Epidemiological Study of Antibiotic Self-Medication in Tehran 1399: A Descriptive Study

Hesam Aldin Varpaei1*, Hossein Esmaeili2, Mohammad Yavari1, Mohammad Mahdi Miremami1, Amir Mahdi Farahani1, Faeze Esmaeili1, Saba Abachi1, Pariya Onsori1, Pedram Nouroozi1 and Ali Kazemi3 1Bachelor of Nursing, Tehran University of Medical Sciences, Iran 2Young Researcher and Elite Clube, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran 3Assistant Professor, Department of Pharmacology, Tehran University of Medical Sciences, Iran


Introduction
Self-medication is the use of medication to prevent, treat, or control the symptoms of illness and often involves a combination of therapeutic resources and the use of over the counter (OTC) medications, including antibiotics [1]. According to the World Health Organization, self-medication means the selection and use of medications by individuals to treat self-diagnosed diseases or symptoms. Self-medication is a relatively widespread practice around the world. Developed and developing countries focus on self-medication as a component of health care policy [2]. It has also been suggested that self-medication can help prevent and treat diseases that do not require medical advice and provide a cheaper alternative to treating common diseases [3]. In fact, self-medication is a part of self-care, which has greatly contributed to the efficient use of antibiotics (correct medication, correct dosage, and course of treatment) can prevent Create an infection, treat, and prevent the infection from spreading. Antibiotic resistance is the ability of a pathogenic microbe to develop resistance to the effects of an antimicrobial (antibiotic) [6].
Antibiotic abuse and poor monitoring have turned antimicrobial resistance (AMR) into a global health crisis, and the situation is exacerbated by the difficult discovery and production of novel antibiotics [7].In recent years, various studies on antibiotic selfmedication have been conducted in different parts of the world to identify the prevalence, risks and factors associated with antibiotic abuse [8][9][10][11]. The World Health Organization announces the sale of drugs without Prescription is challenging in most countries [12], however, according to a 2017 study, it is estimated that more than 50% of antibiotics are purchased without a prescription and are used without a prescription in most parts of the world [13]".
Various studies state that the incorrect use of antibiotics among individuals is due to lack of awareness about the authority use of antibiotics or insufficient information [14][15][16]. However, one study states that despite sufficient knowledge about the side effects of self-medication with antibiotic, self-medication with these drugs is common [17]. In this regard, most studies of education and community awareness are considered important and necessary in the prevention of self-medication with antibiotics [14,18].
Although the World Health Organization has declared antibiotics as prescription-only drugs, research shows that factors related to the socio-cultural, behavioral, economic, and health systems play an effective role in self-medication with antibiotics in low-income countries [19][20][21].Most studies have shown that selfmedication and prescription by a non-physician may be due to the high cost of antibiotics, the high cost of medical consultation, and other economic factors [22,23]. Of course, even in rich countries where most medicines are free and doctors' consultations are free, self-medication with antibiotic is prevalent [18].Therefore, considering the importance of self-medication in human health and the consequences of self-medication with antibiotics (such as antibiotic resistance), the aim of this study was to investigate the prevalence and causes of self-medication with antibiotics in Tehran in 1399. Also, quality (including duration of treatment, Discontinuation, and dose adjustment of self-medication with antibiotics) are also considered.

Materials and Methods
The present study was a cross-sectional descriptive study that was conducted in the spring of 1399 (April to July 2020) on community members (including students, ordinary people, businesses, passers-by, and patients in Tehran). It was done with ethical considerations. After designing the questionnaire, ordinary people in the community entered the study with the condition of consent to participate in the project. All questionnaires were anonymous. Participants were assured of confidentiality.
Questionnaires were filled out by researchers in each section. Data collection tool in this study was the use of a written questionnaire that information was completed using two methods of selffulfillment for literate participants and interviews for illiterate people. The questionnaire included questions in the form of two axes of personal information and self-medication habits with antibiotics and its causes. Each questionnaire was numbered, and coded information was extracted. SPSS 23 software was used for statistical analysis. Data significance level was considered 5% (P-Value <0.05). Descriptive statistics analysis was performed, and the prevalence of selfmedication with antibiotics was calculated. The same descriptive analysis was used to calculate the frequency of causes of selfmedication with antibiotics and drug classes usage.

