Pharmacists: Beware of Greek Actresses with Sick Sisters

Abstract & Commentary

Synopsis: In many countries, antibiotics are commonly dispensed through pharmacies without a physician’s prescription, regardless of the local laws and regulations.

Source: Contopoulos-Ioannidis DG, et al. Pathways for inappropriate dispensing of antibiotics for rhinosinusitis: A randomized trial. Clin Infect Dis. 2001;33:76-82.

It is against the law in Greece to dispense antibiotics without a doctor’s prescription. Investigators in the city of Ioannina decided to investigate whether this was, nevertheless, occurring.

They worked with the University theatrical group to train 2 medical student actress-researchers to present themselves to 98 different pharmacists to ask for antibiotics. The scenario was the case of a sister of the actress-researchers who was ill with the classic symptoms of a viral upper respiratory infection with the exception of the fever, which was said to be 40°C for half the cases and 38.5°C for the others. The presentations were carefully rehearsed and developed to respond consistently to questions the pharmacist might have. If a prescription for an antibiotic was offered, the pharmacist was encouraged to provide a stronger one. Cases and actresses were randomized.

Of the 98 pharmacists approached, 86% offered an antibiotic for the scenario of the 38.5°C temperature and 69% did so for the 40°C one. Of those who offered an antibiotic, 71% offered a broad spectrum one for the lower temperature and 65% offered one for the high fever. Only half of the pharmacists asked any questions about the patient before offering to sell the antibiotic. Two percent refused to dispense because of prescribing regulations. Only one said an antibiotic was not needed. Only 35% of pharmacists in the low fever and 57% of the high fever groups recommended that the sister see a physician. Less then one quarter asked about allergies.

Comment by Alan D. Tice, MD, FACP

The situation in Greece is a common one. The profligate use of antibiotics is an international problem and often beyond the control of physicians. It is particularly disturbing that half of the pharmacists did not even ask about the patient before offering to sell an antibiotic. The concept of a physical assessment of the patient was also ignored as the actresses were asking for medication for a sister who was not present.

The problem of overuse of antibiotics is clearly a global one. While changing physician prescribing has been the major focus for preventing antibiotic resistance in developed countries, there is information to suggest the system is being bypassed. Even in the Bronx, 26% of people surveyed reported using antibiotics from friends, mail order, or pharmacists without a doctor’s prescription.1 In developing countries, it is even hard to enforce regulations without the administrative and legal machinery that is in place in countries such as the United States.

The consumption of antibiotics has generally increased around the world with marked variations among counties. A recent Lancet report demonstrates 2-fold variations among countries in the European Union with no apparent differences in infections or outcomes.2,3

The situation in Greece is analogous to that in Chile where there have been laws on the books that require a physician’s prescription for an antibiotic but they were not enforced. When it was noted that there was a marked increase in antibiotic use, it was decided to enforce the regulations. The result was a decrease in the use of some antibiotics by as much as half, with a savings of $6.5 million or 15% of their total annual cost.4

There is no description of how persuasive or attractive the medical student actress-researchers were or what their bias may have been in the study, but they were at least comparably effective in obtaining antibiotics. The theatrical abilities of the Greeks should never be overlooked.

Perhaps there should be an international antibiotic police force to monitor appropriate use and enforce regulations. Physician-actresses and actors may be a useful component.


1. McKee MD, Millis L. Mainous AG III. Antibiotic use for the treatment of upper respiratory infections in a diverse community. J Fam Pract. 1999;48:993-996.

2. Cars O, et al. Variation in antibiotic use in the European Union. Lancet. 2001;357:1851-1853.

3. Donnelly JP. Antibiotic use in the European Union. Infectious Disease Alert 2001;20:154-156.

4. Bavestrello L. Cabello QFA. Chile enforces regulations on the sale and dispensing of antibiotics. APUA Newsletter. 2001;19:5.

Alan Tice of Infections Limited, Tacoma, Wash., is Associate Editor of Infectious Disease Alert.