Self-Medication with Antibiotics during COVID-19 in the Eastern Mediterranean Region Countries: A Review

Self-medication with antibiotics during the COVID-19 pandemic: A cross-sectional study among adults in Tema, Ghana

BACKGROUND

Antibiotic self-medication is one of the common causes of antibiotic resistance of bacterial organisms. The COVID-19 pandemic introduced a new paradigm shift and significantly influenced healthcare behaviors, including an increase in antibiotic self-medication, which contributes to antibiotic resistance. This study was aimed at determining the prevalence of antibiotic self-medication and the possible associated factors during the peak of the COVID-19 pandemic among adult residents of Tema in Ghana from April to July 2021.

METHODS

Using a cross-sectional design, 400 adults were randomly selected and surveyed using a researcher-assisted questionnaire. Data were analyzed with IBM® SPSS® Statistics Version 22.0, considering associations significant at a 95% confidence interval (p < 0.05).

RESULTS

Of the 400 respondents, (76%) 304 had practiced antibiotic self-medication within the previous 12 months during the COVID-19 pandemic. Significant factors associated with antibiotic self-medication included gender, age, marital status, education, occupation, and National Health Insurance Scheme subscription. Convenience and avoiding long hospital queues were primary non-medical reasons for antibiotic self-medication, while previous successful experience, easy access to antibiotics, treating symptoms, prophylaxis, and fear of hospital infection were the medical reasons for antibiotic self-medication. Commonly self-administered antibiotics were azithromycin (34%), amoxicillin/clavulanic acid (22%), and metronidazole (16%) for perceived respiratory tract and gastrointestinal tract infections.

CONCLUSIONS

The high prevalence of antibiotic self-medication observed during the COVID-19 pandemic underscores the need for enhanced public education and stricter enforcement of regulations governing antibiotic sales. The non-medical and medical factors of convenience, avoiding long hospital queues, previous successful experience, easy access to antibiotics, treating symptoms, prophylaxis, and fear of hospital infection which motivated antibiotic self-medication practices require the implementation of antimicrobial stewardship interventions.

Antimicrobial Resistance: Stewardship and One Health in the Eastern Mediterranean Region

Antimicrobial resistance (AMR) is a major threat in the Eastern Mediterranean region (EMR) due to factors such as the high prevalence of infectious diseases, weak health systems, and the misuse of antimicrobials. This paper aims to discuss how interdisciplinary action and collaboration, specifically through antimicrobial stewardship (AMS) and the One Health approach, can effectively address AMR in the EMR. The review focuses on successful AMS initiatives and the adoption of the One Health approach in countries within the EMR, including the Gulf Cooperation Countries (GCC), Egypt, Iran, Jordan, and Pakistan. The goal is to highlight the potential for progress in combating AMR and identify challenges and opportunities for strengthening interdisciplinary collaboration. The results showcase successful AMS programs and One Health initiatives in various EMR countries, demonstrating their potential to address AMR challenges. The paper also discusses the challenges faced by these nations, such as limited resources, fragmented health systems, and knowledge gaps. Additionally, opportunities for enhancing interdisciplinary action through regional cooperation, international partnerships, and research and innovation are outlined. In conclusion, this paper emphasizes the importance of a comprehensive and collaborative response to combat AMR in the EMR. It advocates for the One Health approach as a crucial framework to guide these efforts, promoting coordinated action, improved surveillance, responsible antimicrobial use, and enhanced interdisciplinary collaboration to effectively mitigate the threat of AMR.

Practices and drivers of self-medication with antibiotics among undergraduate medical students in Eastern Uganda: A cross-sectional study

Self-medication with antibiotics remains one of the major drivers of antimicrobial resistance. Practices of self-medication among nursing and medical students have not been explored in our setting. This study sought to determine the prevalence and factors associated with self-medication with antibiotics among undergraduate university students pursuing health-related courses in Eastern Uganda. A descriptive cross-sectional study design was used. The study was done among undergraduate students who were doing undergraduate programs in Nursing, Anesthesia, and medicine at Busitema University. A self-administered questionnaire was used to collect data from 326 participants. Descriptive statistics were used in data analysis. The prevalence of self-medication with antibiotics was 93.8% (n = 300) of which 80% were either currently using self-medication or had self-medicated in the past six months. The common reasons for self-medication were the perception that it was a minor illness (55%), previous use of antibiotic (52%), a perception that they were health workers (50%), and the notion that they knew the right antibiotic for their condition (44%). Metronidazole (64%) and amoxicillin (65%) were the most commonly used antibiotics. Self-medication was most common for conditions such as peptic ulcer, diarrhea, and wound infections. Inappropriate drug use was common among participants on self-medication which occurred in the form of multiple use of antibiotics (64.4%, n = 194) and a tendency to switch to other antibiotics (58.5%) mostly because the former antibiotic was perceived not to be an effective treatment. The prevalence of self-medication with antibiotics was high among medical students. Prior use of the antibiotic and having a minor illness were the most common drivers of self-medication. Public health strategies should address the high misuse of antibiotics among medical students to negate the likely consequence of antimicrobial resistance.

