Non-prescription antimicrobial use worldwide: a systematic review.

Morgan DJ, Okeke IN, Laxminarayan R, Perencevich EN, Weisenberg S. Source

University of Maryland, School of Medicine, Baltimore, MD, USA. dmorgan@epi.umaryland.edu

Abstract
In much of the world antimicrobial drugs are sold without prescription or oversight by health-care professionals. The scale and effect of this practice is unknown. We systematically reviewed published works about non-prescription antimicrobials from 1970-2009, identifying 117 relevant articles. 35 community surveys from five continents showed that non-prescription use occurred worldwide and accounted for 19-100% of antimicrobial use outside of northern Europe and North America. Safety issues associated with non-prescription use included adverse drug reactions and masking of underlying infectious processes. Non-prescription use was common for non-bacterial disease, and antituberculosis drugs were available in many areas. Antimicrobial-resistant bacteria are common in communities with frequent non-prescription use. In a few settings, control efforts that included regulation decreased antimicrobial use and resistance. Non-prescription antimicrobial and antituberculosis use is common outside of North America and northern Europe and must be accounted for in public health efforts to reduce antimicrobial resistance.

Survey of non-prescribed use of antibiotics for children in an urban community in Mongolia

Abstract
Objective

To estimate the prevalence and identify the determinants of non-prescription use of antibiotics for children in Mongolia.
Methods

A community-based cross-sectional survey was undertaken in 10 subdistricts in Ulaanbaatar, Mongolias capital. We used a structured questionnaire to collect data from a random sample of 540 households with at least one child aged < 5 years. Logistic regression was used to identify factors associated with antibiotic misuse.
Findings

Of 503 participating caregivers, 71% were mothers; 42.3% (95% confidence interval, CI: 37.846.9) of caregivers had used non-prescribed antibiotics to treat symptoms in their child during the previous 6 months. Symptoms commonly treated were cough (84%), fever (66%), nasal discharge (65%) and sore throat (60%). Amoxicillin was the most commonly used antibiotic (58%). Pharmacies were the main source (86%) of non-prescribed antibiotics. Non-prescribed use by mothers was significantly associated with keeping

antibiotics at home (odds ratio, OR: 1.7; 95% CI: 1.042.79), caregiver self-medication (OR: 6.3; 95% CI: 3.810.5) and older child's age (OR: 1.02; 95% CI: 1.011.04). Caregivers with a better knowledge of antibiotics were less likely to give children non-prescribed antibiotics (OR: 0.7; 95% CI: 0.60.8).
Conclusion

The prevalence of non-prescribed antibiotic use for young children was high in Ulaanbaatar. Because such use leads to the spread of bacterial resistance to antibiotics and related health problems, our findings have important implications for public education and the enforcement of regulations regarding the sale of antibiotics in Mongolia.

Utilization of antimicrobial agents with and without prescription by out-patients in selected pharmacies in South-eastern Nigeria.
Esimone CO, Nworu CS, Udeogaranya OP. Source
Department of Pharmaceutics, Faculty of Pharmaceutical Sciences, University of Nigeria, Nsukka, 410001, Enugu State, Nigeria.

Abstract
OBJECTIVE: We conducted a study in out-patient pharmacies in South-eastern Nigeria in order to determine the extent of self-medication of antimicrobial agents in this area, assess the dosing error associated with this practice and to ascertain the extent of involvement of community pharmacies. METHOD: A survey was carried out daily in selected community pharmacies for a period of 90 days. Data were collected on the number of patients visiting these shops for antimicrobial agents, the number getting their medication with a prescription, the number getting their order without prescription and on the type and dose of antimicrobial agents received. MAIN OUT-COME MEASURE: The percentage of patients with prescription and without prescription was compared. The percentage under-dosages or over-dosages associated with how each antimicrobial agent was obtained were compared. The total DDDs of antimicrobial agents dispensed within this period with and without prescription were compared. RESULTS: A total of 4,128 outpatients visited the shops for antimicrobial agents within the period and were involved in the study. Of this number, 1,742 (42.2%) came with a prescription from qualified medical personnel and 2,386 (57.8%) came without a prescription. A total of 13,693.13 DDDs of antimicrobial agents was dispensed, of which 56.38% was dispensed with prescription and 43.62% was dispensed without prescription. The degrees of under-dosing were significantly (P < 0.05) higher in regimen filled without prescription when compared to those filled with prescription. CONCLUSION: Majority of the patients in this region still obtains their antimicrobial agents without a proper prescription, which is associated with sub-therapeutic dosing of these agents. There is a need for better regulation of antimicrobial agents dispensing and utilization in the region.

