Antibiotics in the Community During the COVID-19 Pandemic: A Qualitative Study to Understand Users' Perspectives of Antibiotic Seeking and Consumption Behaviors in Bangladesh

Prevalence of self-medication with antibiotics and its related factors among the general public and health professionals during the COVID-19 pandemic: A cross-sectional study in China

BACKGROUND

Self-medication with antibiotics (SMA) is a common public health concern. This study aimed to assess the prevalence of SMA in the general public and health professionals during the COVID-19 pandemic and identify the associated factors.

METHODS

A cross-sectional study was conducted from October 28, 2022, to November 6, 2022. Logistics regression analysis was used to examine the associated factors.

RESULTS

The rate of SMA was 10.25% in the general public and 12.69% in health professionals. For the public, those who perceived themselves as average or good health, had moderate antibiotic knowledge, and had easy access to nearby health facilities were less likely to SMA; while those who live in rural areas, found it easy to purchase antibiotics without prescriptions, and those who frequently encountered antibiotics recommended by pharmacy staff were more likely to SMA. For health professionals, those who were female, perceived themselves as good health, had moderate or high antibiotic knowledge, and had easy access to health facilities were less likely to SMA; while those who found it easy to purchase antibiotics without prescriptions were more likely to SMA.

CONCLUSIONS

SMA is prevalent in both the general public and health professionals. Promoting the rational use of antibiotics requires joint participation and effort.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n = 173); after removing duplicates and preprints (n = 12) and excluding those that did not meet eligibility criteria (n = 115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). This study is the first to succinctly identify a range of norms, behaviors, and policy contexts driving inappropriate use of antimicrobials in South Asia, emphasizing the importance of working across multiple sectors to design and implement approaches specific to the region.

Use of antimicrobials during the COVID-19 pandemic: A qualitative study among stakeholders in Nepal

The COVID-19 pandemic was a major public health threat and the pressure to find curative therapies was tremendous. Particularly in the early critical phase of the pandemic, a lot of empirical treatments, including antimicrobials, were recommended. Drawing on interviews with patients, clinicians and drug dispensers, this article explores the use of antimicrobials for the management of COVID-19 in Nepal. A total of 30 stakeholders (10 clinicians, 10 dispensers and 10 COVID-19 patients) were identified purposively and were approached for an interview. Clinicians and dispensers in three tertiary hospitals in Kathmandu assisted in the recruitment of COVID-19 patients who were undergoing follow-up at an out-patient department. Interviews were audio recorded, translated and transcribed into English, and were analyzed thematically. The respondents report that over-the-counter (OTC) use of antibiotics was widespread during the COVID-19 pandemic in Nepal. This was mostly rooted in patients' attempts to mitigate the potential severity of respiratory illnesses, and the fear of the stigmatization and social isolation linked to being identified as a COVID-19 patient. Patients who visited drug shops and physicians reportedly requested specific medicines including antibiotics. Clinicians reported uncertainty when treating COVID-19 cases that added pressure to prescribe antimicrobials. Respondents from all stakeholder groups recognized the dangers of excessive use of antimicrobials, with some referring to the development of resistance. The COVID-19 pandemic added pressure to prescribe, dispense and overuse antimicrobials, accentuating the pre-existing OTC use of antimicrobials. Infectious disease outbreaks and epidemics warrant special caution regarding the use of antimicrobials and specific policy response.

