Determinants of antibiotic dispensing without prescription: a systematic review

Background: Some of the inappropriate use of antibiotics is related to the dispensing of antibiotics without a medical prescription. Objectives: To identify the intrinsic factors (socio-demographic characteristics and attitudes) and extrinsic factors (patient-related factors and health-system-related factors) related to the dispensing or selling of antibiotics without a medical prescription (DAwMP) by workers at retail pharmacies, when this should be done by prescription according to the legislation in force in each country. Methods: We conducted a search of the MEDLINE and EMBASE databases, with studies being required to meet the following inclusion criteria: (i) they were published in English or Spanish; (ii) the designated study objective was to explore factors linked to dispensing without prescription; (iii) the study population was defined as pharmacy workers. Results: Thirty-three papers were included. While pharmacy workers' socio-demographic characteristics had no influence on dispensing without prescription (only 2/9 of the quantitative studies that statistically evaluated gender showed a relationship, 2/7 with respect to age and 0/3 with respect to professional status), training (5/8), knowledge and attitudes did however prove significant (12/13). In the case of qualitative or mixed studies, patient-related factors [lack of knowledge (7/13), high demand (9/13), self-medication (6/13) and low socio-economic status (5/13)] and health-system-related factors [lack of rigour in antibiotic policies (7/13) and pressure from pharmacy owners (5/13)] are mentioned in relation to dispensing without a prescription. Conclusions: The results of this review appear to indicate that factors associated with dispensing without prescription are all modifiable. This may be of use when it comes to designing interventions aimed at curtailing this practice and thereby reducing antibiotic use and antibiotic resistance levels worldwide.