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Impact of Over-the-Counter Restrictions on Antibiotic Consumption in Brazil and Mexico
Open accessAbstract
BACKGROUND: In Latin American countries over-the-counter (OTC) dispensing of antibiotics is common. In 2010, both Mexico and Brazil implemented policies to enforce existing laws of restricting consumption of antibiotics only to patients presenting a prescription. The objective of the present study is therefore to evaluate the impact of OTC restrictions (2010) on antibiotics consumption in Brazil and Mexico. METHODS AND FINDINGS: Retail quarterly sales data in kilograms of oral and injectable antibiotics between January 2007 and June 2012 for Brazil and Mexico were obtained from IMS Health. The unit of analysis for antibiotics consumption was the defined daily dose per 1,000 inhabitants per day (DDD/TID) according to the WHO ATC classification system. Interrupted time series analysis was conducted using antihypertensives as reference group to account for changes occurring independently of the OTC restrictions directed at antibiotics. To reduce the effect of (a) seasonality and (b) autocorrelation, dummy variables and Prais-Winsten regression were used respectively. Between 2007 and 2012 total antibiotic usage increased in Brazil (from 5.7 to 8.5 DDD/TID, +49.3%) and decreased in Mexico (10.5 to 7.5 DDD/TID, -29.2%). Interrupted time series analysis showed a change in level of consumption of -1.35 DDD/TID (p<0.01) for Brazil and -1.17 DDD/TID (p<0.00) for Mexico. In Brazil the penicillins, sulfonamides and macrolides consumption had a decrease in level after the intervention of 0.64 DDD/TID (p = 0.02), 0.41 (p = 0.02) and 0.47 (p = 0.01) respectively. While in Mexico it was found that only penicillins and sulfonamides had significant changes in level of -0.86 DDD/TID (p<0.00) and -0.17 DDD/TID (p = 0.07). CONCLUSIONS: Despite different overall usage patterns of antibiotics in Brazil and Mexico, the effect of the OTC restrictions on antibiotics usage was similar. In Brazil the trend of increased usage of antibiotics was tempered after the OTC restrictions; in Mexico the trend of decreased usage was boosted.
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“A number of studies conducted in Zimbabwe, Chile, Colombia, Brazil, Mexico and Korea in addition to a study completed in Saudi Arabia found strict enforcement of existing laws to be effective in containing the non-prescribed antibiotics provision [61–65].”
From No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies (2021) · cites this paper as [63]
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Rationality of Antimicrobial Prescriptions in Community Pharmacy Users
Lima, S. I. V. C., Diniz, R. S., do Egito, E. S. T., de Azevedo, P. R. M., Oliveira, A. G., & de Araújo, I. B. (2015) · PLoS ONE · doi:10.1371/journal.pone.0141615 · Cited by 13
Nabeel, M., Ali, K., Sarwar, M. R., & Waheed, I. (2024) · PLoS ONE · doi:10.1371/journal.pone.0304361 · Cited by 17
“Studies from different regions of the globe predict the increasing problem of antimicrobial resistance as a negative outcome of DAwP [25, 26, 31–33].”
BackgroundHow law can help solve the collective action problem of antimicrobial resistance
Hoffman, S. J., Bakshi, R., & Katwyk, S. R. V. (2019) · Bioethics · doi:10.1111/bioe.12597 · Cited by 12
Lin, L. K., Alam, P., Fearon, E., & Hargreaves, J. (2020) · Implementation Science · doi:10.1186/s13012-020-01018-7 · Cited by 17
Belachew, S. A., Hall, L., & Selvey, L. A. (2023) · BMC Health Services Research · doi:10.1186/s12913-023-09819-4 · Cited by 11
Lami, F., Hameed, I., & Arbaji, A. K. (2018) · JMIR Public Health and Surveillance · doi:10.2196/10905 · Cited by 11
Tawfik, A. G., Abdelaziz, A., Omran, M., Rabie, K. A., Ahmed, A. F., & Abou‐Ali, A. (2020) · International Journal of Clinical Pharmacy · doi:10.1007/s11096-020-01203-0 · Cited by 11
“Reports from other countries also proved that restrictions and regulations on OTC drugs had a great impact on antibiotics consumption [69].”
BackgroundWaleekhachonloet, O., Rattanachotphanit, T., Limwattananon, C., Thammatacharee, N., & Limwattananon, S. (2021) · Pharmacy Practice · doi:10.18549/10.18549/pharmpract.2021.1.2201 · Cited by 11
Can over-the-counter antibiotics coerce people for self-medication with antibiotics?