Rational antibiotic use and academic staff.

Cagri Buke A, Ermertcan S, Hosgor-Limoncu M, Ciceklioglu M, Eren S. Source
Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Ege University, Bornova Izmir, Turkey. cbuke@med.ege.edu.tr

Abstract
This study was devised to determine the knowledge, attitude and behaviour of an educated group of people towards antibiotic use and self-medication with antibiotics. Of 1380 members of academic staff (excluding those from the Faculty of Medicine) of Ege University, 602 were chosen by systematic sampling methods. Two groups were formed. Group A included academic staff from the Faculties of Dentistry and Pharmacy and Group B, members of all other faculties. The mean age was 37.4+/-11.0 and 47.0% were females. The mean antibiotic knowledge score was 7.16+/-3.32. Self-medication with antibiotics was admitted by 45.8% of the total samle and 15.6% of the respondents used antibiotics until their symptoms disappeared regardless of the period of prescription. In Group A 48.8% and in Group B 80.7% of the respondents believed that antibiotics could be used for common cold. It is concluded that priority should be given to knowledge-based behaviour education programmes for the more highly educated community; there must also be restriction on the sale of antibiotics without prescription.

Self-medication with antibiotics in Jordanian population.

Al-Azzam SI, Al-Husein BA, Alzoubi F, Masadeh MM, Al-Horani MA. Source
Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan. sayerazzam@yahoo.com

Abstract
OBJECTIVES: A survey was conducted to estimate the prevalence of self-medication with antibiotics in Jordan and evaluate the factors associated with antibiotic misuse. METHODS: Validated questionnaire was used to collect data from a sample of 1943 households (9281 persons) selected from among different cities in Jordan. RESULTS: 842 (39.5%) of 2133 antibiotic users identified via the survey had used antibiotics without a prescription within a one-month study period. Self-medication with antibiotics was found to be significantly associated with age, income, and level of education. The main reason for self-medication as reported by the participants was their previous experience on the efficacy of treatment. The main sources of antibiotics were the previously prescribed pharmaceuticals stored in the household and those purchased in pharmacies. CONCLUSION: The prevalence of self-medication with antibiotics in Jordan is alarmingly high. Given the growing global resistance to antibiotics and the documented health problems related to their inappropriate use, our findings may have major public health policy implications in Jordan.

Antibiotic use and health-seeking behaviour in an underprivileged area of Per.

Kristiansson C, Reilly M, Gotuzzo E, Rodriguez H, Bartoloni A, Thorson A, Falkenberg T, Bartalesi F, Tomson G, Larsson M. Source
Department of Public Health Science, Division of International Health (IHCAR), Karolinska Institutet, Stockholm, Sweden. charlotte.kristiansson@ki.se

Abstract
OBJECTIVE: To describe the health-seeking behaviour and use of antibiotics in the urban community of Yurimaguas in the Amazonian area of Peru. METHOD: Cross-sectional survey of caregivers of 798 children aged 6-72 months by interview using a semistructured questionnaire. Reported symptoms were classified as illnesses where antibiotics would or would not be recommended based on principles of the integrated management of childhood illnesses algorithm. RESULTS: Forty-one per cent of consultations were with health care professionals; 71% of antibiotics were obtained through the formal public health sector and prescribed mainly by medical doctors. All prescribed antibiotics were on the Peruvian essential drugs list. When prescribing, doctors and nurses hardly discriminated between illnesses where antibiotic treatment was or was not indicated; there was no significant difference in antibiotic prescribing rates between the two (doctors, P = 0.24; nurses, P = 0.32). Not all caregivers sought help for children with severe symptoms. CONCLUSION: Although most of the antibiotics were prescribed by doctors and nurses, they were commonly prescribed for illnesses where they were not indicated. The use of antibiotics needs to be rationalized, and barriers to health care must be overcome.