WHO AWaRe classification for antibiotic stewardship: tackling antimicrobial resistance - a descriptive study from an English NHS Foundation Trust prior to and during the COVID-19 pandemic

Antimicrobial resistance (AMR) is a silent and rapidly escalating pandemic, presenting a critical challenge to global health security. During the pandemic, this study was undertaken at a NHS Foundation Trust in the United Kingdom to explore antibiotic prescribing trends for respiratory tract infections (RTIs), including pneumonia, and the COVID-19 pandemic across the years 2019 and 2020. This study, guided by the WHO's AWaRe classification, sought to understand the impact of the pandemic on antibiotic prescribing and antimicrobial stewardship (AMS). The research methodology involved a retrospective review of medical records from adults aged 25 and older admitted with RTIs, including pneumonia, in 2019 and 2020. The application of the AWaRe classification enabled a structured description of antibiotic use. The study evaluated antibiotic use in 640 patients with RTIs. Notably, it observed a slight increase in the use of amoxicillin/clavulanic acid and a substantial rise in azithromycin prescriptions, highlighting shifts in prescribing trends. Despite these changes, some antibiotics displayed steady consumption rates. These findings highlight the importance of understanding antibiotic use patterns during the AMR threat. The increase in the usage of "Watch" category antibiotics during the pandemic emphasises the urgency of robust AMS measures. The research confirms that incorporating the AWaRe classification in prescribing decisions is crucial for patient safety and combating antibiotic misuse. This study provides essential insights into the changing landscape of antibiotic prescribing during a global health crisis, reinforcing the necessity for ongoing AMS vigilance to effectively address AMR challenges.

Antimicrobial resistance landscape and COVID-19 impact in Egypt, Iraq, Jordan, and Lebanon: A survey-based study and expert opinion

OBJECTIVES

The objective of this study was to assess the antimicrobial resistance (AMR) landscape and the impact of COVID-19 on AMR in Egypt, Iraq, Jordan, and Lebanon, and to gather expert opinions on the barriers to the implementation of antimicrobial stewardship (AMS) initiatives in the region.

METHODS

A cross-sectional questionnaire survey was used to assess the current AMR landscape, existing AMS initiatives, barriers to implementing AMS initiatives, and the impact of COVID-19 on AMR in the four countries.

RESULTS

The survey was completed by 204 physicians from Egypt (n = 82), Lebanon (n = 49), Iraq (n = 43), and Jordan (n = 30). Previous antibiotic use and previous bacterial colonization were perceived as the most common risk factors for an increase in AMR. According to the survey, multidrug-resistant (MDR) gram-negative bacteria were most common in lower respiratory tract infections, and Klebsiella pneumoniae and Escherichia coli were the most commonly identified gram-negative bacteria in hospital-acquired infections. Only 14.8% of pediatric physicians and 28.6% of adult physicians reported that target pathogen genotyping and phenotyping were done in hospitals, and the most commonly reported reasons for the lack of testing were technological and resource constraints. These constraints, coupled with the scarcity and high cost of newer antibiotics, have been identified as the most significant barriers to the successful management of MDR gram-negative bacterial infections in the region. It was reported that the spectrum of activity and safety of the antibiotic, the site of infection, the presence of comorbidities, and published guidelines and local antibiograms determined the choice of empirical antibiotic therapy for patients in the region. The four countries experienced a significant rise in AMR due to several factors during the COVID-19 pandemic, including an increase in hospital occupancy, a shift in priorities away from AMR surveillance, and changes in AMR epidemiology. Additionally, the large volumes of unnecessary and unsubstantiated antibiotic prescriptions during the COVID-19 pandemic has led to subsequent antibiotic shortages and significant increases in AMR in the region. Physicians also noted that the majority of COVID-19 patients were already on antibiotics before visiting the healthcare facility. MDR gram-negative bacteria were found in the majority of COVID-19 patients admitted to the intensive care unit. Despite the fact that various AMS initiatives have been implemented, they are not standardized across the region. Some of the main barriers to AMS implementation in the region are a lack of adequately trained AMS staff, lack of AMS knowledge and training among healthcare professionals, financial constraints, and the lack of AMR surveillance systems.

CONCLUSION

These survey results provide valuable insights into the existing AMR and AMS landscape in the region, as well as the barriers that impede efficient AMS and AMR management. Based on these findings, the authors developed a call to action that suggests ways for each country in the region to address these challenges.

