Antibiotics use and misuse in upper respiratory tract infection patients: Knowledge, attitude and practice analysis in University Hospital, Saudi Arabia

Objective: To assess the awareness and causes of antibiotics use and misuse in patients with upper respiratory tract

primary, secondary and tertiary healthcare services to patients from across the country as well as the Gulf region. Patients aged 16 years or above were included. Wellstructured English language questionnaires were distributed among the participants.
The questionnaire was formed based on the questions taken from previous studies and edited to suit the objectives. 2,14,16,17 A pilot study was conducted to test the validity of the questionnaire. The final version of the questionnaire contained 33 questions divided into four main parts. The first part was about demographic features. The second part was designed to assess recent antibiotics usage in the last year, the reason of the usage, and whether it was used with or without a prescription. The third part contained 11 statements with (Yes-No-Not sure) options to assess participants' general knowledge and attitude towards antibiotics. Statements included role of antibiotics, harmful effects of antibiotics and completion of treatment course. The fourth part was designed to evaluate the behaviours towards antibiotics use. This part consisted of 9 statements about the antibiotics usage in common cold, patient's expectation from the physicians, patient's compliance, sharing and keeping antibiotics for emergency cases and others. Responses were taken also in Yes-No-Not sure pattern. One additional question was asked about the participants' source of information about antibiotics; the options were: from the doctor, pharmacist, internet, media, relatives or friends. A written consent was taken from all respondents before answering the questionnaires. Participants' anonymity was assured by assigning each participant with a code number for the purpose of analysis only. No incentives or rewards were given to participants. Data collection was conducted from December 2013 to February 2014. Data analysis was done using SPSS 21. The prevalence of antibiotic use, misuse and its awareness were determined by comparing outcome measures. Numerical variables were reported as the mean ± standard deviation. P<0.05 was considered significant.
Study was approved by the institutional review board.
Moreover, 182(45.5%) participants were using antibiotics without prescription (p=0.050) and 43(10.8%) were using the antibiotics over a pharmacist's advice (p=0.030). Besides, 69(17.3%) of all age groups had forced the doctor to prescribe antibiotics, and 25(6.3%) of them were aged between 26-35 years (p=0.014). Furthermore, respondents who stopped taking antibiotics when they felt better were higher in the age group of 26-35 years, with a given percentage of 88(22%) out of 207(51.7%) (p=0.007). Moreover, 180(45%) participants agreed on  keeping the antibiotic stocks at home in cases of emergencies, with a higher percentage in the age group between 16-35 years (p=0.010). In addition, 67(16.8%) participants were found to be ignoring the instructions on the label when taking antibiotics (p=0.004) ( Table-2).
Furthermore, 48(12%) participants denied that antibiotics could cause an allergic reaction (p=0.054). The same number of participants believed that the effectiveness of the treatment would not be affected if a course of antibiotic was not completed; of them, 25(6.2%) were males and 23(5.8%) were females (p=0.029). On the other hand, behavioural questions' results revealed that of 26(6.8%) male participants out of 41(10.3%) obtained antibiotics without prescription (p=0.042), and the same percentage was recorded for males getting antibiotics over a pharmacist's advice. Moreover, males and females who took antibiotics when they suffered with common cold represented 98(24.5%) and 76(19%), respectively (p=0.014). Moreover, 121(30.3%) of males and 104(26%) of females expected antibiotics to be prescribed by their doctor if they suffered from symptoms of common cold. However, 41(10.3%) males and 28(7%) females used to force the doctor to prescribe to them antibiotics when they felt sick (p=0.043). The majority of both genders 179(44.8%) showed significant result in keeping antibiotic stocks at home in case of emergency (p=0.006) and also using the leftover antibiotics for a respiratory illness 36 (9%) (p=0.001) ( Table-3).
The logic of comparing participants' knowledge, beliefs and attitudes towards antibiotic use and awareness to antibiotic use without prescription is valid. It shows that the participants who were knowledgeable of antibiotics and knows the danger of using antibiotics without prescription tend not to use antibiotics without proper prescription. That holds true with participants' beliefs and attitudes.   Inflammation was the cause of antibiotic use in 96(24%) participants, fever in 88(22%), respiratory factors in 84(21%), pain in 40(10%), urinary tract infections in 28(7%), skin diseases in 16(4%) and wound in 8(2%) (Figure-1). Furthermore, participants' sources of information about antibiotic were primarily doctors, followed by pharmacists. The other sources were the Internet, relatives and friends, the media, and news and magazine ( Figure-2).

