Antibiotic Use in Community Pharmacies Across Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Background: Dispensing of antibiotics without prescription is common in community pharmacies and drug outlets (CPDOs) in Sub-Saharan Africa (SSA) and is likely to contribute to the high regional burden of antimicrobial resistance (AMR), yet comprehensive evidence on the extent of this practice remains limited. This review aimed to quantify the prevalence of inappropriate antibiotic dispensing in CPDOs across SSA.

Methods: Scholarly databases up to April 2025 were systematically searched for empirical studies examining non-prescription antibiotic dispensing in CPDOs in SSA. Observational, mixed-methods, and randomized controlled studies conducted and published between 2015 and 2025 were eligible. Study quality was assessed using the CASP Cross-Sectional Studies checklist. Data on dispensing practices were analyzed using proportional meta-analysis with a random-effects model in R. The protocol was registered on the Open Science Framework (OSF ID: 10.17605/osf.io).

Results: Eighteen studies involving 2,298 CPDOs across eight SSA countries were included. The pooled prevalence of non-prescription antibiotic dispensing was 68% (95% CI: 63%–72%). Antibiotics were commonly dispensed without prescription for upper respiratory tract infections (45% encounters, 95% CI: 40%–50%) and acute diarrhea (36% encounters, 95% CI: 30%–43%). According to the WHO AWaRe classification, 36% of dispensed antibiotics were from the Access category, 22% from the Watch category, and 2% from the Reserve category.

Conclusion: Non-prescription antibiotic dispensing in CPDOs is widespread in SSA, frequently for self-limiting conditions. Integrating CPDOs into innovative national antimicrobial stewardship programs is necessary to address AMR in the region.