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Attitudes of community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Portugal

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Abstract

Background The inappropriate use of antibiotics is considered a main cause of microbial resistance. This is an important public health problem. Community pharmacists have an important role in the management of drugs for outpatients. Objective Our study sought to explore pharmacists’ knowledge, attitudes, perceptions and dispensing habits insofar as to antibiotics and microbial resistance. Setting The study was developed with community pharmacists in the North of Portugal. Methods Qualitative research in the form of focus groups (FG). Focus groups were conducted with 4–7 pharmacists, using a moderator. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The study was carried out between December 2010 and March 2011 in the five districts of the Northern Health Region of Portugal (ARS-N). Pharmacists from different regions of each district were invited to participate in the study by an investigator responsible for the study. Participants were informed about the study and that sessions were audio-recorded to facilitate data interpretation. They signed an informed consent form before taking part in the focus groups. The Ethical Committee of ARS-N was informed of this study. Main outcome measure Pharmacists’ knowledge and perceptions on antibiotic use and microbial resistance, attitudes related to antibiotic dispensing habits, and pharmacists’ suggestions to improve antibiotic use. Results A total of 6 focus groups were conducted with community pharmacists (n = 32). Attitudes related to the problem of resistance were attributed external responsibility, to patients, to physicians, to other pharmacies, and to veterinary consumption. Some attitudes were identified that could lead to antibiotic dispensing without a prescription. These attitudes are complacency, precaution and external complacency. Conclusions Portuguese pharmacists perceive that antibiotic use and bacterial resistance could be improved, showing a behavioural intention to improve antibiotic dispensing habits.

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References

  1. McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA. 2002;287(23):3096–102.

    Article  PubMed  Google Scholar 

  2. Alzoubi K, Ayoub N, Al-Sakaji S, Al-Azzam S, Mhaidat N, Masadeh M. Awareness of bacterial resistance among physicians, pharmacists and nurses. Int J Occup Med Environ Health. 2009;22(4):363–72.

    Article  PubMed  Google Scholar 

  3. Bronzwaer SL, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, et al. A European study on the relationship between antimicrobial use and antimicrobial resistance. Emerg Infect Dis. 2002;8(3):278–82.

    Article  PubMed  Google Scholar 

  4. World Health Organization (WHO). Policy Perspectives on Medicines—Containing antimicrobial resistance. 2005; 1–6.

  5. Goossens H, Ferech M, Vander Stichele R, Elseviers M, ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365(9459):579–87.

    PubMed  Google Scholar 

  6. Williams RJ, Heymann DL. Containment of antibiotic resistance. Science. 1998;279(5354):1153–4.

    Article  PubMed  CAS  Google Scholar 

  7. Austin DJ, Kristinsson KG, Anderson RM. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci USA. 1999;96(3):1152–6.

    Article  PubMed  CAS  Google Scholar 

  8. Samore MH, Lipsitch M, Alder SC, Haddadin B, Stoddard G, Williamson J, et al. Mechanisms by which antibiotics promote dissemination of resistant pneumococci in human populations. Am J Epidemiol. 2006;163(2):160–70.

    Article  PubMed  Google Scholar 

  9. Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain. Clin Infect Dis. 2009;48(10):1345–9.

    Article  PubMed  Google Scholar 

  10. Howard DH, Scott RD. The economic burden of drug resistance. Clin Infect Dis. 2005;41(Suppl 4):S283–6.

    Article  PubMed  Google Scholar 

  11. Livermore DM. Minimising antibiotic resistance. Lancet Infect Dis. 2005;5(7):450–9.

    Article  PubMed  Google Scholar 

  12. Bjerrum L, Boada A, Cots JM, Llor C, Forés Garcia D, Gahrn-Hansen B, et al. Respiratory tract infections in general practice: considerable differences in prescribing habits between general practitioners in Denmark and Spain. Eur J Clin Pharmacol. 2004;60(1):23–8.

    Article  PubMed  Google Scholar 

  13. André M, Odenholt I, Schwan A, Axelsson I, Eriksson M, Hoffman M, et al. Upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests. Scand J Infect Dis. 2002;34(12):880–6.

    Article  PubMed  Google Scholar 

  14. Samore MH, Bateman K, Alder SC, Hannah E, Donnelly S, Stoddard GJ, et al. Clinical decision support and appropriateness of antimicrobial prescribing. JAMA. 2005;294(18):2305–14.

    Article  PubMed  CAS  Google Scholar 

  15. Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg CS, Monnet DL, et al. Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and the healthcare system. J Antimicrob Chemother. 2008;61(5):1172–9.

    Article  PubMed  CAS  Google Scholar 

  16. Grigoryan L, Burgerhof JG, Haaijer-Ruskamp FM, Degener JE, Deschepper R, Monnet DL, et al. Is self-medication with antibiotics in Europe driven by prescribed use? J Antimicrob Chemother. 2007;59(1):152–6.

