|Year : 2017 | Volume
| Issue : 2 | Page : 31-35
Antibiotic prescribing for upper respiratory tract infections by Libyan community pharmacists and medical practitioners: An observational study
Ahmed E Atia1, Ahmed N Abired2
1 Department of Anesthesia and Intensive Care, Faculty of Medical Technology, Tripoli University, Tripoli, Libya
2 Department of Basic Medical Science, Tripoli Higher Institute of Medical Sciences, Tripoli, Libya
|Date of Web Publication||7-Nov-2017|
Ahmed E Atia
Department of Anesthesia and Intensive Care, Faculty of Medical Technology, Tripoli University, Tripoli
Source of Support: None, Conflict of Interest: None
Background and Aims: Inappropriate uses of antibiotics for the treatment of common self-limiting infections are a major dispensing malpractice worldwide. This potentially may result in the development of resistant bacterial strains, which represents a significant public health problem. This study aimed to describe the pattern of antibiotics dispensing between community pharmacists (CPs) and general practitioners (GPs) regarding symptomatic diagnosis, antibiotic categories, and adherence to therapeutic doses. Subjects and Methods: Between March and June 2017, using trained simulated patients (SPs) with simulated clinical scenarios of having upper respiratory tract infections, a cross-sectional observational study of antibiotic dispensing encounters was conducted at 20 randomly selected pharmacies and clinics in the city of Tripoli, Libya. SPs were trained to deal with both expertise and record their notice after each visit in specific form developed by the researcher. The data were descriptively analyzed using Chi-square and Fisher's exact tests at alpha level of 0.05. Results: CPs dispensed more antibiotics than GPs (P = 0.001) for treating symptoms of common cold. They dispensed more amoxicillin (n = 32, 53.5%) than GPs (n = 18, 30.0%) (P = 0.001). While no CP dispensed ciprofloxacin, only two GPs dispensed this category (P = 0.022). In general, GPs comply better with the symptomatic diagnosis standard than CPs. On the other hand, CPs (n = 26, 59%) adhered better than GPs (n = 4, 12.5%) to therapeutic doses (P = 0.001). Conclusions: The findings suggested poor professional practices by both CPs and GPs. Antibiotic dispensing regulation policies need to be implemented in Libya and CPs must practice ethically.
Keywords: Antibiotics, community pharmacist, general practitioners, simulated patients
|How to cite this article:|
Atia AE, Abired AN. Antibiotic prescribing for upper respiratory tract infections by Libyan community pharmacists and medical practitioners: An observational study. Libyan J Med Sci 2017;1:31-5
|How to cite this URL:|
Atia AE, Abired AN. Antibiotic prescribing for upper respiratory tract infections by Libyan community pharmacists and medical practitioners: An observational study. Libyan J Med Sci [serial online] 2017 [cited 2021 May 8];1:31-5. Available from: https://www.ljmsonline.com/text.asp?2017/1/2/31/217797
| Introduction|| |
The involvement of pharmacist toward the health care of general public is well documented. Community pharmacists (CPs) are an influential source of advice on pharmaceuticals for the community. In Libya, where the separation of dispensing from prescribing has not yet taken place, antibiotic prescription by general practitioners (GPs) is also shared with CPs, who apart from their essential professional responsibilities are dispensing medications. There is a call for the need of “prescription separation” for CP so that they can concentrate on professional services and ensure rational use of medicines.
Antibiotics have altered the health of the world and have saved millions of lives worldwide. Nevertheless, the special success of antibiotics in improving quality of life globally, the dangers of overuse or misuse of antimicrobials are becoming apparent. Nonprescription-based inappropriate antibiotic use for the treatment of prevalent self-limiting infections is a main problem worldwide, with involvement that ranges from the development of antibiotic resistance, increasing medical costs, and increased drug-associated adverse effects. Libya carries a high burden of infectious diseases and consequently has a high antibiotics usages., The antibiotic prescriptions in Libya are not controlled by any policy, and there are no clear guidelines in this regard. Furthermore, the availability and utilization of bacterial culturing facilities are limited.
It is widespread practice in many Libyan community pharmacies to dispense antibiotics on demand from the patient even though a valid prescription from registered medical practitioners is not available. However, there is a paucity of studies that quantify the magnitude of the problem., Therefore, the aim of the present study was to evaluate antibiotic dispensing practice for upper respiratory tract infections (URTIs) undertaken by CPs and GPs and to compare the rationality of antibiotic dispensing practices by both expertise in relation to symptomatic diagnosis, antibiotic categories, and commitment to therapeutic doses.
| Subjects and Methods|| |
Study design and duration
A cross-sectional exploratory design was used in this study and approved by the Department of Pharmacy, University of Tripoli Alahlia (UTA), Janzur, Libya. A simulated client method was used, which involved undergraduate students from the Department of Pharmacy, UTA, who were randomly visiting a chosen community pharmacies and clinics in the city of Tripoli, Libya. Trained simulated patients (SPs) were instructed to display a scenario of having common cold symptoms at GP government clinics and at private community pharmacies to explore the practice of antibiotics dispensing. The study was conducted within the period of March to June 2017 in Tripoli, Libya, without specifying a particular date to avert respondents' awareness and violation of the study.
