Nonprescription Use Is a Major Hurdle in the Fight Against Antibiotic Resistance: Public Health Watch

When it comes to antibiotic resistance, stewardship—or proper prescribing—of existing drugs remains the most effective weapon.

However, it shouldn’t—and can’t—be the only tactic. Particularly not if the results of a recent analysis published in the Annals of Internal Medicine (AIM) are any indication. Indeed, according to the findings, prevalence of nonprescription antibiotic use among patients may be as high as 66%, although findings from the 31 included studies varied.

“The prevalence range among the studies we reviewed varied significantly because all of them used different measures,” co-author Barbara W. Trautner, MD, PhD, professor of infectious diseases in the Department of Surgery at Baylor College of Medicine, told Contagion®. “Still, there is a high level of nonprescription use. And, I just know from being a clinician for 25 years that patients are using antibiotics on their own, and that was an issue we thought worthy of exploration.”

As Contagion® reported in November, it’s estimated that 1 million Americans will die from infections caused by antibiotic-resistant bacteria by 2050.

To try and get to the heart of this issue, Trautner and colleagues searched PubMed, EMBASE, CINAHL, Scopus, and relevant web sites to identify studies reporting “nonprescription use of antibiotics, storage of antibiotics, intention to use antibiotics without a prescription, and factors influencing nonprescription use” over a 19-year period (2000 to 2019). Of 17,422 screened articles, 31 met the authors’ inclusion criteria, which were based on the PCC (Population, Concept, and Context) framework and publication in a peer-reviewed journal.

Within the included studies, antibiotics were obtained without a prescription from previously prescribed courses, local markets or stores, and family or friends, among other sources. Factors contributing to nonprescription use included easy access to sources that obtain antibiotics internationally for “under-the-counter” sales, difficulty accessing the health care system and/or costs of physician visits, long waits in clinics, and transportation issues.

For study co-author Larissa Grigoryan, MD, PhD, assistant professor of family and community medicine at Baylor College of Medicine, the AIM paper serves as merely a continuation of her work on similar research in Europe, where she lived until recently. Her earlier work, which tracked antibiotic use across the continent, identified higher rates of nonprescription antibiotic use in southern and eastern Europe, where patients, she said, often have an expectation that they will receive antibiotics whenever they feel sick, and will acquire and/or use them anyway, whether they get a prescription or not.

The findings overseas prompted Grigoryan to look at the same issues stateside. When she first arrived in Houston, she co-authored a study that surveyed patients in primary care clinic waiting rooms on their antibiotic use. According to Grigoryan, 5% of the surveyed patients acknowledged nonprescription antibiotic use over the prior 12-month period and 25% said they planned to use antibiotics without a prescription in the future if they got sick. The findings of that project were included in the AIM paper.

“This isn’t just about lack of patient education on appropriate antibiotic use,” Trautner said. “There are a lot of social factors as well. You have parents who work and, when their children get sick, they may not be allowed back into daycare unless they are taking an antibiotic. You have others who can’t afford to miss work if they get sick, and they can’t afford to see a doctor either.”

These patients, she added, often resort to taking antibiotics on their own to, in effect, self-treat.

However, although Trautner and Grigoryan acknowledge that lack of access to affordable health care is likely a culprit in driving this nonprescription antibiotic use, they believe that the need for “patient empowerment”—as Trautner describes it—is even more paramount. For example, the pair noted that Houston has a number of free health care clinics for patients who lack insurance and/or the money to pay for care, but far too many are unaware these facilities exist or know how to access them. To address this, the group led by Trautner and Grigoryan has been awarded a grant from the US Agency for Healthcare Research and Quality (AHRQ) to develop a patient-provider communication tool that will help patients assess when they need to see a doctor (based on their symptoms) and, when they do, how to access one. The project will take 5 years to complete.

“We’ll be working with a patient advisory council and other stakeholders,” Trautner said. “Patients need to be better activated to recognize symptoms and know what resources are available to them.”

Before they unwittingly augment the antibiotic resistance crisis we’re already facing.