Non-prescription Antibiotic Dispensing in Community Pharmacies of Islamabad Capital Territory, Pakistan: A Simulated Client Study

BackgroundAntimicrobial resistance (AMR) is a major global health threat with a disproportionate burden in low-and middle-income countries.In Pakistan, rising antibiotic consumption and weak regulatory enforcement contribute to inappropriate antimicrobial use.Despite legal restrictions, community pharmacies frequently dispense antibiotics without a prescription, accelerating resistance. ObjectiveTo assess the prevalence, patterns of dispensing based on scenario type, and associated factors of nonprescription antibiotic dispensing in community pharmacies of Islamabad Capital Territory (ICT), Pakistan. MethodsA cross-sectional study using a simulated client methodology was conducted from December 2024 to November 2025.A simple random sample of 121 pharmacies was selected from 176 eligible outlets.Five trained volunteers presented standardized scenarios of upper respiratory tract infection (URTI), urinary tract infection (UTI), and gastrointestinal infection (GIT).The pharmacies were distributed approximately equally across scenarios, with 40 pharmacies assigned to the URTI scenario, 40 to the GIT scenario, and 41 to the UTI scenario.The prevalence, patterns, and associated factors of non-prescription antibiotic dispensing were all assessed directly from these simulated client encounters; data on dispensing practices, clinical inquiry, counselling, and antibiotic types were recorded immediately after each visit using a structured data collection form.Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 26 (Released 2019; IBM Corp., Armonk, New York, United States), with multivariate logistic regression to identify predictors of antibiotic dispensing. ResultsAntibiotics were dispensed without prescription in 101/121 (83.5%) of encounters, most frequently for URTI 39/40 (97.5%), followed by GIT 36/40 (90%) and UTI 26/41 (63.4%).In 72% of all cases, antibiotics were supplied immediately without patient request (demand level 1).Clinical assessment was inadequate: no staff inquired about drug allergies, and counselling was provided in only 14% of visits.Overall watch group antibiotics predominated, particularly ciprofloxacin (32.7%) and azithromycin (25.7%).Logistic regression identified clinical scenario as the only significant predictor of dispensing (p<0.01). ConclusionNon-prescription antibiotic dispensing in ICT is highly prevalent and antibiotics are readily accessible upon request.The widespread use of broad-spectrum antibiotics poses a significant risk for AMR.Strengthened regulatory enforcement, pharmacist accountability, and targeted antimicrobial stewardship interventions are urgently needed.