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The decline in the introduction of new antibiotics on the market in the past decades has posed a great threat to the treatment of infectious diseases [1] . Antibiotic resistance is currently a global health issue that calls for urgent attention because effective treatment of infectious diseases is an essential component of both human and animal health management [2] [3] [4] . The impact of antibiotic resistance includes increased resource utilization, clinical or economic burdens, and increased use of broad-spectrum antibiotics, increased morbidity, and mortality [5] . Although antibiotic resistance is an inevitable consequence of antibiotic use, the rate and extent of propagation of resistant bacteria are governed by human behavior such as excessive and inappropriate use of antibiotics in health systems [6] . Inappropriate use of antibiotics is directly related to the tendency towards self-medication and the unnecessary use of antibiotics for viral diseases [7] .
It has been observed that most people suffering from viral upper respiratory tract infections such as common colds tend to misuse antibiotics for treatment [8, 9] . This irrational use of antibiotics for some respiratory tract diseases escalates cases of antibiotic-resistant bacteria [10] . Being among respiratory tract infections, Coronavirus Disease 2019 (COVID-19) is likely to escalate antibiotic resistance due to an expected over-prescribing, inappropriate use, and self-prescription of antibiotics [11] [12] [13] [14] . Strategies must be implemented for the management of upper respiratory tract infections and reduce the inappropriate consumption of antibiotics [15] . Therefore, prescribers and all healthcare workers need to be watchful as they prescribe and dispense antibiotics even in times of global pandemics.
Community pharmacists (CPs) are the first point of contact for community members seeking pharmaceutical and medical services due to their ease of accessibility, less waiting time, and cheaper costs [16] [17] [18] [19] . Nevertheless, members of the community find it easier to access the CPs and acquire their medical help [20] . It is noteworthy that members of the community trust the CPs and thus obtain their antibiotics through interaction with CPs [21] . In developing countries, there has been an increase in the use of non-prescribed antibiotics which has been exacerbated by non-prescription sales of antibiotics in community pharmacies [22, 23] . Global estimations have indicated that more than 50% of antibiotics are accessed privately without a prescription; with . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted September 1, 2020. . https://doi.org/10.1101/2020.08.27.20181826 doi: medRxiv preprint 4 | P a g e increased evidence indicating that CPs are failing to promote the rational and appropriate use of antibiotics [24] [25] [26] .
The supply of antibiotics from a community pharmacy without a prescription usually involves interaction with a community pharmacist [27, 28] . The problem of dispensing antibiotics without a prescription has been reported in low-and middle-income countries [29, 30] . Therefore, changing the publics' attitudes and improving their knowledge regarding antibiotic use is the responsibility of the community pharmacist who happens to be the first point of contact and source of these antibiotics [31] . Emphasis has therefore been placed on improving the role of the pharmacist as the main supplier and regulator of antibiotics in communities [32] . In the Zambian setup, there is limited information on the knowledge, attitude, and practices of community pharmacists on antibiotic use and resistance, and ASPs. Therefore, this study is very beneficial to the Zambian pharmacists and all pharmacists globally. This study is also of benefit to other healthcare workers because antibiotic resistance affects everyone. CPs should promote the rational use of antibiotics even in times of global health pandemics to prevent the worsening of the emergence of antibiotic-resistant bacteria.
This was a descriptive cross-sectional study that was conducted in community pharmacies in . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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The data were analysed using Statistical Package for the Social Sciences (SPSS) version 22.0.
Data was initially entered into the Microsoft Excel spread sheet before being exported to SPSS.
Data was presented in form of tables and charts and a Likert scale was used to determine the . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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The study was approved by the University of Zambia Health Sciences Research Ethics Committee (UNZAHSREC), protocol ID: 20190217024, IORG no: 0009227, IRB no: 00011000.
All participants provided consent by reading and signing the consent form prior to responding to the questionnaire.
The demographic characteristics of 144 community pharmacists (CPs) who took part in the study are shown in Table 1 . Most of the respondents were male (63%) and were aged between 30 and 45 years (65%).
The majority of the CPs 93.8% (n=135) had good knowledge and 67.4% had positive attitude with regards to antibiotic resistance. Unfortunately, 75.7% of the CPs had poor practice regarding antibiotic resistance and antimicrobial stewardship ( Table 2) .
The majority of the CPs (29.2% agreed, 67.4% strongly agreed) that antibiotic resistance occurs when antibiotic no longer work to treat bacterial infections. The majority of the CPs (29.7% agreed, 69.7% strongly agreed) that antibiotic resistance occurs due to misuse of antibiotics and it is public health problem in our communities (Table 3) .
