ANTIBIOTICS PRESCRIPTION & DISPENCING PATTERN

IN PHARMACIES NEAR SERVICES HOSPITAL, LAHORE.

Research Conducted by
Muhammad Ahmad nasir (Roll No. 108)
Mishkoat Khan (Roll No. 102)
Muhammad Ahsan (Roll No. 111)
Mishal Salar (Roll No. 103)
Muhammad Asif (Roll No. 116)

4th Year M.B.B.S

Session: 2019-2020

Supervised by: Dr. Afshan Shahid

Mentor: Dr. Rabiah
Tutor: Dr. Sohail

DEPARTMENT OF COMMUNITY MEDICINE & PUBLIC HEALTH

SERVICES INSTITUTE OF MEDICAL SCIENCES, LAHORE
 Services Institute of Medical Science
Jail Road, Lahore, Pakistan

ACADEMIC DISSERTATION
Department of Community Medicine & Public Health
Services Institute of Medical Sciences, Lahore

Supervised By
Dr Afshan Shahid
Head Department of Community Medicine & Public Health
Services Institute of Medical Sciences, Lahore

Mentored By
Dr Rabiah Mehwish
Department of Community Medicine & Public Health
Services Institute of Medical Sciences, Lahore

Tutored By
Dr Sohail
Department of Community Medicine & Public Health
Services Institute of Medical Sciences, Lahore

The originality of this research has been checked using the Turnitin Originality Check service
in accordance with the quality management system of the Higher Education
Commission (HEC), Pakistan.

Copyright ©2018 Muhammad Ahmad Nasir

Printed on Acid-Free paper.

Back and Front Cover designs by the author.
Digital Images of Viruses on covers by kjpargeter / Freepik.

1|Page
 DEDICATED TO
PROF. ASHRAF MAJROH
WHO LAID & CONCRETED THE CULTURE
AND PRINCIPLES OF RESEARCH AND
LEARNING IN OUR INSTITUTE.

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Table of Contents
ACKNOWLEDGEMENTS .............................................................................................. 4
CERTIFICATE OF APPROVAL ..................................................................................... 5
ABSTRACT .................................................................................................................. 6
ABBREVIATIONS ........................................................................................................ 8
INTRODUCTION ......................................................................................................... 9
OPERATIONAL DEFINITIONS: .................................................................................. 15
METHODOLOGY ...................................................................................................... 16
ETHICAL DECLARATION .......................................................................................... 18
RESULTS .................................................................................................................... 19
DISCUSSION ............................................................................................................ 49
CONCLUSION.......................................................................................................... 56
LIMITATIONS ............................................................................................................ 57
RECOMMENDATIONS .............................................................................................. 58
CONFLICTS OF INTEREST ......................................................................................... 59
REFERENCES............................................................................................................. 60
ANNEXURE I: DATA CLLECTION FORM / QUESTIONNAIRE .................................... 64
ANNEXURE II: DATA CLLECTION FORM / QUESTIONNAIRE ................................... 66
ANNEXURE III: CONSENT FORM ............................................................................. 68

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ACKNOWLEDGEMENTS
We are extremely thankful to our worthy and respected head of the
department, Dr. Afshan Shahid for her relentless support and guidance
throughout the course of this research. It would not have been possible
without her trust in us. She nourished our ideas from their infantile stages to
the eventual product presented within this text.
We are also thankful to Dr.Rabiah Mehwish for being continuously linked
with us from the beginning of this research and guiding us at every single
step.
The continuous help and support provided by our demonstrators Dr. Sohail
needs a mention too. He held our hands and walked us through every step
needed to carry out this research. This research would not have been
possible without them.
We would also like to thank the Patients/guardians/Representatives who
took part in this study. Along with the owners, pharmacists and staff of
pharmacies near Services Hospital, Lahore who lent their utmost
cooperation to us and helped us fill the questionnaires with full dedication
and honesty.
In the end it is worth mentioning that this research would not have been
possible without the cooperation and division of labor between the authors
(Roll No. 108 & 102) and other members of research group (Roll
No.103,111,116).

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 CERTIFICATE OF APPROVAL

It is to certify that the project report entitled: Antibiotics Prescription &

Dispensing Pattern in Pharmacies near Services Hospital, Lahore. A
cross sectional study in SHL, submitted to the Department Of Community
Medicine, SIMS, Lahore for the award of annual assessment as partial
fulfillment of her fourth year MBBS Community Medicine curriculum is the
result of the original project work carried out by the students of batch D
Roll numbers (108, 102, 103, 111, 116) under my supervision and to the
best of my knowledge and belief and the work embodied in this project
report does not home part of any thesis dissertation project already
submitted to any university/institution. Their work in this regard is
satisfactory.

