Journal of Infection and Public Health 13 (2020) 118–124

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Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Community pharmacists as antibiotic stewards: A qualitative study

exploring the current status of Antibiotic Stewardship Program in
Bahawalpur, Pakistan
Muhammad Atif a,∗ , Saima Asghar a , Irem Mushtaq b , Iram Malik a
a
Department of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
b
Department of Education, The Islamia University of Bahawalpur, Bahawalpur, Pakistan

a r t i c l e i n f o a b s t r a c t

Article history: Background: The World Health Organization released a Global Action Plan to overcome the threatening
Received 25 April 2019 concerns of antibacterial resistance. One of the cornerstones of this plan is the Antibiotic Stewardship
Received in revised form 23 June 2019 Program (ASP). The study aimed to assess the community pharmacists’ knowledge, perceptions and
Accepted 2 July 2019
current practices regarding ASP.
Methods: A qualitative study was conducted in Bahawalpur, Pakistan, in which data were collected from
Keywords:
the community pharmacists through in-depth, semi-structured interviews. The convenience sampling
Drug regulatory authority of Pakistan
technique was used to recruit the study participants. Interview protocol was pilot tested and the sample
Community pharmacies
Developing countries
size was limited by applying the saturation point criteria. All interviews were audio recorded and tran-
Health education scribed verbatim. The thematic analysis approach was used to analyze the data and draw conclusions
Antibiotic resistance based on study objectives.
Results: A total of fifteen community pharmacists were interviewed. Analysis of the data yielded five
themes and 16 subthemes. All of the respondents had sound knowledge about the irrational use of
antibiotics; however, they were oblivious about the ASP. After explaining the term, the respondents
were of the opinion that these strategies could not be implemented in the current healthcare system
of the country. According to the findings of the study, prescribing and dispensing practices were not
followed. Only a few patients were educated about the antibiotics they were purchasing.
Conclusion: Most of the study participants were unaware of any ASP being offered in the community
pharmacy settings. The study participants agreed to be the antibiotic stewards, but a number of obstacles
were reported. The training of pharmacists, medication reconciliation, the implementation of the good
pharmacy practice guidelines and assurance of pharmacist availability at drug retail outlets were few
suggestions given by the study participants to incorporate the ASP in the community settings.
© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction very high rates of antibiotic resistance in developing countries,

The incessantly high prevalence of multi-drug resistant (MDR)
bacteria is leading towards increased morbidity and mortality due
to infections, which were otherwise treatable in the past [1]. This
phenomenon is evident all over the world, but the data suggested
Abbreviations: ASP, Antibiotic Stewardship Program; GAP, Global Action Plan;
AMR, antimicrobial resistance; MDR, multi-drug resistant.
∗ Corresponding author.
E-mail addresses: pharmacist atif@yahoo.com, muhammad.atif@iub.edu.pk
(M. Atif), saimaasghar93@yahoo.com (S. Asghar), irem atif@yahoo.com
(I. Mushtaq), iramalik686@gmail.com (I. Malik).
though the representative data remain scarce for many of these
regions [2]. It is estimated that in the United States (US) and Euro-
pean Union, around 2.6 million people die each year from MDR
bacteria [3,4]. The mortality rate is more alarming in other parts
of the world, for example, in Southern Asia, where about 9.6 mil-
lion annual deaths occur due to MDR infections [4]. Similarly, the
morbidity rates associated with MDR infections also remain high,
particularly in low and middle income countries (LMICs) where
access to healthcare facilities, appropriate microbiological diagnos-
tic tests and treatment interventions are limited [5].
At this moment, the escalating antibacterial resistance has
created an urgent need for the development of new antibiotics
with novel mechanisms of action [6], while a historical trend

