Good dispensing practices for antibiotics in community pharmacies of the province of Córdoba (Argentina)

INTRODUCTION

Antibiotics (ATBs) are indispensable for treating most bacterial infections; however, the following two problems have emerged: (1) Antibiotic resistance (hereafter AR), especially the emergence of multidrug-resistant bacteria and (2) the scarcity of alternative treatments. These problems pose significant risks to public and animal health [1].

According to the World Health Organization (WHO), Antimicrobial Resistance (AR) poses a threat to modern medicine and to the sustainability of an effective response to the risk of infectious diseases [2]. For this reason, the WHO has identified the optimal use of these drugs as one of its main objectives in its global action plan against AR [2].

The issue of AR is a multifaceted problem that involves a wide range of stakeholders, including healthcare professionals, public administrations, healthcare and academic institutions, pharmaceutical laboratories, livestock plant managers, and citizens in general [3]. Additionally, it has a significant impact on healthcare expenditure, as it leads to increased costs due to prolonged disease duration and increased frequency and duration of hospitalizations [4]. 

Community pharmacists are the most accessible healthcare professionals, possess scientific knowledge of the clinical use of drugs, and have an unequivocal responsibility in the fight against AR. They should actively participate in the development of programs to combat AR through the promotion, prevention, and control of antimicrobial treatments [3, 4, 5, 6, 7]. The self-prescription of antibiotics by patients and the lack of information on their correct use lead to the loss of efficacy of certain treatments due to AR [8]. 

The joint International Pharmaceutical Federation (FIP)/World Health Organization (WHO) Guidelines on Good Pharmacy Practice acknowledge the significance of pharmacists’ role in dispensing medications. They stipulate that minimum standards for this function should be derived from pertinent processes and delineated in accordance with the distinct requirements of various professional domains [5].

The objective of this study was to develop a Good Dispensing Practices (GDP) Program for the most commonly prescribed ATBs in community pharmacies in the province of Córdoba (Argentina). The primary aims of the GDP Program are to reduce adverse events (AEs) and to enhance patient education regarding the necessity of prescription and proper use of ATBs.

SPECIFIC OBJECTIVES

1. Develop a Standard Operating Procedure (SOP) for securing ATB GDPs. 

2. Train community pharmacists on ATB GDPs in order to promote their rational use in patients.

3. Implement the SOP developed in community pharmacies for the dispensing of ATBs that are prevalently used.

4. To assess the level of patient adherence to ATB treatment.

5. Determine the degree of patient satisfaction with the professional pharmaceutical service provided.

METHODOLOGY

It will be described in terms of the specific objectives outlined above.

1: Develop a SOP for securing ATB GDPs.

A working group was established to draft the SOP. The group consisted of the project leaders, the coordinator, and the pharmacists who are members of the Community Pharmacists Commission of Córdoba (FACCOR). The group convened on weekly meetings and conducted a comprehensive bibliographic search of relevant publications. [9,10]. 

In order to ascertain the ATBs with the highest demand, a request was made to two national drugstores and the Observatory of Health, Medicines and Society of the Argentine Pharmaceutical Confederation [11] for information regarding the ATBs with the highest number of dispensations in the previous year. The selection of antibiotics for the study was based on the following criteria: amoxicillin, azithromycin, cephalexin, ciprofloxacin, and the associations amoxicillin plus clavulanic acid and trimethoprim plus sulfamethoxazole, all of which are administered orally.

In order to verify the adequacy of the designed SOP for the intended purpose, a validation process was conducted. This process involved ten pharmacies that are members of the FACCOR committee and spanned a two-week period. During the validation process, the participating pharmacists made contributions, and minor modifications were made to the SOP. 

2: To train community pharmacists on Good ATB Dispensing Practices in order to promote their rational use in patients.

A theoretical-practical virtual course with evaluation was designed and taught by instructors from the National University of Córdoba and the College of Pharmacists of Córdoba (CFC) via the virtual classroom of the CFC [12]. The educational material was established in the form of asynchronous videos and online files.

The training program was designed and implemented from September 11 to October 20, 2020. An extensive promotional campaign was initiated to ensure the participation of pharmacists. This campaign encompassed social media, mass email communications, and the institutional website of the CFC.

