From Visiting a Physician to Expecting Antibiotics: Korean Perspectives and Practices toward Respiratory Tract Infections

The vicious cycle of the public's irrational use of antibiotics for upper respiratory tract infections: A mixed methods systematic review

Background

The public's irrational use of antibiotics for upper respiratory tract infections (URTIs) is prevalent worldwide. This study aims to synthesize evidence on how people use antibiotics to treat URTIs, its prevalence and determinants.

Methods

A mixed methods systematic review was conducted using a convergent segregated approach. Relevant studies were searched from PubMed, Cochrane Library, Embase, and Web of Science. A qualitative analysis was initiated, exploring the public's antibiotic use experience for URTIS based on the Consumer Behavior Model (CBM). This was followed by a quantitative synthesis, tapping into the prevalence and predictors of public behavior in antibiotic usage for URTIs. The segregated syntheses complemented each other and were further integrated.

Results

A total of 86 studies were included: 48 quantitative, 30 qualitative, eight mixed methods studies. The included studies were conducted in Europe (n = 29), Asia (n = 27) and North America (n = 21), assessing the behaviors of patients (n = 46), their parents or caregivers (n = 31), or both (n = 9). Eleven themes emerged covering the six CBM stages: need recognition, information searching, alternative evaluation, antibiotic obtaining, antibiotic consumption, and post-consumption evaluation. The six stages reinforce each other, forming a vicious cycle. The high prevalence of the public's irrational use of antibiotics for URTIs is evident despite the high heterogeneity of the studies (ranging from 0.0 to 92.7%). The perceived seriousness of illness and misbelief in antibiotics were identified consistently across the studies as the major motivation driving the public's irrational use of antibiotics for URTIs. However, individual capacity (e.g., knowledge) and opportunity (e.g., contextual restriction) in reducing antibiotic use have mixed effect.

Conclusion

Systemic interventions concerning both supply and demand sides are warranted. The public needs to be educated about the appropriate management of URTIs and health care providers need to re-shape public attitudes toward antibiotic use for URTIs through communication and prescribing practices.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier: CRD42021266407.

Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis

BACKGROUND

In the past two decades, human antibiotic consumption has increased globally, contributing to the emergence and spread of antimicrobial resistance and calling for urgent effective actions.

OBJECTIVES

To systematically identify and collate studies exploring non-biomedical factors influencing healthcare consumers' antibiotic use globally, in order to inform future interventions to improve antibiotic use practices.

METHODS

Data sources: PubMed, EMBASE, PsycINFO, and Cochrane.

STUDY ELIGIBILITY CRITERIA

Original and empirical studies that identified factors for healthcare consumers' antibiotic use.

PARTICIPANTS

Healthcare consumers. Assessment of risk of bias: Adapted BMJ survey appraisal tools, the Critical Appraisal Skills Programme checklist, and the Mixed Methods Appraisal Tool were utilised for quality assessment. Methods of data synthesis: The Social Ecological Framework and Health Belief Model were employed for data synthesis. We did random-effects meta-analyses to pool the odds ratios of risk factors for antibiotic use.

RESULTS

We included 71 articles for systematic review and analysis: 54 quantitative, nine qualitative, and eight mixed-methods studies. Prevalent non-prescription antibiotic uses and irresponsible prescriptions were reported globally, especially in low-to-middle income countries. Barriers to healthcare - wait time, transportation, stigmatization - influenced people's antibiotic use practices. Further, lack of oversight and regulation in the drug manufacturing and weak supply chain have led to the use of substandard or falsified antibiotics. Knowledge had mixed effects on antibiotic use behaviours. Meta-analyses identified pro-attitudes towards self-medication with antibiotics, relatives having medical backgrounds, older age, living in rural areas, and storing antibiotics at home to be risk factors for self-medication with antibiotics.

CONCLUSIONS

Non-prescription antibiotic use and irresponsible prescriptions in the community are prevalent in all WHO regions and largely driven by a mixed collection of non-biomedical factors specific to the respective setting. Future AMR strategies should incorporate implementation science approach for community-based complex interventions that addresses drivers of the target behaviours tailored to local contexts.

Knowledge and Expectations on Antibiotic Use Among the General Public in Malaysia: A Nationwide Cross-Sectional Survey

BACKGROUND

Identifying knowledge gaps regarding antibiotic use and resistance is important for future interventional strategies. There is limited information on Malaysia's general public's knowledge and expectations on antibiotic use.

PURPOSE

To assess the knowledge of antibiotic use and resistance, expectations from antibiotic prescription, and identify inappropriate practices related to antibiotic use among Malaysia's general public.