https://doi.org/10.1016/j.jiph.2019.07.003
1876-0341/© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 M. Atif et al. / Journal of Infection and Public Health 13 (2020) 118–124
of decreased development of new antibacterial drugs continued
[7]. The World Health Organization (WHO) released the Global
Action Plan (GAP) in 2015 to overcome the threatening concerns
of antibacterial resistance [8]. One of the cornerstones of this GAP
is the Antibiotic Stewardship Program (ASP) which engrosses the
appropriate use of antibiotics in humans as well as in animals [8,9].
The program is aimed to target the optimal clinical outcomes with
minimal undesired consequences of antibacterial therapy, includ-
ing reduction in toxicity, adverse events and cost of therapy [10,11].
In Pakistan, the existence of unregistered medical practitioners
(quacks), low quality prescriptions, self-medication and easy access
to antibiotics at the drug retail outlets are major threats to the
future of antibiotics [12]. Various studies have reported higher than
optimal and inappropriate use of antibiotics in Pakistan [13–17].
Consequently, there is an increase in antibiotic resistance in the
country which is making the drug therapy complex for infectious
diseases [18]. Considering the need to reduce the unnecessary and
inappropriate use of antibiotics [12,19], the Medical Microbiology
and Infectious Diseases Society of Pakistan adopted the general
guidelines provided by the GAP, and initiated the ASP in 2016
[12,19]. The plan was implemented successfully in various hospital
settings, but not in community pharmacy settings despite the fact
that inappropriate antibiotic use is highly prevalent in these set-
tings [16,20]. Data outlining the inappropriate use of antibiotics in
the community justify the extension of ASP in these healthcare set-
tings [16,21]. Community pharmacists can play an important role
in the implementation of ASP and this advanced role of pharmacists
has been witnessed in earlier studies [22–24]. In Pakistani context,
though the community pharmacists are not following the set of ASP
protocols, but it is important to capture their perceptions and cur-
rent practices regarding this program. Therefore, in this study, we
aimed to assess the community pharmacists’ knowledge, percep-
tions and practices regarding ASP in Pakistan. The findings of this
study will not only identify the antibiotic use practices at the com-
munity pharmacies in Pakistan, but will also help the policy makers
to tackle the challenges associated with successful implementation
of ASP in these settings.
Methods
Study design and setting
In this qualitative study, community pharmacists working in
the Bahawalpur district of the Punjab province of Pakistan were
interviewed by using semi-structured interview schema. There are
about 500 drug retail outlets located in various areas of Bahawalpur
[25] but only a few pharmacies provide the services of community
pharmacists [26]. Others are run by non-pharmacist proprietors
only by hiring the license of qualified pharmacists [26]. Most of the
pharmacies in Bahawalpur are clustered around the Bahawal Victo-
ria Hospital, which is a large tertiary care hospital in the Bahawalpur
district, while others are located near populated areas. Community
pharmacists willing to participate in the study, registered with the
Punjab Pharmacy Council and having minimum work experience
of at least one year at community drug retail outlets were included
in the study.
Study instrument
The study instrument was designed by the research team, after
a thorough literature review [4,12,27] to best answer the research
problem and address gaps in the literature. The interview guide was
modified following piloting with two community pharmacists to
ensure the uniformity, face validity and understandability (please
refer to Additional File 1). The pilot interviews were not included
119
in the final analysis. The interview guide underwent iterative revi-
sion during the study to ensure that evolving themes can be best
captured in subsequent interviews [28].
Recruitment and data collection
The study participants were recruited by using the convenience
sampling technique. In the first step, a list of pharmacies was gen-
erated where community pharmacists were working. In the second
step, the target participants were approached and conveniently
selected based on their availability and willingness to participate
in the study. All semi-structured interviews were conducted by
SA. The interviews were conducted at the participants’ workplace
between October and November 2018. Before conducting the inter-
views, written informed consent to participate in the study was
obtained from the participants after explaining the nature and
objectives of the study to them. Prior to initiating the interview, the
participants completed a demographic data collection form which
recorded the details, including gender, age, qualifications, work-
ing experience and details of any specific training undertaken on
antimicrobial stewardship. All interviews were conducted in the
national language of Pakistan (Urdu) and were audio recorded.
Observation notes were also taken for all respondents. The sample
size was limited by applying the saturation point criteria [29].
Data management and analysis
The thematic analysis approach was used to analyze the data
[30]. The data were analyzed in six phases; familiarization with the
data, generation of initial codes, searching for themes, reviewing
themes, defining and naming themes and producing the report [30].
Data familiarization was initiated at an early stage when data were
listened carefully for several times, transcribed verbatim and trans-
lated into English. Open coding was commenced by two authors (SA
and IM) to generate the initial codes representing the study objec-
tives. These initial codes were then categorized and arranged to
generate the potential themes. The generated themes were then
reviewed and refined by all authors. Further analysis was per-
formed in next phase to generate clear definitions and phrase for
each theme. In the final stage, the report was drafted (all authors).
Cross checking of the emergent themes and conclusion was made
by the research team to ensure the data credibility. In case of any
conflict or disagreement, the decision of the senior authors (MA
and IMU) was considered final.
Results
A total of 15 interviews were conducted and the interview
duration ranged from 19 to 47 minutes with a mean duration of
28 minutes (SD = 8.5 min). Among the participants, 10 were males
and five were females. The age of interviewed pharmacists ranged
from 23 to 32 years (mean age = 26.13; SD = 2.41). The participants
had mean work experience of two years (SD = 1.4). The demo-
graphic characteristics of the respondents are outlined in Table 1.
The analysis of the data yielded five overarching themes, includ-
ing knowledge about the irrational use of antibiotics, initiatives to
restrict the irrational use, familiarity with the ASP, current prac-
tices and suggestions for the implementation of the ASP. Themes
were characterized by 16 subthemes to best capture the diversity
of participants’ perspectives. The emerged themes, subthemes and
exemplar quotations are illustrated in Table 2.
Theme 1: Knowledge about irrational use of antibiotics
All respondents had the appropriate knowledge about the irra-
tional use of antibiotics. The respondents pointed out a number
120 M. Atif et al. / Journal of Infection and Public Health 13 (2020) 118–124