    Article  PubMed  CAS  Google Scholar 

  17. Plachouras D, Kavatha D, Antoniadou A, Giannitsioti E, Poulakou G, Kanellakopoulou K, et al. Dispensing of antibiotics without prescription in Greece, 2008: another link in the antibiotic resistance chain. Eur surveill. 2010;15(7):12–5.

    Google Scholar 

  18. Silverman D. Qualitative research: theory, method and practice. London: Sage; 2004.

    Google Scholar 

  19. Kitzinger J. Qualitative research: introducing focus groups. BMJ. 1995;311(7000):299–302.

    Article  PubMed  CAS  Google Scholar 

  20. Galego C, Gomes AA. Emancipação, ruptura e inovação: o “focus group” como instrumento de investigação. Revista Lusófona de Educação. 2005;5:173–84.

    Google Scholar 

  21. Vazquez-Lago JM, Lopez-Vazquez P, López-Durán A, Taracido-Trunk M, Figueiras A. Attitudes of primary care physicians to prescribing of antibiotics and antimicrobial resistance: a qualitative study from Spain. Fam Pract. 2011;29(3):352–60.

    Article  PubMed  Google Scholar 

  22. Halocomb EJ, Phillips J, Davidson PM. Literatue review: considerations in undertaking focus group research with culturally and linguistically diverse groups. J Clin Nurs. 2007;16(3):1000–11.

    Article  Google Scholar 

  23. Powell RA, Single HM. Methdology matters–V. Int J Qual Health Care. 1996;8(5):499–504.

    Article  PubMed  CAS  Google Scholar 

  24. Pena A, Paulo M, Silva LJ, Seifrtová M, Lino CM, Solich P. Tetracycline antibiotics in hospital and municipal wastewaters: a pilot study in Portugal. Anal Bioanal Chem. 2010;396(8):2929–36.

    Article  PubMed  CAS  Google Scholar 

  25. Lopez-Vasquez P, Vasquez-Lago JM, Figueiras A. Misprescription of antibiotics in primary care: a critical systematic review of its determinants. J Eval Clin Pract. 2012;18(2):473–84.

    Article  Google Scholar 

  26. Deschepper R, Grigoryan L, Lundborg CS, Hofstede G, Cohen J, Kelen GV, et al. Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe? BMC Health Serv Res. 2008;8:1–9.

    Article  Google Scholar 

  27. Camins BC, King MD, Wells JB, Googe HL, Patel M, Kourbatova EV, et al. Impact of an antimicrobial utilization program on antimicrobial use at a large teaching hospital: a randomized controlled trial. Infect Control Hosp Epidemiol. 2009;30(10):931–8.

    Article  PubMed  Google Scholar 

  28. Cho HJ, Hong SJ, Park S. Knowledge and beliefs of primary care physicians, pharmacists, and parents on antibiotic use for the pediatric common cold. Soc Sci Med. 2004;58(3):623–9.

    Article  PubMed  Google Scholar 

  29. Azevedo MM, Pinheiro C, Yaphe J, Baltazar F. Portuguese students’ knowledge of antibiotics: a cross-sectional study of secondary school and university students in Braga. BMC Public Health. 2009;9:359.

    Article  PubMed  Google Scholar 

  30. Caamaño Isorna F, Tomé-Otero M, Takkouche B, Figueiras A. Factors related with prescription requirement to dispense in Spain. Pharmacoepidemiol Drug Saf. 2004;13(6):405–9.

    Article  PubMed  Google Scholar 

  31. Denes E, Prouzergue J, Ducroix-Roubertou S, Aupetit C, Weinbreck P. Antibiotic prescription by general practitioners for urinary tract infections in outpatients. Eur J Clin Microbiol Infect Dis. 2012;31(11):3079–83.

    Google Scholar 

  32. Poveda Roda R, Bagan JV, Sanchis Bielsa JM, Carbonell Pastor E. Antibiotic use in dental practice. A review. Med Oral Patol Oral Cir Bucal. 2007;12(3):E186–92.

    PubMed  Google Scholar 

  33. Tonkin-Crine S, Yardley L, Little P. Antibiotic prescribing for acute respiratory tract infections in primary care: a systematic review and meta-ethnography. J Antimicrob Chemother. 2011;66:2215–23.

    Article  PubMed  CAS  Google Scholar 

  34. Llor C, Monnet DL, Cots JM. Small pharmacies are more likely to dispense antibiotics without a medical prescription than large pharmacies in Catalonia, Spain. Euro Surveill. 2010;15(32). http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19635.

  35. Dey RM, de Vries MJ, Bosnic-Anticevich S. Collaboration in chronic care: unpacking the relationship of pharmacists and general medical practitioners in primary care. Int J Pharm Pract. 2011;19(1):21–9.

    Article  PubMed  Google Scholar 

  36. Borenstein JE, Graber G, Saltiel E, Wallace J, Ryu S, Archi J, et al. Physician-pharmacist comanagement of hypertension: a randomized, comparative trial. Pharmacotherapy. 2003;23(2):209–16.