Availability of antibiotics as over-the-counter drugs in pharmacies: a threat to public health in Vietnam.

Van Duong D, Binns CW, Van Le T. Source
Hanoi School of Pharmacy, Vietnam.

Abstract
A survey on the use of antibiotics purchased through retail pharmacies was conducted in the Badinh district of Hanoi, Vietnam. The survey found that purchasers visit a pharmacy when they or those who felt they needed antibiotics had minor symptoms such as cough (34.1%), sore throat (32.5%), stomach upsets (10.0%) and diarrhoea (8.8%). The most often purchased antibiotics were ampicillin (31.1%), amoxyllin (16.7%), cotrimoxazol (11.6%), tetracycline (5.2%) and cephalexin (4.8%). The median of the purchased quantity was 10 tablets, the mean 11.34 tablets (95%CI 9.65-12.97). About 30% of the purchasers intended to take antibiotics for three days or less. The mean cost of a antibiotic purchase was US$1.27 (95%CI 1.06-1.39). The main reason for not taking a full course of antibiotics was not economic

constraint, but the purchasers' poor knowledge about antibiotics. Logistic regression analysis indicates that age of purchasers, length of symptoms and kinds of treatment used before visiting a pharmacy could be used as predictive variables for the decision to buy antibiotics in preference to alternative drugs. Antibiotics are used when illness lasts longer than one week and antibiotics have not yet been taken. Antibiotics are also purchased by young rather than old people. The study documents the need for better health education about the rational use of antibiotics in the general public.

Self-medication with antibiotics in rural population in Greece: a cross-sectional multicenter study

Eystathios Skliros, Panagiotis Merkouris, Athanasia Papazafiropoulou*, Aristofanis Gikas, George Matzouranis, Christos Papafragos, Ioannis Tsakanikas, Irene Zarbala, Alexios Vasibosis, Petroula Stamataki and Alexios Sotiropoulos

* Corresponding author: Athanasia Papazafiropoulou pathan@ath.forthnet.gr

Author Affiliations 3rd Department of Internal Medicine and Center of Diabetes, General Hospital of Nikaia "Ag. Panteleimon" - Piraeus, Greece, 3 D.Mantouvalou Street, GR-184 54 Nikaia, Greece For all author emails, please log on. BMC Family Practice 2010, 11:58 doi:10.1186/1471-2296-11-58

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2296/11/58

Received: 24 February 2010 Accepted: 8 August 2010 Published:8 August 2010

 2010 Skliros et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract
Background

Self-medication is an important driver of antimicrobial overuse as well as a worldwide problem. The aim of the present study was to estimate the use of antibiotics, without medical prescription, in a sample of rural population presenting in primary care in southern Greece.
Methods

The study included data from 1,139 randomly selected adults (545 men/594 women, mean age SD: 56.2 19.8 years), who visited the 6 rural Health Centres of southern Greece, between November 2009 and January 2010. The eligible participants were sought out on a one-to-one basis and asked to answer an anonymous questionnaire.
Results

Use of antibiotics within the past 12 months was reported by 888 participants (77.9%). 508 individuals (44.6%) reported that they had received antibiotics without medical prescription at least one time. The major source of self-medication was the pharmacy without prescription (76.2%). The antibiotics most frequently used for selfmedication were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the most frequent indications for the use of self-medicated antibiotics.