Table 1
Demographic characteristics of participants.

Respondent Gender Age (years) Experience (years) Interview duration (minutes)

Respondent A Female 24 2 34
Respondent B Male 25 3 29
Respondent C Female 25 1 23
Respondent D Male 26 2 22
Respondent E Male 27 1.5 47
Respondent F Male 24 2 22
Respondent G Female 24 1 23
Respondent H Male 26 2.5 26
Respondent I Female 23 1 26
Respondent J Male 28 2 30
Respondent K Male 27 2 19
Respondent L Male 25 1.5 29
Respondent M Male 30 6 24
Respondent N Female 26 2 24
Respondent O Male 32 5 47
Mean duration 28

of aspects involved in the irrational use of antibiotics, including
overuse, underuse, self-medication, improper selection of antibi-
otics and not following the prescription guidelines.
Theme 2: Initiatives to restrict the irrational use of
antibiotics
Many initiatives were suggested by the respondents to ratio-
nalize the use of antibiotics, including evidence-based therapy,
avoidance of broad-spectrum antibiotics, rationalization of pre-
scription and monitoring of antibacterial therapy. According to the
respondents, an empiric therapy based on the physicians’ experi-
ence should be avoided. Instead, antibiotics should be prescribed
after culture and sensitivity testing.
be devised and implemented effectively. Along with the train-
ing of pharmacists, the general public should be educated on the
appropriate use of medicines. Medication compliance should be
assured by the proper counseling of the patients. Moreover, the
national good pharmacy practice guidelines should be developed
and implemented to rationalize the therapy according to the ASP
principles.
The participants further stated that the government should
sponsor the research projects to find the recent trends in antibi-
otic use and antibiotic resistance, and the they further stated that
the availability of qualified persons (pharmacist) should be assured
at all community pharmacy settings.
Discussion

