Antibiotic overuse in children with upper respiratory tract infection in Saudi Arabia: risk factors and potential interventions
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https://www.eduzhai.net Clinical Medicine and Diagnostics 2011; 1(1): 8-16 DOI: 10.5923/j.cmd.20110101.02 Antibiotics Overuse in Children with Upper Respiratory Tract Infections in Saudi Arabia: Risk Factors and Potential Interventions Arwa Alumran1,2,3,*, Cameron Hurst1,2, Xiang-Yu Hou1,2 1School of Public Health, Queensland University of Technology, Brisbane, 4059, Australia 2Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, 4059, Australia 3Health Information and Management Department, College of Applied Medical Sciences, University of Dammam, Saudi Arabia Abstract Background: Antibiotics misuse is currently one of the major public health issues worldwide. This misuse lead to the development of bacterial resistance, increasing the burden of chronic diseases, rising costs of health services, and the development of side effects. Several factors may influence this pattern of overuse. Objectives:This article will review the pertinent factors contributing to the overuse of antibiotics worldwide, and to assess the intervention strategies to limit this overuse. Methods: studies about antibiotics use in children were reviewed from several electronic databases, such as MEDLINE and Pubmed. Results: Factors contributing to the overuse of antibiotics could include psychosocial factors, such as behaviors and attitudes (e.g. self-medication, over-the-counter medication, or patients/parents pressure), and demographic factors, such as socio-economic status and education level. Several intervention strategies were reported to be effective in reducing the overuse of antibiotics, such as health education, doctor-patient communication, and policies change. Multifaceted interventions were found to be the most effective in reducing the antibiotics overuse. Keywords Antibiotics, Misuse, Overuse, Intervention Strategies, Children, Upper Respiratory Tract Infections, Saudi Arabia 1. Introduction Despite the effectiveness of antibiotics in the treatment of numerous bacterial infections, it is often used inappropriately. This misuse of antibiotics is currently one of the major public health issues worldwide (Fahey, Stocks, & Thomas, 1998; Flora, Scott, Jason, & Jonathan, 2008; Grigoryan, et al., 2007; Le, Ottosson, Nguyen, Kim, & Allebeck, 2011; Tenover, 2006). Although antibiotics are targeted to kill or inhibit the growth of bacteria and have no effect on viral agents (JETACAR, 1999), it is often inappropriately used to treat viral infections, such as most of Upper Respiratory Tract Infections (URTIs). Problems associated with the overuse of antibiotics include development of antibacterial resistance, increasing the burden of chronic diseases, raising costs of health services, and the development of side effects (e.g. adverse gastrointestinal effects). Antibiotic misuse was found to be significantly frequent in children, especially when presenting with viral upper respiratory tract infections (URTIs) (Cebotarenco & Bush, * Corresponding author: email@example.com (Arwa Alumran) Published online at https://www.eduzhai.net Copyright © 2011 Scientific & Academic Publishing. All Rights Reserved 2007). El-Gilany(2000) studied the trends in antibiotic use/misuse for adult patients attending primary health care center and found that of all prescriptions for URTIs, approximately 87 percent contained antibiotics. Several contributing factors are evidently associated with the overuse of antibiotics both at the patient’s (or parents of children) level and doctor’s level, namely: cultural factors, behavioral characteristics, socio-economic status, and level of education (Braun & Fowles, 2000; Kozyrskyj, et al., 2004; Teng, Leong, Aljunid, & Cheah, 2004). Furthermore, doctors usually relate their pattern of over prescribing to patients’/parents’ pressure (Peche're, 2001). Also, lack of health education is one of the major contributing factors in the overuse of antibiotics (Cebotarenco & Bush, 2007). Self medication is a very important behavioural aspect that contributes to the misuse of antibiotics (Bi, Tong, & Partonc, 2000; Sarahroodi, Arzi, Sawalha, & Ashtarinezhad, 2010). This article is a review of the literature regarding the global overuse/misuse of antibiotics in children with upper respiratory tract infections. Factors influencing this behavior and interventions targeted to limit this phenomenon are also discussed in this review. 