Signature of the Supervisor--------------------------Date-------------------------

Dr, Sohail
Department of Community Medicine
SIMS, Lahore

Signature of the Mentor------------------------------Date-------------------------

Asst. Prof. Dr. Rabiah Mehwish
MBBS, M.Phil.(Community Medicine)
Department of Community Medicine
SIMS, Lahore

SIGNATURE of the HOD -------------------------------Date--------------------------

Asst. Prof. Dr. Afshan Shahid
MBBS, FCPS (Community Medicine)
Department of Community Medicine
SIMS, Lahore

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ABSTRACT

Background
Antibiotics are commonly used drugs for treating infections of microbes
in all age groups. There is a need of data on prevalence of prescribed
and non-prescribed use of antibiotics especially in our setting. This study
was carried out to assess the prevalence of self-medication in all ages
in pharmacies near services hospital, Lahore.

Objective
To congregate information on prevailing Antibiotic prescription
pattern and dispensing practices in pharmacies near Services
Hospital, Lahore.

Method
A cross sectional study was conducted from May’19 to June’19 in
Pharmacies facing SHL in 200 meters. A Sample size of 231 was
estimated using WHO sample size software. A detailed structured
questionnaire and checklist was used to collect data. After
obtaining informed consent, face-to-face interviews were
conducted. Questionnaires were checked by researchers for
comprehensiveness. Data was analyzed using SPSS v 23 and
associations were tested using the Chi square test.

Results
A total of 231 respondents participated in this study. Among
participants, 72.3% were males and female 27.7%. Respondents of
almost all ages were observed. Prevalence of non-prescription
purchase was 58% and those who had prescription were 42%.
Prevalence of self-medication was higher in male i.e. 65.8% when
compared with female i.e. 37.5%. Self-medication was significantly
higher in under-matric people 73.4% than in people with higher
education 53.8%. 74.7% people did not know that the antibiotics are
prescription only drug. Number of Antibiotics per encounter were One
62.9%, Two 36.1% and three only 1%, with mean of 1.38 antibiotics per
prescription.

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Conclusion and Policy Recommendations
This study validates deviance from rational use in the areas of
antibiotic prescription, dispensing and self-medication, and low
impact of current policy measures. It depicts a noteworthy increase
of self-medication among educated as well as un-educated
people, especially among males. There is a need of public
education to certify safe practices. Strict guidelines need to be
executed on the prescription and sale of antibiotics to prevent this
problem from escalating.

Key words
Antibiotics, Self-medication, Prescription, Dispensing.

© 2019 Muhammad Ahmad Nasir. All rights reserved.

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ABBREVIATIONS
AAD Antibiotic Associated diarrhoea
AAPMS Antibiotic Associated pseudomembranous Colitis
Abn Abnormal
ABX Antibiotics
ATB Antibiotic
ED Emergency department
ER Emergency Room
OPD Out Patient Department

OTC Over the Counter

PC-Hs Public hospitals
Phar. Pharmacy
PHC-Fs Primary health care facilities
PRT-Hs Private hospitals
SEAR Southeast Asian Region
SHL Services Hospital Lahore
SMA Self-medication with antibiotics
SOP Standard Operating Procedure
UT-H University hospital

WHO World Health Organization

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INTRODUCTION
Drugs are the essential tools for preventive, curative, rehabilitative and
promotive health care. The number and type of drugs is constantly
increasing, while the financial resources for health care services in
general, remain limited [1]. The discovery of antibiotics is considered as
one of the greatest medical achievements of the 20th century.
Antibiotics are an essential drug class, an extensive and in demand
group of drugs, nearly and surely prescribed by every genre of medicine
and surgery (figure 1). A significant portion of this exquisite commodity is
wasted either due to wrong procurements and poor storage or incorrect
dispensing practices. So, appropriate prescription and righteous
dispensing is crucial [2].
Any drug prescription should contain, in legible form, elements required
for appropriate dispensing of drugs, including suitable drug with dosage
form and dosage regimen, to ensure continuity of care and legal
purposes [3]. According to the World Health Organization, levelheaded
utilization of medications necessitates that patients get meds suitable to
their clinical needs, in dosages that meet their very own individual
prerequisites for a satisfactory timeframe, with prospective benefits out
weighing the potential risks and at the most minimal expense to them
and their community [4].
Dispensing process covers all the activities involved, from receiving the
prescription to issuing the prescribed medicine to the patient the
consistent, repeated use of good dispensing procedures is fundamental
in guaranteeing that mistakes are recognized and rectified at all phases
of the dispensing process [5]
The blameless way of dispensing of antibiotics is strongly coupled with
proper prescription. Of the numerous factors manipulating the
availability and consumption of drugs, one is retailers engaged in
diagnostic and therapeutic behavior beyond their scope of training or
legal mandate. 35 community surveys from five continents showed that
non-prescription use occurred worldwide and accounted for 19–100% of
antimicrobial use outside of northern Europe and North America [6].
According to another study in Lebanon, over-the-counter antibiotic
availability existed in both higher and lower socio-economic areas,
overall, 32% of antibiotics were dispensed without medical prescription,
with higher frequency in lower socio-economic areas [7].