Study area and population
The study was restricted only to the city of Tripoli, Libya. All general medical practitioners in clinics (n = 60) and CPs in private pharmacies (n = 60) in Tripoli were considered as the study population and informed about the aim and objectives of the study. Two relevant samples of ten governmental clinics and ten community pharmacies were chosen according to the ease of access by the SPs and financial ability since study was not funded by any organization.
Simulated patients training and data collection
Extensive SP interview training sessions were conducted to observe and explore dispensing of antibiotics for URTIs by GPs and CPs in Tripoli, Libya. Twelve students trained for a 1-week training session on how to make complaint of common cold symptoms. They were also trained on how to exhibit these symptoms in front of a medical doctor or a pharmacist. SPs were trained to deal with both expertise and record their notice after each visit in specific form developed by the researchers. To validate the results, the 12 SPs were grouped in 6 pairs. Each two SPs were arranged to visit the same five clinics and five pharmacies in an interchangeable manner. If the first SP visited pharmacy X and clinic X, the second SP visited pharmacy Y and clinic Y in the first round; after few hours, the two SPs interchanged their position to visit the same two clinics and pharmacies. Hence, each CP and GP met with two different SPs leading to a total of sixty encounters in clinics and sixty in pharmacies. SPs were instructed to clarify only about common cold symptoms; they pretended to have and not to give any data or try to answer crucial questions from both expertise to avoid revealing themselves and violating the result. After every visit and away from the clinic or pharmacy, each SP recorded what was spotted in the clinics and pharmacies visited.
The statistical analysis was performed using SPSS software version 22 (SPSS Inc., Chicago III, USA). Antibiotics dispensing and therapeutic doses adherence by both providers were analyzed using descriptive statistics, Chi-square and Fisher's exact tests. Data were expressed as frequencies and percentages, and P < 0.05 was considered statistically significant.
| Results|| |
Different types of medicines were dispensed by both specialists for treating URTIs, ranges from mild analgesics, and multivitamins to prescription remedies such as antibiotics, antihistamines, and cough medicines. Pharmacists and medical doctors differed significantly in dispensing antibiotics (P = 0.001). The majority of CPs (n = 44, 73.3%) prescribed and dispensed antibiotics than did GPs (n = 32, 53.3%) for the symptoms of the common cold displayed by SPs.
In [Table 1], CPs and GPs prescribed and dispensed different types of antibiotics. The dispensed antibiotics were oral penicillin (amoxicillin and amoxiclav), macrolide (azithromycin), cephalosporin (cefixime), and fluoroquinolones (ciprofloxacin). There is statistically significant difference in dispensing oral penicillin between CPs and GPs (P = 0.001). CPs (n = 32, 53.3%) dispensed more amoxicillin and amoxiclav than GPs (n = 18, 30%) for common cold symptoms. Only two GPs (3.3%) dispensed ciprofloxacin while no CP dispensed this antibiotic for SPs (P = 0.022).
|Table 1: Antibiotic categories prescribed and dispensed by general practitioners and community pharmacists for common cold|
Click here to view
Regarding adherence to symptomatic diagnosis, both CPs and GPs adhered to standards for symptomatic diagnosis of the common cold. However, CPs showed to prescribe more antibiotics in relation to these diagnostic parameters. [Table 2] demonstrated that those respondents who inquired about the age of patients differed significantly in dispensing antibiotics (P = 0.001). In more detail, 12 out of 16 CPs who asked about the patient's age gave antibiotics, while only one GP refused to prescribe antibiotics in regard to this management standard (1.6%). In considering the inquiry about the symptoms, of 42 CPs who adhered to this standard, 27 (45.0%) agreed to dispense antibiotics for common cold symptoms. Whereas, 22 (36.6%) of the 53 GPs who adhered to this standard also dispensed antibiotics (P = 0.001). Concerning the question about the duration of symptoms, of 32 CPs who adhered to this standard, 22 (36.6%) agreed to give antibiotics for common cold symptoms. In contrast, 19 (31.6%) of the 49 GPs who adhered to this standard also prescribed antibiotics (P = 0.024). Regarding the question about the color of sputum, of 32 CPs who adhered to this question, 22 (36.6%) agreed to give antibiotics for common cold symptoms in compare to 19 (31.6%) of the 49 GPs who adhered to this standard and who consequently dispensed antibiotics (P = 0.001). Both CPs and GPs who inquired about the recurrence of the same complaints occurring per year differed significantly from each other in prescribing antibiotics (P = 0.015). All CPs who asked about this management standard (n = 5) proceeded to prescribe antibiotics, while only one from those who adhered to this standard (n = 6) gave antibiotics. Regarding soliciting answers about allergies to medicines, of 19 CPs who adhered to this question, 15 (25.0%) agreed to dispense antibiotics for common cold symptoms. In contrast, 10 (16.6%) of the 14 GPs who adhered to this standard still dispensed antibiotics (P = 0.003).
