Antibiotic dispensing practices and antimicrobial stewardship gaps in community pharmacies in Kakamega County, Kenya

A prospective study of 504 dispensing events in Kakamega County, Kenya, reveals that nearly half of antibiotic sales occur over-the-counter with frequent use of broad-spectrum agents and incomplete courses driven by financial constraints, underscoring the urgent need to integrate community pharmacy data into national antimicrobial stewardship strategies.

The Gist

Imagine a busy marketplace in a town called Kakamega, Kenya. In this town, the "medicine shops" (community pharmacies) are like the main gatekeepers for people trying to get better when they feel sick. A team of researchers decided to stand behind the counter for three weeks in August 2025 and watch what happened every time someone bought an antibiotic (a medicine used to fight bacterial infections).

Here is what they found, explained simply:

The "No-Receipt" Problem

Think of antibiotics like a special key that should only be given out if a doctor (the locksmith) has checked the lock first. However, the researchers found that nearly half the time (44%), people walked up to the counter and got these special keys without showing a doctor's note. They just asked for them, and the shop gave them out. This is called "Over-the-Counter" (OTC) dispensing.

While the law says you need a prescription, it's like having a "No Entry" sign on a door that nobody really checks. In this town, almost half the people walked right through the door without a ticket.

What Were People Sick With?

Most people came in because they had trouble breathing or coughing.

• The Big Two: About half of all the visits were for infections in the upper throat (like a bad cold) or the lower lungs (like pneumonia).
• The Rest: People also came in for stomach bugs, skin rashes, toothaches, and other issues.

The researchers noticed that whether you had a doctor's note or not, the types of sickness people were trying to treat were pretty much the same.

The "Big Guns" vs. The "Standard Tools"

When the shopkeepers handed out the medicine, they mostly reached for three specific types: Amoxicillin, Azithromycin, and Metronidazole.

However, there was a concerning trend. For serious infections like pneumonia or sepsis (a severe body-wide infection), they often handed out "Big Guns"—very strong, broad-spectrum antibiotics. Think of this like using a sledgehammer to crack a nut. While it might work, it's often unnecessary and can cause problems later by training the bad bacteria to become stronger and harder to kill (resistance).

The "Empty Wallet" Issue

Sometimes, people wanted a full box of medicine to finish their treatment, but they couldn't afford it.

• In about 6 out of 100 cases, the shopkeeper only gave them a few pills instead of the full course.
• The main reason? Money. The patient simply couldn't pay for the whole box.
• The researchers noted that stopping early is like turning off a fire hose halfway through putting out a fire; the fire (infection) might come back stronger.

The "Already Sick" Pattern

The researchers also asked, "Have you taken antibiotics recently?"

• Shockingly, 31% of people said they had taken antibiotics in the month before they walked into the shop.
• Often, they were taking them for the same sickness again. This is like trying to fix a leaky roof by just adding more shingles without fixing the hole; the problem keeps coming back.

Who Was Making the Decisions?

Usually, a doctor decides what medicine you need. But in this town, the pharmacists and pharmacy technicians were acting like the doctors for many people, especially for coughs and skin issues. They were the ones saying, "Yes, you need this antibiotic," often without a doctor's order.

The Bottom Line

The study concludes that in Kakamega, antibiotics are too easy to get without a doctor's check-up, and people are often using the strongest medicines for simple problems. Because of money issues, people aren't finishing their treatments, and many are taking these drugs over and over again.

The researchers say that to fix this, the town needs to treat these medicine shops as part of the solution. They need to include the shopkeepers in the plan to stop bacteria from becoming super-strong, rather than just focusing on big hospitals. It's about making sure the "gatekeepers" have the right rules and support to hand out the right keys only when they are truly needed.

