A Simulated Client Study on Non-Prescription Antibiotic Sales and Counselling Practices in Iraqi Nurse-Led Clinics: Implications for Antimicrobial Resistance

Amanj Kurdi,1– 4 Awat Jamal Hasan,5 Ari Jamal Hassan II,6 Ying He,7 Omeed Darweesh,2 Karwan M-Amen,8 Kirmanj I Baker,9 Hardee Karwi,10 Brian Godman1,4,11 1Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK; 2College of Pharmacy, Al-Kitab University, Kirkuk, 36015, Iraq; 3College of Pharmacy, Hawler Medical University, Erbil, Kurdistan Region, Iraq; 4Department of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, 0208, South Africa; 5College of Nursing, University of Sulaimani, Sulaimani, Kurdistan Region, Iraq; 6College of Nursing, University of Human Development, Sulaimani, Kurdistan Region, Iraq; 7Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK; 8Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq; 9Department of Surgery, College of Medicine, University of Kirkuk, Kirkuk, Iraq; 10Department of Clinical Pharmacy, Azadi Teaching Hospital, Kirkuk Health Directorate, Ministry of Health, Kirkuk, Iraq; 11Antibiotic Policy Group, Centre for Neonatal and Paediatric Infection, Institute for Infection and Immunity, Antibiotic Policy Group, City St. George’s, University of London, London, SW17 0RE, UKAmanj KurdiStrathclyde Institute of Pharmacy and Biomedical Science, University of Strathclyde, 161 Cathedral Street, Glasgow, G4 0RE, UK, Email [email protected] GodmanSefako Makgatho Health Sciences University, Department of Public Health Pharmacy and Management, Ga-Rankuwa, Pretoria, 0208, South Africa, Email [email protected]: The inappropriate use of antibiotics is a major contributor to antimicrobial resistance (AMR), which is a critical issue in low and middle-income countries such as Iraq. Nurse-led clinics in Iraq are a common point of care for patients seeking treatment for infectious diseases; however, they are currently poorly regulated. This study aimed to assess the extent and appropriateness of antibiotic dispensing in this setting, including the quality of dispensing. In these clinics, only two antibiotics are legally permitted for dispensing. These are amoxicillin and erythromycin. The findings can be used to provide future guidance to improve antibiotic use in the country and reduce AMR where there are concerns.Methodology: A cross-sectional study was undertaken using simulated clients among 235 randomly selected nurse-led clinics in Iraq, presenting with a viral upper respiratory tract infection (URTI). The outcomes included the prevalence, type of antibiotics supplied, including their Access, Watch, and Reserve (AWaRe) classification, as well as the extent and quality of patient counselling. Descriptive statistics were used to summarise dispensing patterns and counselling practices. Multivariable logistic regression was also applied to assess associations between provider’s characteristics and inappropriate antibiotic dispensing.Results: Antibiotics were supplied inappropriately in 60.0% (141/235) of the encounters, with 36.1% (85/235) of them involving antibiotics not legally permitted to be dispensed in these clinics. Amoxicillin/clavulanic acid accounted for 34.0% (48/141) of the antibiotics supplied. Based on their AWaRe classification, 25.5% (36/141) of these were Watch antibiotics. Only 24.8% of providers asked additional clinical questions, and allergy screening occurred in just 7.8% of cases. Clinics with higher-qualified staff were significantly less likely to dispense antibiotics.Conclusion: Widespread inappropriate and, in many cases, illegal antibiotic dispensing was observed in Iraqi nurse-led clinics, with limited patient assessment. These findings underscore the urgent need for enhanced antimicrobial stewardship, provider education, and regulatory enforcement to address AMR in Iraq.Plain Language Summary: Antimicrobial resistance (AMR) poses a substantial threat to public health as it reduces the number of effective antibiotics available to combat infections affecting patients as well as increasing costs and deaths. Iraq is a critical country with high and growing rates of AMR, with associated deaths. Consequently, there is a need to address this. Nurse-led clinics are a key part of primary healthcare delivery in Iraq; however, little is known about the management of patients with respiratory infections in these clinics. Our research identified that 60% of patients with mild respiratory infections that do not require antibiotics received them. Healthcare professionals (HCPs) in these clinics are allowed to dispense two antibiotics without a prescription; however, an appreciable number of antibiotics were dispensed outside of these two antibiotics. Of additional concern is that patients were not typically asked key questions during the consultation including any known allergies to penicillin products. Encouragingly, clinics staffed with higher-qualified HCPs were significantly less likely to dispensing antibiotics for mild respiratory infections. Overall, there is a need for appreciable education among patients and HCPs in Iraq to improve the future use of antibiotics alongside a decrease in AMR in the country.Keywords: antibiotic stewardship, antimicrobial resistance, AWaRe classification, Iraq, nurse-led clinics, non-prescription antibiotic use