|Table 2: Comparison of antibiotic dispensing between community pharmacists and general practitioners who adhered to symptomatic diagnosis of common cold|
Click here to view
In adherence to antibiotic therapeutic doses, the numbers and categories of medicines dispensed by both specialties showed that CPs were more likely than GPs to dispense antibiotics for the common cold symptoms displayed by SPs (P = 0.001), as shown in [Table 3]. Regardless of inappropriate prescription of antibiotics, CPs appeared to adhere to therapeutic dosages (n = 26, 59%) more than the GPs did (n = 4, 12.5%). GPs (n = 28, 87.5%) were more likely to prescribe antibiotics at subtherapeutic doses.
|Table 3: Antibiotics dispensed and adherence to therapeutic doses by general practitioners and community pharmacists|
Click here to view
| Discussion|| |
In Libya, antibiotics without prescription can be easily obtained from community pharmacies. URTIs account for the majority of antibiotic dispensing provided by general physician in Libya., The concept of rational use of medicines was defined by the WHO as “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of times and at the lowest cost to them and their community”. Our result clearly demonstrated that both providers (CPs and GPs) were not complied with the concept of rational use of drugs by unnecessary prescribing and dispensing of antibiotics for URTIs caused by a nonbacterial infection. Controlling for all other factors, we found unnecessary uses of antibiotics by both providers, with inappropriate therapeutic doses of antibiotics (GPs). These irrationalities will lead to wasting of resources and increasing bacterial resistance to antibiotics. Some CPs and GPs in this study prescribed or dispensed antibiotics for common cold symptoms, with CPs dispensed antibiotics more than GPs (73.3%, 53.3%, respectively [P = 0.001]). The symptoms shown by our SPs were common cold symptoms which mainly caused by viral pathogens such as rhinovirus, parainfluenza, and influenza, which resolve without the use of antibiotics. We found no justification for this unnecessary use except the suspect of providers' fear of patient dissatisfaction when refusing to prescribe antibiotics for them. This unnecessary dispensing, if not regulated, bacterial resistance maybe emerges. Our study added to the finding of the study from Saudi Arabia that pharmacists dispense more antibiotics than GPs for common cold symptoms. In our study, penicillins were the most prescribed and dispensed antibiotics by both providers, followed by macrolides and cephalosporins, while only two GPs prescribed ciprofloxacin. These results are found to be consistent with previous studies in Malaysia, India, Egypt, and other parts of Libya.,,,
Antibiotics continue to be the most commonly purchased drugs worldwide. A previous study revealed that nonprescription use occurred globally and accounted for 19%–100% of antibiotics use in developing countries other than developed one. The utilization of antibiotics is largely unregulated, without the participation of a licensed well-trained pharmacist, and is often without prescription. Studies from countries with poor drug dispensing regulation policies show inconstant rates of nonprescription antibiotic uses. Egyptian study in 2014 showed that 13.1% of pharmacies agreed to dispense broad-spectrum antibiotics to patients with URTIs. Several other studies have reported that antibiotics could be easily obtained regardless of regulations prohibiting such practice.,,
Inappropriate use of antibiotic, often called misuse, is when the antibiotic dispensed for other purposes than bacterial infections., The suitable use of antibiotics might not be achieved by focusing on their efficacy but also on the provider's adhering to the rational prescribing guidelines. As the definition of rational use of medicines reveals, the first essential factor of prescribing medicines to the patient is to be appropriate for their clinical needs. Although CPs in this study adhered better to curative doses and duration of antibiotics, they prescribed and dispensed these antibiotics inappropriately regardless the actual clinical needs of their patients. Therefore, unfortunately, they do not properly adhere to the correct dose.