In addition, the Drug Information Center of the Faculty of Chemical Sciences at the National University of Cordoba was consulted for the drafting of ATB drug sheets for pharmacists, information sheets on each ATB for patients, and an information leaflet on the rational use of ATBs.

3: The SOP developed in community pharmacies for the dispensing of ATBs of prevalent use must be implemented.

Pharmacists were recruited for the implementation of the SOP during the training and incorporated patients through a non-probabilistic (consecutive) sampling procedure. 

Participation in the study was offered to patients who entered the pharmacies during the study period and who met the inclusion criteria: patients or caregivers requesting an ATB from the selected group.

The data collection was done through a Google form.

4: To assess the level of patient adherence to ATB treatment.

Subsequent to the dispensing of medications, the pharmacist is responsible for contacting the patient or their caregiver within a week and administering the Morisky-Green test [14]. This test comprises a series of four questions with dichotomous yes/no answers. Subsequent to the administration of the test, the pharmacist is required to upload the data into a Google form. Thereafter, the data is downloaded into an Excel spreadsheet to ascertain the percentage of adherence to treatment.

5: Determine the degree of patient satisfaction with the professional pharmaceutical service provided.

One week after the end of dispensing, together with the determination of adherence, a survey of patient satisfaction with the service provided was conducted by means of a specific anonymous, self-administered, semi-structured questionnaire [15] consisting of 10 closed questions on an interval scale (Likert type), an open section for comments and, finally, demographic data. Registration was carried out in two ways: one directly, by giving the printed questionnaire to the patients, and the other through the social network/messaging services WhatsApp or via mail, sending the Google form to the patients for self-administration. For this reason, two different types of forms are developed. 

The data were downloaded into an Excel spreadsheet, and the level of satisfaction was established by considering the average of the scores for each question and the total score of the questionnaires.

To analyze the results, pharmacists who successfully completed the virtual training were considered “trained,” and those who adhered to the project were documented.

The data derived from the pharmacists’ patient records were downloaded from Google Forms into Excel spreadsheets. These spreadsheets were then exported to IBM SPSS Statistics 25.0, where descriptive statistical analyses were performed, including frequency, mean, and standard deviation. 

RESULTS

The results are organized according to the specific objectives.

1: Develop a Standard Operating Procedure to ensure the GDPs of ATB. 

The 8 working sessions to draft the SOP started in January 2020 and were postponed to August 2020 due to the COVID-19 pandemic.  

In August of 2020, the validation of the designed SOP was carried out, which demonstrated commendable operational and registry performance. It was noted that the recent integration of electronic format prescriptions, in addition to irregular prescriptions resulting from the restriction of access to physicians and dentists due to the pandemic, were subjects of concern.

The SOP that was validated consisted of an initial general section, from which a division is made according to whether the request for ATB is with or without prescription. Figure 1 shows the first part of the developed and validated SOP. Figure 2 shows the validated SOP for prescription ATB requests, and Figure 3 shows the validated SOP for non-prescription ATB requests.

 

Figure 1. Validated SOP for ATB requests (first part)

Figure 2. Validated SOPs for prescription ATB requests

Figure 3. Validated SOPs for over-the-counter or prescription ATB applications

2: Train community pharmacists on ATB GDPs in order to promote their rational use in patients.

The training was conducted by means of videos, reading material and evaluation [12]. In addition, a workshop of practical activities with clinical cases was conducted to reinforce the application of the developed SOP. 

ATB data sheets, patient information sheets and an information leaflet on the rational use of ATBs for patients were also prepared and sent to pharmacists in printed form.

A total of 278 pharmacists passed the training stages and passed the course.

3: Implement the SOP developed in community pharmacies for the dispensing of ATBs of prevalent use.

Of the 278 pharmacists trained, 208 adhered to the project and recorded data, achieving a participation rate of 74.8%.

A total of 2238 patient records were obtained, constituting an average of 10.8 patients per pharmacist. Twenty-one records were discarded because they were incomplete, and the results of 2217 patients were processed.