2. Materials and Methods Clinical Medicine and Diagnostics 2011; 1(1): 8-16 9 Studies about antibiotics misuse were reviewed from sev- United Kingdom have been conducted to evaluate the pre- eral electronic databases, such as MEDLINE and Pubmed. valence of URTIs specifically in children, showed that the A total of 72 worldwide articles were reviewed, countries average number of common cold episodes occurring in each included in this review are: Australia, the United States of child annually is 3-8 times and some children (10-15%) America, Canada, the United Kingdom, some European have at least 12 episodes of common cold per year (West, countries, some Middle East countries (Saudi Arabia, Jordan, 2002). It is argued that this increasing number of URTIs Kuwait, and Iran), some South American countries, some episodes in children is associated with attendance at African countries, and some Asian countries. day-care centers or nurseries (McCutcheon & Fitzgerald, 2001; Palmer & Bauchner, 1997; West, 2002). The public’s 3. Literature Review knowledge in regard to URTIs in Saudi Arabia needs to be further investigated to measure its association with antibio- 3.1. Antibiotics Misuse tics overuse. Antibiotics are chemical agents capable of either killing 3.1.2. Inappropriate Antibiotic Use to Treat Viral URTIs or inhibiting the growth of bacteria (JETACAR, 1999). An- Although antibiotics therapy is considered appropriate for tibiotics have a major role in the treatment of bacterial in- treating acute bacterial infections such as acute otitis media, fections, which have led to significant reduction in child rhino-sinusitis, and bacterial pharyngitis; it is proven to be morbidity and mortality rates worldwide (Teng, et al., 2004). inappropriate for treating bronchitis or viral URTIs (Hoa, et However, since the introduction of antibiotics in 1941 al., 2009; Skull, Ford-Jones, Kulin, Einarson, & Wang, (Waksman, 1947), antibiotics consumption has significantly 2000). Proper decision-making regarding the appropriate increased around the world (Cebotarenco & Bush, 2007). use of antibiotics is challenging and experience is needed to Several researchers have studied this increasing consump- promote decision-making skills. Three criteria were docu- tion of antibiotics through the years and an increasing trend mented by Bennet & Geme (1999) to promote deci- of inappropriate consumption has been demonstrated in a sion-making process regarding antibiotics prescriptions: (1) range of countries (Ahmed & Al-Saadi, 2005; Al-Faris & antibiotics are not indicated at all (e.g. common cold and Al-Taweel, 1999; Irshaid, Al-Homrany, Hamdi, Adje- bronchitis), (2) using clinical criteria to justify the need for pon-Yamoah, & Mahfouz, 2004; JETACAR, 1999; Mainous, antibiotics (e.g. otitis media and sinusitis), or (3) diagnostic Hueston, Davis, & Pearson, 2003; Simasek & Blandino, testing confirming the need for antibiotics (e.g. pharyngitis). 2007; Simoes, et al., 2006). Appropriate judgment can lead to an overall decrease in Huang et al. (2007) believed that a considerable amount antibiotics use and ultimately in reducing antibiotics resis- of antibiotics prescribed to children is inappropriate. This tance (Bennet & Geme, 1999). Physicians’ decision-making significant finding of the escalating antibiotic misuse espe- skills in Saudi Arabia need to be investigated to find its as- cially in children is therefore considered one of the most sociation with the over prescription of antibiotics. important global public health issues. Ali & Ahmed (1995), URTIs are usually viral in nature and using antibiotics to found that antibiotics were the drugs most commonly pre- treat them is considered inappropriate, except for cases scribed by the primary care physicians for all age groups where bacterial infections are obvious. URTIs are usually representing 40-63% of the total drug prescriptions in the self-limiting and resolve in the same amount of time re- Asir region, in southern Saudi Arabia. Similarly, Ahmed & gardless of antibiotic consumption(Wutzke, et al., 2007). A Al-Saadi (2005) studied the prescribing patterns of 200 meta-analysis by Al-Faris & Al Taweel(1999) and several doctors in Saudi Arabia and found that the most frequent systematic reviews(Arroll & Kenealy, 2005; Fahey, et al., drug categories prescribed for all age groups were antibio- 1998) concluded that there is no evidence to support the use tics. Thus, information from these resources emphasizes the of antibiotic treatment for acute bronchitis. Despite the need for continuing medical education on the physicians’ proven ineffectiveness of antibiotics in the treatment of viral rational prescribing behavior. URTIs, research around the world shows a high prevalence 3.1.1. Upper Respiratory Tract Infections (URTIs) of antibiotics used to treat URTIs (Table.1). In a study conducted in Malaysia by Teng et al. (2004), antibiotics were Literature reports (Palmer & Bauchner, 1997; West, 2002) prescribed more frequently in patients with URTIs (68.4%) have shown that upper respiratory tract infections (URTIs) than those without URTIs. Similarly, The Saudi literature are the most common infectious diseases worldwide, in- revealed that the most frequent diagnosis in all age groups cluding common cold, influenza, rhinorria, and bronchitis. for which antibacterial drugs were prescribed was URTI URTIs were responsible for almost one-quarter of all en- (43.8%) (Irshaid, et