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A Knowledge, Attitude and Practices Survey about Antibiotic Misuse Among Pediatric Doctors, Pharmacies and Parents, Pharmacists and Parents in East of Libya

The emergence and spread of bacterial resistance to antibiotics is a growing problem worldwide, which presents a significant threat to public health globally. The present study was designed to determine knowledge, attitude and practice of antibiotic use. A cross-sectional survey was performed using a questionnaire on a sample randomly selected from east Libya for pediatric doctors, pharmacies and parents. A total of 400 participating subjects were approached to be included in the study, 234 agreed to participate giving a response rate of 58.5%. The awareness of antimicrobial resistant was very high among the pharmacist and doctors responder (96.43%) (93.91%) respectively, in contrast participants parents (41.76%). More than one-third (37.36%) were self-medicated with antibiotics to treat mainly common cold and cough. The reasons of antibiotic misuse in the present study according to the opinion of participant doctors were an empirical use, incorrect dose and low level of education with 68.70%, 18. 26%, 13.04% respectively. Pharmacies are the major source of antibiotics reporting more than –quarter 28.57% were sold antibiotic without prescription. These findings presented aid in the assessment of the adequacy of present public educational campaigns to promote specific messages to rationalize antibiotic use, and compensate for knowledge and attitude gaps as an effort towards preventing development of antibiotic resistance.


INTRODUCTION
The last 50 years have witnessed the golden age of antibiotic discovery and their widespread use in hospital and community settings. Regarded as very effective, safe and relatively inexpensive, antibiotics have saved millions of lives. However, this has led to their misuse through use without a prescription and overuse for self-limiting infections [1][2][3]. This misuse of antibiotics is currently one of the major public health issues worldwide [4][5][6]. Although antibiotics are targeted to kill or inhibit the growth of bacteria and have no effect on viral agents, it is often inappropriately used to treat viral infections, such as most of upper respiratory tract infections [7].
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 [8][9][10]. Furthermore, doctors usually relate their pattern of over prescribing to patients'/parents' pressure [11]. Also, lack of health education is one of the major contributing factors in the overuse of antibiotics [12]. Self-medication is a very important behavioral aspect that contributes to the misuse of antibiotics [13,14].
Problems associated with the overuse of antibiotics include development of antibacterial resistance, increasing the burden of chronic diseases, raising costs of health service.
In fact, antibiotic resistance is a growing international threat, with high social costs for communities and severe consequences, such as failure to respond to treatment, prolonged illness, and greater risk of complications and mortality [15]. Rational prescribing practices serve to combat this global public health challenge by preventing antibiotic overuse and misuse [16]. Unfortunately, uptake of this concept has been slow, with fewer than half of all countries having any policies promoting good antimicrobial stewardship [16]. Despite the effectiveness of antibiotics to treat bacterial infections, they are often inappropriately used to treat viral infections [4]. This overuse is currently one of the major public health issues worldwide [17].
The present study was designed to investigate parents, pediatric doctors and pharmacies in relation to medication usage, the knowledge, attitudes and behaviors of medical practitioners, pharmaceutical providers and consumers and to determine the possible risk factors contributing in this issue.

MATERIALS AND METHODS
A cross sectional study with data collection by designed questioner conducted at East of Libya was carried out to achieve the objective. Study was conducted at geographical area in the hospitals of east of Libya (Benghazi, El-bida, Durna, Toubrk, Almarige, Ajdebia) between January 2018 to February 2019. The sample size was 234 participants out 400 giving a response with rate of 58.5%. The participate were approached to be included in the study were 115 of pediatric doctors from different hospitals in the east of Libya which include 60 doctors from Benghzi among sample of 100 statement distributed through them, 23 doctors from El-beida among 30 sample, 13 doctors from Tobrak from 30 sample, 7 from Almarage, 5 from Ajdebia and 12 from Durna among 30 sample of statement for each. The study also include 28 pharmacists collected out of 50 and 91 parents from 100 sample

Source of Data
Data was collected by KAP questionnaire prepared by researchers where the studying groups (pediatrics doctors, pharmacists and parents). It asked about their knowledge, attitude and practice of antibiotic use and misuse. Participants were given the option could read and answer the survey on their own .questions were mainly used to assess 3 major categories, knowledge related to purpose of antibiotic, use of antibiotic, side effect of antibiotic, attitude toward consumption of antibiotic like the need to use of antibiotic, frequency of antibiotic used and practice of antibiotic use like completing the course of antibiotic and self-medication.