Mandal, S. (2015) · Asian Pacific Journal of Tropical Disease · doi:10.1016/s2222-1808(15)60886-6 · Cited by 11
“Interestingly enough in Brazil the tendency of amplified practice of self-medication with antibiotics has been tempered, while in Mexico the trend of reduced usage of antibiotics has been improved on restricting OTC antibiotic usage[16].”
BackgroundSelf-Medication Practice in Mexico
Ortiz, M. I., Flores-Ceron, K. I., & Muñoz‐Pérez, V. M. (2022) · The Senior Care Pharmacist · doi:10.4140/tcp.n.2022.266 · Cited by 10
Yacelga-Gómez, J. J., Valenzuela-Madera, A. J., Chicaiza-Montero, J. F., Medina-León, J. A., & Cargua-Usca, A. M. (2025) · Revista Científica Ciencia y Método · doi:10.55813/gaea/rcym/v3/n4/94 · Cited by 9
“…gravedad y beneficios inmediatos, mientras que el enfoque de Determinantes Sociales de la Salud resalta el papel del nivel educativo, el ingreso económico y el acceso a servicios sanitarios como factores estructurales que la facilitan (Santa-Ana-Téllez et al., 2013; Flores-Torres et al., 2024).”
Saleh, H. A., Borg, M., Lundborg, C. S., & Saliba‐Gustafsson, E. A. (2022) · Antibiotics · doi:10.3390/antibiotics11050661 · Cited by 9
“In fact, in 2011, an estimated 19–100% of antibiotics used outside northern Europe and North America were consumed without a prescription [19], which led several countries to prohibit non-prescription use [19,20].”
BackgroundZhang, X., Jin, F., Lu, Y., Ni, F., Xu, Y., & Xia, W. (2022) · Infection and Drug Resistance · doi:10.2147/idr.s362601 · Cited by 9
“The high prevalence of negative blood cultures was usually associated with the antibiotic treatment given before the blood culture, the insufficient number of blood cultures submitted, highly fastidious bacterial or nonbacterial infections, and inadequate microbiological techniques.(37) In the present study, 75.”
BackgroundTörümküney, D., de la Torre, C., Langfeld, K., Lopez-Turrent, N. P., & Beltrame, C. O. (2022) · Journal of Antimicrobial Chemotherapy · doi:10.1093/jac/dkac216 · Cited by 8
Kopsidas, I., Kokkinidou, L., Petsiou, D., Kourkouni, Ε., Triantafyllou, C., Tsopela, G.-C., & Zaoutis, T. E. (2023) · Antimicrobial Stewardship & Healthcare Epidemiology · doi:10.1017/ash.2022.357 · Cited by 8
The Legislative Momentum of Antimicrobial Stewardship: An International Perspective
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Cross-border antibiotic resistance patterns in trauma patients
Berndtson, A. E., Bricker-Ford, R., Box, K. W., Madsen, G. Z., Malany, L. K., Smith, A. M., Costantini, T. W., & Coimbra, R. S. M. (2019) · Surgery · doi:10.1016/j.surg.2019.03.023 · Cited by 8
Aponte-González, J., Brown, P., & Eslava-Schmalbach, J. H. (2021) · Pharmacy Practice · doi:10.18549/pharmpract.2021.3.2401 · Cited by 6
Rojop, N., Moreno, P., Grajeda, L. M., Romero, J., Reynoso, L., Muñoz, E., Palmer, G. H., Cordón‐Rosales, C., Call, D. R., & Ramay, B. M. (2024) · BMC Pharmacology and Toxicology · doi:10.1186/s40360-023-00720-8 · Cited by 6
Mostafa‐Hedeab, G. (2018) · Asian Journal of Pharmaceutical and Clinical Research · doi:10.22159/ajpcr.2018.v11i8.26308 · Cited by 6
“This phenomenon is not limited to the developing countries, but it is also reported in many European countries as Spain, Greece, Portugal as well as Mexico, and Brazil [3-7] indicating the worldwide spread of this problem.”
BackgroundPrevalence and Associated Factors of Self-Medication with Antibiotics Worldwide: A Systematic Review
Saif, A., Khan, T. M., Bukhsh, A., Saif, A., Baig, M. R., & Tahir, H. (2024) · Archives of Pharmacy Practice · doi:10.51847/stw8psfrrv · Cited by 9
“In many Latin American countries, despite the restricted sale of over-the-counter medications, the policies are rarely enforced, and people tend to self-medicate frequently [10].”