al., 2004). Also, El-Gilany (2000) found counters in a general practice evaluated in a Malaysian consistent results when they assessed the pattern of drug study (Teng, et al., 2004). Bhasin, Budden, Ketkar, & Pa- prescriptions in all age groups attending primary health care war(2002) reported that URTIs are responsible for a large centers in Saudi Arabia; one-third of the prescriptions ana- percentage of consultations in general practices, mostly in lyzed in their study were for URTIs and 87% of those were the case of neonates, infants and children. A study in the prescribed antibiotics. Concurrent results were found in 10 Arwa Alumran et al.: Antibiotics Overuse in Children with Upper Respiratory Tract Infections in Saudi Arabia: Risk Factors and Po-tential Interventions Taiwan where antibiotics were prescribed in 31.3% of patients with common cold (Chang, Shiu, & Chen, 2001). Belongia et al. (2002) revealed that, of those with non bacterial infections, 60% of the adults and 46% of the children were prescribed antibiotics. Also, in a recent study in Vietnam Hoa, et al. (2011) found that 62% of the study children were given antibiotics and 63% of antibiotic courses were used for mild ARIs.These worldwide figures highlight the importance of exploring the factors affecting the excessive use of antibiotics to treat viral URTIs. Table 1. Worldwide Figures Describing the Overuse of Antibiotics. Study (Ali & Ahmed, 1995) (Belongia, et al., 2002) (Chang, et al., 2001) (El-Gilany, 2000) (Irshaid, et al., 2004) (Hoa, et al., 2009) (Hoa, et al., 2011) (Teng, et al., 2004) (Nyquist, Gonzales, Steiner, &Sande, 1998) Subjects 89 primary health care physicians 405 adults and 275 parents of children 190,971 patients visits throughout the study period. 40 primary health care centers 3796 prescriptions Doctors Children 150 clinics 3481 complete forms 531 pediatric office visits % Prescribed antibiotics 40-63% of all diagnoses 60% of adults and 46% of children for non bacterial infections 31.3% of common cold episodes 87% of URTIs 43.8% of URTIs 79% prescribed antibitoics for common cold 63% for mild URTIs 68.4% of URTIs 44% of patients with common colds, 46% with URIs, and 75% with bronchitis. Country Saudi Arabia United States of America Taiwan Saudi Arabia Saudi Arabia Vietnam Vietnam Malaysia United States of America Frequent prescribing of antibiotics to children with URTIs has become a major public health issue (Huang, et al., 2007). According to Nyquist, Gonzales, Steiner, &Sande (1998), in the United States 44% of children with common cold are given different types of antibiotics. Despite the fact that URTIs are caused by various respiratory viruses, most commonly rhinovirus (Simasek & Blandino, 2007; Simoes, et al., 2006; West, 2002), they are often mismanaged and treated with antibiotics even when bacterial complications (e.g., pneumonia, bacterial sinusitis) are not present(Cebotarenco & Bush, 2007; Green, 2006; Wutzke, et al., 2007). In fact, evidence from previous reviews suggests that most URTIs in children are self-limiting and require symptomatic treatment alone. Antibiotic treatment is more likely to be harmful than beneficial (Fahey, et al., 1998).To minimize the harmful effect of antibiotics, it is important to raise people’s awareness regarding the use and misuse of antibiotics and its implications, especially when used to treat URTIs. Nevertheless, data found in Saudi medical literature is mainly about antibiotic misuse in adults, it is therefore important to fill the gap in knowledge in regards to antibiotic misuse in children, by studying the utilization of antibiotics in children with URTIs in Saudi Arabia. 3.2. Problems Associated with Unnecessary Exposure to Antibiotics The excessive use of antibiotics exposes the community to several public health issues, some of which are: 3.2.1. Antimicrobial Resistance Although antibiotics have a significant role in the reduction of morbidity and mortality rates worldwide, their increasing inappropriate consumption leads to the development of bacterial resistant strains. Such resistance to antibiotics is likely to lead to reduction in the effectiveness of many antibiotics (Sorkhou, et al., 2002). Moreover, antimicrobial resistance places both populations and individuals at risk (JETACAR, 1999; Mainous, et al., 2003; Simasek & Blandino, 2007). Green (2006) asserts that antibiotics are becoming inadvisable with the emergence of antibacterial resistance. One of the main reasons that encourage the development of antibiotic resistance is the inappropriate use of antibiotics to treat viral URTIs (Teng, et al., 2004). Individuals’ risk from unnecessary consumption of antibiotics, especially to treat URTIs, should be emphasized. Numerous studies confirmed that high proportions of young children get URTIs from childcare attendance, and most of these children receive antibiotics to treat their URTIs; thus indirectly leading to the development of bacterial resistance in the community (Arnold & Straus, 2005; Nyquist, et al., 1998). Skull et al. (2000) and Kozyrskyj et al.