Drivers of inappropriate use of antimicrobials in South Asia: A systematic review of qualitative literature

Antimicrobial resistance is a global public health crisis. Effective antimicrobial stewardship requires an understanding of the factors and context that contribute to inappropriate use of antimicrobials. The goal of this qualitative systematic review was to synthesize themes across levels of the social ecological framework that drive inappropriate use of antimicrobials in South Asia. In September 2023, we conducted a systematic search using the electronic databases PubMed and Embase. Search terms, identified a priori, were related to research methods, topic, and geographic location. We identified 165 articles from the initial search and 8 upon reference review (n=173); after removing duplicates and preprints (n=12) and excluding those that did not meet eligibility criteria (n=115), 46 articles were included in the review. We assessed methodological quality using the qualitative Critical Appraisal Skills Program checklist. The studies represented 6 countries in South Asia, and included data from patients, health care providers, community members, and policy makers. For each manuscript, we wrote a summary memo to extract the factors that impede antimicrobial stewardship. We coded memos using NVivo software; codes were organized by levels of the social ecological framework. Barriers were identified at multiple levels including the patient (self-treatment with antimicrobials; perceived value of antimicrobials), the provider (antimicrobials as a universal therapy; gaps in knowledge and skills; financial or reputational incentives), the clinical setting (lack of resources; poor regulation of the facility), the community (access to formal health care; informal drug vendors; social norms), and policy (absence of a regulatory framework; poor implementation of existing policies). The findings highlight the importance of working across multiple sectors to design and implement approaches to antimicrobial stewardship in South Asia.

Leveraging the COVID-19 pandemic as a natural experiment to assess changes in antibiotic use and antibiotic-resistant E. coli carriage in semi-rural Ecuador

The coronavirus 2019 (COVID-19) pandemic has had significant impacts on health systems, population dynamics, public health awareness, and antibiotic stewardship, which could affect antibiotic resistant bacteria (ARB) emergence and transmission. In this study, we aimed to compare knowledge, attitudes, and practices (KAP) of antibiotic use and ARB carriage in Ecuadorian communities before versus after the COVID-19 pandemic began. We leveraged data collected for a repeated measures observational study of third-generation cephalosporin-resistant E. coli (3GCR-EC) carriage among children in semi-rural communities in Quito, Ecuador between July 2018 and September 2021. We included 241 households that participated in surveys and child stool sample collection in 2019, before the pandemic, and in 2021, after the pandemic began. We estimated adjusted Prevalence Ratios (aPR) and 95% Confidence Intervals (CI) using logistic and Poisson regression models. Child antibiotic use in the last 3 months declined from 17% pre-pandemic to 5% in 2021 (aPR: 0.30; 95% CI 0.15, 0.61) and 3GCR-EC carriage among children declined from 40 to 23% (aPR: 0.48; 95% CI 0.32, 0.73). Multi-drug resistance declined from 86 to 70% (aPR: 0.32; 95% CI 0.13; 0.79), the average number of antibiotic resistance genes (ARGs) per 3GCR-EC isolate declined from 9.9 to 7.8 (aPR of 0.79; 95% CI 0.65, 0.96), and the diversity of ARGs was lower in 2021. In the context of Ecuador, where COVID-19 prevention and control measures were strictly enforced after its major cities experienced some of the world's the highest mortality rates from SARS-CoV-2 infections, antibiotic use and ARB carriage declined in semi-rural communities of Quito from 2019 to 2021.

Understanding the behavioral determinants that predict barriers and enablers of screening and treatment behaviors for diabetic retinopathy among Bangladeshi women: findings from a barrier analysis

BACKGROUND AND AIM

While early detection and timely treatments can prevent diabetic retinopathy (DR) related blindness, barriers to receiving these DR services may cause permanent sight loss. Despite having similar prevalence to diabetes and DR, women are less likely than men to perform these behaviors due to multi-faced barriers in screening and receiving follow-up treatments for DR. This study, therefore, aimed at identifying the barriers to - and enablers of - screening and follow-up treatments behaviors for DR among women aged more than 40 years with diabetes from the behavioral perspectives in Bangladesh.

METHODS

This Barrier Analysis study interviewed 360 women (180 "Doers" and 180 "Non-doers") to explore twelve behavioral determinants of four DR behaviors including screening, injection of anti-vascular endothelial growth factor (anti-VEGF medication), laser therapy and vitro-retinal surgery. The data analysis was performed to calculate estimated relative risk to identify the degree of association between the determinants and behaviors, and to find statistically significant differences (at p < 0.05) in the responses between the Doers and Non-doers.