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In much of the world antimicrobial drugs are sold without prescription or
oversight by health-care professionals. The scale and effect of this
practice is unknown. According to a study in Egypt, approximately 70%
of the antibiotics dispensed on prescriptions were judged to be
appropriate for the indications while this percentage was around 61% for
antibiotics dispensed on pharmacist recommendation and patient's
request [8]. Safety issues associated with non-prescription use included
adverse drug reactions and masking of underlying infectious processes.
Non-prescription use was common for non-bacterial disease, and anti-
tuberculosis drugs were available in many areas. Antimicrobial-resistant
bacteria are common in communities with frequent non-prescription
use.
Self-medication with antibiotics is becoming increasingly communal due
to manifold factors. Antibiotics that are prescription only drugs and can't
be sold as Over the Counter drugs yet they are self-medicated 76% in
Asia [9]. According to the Centers for Disease Control and Prevention
(CDC), more than 36,000 individuals were victims of a fatal drug over-
dose in 2008(6). The majority of these deaths were related to prescription
drug abuse. In a study only 7% (95% CI ⫽ 2.9–13.9%) referred for a medical
history and physical examination necessary to guide therapy [11].
The proportion of retailers dispensing antibiotics without instructions for
use pharmacies is high. Antibiotic dispensing without instructions may
lead to wrong self-dosages and inappropriate dosing intervals that might
harm the users. Similar findings are evident in Asia where instructions for
medicine use was very minimal, if any, and had to be probed by clients.
Our study attribute a lack of instructions for medicine use to poor
retailers’ knowledge and training. This discovers potential areas for
intervention.[12]
Many retailers usually do not discuss with their clients about antibiotic
side effects. Indian study showed no explanation was given on the side
effects and potential drug allergies. This problem is also present in tertiary
care hospitals. There is a striking variation in the pattern of drug use from
country to country and in different areas of an individual country.
In Pakistan, the results of the present study showed that percentage of
antibiotics per prescription in a sample of Islamabad & Rawalpindi are
58%, which is far more than the standards of less than 30% [9]. Pakistani
dental specialists have endorsed a larger number of anti-infection
agents than required [10]. Another marker used to portray endorsing

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rehearses, the normal number of medications per prescription turns out
to be 2.3 which is yet higher than the standard of underneath 2 meds for
each prescription as driven by the World Health Organization [9].
Prolonged use of antibiotics without indications and without proper
dosage and duration may lead to antibiotic resistance. This is the reason
that we are seeing increased strains of bacteria with antibiotic
resistance. Antibiotic resistant strains of bacteria are very difficult to treat
and may spread and epidemic in the society. The recent outbreak of
multidrug resistant typhoid in Pakistan is an example (figure 4).
This study assess the antibiotic prescription per encounter,
dispensing procedures irregularities and number of medications per
prescription. Assessment of drug prescribing practices in this health
facility helps to identify specific drug use problems, sensitize clinicians on
rational medicine use and provide policy makers with relevant
information that could be used to review medicine-related policies in this
health facility. This study therefore focuses on assessing antibiotic
prescription practices in, & dispensing practices near, Services Hospital,
Lahore using selected WHO rational drug use indicators.[13]

Figure 1. Increasing trends in the number of Antibiotics use in Pakistan,

2000-2015

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resis

Figure 2. Use of all antibiotics in world, 2015

Figure 3. Resistance of Escherichia Coli to Fluoroquinolones, 2017.

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Figure 4. Resistance of Salmonella Typhi to fluoroquinolones
92 %( 83%-97%) in 64 isolates tested, 2015
Source Chugtai Laboratory, Lahore.

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Objective
To assess the practices of antibiotic dispensing & prescription pattern in
pharmacies near Services Hospital, Lahore.

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OPERATIONAL DEFINITIONS:
Dispensing: Dispensing is the process of receiving, validating, 1.

Pharmacy: A place where medicines are compounded or dispensed.

Antibiotic: A semisynthetic substance or product derived from

microorganisms, able to inhibit or kill another microorganism

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METHODOLOGY

1. Study Design
A cross sectional study design with limitations was applied for this
research
2. Study Setting
The Research was conducted in Pharmacies facing Services
Institute of Medical Sciences/ Services Hospital Lahore within
distance of 200m
3. Study Duration:
The duration of this study was three months after the approval of
synopsis i.e. from 10-June-2019 to 20-August-2019.
4. Sample Size:
Sample size was taken according to WHO S-size software by using
formula of estimating population proportion with specific relative
Precision. At a confidence level of 95%, anticipated population
proportion of 75% and relative precision of 8 % a minimum sample
Size of 201 was calculated and 231 patients were taken to
compensate for incomplete form.
5. Sampling Technique
Data was collected by non-probability convenient sampling.
6. Inclusion Criteria
The inclusion criteria consisted of Pharmacies facing Services
Hospital, within distance of 200m.
7. Exclusion Criteria
The exclusion criteria consisted of unwilling and uncooperative
Patients/attendants and pharmacist.

