Assessment of Antibiotics Misuse among People in Erbil City

Background: Antibiotics are only useful for treating bacterial infections. Inadequate use of antibiotics includes overuse, inappropriate type, dose, duration and/or frequency of administration had been a major problem. Antibiotic use has been identified as a major contributor to the development and spread of antibiotic resistance. Objectives: Assessment self-medication and inappropriate of antibiotics were used among people in Erbil city. To find out the associations between the antibiotic use and knowledge related antibiotic consumption. Methods: The study was used a cross-sectional study, which conducted on 500 randomly, selected adult residents in Erbil by using a face-to-face questionnaire. Results: About half of the study samples (52.40%) did not know that antibiotics has adverse effect on humans body, 37.80% were agree to used antibiotic for headache treatment, 65.80% of them did not know that antibiotics kill normal flora, and 57.20% were did not know that bacteria become resistant to antibiotics. In addition, 46.00% were used antibiotics on advice of someone other than a physician or pharmacist, 46.20% of peoples were some time used antibiotics against colds and flu, 52.40% of peoples were some time used antibiotics as injection, and 57.20% of peoples were some time used antibiotic as one capsule when needed. Conclusion: Self-medication and inappropriate use of antibiotics were problems among people in the community. Recommendation: Strict precautions should be taken about antibiotics use and sale without prescriptions.


INTRODUCTION
Antibiotics are among the most common drugs prescribed.The spread of antibiotic resistance is a major threat to public health (1,2) .A direct relationship between excessive antibiotic use and increasing microbial resistance had been documented also influenced by how antibiotics are used by the patient (3,4) .Moreover, levels of bacterial resistance occur in proportion to the volume of community antibiotic use (5,6) .Many commensal and pathogenic bacteria have developed resistance to antibiotics (7) .Antibiotics should be used with care as antibiotic resistance is correlated with antibiotic use (8) .The emergence of antibiotic resistance has been recognised as an important health problem because discovery of new antibiotics is no longer keeping pace with the spread of highly resistant bacteria (9) .The resistance to any antibiotic is promoted by excessive prescribing of broad-spectrum antibiotics, because this overprescribing promotes resistance to agents that are commonly used to complicated infections (10,11) .
The increasing use, overused and abused of antibiotics to treat illness is the greatest factor causing spread of drug resistance.Antibiotics are misused because many patients do not take antibiotics according to prescription instructions (12) .Misuse of antibiotic therapy, including failure to complete therapy, skipping of doses, or reuse of leftover antibiotics, can potentially exposed patients to suboptimal doses of antibiotic therapy (13)(14)(15) .Antibiotics do not have any effect on viral infections.The treatment for a cold is normally getting rest (16) .Misuse of antibiotic therapy has ramifications on treatment failures in patients with antibiotic resistant infections, wasted medication, hospitalisation time, and increased return visits to the physician (13,14) .
Self-medication with antibiotics may increase the risk of inappropriate use and the selection of resistant bacteria (17) .Unnecessary prescription of antibiotics is the main driver for the development of antibiotic resistance (18,19) .Physicians may overprescribe antibiotics because they want to prevent potential infections or simply because they believe that is what patients want (20) .The consequences of antibiotics overuse are striking, every year; millions of people are directly exposed to the side effects of antibiotics (21) .Increased treatment options, more variable benefits and risks, higher financial costs, and the growth of consumerism appear to be central contributors to a growing role for patients in the decision making process (22)   .In low-income countries showed that the cost of medical consultation and low attitudes and behaviour of health personnel might reinforce use of self-medication with antibiotics (23) .The widespread consumption of inappropriate and inadequate doses of antibiotics in developing countries is of a major concern of which resistance to antibiotics has been linked to level of consumption (5) .Many countries increasingly implement actions to control antibiotic resistance through rational use (24) .The objective of the presented study was to evaluate the awareness toward antibiotic usage among the peoples.

METHODS
The cross-sectional study conducted on people in Erbil city.Home visits were conducted a randomly selected households in Erbil quarter from June 2012 to July 2013.Only one member of the household was selected randomly by alphabetically of the names who those above 18 years and able to understand and answer the questionnaire.Participants were given information by completed the questionnaire face to face.Informed consent was obtained from 500 participants in the study.Setting of study: the present study was conducted Erbil city.Instruments composition: Study tool was prepared through literatures review, which involved two parts; Part I: demographic characteristics were include age, gender, marital status, and level of education.Part II: this part composed of the questionnaire toward awareness (11 items) and attitudes (10 items) of participants about antibiotic use.

