Antibiotic resistance is a global problem and antibiotic overuse is cited as the main reason for its development [1
]. Countries with higher consumption have been found to have higher rate of antimicrobial resistance [3
]. Factors leading to antimicrobial overuse in children are complex, involving, among other factors, parental knowledge and attitude, physician beliefs as well as constraints of daily practice [4
]. It is estimated that 20-50% of all antibiotic use is inappropriate [5
]. As per data, most antibiotic prescriptions for respiratory tract infections (RTI) and diarrhoea are inappropriate [3
]. As per International Medical Survey (IMS) Health data, units of antibiotics sold has increased by 40% in India from 2005 to 2009 [5
], whereas in USA a 14% decrease in antibiotic usage was seen from 2002 to 2010 [6
Doctors prescribe antibiotics to patients who do not need them and patients do not adhere to their treatment causing the risk of antibiotic resistance (many take antibiotics in under-dose or for shortened duration) [1
]. Thus, it is also important to study the behaviour of the patients in order to understand the causes of overuse of these drugs. There is limited data regarding the behaviour of caregivers in respect to antibiotic use in the children, therefore, this study aims to explore the parental knowledge and practices regarding antibiotic use for children, and investigate the antibiotic prescription pattern in paediatric out-patient department of a secondary care government hospital of Gurgaon, Haryana, India.
A descriptive cross-sectional study was conducted in a secondary care government hospital of Gurgaon, Haryana over a period of one week (September 2013). The study targeted to interview the caregivers who accompanied the patients to the paediatric out-patient department of the hospital. The prescriptions were also analysed from the out-patient department to study the antibiotic prescription pattern and the rational use of antibiotics (as per National Formulary of India (NFI) guidelines) [7
]. World Health Organization (WHO) guidelines [8
] state that a minimum of 100 prescriptions should be analysed from one health facility and therefore a total of 100 prescriptions were analysed. Only new cases were included in the study and universal sampling method was followed. Similarly, 100 caregivers were interviewed face to face by the interviewer, using a pre-tested close-ended questionnaire.
The questionnaire used to interview the caregivers contained sections on socio-demographic data, knowledge regarding antibiotics, and practices of caregivers regarding the course of treatment prescribed (antibiotics and other medicines). The questions had multiple choice options, with opportunity to choose more than one options in some questions. A proforma was used to collect the information from the prescriptions like signs and symptoms, antibiotic prescribed and laboratory investigations ordered. The research protocol was approved by the ethical committee. The interviewees were informed about the purpose and nature of the study in local language and the consents were obtained. Data was analysed using Epi Info 7 statistical software and univariate and bivariate analysis was performed.
Out of 100 prescriptions examined, 45% had antibiotics prescribed (two of the prescriptions had two antibiotics prescribed in each i.e. 47 antibiotics were prescribed. Of the 47 antibiotics prescribed, 41 (87%) were generic drugs, 44 (93%) were from the WHO Essential Drugs List (EDL)  and 34 (71%) were as per NFI guidelines. Out of the 45 prescriptions, 34 (76%) consisted of single antimicrobial agent, 9 (20%) were fixed-dose combinations and 2 (4%) were antimicrobial combinations (but not fixed-drug combinations).
Maximum antibiotics were prescribed for respiratory tract infections and fever cases. Cases like abdominal pain and diarrhoea also had antibiotics prescribed (Table 1). Amoxicillin (23/47, 49%) followed by Amoxicillin fixed-dose combinations (7/47, 15%) were the most commonly prescribed antibiotics (Table 1).
Of all the caregivers interviewed, 47 were males and 53 were females. 48 care-givers (males=32, females=16) were educated high school and above while 19 (males=3, females=16) were illiterates. 57 caregivers belonged to lower socio-economic class (males=17, females=40) while 43 belonged to middle class and above (males=30, females=13). Only 36 caregivers had knowledge of antibiotics- 21 males (45%) and 15 females (28%). All of them believed that antibiotics are used for the treatment of common cold and only 5 out of these 36 (14%) knew that antibiotics are used for bacterial infections (Table 2). Only 12 caregivers acknowledged that antibiotics have side-effects (33%) and only 3 (8%) agreed that misuse reduces their efficiency and increases antibiotic resistance. Knowledge of antibiotics was higher in caregivers educated till high school or above and belonging to middle class or above and it was significant (p<0.05) (Table 3). 59% parents completed the given course of treatment to their children; 23% stopped giving medicines after symptoms disappeared, 17% stopped few days after recovery and 1% after the medicines finished. In another question, majority of caregivers stated that they never changed medicines (93%) and dosage of medicines (82%) during given course of treatment. Most of the caregivers educated below high school (31/52, 60%) and belonging to middle class (33/57, 58%) completed the full course of treatment. No significant association was present between any demographic factors and the completion of full course of the treatment (Table 3).