(2004) concur that child-care center attendance is an indirect risk factor for developing bacterial resistance. Promoting the judicious use of antibiotics by parents could protect children from bacterial resistance. 3.2.2. Cost The cost of health services will be significantly elevated ifthe problem of antibiotic misuse persists(Al-Faris & Al-Taweel, 1999; Foster & Sabella, 2011; JETACAR, 1999; Sarahroodi, et al., 2010).For example, according to West (2002), $2 billion are spent each year in USA on over-the-counter preparations to treat cold symptoms, mainly in children. Moreover, Mainous & Hueston (1998) examined the use of antibiotics to treat URTIs in outpatient setups in USA, and found that 23% of the total cost was for the unnecessary use of antibiotics. Pestotnik, Classen, Evans, & Burke(1996) assert that antimicrobial agents are one of the costliest drug categories in hospital expenditures, accounting for approximately 20% to 50% of the total spending on drugs in USA.These studies are supportive of Main- Clinical Medicine and Diagnostics 2011; 1(1): 8-16 11 ous & Hueston(1998), who believed that it is important to reduce the use of inappropriate treatments for low-cost, high-volume conditions, such as antibiotics for URTIs, since it has significant implications for the cost of health care. The financial burden of the emergence of bacterial resistant strains is significant. Studies have confirmed that the emergence of bacterial resistance strains leads to significant economic loss, since the cost of length-of-stay and treatment of patients with bacterial resistance infections are significantly increasing(Emanuele, 2010; Mora, et al., 2002). According to Mora, et al. (2002), Almost 100 million dollars are estimated to be spent annually in USA to treat patients with resistant bacterial infections. Minimizing the overuse of antibiotics will lead to reduction in bacterial resistance pattern; which will consequently deflate the excessive cost spent for treatment. Table 2. Factors influencing antibiotics misuse/overuse. Factors Parents’ pressure Scioeconomic status: Selfmedication Country USA (Barden, et al., 1998) Canada (Butler, et al., 2001) UK (Britten & Ukoumunne, 1997) China (Chan, 1996) USA (Huang, et al., 2007) UK(Macfarlane, et al., 1997) USA(Mangione-Smith, et al., 1999) Canada (Paluck, et al., 2001) Kuwait(Sorkhou, et al., 2002) KSA (Al-Faris & Al-Taweel, 1999) USA (Barden, et al., 1998) USA (Braun & Fowles, 2000) Canada(Butler, et al., 2001) Moldova (Cebotarenco & Bush, 2007) China (Chan, 1996) UK (Davey, et al., 2002). USA(Huang, et al., 2007) Canada (Kozyrskyj, et al., 2004) Hungary(Maria; Matuz, et al., 2005) Canada (Paluck, et al., 2001) USA (Vanden Eng, et al., 2003) Turkey(Akici, Kalaca, Ugurlu, & Oktay, 2004) Jordan (Al-Azzam, Al-Husein, Alzoubi, Masadeh, & Al-Horani, 2007) Jordan (Al-Bakri, Bustanji, & Al-Motassem, 2005) Sudan(Awad, Eltayeb, Matowe, & Thalib, 2005) KSA(Bawazir, 1992 ) China(Bi, Tong, et al., 2000) Moldova(Cebotarenco & Bush, 2007) Europe(Grigoryan, et al., 2007) USA(Kogan, Pappas, Yu, &Kotelchuck, 1994) Developing countries (Kunin, et al., 1987) Iran(Sarahroodi, et al., 2010) USA United Sates of America UK United Kingdom KSA Kingdom of Saudi Arabia 3.2.3. Side effects Several side effects may occur from over consumption or inappropriate consumption of antibiotics. A risk of adverse gastrointestinal effects may be caused by antibiotics over use (Irshaid, et al., 2004; Simasek & Blandino, 2007). Ac- cording to Schroeder & Fahey (2002), drowsiness, diarrhea and hyperactivity are also significant side effects related to antibiotic use in children. These adverse effects are more significant in children (Simasek & Blandino, 2007). Moreover, Mora et al. (2002) suggest that adverse events may occur when people use multiple drugs, which may be associated with the increase in resistant bacterial infections. Goolsby(2001) believes that it is important to increase patients’/parents’ awareness regarding antibiotics potential to inflict unnecessary side effects, such as, gastrointestinal effects, allergies, the development of antibiotic-resistant strains, and other infections. Al-Faris & Al Taweel(1999) suggest that doctors also need to be aware of the lack of evidence of effectiveness of antibiotics in the treatment of URTIs, as well as the obvious cost and side effects of many prescriptions for self-limiting conditions. Problems associated with the unjustified use of antibiotics, emphasize the need to educate the community (doctors and parents) about the consequences of the overuse of antibiotics, especially for the treatment of URTIs in children. Therefore, information about patterns of antibiotics utilization and factors influencing this pattern are necessary to be collected in order to develop a constructive approach to minimize this important public health issue. 