The demographics of the 12 community pharmacists who were interviewed are given in table 1. Most of the participants were male (91.6%) as females in Pakistan currently do not usually opt to practice in community pharmacies in Pakistan owing to societal reservations; however, one female consented to be interviewed. The respondents were relatively young, with ages ranging from 24 to 33 years, with experience up to 5 years. One practicing pharmacist was the proprietor of the pharmacy as well. The average number of antimicrobial prescriptions dispensed per day by the community pharmacists working in both independent and chain pharmacies were between 30 and 50 prescriptions per day. After TCA, four major themes emerged: (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR.
Theme I: Knowledge and perception of community pharmacists about antimicrobials
During the interviews, the interviewees were asked about their knowledge and perception about antimicrobials. Most of the pharmacists obtained their information about antimicrobials during their undergraduate studies. Only a few pharmacists kept themselves updated through various online resources and other available information.
I had my basic knowledge from study curriculum and I keep myself updated from guidelines, research from the internet and AKU antimicrobial guidelines—the organization where I work [MY]
Basically I have mostly tried to study different antibiotics from different online courses [M]
We have access to a different software like up-to-date, Lexicomp, etc. through which we consult different issues regarding patients and their prescriptions [U]
The majority of pharmacists did not know about any guidelines for antimicrobial use and ASPs. Only one pharmacist had a clear concept about ASP.
I don’t have any knowledge about guidelines [A]
Yes I know about IDSA guidelines, but we normally do not follow those guidelines in our practice [Z]
I have heard this terminology quit often but I don’t know what it is [Z]
Antimicrobial Stewardship is a program to evaluate the appropriateness of antibiotics and to implement the appropriate use of antibiotics in various organizations [MY].
Most of the pharmacists knew that antimicrobials should not be dispensed without a prescription. In addition, only a few had information about exact antimicrobial dispensing rules in the Drug Act 1976/DRAP Act 2012 of Pakistan.
I have studied drug law in which schedules G and D drugs etc. have been discussed regarding their use. And that these antibiotics should be sold in the presence of a pharmacist only [J]
Well…regarding dispensing of specialized items as antibiotics, we have in Pakistan, schedule G where antibiotics should be sold specifically on prescription from a registered medical practitioner. So, there are certain numbers of antibiotics that shouldn’t be sold without a prescription. But the practice is still not much prevalent across Pakistan [MY]
All the pharmacists agreed that AMR was a major problem around the world as well as in Pakistan. All the interviewees also agreed that irrational use of antibiotics was the main reason behind AMR and pharmacist should play their role to prevent irrational antimicrobial use.
Well…because the pharmacist is an important part of the health system from the antimicrobial point of view. The pharmacist knows the chemistry of the drugs as well as about the resistance [M]
In case of community pharmacy setting, we can rationalize only the self-medication particularly for the upper respiratory tract infections, in which case people prefer self-administered medicines. And in case of hospital settings, we can collaborate with other healthcare professionals regarding the appropriate use of the antibiotics [I]
Actually antibiotic resistance is a worldwide problem, not just in our country or region [I]
Well I think the self-medication trend in particular about antibiotics…being used irrationally is the major reason of resistance in our society [I]
Theme II: Antimicrobials dispensing practices of community pharmacists
The community pharmacists in Pakistan dispense antimicrobials both with and without prescription. Most of the community pharmacists in this study usually dispense antimicrobials without prescription for common ailments including pharyngitis, sore throats, colds, diarrhoea, tooth ache, influenza, sinusitis, ear infections and also for skin infections. However, a few pharmacists were reluctant to dispense an antimicrobial without a prescription.
