Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review

Abstract

Background Many low- and middle-income countries (LMIC) are moving towards enforcing prescription-only access to antibiotics. This systematic literature review aims to assess the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in LMICs, their impact and examine the methods chosen for impact measurement including their strengths and weaknesses. Methods Both PubMed and Embase were systematically searched for studies reporting on impact measurement in moving towards prescription only access to antibiotics in LMICs. The PRISMA methodological review framework was used to ensure systematic data collection and analysis of literature. Narrative data synthesis was used due to heterogeneity of study designs. Results In total, 15 studies were included that assessed policy impact in 10 different countries. Strategies employed to enforce regulations prohibiting OTC sales of systemic antibiotics included retention of prescriptions for antibiotics by pharmacies, government inspections, engaging pharmacists in the design of interventions, media campaigns for the general public and educational activities for health care workers. A variety of outcomes was used to assess the policy impact; changes in antimicrobial resistance rates, changes in levels of antibiotic use, changes in trends of antibiotic use, changes in OTC supply of antibiotics, and changes in reported practices and knowledge of pharmacists, medicine sellers and the general public. Differences in methodological approaches and outcome assessment made it difficult to compare the effectiveness of law enforcement activities. Most effective appeared to be multifaceted approaches that involved all stakeholders. Monitoring of the impact on total sales of antibiotics by means of an interrupted time series (ITS) analysis and analysis of pharmacies selling antibiotics OTC using mystery clients were the methodologically strongest designs used. Conclusions The published literature describing activities to enforce prescription-only access to antibiotics in LMICs is sparse and offers limited guidance. Most likely to be effective are comprehensive multifaceted interventions targeting all stakeholders with regular reinforcement of messages. Policy evaluation should be planned as part of implementation to assess the impact and effectiveness of intervention strategies and to identify targets for further activities. Robust study designs such as ITS analyses and mystery client surveys should be used to monitor policy impact. Electronic supplementary material The online version of this article (10.1186/s12913-019-4359-8) contains supplementary material, which is available to authorized users.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…Multiple strategies are typically needed to reduce unnecessary prescribing and dispensing of antibiotics in ambulatory care among all key stakeholder groups including patients, parents, community pharmacists and physicians 29,40,52,60,70,71,74,97,154,243 . This reflects the complexity of the situation, the different beliefs of key stakeholder groups and often multiple organizations and personnel within a country involved with improving antibiotic utilization and reducing AMR rates 244 .…”

“…In Mexico and Brazil, national restrictions were placed on the self-purchasing of antibiotics in 2010, although a prescription was always a requirement for antibiotics to be dispensed among public pharmacies in Brazil 56,74,298 .…”

“…Other potential activities include instigating and monitoring the impact of measures to restrict the sales of antibiotics without a prescription as seen in Albania, the Republic of Srpska, Ghana and Turkey (Table 2). However, these measures have had variable success 74,134,242,298,299,369,371 , which may reflect concerns about their implementation, coupled with concerns about loss of income 128 . Any measure introduced must be carefully thought through in rural LMIC communities where there is a scarcity of physicians, and community pharmacists may be the only healthcare professional that patients can readily access.…”

“…Unfortunately, antibiotics can achieve good health outcomes even in patients with viral infections, which runs counter to changing public perceptions of their efficacy [56][57][58][59] . Concerns with rising rates of AMR, coupled with the continued irrational use of antibiotics to treat self-limiting infections such as upper respiratory tract infections (URTIs), have resulted in multiple initiatives internationally, regionally, and nationally aimed at reversing current trends 6,8,21,36,40,[60][61][62][63][64][65][66][67][68][69][70][71][72][73][74] .…”

“…We are aware that an appreciable number of publications and ongoing research already exist discussing potential ways to improve antibiotic utilization especially in LMICs, which includes improved surveillance 29,45,61,66,85,100,119,120,151,152 . A number of systematic reviews regarding the management of URTIs and ways to improve both the prescribing and dispensing of antibiotics for patients with URTIs have also been published 21,43,45,57,61,74,85,108,153,154 . These include systematic reviews determining possible reasons behind dispensing antibiotics without a prescription 141,155 , patient-related determinants regarding antibiotic use 156 , and reviews assessing the influence of targeted communications among patients to reduce excessive antibiotic use 157 .…”