The proportion of antibiotic containing prescriptions i.e. 45% in the present study is quite similar to the results of other prescription analysis studies conducted in India [10
] and neighbouring countries [3
]. Most of the antibiotics prescribed in out-patient department were from the WHO EDL list and were generic drugs which is quite dissimilar to what was found in other studies [3
]. This may be because the present study was conducted in a government hospital and the doctors are required to prescribe the drugs from the list of drugs available in hospital.
The rational encounters of the present study were found to be similar to those in previous studies [5
], but the results were dissimilar to WHO data which states that only 30% of prescriptions in public sector are in accordance with the guidelines in South Asia [3
]. It was also found that there was a trend towards prescribing antibiotics for common ailments like respiratory tract infections and diarrhoea. Excessive use of antibiotics is similar to the results obtained from India [5
] and other countries [3
To understand the knowledge of antibiotics among the caregivers, a face to face interview was conducted outside the out-patients department. Overall the results of the study show that the participants had a poor knowledge of antibiotics when compared to the results of the other studies [4
]. In terms of beliefs of antibiotic use, many of them believed that antibiotics are used for common cold, cough and viral fever. Only a few were aware that antibiotics are used for bacterial infections. Many studies have earlier demonstrated that misconceptions exist among the general public regarding the therapeutic effects of antibiotics. It is true that general public is not able to differentiate the types of causal agents of infectious diseases and often confuse the antibiotics with other symptomatic drugs, but when compared to other studies [4
] these misconceptions were higher in the present study. Furthermore, the knowledge of side effects of antibiotics, most importantly antibiotic resistance was very low among the participants which is also in contrast to the results obtained in other studies [4
] However, when lay people talk about ‘resistance’, this term could mean human resists to antibiotics rather than microorganisms to antibiotics.
In the present study, association was present between education and socio-economic status of participant and knowledge of antibiotic. Similarly, education [17
] and socio-economic status [19
] were found to be associated with knowledge of antibiotics in other studies but some did find association with gender and age also [17
Non-adherence to the given treatment is an important factor for the development of antibiotic resistance [1
]. Therefore, compliance to the given course of treatment was assessed among the participants, irrespective of whether antibiotic was prescribed or not. It was noted that compliance was low and this finding was similar to other studies wherein less than 60% participants completed the course of treatment [18
]. Incidentally, no association was found between any of the demographic factors and compliance to treatment.
It can be concluded that though generic drugs and antibiotics from WHO EDL list are commonly prescribed in the paediatric out-patient department of the particular government hospital studied, but the rate of rational prescriptions is still low. Moreover, antibiotic knowledge among the caregivers is very low and this may lead to misuse of antibiotics among the population. The community as a whole need to be made aware of the antibiotics and its side-effects and the doctors need to be motivated to prescribe antibiotics rationally. Although, the results of this study cannot be extrapolated to the population at large, but do reflect the general tendency and the prevalent practices among care-givers.
charya AS. Have we reached a full circle? Time to ponder on antimicrobial resistance! World health day 2011: a public health perspective. Indian J Med Spec 2011;2:5-7.
ashyap B. Combat drug resistance: no action today means no cure tomorrow. World health day 2011: a microbiologist’s perspective. Indian J Med Spec 2011;2:8-11.
olloway A, Dijk LV. The world medicines situation 2011-Rational use of medicines. 3rd ed; 2011. http://www.who.int/medicines/areas/policy/world_medicines_situation/WMS_ch14_wRational.pdf [Accessed on May 4, 2013]
ousounidis A, Papaevangelou V, Hadjipanayis A, Panagakou S, Theodoridou M, Syrogiannopoulos G, et al. Descriptive study on parents’ knowledge, attitudes and practices on antibiotic use and misuse in children with upper respiratory tract infections in Cyprus. Int J Environ Res Public Health 2011;8:3246-62. [PUBMED
tuation analysis antibiotic use and resistance in India. Global antibiotic resistance partnership- India national working group, March 2011. http://www.cddep.org/sites/cddep.org/files/publication_files/India-report-web.pdf Accessed on June 19, 2013.