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8. Data Collection Tool:

A detailed structured questionnaire was used to collect data which

included the form for demographic details and detailed questions
regarding the prescription and purchase of the patient.

9. Data Collection Procedure

A detailed structured questionnaire was prepared, and the patients

were interviewed according to the questions. Face to face
interactions were conducted with the
representative/mother/father/guardian of the Patient buying
medicine in Pharmacies near Services Hospital, Lahore. The
questionnaire was translated into the local language (Urdu/Punjabi)
for the purpose of convenience and to limit the communication
barrier. All the data was collected by the members of the research
group consisting of fourth year medical students. The Questionnaire
was checked on daily basis by researchers for its all-inclusiveness
and comprehensiveness and subsequent revisions were done.

All study protocols were approved by the Ethics Committee of

Services Institute of Medical Sciences and Services Hospital Lahore.
Written informed consent has been obtained from each child’s
participant.

10. Data Analysis:

The data was entered after looking for incomplete responses

manually and SPSS (Statistical Package of Social Sciences) IBMSPSS
23.0 software was used for data entry, statistical calculation,
tabulation, interpretation and recording of the final results. Pie charts
and bar graphs were used to represent socio-demographic variables
of the respondents. The chi - square test was applied to look for
associations between facets of self-medication and socio-
demographic variables, cost/price of antibiotics and dosage forms.
P value less than 0.05 considered as significant. For quantitative
variables, mean and standard deviation has been calculated,
Relationship between different tables was determined and is
represented in the form of tables and diagrams (as shown in the
subsequent pages)

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ETHICAL DECLARATION
1. The members of the research group abided by the declaration of
the World Medical Association made at Helsinki, regarding the
ethical Principles of medical research involving human subjects.
2. Formal approval was taken from ethical committee of Services
Hospital Lahore.
3. A formal permission from the Head, Department of Community
Medicine, Services Hospital Lahore was taken.
4. A written informed consent was taken from the respondents.

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RESULTS
A total of 231 respondents participated in this study and
questionnaire was administered to the representatives buying the
antibiotic to collect relevant information. Among participants,
167(72.3%) were males while female were 64(27.7%). Respondents of
almost all ages were observed and their histogram is given in histogram
figure1. Educational status of respondents is given in pie chart figure 2.
Non-Matric 49(21.2%), Matric 73(31.6%), Bachelor 80(34.6%) and
29(12.6%) with higher education. Prevalence of non-prescription
purchase was 58% and those who had prescription were 42% (Figure3).
Prevalence of self-medication was higher in male i.e. 65.8% when
compared with female i.e. 37.5%. When this distribution was compared
for association with chi-square test it was found statistically significant
with an exact 2-sided significance of less than 0.000.
Self-medication was co-related with educational status of the
subjects, it was found significantly higher in under-matric people 73.4%
than in people with higher education 53.8% with a p-value of 0.015.
Significant relationship (p-value 0.007 was found between self-
medication and ignorance of people, self-medication is significantly less
56.5% in people who have knowledge and significantly higher 74.7% in
people who do not have knowledge that the antibiotics are prescription
only drugs.
Out of the 97 subjects who carried a prescription 70(72.2%) carried
a new prescription while others 27(27.8%) had an old prescription. Total
27 subjects had an old prescription, out of which 8(29.6%) had used it
twice while 19(70.4%) had used the same prescription multiple times. For
chronic disease 3(11.1%), on suggestion of doctor 5(18.5%) and most of

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them 16(59.3%) were doing this by their own choice and 3(11.1%) for
other reasons.

Another variable, number of antibiotics per encounter was also

studied. Number of Antibiotics per encounter were One 62.9%, Two
36.1% and three only 1%, with mean of 1.38 antibiotics per prescription.
In 97 of studied prescriptions, 83(85.6%) of patient had prescriptions with
fully mentioned dosage of the drugs, while 14(14.4%) didn’t have
correctly mentioned dosage of the drug. Most of the antibiotics were
prescribed in solid form 78.4%, syrup/suspension 11.3% and in injection
form 10.3%.
Most of the participants and pharmacist 57.6% do not check the
expiry date at the time of dispensing the drug while 42.4% participants
told that expiry date was checked. Most of the time 85.6% prescription
had fully mentioned dosage of the drug with irregularity of just 14%.
Patient bought the fully mentioned dosage of drug 77.3%, but 22.7%
patient did not buy the full prescribed medicine. 20% of the times
dispenser gave an alternate brand of the drug due to cost effective
issue. 77.9% of the patients did not read the leaflet, with only 21.6% of
patients giving a look to the literature provided inside the drug pack.

Majority of the sample population 58.0% were found buying

antibiotics without prescription and practicing self-medication. And
many other ill-practices were discovered. Out of 134 non-prescribed
antibiotics sales encounters, only in 52.2% of the cases pharmacists
asked about the prescription but in 47.8% they did not care about asking
a valid prescription. Moreover, only in 25.4% of cases pharmacist
suggested the patient to visit a doctor before using an anti-biotic, while
a big majority 74.6% didn’t refer to the doctor. Similarly 75% of

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respondents had previous experience of getting the same non-
prescribed antibiotic before that encounter.