Results
In this study, 932 people in the community were studied, of which 764 (82%) were self-employed and 168 (18%) were other people (companion or parents) who answered the questionnaire.
The mean age of the participants in this study was 62 ±39. Out of the total population, 800 (86%) had self-medication with antibiotics during the last 6 months. Self-reported diseases are listed in the (Table 1). Sore throat (pharyngitis) was the most important cause of antibiotic self-medication. Cough (with or without sputum) and runny nose were two relatively common causes of antibiotic selfmedication. Genital infections (such as vaginitis), diarrhea, and urinary incontinence are less common causes of self-medication with antibiotics.Several antibiotics have been used for selfmedication. Amoxicillin 226 cases, cephalexin 204 cases, cefixime 155 cases, azithromycin 126 cases, erythromycin 40 cases, ampicillin 30 cases were the most used antibiotics. The following were used by 19 cases: ceftriaxone (ampoule) 8 cases, cefazolin (ampoule) 6 cases, penicillin G 4 cases and clindamycin (ampoule) was 1 case.Participants were asked to change the dose of antibiotics used during self-medication.

Discussion
The prevalence of antibiotic self-medication in different countries and regions varies from 31% to 47.6% [9,[15][16][17]. In the present study, the prevalence of self-medication with antibiotics in the last 6 months was about 86%, which is significant. It seems that the difference in the prevalence rate of self-medication may be due to differences in the demographic characteristics of the study samples, research methods, data collection tools, and the definition of antibiotic self-medication. Antibiotic self-medication is a complex phenomenon among individuals that is driven by a wide range of determinants [24].Several reasons for self-medication have been identified in various studies. The most common reason for self-medication is mild illness, followed by the cost of a doctor's visit, previous experience of use, long waiting time to see a doctor, and lack of time and health insurance [25]. In our study, the three main reasons for self-medication with antibiotics were previous experience with specific antibiotics (20.125%) followed by lack of time (18.875%) and family members' recommendations (14.625%).
The results of a similar study confirm these reasons [9].A study in Saudi Arabia shows that penicillins and macrolides are the most widely used antibiotics [26], relatively similar results in our study showed that penicillins, macrolides and cephalosporins were the most commonly used antibiotics.
Amoxicillin and cephalexin are the two most commonly used antibiotics in this study. Amoxicillin is the most widely used antibiotic for self-medication in many countries [9,18,22,27].
Amoxicillin and potassium amoxicillin / clavulanate are considered as effective and safe first-line antibiotics for upper respiratory tract infections such as pharyngitis and otitis media [28,29]. It seems that high use of amoxicillin may be limited due to its low cost, easy availability, and limited side effects [30]. Amoxicillin and macrolides are also the most common antibiotics prescribed and patients tend to use these prescriptions as a reference for similar diseases in the future [31,32]. Also, since the most common disease treated with antibiotics was sore throat or pharyngitis, and amoxicillin is a good treatment for pharyngitis, amoxicillin had the highest rate of selfmedication. Although many cases of sore throat or pharyngitis are related to viral infections and need not to be treated with antibiotics, this study is limited to confirming the bacterial infection of self-treated pharyngitis.In this study, antibiotics were commonly used for sore throats, cold symptoms such as cough, rhinorrhea, and fever.This is consistent with other studies, and several studies confirm that the most reported cases of antibiotic self-medication included sore throat, cold, cough with sputum, flu-like symptoms, pain, fever, and runny nose [22,33,34].
The four main sources of information about self-medication with antibiotics reported by the participants of this study: previous experience (23%), medication prescription (catalog or medicine box) (21%), consultation with a physician (19.5%), search On the Internet (10%), however, a study by health care professionals identified the most important source of antibiotic information [15].A serious finding in the present study was the change in the dose of antibiotics used. Less than half of the subjects changed their dose of antibiotics during the course of self-medication with antibiotics. This is consistent with a similar study [35]. The results of a study show that people often inform the pharmacist and doctor about the course of antibiotic treatment [35].There are several limitations to this study. The cross-sectional study design limited our preference for causal inference between self-medication with antibiotics and related factors. Although self-reported data may contain a reminder bias, our findings were almost consistent with most other studies. Antibiotic selfmedication may vary from population to population, such as medical students. Given that only one province was surveyed, these results cannot be generalized to the whole country. Selection bias was also established by setting a 6-month limit for antibiotic selfmedication.

Conclusion
This study showed a very high prevalence of antibiotic selfmedication, which can lead to the development of microbial resistance, antibiotic resistance, and treatment failure. This study also shows that amoxicillin, cephalexin and cefixime were the most

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Funding
The study was not financially supported.