3.3 Factors Influencing the Overuse of Antibiotics The problem of antibiotic misuse may be influenced by several contributing factors, such as cultural, cognitive (e.g. parents pressure), educational, and socio-economic factors integrated at the level of patients or parents, physicians and pharmaceutical industries (Table.2). 3.3.1. Parents’ Pressure Parental expectation (Real or perceived) is a major factor that influences physicians’ prescribing behavior. Studies have revealed that most parents expect physicians to prescribe antibiotics for their children even when presenting with viral infections such as most URTIs (Huang, et al., 2007). A survey conducted in Hong Kong showed that almost one third of the respondents (adult patients and guardians) presented at the family practice center particularly to obtain antibiotics (Chan, 1996). In addition, about half of pediatricians in USA report frequent parental pressure to prescribe non-indicated antibiotics (Huang, et al., 2007). In Canada nearly half of the physicians believe that they would reduce their antibiotic prescribing if parents pressure for prescriptions was reduced (Paluck, et al., 2001). Parental perceptions regarding antibiotics prescription have a huge impact on physicians’ decision-making.Several researchers believe that although physicians might feel uncomfortable in prescribing antimicrobial to children with URTIs, they may resort to irrational prescription in order to foster good relationship with patients’ guardians (Barden, Dowell, Schwartz, & Lackey, 1998; Butler, et al., 2001; Mangione-Smith, McGlynn, Elliott, Krogstad, & Brook, 1999).Sorkhou et al.(2002) conducted a study in Kuwait (a country similar to 12 Arwa Alumran et al.: Antibiotics Overuse in Children with Upper Respiratory Tract Infections in Saudi Arabia: Risk Factors and Po-tential Interventions Saudi Arabia geographically and culturally) to evaluate the sultations (Al-Faris & Al-Taweel, 1999). These internation- factors influencing the antibiotic misuse, and found that al figures emphasize the importance of health education many physicians feel obliged to prescribe antibiotics to their programs at the community level in order to have a healthier patients assuming the patients’ or guardians’ desire for such population. medication. However, this irrational prescribing behavior The physician-patient relationship needs to be investi- may encourage parents’ false idea of antibiotics to treat gated in the population in order to improve the practice. URTIs and its side effects. Several physician–patient interaction models have been The problem of antibiotic over prescribing may also be suggested to improve proper antibiotic prescribing decisions associated with parents’ expectations regarding antibiotics (Butler, et al., 2001). Barden et al. (1998) reported that par- or physicians’ perception about parents’ expectation. Britten ents believed that physicians’ cooperation in regards to lis- & Ukoumunne(1997) concluded from their study in London, tening to the patients concern, answering their questions, UK that patients’ expectations for prescriptions exceeded and explaining the reasons for treatment, will lead to their doctors’ perceptions of these expectations. On the other satisfaction even where antibiotics are not prescribed. De- hand, Macfarlane, Holmes, & Britten (1997) believed that velopment of educational programs for physicians combined physicians’ generally overestimate patients’ expectations. with community education is necessary to minimize the Therefore, it is important to identify the source of the over- antibiotic misuse and the burden of bacterial resistance. use of antibiotics to treat URTIs, whether it is physicians’ prescribing behavior, parents’ expectations, or an interaction 3.3.3. Socio-economic Status between parents’ expectations and physicians prescribing behavior. Thus, suggesting an intervention strategy that would be beneficial in reducing this inappropriate use of antibiotics. Socio-economic status needs to be considered as an important factor contributing to the rising issue of antibiotic misuse. Kozyrskyj et al. (2004) believed that inappropriate consumption of antibiotics is related to low socio-economic 3.3.2. Lack of Health Education status, which might be associated to low education levels. Similarly, Matuz et al. (2005) suggest that poor so- Health education is an important factor contributing to the cio-economic status is associated with antibiotic consump- escalating problem of antibiotic over prescription. Cebota- tion in Hungary.On the other hand, it was argued that par- renco & Bush(2007) revealed that patients’ or parents’ lack ents with high socio-economic status are more likely to re- of knowledge in antibiotics therapy (i.e. to treat bacterial quest antibiotics, because of the parents believe that antibio- infections) and the harmful effect caused by inappropriate tics treat URTIs faster, thus reducing the time taken off use (i.e. to treat viral infections) is a contributing factor to work (Braun & Fowles, 