Skin diseases are among the most common health problem worldwide which affect around 30 to 70 % of individuals in the United States [1]. Although most of the skin diseases are non-fatal, but they are considered to cause burden on health status as well as quality of life (QOL) [2]. Bacterial skin infection being one of them is usually caused by the invasion of pathogens through the skin flora [3]. In this case, topical antibacterial drug play a vital role to either kills or inhibits the growth of the bacterial [4]. Rod Tucker studied that, topical antibacterial drugs are commonly sought in the community pharmacies, with the empowerment of patient to self-medicate, CPs play a valuable role in gatekeeping these medications and ensure their proper usage [5,6]. The role played by CPs in gatekeeping these medications is very important as inappropriate usage of topical antibacterial drugs has been recognized as one of the factor that leads to antibacterial resistances [7].

According to WHO, CPs should possess specific attitudes, knowledge and skills to support their roles in patient care [6]. Besides that, study also showed that proper and consistent patient counselling will result in the improvement of patient’s understanding about the medication and consequently improve patient’s adherence [8]. In short, CPs must be competent enough in dealing with topical antibacterial drugs as antibacterial resistances worsen by the lack of the development of more potent antibacterial drugs has urge the important to reserve the potency of existing antibacterial drugs [9,10]. Presently, very limited studies have been conducted on the way CPs dispense topical antibacterial drugs. Therefore, the objective of this study was to access the perceptions and experiences of CPs in Kedah state, Malaysia on the dispensing of topical antibacterial drugs.

Study design and population

A cross-sectional study carried out using randomized sampling method. The study was conducted in Kedah State, Malaysia, from June to October 2014 with a validated self-administered questionnaires were distributed to the CPs. A sample size of 101 participants was determined by Krejcie & Morgan formula. However, 103 of CPs had participated in this study. CPs in Kedah, Malaysia, who have 2 years or more pharmacy practice experience and who volunteered to participate were included in this study.

Questionnaire development and validation

A questionnaire with three sections (demogra-phy of participants, perceptions of community pharmacists on the dispensing of topical antibacterial drugs and experiences of community pharmacists in the dispensing of topical antibacterial drugs) was developed and used as a data collection tools in this study. A pilot study was carried out among 30 CPs to validate the questionnaire whose data were not included in this study.

Ethical considerations

IMU-Joint Committee of Research and Ethic Committee, International Medical University approved the study (no. BP I-01/11 (49) 2014).

Statistical analysis

Qualitative data obtained from this study was analysed using statistical package for social sciences (SPSS version 18.0) and analysed descriptively while open questions were coded into themes and analysed descriptively. The results are expressed in terms of frequencies, proportion, and percentages since categorical variables and Likert scales were used extensively in the questionnaires. Spearman’s correlation coefficient was applied to analyze the degree of relationship between years of experience and confidence level. P < 0.05 was considered statistically significant.

Demographics of participants

A total of 103 completed questionnaires were collected from the CPs in Kedah State, Malaysia. The mean age of participants was 36 years. More than 50 % of them were female. The ethnic groups of the participants were Chinese (59.2 %), Malay (33.0 %) and Indian (7.8 %). The participants were having a median of 9 years of pharmacy practices experiences and most of them were graduated from public universities (61.2 %). shows the demographic data of the participants.

Perceptions of community pharmacists on topical antibacterial drug dispensing

More than half of the participating CPs (55/103 or 53.4 %) perceived that topical antibacterial drug was not a must for every topical bacterial infection. CPs identified the following three factors as the main factors influencing their dispensing of topical antibacterial drugs: (1) previous clinical experiences (35 %), (2) practice guidelines (27.2 %) and (3) cost of medications (19.4 %). Besides that, most of them (84/103 or 81.6 %) did not support to switch topical antibacterial drugs to OTC products. CPs in Kedah state perceived that patient’s information gathering using WWHAM mnemonic as well as patient counselling were important whereby the result was as shown in .

Experiences of community pharmacists on topical antibacterial drug dispensing

When CPs were asked to identify the most frequently dispensed topical antibacterial drugs, fusidic acid (31.1 %) was found to be the highest, followed by neomycin (25.2 %) and mupirocin (20.4 %) as shown in . Besides that, CPs also identified the most common bacterial skin infections to be superficial wounds (21.30 %), conjunctivitis (17.52 %) as well as bed sores/ pressure sores (13.74 %) as shown in . On top of that, majority of CPs in Kedah state prefer to dispense single topical antibacterial drugs and occasionally combinations with steroids. The main reason for them to dispense topical antibacterial drugs combinations was identified to be due to the cost-effectiveness of the products. The result was as shown in .

