Appreciable purchasing of antibiotics without a prescription among patients in rural South Africa, the rationale and the implications for addressing antimicrobial resistance

Background: Antimicrobial resistance (AMR) is now a critical issue in South Africa, enhanced by considerable inappropriate prescribing of antibiotics. There is currently variable dispensing of antibiotics without a prescription. Where this occurs, it is principally for urinary tract infections (UTIs) and sexually transmitted infections (STIs). Consequently, a need to comprehensively evaluate antibiotic dispensing patterns and factors influencing this to reduce AMR. Methods: A previously piloted questionnaire was administered to patients exiting three different categories of community pharmacies in a rural province. The questionnaire included data on the prevalence of antibiotics dispensed, whether without a prescription, and the rationale for this. Results: 465 patients were interviewed leaving community pharmacies with a medicine. 54.4% were dispensed at least one antibiotic, with 78.7% dispensed these without a prescription from either independent or franchise pharmacies. Metronidazole (36.1%) and azithromycin (32.7%) were the most dispensed antibiotics. STIs were the most common infectious disease where an antibiotic was dispensed (60.1%), with 99.6% dispensed without a prescription. Upper Respiratory Tract Infections (URTIs) were the most common infection where antibiotics were dispensed with a prescription (60.0%), with little dispensing without a prescription (7.1%). The most frequently cited reasons for obtaining antibiotics without a prescription were prior use (56.8%), long waiting times at PHC clinics (15.6%) and financial constraints (6.0%). Conclusion: An urgent need to review community pharmacist activities, including allowing them to prescribe antibiotics for infectious diseases such as UTIs, similar to other countries. Concomitantly, utilize trained community pharmacists to engage with prescribers to improve future antibiotic use especially for URTIs.