Antimicrobial Stewardship Challenges in Rural South Africa: Non-Prescription Antibiotic Dispensing Dynamics

A cross-sectional study in a rural South African province found that 54.4% of pharmacy customers received at least one antibiotic and that 78.7% of those antibiotics were dispensed without a prescription — a magnitude of non-prescription access directly relevant to stewardship teams monitoring community antimicrobial-resistance pressure.

In exit interviews with 465 customers across independent, franchise, and chain community pharmacies, the study anchors these cross-sectional findings to primary-care and retail access points. The sample frame confirms a population-level prevalence: more than half of patients received antibiotics, and most of those were obtained without a prescription, quantifying a substantial local supply-side contribution to antibiotic exposure.

Leading drivers were prior antibiotic use (56.8% of those obtaining antibiotics without a prescription), long clinic waiting times (15.6%), and financial constraints (6.0%). Prior use fosters repeat self-medication, long waits incentivize bypassing primary-care visits, and out-of-pocket costs push patients toward retail purchase — together creating predictable demand- and access-driven pathways that amplify community-level selective pressure for resistance.

The authors propose mobilizing community pharmacists as a practical supply-side lever to reduce non-prescription dispensing and strengthen stewardship. Suggested interventions include supervised pharmacist prescribing for limited indications (for example, agreed short-course regimens for uncomplicated UTIs), pharmacy-led triage and short-course dispensing protocols at point-of-sale, and targeted patient education delivered at the counter to reduce repeat self-medication. Shifting supply-side practice toward these measures could align access with guideline-based indications and reduce community AMR pressure.

These high-confidence, primary-study findings prioritize immediate operational focus for clinicians, stewardship teams, and health-system planners in similar rural settings, and point to pharmacy workflows as a proximate target for intervention.