The majority of the CPs 69.4% agreed that antibiotic resistance is a public health problem. The majority of the CPs 57.6% agreed that appropriate use of antibiotics improves patient care and outcome (Table 4) .
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The majority of the CPs (32.6%) rarely collaborates with other healthcare workers in activities that promote infection control and AMS. In addition, the majority of the CPs do not take part in antibiotic awareness campaigns nor educate the public on antibiotic use (Table 5) .
Statistical significance was found between age and attitude, age and practices, work experience and knowledge, and work experience and practices ( Table 6 ).
We assessed that knowledge, attitude, and practice of community pharmacists (CPs) on antibiotic resistance and antimicrobial stewardship. Currently, there is limited information about the knowledge, attitude, and practice of CPs on antibiotic resistance and AMS in Zambia. . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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Our study found that 67.4% of the CPs had a positive attitude towards antibiotic resistance that was related to their age. Our findings are encouraging because the positive attitude of CPs may influence them not to dispense antibiotics without a prescription [73] . In Syria, the majority of is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted September 1, 2020. . Collaboration between pharmacists and physicians helps to . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted September 1, 2020. All the CPs in our study revealed that they dispensed antibiotics without a prescription.
Antibiotics, just like other prescription only drugs, must be dispensed on prescription only [102] .
Dispensing antibiotics without prescription is very common in most countries in the world [83, [103] [104] [105] [106] [107] . This practice contributes greatly to the emergence of antibiotic-resistant bacteria [108] [109] [110] [111] [112] [113] [114] . In Zambia, it is a common practice of selling and dispensing antibiotics without a prescription [115] . This practice may escalate antibiotic resistance and thus requires urgent interventions. Therefore, pharmacists must continue playing the role of gatekeepers of antibiotics [116] . Educational interventions must be put in place to improve the appropriate prescribing and dispensing of antibiotics [117] [118] [119] .
Concerning policy implications for this research study, antimicrobial stewardship programmes aimed at reducing antimicrobial resistance (AMR) need to be promoted in a multi-disciplinary approach. In Zambia, the National Action plan (NAP) on AMR was developed to address this gap through One Health approach [120] . Currently, the status of AMR in Zambia is mainly focussed on knowledge strengthening as well as evidence obtained from surveillance and research activities. Further training of community pharmacists in Zambia should involve bridging the gap between knowledge and practice. Substantial effort need to be directed towards motivating community pharmacists in undertaking on the job of antimicrobial training through . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
The copyright holder for this preprint this version posted September 1, 2020. 'rationalised antibiotic usage policy' into their 'national health policies' to avoid any serious complications and outcomes in future. It should also be recommended the prescription and usage of antibiotics based on proofs but not empirical applications.
We acknowledge that the current study has some limitations. It focused on assessing the knowledge, attitude, and practices of community pharmacist leaving out pharmacy technologists who work under the supervision of the pharmacists. Therefore, the results should be interpreted in the context of community pharmacists. Study was led in Lusaka province only; the results could not show the practice, knowledge, and attitude of community pharmacists working in further provinces of the Zambia. Since we did not include community pharmacists from all the ten provinces of Zambia, and so, generalization of the results should be done with caution. In addition, self-governed forms used in this research are disposed to common interest unfairness.
The study only focussed on registered community pharmacists and this could create a bias on the findings as illegal drug outlets are a nuisance in the country and could be the important drivers of antibiotic resistance and hamper the efforts towards AMS activities. In any case, this study has provided the much needed baseline information for future research work in as far as antimicrobial resistance in relation to community pharmacists is concerned.
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Community pharmacists in Lusaka Zambia had good knowledge and attitude but poor practices regarding antibiotic resistance. There is a need to promote ASPs in community pharmacies that may lead to the improved practice of community pharmacists with regards to antibiotic use, resistance, and AMS. Community pharmacists must be recognized as key players in the control and prevention of infections among community members. Therefore, educational intervention programmes with regards to antibiotic use, resistance, and AMS should be periodically focussed on community pharmacy practice.
We would like to acknowledge the owners of the community pharmacies and the pharmacists for cooperating with us during data collection from their premises. We are grateful to the University of Zambia Library for providing access to many articles that were used for reference in this manuscript.
Funding: No external funding sources were received.
All authors report no conflict of interest.
Steward . CC-BY-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
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Antibiotic resistance is a serious public health is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)
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