Trends in Practices of Self-Medication with Antibiotics among Medical Undergraduates in India.

Background: Self-medication with antibiotics (SMA) without the consultation of a professional is a serious health concern and can lead to serious health hazard. This study was designed to evaluate the trends in SMA behavior and risk factors in medical undergraduates to further explore the association between SMA practices and adverse drug events (ADEs). Materials and
Methods: This cross-sectional questionnaire-based study was carried out among 360 volunteering medical undergraduates at a tertiary care teaching hospital in New Delhi.
Results: 67.78% of students (244/360) gave a history of SMA practice with females dominating (54.09%). Out of 244 students giving a positive history of SMA, 182 (74.59%) experienced ADE, reflecting a strong positive association between the two. Convenience (86.07%) was observed to be the main reason of practicing SMA in this study. Over-the-counter sale of prescription-only drugs, namely antibiotics by the community pharmacies, is as high as 90.16%, leading to the main source of acquiring antibiotics for self-medication. Fever (47.54%) and respiratory infections (39.34%) emerged as the major indications for SMA. Extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics for SMA.
Conclusion: Our findings endorse high SMA prevalence among Indian medical students. Strict regulations on antibiotic sales and public education reinforced by strong antibiotic stewardship program at all levels are highly recommended. Copyright:

INTRODUCTION

Self-medication with antibiotics (SMA) is the use of drugs to cure self-diagnosed disease or its associated symptoms leading to intermittent or continued consumption of a prescribed drug for a chronic or a recurrent health condition.[1] SMA without the consultation of a professional is a serious health hazard.[2] As per an estimate, more than 50% of antibiotics are procured without a valid prescription and misused as over-the-counter drugs all over the world.[3] Around 3%–19% of the general population are practicing SMA in developed countries and 9%-100% in developing countries.[4] This irrational use of antibiotics without any professional advice is responsible for several adverse drug events (ADEs), drug toxicity, resistance to the antibiotic, and ultimately failure of treatment of the underlying disease.[35] An adverse event or experience is defined as any untoward medical occurrence that may present during treatment with a drug but which does not necessarily have a causal relationship with this treatment.[6] ADEs have a strong association with SMA but rarely reported due to lack of awareness, difficulties in follow-up, and critical causality assessment to establish adverse drug reactions (ADR).[7]

SMA often leads to irrational treatment and antibiotic resistance. Emergence of multidrug-resistant bacterial strains are, thus, posing a serious threat to medical management of infectious diseases.[89] The overall treatment period gets prolonged due to resistant strains, leading to longer duration of illness, prolonged hospital stay, and increase in total expenditure calling for urgent need to reserve our antibiotics pool. Hence, well-formulated and detailed studies on the trends of antibiotics usage (SMA) are the stepping stones toward planning and implementing strategies to prevent indiscriminate use of antibiotics.

With this background, the current study was planned to evaluate the prevalence and factors associated with SMA, highlighting the prevalence of ADE among the undergraduate medical students.

MATERIALS AND METHODS

Study design, study population & study period

This was a cross sectional questionnaire based survey and the study population comprised of medical students from 4th, 5th, 6th, and 7th semester of a tertiary care teaching hospital in New Delhi, India. The study was conducted over a period of 4 months and data were collected between October 2019 to February 2020.

Sampling method and sample size

A purposive sampling method was used. 4th, 5th, 6th, and 7th semester undergraduate medical students who have an exposure to pharmacology were invited to take part in the survey. Out of a total strength of 400 students, 360 participated voluntarily in the survey.

Techniques of data collection

A structured and pretested questionnaire in English, designed after a thorough literature review of comparable studies, was modified and drafted as per the local needs.[710] A pilot study was done on 10 students to validate the questionnaire, and these students were not enrolled in the study. Three hundred and sixty students (out of 390) who consented to be a part of the study were enrolled. Students were briefed, questionnaire was distributed and each student was requested to respond independently within a time frame of 30 minutes. Owing to the ingrained issues around validity and reliability of self-administered questionnaire, the cognitive validity of the responses was ascertained by requesting the students to accurately outline the questions and their knowledge on the topic. In addition, the situational validity was ascertained by ensuring that participating students responded to the questions individually to accord anonymity and any fear of stigmatization on their response. The reliability of the responses from the participant students in the main study was compared with the results of the pilot testing of questionnaire.[1112]

The questionnaire included 13 questions regarding the demographic profile and trends in SMA practice among the students. SMA was defined as taking over-the-counter antibiotics without prescription for self-treatment. Information on demographic characteristics and semester was recorded.

Data analysis

The data entry and analysis were performed using Microsoft Excel and SPSS version 17.0 (SPSS Statistics for Windows. Version 17.0 Chicago, SPSS Inc). Frequency tables of major factors influencing self-medications were generated. Frequencies and proportions were calculated.

