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      What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India

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          Abstract

          Objectives

          There are only 0.70 licensed physicians per 1000 people in India. Thus, pharmacies are a primary source of healthcare and patients often seek their services directly, especially in village settings. However, there is wide variability in a pharmacy employee's training, which contributes to inappropriate antibiotic dispensing and misuse. These practices increase the risk of antibiotic resistance and poor patient outcomes. This study seeks to better understand the factors that drive inappropriate antibiotic dispensing among pharmacy employees in India's village communities.

          Design

          We conducted a mixed-methods study of the antibiotic dispensing practices, including semistructured interviews and a pilot cross-sectional Knowledge, Attitudes and Practice survey. All data were transcribed, translated from Hindi into English, and coded for themes.

          Setting

          Community pharmacies in villages in Haryana, India.

          Participants

          We recruited 24 community pharmacy employees (all male) by convenience sampling. Participants have a range of characteristics regarding village location, monthly income, baseline antibiotic knowledge, formal education and licensure.

          Results

          75% of pharmacy employees in our study were unlicensed practitioners, and the majority had very limited understanding of antibiotic resistance. Furthermore, only half could correctly define the term antibiotics. All reported that at times they dispensed antibiotics without a prescription. This practice was more common when treating patients who had limited access to a licensed physician because of economic or logistic reasons. Many pharmacy workers also felt pressure to provide shortened medication courses to poorer clientele, and often dispensed only 1 or 2 days' worth of antibiotics. Such patients rarely returned to the pharmacy for the complete course.

          Conclusions

          This study highlights the need for short-term, intensive training programmes on antibiotic prescribing and resistance that can be disseminated to village pharmacies. Programme development should take into account the realities of working with poor clientele, especially in areas of limited healthcare access.

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          Most cited references29

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          Antibiotic resistance-the need for global solutions.

          The causes of antibiotic resistance are complex and include human behaviour at many levels of society; the consequences affect everybody in the world. Similarities with climate change are evident. Many efforts have been made to describe the many different facets of antibiotic resistance and the interventions needed to meet the challenge. However, coordinated action is largely absent, especially at the political level, both nationally and internationally. Antibiotics paved the way for unprecedented medical and societal developments, and are today indispensible in all health systems. Achievements in modern medicine, such as major surgery, organ transplantation, treatment of preterm babies, and cancer chemotherapy, which we today take for granted, would not be possible without access to effective treatment for bacterial infections. Within just a few years, we might be faced with dire setbacks, medically, socially, and economically, unless real and unprecedented global coordinated actions are immediately taken. Here, we describe the global situation of antibiotic resistance, its major causes and consequences, and identify key areas in which action is urgently needed. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis.

            The spread of antibiotic-resistant bacteria is associated with antibiotic use. Children receive a significant proportion of the antibiotics prescribed each year and represent an important target group for efforts aimed at reducing unnecessary antibiotic use. To evaluate antibiotic-prescribing practices for children younger than 18 years who had received a diagnosis of cold, upper respiratory tract infection (URI), or bronchitis in the United States. Representative national survey of practicing physicians participating in the National Ambulatory Medical Care Survey conducted in 1992 with a response rate of 73%. Office-based physician practices. Physicians completing patient record forms for patients younger than 18 years. Principal diagnoses and antibiotic prescriptions. A total of 531 pediatric office visits were recorded that included a principal diagnosis of cold, URI, or bronchitis. Antibiotics were prescribed to 44% of patients with common colds, 46% with URIs, and 75% with bronchitis. Extrapolating to the United States, 6.5 million prescriptions (12% of all prescriptions for children) were written for children diagnosed as having a URI or nasopharyngitis (common cold), and 4.7 million (9% of all prescriptions for children) were written for children diagnosed as having bronchitis. After controlling for confounding factors, antibiotics were prescribed more often for children aged 5 to 11 years than for younger children (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.13-3.33) and rates were lower for pediatricians than for nonpediatricians (OR, 0.57; 95% CI, 0.35-0.92). Children aged 0 to 4 years received 53% of all antibiotic prescriptions, and otitis media was the most frequent diagnosis for which antibiotics were prescribed (30% of all prescriptions). Antibiotic prescribing for children diagnosed as having colds, URIs, and bronchitis, conditions that typically do not benefit from antibiotics, represents a substantial proportion of total antibiotic prescriptions to children in the United States each year.
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              Understanding the culture of prescribing: qualitative study of general practitioners' and patients' perceptions of antibiotics for sore throats.

              To better understand reasons for antibiotics being prescribed for sore throats despite well known evidence that they are generally of little help. Qualitative study with semi-structured interviews. General practices in South Wales. 21 general practitioners and 17 of their patients who had recently consulted for a sore throat or upper respiratory tract infection. Subjects' experience of management of the illness, patients' expectations, beliefs about antibiotic treatment for sore throats, and ideas for reducing prescribing. Doctors knew of the evidence for marginal effectiveness yet often prescribed for good relationships with patients. Possible patient benefit outweighed theoretical community risk from resistant bacteria. Most doctors found prescribing "against the evidence" uncomfortable and realised this probably increased workload. Explanations of the distinction between virus and bacterium often led to perceived confusion. Clinicians were divided on the value of leaflets and national campaigns, but several favoured patient empowerment for self care by other members of the primary care team. Patient expectations were seldom made explicit, and many were not met. A third of patients had a clear expectation for antibiotics, and mothers were more likely to accept non-antibiotic treatment for their children than for themselves. Satisfaction was not necessarily related to receiving antibiotics, with many seeking reassurance, further information, and pain relief. This prescribing decision is greatly influenced by considerations of the doctor-patient relationship. Consulting strategies that make patient expectations explicit without damaging relationships might reduce unwanted antibiotics. Repeating evidence for lack of effectiveness is unlikely to change doctors' prescribing, but information about risk to individual patients might. Emphasising positive aspects of non-antibiotic treatment and lack of efficacy in general might be helpful.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2017
                2 March 2017
                : 7
                : 3
                : e013190
                Affiliations
                [1 ]Department of Population Health Sciences, University of Wisconsin, School of Medicine and Public Health , Madison, Wisconsin, USA
                [2 ]Medanta Institute of Education and Research , Medanta the Medicity Hospital , Gurgaon, Haryana, India
                [3 ]Department of Clinical Microbiology & Infection Control, Medanta the Medicity Hospital , Gurgaon, Haryana, India
                [4 ]Department of Medicine, University of Wisconsin, School of Medicine and Public Health , Madison, Wisconsin, USA
                [5 ]William S. Middleton Memorial Veterans Affairs Hospital , Madison, Wisconsin, USA
                Author notes
                [Correspondence to ] Dr Nasia Safdar; ns2@ 123456medicine.wisc.edu
                Article
                bmjopen-2016-013190
                10.1136/bmjopen-2016-013190
                5353334
                28255093
                dc13437e-6155-4b58-87be-64f68005446e
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                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 and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 27 June 2016
                : 13 January 2017
                : 2 February 2017
                Categories
                Global Health
                Research
                1506
                1699
                1706
                1725
                1724

                Medicine
                infectious diseases,tropical medicine
                Medicine
                infectious diseases, tropical medicine

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