Antibiotic misuse and improper practices in India: Identifying the scope to improve through a narrative review

3.1. Use of antibiotics without prescription

In India, antibiotics are scheduled as ‘H’ drugs which means a valid prescription is required to purchase these medicines [17]. However, this has been followed more in policy and less in practice, with a large number of antibiotics in the country dispensed without prescriptions [9]. A study by Shet et al., which assessed antibiotic dispensing practices across the country, found that 66.7% pharmacies dispense antibiotics without a prescription [10]. Based on our review of the studies conducted in the country, we identified three core issues that contributed towards the use of antibiotics without prescription. The first is administration of leftover prescriptions. Studies conducted in various parts of the world pertaining to antibiotic use have reported this problem and it has been very commonly associated with self-medication and treatment failure [18]. The tendency to use the leftover antibiotics is more for a family member who is showing symptoms similar to the one treated earlier. In this practice, the patient is more likely to use the drugs at his own discretion without consulting a physician.

The second practice reported was the tendency to save antibiotics for the future use and was an important contributing factor to the use of antibiotics without prescription [19]. A possible reason for this attitude could be the lack of awareness about the adverse outcomes of irrational antibiotic use. This was corroborated as per a study by Banerjee et al. where many participants were not aware that “the red line on antibiotics means it could be given only by prescription” [11]. Another observation which highlighted poor awareness was that patients were unable to distinguish between OTC drugs and antibiotics. In the study by Virmani et al., at least 30% of the participants agreed to have obtained the antibiotics over the counter. The most common ones were Beta lactam antibiotics and at least 40% agreed to have used them [14]. Rajendran et al., found that the frequency of self-medication ranged from one to five times in about three months and self-medication was more commonly followed for conditions such as fever, sore throat and cough [12]. Azithromycin was identified to be the most popular drug used for self-medication and the factors that influenced the decision of the patient to undergo self-medication were: previous experience with the drug, suggestion by friends and leftover drugs from an earlier prescription [13]. The switch of antibiotics during treatment was another common aspect which was noted. Surprisingly, the self-medication incidence was higher among adults as compared to children [13] and the average duration of self-medication was found to be six months [14]. Interestingly, at least 20% of patients were confident of curing themselves through self-medication [14] and had the tendency to save for future use. Another disturbing aspect was that around 8% used antibiotics post the expiry date [14]. Certain sections of the population, however, followed a more disciplined approach and participants mentioned that they did not start an antibiotic treatment without consulting the doctor [15]. A study by Jayabalan et al. observed that the student population were more proactive in terms of declining the use of leftover antibiotics to treat conditions such as cough, cold etc. [16]. Thus, the practice of antibiotic consumption varied based on the type of population and could be influenced by previous training or greater awareness on antibiotic use and adverse outcomes.

The third reason for use of antibiotics without prescription was the lack of regulation to curb irrational dispensing practices. Quite often, patients who recalled the name of antibiotics were given the drug without any prescription by the pharmacies. This dispensing practice was often based on an assumption that “patients are well versed with its use and purpose” [9]. It was observed that many of the pharmacists in the medical shops who indulged in such dispensing did not have a clinical degree and had poor knowledge about antibiotics. Another disturbing fact was that the pharmacy shop owners routinely prescribed antibiotics without any medical advice from the physicians [9]. Therefore, there should be strict monitoring of the dispensing at retail level. Also, if dispensing of antibiotics by only qualified pharmacists is implemented effectively through a mandate then it could be an important step against improper antibiotic practice.

3.2. Overprescription of antibiotics

Overprescription of antibiotics was a second common unethical practice seen in India and this practice is a concern in many other countries as well. A study conducted by Centers for Disease Control and Prevention (CDC) found that at least 30% of the antibiotics were overprescribed in the United States (US) [17]. In India, relatively, the numbers are higher with at least 50% prescriptions that could be termed as inappropriate. It was further observed that an overwhelming number of prescriptions were that of broad-spectrum antibiotics [20]. When we analyzed the existing knowledge and practices pertaining to antibiotic use, some critical aspects were seen, one of which is the lack of a definitive therapy approach. For instance, in a study by Landstendt et al. it was observed that in two hospitals at Madhya Pradesh, at least 35% of the patients with cardiovascular ailments who did not need an antibacterial were prescribed antibiotics [19]. Similarly, even among dentists, it was found that for certain conditions such as paediatric periodontal disease antibiotics were prescribed despite not needed [21]. In dental practice, the most popular drug was amoxicillin followed by ornidazole and ofloxacin [21]. In a study among physicians by Thakolkaran et al., almost 89% physicians were reported to have overprescribed antibiotics [22]. Co-amoxiclav was among the most misused oral antibiotic drug, while among parenterals it was ceftriaxone (a third-generation cephalosporin) followed by piperacillin/tazobactam [23]. Among the topical ones, mupirocin, fusidic acid and neomycin were the ones most frequently misused [23]. Surprisingly, being aware of antibiotic use did not result in an improvement in antibiotic practice. A study by Nair et al. in the Paschim Bardhaman district of West Bengal found that some physicians despite being aware of the scope of antibiotics, continued to prescribe it for viral infections [24]. The practice, however, varied across institutions and cannot be generalized for all because a study by Chundru et al. found that over 90% did not endorse the use of antibiotics unless there was a serious infection [25].