2000; Vanden Eng, et al., 2003). the trend of antibiotic misuse. For example, the majority of Braun & Fowles(2000) argued that full-time employed par- the parents of patients attending family practice centers in ents are more likely to request antibiotics. Results from the Hong Kong had a false notion that URTIs affecting their Vanden Eng et al. (2003) study shows that patients with children would not resolve on its own and antibiotics are higher socioeconomic status are more likely to consume necessary to treat the symptoms (Chan, 1996). Cebotarenco antibiotics, which may be due to their better access to health & Bush(2007) believed that parents’ misconceptions about care services. Although many researchers considered pa- appropriate indication for antibiotics use leads to an increase tients’ socioeconomic status as an important factor in the in their children’s consumption of antibiotics often without use of antibiotics (Braun & Fowles, 2000; Kozyrskyj, et al., physicians’ knowledge. Moreover, almost all physicians 2004; Maria Matuz, et al., 2005; Vanden Eng, et al., 2003), (93.5%) in a study conducted in Canada believed that edu- there is a lack of worldwide information regarding the asso- cating parents about antibiotics and their implications would ciation between socioeconomic status and antibiotic use, reduce expectations for antibiotics (Paluck, et al., 2001). therefore, it is important to study this association, as a con- Patients’ lack of health education needs to be emphasized in tribution to the knowledge gaps. order to minimize the irrational use of antibiotics. Health education could take place in physician’s offices, 3.3.4. Self-medication schools, and universities. However, evidence shows that Self-medication was identified by Kunin et al.(1987) as health education is minimal in many pediatric clinics, which self-administering inadequate doses of non-prescription me- may be due to the lack of time. Several researchers consi- dicines prior to doctors’ diagnosis. High rate of dered the lack of time to negotiate a different management self-medication, especially antibiotic self-medication, may plan as an important issue that needs to be addressed in or- cause several problems to the child: it slows down children der to improve antibiotics prescription practices (Davey, development, increases drug resistance, creates an unba- Pagliari, & Hayes, 2002). Huang et al.(2007) revealed that lanced bacteria distribution, and leads to other side effects mothers often felt that physicians do not clarify why an an- (Bi, Tongb, & Partonc, 2000). Moreover, studies have been tibiotic is not needed. Evidence shows that in a Saudi health conducted to measure the extent of parental self-medication care centre, 75% of consultations ended with a prescription, to their children. In Turkey, Akici, Kalaca, Ugurlu, & Ok- while health education took place in only 7.6% of the con- tay(2004), found that almost 60% of parents had Clinical Medicine and Diagnostics 2011; 1(1): 8-16 13 self-medicated their children before visiting the doctor. Likewise, Bi et al. (2000) found that almost 59% of children in China had parental self-medication. Furthermore, URTIs were the most common reasons for self-medication in Europe (Grigoryan, et al., 2007). It is necessary to consider the problem of self-medication when exploring factors influencing antibiotics misuse. Self-medication is more common in developing countries due to factors such as ready availability of antibiotics without prescription, the unrestricted access to antibiotics,lack of regulation over drugs, and physicians and pharmacists prescribing and dispensing antibiotics without regard to the cause of infection(Bawazir, 1992 ; Bi, Tong, et al., 2000; Cebotarenco & Bush, 2007; Grigoryan, et al., 2007; Le, et al., 2011). Bi et al. (2000) also studied factors associated with parental self-medication in China and found that well-educated mothers are more likely to self-medicate their child, parental self-medication usually increases with the age of the child, and severity of disease was related to parental self-medication (i.e. when the diseases were not serious self-medication and antibiotics misuse are more likely to occur). Grigoryan et al.(2007) reported that past experience with prescribed use of antibiotics triggers people to use self-medication. These factors may vary according to geographical locations, social behaviors, patients’ educational status, and cultural factors. Self-medication is an important issue in Saudi Arabia (Bawazir, 1992 ) and several adjacent countries such as Iran (Sarahroodi, et al., 2010), Jordan (Al-Azzam, et al., 2007; Al-Bakri, et al., 2005) and Sudan (Awad, et al., 2005). However, self-medication is a significantly growing public health issue in developed countries as well as developing countries (Bi, Tongb, et al., 2000). For example, a survey in USA showed that 54% of children had parental self-medication (Kogan, et al., 1994). Factors influencing this behavior (self-medication) in Saudi Arabia need to be measured in order to minimize to the overuse of antibiotics in children with URTIs and therefore reducing antibacterial resistance in the community. 