By Stan Deresinski, MD, FACP, FIDSA

Clinical Professor of Medicine, Stanford University

Dr. Deresinski reports no financial relationships relevant to this field of study.

SYNOPSIS: Acquisition of antibiotics without a prescription can be easy in the United States.

SOURCE: Grigoryan L, Germanos G, Zoorob R, et al. Use of antibiotics without a prescription in the U.S. population: A scoping review. Ann Intern Med 2019 Jul 23. doi: 10.7326/M19-0505. [Epub ahead of print].

Grigoryan and colleagues performed a scoping review to assess the prevalence and factors influencing the use of antibiotics without a prescription in the United States. The purpose of a scoping review is to identify and map the available evidence at a time while the latter remains in flux.1 As the evidence matures, a systematic review becomes more appropriate.

Only 31 of 17,422 screened articles met inclusion criteria for review. Venues where antibiotics were acquired included flea markets, pet stores, botanical stores, health food stores, and online sources. Additional sources were family and friends, markets or stores, leftover prescribed antibiotics, and other countries. Four populations were studied: patients or parents outside healthcare systems, those within healthcare systems, Hispanics/Latinos, and injection drug users. The prevalence of nonprescribed antibiotic use was highly heterogeneous, ranging from 1% to 68%, as was the intent to store an antibiotic for future use, which varied from 14% to 48%. Among patients in a primary care practice, 25% intended to use antibiotics without a prescription.

Factors that were reported to contribute to nonprescription antibiotic use were easy access to stores and markets that obtain antibiotics from outside the United States for under-the-counter sales, difficulties in accessing the healthcare system, costs and long waiting times associated with visits to clinicians, and transportation difficulties.

COMMENTARY

In 2002, a reporter for the The New York Times interviewed Marina Aguilera in her New York City West 135th Street apartment as she held a package of ampicillin tablets in her hand.2 Ms. Aguilera, like many other Dominicans in her neighborhood, purchased them over-the-counter at her local bodega — no prescription needed. She said she took them for sore throats, earaches, chest pains, and bad colds, but she is doubtful that they are helpful in treating headaches.

The scoping review provides an estimate of the prevalence of the use of antibiotics absent a prescription and, more importantly, pointed to potential interventions to reduce nonprescription antibiotic use. Many of these undoubtedly apply in low- and middle-income countries in which evidence indicates that the high copays for drugs in the public sector actually may drive patients together with a requirement for prescriptions to settings where there is an incentive to provide such prescriptions.3 The likelihood of antibiotic overuse in that circumstance is consistent with the investigators’ finding that high drug copays are associated with a significantly increased prevalence of antibiotic resistance.

REFERENCES

  1. Munn Z, Peters MDJ, Stern C, et al. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC Med Res Methodol 2018;18:143.
  2. Bruner F, Chandler G. Neighborhood Report: Washington Heights; At the bodega, antibiotics with no prescription needed. The New York Times Feb. 10, 2002.
  3. Alsan M, Schoemaker L, Eggleston K, et al. Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: An economic analysis. Lancet Infect Dis 2015;15:1203-1210.