A just-published review found that antibiotics remain readily available in the United States without a prescription. The authors found that between 1-66% of studied populations reported possession and/or planned use of antibiotics obtained from sources other than a prescriber's order. With implications for both personal side effects and population-wide antibiotic resistance, examining the factors contributing to nonprescription antibiotic use may lead to some solutions.
The authors performed a scoping review with the goal of answering these two questions: "What are the prevalence, sources, and characteristics of nonprescription antibiotic use in the US, and what are the factors influencing it?" They identified 31 articles that met their inclusion criteria:
Several studies focused on the availability of antibiotics without a prescription from flea markets, pet stores, botanical or health food stores, or online. Others explored nonprescription use from a range of sources, including leftover prescribed courses, markets or stores, family or friends, and antibiotics obtained without a prescription from other countries. In 1 study, patients in an STI clinic and a county jail were interviewed about self-treatment with antibiotics. All studies of injection drug users examined self-treatment of abscesses and injection-related wounds with antibiotics obtained on the street.In reviewing these studies, the authors identified several factors that influenced nonprescription use of antibiotics; wait times to see a physician, cost of the physician visit, and lack of transportation were prominent as might be expected, but concerns about judgment by healthcare staff when seeking care for sexually transmitted infections and injection-drug-use-related infections were also noted. Of course, the ready availability of antibiotics from a multitude of sources enabled nonprescription use, too.
According to the basic tenets of health behavior theory, most adults make decisions about their health that they deem rational in the context of their knowledge, environment, and social norms. It makes sense, for example, that persons with ready access to antibiotics who are concerned about the cost and/or stigma of seeking medical care would choose the easier route of bypassing the physician's office. Tackling the problem of antibiotic resistance may need to include efforts to reduce barriers and stigma around receiving treatment for more potentially sensitive conditions.
The AAFP's Everyone Project toolkit contains a wealth of resources to help your patients who have barriers to accessing healthcare. The Canadian Public Health Association has a toolkit to help practices identify and decrease stigmatizing language and behaviors. Limiting inappropriate antibiotic prescribing remains important, too, as Dr. Lin and I discussed on an AFP tweet chat back in 2017; here are the AFP references we used, which contain pragmatic, evidence-based strategies for reducing antibiotic overuse.
Antibiotic overuse remains a complex challenge, and hopefully we'll see future studies continuing to address not only its multifaceted causes but also successful strategies to combat them.