MATERIALS AND METHODS

A nationwide cross-sectional survey was conducted among Malaysians aged 18 years and above from each state, from May to November 2019. Participants were recruited via quota sampling, followed by convenient sampling. A validated self-administered questionnaire was used to collect data.

RESULTS

Of the 1971 respondents recruited, 56.6% had engaged in at least one inappropriate practice; particularly, not completing the antibiotic course (48.8%). The mean total knowledge score was 8.57±4.24 (total 20). The majority incorrectly believed that antibiotics work on viral infections (79.1%) and colds and coughs (77.0%). Less than half of them believed that antibiotics could be stopped when symptoms improved (42.8%). Most respondents incorrectly perceived that antibiotic resistance occurs when the body becomes resistant to antibiotics (90.2%) and antibiotic resistance is not an issue in the country (62.9%). More than half the participants expected antibiotics to be prescribed for self-limiting symptoms (fever: 62.9%, sore throat: 57.2%, cold or flu: 50.9%). Respondents with better knowledge were less likely to engage in inappropriate antibiotic use (never engaged: 9.26±4.40 versus had engaged: 8.11±4.00, p<0.001), and expect doctors to discuss with them the need for antibiotics (agree/strongly agree: 9.03±4.25 versus neutral: 6.62±3.91 versus disagree/strongly disagree: 8.29±4.00, p<0.001).

CONCLUSION

Knowledge gaps in the role of antibiotics and understanding of antibiotic resistance should be considered whtpen designing future educational strategies for the general public.

Validation of a Questionnaire for Patient Awareness and the Need for a Community-Based Outpatient Antimicrobial Stewardship Program (O-ASP): A Pilot Study

An outpatient antimicrobial stewardship program (O-ASP) was developed and implemented to promote appropriate antibiotic therapy in outpatient settings. As active patient involvement is a critical component of an effective O-ASP, this study aimed to develop and validate a questionnaire addressing patient awareness for appropriate antibiotic therapy and the need for pharmaceutical care services (PCS) in the O-ASP in Korea. The questionnaire was drafted based on ASPs and PCS guidelines and validated for content and construct validity using the item-content validity index (I-CVI) and Cronbach’s alpha, respectively. The estimated I-CVI and Cronbach’s alpha were considered excellent or adequate (≥0.8 and 0.70–0.90, respectively) for most of the survey items (17 out of 23 items). The validated questionnaire was utilized in a pilot survey study, including 112 individuals (37% male) with the mean ± SD age of 37 ± 13 years. Among the survey participants, 68% responded that antibiotics had been prescribed appropriately; however, ≥50% showed a lack of knowledge regarding their antibiotic therapy. The participants expressed the need for PCS as part of an O-ASP in the questionnaire (average Likert score ≥3.4/5). In conclusion, our newly validated questionnaire successfully measured patient awareness and knowledge of antimicrobial use and the need for PCS in the O-ASP.

Patients with Sore Throat: A Survey of Self-Management and Healthcare-Seeking Behavior in 13 Countries Worldwide

Background

Acute sore throat is one of the most common problems for which patients consult their general practitioner and is a key area for inappropriate antibiotic prescribing. The objective of this study was to investigate patients’ attitudes related to healthcare-seeking behavior and self-management of sore throat.

Methods

We conducted an observational, questionnaire-based study across 13 countries (Australia, Brazil, China, France, Germany, Italy, the Philippines, Russia, Saudi Arabia, South Africa, Thailand, the UK and the USA) on respondents who reported having had a sore throat in the previous 12 months. Data were collected on their experiences, contact with healthcare professionals, treatment practices and opinions about antibiotics.

Results

A total of 5196 respondents (approximately 400 per country) completed the survey. Over 80% of respondents sought advice for a sore throat, with 30% consulting a general practitioner. The desire to limit the worsening of symptoms was the main reason for seeking treatment. Other reasons concerned resolving persistent symptoms and reducing the impact on daily life/sleep. Self-management for sore throat was mainly medicated sore throat remedies. “Wanting an antibiotic” was rated much lower (55%) than most other reasons for visiting a doctor, but this differed greatly between countries. The percentage of respondents using antibiotics varied widely, for example, 10% in the UK and 45% in Saudi Arabia. There was considerable variation in the proportion of respondents who thought that antibiotics would be effective against sore throat (from 24% in France to 94% in Saudi Arabia).

Conclusions

Our findings suggest that knowledge of effective treatments for sore throat varied widely. The results of this study should enable healthcare professionals to better anticipate patients’ needs. This will support healthcare professionals in their role as antibiotic stewards, helping to reduce the misuse of antibiotics, and further guiding patients towards symptomatic self-management of sore throat.