Theme 3: Familiarity with the Antibiotic Stewardship

Program
The familiarity with the ASP was the third emergent theme of
this study. This program was a new concept for most of the study
participants. However, after explaining the phenomenon to them,
the respondents revealed a great interest in ASP activities. Accord-
ing to them, community pharmacists can be a major role player in
the stewardship programs.
Theme 4: Current practices of the Antibiotic Stewardship
Program
Almost all respondents stated that it is almost impossible to
implement ASP components in Pakistani healthcare settings. Pre-
scribing practices cannot be followed due to lack of patient records
and the unwillingness of the physicians to cooperate because the
physicians do not like any check on their prescribing practices. In
pharmacies, the percentages of antibiotics dispensed per month
were only considered for procurement purposes and to maintain
the stock at the pharmacy. The patients were never asked about
any complications or side effects of therapy. The study participants
reported that only a few patients were educated per day about the
appropriate use of antibiotics due to patient overload and absence
of patient records.
Theme 5: Suggestions for the implementation of the
Antibiotic Stewardship Program
The participants were asked to give suggestions for the imple-
mentation of ASP to minimize the irrational use of antibiotics. The
respondents stated that prescription monitoring system should
The judicious use of antibiotics is crucial to preserve the efficacy
of these agents against infectious diseases. Antibiotic stewardship
provides the basis for their rational use and should be viewed
as a safety initiative for patient and public health [22]. Commu-
nity pharmacists have a responsibility to take prominent roles in
infection control programs because patients can easily approach
them at drug retail outlets. Although community pharmacists had
appropriate knowledge about antibiotics and their rational use, the
current study highlighted that the community pharmacists did not
adopt the modern strategies like antibiotic stewardship to ratio-
nalize the antimicrobial therapy. This study provides a first detailed
insight regarding the knowledge, perceptions and current practices
of community pharmacists towards ASP in Pakistan.
The results of this study indicated that the community phar-
macists had adequate knowledge about the irrational use of
antibiotics. A number of strategic initiatives such as definitive
antimicrobial therapy, monitoring the prescribing practices and
limited use of broad spectrum antibiotics were suggested by the
respondents to rationalize the antimicrobial therapy and to limit
the consequences of inappropriate use of antibiotics. These find-
ings are consistent with the findings of previous studies conducted
in Syria and Pakistan [2,19]. However, it was noted that this
above par knowledge could not be translated into practices that
can inhibit the inappropriate use of antibiotics or decrease the
propagating resistant infections. File and co-workers stated that
inappropriate antibacterial therapy was associated with a pro-
longed hospital stay, increased rates of clinical failure, requirement
for additional antimicrobial therapy, increased cost and higher
death rates [31]. Another study highlighted that indiscriminate use
of broad-spectrum empirical antibiotics was associated with an
increased risk of adverse events and the development of antimi-
crobial resistance [32].
 M. Atif et al. / Journal of Infection and Public Health 13 (2020) 118–124 121

Table 2
Respondents’ views about the Antibiotic Stewardship Program; themes, subthemes and exemplar quotations.

