Antibiotics are a major achievement in medicine and are vital for treating bacterial infections. However, in some regions, their availability over the counter (OTC) has sparked debates about the benefits and risks. While OTC antibiotics can enhance access to life-saving treatments, their misuse poses significant threats to future applications of medicine. This article explores the pros and cons of OTC antibiotics and the suggestions to combat the issue.
What Are Over-the-counter Antibiotics?
In many countries, antibiotics are regulated and require a prescription from a healthcare provider. However, in some parts of the world, antibiotics can be purchased without a prescription in stores. For example, in a study conducted by Moreno and colleagues in 2020, researchers assessed antibiotics’ availability in corner stores in Guatemala. They discovered that amoxicillin was the most widely available antibiotic, found in 246 out of 295 stores, which accounts for 83% of the surveyed locations. Additionally, tetracycline was the second most common antibiotic, present in 195 out of 295 stores, representing 66% of the total surveyed. However, the study examined the accessibility of antibiotics in corner stores in the areas researched. It is important to note that these findings may not reflect the entire situation in Guatemala. Healthcare disparities, lack of medical infrastructure, or economic necessity often drive this accessibility.
Over-the-counter antibiotics have some benefits, like increased accessibility, cost savings, and immediate relief, but they also have risks, like antibiotic resistance, allergic reactions, and disruption of gut bacteria.
Increased Accessibility
In regions with limited access to healthcare, OTC antibiotics can provide timely treatment for bacterial infections, preventing complications or fatalities. For instance, Saha and Hossain conducted a cross-sectional study in 2017 in Rajshahi, Bangladesh, to investigate the medicine dispensing patterns of pharmacies in the area. The researchers found that the highest-selling OTC medicines were antimicrobials. This suggests that in those areas, OTC antibiotics are saving lives by providing quick treatment for bacterial infections and preventing complications and fatalities.
Cost Savings
Avoiding consultation fees makes treatment more affordable for economically disadvantaged populations. For example, a mixed-method study by Barker and colleagues in 2017 surveyed pharmacy employees in Haryana, India, who provide OTC medications. This practice was more common among patients who had limited access to licensed physicians due to economic or logistical reasons. Many pharmacy employees felt pressured to provide shorter medication courses to less affluent clients, often dispensing only one or two days’ worth of antibiotics.
Immediate Relief
Patients can begin treatment promptly, with OTC antibiotics, potentially reducing the severity and duration of infections. For example, in the UK seven conditions such as sore throat, earache, sinusitis, impetigo, shingles, infected insect bites and uncomplicated urinary tract infections in women can be treated by walking straight into a chemist.
Risks of Over-the-Counter Antibiotics
Antibiotic Resistance
The greatest risk of OTC antibiotics is misuse, such as incorrect dosing, incomplete courses, or use for viral infections like the flu. This accelerates the development of antibiotic-resistant bacteria, a global public health crisis. For example, in a 2014 review by Tanwar and colleagues, researchers found that more and more bacteria are becoming resistant to several antibiotics. This resistance leads to the problem of multidrug-resistant (MDR) bacteria.
Reactions
Allergic reactions, side effects, or interactions with other medications may go unrecognised or unmanaged without professional oversight. For example, Antibiotics particularly beta-lactam such as (Penicillin and Cephalosporin) are some of the most common causes of antibiotic allergy. The reactions can vary in severity, ranging from mild skin rashes to more serious anaphylactic responses.
Disruption of Gut Bacteria
Indiscriminate use of antibiotics can harm beneficial gut bacteria. For example, a review conducted by Ramirez and colleagues in 2020 emphasised that the growing use of antibiotics is concerning as they disrupt gut microbiota. Studies now indicates that gut microbiota is essential for the normal development and functioning of the human body, particularly in priming and maturing the adaptive immune system.
How to Address the Over-the-Counter- Antibiotics
Public Education
Campaigns to inform the public about the dangers of misuse and the importance of completing prescribed courses promote knowledge on proper antibiotic uses. For example, a meta-analysis by Mallah and colleagues in 2022, which included data from 42 countries of varying socio-economic statuses, found that individuals misuse antibiotics regardless of their education level. Henceforth, the researcher suggested intervention programs to enhance the proper use of antibiotics should target all communities irrespective of their education level.