68.1% (n=1509) of the registrations corresponded to prescription requests and were mostly for amoxicillin (n=400) and amoxicillin + clavulanic acid (n=395), followed by azithromycin (n=237), ciprofloxacin (n=189), cephalexin (n=170) and trimethoprim + sulfamethoxazole (n=116).

In regard to the characteristics of the prescribers, the data reveal that 69.5% (n = 1049) of the cases corresponded to physicians (non-infectiologists), 25.2% (n = 380) to dentists, 2.8% to infectologists (n = 43), and no data were recorded for 37 requests.

A total of 1,306 prescriptions were reviewed, of which 86.5% (n=1,306) corresponded to initial treatments. The study found that 77.4% (n=1,168) of the prescriptions were made via a printed or electronic prescription, while 16.0% (n=241) were made via WhatsApp or other electronic messaging means.

A total of 708 requests for antibiotics were made without a prescription, constituting 31.9% of the total. Most of these users were between the ages of 25 and 44 years (n=336), followed by those between 45 and 65 years (n=155) and those between 13 and 24 years (n=145). The most frequently requested antibiotics were amoxicillin (n=209) and ciprofloxacin (n=163), followed by azithromycin (n=116) and amoxicillin+clavulanic acid (n=93).

Concerning the purpose of antibiotic utilization, the majority of respondents reported previous use for similar symptoms (n = 434) or limited time to consult a medical professional (n = 203).

 

With regard to pharmacists’ interventions in the case of non-prescription requests, the majority of cases involved referral to the corresponding professional (67.4% of cases), in addition to providing information on the correct use of antibiotics and referral to the Minor ailments Community Pharmacy Service (CPS). (Figure 4).

Figure 4. Pharmaceutical interventions performed upon request for antibiotics without prescription

4. To assess the level of patient adherence to ATB treatment.

1,417 records were obtained (93.9% of the total number of prescription requests), with a 57.3% adherence rate.

5. The degree of patient satisfaction with the professional pharmaceutical service provided must be ascertained.

 

A total of 1,481 questionnaires were completed, representing 66.8% of the total sample, with an average score of 4.2 ± 0.7 on a scale ranging from 1 (strongly disagree) to 5 (strongly agree) (Table 1).

Table 1. Patient Satisfaction Questionnaire item scores

DISCUSSION

This project led to the development of a SOP for securing the most prevalent ATB GDPs, including prescription and over-the-counter requests. A systematic review of interventions to improve the effective and safe use of medicines by users found that those involving pharmacists had positive effects on use, adherence and clinical outcomes. [16].

In the event of a prescription request, the pharmacist is obligated to verify the non-dispensing criteria (allergies, contraindications, and duplications). Moreover, the pharmacist must ensure that the patient is informed of the treatment’s purpose, the manner and time in which the ATB should be used, and any other specific information regarding the medication. The patient is also provided with an information sheet that details the ATB in question, including instructions on how to proceed in the event of a missed dose, the importance of adhering to the prescribed treatment regimen, potential complications to be aware of, and the proper method of storage. These measures collectively promote a judicious utilization of the prescribed ATB.

In the case of non-prescription requests, the SOP stipulates that the pharmacist evaluate the disorder to determine whether it can be resolved with an OTC medication or non-pharmacological measures (CPS of minor ailments). If a referral to a medical or dental professional is deemed necessary, the SOP also outlines the protocol for such referrals. Furthermore, the correct use of ATBs and AR is reinforced through a dedicated informational brochure.

The SOP, validated prior to its large-scale application, proved to be an effective instrument, both in operational aspects and in the recording of interventions. 

The training was administered via a virtual theoretical-practical course in asynchronous mode due to restrictions imposed by the COVID-19 ongoing pandemic, with the objective of facilitating the participation of a greater number of pharmacists.

The course covered aspects related to antibiotic therapy and AR, with an in-depth study of pharmacological aspects of the most prevalent ATBs. The use of ATBs in pregnancy and lactation was also considered, as well as the responsibility of community pharmacists in the rational use of antibiotics and in the management of antibiotic residues. Finally, a workshop on clinical cases allowed participants to practically manage the SOP on ATB GDP and to learn how to record the interventions derived from its application.

The training stage was completed with 278 pharmacists; however, 74.8% of them adhered to the project. This could be explained by the greater dedication of pharmacists to other activities in community pharmacies due to the pandemic context.