Prevalence of antibiotics prescription amongst patients with and without COVID-19 in low- and middle-income countries: a systematic review and meta-analysis

Antimicrobial resistance (AMR) poses a substantial risk to public health. In low-income and middle-income (LMICs) nations, the impact of AMR is significantly more severe. The absence of data from low-income countries (LMICs) causes this topic to be frequently overlooked. Additionally, the COVID-19 pandemic could make the AMR issue even worse. Earlier guidelines recommended antibiotic use in patients with COVID-19, even in those without bacterial coinfection. This study aims to investigate the proportion of antibiotic prescriptions in LMICs among patients with and without coronavirus disease-2019 (COVID-19), the proportion of inappropriate antibiotics, and multi-antibiotic prescribing. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We retrieved data through online databases, including PubMed, Scopus, and ScienceDirect. Amongst COVID-19 patients, the meta-analytic estimate of antibiotic prescription was 0.80 (95% CI: 0.72-0.88), whereas antibiotic use among patients with non-COVID-19 infections was 0.54 (95% CI: 0.49-0.58). Half of those prescribed antibiotics (0.52, 95% CI: 0.32-0.72) are inappropriate prescriptions. In addition, we found that one-third of antibiotics prescriptions consisted of more than one antibiotic (0.32, 95% CI: 0.21-0.43). In conclusion, antibiotics are highly prescribed across LMICs, and their use is increased in patients with COVID-19. Amongst those prescriptions, inappropriate and multiple use was not uncommon. This study has several limitations, as it included two studies in an ambulatory setting, and some of the studies included in the analysis were conducted on a small scale. Nevertheless, our findings suggest that urgent action to improve prescribing practices is essential.

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.

Perceptions of COVID-19 symptoms, prevention, and treatment strategies among people in seven Arab countries: A cross-sectional study

BACKGROUP

the widespread COVID-19 infection worldwide has resulted in the inability of healthcare facilities to receive all infected patients; therefore, most are treated at home. In addition, factors such as high mortality, types and severity of symptoms, and the prevalence of unreliable information have prompted patients to resort to self-treatment.

OBJECTIVES

To assess prevention, treatment, degree of symptoms, and sources of information among patients with COVID-19 in Arab countries METHOD: A cross-sectional study was conducted in seven Arab countries: Algeria, Egypt, Iraq, Lebanon, Libya, Tunisia, and the United Arab of Emirates. People who have recovered from COVID-19 completed the study questionnaire. Score of symptoms during and after COVID-19 infection has been calculated by giving the participants a list of 13 symptoms.

RESULTS

A total of 3519 participants completed the survey. Mostly females (68.3%), and aged between 18 and 40 years old (59.4%). Prophylaxis treatments, including vaccines and antibiotics, have been used in around 40% of the participants. The total average score of symptoms during the infection period was found 7.31 ± 3.66 out of 13. However, the symptoms score upon recovery was low (0.48 ± 1.11 score). The significant associations with increased incidence of symptoms during infection were reported with older people, married, divorced or widowed, people with chronic diseases, and obese. Moreover, significant associations with decreased symptoms were reported with those who worked in the health sector, non- or ex-smokers, and vaccinated people.

CONCLUSION

The use of medication and other treatments to prevent infection with COVID-19 was common among the participants in the seven countries. Taking the vaccine was the only effect on the number of symptoms experienced by patients. Although nearly two years have passed since the onset of the disease, there is still a need to raise treatment awareness among patients at home.

A Threshold Logistic Modelling Approach for Identifying Thresholds between Antibiotic Use and Methicillin-Resistant Staphylococcus aureus Incidence Rates in Hospitals

The aim of this study was to demonstrate the utility of threshold logistic modelling, an innovative approach in identifying thresholds and risk scores in the context of population antibiotic use associated with methicillin-resistant Staphylococcus aureus (MRSA) incidence rates in hospitals. The study also aimed to assess the impact of exceeding those thresholds that resulted in increased MRSA rates. The study was undertaken in a 700-bed hospital in England between January 2015 and December 2021 (84 monthly observations). By employing the threshold logistic modelling approach, we: (i) determined the cut-off percentile value of MRSA incidence that defines a critical level of MRSA; (ii) identified thresholds for fluoroquinolone and co-amoxiclav use that would accelerate MRSA incidence rates and increase the probability of reaching critical incidence levels; (iii) enabled a better understanding of the effect of antibiotic use on the probability of reaching a critical level of resistant pathogen incidence; (iv) developed a near real-time performance monitoring feedback system; (v) provided risk scores and alert signals for antibiotic use, with the ability to inform hospital policies, and control MRSA incidence; and (vi) provided recommendations and an example for the management of pathogen incidence in hospitals. Threshold logistic models can help hospitals determine quantitative targets for antibiotic usage and can also inform effective antimicrobial stewardship to control resistance in hospitals. Studies should work toward implementing and evaluating the proposed approach prospectively, with the aim of determining the best counter-measures to mitigate the risk of increased resistant pathogen incidence in hospitals.