Assessment of non-prescription antibiotic dispensing at community pharmacies in China with simulated clients: a mixed cross-sectional and longitudinal study

Background Non-prescription dispensing of antibiotics at community pharmacies is a major driver of antimicrobial resistance. China has regarded curbing non-prescription sales of antibiotics at community pharmacies as an important task for tackling antibiotics resistance and planned to eliminate this practice nationwide before 2020. We aimed to quantify non-prescription dispensing of antibiotics cross-sectionally at community pharmacies in China in 2017, and longitudinally (2011-17) in a single province. Methods A simulated client method was used to measure non-prescription antibiotic dispensing based on scenarios about paediatric diarrhoea and adult acute upper respiratory tract infection (URTI), which were presented at each pharmacy. We collected cross-sectional data for 2423 community pharmacies from 221 counties or districts in six provinces in different regions of China, in 2017. We also assessed 213 community pharmacies in Shaanxi province with a baseline survey in 2011 and subsequent follow-up surveys every 2 years until 2017. In the cross-sectional analysis, multivariate binary logistic regression with random-intercepts was used to evaluate the factors associated with non-prescription dispensing of antibiotics. We also estimated unadjusted period effects of non-prescription antibiotic dispensing using generalised estimated equations. Findings After excluding invalid interactions within 12 community pharmacies, the study included 4822 simulated interactions within 2411 community pharmacies. Non-prescription antibiotic dispensing was observed during 1169 (48.5% [95% CI 46.5-50.5]) of 2411 diarrhoea interactions and 1690 (70.1% [68.2-71.9]) of 2411 adult URTI interactions. Non-prescription antibiotic dispensing was more prevalent in rural areas and the central and western provinces, and was negatively associated with the presence of a pharmacist on-site (odds ratio 0.66 [0.56-0.78], p<0.0001) and being part of a chain pharmacy (0.75 [0.62-0.89], p=0.0012). In Shaanxi province, significant decreases of non-prescription antibiotic dispensing occurred in paediatric cases (from 154 [72.3%] of 213 community pharmacies to 107 [50.2%], p<0.0001) and adult cases (from 204 [95.8%] to 148 [69.5%], p<0.0001) between 2011 and 2017. Interpretation Non-prescription dispensing of antibiotics at community pharmacies was still prevalent nationwide in China in 2017, although a decrease was observed in Shaanxi Province since 2011. Multifaceted measures, including regulatory interventions, professional training, and public health education are needed. Funding Young Talent Support Plan and High Achiever Plan of Health Science Center, Xi'an Jiaotong University, Central University Basic Research Fund, Early Career Research Start-up Plan of Xi'an Jiaotong University. Copyright (c) 2019 Elsevier Ltd. All rights reserved.