Understanding Antibiotic Purchasing Practices in Community Pharmacies in Bangladesh: A Potential Driver of Emerging Antimicrobial Resistance
Authors: Masud Abdullah , Walpola Ramesh Lahiru , Sarker Malabika , Kabir Alamgir , Asaduzzaman Muhammad , Islam Md Saiful , Mostafa Ayesha Tasnim , Akhtar Zubair , Barua Mrittika , Seale Holly 
Published: May 2024

Background
Antimicrobial resistance (AMR) poses significant health threats for low-and-middle-income countries (LMICs) and 80% of antibiotics are used in the community, with 20–50% inappropriate use. Southeast Asia, including Bangladesh, faces higher AMR risk due to suboptimal healthcare standards and over-the-counter antibiotic usage.
Methods
This cross-sectional survey included 365 antibiotic customers from pharmacies, alongside structured observation of over 1,000 medicine dispensing events across four urban and rural areas in Bangladesh, aiming to understand antibiotic dispensing patterns in community pharmacies and identify factors influencing purchasing behaviors contributing to irrational usage. Hospital-adjacent areas were excluded to minimize potential biases of formal healthcare medication patterns. Descriptive analyses characterized antibiotic use, while Poisson regression assessed the influence of patients' demographic factors and health conditions on their prescription behavior.
Results
Out of 1,000 observed medicine dispensing events, 25.9% were antibiotics. In the survey, 56.6% customers purchased antibiotics without a prescription from drug-sellers and informal healthcare providers, mainly for “acute and non-severe” conditions like upper respiratory-tract infections (37.4%), fever (31.7%), and uncomplicated skin infections (20%), gastrointestinal-infections (11.2%), urinary-tract infections (10.1%). Commonly purchased antibiotics included macrolides (21.8%), third-generation cephalosporins (20.8%), second-generation cephalosporins (16.9%). Following WHO-AWeRe classifications, 73.5% antibiotics fell into the Watch, 23.1% in the Access category, and 8.8% were not-recommended beta-lactamase inhibitors. The likelihood of presenting a prescription while purchasing antibiotics was 27% lower for individuals aged 6–59 compared to those ≤ 5 or ≥ 60. Lower respiratory-tract infections and enteric fever exhibited a greater influence with higher prescription rates than other health conditions, with adjusted prevalence ratios were respectively 1.78 (95% CI: 1.04, 3.03) and 1.87 (95% CI: 1.07, 3.29). Other demographic factors, including sex, urban-rural locations, income, education, and number of health-symptoms, showed no statistically significant influences on prescription likelihood after adjusting for confounders.
Conclusions
This study underscores widespread broad-spectrum antibiotic sales without prescriptions, emphasizing the need for tailored interventions considering prevailing health-seeking practices in diverse informal healthcare settings in LMICs. Imposing prescription-only rules faces challenges due to easy access through community pharmacies and potential conflicts of interest. Formulating feasible interventions requires user-centric approaches involving co-designed research with stakeholders, alongside prioritizing mass awareness and monitoring over-the-counter antibiotic sales.