Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study

Abstract

SummaryBackgroundIndia's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India.MethodsIn this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both.FindingsBetween April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour.InterpretationOnly some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions.FundingGrand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.

Do chain pharmacies perform better than independent pharmacies? Evidence from a standardised patient study of the management of childhood diarrhoea and suspected tuberculosis in urban India

“…The one other SP study that has investigated how pharmacies respond to TB in India showed that antibiotic use substantially decreased when SPs presented with a known diagnosis, as opposed to just symptoms. 27 In our scenario, while SPs did not present with a medically confirmed diagnosis, they mentioned contact with an infected individual and hence a suggestion that they might have TB. This is more in line with a known diagnosis and our results are therefore likely presenting pharmacy behaviour at the more positive end of the spectrum.…”

“…This is an important finding, which corroborates the research of Satyanarayana and colleagues who report that pharmacies in other Indian cities (Mumbai, Patna and Delhi) also did not sell any first-line anti-TB medicines when presented with an SP. 27 Adherence to restrictions on the prescription of H1 medicines appears to be a positive finding for TB control efforts.…”

“…Treatment results are in keeping with other studies that presented one of these conditions as a standalone case at pharmacies in India. 27 40 We, therefore, have no reason to believe that pharmacy staff acted differently because SPs presented both cases in a single client interaction.…”

Quality of tuberculosis care in high burden countries: the urgent need to address gaps in the care cascade

“…Indian pharmacists are frequently consulted by patients for over-the-counter medications. 20 Satyanarayana and colleagues trained simulated patients to present as two cases. Case 1 was a simulated patient presenting with 2–3 weeks of cough and other typical TB symptoms.…”

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

“…Inappropriate management is also a concern in countries with high rates of infectious diseases such as HIV, malaria and tuberculosis (TB), which is the case in sub-Saharan Africa, as this may complicate treatment [110][111][112] . Certain antibiotics temporarily suppress symptoms of TB, leading to delays in diagnosis and patients potentially receiving several antibiotics due to the wrong clinical diagnosis 113 . Ideally, patients with TB should be referred by pharmacists to specialists if patients first visit them.…”