RESULTS

Access to healthcare facilities was the major barrier impeding women from performing DR behaviors. Difficulty in locating DR service centers, the need to travel long distances, the inability to travel alone and during illness, challenges of paying for transportation and managing workload significantly affected women's ability to perform the behaviors. Other determinants included women's perceived self-efficacy, perceived negative consequences (e.g. fear and discomfort associated with injections or laser treatment), and cues for action. Significant perceived enablers included low cost of DR treatments, supportive attitudes by healthcare providers, government policy, and perceived social norms.

CONCLUSION

The study found a host of determinants related to the barriers to and enablers of DR screening and treatment behaviors. These determinants included perceived self-efficacy (and agency), positive and negative consequences, perceived access, perceived social norms, culture, and perceived risk. Further investments are required to enhance the availability of DR services within primary and secondary health institutions along with health behavior promotion to dispel misconceptions and fears related to DR treatments.

Public knowledge of antibiotics, self-medication, and household disposal practices in Jordan

BACKGROUND

This study aimed to assess public understanding of antibiotics, self-medication, and drug disposal practices.

METHODS

A cross-sectional self-administered online survey was undertaken in Jordan.

RESULTS

The study was completed by 1,105 participants. When asked about their knowledge of antibiotics, rational antibiotic use, and disposal practices, 16% percent believed they should discontinue antibiotics once they felt better, and 12% agreed to take the same antibiotics prescribed to others for the same illness. Self-medication with antibiotics was practiced by 44% of the participants. Prior experience, healthcare costs, and pharmacy location were all major determinants of self-medication. Only 6.4% of unneeded antibiotics were returned to the pharmacy, 60% were kept at home, and 26.6% were disposed of at home. Almost half of those who kept the antibiotics said they would use them again, and one-third said they would give them to friends and family. Respondents who had used antibiotics within the previous 6 months (p = 0.052) and relied on medication leaflets (p = 0.031) and physician recommendations (p = 0.001) were less likely to self-medicate with antibiotics.

CONCLUSIONS

The study highlighted areas of inappropriate use of antibiotics, self-medication and the improper antibiotic disposal that can inform antimicrobial stewardship.

Structure-activity relationships of antibacterial peptides

Antimicrobial peptides play a crucial role in innate immunity, whose components are mainly peptide-based molecules with antibacterial properties. Indeed, the exploration of the immune system over the past 40 years has revealed a number of natural peptides playing a pivotal role in the defence mechanisms of vertebrates and invertebrates, including amphibians, insects, and mammalians. This review provides a discussion regarding the antibacterial mechanisms of peptide-based agents and their structure-activity relationships (SARs) with the aim of describing a topic that is not yet fully explored. Some growing evidence suggests that innate immunity should be strongly considered for the development of novel antibiotic peptide-based libraries. Also, due to the constantly rising concern of antibiotic resistance, the development of new antibiotic drugs is becoming a priority of global importance. Hence, the study and the understanding of defence phenomena occurring in the immune system may inspire the development of novel antibiotic compound libraries and set the stage to overcome drug-resistant pathogens. Here, we provide an overview of the importance of peptide-based antibacterial sources, focusing on accurately selected molecular structures, their SARs including recently introduced modifications, their latest biotechnology applications, and their potential against multi-drug resistant pathogens. Last, we provide cues to describe how antibacterial peptides show a better scope of action selectivity than several anti-infective agents, which are characterized by non-selective activities and non-targeted actions toward pathogens.