Most of the dispenser 58.2% didn’t give any instructions to the subjects
about drugs storage, intake, dosage or any other thing. 76.1 % of the
pharmacists didn’t asked about any drug allergy. 53.7% of subjects
claimed to have the knowledge of proper dosage, others accepted
their ignorance.

Most of the people i.e. 29.9% go for self-medication because of

easy availability of antibiotics. Second most common i.e. 28.4% came
out that people consider their disease simple don’t bother paying a visit
to the doctor. 22.4% subjects were choosing self-medication based on
their previous experience. Similarly, multiple responses from the
participants were obtained when they were asked to give source of self-
medication. Most common source of self-medication i.e. 38.8% of the
study population is through pharmacist while previous experience of the
drug amounts to 26.1% leading to self-medication. While
Friend/relatives’ recommendation 19.4% was the 3rd most common
answer. Most of the respondents 53.0% practice self-medication on a 3
day ailment and 23.1% on 1st day of ailment. Alarming 13.4%
respondents told they don’t visit a doctor and always practice self-
medication.
Out of 231 respondents who took part in our study, 45.9% told that they
didn’t bought the full pack of antibiotic. 77.9% did not read the leaflet
inside the pack of drugs. In 92.6% of cases pharmacist did not instruct
subjects about cautions of drug storage. In 84.0% of cases pharmacist
did not instruct buyers about any drug interactions/allergies.

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DISCUSSION
In this study antibiotic prescription pattern and dispensing
practices were studied in sample pharmacies near Services Hospital,
Lahore. Prevalence of self-medication in our society was studied
considering nonprescription purchase of antibiotics as self-medication
and relationship between self-medication or non-prescription purchase
of antibiotics with demographic variables like age, gender, educational
status, personal knowledge, etc. of the subject was studied. Antibiotic
dispensing pattern by the pharmacist was also studied. Comprehensive
questionnaire was used to assess the quality of dispensing practices and
to question the level to which standard operating procedures are
adopted in dispensing antibiotics.

Our study comprised of 231 participants who were buying

antibiotics in 5 pharmacies near services hospital, Lahore. Two annexures
of questionnaire were developed, annexure 1 for participants who were
buying antibiotic with a valid prescription and annexure 2 was handed
over to the participants who were buying antibiotic without prescription.
Among participants, 167(72.3%) were males while female were
64(27.7%). A possible explanation for the percentage of males in this
sample is that most of the send a male representative from family to
pharmacy to buy drugs for them. Respondents of almost all ages were
observed and their histogram is given in histogram figure1.

In our study, Prevalence of non-prescription purchase was 58% and

those who had prescription were 42%. People were easily able to buy
antibiotic without prescription without any hesitation either from the
buyer or from the pharmacist. Worldwide self-medication of antibiotic
varies from 19 to 100% it is less in the Europe and America and more in
the underdeveloped countries [6]. Its frequency is higher in low social

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economical areas. According to a study in Egypt 70% of the antibiotics
are dispensed on prescription [8] while in a study of Islamabad and
Rawalpindi self-medication of antibiotics was also 58% [9]. Self-
medication of antibiotics is higher in Asia and it is UPTU 76% in South Asia
[9].

Antibiotics are serious drugs that they can be lifesaving as well as

problematic. Antibiotics have great number and extent of side effects.
Prolonged use of antibiotics without indications and without proper
dosage and duration may lead to antibiotic resistance. This is the reason
that we are seeing increased strains of bacteria with antibiotic
resistance. Antibiotic resistant strains of bacteria are very difficult to treat
and may spread and epidemic in the society. The recent outbreak of
multidrug resistant typhoid in Pakistan is an example. Moreover, improper
storage and administration of antibiotics may lead to fatal results.
According to the center of disease control and prevention, more than
36000 individuals were victims of drug overdose in 2008.[6]

Prevalence of self-medication was significantly higher in males i.e.

65.8% when compared with females i.e. 37.5%. According to a study of
Egypt self-medication is significantly affected by different age groups
but not by gender [17]. And self-medication was higher in adults. But
another cross-sectional study of Sudan showed that self-medication is
more in female gender lower income and higher level of education. [30]
In a study of LITHUANIA, 22.0% of respondents used antibiotics
without prescription, whereas 45.0% of them used antibiotics for Intended
self-administration [22]. Adjustment for all the factors revealed the
impact of the age, occupation and place of residence on self-
medication with antibiotics. But there are some limitations of our study as
it does not establish a relationship between self-medication and the