Themes and subthemes Quotes

Theme 1: Knowledge about the irrational use

of antibiotics
Knowledge about the term “Irrational” “Yes, irrational use is that when prescription is not written in proper hand writing, medicines written
are not readable. There are interactions in written medicines or the dose, time, administration of drug
or the patient is not right”. (Respondent G)
“Irrational use of medicine includes overuse, misuse, underuse, use without prescription and
self-diagnosing. These all are included in irrational use”. (Respondent J)
Theme 2: Initiatives to restrict the irrational
use of antibiotics
Avoidance of broad spectrum antibiotics “A definitive therapy should be used for antibiotics. If we expose the germs with broad spectrum
antibiotics earlier without any culture test, it will cause hazardous effects. If we decide after proper
culture test and then diagnose the causative agent and use the appropriate antibacterial agent, this will
lead to the rational use. But here no trend like this exists. In Pakistan, we just see some indications and
decide whether it would be Gram negative or Gram positive bacteria”. (Respondent O)
“Broad spectrum antibiotics should be avoided. Here in Pakistan, doctors start with high levels of
antibiotics instead of writing 1st generations. In developed countries this is not the case. In developed
countries doctor always start with 1st generations then move to higher ones so resistance cannot
develop. But here in Pakistan doctor starts with 3rd or 4th generation”. (Respondent J)
Rationalize the prescription “Prescription should be rationalized. If a patient comes with a prescription, written with those
medicines which were not required in his condition or a different combination was given in which
drugs have interaction. The prescription is not standardized according to guidelines then leading to
irrational use of antibiotics”. (Respondent E)
“Irrational prescribing of antibiotics is very common in our healthcare system. Doctors write antibiotics
even when these are not required mean without any clinical indications. Sometimes dose or dosing
schedule is also not accurate. To make the antibacterial therapy rational, prescription should be focused
and made appropriate”. (Respondent J)
Monitoring the therapy “Antibiotic therapy should be monitored to overcome the compliance issues as in DOTs (directly
observed treatment, short-course) therapy for TB (tuberculosis) leads to improved results. Similarly
monitoring of therapy will lead to the improvement in rational use of antibiotics”. (Respondent K)
Theme 3: Familiarity with the Antibiotic
Stewardship Program
Awareness of the program “No I had not heard the term. I am not aware of it. This is new thing for me and I heard it for the 1st
time” (Respondent E)
The program perspectives were explained to the
respondents who did not know about antibiotic
stewardship
Theme 4: Current practices of the Antibiotic
Stewardship Program
Monitoring the prescribing practices “In antibiotic stewardship program, main thing is strict monitoring and supervision of prescribing
practices. However, to track the prescribing practices you must have patient record and electronic data
and in Pakistan, data is not available. So implementation of antibiotic stewardship program at my
setting is very difficult or almost impossible”. (Respondent N)
“Here is no trend of monitoring the prescribing practices because there is no collaboration between
community pharmacists and prescribing bodies. Physicians do not like any check on their prescribing
practices. They even do not answer properly”. (Respondent L)
Tracking the use of antibiotics “Antibiotics sold per month cannot be tracked out because of patient overload and absence of patient
records. We just consider the percentage of antibiotics dispensed per month for our stock management
or procurement purposes not for tracking and making summaries of use”. (Respondent E)
“I tried to do that and you will be astonished to hear that antibiotics are used in Bahawalpur as candies.
If I received 100 prescriptions, you will be surprised to hear that 80% of them contain antibiotics written
and this is a big dilemma”. (Respondent J)
“Here community pharmacy profession is adopted as a business, not as a welfare system for health.
People are taking it just as a business and they are providing everything they get in hand. Dispensers
have no concern to guide the patients. Selfishness, business orientation and no incorporation of
pharmacist are major hurdles so use of medicines cannot be tracked out”. (Respondent L)
Follow-up activities “No, I never contacted the patient for follow-up or asking about the side effects or to ask about any
complication. The reason is that we do not have patient records and their contact details. Here is no
trend of such activities. Patients even do not come to only one pharmacy. They purchase medicines
from where they want”. (Respondent A)
Counseling about antibiotics use “If 100 patients are visiting the pharmacy only 10-15% patients are those who listen if we tell them I am
pharmacist. People do not know about the pharmacist although pharmacist tag is present. They think
we are manger or data entry operator. Illiterate people have no concept about this”. (Respondent D)
“About side affects you know well that WHO also has concerns whether these should be told or not.
Generally we do not tell more about side effects as patients feel these side effects even if they are not
occurring”. (Respondent E)
“We try to guide the people about the use of antibiotics. Some people ask questions about their
medicines. Educated people mostly ask about these things. Illiterate people do not have any idea about
that”. (Respondent D)
Theme 5: Suggestions for the implementation
of the Antibiotic Stewardship Program
Training “Government should introduce training courses for pharmacist to act better in patient management
and in rationalize use of medicines especially for antibiotics. Workshops and seminars can be arranged