Discussion
Antibiotics' misuse can lead to a wide range of adverse consequences. The patients' knowledge and beliefs about antibiotics can dramatically affect the way they use these medications. Therefore, it is necessary to assess the extent of patients' knowledge in order to reach the right interventions, which in turn guide the patients' behaviours and usage toward these drugs. 14 This study demonstrates that the majority of the participants were using antibiotics frequently from two to four times per year. Furthermore, 281(70.3%) of the respondents had used antibiotics within the past year. In addition, the percentage reported in this study was even higher than the percentage reported by a study conducted in Oman by Jose et al., 14 in which only 66% of the respondents had used antibiotics recently within the last year. 14 The causes for using antibiotics varied from one respondent to the other with higher percentages given to reason for   10 This confirms the lack of knowledge of the participants and their inability to recognise the differences between bacteria and viruses allied diseases. The reason behind this can be due to the use of the word "germs" when counselling and seeking a medical advice instead of using the words "bacteria" or "viruses". 2 Moreover, the majority of respondents believe that antibiotics can also be used to relieve pain and fever. When the participants were questioned directly about their behaviours towards antibiotics, 82.7% had the correct behaviour in disagreement to the statement about "I usually force my doctor to prescribe me antibiotics when I get sick". Nevertheless, 56.3% were expecting their doctors to prescribe them an antibiotic when suffering from common cold. This can be attributed to the large number of prescriptions for antibiotics in respiratory viral infections, which in most of the cases are self-limiting. This leads to the impact on the general belief that such medicines are effective against these diseases. Consequently, such incorrect belief contributes to the raising of the expectations that antibiotics are an appropriate treatment for common colds. 2 The vast majority of participants (88%) in the current study were more aware that if an antibiotic's full course was interrupted, the effectiveness will decrease; this finding was in comparison with a study conducted by Oh et al. in which 71.1% participants answered correctly. 2 However, 51.8% agreed that they would stop using antibiotics when they start feeling better. This showed the inadequacy of knowledge wherein most people do not understand the real cause and the actual significance of completing the antibiotic's full course. 2 The results of this study stressed the need for an urgent intervention by educating people through annual campaigns about antibiotics' uses, and the importance of compliance. Moreover, it is important to clarify the differences between bacteria and viruses, causes of common colds, and how to alleviate their symptoms apart from antibiotics' usage. The analysis of awareness based on demographics showed significant correlation between misuse and three main factors which are age, gender, and educational level. It was found that those in the age group between 26-35 years were behaving incorrectly more than the other age groups. Furthermore, it had been shown that after the age of 35, individuals become more aware and tend to have a more positive attitude towards antibiotics as their age progresses. This guides us to direct these campaigns to this age group in particular and the other age groups in general. Moreover, in this study females seemed to be behaving better than males in several ways like in using antibiotics without prescriptions, keeping stocks, and using leftover antibiotics. We can attribute this result to the females' nature where they are more careful and practical than men when it comes to their lives. 18 As reported, there is correlation between misusing antibiotics and high educational level. When the participants were questioned directly about their source of information about antibiotics, physicians were occupying the first place followed by the pharmacists. Therefore, it is also important to alert physicians to educate people about the rational uses of antibiotics, its adverse consequences, common cold aetiology, and its management. In addition, pharmacists should be willing to refuse any selling of an antibiotic without prescription. Moreover, health officials can set policies to limit these actions globally. Furthermore, since the majority of participants get their information from their doctors, educating patients by physicians about antibiotic uses, its role in treating aetiologies of URTIs and its adverse effects will have a great impact on patients' knowledge and behaviour. Major changes in prescribing practice supported by a national information campaign would be beneficial to reduce patient's expectation from antibiotics and to raise awareness about antibiotic resistance.

Conclusion
Misconceptions existed about the use and indications of antibiotics. This study highlights the need to educate patients regarding antibiotic use and the consequences of misuse. Which diseases actually require antibiotics, why full daily doses must be respected, risk of keeping part of a course for future uncontrolled use and need of a prescription for getting antibiotics from the pharmacist are some of the issues to be discussed with the patients. The majority of participants who show misuse were from age group 26-35, which makes them the main target for future awareness and educational programmes to improve the knowledge, attitude and behaviour towards antibiotic uses. Interaction is required between physicians and patients and involvement of both print and electronic media may help to improve the antibiotics knowledge and practices in community and consequently control the antibiotics misuse.