat and fever. Often patients purchased fewer of responsibility among the pharmacists themselves. This isthan 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 weekpressure and pharmacists themselves followed the prescribing could be used as an intervention programme. Pharmacy week ispractices 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 aboutshowed 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 shortsupply. Underuse of antibiotics is as dangerous as overuse. STRENGTHS AND LIMITATIONSDeficiencies in the provision of drugs in primary health care areattributable to inadequacies within the drug distribution chain Our study was undertaken in West Delhi and pharmacists fromin 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 themesstandpoint 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 publicnidazole for diarrhoea because they have seen prescriptions and private sector pharmacists. It was encouraging that most offrom doctors commonly prescribing these two antimicrobials the pharmacists were concerned about antibiotic resistance andfor diarrhoea. Pharmacists described their own prescribing were willing to participate in educational programmes.habits as necessary for economic survival and as a response topatient pressure and pressure from doctors. They also above WHAT IS NEW AND CONCLUSIONSall attributed their poor prescribing to their own lack ofawareness 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 ofneed to devise effective interventions to improve prescribing of this in-depth qualitative study. Community pharmacists wereantibiotic by pharmacists in low-income countries. There are no willing to participate in educational programme aimed atpublished results of such interventions. Important feedback improving use of antibiotics. Such programmes should beobtained 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 andSome 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- ACKNOWLEDGEMENTStion 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 inform of a certificate and/or award to display in their pharma- arrangements and conduct of FGDs. We thank Shashi Katewacies. The pharmacists also stressed that enforced regulatory for helping in transcribing the videotapes of FGDs and helpingaction 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 participantsto practice is a Diploma in Pharmacy which is a 2-year course and Zonal incharge, West Zone, Central & New Delhi Zone andfollowed by 3 months’ training at an approved hospital. There Directorate Health Services, Government of NCT, no obligation for continuing education. Our results are similarto those of a study in Karnataka, India, where respondents FUNDINGdeclared themselves ready to accept pharmacists’ extended rolesif they improved their knowledge base and communication The study was funded by WHO, Geneva (OD/TS-07-00163).ª 2011 Blackwell Publishing Ltd Journal of Clinical Pharmacy and Therapeutics, 2012, 37, 308–312 311
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