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      Prevalence and determinants of inappropriate antibiotic dispensing at private drug retail outlets in urban and rural areas of Indonesia: a mixed methods study

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          Abstract

          Introduction

          The aim of this mixed-method study was to determine the extent and determinants of inappropriate dispensing of antibiotics by licensed private drug retail outlets in Indonesia.

          Methods

          Standardised patients (SPs) made a total of 495 visits to 166 drug outlets (community pharmacies and drug stores) between July and August 2019. The SPs presented three clinical cases to drug outlet staff: parent of a child at home with diarrhoea; an adult with presumptive tuberculosis (TB); and an adult with upper respiratory tract infection (URTI). The primary outcome was the dispensing of an antibiotic without prescription, with or without the client requesting it. We used multivariable random effects logistic regression to assess factors associated with the primary outcome and conducted 31 interviews with drug outlet staff to explore these factors in greater depth.

          Results

          Antibiotic dispensing without prescription occurred in 69% of SP visits. Dispensing antibiotics without a prescription was more likely in standalone pharmacies and pharmacies attached to clinics compared with drug stores, with an OR of 5.9 (95% CI 3.2 to 10.8) and OR of 2.2 (95% CI 1.2 to 3.9); and more likely for TB and URTI SP-performed cases compared with child diarrhoea cases, with an OR of 5.7 (95% CI 3.1 to 10.8) and OR of 5.2 (95% CI 2.7 to 9.8). Interviews revealed that inappropriate antibiotic dispensing was driven by strong patient demand for antibiotics, unqualified drug sellers dispensing medicines, competition between different types of drug outlets, drug outlet owners pushing their staff to sell medicines, and weak enforcement of regulations.

          Conclusion

          This study shows that inappropriate dispensing of antibiotics by private drug retail outlets is widespread. Interventions will need to address not only the role of drug sellers, but also the demand for antibiotics among clients and the push from drug outlet owners to compete with other outlets.

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          Most cited references49

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          Interval Estimation for a Binomial Proportion

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            A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance

            Background Greater use of antibiotics during the past 50 years has exerted selective pressure on susceptible bacteria and may have favoured the survival of resistant strains. Existing information on antibiotic resistance patterns from pathogens circulating among community-based patients is substantially less than from hospitalized patients on whom guidelines are often based. We therefore chose to assess the relationship between the antibiotic resistance pattern of bacteria circulating in the community and the consumption of antibiotics in the community. Methods Both gray literature and published scientific literature in English and other European languages was examined. Multiple regression analysis was used to analyse whether studies found a positive relationship between antibiotic consumption and resistance. A subsequent meta-analysis and meta-regression was conducted for studies for which a common effect size measure (odds ratio) could be calculated. Results Electronic searches identified 974 studies but only 243 studies were considered eligible for inclusion by the two independent reviewers who extracted the data. A binomial test revealed a positive relationship between antibiotic consumption and resistance (p < .001) but multiple regression modelling did not produce any significant predictors of study outcome. The meta-analysis generated a significant pooled odds ratio of 2.3 (95% confidence interval 2.2 to 2.5) with a meta-regression producing several significant predictors (F(10,77) = 5.82, p < .01). Countries in southern Europe produced a stronger link between consumption and resistance than other regions. Conclusions Using a large set of studies we found that antibiotic consumption is associated with the development of antibiotic resistance. A subsequent meta-analysis, with a subsample of the studies, generated several significant predictors. Countries in southern Europe produced a stronger link between consumption and resistance than other regions so efforts at reducing antibiotic consumption may need to be strengthened in this area. Increased consumption of antibiotics may not only produce greater resistance at the individual patient level but may also produce greater resistance at the community, country, and regional levels, which can harm individual patients.
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              Global access to antibiotics without prescription in community pharmacies: a systematic review and meta-analysis

              To estimate the proportion of over-the-counter antibiotic requests or consultations that resulted in non-prescription supply of antibiotics in community pharmacies globally.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                2021
                3 August 2021
                : 6
                : 8
                : e004993
                Affiliations
                [1 ] departmentThe Kirby Institute , University of New South Wales , Sydney, New South Wales, Australia
                [2 ] departmentFaculty of Medicine , Universitas Udayana , Denpasar, Bali, Indonesia
                [3 ] departmentDepartment of Global Health and Development , London School of Hygiene and Tropical Medicine , London, UK
                [4 ] departmentPathology & Community Health Sciences , The Aga Khan University , Karachi, Sindh, Pakistan
                [5 ] departmentSchool of Tropical Medicine and Global Health , Nagasaki University , Nagasaki, Japan
                [6 ] departmentFaculty of Public Health , Mahidol University , Bangkok, Thailand
                [7 ] departmentCenter for Tropical Medicine , Universitas Gadjah Mada , Yogyakarta, Indonesia
                [8 ] departmentFaculty of Medicine , Universitas Mataram , Mataram, Nusa Tenggara Barat, Indonesia
                [9 ] departmentFaculty of Medicine , Universitas Sebelas Maret , Surakarta, Jawa Tengah, Indonesia
                [10 ] departmentFaculty of Medicine , Public Health and Nursing , Universitas Gadjah Mada, Yogyakarta, Indonesia
                [11 ] departmentInstitute for Global Health , University College London , London, UK
                [12 ] The George Institute for Global Health, UNSW Sydney , Newtown, New South Wales, Australia
                [13 ] departmentSt Vincent’s Clinical School , University of New South Wales , Sydney, New South Wales, Australia
                [14 ] departmentCentre for International Health Protection , Robert Koch Institute , Berlin, Germany
                [15 ] departmentAntibiotic Resistance Control Committee , Indonesian Ministry of Health , Jakarta, Indonesia
                [16 ] departmentDepartment of Clinical Research , London School of Hygiene & Tropical Medicine , London, UK
                Author notes
                [Correspondence to ] Dr Virginia Wiseman; virginia.wiseman@ 123456lshtm.ac.uk
                Author information
                http://orcid.org/0000-0002-3397-3648
                http://orcid.org/0000-0002-8967-1761
                http://orcid.org/0000-0003-0829-291X
                https://orcid.org/0000-0003-0666-4302
                http://orcid.org/0000-0002-3494-9842
                http://orcid.org/0000-0003-3171-5271
                http://orcid.org/0000-0003-0477-4575
                https://orcid.org/0000-0002-8175-8125
                http://orcid.org/0000-0002-6399-7624
                http://orcid.org/0000-0002-7639-4355
                http://orcid.org/0000-0002-2929-4634
                http://orcid.org/0000-0002-3540-8837
                http://orcid.org/0000-0002-6045-6937
                http://orcid.org/0000-0001-9487-2333
                http://orcid.org/0000-0003-2839-1405
                http://orcid.org/0000-0002-0997-0850
                http://orcid.org/0000-0002-7911-0741
                Article
                bmjgh-2021-004993
                10.1136/bmjgh-2021-004993
                8336216
                34344668
                64561a63-3bd3-464a-b131-528219eeccab
                © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 17 January 2021
                : 29 June 2021
                Funding
                Funded by: Indo-Pacific Centre for Health Security;
                Categories
                Original Research
                1506
                Custom metadata
                unlocked

                public health,health services research,cross-sectional survey,qualitative study,health systems evaluation

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