Impact of the COVID-19 Outbreak on the Antibiotic Use Patterns among a Rural Community Population in Eastern China

There are growing concerns that the coronavirus disease of 2019 (COVID-19) pandemic may change antibiotic use patterns and accelerate antibiotic resistance, but evidence from the community level is lacking. This study aims to estimate the impact of the COVID-19 outbreak on the antibiotic use patterns among a community population in Eastern China. A self-administered medicine diary was used to collect information on antibiotic use from July 2019 to June 2021 among a rural community in Eastern China. We analyzed the changes in antibiotic use patterns over five months from August to December 2019 and the corresponding months in 2020. The risk of antibiotic use and its changes were measured with the incidence rate (IR) and relative risk (RR). In total, 1111 participants were eligible for the final analysis (440 in 2019 and 671 in 2020). After the COVID-19 outbreak, antibiotic use increased by 137% (5.43 per 100 person months in the 2019 vs. 12.89 per 100 person months in the 2020), and after the adjustment of covariates, the adjusted RR was 1.72 (95% CI: 1.10~2.34). It was higher among those who were women (RR = 2.62), aged 35−59 years old (RR = 2.72), non-farmers (RR = 2.75), had less than six years of education (RR = 2.61), had an annual household income over CNY 100,000 (USD 14,940) (RR = 2.60), and had no history of chronic diseases (RR = 2.61) (all p < 0.05). The proportion of cephalosporins consumed increased from 54.29% in 2019 to 64.92% in 2020 (p = 0.011). Among those aged 35 years and older, the proportion of antibiotics obtained from medical facilities increased, while the proportion obtained from retail pharmacies, homes, and other sources decreased (all p < 0.05). The COVID-19 outbreak changed antibiotic use patterns in this study population (Eastern China) significantly. More efforts to monitor and enhance antibiotic stewardship activities at the community level are needed in future.

The Impact of Multiplex PCR in Diagnosing and Managing Bacterial Infections in COVID-19 Patients Self-Medicated with Antibiotics

The multiplex PCR is a powerful and efficient tool that was widely used during the COVID-19 pandemic to diagnose SARS-CoV-2 infections and that has applications for bacterial identification, as well as determining bacterial resistance to antibiotics. Therefore, this study aimed to determine the usability of multiplex PCR, especially in patients self-medicated with antibiotics, where bacterial cultures often give false-negative results. A cross-sectional study was developed in two COVID-19 units, where 489 eligible patients were included as antibiotic takers and non-antibiotic takers. Antibiotic takers used mostly over-the-counter medication; they suffered significantly more chronic respiratory conditions and were self-medicated most often with cephalosporins (41.4%), macrolide (23.2%), and penicillin (19.7%). The disease severity in these patients was significantly higher than in non-antibiotic takers, and bacterial superinfections were the most common finding in the same group (63.6%). Antibiotic takers had longer hospital and ICU admissions, although the mortality rate was not significantly higher than in non-antibiotic takers. The most common bacteria involved in secondary infections were Staphylococcus aureus (22.2%), Pseudomonas aeruginosa (27.8%), and Klebsiellaspp (25.0%). Patients self-medicating with antibiotics had significantly higher rates of multidrug resistance. The multiplex PCR test was more accurate in identifying multidrug resistance and resulted in a quicker initiation of therapeutic antibiotics compared with instances where a bacterial culture was initially performed, with an average of 26.8 h vs. 40.4 h, respectively. The hospital stay was also significantly shorter by an average of 2.5 days when PCR was used as an initial assessment tool for secondary bacterial infections. When adjusted for age, COVID-19 severity, and pulmonary disease, over-the-counter use of antibiotics represented a significant independent risk factor for a prolonged hospitalization (AOR = 1.21). Similar findings were observed for smoking status (AOR = 1.44), bacterial superinfection (AOR = 1.52), performing only a conventional bacterial culture (AOR = 1.17), and a duration of more than 48 h for bacterial sampling from the time of hospital admission (AOR = 1.36). Multiplex PCR may be a very effective method for diagnosing secondary bacterial infections in COVID-19 individuals self-medicating with antibiotics. Utilizing this strategy as an initial screen in COVID-19 patients who exhibit signs of sepsis and clinical deterioration will result in a faster recovery time and a shorter period of hospitalization.