Antibiotic dispensing practices in community pharmacies: Implications for antimicrobial stewardship in resource-constrained settings

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

Most drug-sellers were aged 41–50 years (35.0 %), with 39.2 % holding a bachelor's degree or higher, and 65.8 % having pharmacy-dispensing training. The overall knowledge score on antibiotic use and AMR was moderate at 60.2 % (5–7 out of 10), with 32.5 % scoring ≤4, indicating poor knowledge; trained drug-sellers scored significantly better (p = 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.