Inappropriate antibiotic dispensing for upper respiratory tract infections in community pharmacies – a simulated patient study

Background: Upper respiratory tract infections (URTIs) are predominantly viral and self-limiting, yet inappropriate antibiotic dispensing remains common in many low- and middle-income countries. (1) In Nepal, community pharmacies serve as the first point of contact for minor ailments, making the role of dispensers crucial.(2) This study assessed the appropriateness of antibiotic dispensing practices for URTIs in community pharmacies using a simulated patient (SP) approach. Methods: A cross-sectional simulated patient (SP) study was conducted in community pharmacies across Kathmandu, Lalitpur, and Bhaktapur districts. Using stratified random sampling, 40 pharmacies located within a two-kilometre radius of major government and private hospitals were selected. Five trained SPs presented a standardized case of a young adult with mild fever and sore throat suggestive of an uncomplicated upper respiratory tract infection (URTI). SPs were trained through scenario familiarization, role-play, and Nepali language standardization to ensure consistent presentation. During each visit, SPs did not request specific medicines and allowed dispensers to manage the case naturally. After each encounter, SPs completed a structured assessment form documenting medicines dispensed, counselling provided, interaction duration, and dispenser behaviour using a predefined counselling checklist. Results: A total of 40 SP visits were completed. Antibiotics were dispensed inappropriately in a substantial proportion of encounters, with azithromycin being supplied in 12 cases, despite the patient scenario not meeting clinical criteria for antibiotic therapy. Other commonly dispensed medicines included paracetamol (n=8) and cough syrups (n=4). Counselling practices were suboptimal, with limited explanation on medication purpose, dosing, adverse effects, and duration of use. The average consultation time ranged from 30 seconds to 2 minutes, indicating brief interactions that may compromise appropriate decision-making. Overall, dispensing practices did not align with evidence-based recommendations such as NICE guidelines, which discourage antibiotics for uncomplicated URTIs. Conclusion: This study highlights a high rate of inappropriate antibiotic dispensing for URTIs in community pharmacies in Nepal. Poor counselling practices and short consultation times further exacerbate the risk of misuse. Strengthening regulatory enforcement, providing targeted educational interventions for pharmacy staff, and promoting antimicrobial stewardship are essential to improve rational medicine use and reduce antibiotic resistance.