| Conclusions|| |
The findings of this study revealed unnecessary dispensing of antibiotics practiced by both CPs and GPs in Libya. CPs dispensed more antibiotics than GPs. Despite CPs adhere better to symptomatic diagnosis and curative dosing of antibiotics than GPs, they unnecessarily prescribe and dispense more antibiotics for URTI symptoms which mainly caused by viral pathogens, thus are inappropriate indications for antibiotic prescribing. These results suggest the need for better enforcement of pharmacy laws. They also highlight the need for the development of evidence-based guidelines and the delivery of educational program to promote better antibiotic prescribing and dispensing practices that can be beneficial in improving current practice. Public education to word the outcome of antibiotic misuse also helps to restrict the widely spread practice of antibiotics self-medication. More studies about the appropriate use of medicines and rigorous guidelines are necessary to enhance the safe use of medicines in the Libyan community.
We are grateful for all the pharmacists and general practitioners who involved in the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Alabid AH, Ibrahim MI, Hassali MA. Antibiotics dispensing for URTIs by community pharmacists (CPs) and general medical practitioners in Penang, Malaysia: A Comparative study using simulated patients (SPs). J Clin Diagn Res 2014;8:119-23.
Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al.
Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013;13:1057-98.
GPCHE: Annual Statistical and Health Report, MOH/HIS; 2010.
Elmehdawi R, Albarsha A. Pattern of antibiotic prescription to hospitalized patients in a teaching hospital in Benghazi-Libya. Libyan J Infect Dis 2008;2:29-34.
Ghaieth MF, Elhag SR, Hussien ME, Konozy EH. Antibiotics self-medication among medical and nonmedical students at two prominent universities in Benghazi city, Libya. J Pharm Bioallied Sci 2015;7:109-15.
Domma A, Gamal M, Bioprabhu S. Common antibiotics prescribed for acute respiratory tract infected children in Libya. IOSR J Pharm 2015;5:19-22.
World Health Organization. How to Develop and Implement a National Drug Policy. 2nd
ed. Geneva: WHO; 2001.
Mahmood A, Elnour AA, Ali AA, Hassan NA, Shehab A, Bhagavathula AS, et al.
Evaluation of rational use of medicines (RUM) in four government hospitals in UAE. Saudi Pharm J 2016;24:189-96.
Adult Treatment Guidelines: Upper Respiratory Tract Infections. Principles of Appropriate Antibiotic use Apply to the Diagnosis and Treatment of Acute Upper Respiratory Tract Infection (common cold) in Otherwise Healthy Adults. Available from: http://www.cdc.gov/getsmart
. [Last accessed on 2017 Jun 14].
Hamm RM, Hicks RJ, Bemben DA. Antibiotics and respiratory infections: Are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62.
Mensah KB, Ansah C. Irrational use of antibiotics and the risk of diabetes in Ghana. Ghana Med J 2016;50:107-14.
Hadi MA, Karami NA, Al-Muwalid AS, Al-Otabi A, Al-Subahi E, Bamomen A, et al.
Community pharmacists' knowledge, attitude, and practices towards dispensing antibiotics without prescription (DAwP): A cross-sectional survey in Makkah Province, Saudi Arabia. Int J Infect Dis 2016;47:95-100.
Shet A, Sundaresan S, Forsberg BC. Pharmacy-based dispensing of antimicrobial agents without prescription in India: Appropriateness and cost burden in the private sector. Antimicrob Resist Infect Control 2015;4:55.
Sabry NA, Farid SF, Dawoud DM. Antibiotic dispensing in Egyptian community pharmacies: An observational study. Res Social Adm Pharm 2014;10:168-84.
Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non-prescription antimicrobial use worldwide: A systematic review. Lancet Infect Dis 2011;11:692-701.
Shamsuddin S, Akkawi ME, Zaidi ST, Ming LC, Manan MM. Antimicrobial drug use in primary healthcare clinics: A retrospective evaluation. Int J Infect Dis 2016;52:16-22.
Saha S, Hossain MT. Evaluation of medicines dispensing pattern of private pharmacies in Rajshahi, Bangladesh. BMC Health Serv Res 2017;17:136.
Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain. Clin Infect Dis 2009;48:1345-9.
Kronman MP, Zhou C, Mangione-Smith R. Bacterial prevalence and antimicrobial prescribing trends for acute respiratory tract infections. Pediatrics 2014;134:e956-65.
Fleming-Dutra KE, Hersh AL, Shapiro DJ, Bartoces M, Enns EA, File TM Jr., et al.
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010-2011. JAMA 2016;315:1864-73.
Maciulaitis R, Janusonis T, Petrikaite V, Aukstakalniene A. Assessment of antibiotic use and comparison with recommendations for their rational use. Medicina (Kaunas) 2006;42:999-1005.
[Table 1], [Table 2], [Table 3]