No, I never did that. I follow the drug act and don’t dispense antimicrobials without prescription [J]
If the patient has a good outcome with previously prescribed item, then I would not resist and I will give that antibiotic [I]
When a poor patient comes to us rather than going to a physician, then as a community pharmacist I help them by giving them antibiotics keeping in mind their cost-effectiveness [K]
If the course is not complete then I dispense antibiotics without prescription as well [A]
Encouraging, the majority of the pharmacists interviewed preferred to refer patients with a critical condition to a physician instead of dispensing antimicrobials.
First I ask them if the patient has a fever, if he has a mild fever then I dispense…otherwise, if he has a high fever or generalized malaise or fatigue as symptoms or sinusitis, then I usually refer him to a physician, I don’t usually dispense [FA]
I dispense only when he is in obvious and dire need of an antibiotic. But first I ask him to go to the doctor [A]
Well, as far as a sore throat is concerned, if a patient comes to my pharmacy without a prescription, then, first of all, I ask him to visit a doctor, get a prescription and then I will give you the antibiotic according to that [W]
Encouragingly, the community pharmacists interviewed typically counselled their patients about the appropriate dosage regimen of the antibiotic dispensed. They also recommend that the patients manage their mild self-limiting infections without antimicrobials.
Most of the times, I counsel the patients to use house hold remedies for the common cold and upper respiratory tract infections and other infections too, because it’s the job of the physician to prescribe [IY]
We have a system that instructions to be given to a patient are added in software and then we print a label of it when dispensed. The label is put in the pack of antibiotic. All the instructions are mentioned on that label according to which we give that antibiotic [U]
Most of the interviewed pharmacists also counselled their patients verbally and a few also gave written instruction on the proper use of any medicine.
Verbally and written too. Patient forgets the verbal instructions…verbal and written both instructions are very necessary [K]
Mostly we try to write the instructions on the label or package of the bottle or sometimes we communicate verbally [M]
The interviewed pharmacists also quite often tried to convince the patients on generic substitution to save costs. However, the acceptability of substitution in Pakistan for any prescribed brand, that is, the originator, is currently limited.
We guide the patient while dispensing that the dispensed medicine is a different brand with the same generic or formula [J]
The patient usually doesn’t trust the pharmacist on generic substitution. They usually insist on the medicine prescribed by the doctor on prescription only [FA]
Sometimes there is a good response regarding its cost-effectiveness because we sometimes substitute medicine with a less costly brand [IY].
Sometimes due to unavailability of drugs we go for generic substitution and when sometimes patient cannot afford that specific brands [U]
The community pharmacists are used to dispense antimicrobials both with and without prescription in children, older adults and pregnant females. However, most of the interviewed pharmacists showed concern while dispensing antimicrobials to these populations.
I refer paediatric patients to the children emergencies or children wards or any place like that where they can be treated [W]
I never take risks in case of pregnant women. I always refer them to a specialist for their proper treatment [Z]
For a geriatric or paediatric patient with severe infection, I do not dispense without prescription [K]
I just try to evaluate the patients based on symptoms. I never go for the age or gender of the patient [M]
Theme III: Determinants of antimicrobial resistance
One of the main reasons for AMR identified by the interviewees is unnecessary antimicrobial prescribing and dispensing.
Sometimes patients come with 4 antibiotics written on their prescription. Sometimes, patients come with a prescription of 5–6 antibiotics prescribed for chest infection…which I believe is unnecessary [K]
AMR is a big problem because doctors don’t go for identification tests of microbes and randomly prescribe antibiotics [M]
Socioeconomic factors are important in determining irrational practices. Most of the time the patients demand a lesser amount of antibiotic than the full prescribed course because they cannot afford the full course.
Well, it depends upon the patient that if he cannot afford the full course of medicine that is written by the doctor, then obviously I have to give him a lesser quantity [W]
Mostly, poor people come to me without prescription who cannot afford to pay the physician. The people in our society are familiar with the thing that a pharmacist is available at the pharmacy we can advise him [K]
The respondents mentioned that most of the patients use leftover antibiotics from their homes that had been prescribed previously to any person within the same family.