Quite often, misconceptions also fuelled the irrational prescribing of antibiotics. For example, in a study conducted by Sharma et al. among medical students in a government medical college in Kerala, it was found that 60% believed that antibiotics could cure a common cold and cough, while 28% were of the opinion that antibiotics can treat viral infections [26]. In another study by Gauri et al., 65% patients believed that antibiotics could speed up recovery of the common cold and 37% frequently used antibiotics against viral infections [27]. As per the study by Chatterjee et al., a sizable number of medical students were not aware that cold and cough is caused by viruses [23]. Thus, the problem of ignorance was seen not only in patients but also healthcare providers.

Some reasons for overprescription of antibiotics could be a lack of institutional policy for infection control and mandatory antimicrobial susceptibility testing. A study by Thakolkaran et al. found that only 50% of the surveyed physicians performed antimicrobial susceptibility frequently and only 51% recommended antimicrobial susceptibility testing before prescribing antibiotics [22]. A medical audit data from India revealed that, the common ailments for which antibiotics were prescribed included acute respiratory infections, lower respiratory infections, disorders of urinary system, cough and acute nasopharyngitis [28]. Among physicians, the most common source for knowledge about antibiotic use was the medical textbooks. Also, many physicians emphasized the need to have local guidelines rather than international or national guidelines [22]. The physicians in the study also stated that certain measures such as appropriate diagnostic testing, improved antibiotic knowledge and awareness, standard treatment guidelines and periodic updates on resistance patterns could help to improve the existing practices. Therefore, a need for a guideline to bring more robust prescription practices might help.

3.3. Non-adherence to treatment regimes

Antibiotic non-adherence can be defined as the non-compliance with the indicated treatment regime. This was another major issue noticed in the studies done across the country for assesing antibiotic use. Quite often, patients discontinued therapy once they had obtained symptomatic relief. As per data available in the literature, one out of every four-persons stopped the therapy when they felt better [29]. Non-adherence to antibiotic regime is a common problem in India and is responsible for treatment failure and reinfection. As per a study conducted by Sharma et al., it was observed that only 6.4% recommended the completion of the antibiotic course while 55% did not stop the drug after feeling better [26]. Some of the key deficiencies that were identified which if addressed could make a difference were, first, lack of awareness among participants about the importance of complying with the regime. However, studies indicate that very few practitioners take the initiative to counsel participants about antibiotic use. A study by Remesh et al. among medical practitioners observed that only 38% had undertaken some training related to new antibiotics and less than 50% counselled patients about antibiotic use [30]. The training of practitioners at the undergraduate and postgraduate level is also important and unfortunately the number of physicians who undergo regular training is small [30]. Non-compliance to antibiotics was a problem not restricted to only lay public but also health care students. It was observed that 68% nursing students, 45% pharmacy students and 33% of medical students did not complete the antibiotic course once started [14]. This indicates that existing knowledge may not necessarily be implemented unless there is monitoring and rigorous systems for implementation.

A second important deficiency identified related to antibiotic non-adherence was the lack of uniform prescription practices. A variation in prescription pattern was observed based on the qualification and experience of the practitioner. For example, in a study by Ramchandran et al. it was observed that the BDS practitioners prescribed a short duration antibiotic course relative to the MDS practitioners [31].

Similarly, a survey among healthcare providers in West Bengal found that over 88% allopathic practitioners and 85% informal health providers routinely prescribed antibiotics for conditions such as the common cold or sore throat. It was also observed that a majority of the healthcare providers recommended a short term 3-day course rather than the full course [24]. The prescription of broad-spectrum antibiotics such as third-generation cephalosporins were particularly higher in some hospitals [19]. Lack of uniform policies on prescription and treatment regime has been consistently observed and could be addressed through regular training and by effective guidelines. A summary of the core problems and reasons is provided in Table 1.

Variables that were found to be significant predictors of antibiotic awareness and knowledge were beliefs or attitude, social norms such as age, gender, education and financial status [30]. A review of the studies conducted across India which assessed knowledge, attitude and practice related to antibiotic use, found that variables such as gender, qualification and age influence perception and practice related to antibiotic use. Patients who had previously used antibiotics were found to be more aware as compared to new users. It was also observed in some studies that males and better-educated patients scored better in terms of knowledge and awareness about antibiotic use [31]. The level of understanding about antibiotic use got better with an increase in the level of education. For example, studies by Konde et al. and Ramchandran et al. found that the prescription rate was higher in BDS practitioners as compared to the MDS [20,31]. This was more distinctly evident in the case of students as well where it was found that awareness among postgraduate students was better as compared to undergraduate students and improved in students with better qualification. Variation was also observed among students of different streams. For example, a study by Dass et al. observed that medical students were more aware of the problem pertaining to antibiotic misuse and resistance as compared to dental students [32]. The physicians with prior medical training were more likely to follow the rationale prescribing practices as compared to those who had not undergone training. However, despite this not all physicians were found to be keen for training. For example, a study by Ghosh et al. found that 87% of physicians had not undergone any training in antibiotic use during an entire year preceding the study [33].

Gupta et al. showed that female participants were very particular and therefore showed greater compliance with the given dosing regimen [15]. This was an interesting finding given that awareness was more among males as compared to females. It also indicates that there is a gap between instituting policies and implementation. Also, males were found to practice self-medication more than females. Age was also found to be an important variable here. A study by Ray et al. found that self-medication was more common among adults as compared to children. The better compliance observed among children could be due to more vigilance shown by parents or guardians regarding the child’s health [34]. This also indicates that if there is rigorous monitoring, better compliance in the dosing regimen can be obtained. The occupation of the participant also played an important role. A study by Rajendran et al. found that self-medication was more commonly practiced by skilled workers and professionals as compared to unskilled workers [12]. Thus, the use of antibiotics varied based on several factors and these must be considered while developing antibiotic policies in India.