by the government and NGOs (non-governmental organizations) time by time. . ..”.(Respondent K)
“It can be done if training system is present according to current needs and stakeholders take part in
these training systems actively”. (Respondent D)
122 M. Atif et al. / Journal of Infection and Public Health 13 (2020) 118–124
Table 2 (Continued)
Themes and subthemes
Patient education
National good pharmacy practice guidelines and
their implementation
Medication reconciliation
Research
Availability of community pharmacist
Awareness of newer trends in antibacterial
therapy
The findings of the current study demonstrated a lack of aware-
ness about ASP among the community pharmacists. These findings
are in line with a study conducted in England, where community
pharmacists were generally unaware of any stewardship initiatives
from within and outside of the community pharmacy settings [33].
The majority of our study participants had never heard of the term
“antibiotic stewardship”. Despite this lack of awareness, when the
term was explained to them, they believed that they had a role
in monitoring the antimicrobial therapy and in the education of
the general public about the appropriate use of antibiotics. Simi-
lar results were shown in a previous study conducted in Malaysia
where community pharmacists were eager to take part in ASP and
recognized the importance of this program [4]. According to our
study participants, surveillance of antibiotic use practices in Pak-
istani community was not possible due to lack of access to patient
medical records. This might be possibly associated with absence
of medication reconciliation practices in the country [4] and the
same was reported in our study. Improved communication among
the healthcare professionals could significantly assist in optimiz-
ing the use of antibiotics and is an essential feature of ASP [34].
Similar implications were suggested in a previous Pakistani study
which stated that the healthcare professionals should work within
multi-disciplinary teams to reduce the problem of antimicrobial
resistance and improve the quality of life of patients [12].
Similar to the findings of Rehman et al., our respondents were
of the opinion that suitable training of community pharmacists is
necessary for the successful implementation of ASP [12]. Accord-
ing to the respondents, stewardship programs should be initiated
in all community pharmacy and institutional settings, and antibi-
otic competency and training programs should be offered to the
Quotes
“General public training is necessary. Public can wait at doctor’s clinic even for hours but at pharmacy
if they have to wait for 5 minutes they are about to die”. (Respondent A)
“Patients should be guided about completion of therapy. Blister packing should be stopped and
complete bottle should be dispensed and sold which contain complete course of therapy. When the
patients will purchase medicine by spending money then they tend to complete the therapy as they had
spent money on it”. (Respondent B)
“Patient guidance material can be used such as display cards or pictures to make the patients
understand in better way”. (Respondent E)
“Policies and rules at national as well as institutional levels should be devised for good pharmacy
practice. It may involve existing global antibiotic ASP guidelines or develop their own ones. These rules
should be implanted by the government. Some guidelines are present but these are not implemented. If
these will be implemented then system will improve”. (Respondent D)
“Pharmacy practice guidelines provided by the WHO and other organizations should be introduced at
national level including the supply of quality medicines with appropriate guidance and resolving
economic issue”. (Respondent I)
“The concept of prescription assessment and check for errors in prescribed medicines should be
introduced at community pharmacies. Pharmacist is a qualified person to perform these tasks and to
improve the patient health”. (Respondent M)
“Dose, dosing frequency, interactions, side effects and then discussion about these things if there is any
problem with the physician is necessary to perform the monitoring of therapy which is an essential part
of stewardship as you explained” (Respondent J)
“I had seen in a report from India that by 2025 the whole India will be resistant to antibiotics. If India is
going to be resistant by 2025 then in Pakistan it will be earlier. We are such a nation which does not
have data that how many patients are resistant to which antibiotics. We must have data. The
government should sponsor the research projects for finding facts about this serious issue. Rules and
regulations should be made and implemented properly”. (Respondent E)
“Pharmacist should be available at every community set-up. Awareness should be increased among the
community. Campaigns should be arranged. There is an urgent need to educate the general public
about the role of pharmacist and appropriate use of antibiotics”. (Respondent D)
“Pharmacist duty timing should be increased and availability should be assured for all the time when
pharmacy is opened”. (Respondent H)
“Pharmacists should have sound knowledge about ASP. Only then they can take part in tracking and
monitoring strategies for the proper use of antibiotics. Community pharmacists should keep them up-to
date with newer global campaigns and international trends to play their role in effective patient
management”. (Respondent O)
“Community pharmacists should follow the good practice guidelines provided by the international and
national organizations and perform expanded activities of pharmacist at community settings. This will
be helpful in implementation of ASP strategies”. (Respondent I)
healthcare professionals. This finding indicates that antimicrobial
awareness seminars and workshops were not offered to healthcare
professionals in Pakistan. This is contrary to the findings of stud-