The importance of pharmacists in preventing AR has been pointed out, since the factors associated with dispensing without prescription are potentially modifiable (lack of knowledge, lack of training, inadequate attitudes) and, therefore, should be the target of the interventions to be developed [17,18].

As indicated by another publication, community pharmacists are aware of the issue of antibiotic resistance (AR) and consider it a major health problem, recognizing that irrational antibiotic use is one of the main causes of its increase [19]. In addition, pharmacists can function as collaborators between prescribers and patients, educating patients on the effective use of antibiotic (ATB) treatments. [20]. 

Other authors have also pointed out that programs with multiple activities, such as the one developed here, have improved the use of ATB and should be continued over time [21]. 

The significance of training pharmacists to enhance comprehension, confidence, dedication, and readiness to utilize the instruments provided in counseling patients requesting antibiotics has been underscored [22]. It was also observed that the most effective approach to augment patient knowledge is to integrate face-to-face education with the dissemination of an educational brochure [22]. This evidence substantiates the project developed, as written materials were incorporated in conjunction with the provision of verbal information.

The average of 10.8 patients registered per pharmacist is a low number and could be due to the fact that the demand for antibiotics has been lower than in other epidemiological contexts [23].

A total of 68.1% of the requests were attributable to prescription ATBs. This percentage is slightly lower than that reported in publications from other countries [24, 25]. Conversely, the percentage of requests without prescription is higher than that observed in other studies, which is likely attributable to the context of the pandemic itself, which prevents or hinders access to health professionals, thus serving as a limitation of the study [24, 25]. 

The primary motivations underlying ATB requests without prescription align with those identified in extant studies [26], encompassing previous utilization for similar symptoms and the constraints of time, which impede timely consultation with a medical professional. Consequently, it is imperative to prioritize future research in these areas, along with other underlying factors contributing to this phenomenon.

It has been observed that a number of factors contribute to the promotion of self-medication with antidepressants (ATBs). These factors include pharmacist indifference, compliance with patient/customer demands, external accountability, and insufficient patient knowledge [19]. 

With regard to pharmacists’ interventions when confronted with requests for non-prescription ATBs, the majority of cases involved referral to the corresponding professional (67.4% of cases). 

This was accompanied by the provision of information on their proper use and referral to the minor ailments CPS. These actions were consistent with the proposed SOP and the objective of achieving rational use of ATBs.

In regard to the degree of adherence to treatment, the study documented an adherence rate of 57.3%, which is consistent with the findings reported in analogous studies [27, 28]. For subsequent research endeavors, it would be advantageous to employ an alternative validated questionnaire, such as the Morisky-Green questionnaire, or to adopt an alternative methodology to assess adherence to treatment.

Patient satisfaction levels with the service provided by the pharmacist have been high, reflecting the high level of care provided through the implementation of the SOP.

It is important to note that, in the design of this study, the evaluation of the study not only focused on generating a change in the behavior of the community pharmacist, but also evaluated the adherence and satisfaction of the pharmacy users, which reinforces the scope of the program developed [22]. 

CONCLUSIONS

The development of this work allowed the elaboration of a SOP to ensure ATB GDPs, in order to promote their rational use in patients. To this end, community pharmacists were trained on ATB GDPs and the SOP developed in community pharmacies was implemented.

The findings of this study underscore the imperative for the implementation of this SOP on ATB GDPs in the nation’s community pharmacies. This initiative is poised to empower pharmacists to assume a pivotal role in health education, with the overarching objective being to address the global menace of AR and ensure the continued efficacy of existing therapeutic interventions.

ACKNOWLEDGMENTS

 

The authors would like to thank the Colegio de Farmacéuticos de la Provincia de Córdoba and the Foro Farmacéutico de las Américas for their support in making this project possible. Also, to the teachers who participated in the training stage: Dr. María Gabriela Paraje, Dr. Fabiana Alovero and Dr. Analia Valdomero. Also to the colleagues belonging to the Community Pharmacists Commission (FACCOR), to the professionals who implemented the good antibiotic dispensing practices in their pharmacies and to Dr. Sonia Uema.

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