Impact of a program to reduce the dispensing of antibiotics without a prescription in Spain
Background: In 1999, the Pharmacists Association of Gipuzkoa, a Spanish province with a population of 700,000, initiated a campaign to reduce the common practice in community pharmacies of dispensing antibiotics without prescription.
Objective: The study was designed to assess the ongoing effectiveness of this program in reducing nonprescription dispensing of antibiotics.
Methods: In March 2009, 2 young women posed as simulated patients and visited each of the 280 operating community pharmacies in Gipuzkoa. In 139 of these pharmacies, randomly selected, the simulated patients feigned the symptoms of an uncomplicated urinary tract infection and requested an unspecified antibiotic. In the remaining 141, the actress requested a specific antibiotic, only describing her symptoms upon request by the dispensing staff. The rate of nonprescription dispensing had previously been estimated at 70.5% in 2000 and 42.2% in 2004. Univariate and multivariate analyses were performed, based on a number of variables related to the pharmacy and staff.
Results: In the current study, antibiotics were dispensed without prescription by 49 of 280 pharmacies (17.5%). The product- and symptom-based scenarios had similar rates of 16.3% and 18.7%, respectively. The only variables which appeared to affect the nonprescription dispensing rate were the gender of the dispenser, being males more likely to dispense (OR=3.135, 95%CI [1.286, 7.646]), and the number of previous antibiotic-awareness campaigns in which the pharmacy had participated (OR=1.057, 95% CI [1.008, 1.107]). The community population, its number of pharmacies, the years in business of each pharmacy, or its revenue, did not appear to influence the nonprescription dispensing rate.
Conclusion: A long-term multifactorial program set up by the pharmacists association of Gipuzkoa, Spain, appears to have been effective in reducing the rate at which antibiotics are dispensed without a prescription in community pharmacies.
2. Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, Kool JL, Sprenger MJ, Degener JE; European Antimicrobial Resistance Surveillance System. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis. 2002;8(3):278-282.
3. Ebert SC. Factors contributing to excessive antimicrobial prescribing. Pharmacotherapy. 2007;27(10 Pt 2):126S-130S.
4. Shankar PR, Partha P, Shenoy N. Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study. BMC Fam Pract. 2002;3:17.
5. Raz R, Edelstein H, Grigoryan L, Haaijer-Ruskamp FM. Self-medication with antibiotics by a population in northern Israel. Isr Med Assoc J. 2005;7(11):722-725.
6. Fuentes Albarran K, Villa Zapata L. Analysis and quantification of self-medication patterns of customers in community pharmacies in southern Chile. Pharm World Sci. 2008;30(6):863-868. doi: 10.1007/s11096-008-9241-4
7. Apisarnthanarak A, Tunpornchai J, Tanawitt K, Mundy LM. Nonjudicious dispensing of antibiotics by drug stores in Pratumthani, Thailand. Infect Control Hosp Epidemiol. 2008;29(6):572-575. doi: 10.1086/587496
8. Barah F, Morris J, Goncalves V. Irrational use and poor public beliefs regarding antibiotics in developing countries: a pessimistic example of Syria. Int J Clin Pract. 2009;63(8):1263-1264. doi: 10.1111/j.1742-1241.2009.02093.x
9. Matuz M, Benko R, Doro P, Hajdu E, Soos G. Non-prescription antibiotic use in Hungary. Pharm World Sci. 2007;29(6):695-698.
10. Awad AI, Eltayeb IB. Self-medication practices with antibiotics and antimalarials among Sudanese undergraduate university students. Ann Pharmacother. 2007;41(7):1249-1255.
11. Väänänen MH, Pietilä K, Airaksinen M. Self-medication with antibiotics--does it really happen in Europe? Health Policy. 2006;77(2):166-171.
12. Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JG, Mechtler R, Deschepper R, Tambic-Andrasevic A, Andrajati R, Monnet DL, Cunney R, Di Matteo A, Edelsein H, Valinteliene R, Alkerwi A, Scicluna E, Grzesiowski P, Bara AC, Tesar T, Cizman M, Campos J, Lundborg CS, Birkin J. Self-medication with antimicrobial drugs in Europe. Emerg Infect Dis. 2006 Mar;12(3):452-459.