hai G, Governale L, McMahon AW, Trinidad JP, Staffa J, Murphy D. Trends of outpatient prescription drug utilization in US children, 2002–2010. Pediatrics 2012;130:23–31. [PUBMED
nti-infectives. In: National Formulary of India. Ministry of Health and Family Welfare, India. 2011 4th edn, pp.105-234. http://www.cdsco.nic.in/NFI_2011.pdf Accessed on Sep 17, 2013.
ow to investigate drug use in health facilities: selected drug use indicators. WHO publication, 1993. http://apps.who.int/medicinedocs/en/d/Js2289e/ Accessed on May 9, 2013.
HO Model List of Essential Medicines. 18th List. April 2013, pp. 9-12 http://www.who.int/medicines/publications/essentialmedicines/en/index.html Accessed on July 21, 2013.
mane H, Priyadarshini KOP. Prescription analysis to evaluate rational use of antimicrobials. Int J Pharm Bio Sci 2011;2:314-9. http://www.ijpbs.net/volume2/issue2/pharma/41.pdf Accessed on July 21, 2013.
attopadhyay A , Mondal T, Saha TK, Dey I, Sahu BK, Bhattacharya J. An audit of prescribing practices in CGHS dispensaries of Kolkata, India. IOSR-JDMS 2013;8:32-7. http://iosrjournals.org/iosr-jdms/papers/Vol8-issue1/G0813237.pdf Accessed on Dec 4, 2013.
diveni T, Chandra DS, Sundresh NJ, Kumar BA, Padmini P, Haritha K. Analysing the rationality of antibiotics in comparing the different departments in RMMCH. Journal of Biomedical and Pharmaceutical Research 2013;2:74-6. http://jbpr.in/index.php/jbpr/article/view/135/141 Accessed on Dec 4, 2013.
hmed SM, Islam QS. Availability and rational use of drugs in primary healthcare facilities following the national drug policy of 1982: Is Bangladesh on right track? J Health Popul Nutr 2012;30:99-108. [PUBMED
ldeyab MA, Kearney MP, McElnay JC, Magee FA, Conlon G, Gill D, et al. A point prevalence survey of antibiotic prescriptions: benchmarking and patterns of use. Br J Clin Pharmacol 2011;71:293–6. [PUBMED
g DSY, Kuyvenhoven MM, Dijk LV, Verheij TJM. Antibiotics for respiratory, ear and urinary tract disorders and consistency among GPs. J Antimicrob Chemother 2008; 62:587–92. [PUBMED
otwani A, Holloway K. Trends in antibiotic use among outpatients in New Delhi, India. BMC Infect Dis 2011;11:99. [PUBMED
idayati A, Suryawati S, Crespigny CD, Hiller JE. Knowledge and beliefs about antibiotics among people in Yogyakarta city Indonesia: a cross-sectional population-based survey. Antimicrob Resist Infect Control 2012;1:38. [PUBMED
rimi N, Pereira LMP, Prabhakar P. Caregivers’ practices, knowledge and beliefs of antibiotics in pediatric upper respiratory tract infections in Trinidad and Tobago: a cross-sectional study. BMC Fami Pract 2004;5:28. [PUBMED
h AL, Hassali MA, Al-Haddad MS, Sulaiman SAS, Shafie AA, Awaisu A. Public knowledge and attitudes towards antibiotic usage: a cross-sectional study among the general public in the state of Penang, Malaysia. J Infect Dev Ctries 2011;5:338-47. [PUBMED
eder SI, Ayed IA. A survey of public knowledge and behavior related to antibiotic use and resistance in community pharmacies in Khartoum State. Int J Bioassays 2013;2(5). ebioscholar.com/ojs/index.php/ijb/article/view/310 Accessed on Dec 4, 2013.
J, Jimmy B, Al Sabahi AGMS, Al Sabie GA. A study assessing public knowledge, belief and behavior of antibiotic use in an Omani Population. Oman Med J 2013;28:324-30. [PUBMED