3.4. Interventions to Prevent Overuse of Antibiotics Carefully planned and well-designed methodological intervention can result in behavior change for achieving the expected outcome. Several intervention protocols have been implemented around the world to reduce the overuse of antibiotics. It is important to investigate these worldwide intervention strategies and find the best protocol to be used in countries like Saudi Arabia according to the contributing factors to this overuse of antibiotics. nity-wide educational materials (e.g. printed leaflets)(Belongia & Schwartz, 1998). All of these methods could be effective in delivering information about the use of antibiotics to the general population. There is a need for educational programs for physicians; Croft et al. (2007) suggested that physicians should receive evidence-based recommendations for diagnosis and treatment from professional societies, as well as feedback about their antibiotic use to facilitate behavior change. Although some methods were proven to be effective, some of the interventions targeting physicians were evidently ineffective. Arnold & Straus(2005) compared different intervention strategies around the world to find the most effective interventions in reducing the overuse of antibiotics: physicians’ printed educational materials, audits, and feedback were found to be ineffective, but educational meetings appeared to be more effective. Several studies have also found that multi-faceted interventions, directed at both patients’/guardians’ level and doctors’ level, are more successful in reducing the inappropriate use of antibiotics than a single intervention (Belongia, et al., 2002); Combining health care provider, patient, and public education after addressing local barriers to change(Arnold & Straus, 2005; Belongia & Schwartz, 1998; Gonzales, Barrett, Crane, & Steiner, 1998). Rising public and health care providers’ awareness regarding antibiotics is evidently effective in reducing antibiotic misuse. However, delivering such education may differ according to the setting where the intervention strategy is targeted. 3.4.2. Doctor-patient Communication Shared decision making has been shown to be an effective tool that can help in reducing overuse of antibiotics, where the physician provides clear information about the disease and treatment, and the patients provide their experience of the symptom and their beliefs, and knowledge about the treatment (Akici, et al., 2004; Butler, et al., 2001). This way both the patients’ guardians and the physician facilitate the decision-making process. Furthermore,Britten & Ukoumunne(1997) suggest that physicians may ask the patients or their guardians directly if they were hoping for an antibiotic, leading to the discussion of the reasons for such expectations. Moreover, Belongia & Schwartz(1998) believe that physicians should be convinced that patients’ satisfaction is based on communication more than prescription. Patient-physician communication is clearly important. Thus, interventions targeted at improving this communication may lead to a decrease in antibiotics overuse. 3.4.1 Health Education 3.4.3. Changing Policies Evidence shows that careful health professional education in addition to patient awareness would be effective in reducing excessive use of antibiotics (Green, 2006; Panagakou, et al., 2011; Teng, et al., 2004). Public educational interventions may include: simple messages delivered by public relation campaigns, clinic-based education and commu- Some studies advocate developing organizational policies or review of existing ones, to support judicious use of antibiotics (Belongia & Schwartz, 1998; Radyowijati & Haak, 2003). While others, believe that a computerized antibiotic-management program can improve the overall quality of patient care(Evans, et al., 1998). The latter was confirmed 14 Arwa Alumran et al.: Antibiotics Overuse in Children with Upper Respiratory Tract Infections in Saudi Arabia: Risk Factors and Po-tential Interventions by a seven year intervention study by Pestotnik et al. (1996),  Ahmed, K., & Al-Saadi, A. (2005). A survey of multiple which found that using computer-based decision-making programs with specific guidelines brought about a remarka- prescriptions dispensed in Saudi Arabia. Pakistan Journal of Pharmaceutical Sciences, 18(2), 1-2 ble reduction in antibiotic misuse and its associated cost.  