Validity of questionnaire:
Five experts from different related specialties were evaluated the questionnaires.Statistical methods: Data was analyzed using SPSS 19.0 software.Qualitative variables were compared using the Chi-square (X 2 ).All p-values with p < 0.05 were considered significant.This table shows that the demographic characteristic of 500 population-studded shows that the majority (50.8%) of ages were 18 to 24 years of which males were 68.2%, while females were 31.8% and the married status were 44.2%.According to the educational status, high percentage 59.6% of the population was in the level 7-12 (Table 1).  2 shows that there is high significant (P = 0.02) relation between antibiotic taken and level of education, while there are no significant with age (P = 0.48), gender (P = 0.11), and marital status (P = 0.25) (Table 2).  3 show that there are significant differences between age group and stop taking of the antibiotic when feeling better (P = 0.04).However, there are no statistical differences with others statements under table 3.  4 shows that positive relation were found between age group with following statements; complete the course of prescribing antibiotics and avoid cutting the course of treatment (P = 0.02); antibiotic effective against cold and flu (P = 0.01); Antibiotic used for headache treatment (P < 0.01), and; all antibiotic are similar in same activity and way of use (P = 0.04) (Table 4).5 shows that there were significant relations were found between gender and most of statements, while no significant relations were found in statements; Used old prescription of antibiotics (P =0.78); stop taking antibiotic when feeling better (P=0.27);Change the antibiotic if do not feel better immediately (P = 0.843), and; used overdose of antibiotics (P= 0.28) (Table 5).6 present there were no difference between male and female in the statements; taking antibiotic has adverse effect on your body (P = 0.11); Antibiotic kill normal flora (P = 0.57), and; bacteria become resistant to antibiotic (P = 0.10) (Table 6).Sig.= Significant, N.S= Not significant Table 7 reveals that there were significant relations between level of education and following statements; Used antibiotics on advice of someone other than a physician or pharmacist (P= 0.02); Antibiotic used as one capsule when needed (P= 0.01); Used overdose of antibiotics (P= 0.01) (Table 7).Sig.= Significant, N.S= Not significant Table 8 shows that there were statistical associated between level of education with the following statements; Taking antibiotics has adverse effect on your body (P= 0.01); Unnecessary use of antibiotics has adverse effect on your body (P < 0.01); Complete the course of prescribing antibiotics and avoid cutting the course of treatment (P= 0.02) Antibiotics kill normal flora (P < 0.01); Antibiotic is a fever lowering agent (P < 0.01); Antibiotics effective against colds and flu (P < 0.01); Antibiotic used for headache treatment (P < 0.01); All antibiotics are similar in the same activity and way of use (P < 0.01); used overdose of antibiotic (P= 0.02), and; Bacteria become resistant to antibiotics (P < 0.01) (Table 8).

DISCUSSION
Antibiotic resistance is a serious and growing problem in nations around the globe (25) .A direct relationship between rates of antibiotic use and misuse with the rising bacterial resistance has been reported (6) .The current study was assessed the antibiotic abuse in community of Erbil city, this study investigate the prevalence of self medication among population of which, 62.3% used antibiotics for headache, 49.8% for fever and 48.3% for cold and flu.
The result found that about half of the people use antibiotics on advice of someone other than a physician or pharmacist, in compared with others studies, 46% of the community uses antibiotics without prescription in Jordan (26) .While in Greek population, the level of use of non-prescribed antibiotic was as high as 74.6% (27) .This difference in results may be attributable to the public awareness, different cultures, and health system.Antibiotics resistances are affected not only by over dose of it but also by the way of antibiotics used, which emphasizing pharmacists role and responsibility in stopping antibiotic sale without prescription.The prescribing practices of practitioners are not regulated (28) .
The study found about half of participants declared about the price of which some of the people may not have enough money to go to physicians or have time.In addition, the study found that some of the people choose antibiotic according to the colour and shape thus, it is necessary to raise awareness about the threat of antibiotic resistance and the importance of prudent antibiotic use.The study were conclusion that weak awareness and irrational of antibiotics used among people in Erbil city.

CONCLUSION
Self-medication and irrational use of antibiotics is common among the people in the community in Erbil city.Education increases attitudes of awareness toward antibiotic use.

RECOMMENDATION
The development of antibiotics management and the promotion of the role of the pharmacist in antibiotics prescribing, also improved strategies for antibiotics prescribing.