13. Deschepper R, Grigoryan L, Lundborg CS, Hofstede G, Cohen J, Kelen GV, Deliens L, Haaijer-Ruskamp FM. Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe? BMC Health Serv Res. 2008;8:123. doi: 10.1186/1472-6963-8-123
14. Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg CS, Monnet DL, Scicluna EA, Birkin J, Haaijer-Ruskamp FM; SAR consortium. Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study. Pharmacoepidemiol Drug Saf. 2007;16(11):1234-1243.
15. Orero González A, Ripoll Lozano MA, González Núñez J. [Analysis of automedication with antibiotics in Spain]. Enferm Infecc Microbiol Clin. 1998;16(7):328-333.
16. Campos J, Ferech M, Lázaro E, de Abajo F, Oteo J, Stephens P, Goossens H. Surveillance of outpatient antibiotic consumption in Spain according to sales data and reimbursement data. J Antimicrob Chemother. 2007;60(3):698-701.
17. Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain. Clin Infect Dis. 2009;48(10):1345-9. doi: 10.1086/598183
18. Colomina Rodriguez J, Dominguez Marquez V, Gimeno Vilarrasa F, Sarrio Montes G, Guerrero Espejo A. [Impact of Integrated Model for Rational Use of Antibiotics in a health area (project MIURA)]. Rev Esp Salud Publica. 2010;84(3):281-291.
19. Gastelurrutia MA, Larrañaga B, Ortega B, Puntonet L. [Assessment of the program for rational use of antibiotics in Gipuzkoa. First phase: 1999-2000]. Pharm Care Esp. 2002;4(3):143-157.
20. Gastelurrutia MA, Larrañaga B, Ortega B. [First program on rational use of antibiotics in Gipuzkoa. Assessment of 1999-2004 period]. Pharm Pract (Granada). 2006;4(1):1-8.
21. Franke RH, Kaul JD. The Hawthorne experiments: first statistical interpretation. Am Sociol Rev 1978;43:623-643.
22. Alte D, Weitschies W, Ritter CA. Evaluation of consultation in community pharmacies with mystery shoppers. Ann Pharmacother. 2007;41(6):1023-1030.
23. Watson MC, Cleland JA, Bond CM. Simulated patient visits with immediate feedback to improve the supply of over-the-counter medicines: a feasibility study. Fam Pract. 2009;26(6):532-542. doi: 10.1093/fampra/cmp061
24. Benrimoj SI, Werner JB, Raffaele C, Roberts AS. A system for monitoring quality standards in the provision of non-prescription medicines from Australian community pharmacies. Pharm World Sci. 2008;30(2):147-153.
25. Watson MC, Norris P, Granas AG. A systematic review of the use of simulated patients and pharmacy practice research. Int J Pharm Pract. 2006;14(2):89-93.
26. Watson MC, Skelton JR, Bond CM, Croft P, Wiskin CM, Grimshaw JM, Mollison J. Simulated patients in the community pharmacy setting. Using simulated patients to measure practice in the community pharmacy setting. Pharm World Sci. 2004;26(1):32-37.
27. Zalmanovici Trestioreanu A, Green H, Paul M, Yaphe J, Leibovici L. Antimicrobial agents for treating uncomplicated urinary tract infection in women. Cochrane Database Syst Rev. 2010;(10):CD007182. doi: 10.1002/14651858.CD007182.pub2
28. Llor C, Rabanaque G, Lopez A, Cots JM. The adherence of GPs to guidelines for the diagnosis and treatment of lower urinary tract infections in women is poor. Fam Pract. 2011;28(3):294-299. doi: 10.1093/fampra/cmq107
29. Llor C, Monnet D, Cots J. Small pharmacies are more likely to dispense antibiotics without a medical prescription than large pharmacies in Catalonia, Spain. Euro Surveill. 2010;15(32). pii: 19635.
30. Gonzales R, Corbett KK, Wong S, Glazner JE, Deas A, Leeman-Castillo B, Maselli JH, Sebert-Kuhlmann A, Wigton RS, Flores E, Kafadar K. "Get smart Colorado": impact of a mass media campaign to improve community antibiotic use. Med Care. 2008;46(6):597-605. doi: 10.1097/MLR.0b013e3181653d2e
31. Goossens H, Guillemot D, Ferech M, Schlemmer B, Costers M, van Breda M, Baker LJ, Cars O, Davey PG. National campaigns to improve antibiotic use. Eur J Clin Pharmacol. 2006;62(5):373-379
32. Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Boëlle PY, Watier L, Guillemot D. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med. 2009;6(6):e1000084. doi: 10.1371/journal.pmed.1000084