INTRODUCTION

Dispensing of antibiotics without prescription is one of the factors contributing to irrational use of antibiotics and increasing the rate of antimicrobial resistance (AMR). ¹ , ² Antimicrobial resistance has become a concern of public health. ² In low and middle income countries, AMR associated with poor practices of healthcare professionals and patients' behavior towards using antimicrobials in addition to the supply and sale of antimicrobials. ³ It is estimated that over 50% of the antimicrobials worldwide are obtained without a prescription from community pharmacies. ⁴ The non-prescription sale of antibiotics leads to inappropriate choices of antibiotics, and increases the rate of non-adherence to the prescribed course of antibiotics. ⁵ Iraqi people tend to use antibiotics for all respiratory infections even those caused by viral infection, such as flu. Although, antibiotics are prescription only medicines, people can easily obtain them without a prescription. Many community pharmacists ignore the general legal guidelines for dispensing antibiotics by making them available without a prescription. ⁶ , ⁷ In Iraq, antibiotics are dispensing in government sector includes primary healthcare centers, public hospitals and outpatient clinics. In private sector, antibiotics are only dispensing in community pharmacies because private hospitals do not have own pharmacies. Private hospitals are referring their patients to obtain prescription medicines from community pharmacies. While, there are no community pharmacy chains in Iraq. Community pharmacies are private independent pharmacies which are usually managed by licensed pharmacists to dispense prescribed medicines. ⁷ , ⁸ Antibiotics are only prescription medicines in Iraq, but dispensing them without a prescription is very common practice in community pharmacies. In other words, the dispensing of antibiotics in community pharmacies is not regulated well. While the prescribing and dispensing of antibiotics in governmental sector is better controlled due to the official rules, the regular reviews of antibiotics' stocks and records by governmental inspectors; in addition to pharmacists' tendency to protect themselves from any legal accountability. ⁷ Previous studies reported that dispensing of antibiotics without prescription is frequent in community pharmacy, not only in low-income countries but in the developed countries as well. ⁹ , ¹⁰ In Middle East, it has been found that the dispensing of antibiotics without prescription remains a serious problem in many countries such as Syria, Egypt, Jordan, Saudi Arabia, and Iraq. ⁶ , ¹¹ - ¹⁴ Other studies reported that the quality of community pharmacy practice is significantly associated with antibiotics misuse. ¹⁵ - ¹⁷ The majority of antibiotics are prescribed and dispensed in community pharmacy; therefore optimizing the use of antibiotics is very important in this setting. ¹⁸ However, pharmacists are critically involved to play an active role to improve the appropriate use of antibiotics and to reduce the rates of antibiotics resistance, which are reported in many countries.19 Consequently, a global action plan on antibiotics resistance is prompted to improving the awareness and perception about antibiotics resistance, strengthening the monitoring and researches, reducing the incidence of infections, and optimizing the use of antibiotics. ²⁰ Within this context, the appropriate dispensing practices in community pharmacy are essential to ensure the optimal utilization of antibiotics in public. ²¹ However, using qualitative approach in pharmacy researches are valuable to explain, understand, and explore perceptions, beliefs, and feelings of pharmacists or patients. ²² Besides, there is a lack of information about the dispensing of antibiotics in community pharmacy in Iraq. Pharmacists' perception about the dispensing of antibiotics will give an explanation about the use of antibiotics in community setting. This is very important to implement the needful interventions for supporting antibiotics stewardship in Iraq. This study aimed to explore the dispensing practice of antibiotics in community pharmacies in addition to understand the community pharmacists' perceptions about dispensing of antibiotics without prescription.

METHODS

RESULTS

The majority of the participants (18) have a bachelor degree in pharmacy and only two of them completed higher degree. Most of them have experience of more than 10 years in community pharmacy. Table 1 shows the community pharmacists' characteristics.