Technical Summary

Technical Summary: Antibiotic Dispensing Practices and Antimicrobial Stewardship Gaps in Community Pharmacies in Kakamega County, Kenya

Problem Statement
Antimicrobial resistance (AMR) poses a critical global health threat, with sub-Saharan Africa bearing a disproportionate burden. In Kenya, community pharmacies serve as a primary interface for antibiotic access, yet regulatory enforcement of prescription-only sales remains inconsistent, particularly in peri-urban and rural areas. While data exists for Nairobi, there is a significant surveillance gap regarding antibiotic dispensing practices in other counties. This lack of localized data hinders the implementation of effective antimicrobial stewardship (AMS) interventions aligned with Kenya's National Action Plan on AMR (2023–2027).

Methodology
The study employed a prospective descriptive cross-sectional design conducted between August 3rd and August 22nd, 2025, across 22 licensed community pharmacies in Kakamega County, western Kenya.

• Data Collection: Pharmacy staff prospectively recorded 504 consecutive antibiotic dispensing events involving systemic human antibiotics.
• Variables: Data captured included the dispensing source (over-the-counter [OTC] vs. prescription), clinical indication, specific antibiotics dispensed, whether a full course was supplied, reasons for partial courses, and self-reported antibiotic use within the preceding month.
• Analysis: Clinical indications were categorized into eight groups (e.g., URTI, LRTI, GI). Antibiotics were classified according to the WHO AWaRe framework. Descriptive statistics were calculated, and Pearson's chi-square ($\chi^2$) tests were used to examine associations between dispensing sources and other characteristics. Analyses were performed using Python 3.10.

Key Results

• Dispensing Sources: Of the 504 events, 44.4% (224) were dispensed over-the-counter (OTC) without a prescription, while 55.2% (278) were prescription-based.
• Clinical Indications: Respiratory tract infections were the dominant drivers of antibiotic use. Upper respiratory tract infections (URTI) accounted for 31.0% of events, and lower respiratory tract infections (LRTI) for 18.8%. Gastrointestinal infections (12.9%) and skin/soft-tissue infections (10.9%) followed.
• Antibiotic Selection: The most frequently dispensed agents were amoxicillin, azithromycin, and metronidazole. Broad-spectrum agents, including fluoroquinolones and cephalosporins, were commonly used for LRTIs, urinary tract infections (UTIs), and sepsis. Azithromycin was the primary choice for URTIs.
• Adherence and Repeat Use: Partial antibiotic courses were dispensed in 6.5% of events, primarily due to financial constraints (45.5% of partial cases). Self-reported antibiotic use within the preceding month occurred in 31.0% of cases, with 53.8% of these being repeats for the same condition.
• Statistical Associations: No significant association was found between dispensing source (OTC vs. prescription) and clinical indication. However, the source of the clinical indication varied significantly by infection type; pharmacists/technicians frequently determined indications for LRTIs and skin infections, whereas doctors were the primary source for dental infections, UTIs, and sepsis.

Significance and Claims
The paper asserts that this study provides one of the first detailed descriptions of antibiotic dispensing practices in community pharmacies outside Nairobi. The authors claim the findings highlight critical gaps in community antibiotic governance, specifically:

1. High OTC Accessibility: The 44.4% OTC rate exceeds estimates from urban Kenyan settings, suggesting weaker regulatory enforcement in rural and peri-urban Kakamega.
2. Empiric and Broad-Spectrum Use: The reliance on Watch-group antibiotics (e.g., azithromycin) and broad-spectrum agents for common infections reflects empiric prescribing driven by symptom assessment rather than diagnostic confirmation.
3. Socioeconomic Barriers: Financial constraints are a documented driver of incomplete antibiotic courses, which poses risks for treatment failure and resistance selection.
4. Role of Pharmacists: Pharmacists and technicians play a central, often autonomous, role in clinical decision-making for common infections, presenting a key opportunity for integrating community pharmacies into county-level AMS programs.

The authors conclude that incorporating community pharmacy dispensing data into county-level surveillance and national AMR frameworks is essential to optimize antibiotic use and support the goals of Kenya's National Action Plan. They emphasize that effective stewardship in this context requires both strengthened regulatory enforcement and pragmatic, pharmacy-led interventions.