    Article  PubMed  Google Scholar 

  37. Chelminski PR, Ives TJ, Felix KM, Prakken SD, Miller TM, Perhac JS, et al. A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity. BMC Health Serv Res. 2005;5(1):3.

    Article  PubMed  Google Scholar 

  38. Kiel PJ, McCord AD. Pharmacist impact on clinical outcomes in a diabetes disease management program via collaborative practice. Ann Pharmacother. 2005;39(11):1828–32.

    Article  PubMed  Google Scholar 

  39. Straka RJ, Taheri R, Cooper SL, Smith JC. Achieving cholesterol target in a managed care organization (ACTION) trial. Pharmacotherapy. 2005;25(3):360–71.

    Article  PubMed  Google Scholar 

  40. Coenen S, Van Royen P, Michiels B, Denekens J. Optimizing antibiotic prescribing for acute cough in general practice: a cluster-randomized controlled trial. J Antimicrob Chemother. 2004;54(3):661–72.

    Article  PubMed  CAS  Google Scholar 

  41. Cars O, Mölstad S, Melander A. Variation in antibiotic use in the European Union. Lancet. 2001;357(9271):1851–3.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors wish to express their sincere thanks to Michael Benedict for reviewing and revising the English of this manuscript.

Funding

This work was supported by Foundation for Science and Technology (Fundação para a Ciência e Tecnologia) grants [PTDC/SAU-ESA/105530/2008] and [PEst-OE/EGE/UI4056/2011] from the Portuguese Ministry of Science & Education, and Health Research Fund (Fondo de Investigación Sanitaria) grants [PI081239 and PI09/90609] from the Spanish Ministry of Health.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Author information

Authors and Affiliations

  1. Center for Cell Biology, University of Aveiro (CBC/UA), Aveiro, Portugal

    Fátima Roque, Sara Soares & Maria Teresa Herdeiro

  2. Research Unit for Inland Development, Polytechnic Institute of Guarda (UDI/IPG), Av. Rainha D. Amélia S/N., 6300-749, Guarda, Portugal

    Fátima Roque

  3. University of Beira Interior (UBI), Covilhã, Portugal

    Fátima Roque

  4. Health Sciences Research Centre, University of Beira Interior (CICS/UBI), Covilhã, Portugal

    Luiza Breitenfeld

  5. Department of Clinical Psychology, University of Santiago de Compostela, Santiago de Compostela, Spain

    Ana López-Durán

  6. Consortium for Biomedical Research in Epidemiology & Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), University of Santiago de Compostela, Santiago de Compostela, Spain

    Adolfo Figueiras

  7. Center for Health Technology & Information Systems Research (CINTESIS/FMUP), University of Porto, Porto, Portugal

    Maria Teresa Herdeiro

  8. Health Technology Research Center (CITS/CESPU), Vila Nova de Famalicão, Portugal

    Maria Teresa Herdeiro

Authors
  1. Fátima Roque
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  4. Ana López-Durán
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  5. Adolfo Figueiras
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Corresponding author

Correspondence to Fátima Roque.

Appendix

Appendix

Moderator’s guide for focus groups

  • “What are your opinions about the latest campaigns on the correct use of antibiotics? (latest years, type of campaign—pamphlets in pharmacies, television advertisements).”

  • “Are there pharmacists that dispense antibiotics without a prescription? What about 5 years ago? Were there any?”

  • “What are the causes of antibiotics being dispensed without a prescription? In case of no answer being forthcoming, specify:

    • Difficult access to health care.

    • Patient pressure. Aggressive attitudes, excuses such as they cannot miss work, travelling issues, patients known in the neighbourhood.

    • Is pharmacists’ behaviour towards a known patient different from that towards an unknown one? And towards a young patient versus an elderly patient?

    • Are younger pharmacists more likely to ask for a prescription than older professionals?

    • If the antibiotics are not sold at this pharmacy, can customers get them somewhere else?

    • Will you dispense the antibiotic with the customer’s commitment to bring you the prescription later?

    • To maintain customers.

    • In order to save time because you know that the doctor will prescribe it.

    • Do you believe that there is some influence from the pharmaceutical industry?

    • The antibiotic is dispensed because the prescription for the needed treatment was incomplete.

    • Antibiotics were prescribed over the telephone.

    • What can you say about antibiotic use on animals?”

  • “Do you consider that the importance of antibiotic use is conveyed to patients? Do you think that recent graduate students are more or less aware of this transmission of information? What about pharmaceutical technicians?”

  • “Do you believe that dispensing generics has any advantages?”

  • “In your opinion, what is the percentage of pharmacies that sell antibiotics without a prescription?”

  • “Out of every 10 boxes of antibiotics sold at your pharmacy, how many are sold without a prescription?”

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Roque, F., Soares, S., Breitenfeld, L. et al. Attitudes of community pharmacists to antibiotic dispensing and microbial resistance: a qualitative study in Portugal. Int J Clin Pharm 35, 417–424 (2013). https://doi.org/10.1007/s11096-013-9753-4

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  • DOI: https://doi.org/10.1007/s11096-013-9753-4

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