Ethical considerations

The research study was approved by the Institutional Ethics Committee. The study population was informed that the data gathered would be anonymized and will be used for only publication and that the study participation was entirely voluntary.

RESULTS

Sociodemographic characteristics of the recruited participants

The demographic profile and general characteristics of the participating medical undergraduates as a function of their SMA practices are given in Table 1. The students between 19 and 23 years with a mean age of 20 years participated in the study. Around 68% (67.78%) of students (244/360) gave a history of practicing SMA with females outnumbering (54.09%) the males. Out of 244 students with a positive history of SMA, 53.27% gave a history of multiple (defined by >1) SMA practice. Further 74.59% (182/244) students practicing SMA experienced ADEs, reflecting a strong positive association.

Table 1

Demographic profile and general characteristics of participants as a function of self-medication with antibiotic practices

Demographic and general characteristics	Yes, n (%)	No, n (%)	Total, n (%)
SMA (n=360)	244 (67.78)	116 (32.23)	360 (100)
Male	116 (47.50)	56 (48.27)	168 (46.67)
Female	132 (54.09)	60 (51.72)	192 (53.33)
Multiple SMA (n=244)	130 (53.27)	114 (46.72)	244 (100)
Male	54 (41.54)	50 (43.85)	104 (42.62)
Female	76 (58.46)	64 (56.14)	140 (57.37)
Experienced adverse drug event after SMA (n=244)	182 (74.59)	62 (25.40)	244 (100)

SMA: Self-medication with antibiotic

The results of Table 2 show common practices during SMA. Of the 244 students with SMA, the practice of reading drug literature before use was minimal (77.8% never read a literature). Around 7% patients always changes the dose of antibiotic and 40% discontinued therapy after symptoms got relieved. The outcome of such self medication was restricted to partial relief only, responded by as high as 51% responders. Attitude toward SMA was still deemed acceptable by the 58% of participating students either generally or during an emergency.

Table 2

Trends in self-medication with antibiotic practices

Trends in SMA (n=244)	Frequency, n (%)
Do you read drug literature before use?
Always	2 (0.81)
Sometimes	52 (21.31)
Never	190 (77.86)
Do you change the dose of antibiotic during the course of treatment?
Always	16 (6.55)
Sometimes	116 (47.54)
Never	112 (45.90)
Do you change the antibiotic during the course of treatment?
Always	2 (0.81)
Sometimes	100 (40.98)
Never	142 (58.19)
Do you ever discontinue antibiotic use during the course of treatment?
At the completion of course	92 (37.70)
A few days after recovery	52 (21.31)
After symptoms disappear	100 (40.98)
Outcome of SMA
Successful treatment	96 (39.34)
Partial relief	124 (50.81)
Unsuccessful	24 (9.83)
What is your attitude toward SMA? (n=360)
Good/acceptable practice	102 (28.30)
Should be practiced only in emergency	108 (30)
Wrong/prescription-only by a doctor	150 (41.66)

SMA: Self-medication with antibiotic

The graphical presentation in Figures 1-4 reflects convenience (86.07%) as the main reason of SMA, community pharmacy (90.16%) as the main source of acquiring antibiotics for self-medication, fever (47.54%) as the major indication followed by respiratory infections (39.34%), and gastrointestinal problems with 35.25%. Extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics.

Figure 1

Common reasons for self-medication with antibiotics. *Past experience. ϮKnowledge of Antimicrobials

Figure 4

Percentage frequency of antibiotics used for self-medication

Common sources for acquiring the self-medicated antibiotics

Common indications for self-medication with antibiotics

DISCUSSION

The prevalence of SMA practices: One of the major observations of this survey is the alarmingly high (67.78%) prevalence of SMA among the medical undergraduates of North India. The outcome of this study is on similar lines with those that of SMA patterns in various developing nations where the overall median proportion of self-medication reported is around 38.80%.[13] When it comes to university students of different countries, the SMA rates have been reported between 24%–90%[141516] in contrast to Europe and other developed countries where only 1%–4% of prevalence rate was found for SMA,[4] indicating that strict regulations as far as over-the-counter (OTC) sales of antibiotics are concerned.

Inappropriate practices in SMA: Literature search showed that the most common inappropriate practices in the non-prescription use of antibiotics includes using antibiotics as prophylaxis,[17181920] as analgesic,[18] for the treatment of viral infections[212223242526] and usage at reduced dose.[272829] Further studies showed that changing antibiotic without consulting the doctor[27] and not taking antibiotics for the prescribed period which included either reducing the duration of treatment (mostly <5 days[2728]) or prolonging the duration of treatment (mostly more than 7 days).[1719] Similar to a study by Belkina et al.,[27] our findings reflect that around 41% respondents discontinued their antibiotic after disappearance of symptoms.