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occupation and residence of the respondents. The reason for this is
people were not comfortable in sharing their residence, occupation and
personal profile. Secondly we were questioning representatives buying
antibiotics not actual patients, so establishing a relationship between
self-medication and age/ occupation of representative is not logical.
But this is an evident of the fact that in developing countries like Pakistan,
less income and less resources forced people towards cheaper ways of
getting health facilities and treatment. So people tend to find self-
medication as a cheap alternative source to avoid physician and
consultant fees.
Self-medication is more prevalent in people who have lower
socioeconomic status. In this study the educational status of the
respondents is given. Self-medication was co-related with educational
status of the subjects, it was found significantly higher in under-matric
people 73.4% than in people with higher education 53.8 with a p-value
of 0.015. While a similar study conducted in Ghana reported that 70.8%
percent of the people who purchased drugs without prescription had at
least secondary education [19]. In our study, Significant relationship (p-
value 0.007 was found between self-medication and ignorance of
people, self-medication is significantly less 56.5% in people who have
knowledge and significantly higher 74.7% in people who do not have
knowledge that the antibiotics are prescription only drugs. Israel has a
population with high literacy rate, so study of September 2012 showed
non-prescription use of antibiotics to be only 5.1%. [25]
Our study also high lightened the fact that only 47.8% of the times
dispenser didn’t asked for the prescription. In October, 2011 in Greece,
It was documented in a cross sectional study on dispensing of antibiotics
without prescription that in 107 (85%) of the 126 visits where the antibiotic
was sold without prescription, no comment was made by the pharmacist

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and no reason for the intended antibiotic use was requested [27]. Our
study shows that only 25.4% of the pharmacists try to recommend the
patient to visit the doctor before using any antibiotic.
Our study also highlighted the fact that patients bought the fully
mentioned dosage of drug 77.3%, but 22.7% patient did not buy the full
prescribed medicine. 20% of the times dispenser gave an alternate
brand of the drug due to cost effective issue. According to a review on
improving antibiotic use in low income countries, chemists in Kenya were
willing to sell smaller doses of antibiotics when requested [26]. Pharmacy
Staff in Nigeria stated that they would not refuse to meet patients'
demands for antibiotics, as they feared that patients would go to
another pharmacy. In India, pharmacies changed antibiotic
prescriptions to suit the financial means of customers. [26]

Most of the participants and pharmacist 57.6% do not check the expiry
date at the time of dispensing the drug. Most of the dispenser 58.2%
didn’t give any instructions to the subjects about drugs storage, intake,
dosage or any other thing. They just handed the medicines without
following any standard procedures of antibiotic dispensing. But
according to a study of Catalonia, Spain, the pharmacists provided an
explanation as to the number of times per day the drug should be taken
in 84.3%, explained the duration of treatment in 68.7% [24]. 76.1 % of the
pharmacists didn’t asked about any drug allergy before giving antibiotic
without prescription, only 23.9 % asked about drug allergy. While in Spain,
pharmacist inquired about allergies prior to the sale of the antibiotic in
only 16.9% [24]. In October 2011, in Greece, 174 visits different
pharmacies were performed. In only three cases of antibiotic dispensing,
the collaborator was informed by the pharmacist about adverse events
- mainly allergies and diarrhea. [27]

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 Most of the participants and pharmacists, 57.6%, do not check the
expiry date of the antibiotic. 20.6% pharmacist gave alternate brands of
antibiotics due to cost effective issues. A study was conducted in March
2014 to assess the antibiotic dispensing at US-Mexican border [29]. Results
depicted that 58% medicines were dispensed without prescription When
the client presented a prescription (n=53) the clerk offered an alternative
brand name or generic in 23% of the cases, The interviewees revealed
that the salary of some pharmacy clerks is tied to the amount and type
of medicines they sell, and a pharmacy owner acknowledged that
often, along with the products, they sell the corresponding pre-signed
prescription.

In America they asked clients if they knew how to use the medicines in
47% of transactions. Clients only asked about how to use the medicines
during 9% of transactions [29]. In our study, when the subjects were asked
the knowledge of proper dosage/regimen, 53.7% of subjects claimed to
have the knowledge of proper dosage. But 77.9% did not read the
leaflet inside the pack of drugs. In 92.6% of cases pharmacist did not
instruct subjects about cautions of drug storage.

In our study, out of the respondents who were having a prescription,

majority carried a new prescription. 75% of respondents had previous
experience of getting the same non-prescribed antibiotic before that
encounter. They had used the prescription twice or multiple times for
chronic disease 11.1%, on suggestion of doctor 18.5% and most of them
59.3% were doing this by their own choice and 11.1% for other reasons.