Sometimes patients use leftover prescriptions to take antibiotics for the same indication and sometimes they suggest antibiotics to their friends and relatives for certain conditions that I used this antibiotic and got recovered you should also use this [MY]
The patients in Pakistan are like that if one person from a family is prescribed levofloxacin for a upper respiratory tract infection, then when any other family member gets the same disease, patients follows the same prescription so they normally insist to give same antibiotic [Z]
According to a few of the pharmacists interviewed, one of the main reasons for irrational antimicrobial use and subsequent AMR is the business nature of pharmacy. However encouragingly, most of the pharmacists do not have any pressure to sell antimicrobials.
Dispensing antibiotics even without prescription will enhance our sale; output and the owner of pharmacy will also appreciate us” [K]
In the organization where I work, there is not such pressure from the owners because they appreciate the pharmacist intervening but I have seen a number of cases in local pharmacies where the pharmacy managers do have a pressure on the pharmacists to prescribe the antibiotics to boost up their sales [MY]
In a pharmacy where I am doing the job, a separate medicine rack is assigned to me. I used to dispense medicine including antibiotics for common disease conditions to patients. At the end of the month, I get a good incentive based on the sale [Z]
There was a mixed response of interviewees about the promotional activities by the pharmaceutical company representatives and their visits to pharmacies for the promotion of their products, particularly antibiotics.
I think they have a negative effect. They usually push us to sell their product. I think that is not very good practice [FA]
The visit of the sales representatives at community pharmacies is not so influential to increase the sale of antimicrobials [MY]
Mostly, the sale representatives don’t approach the pharmacist, but the doctors [K]
Theme IV: Potential interventions to control antimicrobial resistance
Interviewees typically agreed that we cannot control AMR without the implementation of laws and legislation for antibiotic use. The interviewed pharmacists also pointed out a few strategies to control the emergence of AMR by involving all key stake holders of the healthcare system including physicians, nurses and pharmacists.
At the individual level, we cannot play a special role to overcome this problem. Every sector of the healthcare should participate in its role [I]
For this, a proper guideline and a country-wide policy should be made. Data should be collected, problems should be identified which should be faced steadily [U]
First of all, we need to conduct certain educational seminars and awareness programs for the healthcare professionals and this does not only include the pharmacists but also the doctors, nurses and the paramedical staff [MY]
The community pharmacists also highlighted restriction strategies to control the misuse of antimicrobials.
We can reduce the risk of antimicrobial resistance by limiting the overprescribing of antibiotics for unlabeled indications [A]
Like narcotics and other control drugs, antibiotics should also be controlled to dispense without prescription and the proper record should be maintained [Z]
All the pharmacists agreed that conferences, workshops and continuous education programmes could play a significant role to overcome the threat of AMR. However, they themselves typically didn’t attend any such event related to antimicrobials.
Yes definitely, one doesn’t get to know everything at once. Learning is a continuous process. So, to update our knowledge a pharmacist should attend every kind of conferences and seminars to increase and enhance his previous knowledge [J]
I totally agree that such conferences should be held especially for fresh graduates who don’t know much about dosage and indications for which antibiotics are used [K]
I didn’t attend any workshop in the past one year because no such workshop was arranged [B]
I attended a workshop in PC by GSK on minimizing the use of antibiotics, avoiding new generation antibiotics to stop resistance [IY]
As healthcare professionals, pharmacists are also getting recognition as a healthcare provider and patients also come to pharmacists for consultation. Consequently, community pharmacists should be involved in the national action plan of Pakistan on AMR.
When we tell them that we are pharmacist, they trust us knowing that we are qualified and literate [J]
Patients of the elite class are satisfied mostly. They are familiar with the pharmacists [Y]
Health authorizes should recognize the role of community pharmacists as healthcare provider if they want to fight against antimicrobial resistance [I]
Pharmacist should be given a proper role which nowadays they don’t have [U]