Ideal management (referral to a health-care provider without giving any antibiotics and steroids) was recorded in 13% of Case1 interactions (simulated patients with TB symptoms) in sharp contrast to 62% of Case 2 interactions (patients presenting with confirmed TB diagnosis).
The most common classes of drugs dispensed for Case 1 were analgesics like paracetamol and nimesulide, antibiotics, cough syrups, and anti-allergy drugs. Overall, antibiotics (like amoxicillin), steroids (betamethasone and prednisolone) and fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin), were dispensed in 37% , 8% and 10% of the interactions respectively. The classes of drugs dispensed for Case 2 were similar to Case 1, although the overall uses were much lower--antibiotic use was significantly lower at 16% in Case 2 interactions. First-line TB drugs were not dispensed by any pharmacy.
Thus, while only some urban Indian pharmacies correctly managed patients with presumptive TB, most of them correctly managed cases of confirmed TB. No pharmacy dispensed TB drugs for either case. The study confirmed that absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions.
Main conclusions
(i) Although antibiotic use is high, and such use can delay diagnosis, none of the pharmacies dispensed first-line TB drugs, and the use of stronger fluoroquinolone antibiotics and heavily restricted drug classes was low. So concerns regarding pharmacies being sources of irrational use of TB drug that contributes to multidrug-resistant TB (MDR-TB) seem to be unfounded, at least in major cities.
(ii) The use of all antibiotics decreased sharply when the patient's diagnosis was made available to the pharmacists. However, 37% of the pharmacies dispensed antibiotics or steroids to people with TB symptoms but no test results. The use of fluoroquinolones and steroids, although low, is worrying because these drugs delay TB diagnosis. Additionally, fluoroquinolones are also an essential part of MDR-TB treatment regimens and emerging regimens, so quinolone abuse is a concern.
(iii) The widespread use of antibiotics and steroids for respiratory symptoms also has implications for community- acquired infections more generally.
The study results not only add to the growing evidence on antibiotic abuse, but also underscore that the use and misuse of antibiotics are mediated by drug category and the information that patients present. Thus it seems that, as far as pharmacists are concerned, the main problem- both in the management of TB and antimicrobial resistance - is the information that patients present to the pharmacist. Confirmed diagnoses discipline what pharmacists do, with sharp increases in ideal management and large decreases in antibiotic use. This dramatic difference suggests that the main challenge faced by pharmacists is confusion about the likely diagnosis, in which case better training regarding TB symptoms and encouraging early referrals for patient with TB symptoms might help.
India has over 750,000 private retail pharmacies that provide easy access to drugs. Pharmacists respond to the health-care needs of a substantial proportion of India's population. Many TB patients do seek medical advice and drugs from pharmacies, driven by the ease of access and the possibility of avoiding consultation charges by doctors. These findings can inform interventions to engage pharmacies in TB control and initiatives to improve protect antibiotics from misuse.
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