Al Masud Abdullah, Walpola Ramesh Lahiru, Sarker Malabika, Asaduzzaman Muhammad, Islam Md Saiful, Mostafa Ayesha Tasnim, Akhtar Zubair, Kabir Alamgir, Seale Holly
School of Population Health, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
School of Health Sciences, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
Explor Res Clin Soc Pharm. 2025 Apr 22;19:100606. doi: 10.1016/j.rcsop.2025.100606. eCollection 2025 Sep.
Over-the-counter antibiotic sales in community-pharmacies significantly drive antimicrobial resistance (AMR) in low- and middle-income countries (LMICs) due to inappropriate use and early treatment discontinuation. In Bangladesh, community pharmacies, which dispense 56.6 % of antibiotics without prescriptions, serve as the first health-seeking touchpoint, yet conventional stewardship strategies often overlook these informal providers, heightening AMR risks. This study examines drug-sellers' understanding and practices towards antibiotic dispensing and compares their symptomatic-treatment practices with Bangladesh's Standard Treatment Guidelines (STGs) to understand the extent of antibiotic misuse.
A cross-sectional survey in two urban and two rural areas of Bangladesh involved 120 drug-sellers from 30 randomly selected pharmacies per site. Knowledge was compared between drug-sellers with pharmacy-dispensing training and those without training, and their suggested treatments for two simulated health-symptoms-upper respiratory-tract and gastrointestinal infections-were evaluated against STGs to determine the extent of misuse.
Most drug-sellers were aged 41-50 years (35.0 %), with 39.2 % holding a bachelor's degree or higher, and 65.8 % having pharmacy-dispensing training. The overall knowledge score on antibiotic use and AMR was moderate at 60.2 % (5-7 out of 10), with 32.5 % scoring ≤4, indicating poor knowledge; trained drug-sellers scored significantly better ( = 0.008). Over half (57.5 %) were unaware of antibiotic dispensing policies, though most (75.8 %) acknowledged the link between AMR and antibiotic use. For simulated upper respiratory-tract infections, 54.2 % recommended single antibiotic-90.8 % Watch, 9.2 % Access (per WHO-AWaRe classification)-with 66.2 % of these prescriptions deviating from guidelines due to inappropriate selection or dosage. For gastrointestinal infections, 55.8 % recommended single antibiotic (40.3 % Watch, 59.7 % Access), with 82.1 % deviated from the guidelines. Additionally, 26.7 % recommended two antibiotics (51.6 % Watch, 48.4 % Access), all of which were inconsistent with guideline recommendations. For both simulated symptoms, no significant difference was observed in drug sellers' treatment practices based on their knowledge level.
This study highlights the need for context-specific policies and regulatory measures in informal healthcare settings. While improving drug-sellers' knowledge is vital for antimicrobial stewardship in LMICs like Bangladesh, it alone is insufficient due to market competition, weak regulation, and patient-driven demand. Thus, curbing inappropriate antibiotic use at the community level requires stronger enforcement and multifaceted, context-tailored interventions-including public awareness, targeted training, and market-responsive strategies.
在低收入和中等收入国家（LMICs），社区药店的非处方抗生素销售因使用不当和过早停药而显著推动了抗菌药物耐药性（AMR）的发展。在孟加拉国，社区药店在没有处方的情况下配发了56.6%的抗生素，是患者寻求医疗服务的首个接触点，但传统的管理策略往往忽视了这些非正规医疗服务提供者，从而增加了AMR风险。本研究调查了药品销售人员对抗生素配发的理解和做法，并将他们的对症治疗做法与孟加拉国的标准治疗指南（STGs）进行比较，以了解抗生素滥用的程度。
在孟加拉国两个城市和两个农村地区进行的一项横断面调查，涉及从每个地点随机选择的30家药店的120名药品销售人员。比较了接受过药房配发培训和未接受培训的药品销售人员的知识水平，并根据STGs评估了他们针对两种模拟健康症状（上呼吸道感染和胃肠道感染）的建议治疗方法，以确定滥用程度。
大多数药品销售人员年龄在41-50岁之间（35.0%），39.2%拥有学士学位或更高学历，65.8%接受过药房配发培训。抗生素使用和AMR的总体知识得分中等，为60.2%（满分10分，得5-7分），32.5%的得分≤4分，表明知识水平较差；接受过培训的药品销售人员得分明显更高（P = 0.008）。超过一半（57.5%）的人不知道抗生素配发政策，尽管大多数人（75.8%）承认AMR与抗生素使用之间的联系。对于模拟的上呼吸道感染，54.2%的人推荐单一抗生素——90.8%为观察类，9.2%为可及类（根据世界卫生组织-抗菌药物可及性和使用监测（WHO-AWaRe）分类）——其中66.2%的这些处方因选择或剂量不当而偏离指南。对于胃肠道感染，55.8%的人推荐单一抗生素（40.3%为观察类，59.7%为可及类），82.1%的处方偏离了指南。此外，26.7%的人推荐两种抗生素（51.6%为观察类，48.4%为可及类），所有这些都与指南建议不一致。对于两种模拟症状，根据药品销售人员的知识水平，在他们的治疗做法上未观察到显著差异。
本研究强调了在非正规医疗环境中制定因地制宜的政策和监管措施的必要性。虽然提高药品销售人员的知识对于孟加拉国等低收入和中等收入国家的抗菌药物管理至关重要，但由于市场竞争、监管薄弱和患者驱动的需求，仅靠这一点是不够的。因此，在社区层面遏制不当抗生素使用需要更强有力的执法和多方面、因地制宜的干预措施，包括公众意识、针对性培训和市场响应策略。
