Non-prescription sales of antimicrobial agents at community pharmacies in developing countries: a systematic review

Antimicrobial resistance (AMR) is a global challenge. Developing countries are more vulnerable to the consequences of AMR than developed nations because of complex issues pertaining to the nature of their healthcare systems. Inappropriate antimicrobial drug use and the unrestricted availability of antimicrobial agents in community pharmacies in developing countries can contribute to the emergence of resistant microbes. The aim of this systematic review was to explore the availability of antimicrobial agents without a doctor's prescription in developing countries and to investigate factors that contribute to inappropriate antimicrobial supply in developing countries. The EMBASE, MEDLINE and International Pharmaceutical Abstracts databases were searched for articles published between 1980 and November 2017 describing studies using simulated client (or pseudo-patient) methodology in community pharmacies supplying non-prescription antimicrobial agents. Overall, 50 studies were included in this systematic review. All of the studies involved supply of one or more antimicrobials without a prescription. These studies involved using a hypothetical case presentation or direct product request by a simulated client. The review found non-prescription supply of antimicrobials as reported in 28 developing countries across Asia, Africa, South America, Europe and Middle Eastern regions. Contributing factors for non-prescription antimicrobial supply were poor national medicines regulations, limited availability of qualified pharmacists, commercial pressure on pharmacy staff, consumer demand, inappropriate prescribing practices and lack of awareness of AMR.