The dispensing practice of antibiotics was explored based on semi-structured interviews with twenty community pharmacists. With regard to dispensing practice of antibiotics, pharmacists in both types of pharmacy were commonly dispensed antibiotics without prescription. The estimated numbers of antibiotics dispensed without prescription was various from 10 cases to 50 cases per day as shown in Table 2 . However, all the pharmacists explained that they dispense antibiotics without prescription for different medical conditions including Respiratory Tract Infections (RTIs), tonsillitis, otitis media, Urinary Tract Infections (UTIs), diarrhea, skin infection, toothache, sore throat, common cold and flu. The most commonly dispensed antibiotics without prescription were amoxicillin, ciprofloxacin, cephalexin, cefixime, erythromycin, azithromycin, doxycyclin, trimethiprem, and amoxicillin/ clavulanic acid.

From thematic analysis, five themes were identified to influence the dispensing practice of antibiotics without prescription in community pharmacy. The main themes were: (1) perception towards factors motivating dispensing of antibiotics without prescription, (2) perception towards factors preventing dispensing of antibiotics, (3) awareness about antibiotic stewardship; (4) knowledge about antibiotic resistance; and (5) reasons of antibiotic resistance.

DISCUSSION

This study found that dispensing of antibiotics without prescription was a common in both types of community pharmacy in Baghdad. Community pharmacists tend to dispense antibiotics when requested they by name. This finding is similar to previous studies conducted in middle-east countries indicated that pharmacists seem to be irresponsible to dispense antibiotics without prescription by ignoring the rules and regulations in many cases. ¹⁴ , ²⁵ , ²⁶ However, a study in Saudi Arabia showed that the law enforcement was associated with reducing the dispensing practice of antibiotics without prescription. ²⁷

This study also showed that pharmacists have the tendency to manage some medical conditions by prescribing and dispensing antibiotics without prescription. Most of them prescribe antibiotics without doctor's prescription for some infections such as urinary tract infections (UTIs), tonsillitis, and skin infections. However, dispensing of antibiotics without prescription is releasing a wrong message to patients and encouraging them to continue obtaining antibiotics without doctor's consultation. Previous studies showed that community pharmacists dispensed antibiotics without prescription for certain medical conditions. ²⁷ - ²⁹ Obtaining antibiotics without medical prescription could raise the risk of antibiotics resistance. ²⁹ , ³⁰ In many cases, pharmacists have difficulties to differentiate between bacterial and viral infections to dispense the right antibiotics for the right patient; and increasing the possibility of negative outcomes. ¹⁴ This might be happened due to the poor restrictions of dispensing practice in Iraq is not effectively applied to control the decision of community pharmacists in dispensing antibiotics without doctor's consultation. On the other hand, some pharmacists in this study believed that antibacterial agent has lesser side effects compare to other antimicrobial agents that they felt it is safe to dispense antibiotics without prescription. A study by Al-Mohamadi et al. (3013) indicated that some pharmacists considered antibiotics are safe to patients, and this represents the risk implied to society, requiring an urgent reconsideration from the health authorities. ³¹ This misconception requires efforts to improve the education of pharmacists about the possible side effects of antimicrobials and its appropriate dispensing. ³²