Association between self reported ADE and SMA practices: As per our study, it was concluded that there was a strong positive association between self reported ADE and SMA practices. About 74.59% of the students were observed to have suffered from ADEs in the group practicing SMA. In contrast to the current study, experience of ADEs was found to be much lower in an online survey conducted at a Chinese University where only 13.3% of self medicated students had experienced ADEs. Thirty two out of 42 students stopped taking antibiotics and the reason for such a disparity could be either racial difference or lack of awareness.[7]

Possible reasons for SMA: It was observed in our study that convenience (86.07%), past experience of the illness (24.59%), and prior knowledge of antibiotics (20.49%) were the most commonly cited reasons for SMA. These reasons are consistent with the findings from other studies in the developing countries.[303132] The root causes leading to SMA in India are majorly due to poor regulation of antibiotic sale and use[1831] , lack of awareness of consequences of inappropriate antibiotic use and misconceptions about antibiotics and the disease etiology.[2526] Female being more cautious about self-care and prone to SMA for menstrual symptoms may explain the higher prevalence in female gender.[3334] It is noteworthy that although our students had a good antibiotic knowledge, they had poor SMA practices and attitude. Such deficient translation of knowledge into practices and behavior has also been reported among other Indian and Turkish University students.[1415]

Common sources for acquiring the self-medicated antibiotics: Previous studies have reported that the majority of the populations acquired self-medicated antibiotics from a variety of sources, such as pharmacies, stored leftover drugs, friends/relatives, or online purchase.[2528] Since pharmacies were the main source of acquiring antibiotics in this study, pharmacists could play an important role in educating patients, rationalizing antibiotic use, and stopping antibiotic sales without a prescription.[13] Moreover, the manufacturer's fixed packaging, driven by cost of economics often results in under- or- oversupply of antibiotics, contributing to antibiotic resistance.[35] Such oversupply of antibiotics observed in an Indian study[36] is similar to ours, with left over antibiotics being the second most important source of self- medicated antibiotics.

The most common indications for which the respondents would self-medicate match in totality with those across the globe,[2225] which are fever (47.54%), respiratory tract infections (39.34%), and GIT associated problems (35.25%). These are predominantly viral in origin and therefore not treated with antibiotics. This finding is concordant with reported results from studies in the Euro-Mediterranean region[37] and developing countries.[13]

Antibiotics frequently used for self-medication: As evaluated by the data from previous studies, some of the antibiotics commonly used for self-medication were extended-spectrum penicillins (amoxicillin/amoxicillin–clavulanic acid), macrolides, cephalosporins, fluoroquinolones, and tetracycline.[263138]

However, the extended-spectrum penicillins (60.66%) were the most commonly used class of antibiotics for self-medication in our study, followed by quinolones (33.61%) and cephalosporins (20.49%). The high use of extended-spectrum penicillins without prescription may be due to penicillin's widespread reputation, its low cost, and the fact that it does not have disturbing side effects, unlike other classes of antibiotic.[25]

Recommendations to reduce the irrational use of antibiotics: By far the most effective way to counter SMA, according to various studies across the globe was public education[3940] through mass media campaigns[3138] and implementation of strict law against OTC sale of ‘prescription-only drugs’.[34142] Strict national policy in South Korea and Chile, which prohibits physicians from dispensing drugs has considerably brought down antibiotic usage and improved rationale use of antibiotics by limiting unnecessary prescription for irrelevant conditions like viral infections.[4344]

Literature search of recent studies across the globe concluded as following:

Torres et al. concluded that nonprescribed antibiotic utilization was perceived as an expression of self care where participants experience self perceived symptoms[45] Haque et al., found SMA common amongst Malaysian students despite understanding the drawbacks of SMA and that even the medical students self medicate.[46] A study of SMA in a health center in Riyadh (2016) showed that the prevalence of self-prescription was as high as 78.7%, while the practice is slightly better among medical students in India in our study (67.78%). The most common predictors were friend's advice and proximity of the participants to pharmacy[47] in contrast to our study where friends and relatives contributed to only 13.11%.

CONCLUSION

It can be concluded from the findings of our survey that SMA is highly prevalent among medical undergraduates with convenience and OTC sale of antibiotics as the main reason and source of self-medication, respectively. We also observed a strong association of experiencing adverse events with SMA practices. A student being the future prescribing physician, it is critical to impress upon the significance of rational use of antibiotics with the increasing burden of antimicrobial resistance, justified by the recent incorporation of antimicrobial stewardship in the pharmacology curriculum. However, to address the irrational use of antimicrobials, enforcing regulatory measures on OTC antibiotic sale, restricting access to prescription only medications, controlling physician over prescribing, and further incorporating it into a strong national/global network is highly recommended. The results of our study suggest conducting large-scale prospective longitudinal studies to determine the level of antimicrobial resistance, treatment failure, and confirm causality of ADRs associated with SMA practices.

Study limitations

The limitations of such self-reported studies are risk of recall bias and obtaining socially desirable responses. Moreover, students practicing SMA could have been attracted to this study; which could also have introduced bias in SMA frequency estimates and generalizing our findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.