Understanding determinants of patients' decisions to attend their family physician and to take antibiotics for upper respiratory tract infections: a qualitative descriptive study

Background

Although antibiotics have little or no benefit for most upper respiratory tract infections (URTIs), they continue to be prescribed frequently in primary care. Physicians perceive that patients’ expectations influence their antibiotic prescribing practice; however, not all patients seek antibiotic treatment despite having similar symptoms. In this study, we explored patients’ views about URTIs, and the ways patients manage them (including attendance in primary care and taking antibiotics).

Methods

Using a qualitative descriptive design, adult English-speaking individuals at a Canadian health center were recruited through convenient sampling. The participants were interviewed using semi-structured interview guide based on the Common Sense-Self-Regulation Model (CS-SRM). The interviews were transcribed verbatim and coded according to CS-SRM dimensions (illness representations, coping strategies). Sampling continued until thematic saturation was achieved. Thematic analysis related to the dimensions of CS-SRM was applied.

Results

Generally, participants had accurate perception about the symptoms of URTIs, as well as how to prevent and manage them. However, some participants revealed misconceptions about the causes of URTIs. Almost all participants mentioned that they only visited their doctor if their symptoms got progressively worse and they could no longer self-manage the symptoms. When visiting a doctor, most participants reported that they did not seek antibiotics. They expected to receive an examination and an explanation for their symptoms.

Conclusion

Our participants reported good understanding regarding the likely lack of benefit from antibiotics for URTIs. Developing interventions that specifically help patients discuss their concerns with their physicians, instead of providing more education to public may help in reducing the use of unnecessary antibiotics.

Knowledge and Expectations on Antibiotic Use among Older Adults in Malaysia: A Cross-Sectional Survey

Antibiotics are commonly prescribed among older adults, and inappropriate use of antibiotics has been noted. However, there is limited information about their knowledge and expectations for antibiotics. This study aimed to assess older adults' knowledge of antibiotic use and resistance, their expectations for antibiotics and the relationship between knowledge, expectation and inappropriate practices related to antibiotic use. A cross-sectional survey involving respondents aged 60 years and above was conducted, using a validated questionnaire. A lack of knowledge about the role of antibiotics was observed, whereby more than half of the respondents incorrectly believed that antibiotics can treat viral infections (53.5%) and colds and coughs (53.7%). Also, 67.9% of respondents incorrectly believed that antibiotic resistance occurs when the body becomes resistant to antibiotics. Almost half of the respondents would expect antibiotics for symptoms of self-limiting viral infections. Respondents who answered correctly for the role of antibiotics in viral infections were more likely not to expect antibiotics for cold, flu and cough (p < 0.001). Respondents who answered correctly regarding the need to adhere to antibiotics were more likely to have completed their antibiotic course (p < 0.001). Future educational initiatives should provide key information on the role of antibiotics and the importance of complying with antibiotics in this population.

Patients with respiratory tract infections who do not want antibiotics: direct observational study of primary care in Poland

BACKGROUND

Requests by patients for antibiotics are known to strongly affect doctors' decisions to prescribe them.Objective. The aim of this study was to establish how frequently patients presenting with respiratory tract infections (RTIs) express their expectation not to be treated with antibiotics, which symptoms and physical findings are related to their perception of antibiotics not being helpful, and to what degree their expectations influence doctors' decisions.

METHODS

This was a direct observational study set in primary care practices in Bialystok, Poland. The observers completed a checklist while observing a patient with RTI visiting a family doctor.

RESULTS

Overall, 80 (5.5%) out of 1456 patients with RTIs openly requested not to be prescribed antibiotics. Patients not wanting antibiotics were prescribed antibiotics significantly less frequently [25/80 (31.3%)] than the remaining patients [765/1376 (55.6%), P < 0.001]. Univariate logistic regression revealed that cough and runny nose significantly increased the odds of patients not wanting antibiotics [odds ratio (OR) 1.8, 95% confidence intervals (CI): 1.01-3.20 and OR 1.6, 95% CI: 1.01-2.6, respectively] while the presence of tonsillar exudates significantly decreased the odds (OR 0.3, 95% CI: 0.08-0.86). Belief in a self-limited course (20%), recent treatments with antibiotics (16.3%), suspected viral aetiology (12.5%), and concerns about possible harm (12.5%) were the principal reasons for not wanting antibiotics.

CONCLUSIONS

A patient's wish not to be prescribed antibiotics leads to less frequent antibiotic prescribing. Antimicrobial resistance, though important from a public health viewpoint, is not seen as a priority for individual patients with infections.