With regard to the factors encouraging pharmacists to dispense antibiotics without prescription, this study found that most of the pharmacists dispense antibiotics without prescription when the patient requests them by name. Similar findings have been found in previous studies showed that the community pharmacists dispense antibiotics when patients requested them by name due to the familiarity with such antibiotics or because patients had been used them previously. ¹⁴ Another study stated that patients can easily obtain antibiotics from community pharmacy either by requesting them by name or by simply presenting their medical condition to the pharmacist. ²⁶ While other studies reported that requesting antibiotics by name and the financial benefits were the main reasons for dispensing of antibiotics without prescriptions. ¹⁴ , ²⁶ , ³³ This study revealed that all the pharmacists have the tendency to dispense antibiotics without prescription for emergency conditions such as diarrhea and upper respiratory infections especially when the doctor's clinic is not available. In concordant with a study in Saudi Arabia reported that the emergency cases and the unavailability of clinic after working hours were the reasons given by pharmacists to dispense antibiotics without prescription.14 However, a study in Lebanon reported that almost 41% of the antibiotics prescribed by pharmacists were unnecessary because the medical condition is most likely of a viral infection especially in respiratory conditions and diarrhea. ²⁶ Another study in Saudi Arabia indicated that pharmacists prescribed unnecessary antibiotics for diarrhea, respiratory infections and urinary tract infections. ¹⁵ This might explain the tendency of pharmacists to manage some infections depending on their skills and experiences by giving reasonable cases for this practice. This study was also showed that most of the pharmacists tend to dispense antibiotics without prescription to their regular customers and few of them dispensing of antibiotics to regular customers to avoid losing them or because antibiotics can be obtained from other community pharmacies. Similarly, previous studies also showed that the community pharmacists dispensed antibiotics without prescription to avoid losing their customer. Pharmacists stated that refusing to dispense antibiotics without prescription will negatively influence their sales and earnings; especially when the customer would be able to obtain antibiotics from other community pharmacies. ¹⁶ , ²⁷ , ³¹ Lack of drug regulations is the main reason for increasing sale of antibiotics without prescription for pharmacist who need to ensure business-continued existence. ¹⁷

In this study, pharmacists stated that patients prefer to buy antibiotics from community pharmacy to save time and cost of doctor's consultation. Various studies have reported similar findings indicating that saving time and cost was associated with dispensing of antibiotics without prescription. ¹⁰ , ¹⁴ , ¹⁵ In fact, patients may spend long time for consulting a doctor and keep waiting in a long queue in the primary healthcare centers or even in the private clinics. ³⁴ However, the cost of doctor's consultation is apparently expensive leading the patients to self-purchasing of antibiotics from community pharmacy. ³⁴ , ³⁵ In addition, there is a lack of awareness that unnecessary use of antibiotics is ineffective and costly; and it can contribute to antimicrobial resistance. ³⁶ Pharmacists in this study reported that the availability of brand antibiotics in community pharmacy encouraged them to dispense antibiotics without prescription. Previous studies showed that dispensing of brand antibiotics without prescription was common due to the impact of pharmaceutical companies to promote their brand in any possible way. ³⁴ Another study in Jordon showed that 67% of the dispensed antibiotics were brands antibiotics. Costumers' tendency to obtain brand medicines was leaded to self-purchasing of antibiotics. ³⁷ Community pharmacists might be negatively perceived that brand antibiotics are safe and more effective than generic ones; without taking into account the burden of cost for unnecessary antibiotics.

On the other hand, this study is also revealed that the poor healthcare services and the lack of medications in public healthcare facilities influenced the community pharmacists to dispense antibiotics without prescription. Similar finding was reported by Saleem et al . (2016) that the lack of healthcare services and poverty of people to afford the cost of doctor's consultation increased the self-purchasing of antimicrobials. ³⁸ The lack of access to good-quality in primary healthcare increased the problem of antibiotic resistance especially in low- and middle-income countries where the healthcare services are under-estimated. These countries are particularly at risk of high rate of resistance because the second-line antibiotics required to fight the most resistant infections are often unaffordable. ³⁸ , ³⁹

With regard to factors preventing pharmacists from dispensing of antibiotics, this study showed that pharmacists stated to stop dispensing of antibiotics when they feel that the choice of antibiotics is inappropriate and some of pharmacists tended to refer patients to respective doctor to confirm the choice of antibiotic. A study in Saudi Arabia reported that the pharmacists were concerned about physicians' prescribing decisions to write unnecessary antibiotics without any medical justification. ³⁴ Incorrect choice of antibacterial is considered as a significant aspect involved in irrational use of antibacterial. ⁴⁰ However, a study in Jordon showed that the choice of dispensed antibiotics by community pharmacists was inappropriate. ³⁷