In response to the questions related to CPs’ confidence in distinguishing topical bacterial infections, patients’ counselling as well as dispensing appropriately, they responded using a 5 point scale where 1 = not confident at all, and 5 = confident. The choices made by pharmacist were displayed as percentage shown in whereby most of the CPs in Kedah state showed confident in the activities mentioned previously.

Majority of CPs (62 %) did not encounter patient’s complaints of side effects of topical antibacterial drugs while 32 % stated that they did. The results obtained show that 12.6 % of CPs encountered antibacterial resistance issues but none of them reported to the respective authorities while 87.4 % did not encounter any; no CP reported any encountered resistance issue.

The result of this study provides an empirical view on the perceptions and experiences of CPs on the dispensing of topical antibacterial drugs in Kedah state, Malaysia. In this study, majority of the CPs perceived that topical antibacterial drug was not a must for every topical bacterial infection. This was supported by several studies which mentioned that topical antibacterial drug was not necessary to improve therapeutic outcomes since minor topical bacterial infections were usually self-limiting which can resolve with proper debridement and hygiene care [11-13]. Although more than half of the CPs in Kedah state had the right perceptions, however, there were still considerable number of them (46.6 %) had the opposite view. This may expose the patients’ to the unnecessary use of topical antibacterial drugs and eventually increased the risks of antibacterial resistances.

Besides that, majority of the CPs in Kedah state were of the opinion that topical antibacterial drugs should not be switched to OTC products. This was supported by several studies that stated when such drugs were made available over the counter, wider availability will increased the risk of drug misuse and consequently drive the emergence of antibacterial resistances [7,14]. Moreover, patient were often not well trained as healthcare professionals, they may make wrong self-diagnosis which leads to the treatment failure [14]. The result of this study implied that CPs were aware about the negative impacts that may cause by deregulating topical antibacterial drugs to OTC products.

On the other hand, gathering patients’ information before dispensing was very important as study stated that this would help in decision making [15]. Effective communication between CPs and patients not only enhanced the use of medications, it also ensure optimal therapeutic outcomes [16]. In this study, majority of the CPs felt that WWHAM mnemonics and patient counselling were important while dispensing topical antibacterial drugs. Nonetheless, WWHAM mnemonic was not purposely designate to establish the diagnosis of diseases, thus, CPs should always keep themselves up-to-date to have a strong basic knowledge on managing topical bacterial infections [15].

Based on the experiences of CPs in Kedah, the most frequently dispensed topical antibacterial drug was fusidic acid. Meanwhile, the most frequently encountered topical bacterial infection was identified to be superficial wounds. With Staphylococcus aureus being the ordinary pathogen in most of the infected wounds, fusidic acid had been suggested as an effective treatment by several studies [17,18]. Besides that, articles also supported that fusidic acid provides a relatively good penetration rate as it possessed a steroid like structure that enable it to maintain high concentration at the site of infections [17,18]. All these may explain why fusidic acid appeared to be the most frequent dispensed topical antibacterial drugs in Kedah state. However, studies had shown that increased and prolonged usage of topical fusidic acid treatment had led to the increase of antibacterial resistance rates which stressed the judicious use of topical antibacterial drugs by healthcare professional especially CPs [19-22].

Several topical antibacterial drugs had reported to show bacterial resistance by several studies, for instances, mupirocin, fusidic acid, clindamycin and neomycin [22-24]. In this study, CPs in Kedah state encountered antibacterial resistance issue with neomycin. The reason behind may be due to the frequent usage of neomycin as it appeared to be the second highest topical antibacterial drugs dispensed in community pharmacies. Studies claimed that the ability of neomycin to bind to the fatty acid of the skin was responsible for the emergences of antibacterial resistances as it enhances the survival of neomycin-resistant strains on the skin surface [24,25]. Although 12.60 % of CPs encountered antibacterial resistance issue, none of them reported the cases. This showed that CPs in Kedah state had low vigilance on antibacterial issue which may be due to the lack of knowledge on the reporting system available in Malaysia.

Limitations of the study

This study was a cross-sectional study carried out within a short period among community pharmacists in Kedah State and the sample size was small; thus, the results is not be sufficient to represent all CPs practicing in Malaysia. Besides, comparisons were not carried out due to the lack of previous studies on dispensing of topical antibacterial drugs in community pharmacy settings in Malaysia.

The findings of this study constitute important baseline data that may help in developing future topical antibacterial guidelines to improve dispensing practice and combat drug resistance issues in Malaysia. CPs should be vigilant to enable them detect bacterial resistance as they are suited for adverse event monitoring and reporting. Extended studies using random sampling technique in other states of Malaysia would be helpful in providing a clearer picture of this issue across community settings in Malaysia.