Using Simulated Clients to Assess Nonprescription Antibiotic Dispensing at Community Pharmacies in China: A Mixed Cross-Sectional and Longitudinal Study

Background: Antibiotic resistance is a global threat. Nonprescription dispensing of antibiotics at community pharmacies is a global problem. China has regarded curbing nonprescription sales of antibiotics at community pharmacies as an important task for tackling antibiotics resistance and planned to eliminate this practice nationwide before 2020. Herein, we aimed to quantify nonprescription dispensing of antibiotics at community pharmacies in China shortly before 2020 and track the recent trend of this practice. Methods: We collected cross-sectional data of a nationally representative sample of 2411 community pharmacies from 221 counties/districts in 6 provinces in different regions of China in 2017. We also developed a panel of 213 representative community pharmacies in Shaanxi Province with baseline survey in 2011 and subsequent follow-up surveys every 2 years through 2017. Simulated client method was used to measure nonprescription antibiotic dispensing based on scenarios about paediatric diarrhoea and adult acute upper respiratory infection, which were presented at each pharmacy. We performed multivariate logistic regression analyses of cross-sectional data using mixed effects model with random regional effects. We also estimated unadjusted period effects of nonprescription antibiotic dispensing using generalized estimated equations with logit link function and binomial distribution. Findings: Nationally, nonprescription antibiotic dispensing was observed at 48·5% [1169/2411] (95%CI: 46·5-50·5) and 70·1% [1690/2411] (95%CI, 68·2-71·9) of community pharmacies when paediatric diarrhoea and adult respiratory infection were simulated, respectively. Nonprescription antibiotic dispensing was negatively associated with the presence of a pharmacist on-site and being part of a chain pharmacy. In Shaanxi Province, significant decreases of nonprescription antibiotic dispensing occurred in paediatric cases (from 72·3% to 50·2%) and adult cases (from 95·8% to 69·5%) between 2011 and 2017. Interpretation Nonprescription dispensing of antibiotics at community pharmacies was still prevalent nationwide in 2017, although a decreasing trend in nonprescription dispensing of the medicines since 2011 was observed in Shaanxi Province. Multifaceted measures including and not limited to regulatory interventions, professional training and public health education are urgently needed. Funding Statement: This work was funded by “Young Talent Support Plan”, “High Achiever Plan” of Health 373 Science Center, Xi’an Jiaotong University, Central University Basic Research Fund (2015qngz05) and “Early Career Research Start-up Plan” of Xi’an Jiaotong University. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: The study was approved by the Ethics Committee for Medical Research of Xi’an Jiaotong University and was conducted accordingly. Given that we used the SC method, the committee permitted a waiver of informed consent from pharmacies.