Non-prescription antibiotic dispensing in community pharmacies in LMICs: a systematic review of prevalence, drivers, and policy implications.

BACKGROUND

Community pharmacists dispensing antibiotics without a prescription (DAwP) remain a contributing factor to antimicrobial resistance (AMR) in low- and middle-income countries (LMICs). Multiple structural, behavioral, and systemic factors influence this practice, yet the diversity and interaction of these drivers remain insufficiently explored.

OBJECTIVE

This systematic literature review aims to identify and synthesize the internal and external factors contributing to DAwP among community pharmacists in LMICs, integrating evidence from both qualitative and mixed-method studies to offer updated, context-specific insights.

METHODS

A comprehensive literature search was conducted up to August 2025 across PubMed, Scopus, EBSCO, and Web of Science (WoS) using Boolean search techniques, with no restrictions on publication date or language. Studies were screened according to predefined eligibility criteria, focusing on primary research conducted in LMICs. The review included quantitative, qualitative, and mixed-methods studies. The review protocol was registered in PROSPERO (CRD420251108428).

RESULTS

A total of 24 studies were included. Quantitative synthesis revealed an alarmingly high prevalence of DAwP, averaging 66.6% (range: 25.9–100%) across included surveys, highlighting a significant gap between professional knowledge and practice. Factors influencing DAwP were categorized into seven major themes: (1) economic and socio-demographic factors, (2) pharmacy and pharmacist characteristics, (3) knowledge and attitudes, (4) customer demand and behavior, (5) regulatory and legal environment, (6) healthcare system limitations, and (7) interventions and solutions. While awareness of AMR exists, weak enforcement, patient pressure, and systemic healthcare gaps perpetuate non-compliant dispensing practices.

CONCLUSION

DAwP in LMICs results from a complex interaction of individual, institutional, and policy-level factors. Addressing this requires comprehensive strategies—regulation, education, systemic transformation, and community involvement—to minimize incorrect antibiotic usage and combat AMR.