Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study

Abstract

Background Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda. Methods This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis. Results Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS. Conclusion There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda’s fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.

High prevalence of inappropriate antibiotic prescriptions in selected health care facilities in Uganda

“…These ndings are similar to those of studies in other WHO African countries and India [26,40]. This could be because of limited knowledge, refresher training and support supervision in private health facilities [32].…”

“…Amoxicillin and azithromycin are the commonly prescribed antibiotics. This nding is similar to ndings elsewhere in low-and middle-income countries (LMICs) where either of these two antibiotics are the most commonly prescribed [24,25,[30][31][32]. The two antibiotics were commonly prescribed, possibly because of their availability in public health facilities, as they fall under the WHO Access and the National Essential Medicine List.…”

“…These antibiotics are hence readily supplied by National Medical Stores, the government agency responsible for the procurement, storage and delivery of essential health supplies and drugs to health facilities in Uganda. Moreover, this study was conducted in 2022 at the peak of the COVID-19 pandemic, when azithromycin was being repurposed for the management of COVID-19 despite evidence of no treatment gains [32][33][34]. Azithromycin belongs to the WHO Watch group and must be used with caution and monitored because it has a high potential for resistance.…”