Inappropriate antibiotic prescribing by online pharm...

"Scientists found antibiotics illegally available on 45% of websites they tested," the Mail Online reports.

This headline was prompted by research into 20 online pharmacies selling antibiotics to the UK public.

Researchers looked at whether the online pharmacy was properly registered – and therefore legal – as well as whether they required a prescription before selling the antibiotics and if safety information was provided.

The majority of sellers were not registered and therefore illegal. Most were thought to be based outside the UK, although half did not provide details on where they were based. Almost half did not require a prescription to purchase antibiotics.

The finding that the UK public are buying antibiotics from illegal unregistered prescribers is worrying, particularly when they can choose the specific antibiotic and dose themselves.

Because antibiotics have been overused and prescribed inappropriately, the drugs are losing their effectiveness at treating bacterial infections (antibiotic resistance). The more we use them, the greater the chance bacteria will become resistant to the drugs.

If the ticking timebomb of antibiotic resistance continues, we could end up in a world where previously trivial infections are untreatable.

It's important to use antibiotics in the right way – to use the right medicine, at the right dose, at the right time, for the right duration.

Always consult a GP or another health professional before taking antibiotics, and only take antibiotics and medication that has been specifically prescribed for you.

Where did the story come from?

The study was carried out by researchers from Imperial College Healthcare NHS Trust, the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, and the UCL School of Pharmacy, all in the UK.

It was funded by the National Institute for Health Research Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London, in partnership with Public Health England and Imperial College Healthcare NHS Trust and the Imperial National Institute for Health Research Biomedical Research Centre.

Three authors declared consulting for pharmaceutical companies, but state that the views expressed are their own.

The study was published in the peer-reviewed Journal of Antimicrobial Chemotherapy.

The UK media's reporting of the study was accurate.

Professor Dame Sally Davies, the government's chief medical officer, is quoted in the Mail Online as saying: "Clinicians across the country are making great progress in reducing inappropriate prescriptions, and this cannot be undermined by reckless illegal online pharmacies."

She added: "It is essential that we look after our antibiotics and only use them where clinically appropriate.

"Inappropriate use drives the development of drug-resistant infections, which could halt treatments and operations that we consider routine, such as hip operations, chemotherapy and caesareans."

What kind of research was this?

This cross-sectional analysis of data aimed to look at the quality and legal status of online pharmacies selling antibiotics to the UK public.

It aimed to describe the processes for obtaining antibiotics online and look at the approach to promoting and monitoring the use of antimicrobials, including antibiotics, and examine patient safety issues.

Cross-sectional analyses are good at looking at the overall picture at a specific point in time. But they can't show trends over time, so can't tell us if the quality and legality of online pharmacies and the process of obtaining antibiotics online is getting worse or better.

What did the research involve?

This was an exploratory cross-sectional analysis of a representative sample of online pharmacies with the overall aim of understanding the current state of online antibiotic sales in the UK.

A search for "buy antibiotics online" was done on Google and Yahoo, as researchers said these were two of the most popular search engines in the world.

They took 20 websites in total, including the first 10 identified from each search engine, that were in English and selling to consumers within the UK. They then looked to identify the country the website was operating from.

The researchers aimed to understand the state of online antibiotic sales in the UK.

They reviewed the 20 websites by:

assessing the quality and legal status of these online pharmacies using registration status as an indication of quality and legal status
identifying any Antibiotic Stewardship or patient safety issues
analysing the processes for purchasing online antibiotics, and if these were consumer-driven or prescriber-driven

Consumer-driven was described as whether the customer first selected an antibiotic of their choice to put in their online shopping basket.

Prescriber-driven was when the customer was directed through an online consultation after clicking on a specific illness, and an antibiotic was selected by the online prescriber if required.

What were the basic results?

Of the 20 websites selling antibiotics:

15 were not registered with the necessary bodies – the General Pharmaceutical Council (GPhC) in Great Britain or the UK Medicines and Healthcare products Regulatory Agency (MHRA), who also investigate websites suspected of operating illegally. Of these 15, three were operating from India, two from Cyprus, and the location was unclear for the rest. The five sellers registered with the GPhC and MHRA were all operating from the UK.
16 of the 20 websites were consumer-driven regarding antibiotic choice, dose and duration. This meant people could put the medicine in their shopping basket straight away without having an online consultation or providing a prescription.
9 of the 20 websites did not require a prescription before buying antibiotics.
14 of the 20 websites did provide information before purchase on safety and possible side effects, or when to avoid using antibiotics.

At the end of the study, all online providers found to be illegally selling antibiotics within the UK were reported to the MHRA.

How did the researchers interpret the results?

The researchers concluded: "Wide variation exists among online pharmacies in relation to antibiotic practices, highlighting considerable patient safety and antibiotic stewardship issues.

"Improved education, legislation, regulation and new best practice stewardship guidelines are urgently needed for online antibiotic suppliers."

They added: "In order to promote patient safety and preserve antibiotic therapy, an efficient and operational multidisciplinary taskforce is needed to address the issues we have identified."

Conclusion

Worryingly, most of the online pharmacies had no evidence of the registration required by current UK and European legislation.

This could be because some of the operators were based outside Europe – but regardless of where they are based, they are still subject to UK legislation if selling to the UK public.

The study raises concerns about the effectiveness of current UK legislation and the regulation of companies selling antibiotics over the internet.

This research does have some limitations, however:

Google and Yahoo searches are not identical when different browsers are used or when searches are performed at different times. This means other websites might have been identified at a different time.
Illegal sellers might change their name frequently to remain operational, so the same seller might have been identified more than once in this search under different names.
The researchers did not proceed to payment in their investigation of the sellers, so extra information on safety or prescribing might have been missed. Websites without information about requiring a prescription might have asked for one at a later stage or refused to prescribe antibiotics.

Aside from the clear safety issues, buying antibiotics online without a prescription can contribute to the growing problem of antibiotic resistance, where antibiotics are no longer effective against infections.

If you think you may need antibiotics, get advice from your GP or pharmacist. Your GP will prescribe medication, including antibiotics, if it is safe and appropriate to do so.

People can help fight the problem of antibiotic resistance by:

not buying antibiotics online
using antibiotics only when prescribed by a health professional
recognising that many coughs and colds, sore throats and stomach upsets are viral and do not need – and will not get better – with antibiotics
taking the full course of antibiotics as prescribed, even if you start to feel better
never sharing or passing on antibiotics to others

Sourcing antibiotics from a foreign country, especially without consultation with a GP, is not recommended.

Aside from the concerns mentioned above, the safety profile of the drug itself may not match the rigorous UK standards for pharmaceutical manufacturing.