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It is easy to obtain antibiotics without prescription in retail pharmacies in China, even though selling antibiotics without a prescription conflicts with regulations, a study published in the open access journal Antimicrobial Resistance & Infection Control suggests. More work needs to be done to ensure that antibiotics are obtainable by subscription only, according to researchers at Zhejiang University School of Medicine, Hangzhou, China.

At the G20 summit in China in 2016, a comprehensive plan to address antimicrobial resistance (AMR) was announced, which included making antibiotics prescription-only in pharmacies in all Chinese provinces by 2020. The authors investigated the degree of progress towards that goal and to quantify the proportion of pharmacies in which antibiotics could be purchased without a prescription, across the three regions of China.

Thérèse Hesketh, from Zhejiang University and University College London (UCL), the corresponding author of the study said: “Following strong leadership by the Chinese government, antimicrobial Stewardship has improved in hospitals in China over the past 10 years, but little is known about access to antibiotics in retail pharmacies. We document the ease of access to antibiotics in pharmacies without prescriptions. Care needs to be taken to enforce the regulations around these sales, as part of wider stewardship efforts to control AMR.”

The authors conducted a survey in 13 Chinese provinces, using a Simulated Patient method. From July to September 2017, forty medical students acted as real patients, presenting at pharmacies with mild upper respiratory tract symptoms, but without visible symptoms. The students recorded characteristics of the pharmacies they visited, such as location, distance from the nearest hospital and whether the pharmacy was independent or part of a chain. They also recorded details of their experience, including at which stage in the process—symptoms only described, asked for antibiotics, asked for a specific antibiotic—they were offered antibiotics.

The authors found that out of a total of 1,106 pharmacies included in the study, antibiotics could be obtained without a prescription in 925 (83.6%) cases. Of these, 279 (25.2%) gave out antibiotics with only mild symptoms being described, 576 (52.1%) gave out antibiotics when specifically asked for them and 70 (6.3%) gave out antibiotics when asked for a specific type (penicillin or cephalosporins). Of the 181 (16.4%) pharmacies in which no antibiotics were offered, the reasons given included that a prescription was necessary (113 pharmacies or 10.2%), that antibiotics were not indicated (58 pharmacies or 5.2%), or that there were no antibiotics in stock (six pharmacies or 0.5%).

The authors found no significant differences in access to antibiotics between urban or rural location of the pharmacy (city, county, township or village), or between independent pharmacies and ones that were part of a chain. However, it was easier to obtain antibiotics in pharmacies more than 2km away from a hospital.

The results suggest that, in the case of retail pharmacies, little progress has been made towards the goal to make antibiotics obtainable by prescription only by 2020. The findings raise concerns about the potential role of pharmacies in antibiotics misuse and its contribution to AMR, according to the authors. They suggest that pharmacists need to be trained to explain to customers why antibiotics are refused and that public education campaigns may be needed to raise awareness of antibiotics misuse and its consequences within the general population.

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