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Women should be able to get antibiotics for urinary tract infection without a prescription

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3441 (Published 14 July 2015) Cite this as: BMJ 2015;351:h3441

The sale of antibiotics without prescription: More cons than pros.

Kyle Knox states that women should be able to get antibiotics for urinary tract infections (UTI) without a prescription in the UK since most need to be treated with these drugs and this strategy could avoid unnecessary visits to the GPs. This could only be true for these women who have recurrent uncomplicated UTIs as long as the antibiotics sold are effective and have a narrow spectrum. Sale of antibiotics without prescription is hazardous for several reasons:
1. The link between this practice and antibiotic overconsumption is clearly established. Southern European countries usually rank at the top in terms of the consumption of antibiotics [1]. Similarly, over-the-counter sale of antibiotics is reportedly common in such countries [2]. In Spain in 2014 , with the use of a mystery shopper who presented at community pharmacies requesting an antibiotic for one of three different clinical scenarios, our group observed that these drugs were sold in 54.1% of the pharmacies without a medical prescription. Moreover, this percentage was over 80% when the actress simulated an uncomplicated UTI, mimicking a similar previous study carried out in 2007 [3,4].
2. Individuals get accustomed to going directly to pharmacies and bypassing their GPs. Individuals migrating from areas where the sale of antibiotics without prescription is forbidden to places where this practice is still available acquire the habit of obtaining the antibacterials at the pharmacies instead of making an appointment at the GP’s practice. In a study carried out in a Finnish community living in Spain, Väänänen et al found that antibiotics, which are considered as prescription-only medicines in Finland, were purchased by 41% of the immigrants who admitted having taken an antibiotic in the previous 6 months [5].
3. The over-the-counter sale of antibiotics both encourages self-medication and the storage of leftover antimicrobials. Self-medication with antimicrobials is widespread among the population in the same countries where over-the-counter sale is available [2]. Antibiotics available at home have been found to be an important risk factor for this practice [6], and leftover medication may later be considered for self-medication, sometimes leading to inappropriate usage of these drugs and further compounding the problem of antimicrobial resistance.
4. Diagnosis of uncomplicated UTIs is not straightforward. Between 34% and 60% of patients treated with an antibiotic do not have a microbiologically proven UTI [7].
5. The sale of antimicrobials without a prescription often leads to a wrong choice of these drugs. For instance, in our study carried out in 2007, fluoroquinolones, which are considered as critically important antimicrobials by the World Health Organization as also are third- and fourth-generation cephalosporins and macrolides) [8], accounted for 40% of the antibiotics sold for UTIs [4].
6. Over-the-counter sales without a prescription may also lead to the use of insufficient dosages, with lower doses dispensed being more common when the antibiotic is sold at the pharmacies compared to other healthcare facilities, leading to an increase of emergence of resistances [2].
7. Safety issues associated with non-prescription use also include adverse drug reactions and masking of underlying infectious processes. In a study carried out in Taiwan, patients with detectable antibiotic concentrations in urine were nearly twice as likely to have a missed diagnosis of a true bacterial infection compared to patients without any antimicrobial detected [9].
8. Another inconvenience is the pressure of the population on both the pharmacist and the physician. In the first case this pressure is related to the selling of the antimicrobial and in the second, to obtaining the prescription of the drug sold by the pharmacist to thereby be partially or totally reimbursed for the cost of the antimicrobial.
The sale of antibiotics without prescription has pros and cons but, in any case, this policy requires that pharmacists have a key role as healthcare agents. In our study, however, the pharmacists who refused to sell antibiotics without a prescription gave responses related to health or resistance issues in only 30% of the cases, and they only asked about possible allergies, or potential pregnancy and side effects in less than half of the subjects to whom antibiotics were sold [4]. Proper diagnosis of an uncomplicated UTI can also be challenging in a pharmacy. Education is therefore particularly important when patients ask for an antibiotic and when patients choose self-care, there is often no possibility to obtain advice from a physician, and thus, the responsibility of providing appropriate information falls on pharmacists. The sale of antibiotics without a prescription might be considered for women with UTI if they are only recurrent – who clearly know their symptoms – and only limited to short-courses of narrow-spectrum antibacterials, such as nitrofurantoin (or fosfomycin or pivmecillinam in other countries); otherwise, this practice should be forbidden.

References
1. European Centre for Disease and Prevention Control. Summary of the latest data on antibiotic consumption in the European Union, November 2014. Available at: http://ecdc.europa.eu/en/eaad/Documents/antibiotic-consumptio-ESAC-Net-2...
2. Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Non-prescription antimicrobial use worldwide: a systematic review. Lancet Infect Dis 2011;11:692–701.
3. Guinovart MC; FIgueras A, Llop JC, Llor C. Obtaining antibiotics without prescription in Spain in 2014: even easier now than 6 years ago. J Antimicrob Chemother 2015;70:1270–1.
4. Llor C, Cots JM. The sale of antibiotics without prescription in pharmacies in Catalonia, Spain. Clin Infect Dis 2009;48:1345–9.
5. Väänänen MH, Pietilä K, Airaksinen M. Self-medication with antibiotics--does it really happen in Europe? Health Policy 2006;77:166–71.
6. McNulty CA, Boyle P, Nichols T, Clappison DP, Davey P. Antimicrobial drugs in the home, United Kingdom. Emerg Infect Dis 2006;12:1523–6.
7. Salvatore S, Salvatore S, Cattoni E, Siesto G, Serati M, Sorice P, Torella M. Urinary tract infections in women. Eur J Obstet Gynecol Reprod Biol 2011;156:131–6.
8. World Health Organization Advisory Group on Integrated Surveillance of Antimicrobial Resistance (AGISAR). Critical important antimicrobials for human medicine. World Health Organization, 2012. Available at: http://apps.who.int/iris/bitstream/10665/77376/1/9789241504485_eng.pdf
9. Liu YC, Huang WK, Huang TS, Kunin CM. Inappropriate use of antibiotics and the risk for delayed admission and masked diagnosis of infectious diseases: a lesson from Taiwan. Arch Intern Med 2001;161:2366–70.

Competing interests: I had a grant from the Fundació Jordi Gol I Gurina for a research stage at the University of Cardiff in 2013. I also report receiving research grants from the European Commission (Sixth and Seventh Programme Frameworks), Catalan Society of Family Medicine, and Instituto de Salud Carlos III (Spanish Ministry of Health).

18 July 2015
Carl Llor
GP and senior researcher
Primary Healthcare Centre Via Roma.
c. Manso, 19. 3a planta. 08015 Barcelona, Spain