Discussion

This study explored the practices, barriers, and facilitators associated with AMS in community pharmacies in Uyo, Akwa Ibom State, Nigeria. Additionally, it assessed the participants’ knowledge and perceptions regarding AMS.

The participants reported generally favorable practices related to AMS. Most pharmacists reported that they would not dispense antibiotics “just in case” nor accede to patient-specific demands for antimicrobials. However, about half of them admitted to dispensing broad-spectrum antibiotics in cases of diagnostic uncertainty. This practice of dispensing broad-spectrum antibiotics when diagnosis is uncertain supports earlier report of widespread use of fluoroquinolones and penicillins among residents of the city where the current study was conducted. ^{Reference Orebiyi, Usifoh, Udoh, Ebong, Ekuma and Awofisayo24} According to the authors, most antibiotics consumed were from the Watch category of the WHO AWaRe (Access, Watch, Reserve) classification, which has a higher resistance potential than the Access group. ^{Reference Orebiyi, Usifoh, Udoh, Ebong, Ekuma and Awofisayo24,25} Similarly, a nationwide study of antibiotic dispensing among community pharmacists revealed that cephalosporins, penicillins, and quinolones were the major classes of antibiotics dispensed. ^{Reference Gladys, Gabriella, Lawal, Bukola, Amaechi and Augustine26} Although most penicillins belong to the Access group, most cephalosporins and all quinolones generally fall under the Watch group. ²⁵ There is a need for antibiotic stewardship interventions aimed at educating community pharmacists about the WHO AWaRe classification of antibiotics and the importance of minimizing the dispensing of Watch-group antibiotics without a prescription or clear clinical indication. ^{Reference Belachew, Hall and Selvey27,Reference Santos Caxico-Vieira and da Silva Moura28} Targeted training has been reported to significantly improve dispensing appropriateness and reduce inappropriate antibiotic recommendations among community pharmacists. ^{Reference Santos Caxico-Vieira and da Silva Moura28}

Most of the participants in our study reported that they regularly educate patients on proper antimicrobial use and resistance-related issues. This contrasts with reports from Pakistan ^{Reference Nabeel, Ali, Sarwar and Waheed29} where community pharmacists seldom provided such counseling. Strengthening patient education with formal support and resources would amplify its impact, as reported in previous research. ^{Reference Mason, Trochez, Thomas, Babar, Hesso and Kayyali30}

The results of this study also indicate that most of the community pharmacists surveyed would encourage patients to run a sensitivity test before taking an antibiotic. This report supports findings from a previous study conducted in Western Nigeria, suggesting that community pharmacists in Nigeria understand the importance of a personalized treatment approach. ^{Reference Akande-Sholabi, Oyesiji and Adebisi31}

In our study, limited access to patient records for evaluating the appropriateness of prescribed antibiotics was the most commonly cited barrier to implementing AMS in community pharmacies, consistent with a previous study that also identified this as a barrier. ^{Reference Barakat and Abougalambou32} Most of our participants also reported that patient access to antimicrobials without a prescription poses a barrier to implementing AMS in community pharmacies. Unrestricted access to antimicrobials continues to pose a global barrier to attaining AMS goals, especially in low-and middle-income countries (LMICs). ^{Reference Belachew, Hall and Selvey27} This highlights the need for stricter enforcement on the rational and clinical use of antimicrobials in attaining these goals. Another major barrier identified was physicians’ resistance to pharmacists intervening in antibiotic selection or the dose/duration of prescribed antibiotics. This echoes findings from an Australian study which revealed that pharmacists and physicians rarely collaborated on concerns related to AMS. ^{Reference Saha, Kong, Thursky and Mazza33} It is crucial to develop and implement ongoing AMS education programs for healthcare professionals, including physicians, because AMS requires a multidisciplinary team effort across healthcare settings.

In spite of the importance of AMS education progrmmes, our study revealed that most of our participants had never attended a training on AMS. This gap likely reflects the limited integration of comprehensive AMS lectures in undergraduate pharmacy curricula in Nigeria. ^{Reference Abdu-Aguye, Barde, Yusuf, Lawal, Shehu and Mohammed34} This observation also mirrors findings from Australia, where pharmacists reported insufficient training to confidently engage in AMS programs. ^{Reference Rizvi, Thompson, Williams and Zaidi35}

Most pharmacists acknowledged AMR as a pressing issue in community pharmacies and recognized how a lack of microbiological diagnostics and non-prescription dispensing exacerbate AMR. Similar findings were reported by participants in a previous study. ^{Reference Al-Shami, Abubakar, Hussein, Hussin and Al-Shami36} The overall high awareness of participants on AMS aligns with findings from Pakistan, where pharmacists exhibited good general knowledge of AMS despite misconceptions regarding resistance drivers.Reference Hashmi, Muhammad, Hussain, Gajdács and Jamshed ²¹

Key facilitators of AMS in community pharmacies identified in our study were enhanced availability of pharmacy education programs on AMS, improved access to patients’ clinical data, public awareness initiatives that emphasize the role of community pharmacists in AMS, and stronger collaboration with physicians in hospitals. Globally, pharmacists in LMICs show willingness to adopt AMS practices when supported with training, diagnostic tools, and interprofessional collaboration. ^{Reference Raju, Srinivas and Siddalingegowda16,Reference Barakat and Abougalambou32} Interestingly, only a small minority felt that monetary compensation was a motivating factor, a mindset equally shared by community pharmacists in a survey done in Thailand.Reference Netthong, Kane and Ahmadi ³⁷ Most participants also reported that AMS in community pharmacies will enhance pharmacists’ job satisfaction. These findings suggest that while financial recognition may be beneficial, pharmacists’ commitment appears to be largely driven by professional responsibility and a sense of service. These findings also reflect a widespread professional eagerness to engage in AMS, consistent with a previous study that reported strong interest among Australian pharmacists in adopting stewardship roles in primary care. ^{Reference Saha, Kong, Thursky and Mazza33}

To our knowledge, this is the first study that evaluates the practices, facilitators, and barriers regarding AMS in community pharmacies in south-south Nigeria. Consequently, the findings offer locally relevant and actionable insights into AMS at the community level. However, several limitations should be noted. The cross-sectional design may limit causal inferences, and reliance on self-reported behaviors may be subject to social desirability bias. Furthermore, as the study was conducted in only one state, this may limit the generalizability of the findings.