Awareness and Knowledge of Antibiotics and Antimicrobial Resistance among Beneficiaries Attending the General Outpatient Clinic of a Tertiary-level Hospital in India

INTRODUCTION WITH OBJECTIVES

The World Health Organization (WHO) has declared antimicrobial resistance (AMR) as one of the top 10 global public health threats to humanity. Without effective antimicrobials, the success of modern medicine in treating infections, including those during major surgery and cancer chemotherapy would be compromised. Misuse and overuse of antimicrobials are the main drivers in the development of drug-resistant pathogens.¹ Globally, AMR is one of the leading causes of death directly responsible for approximately 1.27 million deaths and associated with 4.95 million additional deaths in 2019.² The cost of AMR to the economy is enormous, impacting higher rates of death and disability, prolonging illness, longer hospital stays, and the need for more expensive medicines.¹ It is estimated that failing to address AMR will cost the world’s economy US$ 100 trillion by 2050.³

AMR awareness raising, education, and behavior change of communities against non-prescription AMR use are included in the WHO core package of AMR interventions.⁴ There is a further recommendation that the rate of antibiotic prescription in general practice (GP) should not exceed 27% of all prescriptions.⁵ Studies from Ghana report antibiotic usage in GP between 50 and 82%.^6,7 Recent estimates on GP antibiotic usage in India are lacking in published literature, but irrational prescription of antibiotics appears to be high.⁸ A multisite, multicountry study reports high awareness of AMR among providers, which ironically did not result in reduced antibiotic prescribing.⁹ Patients are important stakeholders in antibiotic usage and acquisition of AMR; however, 55.6% of respondents in a study from Pakistan had poor knowledge of AMR.¹⁰ Hence, this study was planned to assess awareness of AMR and antibiotic usage among patients attending the general outpatient department (GOPD) of a tertiary-level hospital.

MATERIALS AND METHODS

This was a descriptive study of cross-sectional design. The study was conducted from May to July 2022 at the GOPD of Kolkata Medical College Hospital. All patients aged 18 years and above, attending GOPD during the data collection period were eligible to participate in the study. Seriously sick patients, those unable to understand and respond to questions due to language, psychological, hearing or speech problems, and unwilling patients were excluded from the study.

RESULTS

A total of 117 completed schedules were analyzed. The mean age of the respondents was 39.1 years with a standard deviation of 12.3 years and ranged from 18 years to 63 years. There was nearly equal distribution of respondents by gender, and 58.9 % of respondents were educated up to the primary level or lower. The background characteristics of respondents are shown in Table 1.

The awareness of antibiotics, their use, and correct knowledge related to antibiotic use is shown in Table 2. Nearly, 70% of respondents were aware of antibiotics, and almost all have used at least one antibiotic within the past 12 months. Most of them used antibiotics as prescribed by a doctor. Higher responses for correct knowledge were obtained for items related to the use of antibiotics relative to the action of antibiotics.

Awareness of AMR was quite low, with only 14.5% of respondents being aware of AMR. Among them, most knew of AMR to be acquired by pathogens [Table 3].

Awareness of antibiotics was likely to be associated with gender, education, occupation, and marital status. Male gender, education of secondary or higher level, and respondents who were currently working and unmarried had higher awareness of antibiotics [Table 4]. For this study population, healthcare providers were reported to be the primary source of information.

DISCUSSION

AMR is one of the major public health problems, especially in developing countries like India where high infectious disease burden, relatively easy availability, and higher consumption of medicines led to a higher incidence of inappropriate and irrational use of antimicrobial agents against these diseases culminating in an ever-increasing development of AMR.¹³ As self-medication and poor compliance are reported to be major contributors to the development of AMR, the present study aimed to assess the awareness and knowledge of AMR among beneficiaries attending a tertiary-level government hospital. The results of our study show that nearly 70% of the respondents were aware of the term “antibiotics,” and almost all (97.5%) have used at least one antibiotic within the past 12 months. Antibiotic resistance has been attributed majorly to discontinuation of treatment when symptoms subside before the pathogen is eliminated.¹⁴ However, in the present study, the majority had correct knowledge about the use of antibiotic regimens in prescribed doses and duration. Many gaps in knowledge were noted regarding the action of antibiotics and their expiry date. About 28.4% of respondents answered that the common cold is cured by antibiotics, while 12.3% said that fever is cured by antibiotics. About 21% of people could correctly answer about the expiry date of antibiotics. Similar levels of knowledge have been reported from Sweden, the Netherlands, and Australia; however, in Britain and USA, it was higher.^15-20 In studies conducted in Middle East Asia, like Iraq and Jordan, 33.3% and 47.3% of the public, respectively, had poor levels of knowledge about antibiotics.^21,22 These misconceptions can increase the indiscriminate use of antibiotics and lead to the emergence and spread of resistant bacterial strains.^23,24 In the present study, confusion among study participants was also noted regarding whether antibiotics are effective against bacteria or viruses (49.4 % vs. 27.2%), which was similar to the findings reported in previous studies.^15,21 As pointed out by Shehadeh et al., this could be because many people did not understand the differences between bacteria and viruses and believed that antibiotics work against both, which subsequently led to unnecessary use.²² André et al. have discussed the benefit of using the terminology “bacteria” and “virus” instead of “microbes” while explaining the prescribing decision to the patient regarding antibiotics to avoid this ambiguity.¹⁵

A considerable proportion of the study sample (85.5%) was unaware of AMR. Among those who had heard about AMR, more people believed that AMR is acquired by pathogens (94.1%) rather than humans and animals (52.9% and 76.5%, respectively). This belief may be influenced by the inability of people to understand clearly the biological mechanism of resistance.¹⁵

In the present study, education was noted to be associated with a higher level of knowledge about antibiotics, which runs in agreement with the findings in many previous literature.^15,25-27 Other factors found to be associated with awareness about antibiotics were gender, occupation, and marital status. This may be because male respondents who were currently working had more access to sources of information related to antibiotics than the comparison groups.

The study findings helped us to identify knowledge gaps that can be used in formulating interventions leading to the judicious use of antibiotics and help in the containment of AMR.

CONCLUSION

Awareness and prescription use of antibiotics was high with two out of three aware respondents having correct knowledge on the use of antibiotics. Awareness of AMR, however, was very low, and poor communication about this threat may not sustain the good practice of prescription use of antibiotics.