On the other hand, this study showed that pharmacists refused to dispense antibiotics without prescription to patient with complicated symptoms or critical conditions which are required a doctor's consultation. Similar findings have found in literature that pharmacists would not dispense antibiotic in complicated medical cases and for patients with lack of medical history; this probably because pharmacists want to protect themselves from any negative outcomes that make them legally accountable. ¹⁴ In this study, pharmacists stated to stop dispensing of antibiotics in case of patient allergic to certain antibiotics. In consistent with a study by Bahnassi, (2015) reported that pharmacists asked patients about antibiotic allergy, presence of chronic diseases, or using other medications before dispensing the antibiotics. ¹⁶ Another study also reported that most of the pharmacists asked patients about antibiotics allergy. ⁵ Pharmacist is responsible for patient safety when ensuring that the patients are not allergic to prescribed medications, or there are no interactions with another medication using by patients or food interactions. ⁴¹ This might explain that pharmacists have the awareness about patient's safety in case of drug allergy; in addition to pharmacists' skills and experiences to avoid any negative outcome.

With regard to the awareness about antibiotic stewardship, this study indicated that community pharmacists were unaware about antibiotic stewardship programs. Findings from previous studies found that there is a lack of awareness about antibiotic stewardship among pharmacists, and lack of training to carry out antibiotic stewardship. ⁴⁰ , ⁴² , ⁴³ However, antibiotic stewardship should importantly focus on pharmacy education since postgraduate training is not implemented for pharmacists. Pharmacists may not have been provided by essential and adequate amounts of education to improve antibiotic stewardship. ⁴⁴

This study showed that pharmacists have the basis knowledge about antibiotic resistance that antibiotics are ineffective to kill the bacteria. Pharmacists also stated that antibiotic resistance occurred due to the irrational use of antibiotics in terms of overuse and underuse of antibiotics. Other pharmacists explained other reasons such as the cost of antibiotic course, patient's belief about using antibiotics, self-medication, poor restrictions and easy accessibility, doctors' tendency to prescribe antibiotics, and poor pharmacy practice. A pervious study in Pakistan reported that the pharmacists had good knowledge about rational use of antibiotics, but they did not apply the current strategies of antibiotic stewardship to optimize the use of antimicrobials. ⁴⁰ A study found that dispensing of antibiotics without prescription was high compared to prescribed antibiotics, and community pharmacists have lack of knowledge about antibiotic resistance. ⁴⁵ This study is limited to face to face interviews, so the findings may explain the perception towards the dispensing practice of antibiotics but it does not show the appropriateness of practice when antibiotics dispensed without prescription. In addition, factors influencing perception of community pharmacists were not assessed in this study. It is suggested that a survey study can help to show factors associated with pharmacists' perception towards the dispensing of antibiotics. In addition, pharmacists may influence by the moderator when explaining his opinions and perceptions toward dispensing of antibiotics, so this may contribute to bias findings into the study.

CONCLUSIONS

This study showed that dispensing of antibiotics without prescription was a common practice in community pharmacy. Pharmacists' perception towards dispensing of antibiotics without prescription was associated with many factors encouraging pharmacists to ignore the rules and regulations; in addition to the poor restrictions for this practice at the community-pharmacy level. Pharmacists were well aware about the negative impact of antibiotics misuse on public health especially in term of antibiotic resistance, but their inappropriate dispensing practices were apparently poor in many cases. In addition, there was a lack of awareness about antibiotic stewardship leading to inappropriate dispensing practice. The regulations for dispensing prescription medicines should be enforced at the community pharmacy to control the dispensing practice of antibiotics without prescription. Educational interventions are needed to improve pharmacists' knowledge about antibiotic resistance; in addition to adequate training for pharmacists and physicians about the rational use of antibiotics to improve their understanding about antimicrobial stewardship. This will help to optimize the use of antibiotics in community setting. Moreover, information about antibiotics use and antibiotic resistance should be incorporated in the curriculum of pharmacy colleges to ensure good pharmacy practice in the future.