Morberg, D. P., López, Y. A. A., Moreira, S., Prata, N., Riley, L. W., & Peña, M. S. B. (2019) · Public Health · doi:10.1016/j.puhe.2019.03.015 · Cited by 5
The Antimicrobial Resistance Crisis: How Neoliberalism Helps Microbes Dodge Our Drugs
Dutescu, I. A. (2020) · International Journal of Health Services · doi:10.1177/0020731420949823 · Cited by 5
Gornyk, D., Scharlach, M., Buhr-Riehm, B., Klett-Tammen, C. J., Eberhard, S., Stahmeyer, J. T., Großhennig, A., Smith, A., Meinicke, S., Bautsch, W., et al. (2021) · Frontiers in Pharmacology · doi:10.3389/fphar.2021.533248 · Cited by 5
Schiaffino, F., Colston, J. M., Olórtegui, M. P., Pinedo, S. R., Zamora-Babilonia, M., Asayag, C. R., Yori, P. P., & Kosek, M. N. (2022) · Clinical Infectious Diseases · doi:10.1093/cid/ciac500 · Cited by 5
“objective data support this assumption as universal [22].”
BackgroundTrade-offs between access and quality in healthcare: Evidence from retail clinics in Mexico
Rubli, A. (2023) · Journal of Public Economics · doi:10.1016/j.jpubeco.2023.104938 · Cited by 5
Antimicrobial Resistance Paradigm and One-Health Approach
Singh, K. S., Anand, S. K., Dholpuria, S., Sharma, J. K., & Shouche, Y. S. (2020) · Sustainable agriculture reviews · doi:10.1007/978-3-030-53024-2_1 · Cited by 5
Lajunen, T. J., Silva, L. S., & Sullman, M. J. M. (2025) · Antibiotics · doi:10.3390/antibiotics14111074 · Cited by 8
“Interrupted time-series analyses confirm that the 2010/2011 regulations reduced population-level antibiotic consumption, but long-term effectiveness has been limited by inconsistent enforcement and substitution with other medicines [7,8].”
Lim, A. H., Rahman, N. A., Ong, S. M., Azman, S. R. M., Rathi, F. Z. M., Ismail, M., Tok, P. S. K., Ho, B. K., & Sivasampu, S. (2024) · Journal of Pharmaceutical Policy and Practice · doi:10.1080/20523211.2024.2355666 · Cited by 4
“…despite the different overall usage patterns of antibiotics in these countries, the restrictions on sale of over the counter antibiotics had decreased the overall antibiotics consumption in these two countries by 1.35 and 1.17 DDD per 1000 inhabitants, respectively (Santa-Ana-Tellez et al., 2013).”
BackgroundInfluentialMedicines policy, access and use in Mexico: a systematic literature review 2000–2022
López, L. C. V., Gallegos, D. C., Borjas, D. M. B., & Wirtz, V. J. (2024) · Drugs in Context · doi:10.7573/dic.2023-7-3 · Cited by 4
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Self-citationAntibiotic surveillance: an action-oriented integrated approach
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Self-citationAlrasheed, M. A., Mansy, W., & Al-Arifi, M. N. (2024) · Saudi Pharmaceutical Journal · doi:10.1016/j.jsps.2024.102027 · Cited by 1
Netthong, R., Donsamak, S., John, D., Kane, R., & Armani, K. (2024) · Exploratory Research in Clinical and Social Pharmacy · doi:10.1016/j.rcsop.2024.100535 · Cited by 1
Metadata
- Authors
- Santa-Ana-Tellez, Y., Mantel-Teeuwisse, A. K., Dreser, A., Leufkens, H. G. M., & Wirtz, V. J.
- Affiliations
- Utrecht University (NL)
- Boston University (US)
- Corresponding author
- Mantel-Teeuwisse, Aukje K.
- Leufkens, Hubert G. M.
- Wirtz, Veronika J.
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2013-10-16
- Volume
- 8
- Issue
- 10
- Pages
- e75550
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3797702
- OpenAlex
- W1978318446
- Cited by
- 135
- References
- 13
- Citations by year
- 2026: 4 · 2025: 4 · 2024: 12 · 2023: 8 · 2022: 21 · 2021: 19 · 2020: 18 · 2019: 13 · 2018: 11 · 2017: 5 · 2016: 8 · 2015: 10 · 2014: 2
- FWCI
- 5.90
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- ZonMw
- College ter Beoordeling van Geneesmiddelen
- Consejo Nacional de Ciencia y Tecnología
- Top Institute Pharma
- Topics
- Health Sciences › Medicine › Infectious Diseases › Antibiotic Use and Resistance
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Pharmaceutical Economics and Policy
- Health Sciences › Medicine › Microbiology (medical) › Antibiotic Resistance in Bacteria
- Keywords
- antibiotic use, defined daily doses, penicillin, sulfonamides, macrolides, antimicrobial policy, Brazil, Mexico, Latin America
- MeSH terms
- Anti-Bacterial Agents, Brazil, Drug Utilization, Nonprescription Drugs, Humans, Mexico, Prescription Drug Misuse
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