Akici, A., Kalaca, S., Ugurlu, U., & Oktay, S. (2004). Furthermore, implementing a policy for delaying antibiotic prescription for 48 hours is another method that was suggested by Spurling, Del Mar, Dooley, & Foxlee(2006), this Prescribing habits of general practitioners in the treatment of childhood respiratory-tract infections. Eur J Clin Pharmacol, 60, 211-216 may give self-limiting conditions time to heal without using  Al-Azzam, S., Al-Husein, B., Alzoubi, F., Masadeh, M., & medications. Evidently this method is likely to be effective in reducing antibiotic use, however, it may as well reduce Al-Horani, M. (2007). Self-Medication with Antibiotics in Jordanian Population. IJOMEH, 20(4), 373-380 patient satisfaction. Although policy change is an effective  Al-Bakri, A., Bustanji, Y., & Al-Motassem, Y. (2005). method in reducing antibiotic overuse, targeted policies Community consumption of antibacterial drugs within the need to be reviewed before suggesting the intervention strategy in order to ascertain the aspects that need to be improved. Jordanian population: sources, patterns and appropriateness. International Journal of Antimicrobial Agents, 26(5), 389 395  Al-Faris, E., & Al-Taweel, A. (1999). Audit of prescribing patterns in Saudi primary health care: What lessons can be 4. Conclusions learned? Ann Saudi Med, 19(4), 317-321 Antibiotics misuse/overuse is an important public health  Ali, M., & Ahmed, M. (1995). Problems of drug prescription at primary health care centres in Southern Saudi Arabia. issue that affects the community and the individual. Using Saudi Medical Journal, 16(3), 213-216 antibiotics to treat children from upper respiratory tract in- fections is evidently inappropriate unless the infection was proven to be bacterial. This misuse of antibiotics, especially  Arnold, S., & Straus, S. (2005). Interventions to improve antibiotic prescribing practices in ambulatory care (Review) Cochrane Database of Systematic Reviews(4) in children, will increase the risk of developing bacterial resistance which emphasis on the need to discover the con-  Arroll, B., & Kenealy, T. (2005). Antibiotics for the common tributing factors to this overuse of antibiotics. Factors influencing the misuse/overuse of antibiotics in the literature cold and acute purulent rhinitis (Review). Cochrane Database of Systematic Reviews(3) include (1) psychosocial factors, such as: behaviors, beliefs,  Awad, A., Eltayeb, I., Matowe, L., & Thalib, L. (2005). and attitudes (e.g., self-medication & over-the-counter medication), (2) parents pressure, often documented by doctors, (3) demographic characteristics (e.g., socio-economic status, Self-medication with Antibiotics and Antimalarials in the community of Khartoum State, Sudan J Pharm Pharmaceut Sci 8(2), 326-331 education levels) and (4) and lack of health education. Dis-  Barden, L., Dowell, S., Schwartz, B., & Lackey, C. (1998). covering the factors affecting the misuse/overuse of antibiotics in Saudi Arabia, whether they are patients’/ parents’-related or doctors’-related could assist in the develop- Current Attitudes Regarding Use of Antimicrobial Agents: Results from Physicians' and Parents' Focus Group Discussions. Clinical Pediatrics, 37(11), 665-671 ment and implementation of a well-designed methodologi-  Bawazir, S. (1992 ). Prescribing pattern at Community cal intervention protocol that can lead to a decrease in antibiotics use. Pharmacies in Saudi Arabia. International Pharmacy Journal, 6(5) Interventions that could lead to the reduction in antibio-  Belongia, E., Naimi, T., Gale, C., & Besser, R. (2002). tics overuse may include: (1) health education campaigns, professional education as well as public awareness campaigns are evidently effective in the reduction of the unne- Antibiotic Use and Upper Respiratory Infections: A Survey of Knowledge, Attitudes, and Experience in Wisconsin and Minnesota. Preventive Medicine, 34(3), 346-352 cessary use of antibiotics in children with upper respiratory  Belongia, E., & Schwartz, B. (1998). Strategies for tract infections. (2) Doctor-patients interactions, where the patient/parent gets involved in the decision making process promoting judicious use of antibiotics by doctors and patients. BMJ, 317(7159), 668-671 with the doctor. And/or (3) policy change, such as: imple-  Bennet, J., & Geme, J. (1999). Bacterial Resistance and menting a new policy for delaying antibiotics prescription Antibiotic Use in The Emergency Department. Pediatric for 48 hours which will give the self-limiting conditions to Clinics of North America, 46(6), 1125-1143 time to heal without the use of medications. Choosing the  Bhasin, S., Budden, E., Ketkar, A., & Pawar, A. (2002). best intervention protocol relays on discovering the most Current trends in the treatment of upper respiratory tract influencing factor(s) associated with this overuse. infections in neonates, infants and children: A survey. Indian Journal of Pharmacology, 34, 62-63 REFERENCES  Bi, P., Tong, S., & Partonc, K. (2000). Family self-medication and antibiotics abuse for children and juveniles in a Chinese city. Social Science & Medicine, 50(10), 1445-1450 Clinical Medicine and Diagnostics 2011; 1(1): 8-16 15  Bi, P., Tongb, S., & Partonc, K. (2000). Family self-medication and antibiotics abuse for children and juveniles in a Chinese city. 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