Over-the-Counter Sale of Antibiotics in India: A Qualitative Study of Providers’ Perspectives across Two States

Abstract

India has one of the highest rates of antimicrobial resistance (AMR) worldwide. Despite being prescription drugs, antibiotics are commonly available over-the-counter (OTC) at retail pharmacies. We aimed to gain insight into the OTC sale of antibiotics at retail pharmacies and to elucidate its underlying drivers. We conducted face-to-face, in-depth interviews using convenience sampling with 22 pharmacists and 14 informal dispensers from 36 retail pharmacies across two Indian states (Haryana and Telangana). Thematic analysis revealed that antibiotics were often dispensed OTC for conditions e.g., fever, cough and cold, and acute diarrhea, which are typically viral and self-limiting. Both Access and Watch groups of antibiotics were dispensed for 1–2 days. Respondents had poor knowledge regarding AMR and shifted the blame for OTC practices for antibiotics onto the government, prescribers, informal providers, cross practice by alternative medicine practitioners, and consumer demand. Pharmacists suggested the main drivers for underlying OTC dispensing were commercial interests, poor access to public healthcare, economic and time constraints among consumers, lack of stringent regulations, and scanty inspections. Therefore, a comprehensive strategy which is well aligned with activities under the National Action Plan-AMR, including stewardship efforts targeting pharmacists and evidence-based targeted awareness campaigns for all stakeholders, is required to curb the inappropriate use of antibiotics.

Repurposing of Antibiotics: Sense or Non-sense

“…The study illustrated a possible mechanism of doxycycline-selected resistance and co-resistance in V. cholerae and warranted strict restrictions on the indiscriminate use of antibiotics. Another facet is the limitation of unrestricted sale of these antibiotics without prescription especially in developing countries like India, one of the largest antibiotic consumer ( Kotwani et al, 2021 ). So, the controlled usage of these repurposed antibiotics will be jeopardized.…”

Pandemic panic and indiscriminate prescriptions drive India’s antimicrobial resistance

“…A qualitative study published in September 202110 looking at antibiotic overuse in two Indian states (Haryana in the north and Telangana in the south) found that in 36 retail pharmacies, antibiotics from the WHO’s access and watch groups were often dispensed for fever, cough, cold, and acute diarrhoea. They cited profit motives, as well as patients buying antibiotics because they can’t see a doctor (because of access issues or cost), as reasons behind the overuse.…”

Perspectives on the Ethics of Antibiotic Overuse and on the Implementation of (New) Antibiotics

“…One way to potentially change individual ethical behaviour is through targeted prescriber and general public education campaigns so that doctors and the general public are continuously made aware of the deleterious effect and risk associated with the irrational use of antibiotics to treat unconfirmed bacterial infections [ 11 ]. Ethically speaking, however, one of the possible ethical consequences of such policy implementations may be a reduction in the standard of living of vendors via the profits made by selling antibiotics [ 12 , 13 ]. Another ethical problem is that blocking access to antibiotics may unfairly target lower income groups who cannot afford to pay for a visit to a doctor, or a diagnostic test, on top of the cost of antibiotic treatment.…”