Conclusion

In Greece, despite the open and rapid access to primary care services, it appears that a high proportion of rural adult population use antibiotics without medical prescription preferably for fever and common cold. Background Since the introduction of penicillin, 60 years ago, antibiotics have played an important and crucial role in the treatment of infectious diseases, especially those caused by bacteria. However, the inappropriate use of those drugs has led to the phenomenon of antimicrobial resistance, which is becoming a worldwide public health problem [1,2]. Recent studies in Europe, including Greece, have showed high rates of outpatient antibiotic use and resistance [2-5]. In particular, a shift from the old narrow-spectrum antibiotics to the new broad-spectrum antibiotics was observed [3]. They also recorded seasonal fluctuations with heightened winter peaks in countries with high yearly use of antibiotics [3]. It is noteworthy, that our country had one of the highest uses of antimicrobial agents in ambulatory care [5]. Self-medication is an important driver of antimicrobial overuse, especially, in lowand middle-income countries, where antibiotics are easily obtained over the counter [1,6,7]. Studies showed that the prevalence of actual self-medication was high in eastern and southern Europe and low in northern and western Europe [8-10]. This studies showed that the most common reasons for self-medication were throat symptoms and bronchitis [8,10] while the main medication sources were pharmacies and medication leftover from previous prescriptions [8-10]. In Greece, the limited data concerning urban population indicate that the prevalence of self-medication is high[11,12]. However, data about self-medication in rural areas are lacking. Therefore, the aim of the present study was to evaluate the prevalence of selfmedication with antibiotics in rural population in Greece. Methods
Population

The study included data from 1,139 adults (545 men/594 women, mean age SD: 56.2 19.8 years), who visited the 6 rural Health Centres of southern Greece, between

November 2009 and January 2010. Physicians of the above Health Centres carried out the study. Physicians asked each consecutive patient to fill an anonymous questionnaire and to return it at the practice. The refusal rates were low. The questionnaire included items relating to demographic characteristics, overall use of antibiotics and self-medication with antibiotics. In particular, information about the type of antibiotics, the sources of self-medication, the symptoms for which the drugs were reportedly used, and duration of use were collected. The study was conducted in accordance with the 2004 amendment of the Declaration of Helsinki, the guidelines for Good Epidemiological Practice [13], and local regulatory requirements. The protocol was approved by the local ethics committee in each study area.
Statistical Analysis

Statistical analysis was preformed using programs available in the SPSS statistical package (SPSS 15.0, Chicago, USA). All variables were tested for normal distribution of the data. Data are shown as mean SD. A chi-square test was used for categorical variables. P < 0.05 (two-tailed) was considered statistically significant. Results Use of antibiotics within the past 12 months was reported by 888 participants (77.9%). 508 individuals (44.6%) reported that had received antibiotics without medical prescription at least one time in the past 12 months. The major source of selfmedication was the pharmacy without prescription (76.2%) followed by leftover medications at home (15.3%) and drugs obtained from relatives or friends (7.2%). The most frequently self-medicated antibiotics were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the most frequent indications for their use. Only 9.1% (57/630) of the participants who did not report self-medication with antibiotics, had stored drugs at home compared to 49.2% (250/508) of the participants

