Non-prescription antibiotic dispensing and counseling practices in Iraqi community pharmacies: implications for antimicrobial stewardship and resistance containment.

BACKGROUND

To assess the prevalence, characteristics, dispensing practices, and counseling behavior of non-prescription antibiotic dispensing among Iraqi community pharmacies to inform antimicrobial stewardship (AMS) policy.

RESEARCH DESIGN AND

METHODS

A cross-sectional simulated client study was conducted among 696 pharmacies across five Iraqi provinces. Standardized scenarios of upper respiratory tract infection were used to evaluate dispensing behavior, counseling quality (defined as whether staff provided key counseling components including enquiry about symptoms, allergy status, dosage instructions, and treatment duration), and antibiotic class distribution according to the WHO-AWaRe framework. Data were analyzed using descriptive and multivariable logistic regression.

RESULTS

Antibiotics were dispensed without prescription in 80.6% (95%CI:77.6-83.5%) of the visits. Access antibiotics accounted for 60.8% (95%CI:56.9-65.0%) and Watch agents for 39.2% (95%CI:34.9-43.1%), with amoxicillin-(26.4%), amoxicillin-clavulanate-(30.7%), and azithromycin-(25.5%) most common. Counseling was poor; only 15% (95%CI:12.3-18.3%) of the providers asked any clinical question and only 7.7% (95%CI:5.5-9.9%) enquired about allergy history. Non-pharmacist staff (nurses) were significantly more likely to dispense antibiotics without prescription compared with pharmacists (OR = 5.7; 95%CI:3.2-10.1).

CONCLUSIONS

Non-prescription antibiotic dispensing and minimal counseling remain widespread in Iraqi pharmacies. Effective AMS in Iraq will require phased, system-level approaches, including strengthened regulatory enforcement, workforce support addressing all pharmacy personnel, and integration of community pharmacies into national AMR strategies.