This study indicated the multiple responses from the participants when
they were asked to give source of self-medication. Most common source
of self-medication i.e. 38.8% of the study population is through
pharmacist while previous experience of the drug amounts to 26.1%

53 | P a g e
leading to self-medication. While Family members were also the 3rd most
common answer. A review was conducted in July 2015. It revealed that
drug store customers in the Philippines, India, Mexico and Brazil based
their decisions to buy antibiotics on advice that was given by friends or
relatives. Lay people’s advice is often strongly influenced by earlier
medical prescriptions. [19]

Another indicator used in this study to describe prescribing practices is

the average number of medicines per prescription. Number of
Antibiotics per encounter were One 62.9%, Two 36.1% and three only 1%,
with mean of 1.38 antibiotics per prescription. Most of the antibiotics
were prescribed in solid form 78.4%, syrup/suspension 11.3% and in
injection form 10.3%. While Average Number of drugs per prescription
was 9.1 in certain tertiary care hospitals of Ghana [26]. Prescribers may
obtain financial incentives from the industry by selling a drug. In February
2016, in public sector of Pakistan, the average number of drugs per
prescription turned out to be 2.7 out of which only 1.6 drugs were being
dispensed from the facility [31]. More than half of the prescriptions
contained antibiotics and 15% of patients were prescribed with
injectable. In another study it was 3.0 drugs per prescription [32], while
WHO recommends 2.0 as standard.

Most of the respondents 53.0% practice self-medication on a 3 day

ailment and 23.1% on 1st day of ailment. Alarming 13.4% respondents
told they don’t visit a doctor and always practice self-medication. This is
due to the belief that common diseases are not worth physician’s
consultation. Similarly In Egypt, Different socioeconomic Levels among
the surveyed sample preferred ways other than consulting physicians
based on The belief that common diseases do not worth physician’s
consultation 47.3%. [17]

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Multiple responses from the participants were obtained when they were
asked to give reason for self-medication. Most of the people i.e. 29.9%
go for self-medication because of easy availability of antibiotics. Second
most common i.e. 28.4% came out that people consider their disease
simple don’t bother paying a visit to the doctor. 22.4% subjects were
choosing self-medication based on their previous experience. People
are also involved in self-medication to save money and time, in our study
their count was 22 (16.4%). Very few, only 3% chooses self-medication
for faster relief from ailment. A cross-sectional, study was conducted in
July 2011 Karachi, The most common reason for self-medication was
previous experience (50.1%).[34]

This study reveals that awareness about the antibiotic drugs of not being
for over the counter sale is low among the respondents, 39.4%. This is a
major contributing factor to over the counter sale of antibiotics leading
to antibiotic resistance.

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CONCLUSION

This study validates deviance from rational use in the areas of antibiotic
prescription, dispensing and self-medication, and low impact of current
policy measures. 58% people are involved in self-medication with
Antibiotics. It depicts a noteworthy increase of self-medication among
educated as well as un-educated people, especially among males.
There is a need of public education to certify safe practices. Strict
guidelines need to be executed on the prescription and sale of
antibiotics to prevent this problem from escalating.

56 | P a g e
LIMITATIONS
Research Group:
1. Several problems were confronted by the students of research
group during data collection, significant ones are mentioned:
2. Cooperation on part of patient was a real big issue. Being informed
that we are doctors, a noteworthy change in attitude was noticed.
An alarming level of hatred/threat was faced.
3. Provision of time by patient was also a hurdle as many of them
were from far areas, frustrated by rush and illness.
4. Translation of questionnaire to illiterate patient was also time
consuming and tiring for both, the patient and the doctor.
5. Previous misbehave or bad conduct with patient by hospital staff
was also blurring the importance of this study in our sample.
6. Gender approach was also a limitation. Females were only
cooperative with female students, hence influencing the results
and transparency of this study.
7. Some patients had no interest in sharing information under the idea
that it’s no benefit at their end, so a noteworthy population was
not participating
8. Prescription patterns followed by some doctors were not
appropriate, with no legible script, dosage and cautions were not
mentioned for guidance of patient, thus rendering some questions
unanswered.

Pharmacies:
9. Several pharmacies felt threatened by interviews of their
customers, this non cooperative behavior was a significant
limitation.
10. Some incidents of misconduct with research members were also
accounted, especially those which were not certified and
recognized by health department of Pakistan.

Study population:
11. Several patients with no prescription felt accountable and
decided not to cooperate.

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RECOMMENDATIONS

1. WHO’s recommended SOPs of prescription writing and dispensing

should be strictly followed to eliminate errors at the ends of doctors
and pharmacist.
2. Drugs should be prescribed by its Generic name or by
Pharmacological formula not by brand/commercial name and
should be properly dispensed by qualified pharmacist to patient
under cautions.
3. Burden of patients per doctor can be reduced by evening shifts of
OPD. It will not only be convenient for working masses of society
who are at jobs during day time, but also for the doctors to attend
a patient within appropriate limit of time. Hence, ensuring
availability of medical health facility for all and discouraging
private practices.
4. Treatment plan analysis should be done periodically, depending
on prognosis. If needed, should be revised.
5. Compliance of patient should be made compulsory on part of
doctor especially in Antibiotic therapy.
6. There is a constant need of research-based analysis and policy
formation, implementation & follow up and progress is needed on
grounds of antibiotic prescription and dispensing practices in
Pakistan. The space must be filled to ensure standardized provision
of medical facility.
7. Self-prescription is the major uprising issue in Pakistan. A
comprehensive, strategic, community education is proposed for
sensitization of antibiotic resistance on part public.
8. OTC dispensing of all kind of drugs must be discouraged.
9. A law enforcement strategic policy is needed suppress illegal
practices. It should be dealt as a crime and penalty should be
Imprisonment or significant fine.
10. Periodic assessment of Pharmacies must be done to recognize and
certify pharmacies with qualified pharmacist and strict reactionary
attitude against uncertified dispensers and pharmacy owners.