who reported self medication (P < 0.001). Finally, 31.5% of the participants reported earlier discontinuation of antibiotics when symptoms improved. Discussion Our results showed that the prevalence of self-medication with antibiotics in rural population in southern Greece was high. Our results are comparable to those of Jordan were 46% of patients reported antimicrobial self-medication [6]. However, antimicrobial drug self-medication prevalence varies widely among different European regions. Studies in Denmark and Spain showed that self drug consumption was 3% and 11% respectively[14,15]. In Malta and Lithuania the prevalence of selfmedication was 19% and 22% respectively [7,16]. A prospective survey of emergency department patients in the USA established that 17% of patients had taken leftover antibiotics without consulting a physician, most commonly for a cough (11%) or sore throat (42%) [17]. A recent study in Europe reported that Greece had one of the highest outpatient antibiotic uses in Europe with cephalosporins and macrolides being the most frequently used antibiotics [3]. Substantial variation in the prevalence rates of antimicrobial drug self-medication among the European regions suggests that socioeconomic factors play a role, as do disparities in health care systems such as reimbursement policies, access to health care, and drug dispensing policies [18]. Another factor is the acquisition of antimicrobial drugs from pharmacies without prescription, which occurred most frequently in eastern and southern European countries [18]. Although most of the responsibility regarding inappropriate antibiotic use belongs to the physicians' prescribing practices, several studies found that patients, too, contribute to inappropriate antibiotic usage [15,18]. Self-medication with antibiotics is possible via several sources: a) they are legally available over the counter, b) antibiotics initially prescribed by physicians are saved and subsequently used without medical consultation, c) antibiotics are obtained through friends or relatives, and d) they can be acquired via Internet [15,18]. In the present study the major source of self-medication was the pharmacy. It must be mentioned that in Greece law still allows patients to obtain antibiotics from the

pharmacists without any medical prescription. A study by Contopoulos-Ioannidis et al., reported that 77% of Greek pharmacists offered antibiotics without a medical prescription [19]. The same study showed that most of pharmacists offered expensive broad-spectrum antibiotics. Antibiotics were most frequently offered for treatment of patients with symptoms that were suggestive of a common cold [19]. Conclusions In Greece, despite the open and rapid access to primary care services, it appears that a high proportion of rural adult population prefers to use antibiotics without medical prescription. The high prevalence of self-medication with antibiotics in rural population in Greece emphasizes the role of the primary care physician who should advise patients about the correct use of the prescribed antibiotics. Another important intervention to reduce the major problem of self-medication with antibiotics in Greece should be legislative changes banning unregulated sale of antibiotics without medical prescription. Finally, efforts like the European Antibiotic Awareness Day [20] emphasize the importance of using antibiotics responsibly by reducing their unnecessary use and encourage people to follow their doctor's instructions on how to take antibiotics in the appropriate way, especially in children.

Survey of antibiotic use of individuals visiting public healthcare facilities in Indonesia.

Hadi U, Duerink DO, Lestari ES, Nagelkerke NJ, Werter S, Keuter M, Suwandojo E, Rahardjo E, van den Broek P, Gyssens IC; Antimicrobial Resistance in Indonesia 'Prevalence and Prevention' study group.
Collaborators (30)

Source
Department of Internal Medicine, Dr. Soetomo Hospital - School of Medicine, Airlangga University, Jl. Manyar Tirtomoyo II/21, Surabaya 60118, Indonesia. i.gyssens@aig.umcn.nl

Abstract
OBJECTIVES: To estimate the antibiotic use of individuals visiting public healthcare facilities in Indonesia and to identify determinants of use against a background of high resistance rates. METHODS: Patients on admission to hospital (group A), visiting a primary health center (group B), and healthy relatives (group C) were included in the study. A questionnaire on demographic, socioeconomic, and

healthcare-related items including health complaints and consumption of antibiotics was used. Logistic regression was performed to determine the co-variables of antibiotic use. RESULTS: Of 2996 individuals interviewed, 486 (16%) had taken an antibiotic. Compared to group C (7% consumption), groups B and A exhibited a three-fold and four-fold higher use of antibiotics, respectively. Respiratory (80%) and gastrointestinal (13%) symptoms were most frequent. Aminopenicillins and tetracyclines accounted for 80% of the prescribed antibiotics. Similar antibiotics were self-medicated (17% of users). Age less than 18 years and health insurance were independent determinants of antibiotic use. Urban provenance, being adult, male, and having no health insurance were independent determinants of self-medication. CONCLUSIONS: In addition to health complaints, other factors determined antibiotic consumption. In view of the likely viral origin of respiratory complaints and the resistance of intestinal pathogens, most antibiotic use was probably unnecessary or ineffective. Future interventions should be directed towards healthcare providers.