ies conducted in many countries where these seminars were held
regularly [4,9,35,36]. Our respondents advocated the organization
of conferences, workshops and seminars for the community phar-
macists to build their competency for the active involvement in
the ASP and antibiotic surveillance. These findings are similar to
the findings of an Ethiopian study in which 90.5% of pharmacists
suggested such training programs [35].
Knowledge of antibiotic resistance patterns, increased aware-
ness about latest treatment guidelines, effective patient counseling
and monitoring the antibiotic use patterns were the important
strategies suggested by our respondents as a part of community-
based ASP. According to them, community pharmacists are suitable
healthcare providers to handle the vast majority of patient-initiated
consultations, and should be more systematically involved in a
triage-type role on the front line. The participants of the current
study emphasized that the presence of community pharmacists
should be assured at drug retail outlets so that the patients in the
community are able to seek advices about their health issues [37].
The strength of the present study is that it highlighted a health
policy issue in which the availability of evidence-based literature is
very limited, especially from developing countries. This study has
a few limitations as well. First, we used the convenience sampling
strategy to recruit the study participants. The random selection of
study participant was not possible because only a limited number of
pharmacies in Bahawalpur render the services of pharmacists and
some of the pharmacists were not willing to talk, possibly because
of their lack of knowledge about ASP. Therefore, those who were
 M. Atif et al. / Journal of Infection and Public Health 13 (2020) 118–124
willing to participate in the study were selected. Second, the find-
ings of this study may not be generalized for the whole of Pakistan
because this study was conducted in one city. However, since a
uniform healthcare policy is implemented throughout the country
and availability of pharmacists at retail drug outlets is scarce in the
country, therefore, our findings provide an insight of what is hap-
pening in the country. Third, the age of the participants ranged from
23 to 32 years with a mean age of 26 years. One might argue that
the study participants are relatively young with little experience.
In Pakistan, the concept of the presence of pharmacists at commu-
nity pharmacies is relatively new. Most of the drug retail outlets are
run without the presence of a pharmacist. For the past few years,
the government is trying to enforce the pharmacy rules. As a result,
some of the pharmacy owners have now employed pharmacists
at their businesses. However, because this is a new dimension of
the pharmacy profession in Pakistan, therefore, relatively a young
lot of pharmacists are available in community pharmacy settings,
though there could be very few exceptions where senior commu-
nity pharmacists are available.
Implications for practice and research
The study will contribute to the literature by addressing the cur-
rent status and future prospects of ASP at community pharmacies
in Pakistan. Besides the implication of this study to literature, the
findings warrant the active considerations by policy makers, who
may need to put legislation to introduce the ASP at community
settings in Pakistan. In practice terms, training and involvement of
community pharmacists with regard to ASP are necessary to mini-
mize the escalating antimicrobial resistance issue. Measures should
be taken to improve the collaboration among different healthcare
professionals becasue implementation of ASP requires the exten-
sive team efforts and interdisciplinary correlation among different
healthcare professionals. Future interventional studies are needed
to assess the effects of ASP on patient health outcomes. Moreover,
the effects of any intervention are needed to be evaluated in a range
of pharmacy settings. It will also be important to capture the view
point of all target audiences such as physicians, pharmacists, gen-
eral public and policy makers to understand the potential barriers
and facilitators for implementation of this program in the country.
Conclusion
Most of the study participants were unaware of any ASP being
offered in the community settings. Though they agreed to be the
antibiotic stewards, but according to them there are many obsta-
cles in this. Training of pharmacists, medication reconciliations,
multi-disciplinary team efforts, implementation of good pharmacy
practice guidelines and the availability of pharmacists at all drug
retail outlets were few suggestions given by the study participants
to incorporate ASP in the community pharmacy settings.
Authors’ contributions
SA and MA contributed in conception and design; SA collected
data; All authors contributed in data analysis and interpretations;
IMU lead the data analysis and interpretations; IMU, IM and SA
drafted manuscript; MA critically revised manuscript; All authors
have read and approved the final manuscript.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
123
Ethical approval
The approval for the conduct of study was obtained by the Phar-
macy Research Ethics Committee (PREC) at the Islamia University
Bahawalpur (Reference: 41/S-2018-/PREC, dated May 31, 2018)
and permission to conduct research at community pharmacies was
obtained from the Drug Controller, Bahawalpur.
Competing interests
None declared.
Availability of data
The datasets used and analyzed during the current study are
available from the corresponding author on request.
Acknowledgements
We would like to thank the respondents for their participation.
Appendix A. Supplementary data
Supplementary material related to this article can be found,
in the online version, at doi:https://doi.org/10.1016/j.jiph.2019.07.
003.
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