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CONFLICTS OF INTEREST
This study is entirely self-financed by the members of the research group
and no research grants were given by any institution, government
organization or non-government organization (NGO).

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ANNEXURE I: DATA CLLECTION FORM / QUESTIONNAIRE

Antibiotic Prescription & Dispensing pattern in pharmacies near

Services hospital, Lahore
QUESTIONNAIRE
A) SOCIO-DEMOGRAPHIC DETAILS:
1. Name: _________________
2. Father's /Husband's name: _________________
3. Age: ___________________
3. Address: ____________________________________________
4. Date Today: ____________
7. Gender:
Male Female
9. Educational status:
Non-Matric Matric Bachelor Higher

B) QUESTIONNAIRE:

1. Do you have a prescription?

Yes No

2. Who wrote the prescription?

Doctor Other

3. Does the prescription have an antibiotic?

Yes No

4. Number of antibiotics per encounter?

One Two Three More

Is this prescription,
New Old

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 If, old

5. For how many times you have used this prescription?

Twice Multiple

6. Why are you using the same prescription for many times?

Chronic disease Suggested by doctor Your own choice

7. Does the prescription fully mention dosage of drugs?

Yes No

8. Dosage form:

Solid (tablet/Capsule) Liquid (Syrup/suspension) Parenteral

9. Did you buy the whole prescribed medicine?

Yes No

10. Did dispenser give you the full pack of prescribed Antibiotic?

Yes No

11. Did pharmacist give you an alternate brand of drug due to cost
effective issues?
Yes No
12. Did you/pharmacist check the expiry date of prescribed drug?

Yes No

13. Did you read the leaflet inside the pack of drugs?

Yes No

14. Did he (pharmacist) instruct you about cautions of drug storage?

Yes No

15. Did he (pharmacist) instruct you about any drug interactions/allergies?

Yes No

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ANNEXURE II: DATA CLLECTION FORM / QUESTIONNAIRE

ANTIBIOTIC PRESCRIPTION & DISPENSING PATTERN IN PHARMACIES NEAR

SERVICES HOSPITAL, LAHORE.

QUESTIONNAIRE
A) Socio-demographic Details:
1. Name: _________________
2. Father’s /Husband’s name: _________________
3. Age: ___________________
3. Address: ____________________________________________
4. Date Today: ____________
7. Gender:
Male Female
9. Educational status:
Non-Matric Matric Bachelor Higher

B) QUESTIONNAIRE:

If buying without prescription:

1. Did dispenser ask about the prescription?

Yes No

2. Why did the patient choose that Antibiotic?

a) Doctor recommendation
b) Pharmacist recommendations
c) Friend/Relative recommendation
d) tried it before
e) other
3. Did the pharmacist try to recommend the patient to visit the doctor
before using any antibiotic?

Yes No

4. Did the patient use it before:

Yes No

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5. For how many times you have used this Antibiotic?

Twice Multiple

6. Did you get any instructions from the dispenser?

Yes No

7. Did the dispenser ask about the drug allergy?

Yes No

8. Do you know the proper dosage/regimen?

Yes No

9. How often you practice self-medication?

i. 1 day ailment
ii. 3 day ailment
iii. 1 week ailment
iv. always
10. Reason for self-medication?

i. Disease is simple
ii. Easy availability
iii. Knowledge from previous experience
iv. Time and money saving
v. Fast relief
11. Do you know Antibiotics are prescription only drugs?

Yes No

12. Did you/pharmacist check the expiry date of prescribed drug?

Yes No

13. Did dispenser give you a full pack of Antibiotic?

Yes No

14. Did you read the leaflet inside the pack of drugs?

Yes No

15. Did he (pharmacist) instruct you about cautions of drug storage?

Yes No

16. Did he (pharmacist) instruct you about any drug interactions/allergies?

Yes No

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ANNEXURE III: CONSENT FORM

Consent:
We are conducting a research study titled as ANTIBIOTICS PRESCRIPTION
& DISPENCING PATTERN IN PHARMACIES NEAR SERVICES HOSPITAL,
LAHORE. This study is being conducted by4th year medical students of
Services Institute of Medical Sciences, Lahore. The purpose of this study
is to assess prescription & dispensing practices in pharmacies. Your
participation in this study is completely voluntary and if you to take part
in this study, you will be asked some questions. To the best of our ability,
your data and answers in this study will remain confidential and your
data will only be used for study purposes. There are no physical,
psychological and social risk factors involved in the study.

Consent Statement:

I hereby agree to take part in this survey; I have fully understood what I
have to do, and I know that I can refuse to take part in this survey
anytime.

Signature: _________________________

Date: _____________________________

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