Knowledge and attitudes towards antibiotics and antimicrobial resistance among patients in rural South Africa and the implications for future policies

Tiyani Milta Maluleke¹Morgan Tiyiselani Maluleke²Nishana Ramdas¹Ana Golić Jelić³Amanj Kurdi⁴Inaam Ur Rehman⁵Stephen Campbell¹Vanda Marković-Peković³Natalie Schellack⁶Audrey Chigome¹Aislinn Cook⁷Brian Godman^1*Johanna Catharina Meyer¹

• ¹Sefako Makgatho Health Sciences University School of Medicine, Pretoria, South Africa
• ²Saselamani Pharmacy, Saselamani, South Africa
• ³Univerzitet u Banjoj Luci, Banja Luka, Bosnia and Herzegovina
• ⁴University of Strathclyde Institute of Pharmacy and Biomedical Sciences, Glasgow, United Kingdom
• ⁵University of the Punjab, Lahore, Pakistan
• ⁶University of Pretoria, Pretoria, South Africa
• ⁷City St George's University of London - Tooting Campus, London, United Kingdom

Background: Antimicrobial resistance (AMR) is an appreciable public health threat, exacerbated by considerable inappropriate use of antibiotics including for upper respiratory tract infections (URTIs) Whilst there have been high levels of inappropriate prescribing of antibiotics in primary care in South Africa, study findings vary regarding the extent of dispensing of antibiotics without a prescription. Where this occurs, this is typically for patients with urinary tract infections (UTIs) and sexually transmitted infections (STIs). Consequently, there is a need to update knowledge regarding antibiotic dispensing patterns in primary care in South Africa alongside key factors influencing this. The findings can provide future direction to key stakeholders in South Africa grappling with high AMR rates Methods: A previously piloted questionnaire was administered to patients leaving community pharmacies in a rural province using their preferred language. The questionnaire included data on current antibiotic utilisation patterns alongside their knowledge and attitudes towards AMR. Results: 465 patients were interviewed exiting community pharmacies with a medicine. 78.7% of patients dispensed antibiotics were dispensed these without a prescription. Perceived STIs were the most common infectious disease where this occurred, with 99.1% of antibiotics issued for this condition dispensed without a prescription. Only 1 out of 116 patients with perceived STIs were prescribed antibiotics. The reverse was seen with patients with URTIs where there was very little dispensing of antibiotics without a prescription for these patients. This may be because surveyed patients were happy to take advice from community pharmacists, who typically offered symptomatic relief to patients with suspected URTIs. This situation contrasts with prescribers where URTIs were the most common infection where antibiotics were prescribed (59.3%). Questioning patients in their own language enhanced their understanding of key issues. Conclusion: There is an urgent need to re-consider community pharmacist activities in South Africa with some countries allowing them to prescribe antibiotics for UTIs. Trained community pharmacists can also potentially engage with patients to help prevent and manage STIs with patients appearing to preferentially seek help from community pharmacists for their perceived STIs. Community pharmacists can also potentially work with prescribers to improve their antibiotic use especially for URTIs.