Strengthening Regulations
Implementing stricter regulations on antibiotic sales ensures that these medications are dispensed only with a prescription. For instance, many low- and middle-income countries are working towards making antibiotics available by prescription only. A systematic review conducted by Jacobs and colleagues in 2019 aimed to evaluate the interventions used to enforce existing legislation prohibiting over-the-counter (OTC) sales of antibiotics in these countries. However, the review found that the available data is limited and sparse.
Promoting Alternatives
Encouraging the development and use of rapid diagnostic tools to differentiate between bacterial and viral infections. For example, Tsao and colleagues in 2020 review potential protein biomarkers and host-derived gene expression signatures for distinguishing between bacterial and viral infections in children. The researchers concluded that rapid advancements in this field are likely to enhance paediatric care and further decrease global antibiotic overuse.
Global Collaboration
Initiatives like the World Health Organisation’s (WHO) Global Action Plan aim to combat antibiotic resistance by standardising policies and practices worldwide. For example, WHO policy Guidance on Integrated Antimicrobial stewardship activities which provide evidence-based and pragmatic recommendations on the issue.
Conclusion
While the accessibility of over-the-counter(OTC) antibiotics presents some benefits, the long-term risks often outweigh such benefits, especially regarding the promotion of antibiotic resistance. Finding a balance between accessibility and responsible use necessitates increased public awareness, stronger regulations, promoting alternatives and global cooperation. By implementing these measures, we can preserve the effectiveness of antibiotics for future generations.
References:
Barker, A. K., Brown, K., Ahsan, M., Sengupta, S., & Safdar, N. (2017). What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India. BMJ Open, 7(3), e013190. https://doi.org/10.1136/bmjopen-2016-013190
BBC, N. (n.d.). Seven conditions that your local chemist can now treat.
Jacobs, T. G., Robertson, J., van den Ham, H. A., Iwamoto, K., Bak Pedersen, H., & Mantel-Teeuwisse, A. K. (2019). Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review. BMC Health Services Research, 19(1), 536. https://doi.org/10.1186/s12913-019-4359-8
Mallah, N., Orsini, N., Figueiras, A., & Takkouche, B. (2022). Education level and misuse of antibiotics in the general population: a systematic review and dose–response meta-analysis. Antimicrobial Resistance & Infection Control, 11(1), 24. https://doi.org/10.1186/s13756-022-01063-5
Moreno, P., Cerón, A., Sosa, K., Morales, M., Grajeda, L. M., Lopez, M. R., McCraken, J. P., Cordón-Rosales, C., Palmer, G. H., Call, D. R., & Ramay, B. M. (2020). Availability of over-the-counter antibiotics in Guatemalan corner stores. PLOS ONE, 15(9), e0239873. https://doi.org/10.1371/journal.pone.0239873
Ramirez, J., Guarner, F., Bustos Fernandez, L., Maruy, A., Sdepanian, V. L., & Cohen, H. (2020). Antibiotics as Major Disruptors of Gut Microbiota. Frontiers in Cellular and Infection Microbiology, 10. https://doi.org/10.3389/fcimb.2020.572912
Saha, S., & Hossain, Md. T. (2017). Evaluation of medicines dispensing pattern of private pharmacies in Rajshahi, Bangladesh. BMC Health Services Research, 17(1), 136. https://doi.org/10.1186/s12913-017-2072-z
Tanwar, J., Das, S., Fatima, Z., & Hameed, S. (2014). Multidrug Resistance: An Emerging Crisis. Interdisciplinary Perspectives on Infectious Diseases, 2014, 1–7. https://doi.org/10.1155/2014/541340
Tsao, Y.-T., Tsai, Y.-H., Liao, W.-T., Shen, C.-J., Shen, C.-F., & Cheng, C.-M. (2020). Differential Markers of Bacterial and Viral Infections in Children for Point-of-Care Testing. Trends in Molecular Medicine, 26(12), 1118–1132. https://doi.org/10.1016/j.molmed.2020.09.004
World Health Organisation. (2021). WHO Policy Guidance On Integrated Antimicrobial Stewardship Activities.
© 2025 Dr Mukta Bhattarai Pandey (MD, PGDip Public Health, MRCP(UK), MRes)