Antimicrobial stewardship in sub-Saharan African community pharmacies: a systematic review of community pharmacists’ knowledge, practice and challenges faced
Authors: Orisile A G , Lim R H M , Naqvi A A , Amlogu A 
Published: November 2024

Abstract

Introduction
The indiscriminate use of antimicrobials contributes significantly to antimicrobial resistance (AMR). The World Health Organization (WHO) recommends antimicrobial stewardship (AMS) as one of the global sustainable development interventions to tackle AMR. Implementation of AMS interventions have been documented to be successful in high-income countries 1, however, there is paucity of data regarding the implementation and effectiveness of AMS in low-income settings including sub-Sahara Africa (SSA). Community pharmacies in the SSA play a critical role in the dispensing of medicines, including antibiotics.

Aim
To evaluate community pharmacists' knowledge, practice, and challenges faced in relation to AMS in SSA community pharmacies.

Methods
The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) framework guided the review. We searched six electronic databases (PubMed, Web of Science, ProQuest Central, Google Scholar, African Journal Online and Wiley Online library) from January 2010 to December 2022. Reference lists of included articles were screened for additional studies. Studies published in English that described AMS interventions, antibiotic dispensing practices, community pharmacists’ knowledge and perceptions of AMS/AMR were included. Literature reviews and systematic reviews were excluded. AMS in hospital pharmacy and animal studies were also excluded. Two reviewers independently screened the abstracts and full texts according to pre-defined inclusion criteria. Disagreements were resolved through discussion. The Mixed Methods Appraisal Tool (MMAT) was employed to assess the quality of the included studies2. Data were extracted using a standardised form in Microsoft excel and double checked for accuracy. Data were synthesised using narrative synthesis. The review protocol was registered with PROSPERO (CRD42023381320). The study did not require ethical approval because it did not involve conducting primary or secondary research involving human participants.

Results
The review identified 1972 articles, of which 23 studies met the inclusion criteria. Studies varied in settings, design, and data collection methods. Two broad categories were identified from the narrative synthesis. (1) Community pharmacists’ knowledge, attitude, perception, and dispensing practices (n=20). Studies reported that community pharmacists displayed an understanding of how antibiotics work. They also acknowledged threats posed by AMR. Some studies reported misconceptions on clear guidelines about the practical implementation of AMS, other studies described good adherence to antibiotic dispensing practices, including taking medication histories, assessing symptoms, advising on completion of antibiotic courses and making referrals. One study described the perception of community pharmacists of AMS as crucial for improving patient care.
(2). Determinants of non-prescription antibiotic sales (n=3). The studies explored factors influencing the sale of antibiotics without prescription. Studies identified pharmacy owners’ expectations (profitability) and lack of public awareness regarding the risks of non-prescription antibiotic use as contributing factors. Limited patient access to doctors and low economic status in SSA were also cited as determinants.

Conclusions
Community pharmacists have knowledge of antibiotics, and they also acknowledged the importance of AMS. There were also positive dispensing practices despite existing challenges regarding implementation of AMS and sales of antibiotics without prescription. Further research should prioritize well-designed studies that evaluate the effectiveness of AMS in this setting and address the challenges identified. Heterogeneity of study methods limits the generalisability of findings.

References
1. Trivedi KK, Dumartin C, Gilchrist M, Wade P, Howard P. Identifying Best Practices Across Three Countries: Hospital Antimicrobial Stewardship in the United Kingdom, France, and the United States. Clinical Infectious Diseases. 2014 Oct 15;59 (suppl_3): S170–8.
2. Hong QN, Gonzalez-Reyes A, Pluye P. Improving the usefulness of a tool for appraising the quality of qualitative, quantitative and mixed methods studies, the Mixed Methods Appraisal Tool (MMAT). Journal of Evaluation in Clinical Practice [Internet]. 2018 Feb 21;24(3):459–67