A Simulated Client Study on Non-Prescription Antibiotic Sales and Counselling Practices in Iraqi Nurse-Led Clinics: Implications for Antimicrobial Resistance

Background: The inappropriate use of antibiotics is a major contributor to antimicrobial resistance (AMR), which is a critical issue in low and middle-income countries such as Iraq. Nurse-led clinics in Iraq are a common point of care for patients seeking treatment for infectious diseases; however, they are currently poorly regulated. This study aimed to assess the extent and appropriateness of antibiotic dispensing in this setting, including the quality of dispensing. In these clinics, only two antibiotics are legally permitted for dispensing. These are amoxicillin and erythromycin. The findings can be used to provide future guidance to improve antibiotic use in the country and reduce AMR where there are concerns. Methodology: A cross-sectional study was undertaken using simulated clients among 235 randomly selected nurse-led clinics in Iraq, presenting with a viral upper respiratory tract infection (URTI). The outcomes included the prevalence, type of antibiotics supplied, including their Access, Watch, and Reserve (AWaRe) classification, as well as the extent and quality of patient counselling. Descriptive statistics were used to summarise dispensing patterns and counselling practices. Multivariable logistic regression was also applied to assess associations between provider's characteristics and inappropriate antibiotic dispensing. Results: Antibiotics were supplied inappropriately in 60.0% (141/235) of the encounters, with 36.1% (85/235) of them involving antibiotics not legally permitted to be dispensed in these clinics. Amoxicillin/clavulanic acid accounted for 34.0% (48/141) of the antibiotics supplied. Based on their AWaRe classification, 25.5% (36/141) of these were Watch antibiotics. Only 24.8% of providers asked additional clinical questions, and allergy screening occurred in just 7.8% of cases. Clinics with higher-qualified staff were significantly less likely to dispense antibiotics. Conclusion: Widespread inappropriate and, in many cases, illegal antibiotic dispensing was observed in Iraqi nurse-led clinics, with limited patient assessment. These findings underscore the urgent need for enhanced antimicrobial stewardship, provider education, and regulatory enforcement to address AMR in Iraq.