Statistical Analysis
The total KAP scores were calculated by summing up the Likert scale responses for each category (after reversing the scores for those that required either yes or no as the most appropriate answer). The data were interoperated in Tables and Figures, the numerical data were shown as number and percentage. To find the significant difference between the observed variable studied, Chi -Sequre test, unpaired t test were used, P value was taken as level of significance at <0.05. Statistical analysis was carried out in Minitab software (version17).
According to the doctors practice, (80.87%) they do not prescribed antibiotic for any admission while 22 (19-13%) they prescribed (p=0.00) and 68 (59.13%) they do not prescribe antibiotic until specialize consulting while 47 (40.87%) do not waiting the specialist treatment (p=0.005) ( Table-1). Nineteen doctors (16.52%) they recommend an antibiotic therapy over the phone and 96 (83.48%) they do not recommend antibiotic by the phone which statistically significant (p=0.00) ( Table-1). Of the total 33 (27.70%) they were complete the iv course of antibiotic outside hospital while 82 (71.3%) they complete iv course of an antibiotic inside the hospital which spastically significant (P=0.00) ( Table-1). Ninety seven doctors (84.35%) were investigate before antibiotic description which reveals significantly higher than doctors they do not perform investigation before antibiotic use 18 (15.65%) P=0.00 (Table-1). Regarding use of single antibiotic 96 (83.47%) they prefer to use single antibiotic while only 16 (16.52%) they prescribe multiple antibiotics which is statistically significant (P=0.00) ( Table-1 In term of positive attitude of the doctors they were not routinely prescribe an antibiotic, do not prescribe antibiotic once the patient insist, do not prescribing antibiotic immediately once child had fever and others consult their specialist before use antibiotic P(0.00),(0.001),(0.003) and (0.00) respectively (Table  2).
According to the knowledge (108) (93.91%) they awarded about antibiotic resistant compare to (7)(6.09 %)who do not aware about antibiotic resistant. (94) (81.74 %) of them were followed guideline for antibiotic prescription with statistically significant (Table 3). Sixty four (55.65%) of the doctors was awarded about current guideline for an antibiotic prophylaxis compare to (51) (44.35%) of them do not aware with statistically significant P(0.006) ( Table 3). In term to the knowledge of the doctors (103)(89.57% ) was agreed about antibiotic misuse which significantly higher than these not having knowledge of antibiotic misuse p(0.00) and the reasons of the misuse through to their opinion (79) (21) (75 %) were gave adequate information about the antibiotic to the patient which significantly higher than those do not P(0.00) (Table4). According to the pharmacists opinion responsible about misuse of antibiotic were doctors (9.1%), pharmacists (1.2 %), patients (89.9) (Figure-5).
Out of the (91) parents who were asked to fill the questionnaire (53)(58.24%) was knew about the term antibiotic resistant , only( 20)( 21.89%) of the respondents felt un happy if the doctor not prescribe antibiotic P(0.00) for each. Concerning the reason of use of antibiotic, majority (48)(52.71%) of the parents was gave it to the child for fever, followed next by flu symptoms and ear inflammation (33) (36.263%) and (10)( 10.99 %) for diarrhea. The parents were thought that most common cold and gastroenteritis were treated with use of an antibiotic (52)(57.14%) respectively. Forty nine (53.85%) of the parents was said that their child received antibiotic from previous prescription P(0.007), (75)(82.42%)of the parents were complete course of antibiotic prescribed by the doctors and (32)( 35.16%) of them asked their doctors to prescribe antibiotic. (57) (62.24%) of them were used antibiotic because pharmacists recommendation P(0.00). Fifty one (56.04 %) of the parents was declared that more confident in the doctor who prescribe antibiotic, 73 (80.22%) respond that their children get better faster when used antibiotic with statistically significant (Table-5).

DISCUSSION
The present study was described the results from a KAP-survey among 115 pediatrics doctors, 28 pharmacist and 91 parents who practiced from East of Libya. Overall, the theoretical knowledge of antibiotic use and misuse use (AMS) for doctors and pharmacist about antimicrobial knowledge including indications, administration and side effects ranged from very good to excellent. However in contrast, AMR was much less recognized as a problem in participants parents (41.76%). On the other hand, qualitative research among general practitioners in the U.S. showed that most of the physicians interviewed were aware that inappropriate use of antimicrobial in their own practice contributes to increasing AMR [18]. The present study was also showed that 37.36 % of the whole sample was found to be using un-prescribe antibiotics, which is lower than southern Spain study 41% conducted on 2006 [19]. Different factors had an influence on this behavior as age, socioeconomic level and drug availability. Inappropriate and excessive use of antibiotics are among the key factors for the increase and spread of resistance [19][20][21]. According to this study, the most frequent clinical indication for which antibiotics were prescribed were prescribed for symptoms or diagnoses associated with the respiratory system and gastroenteritis which similar to study done in Jordan. 2010 [22]. However, in another study on assessment of antibiotic use in pediatric patients put pneumonia at the bottom of the proportion of disorders for which were prescribed and gastroenteritis the most commonly occurred disorder [23]. Similar study conducted by Finkelstein reported that otitis media accounted for the majority of antibiotic courses dispensed [24]. This discrepancy might be due to the difference in the time period during which these study was conducted as there is seasonal variation regarding the prevalence of some diseases. Antibiotics are the most commonly prescribed drugs in hospitals and in developed countries around 30% of the hospitalized patients were treated with these drugs [23]. In this study according to the doctors practice was showed that Augmentin was the most frequently prescribed antibiotic (51.3%). Ceftriaxone less prescribed antibiotic 7%. The difference might be due to the fact that in this similar study antibiotic selection was based on the sensitivity of the responsible pathogens unlike in our case which was empiric. In addition to this, the difference in the indications between the present study and this similar study for which antibiotics prescribed may matter. This seems reasonable as fever is the most common finding as the sign of infection during presentation to hospital and other respiratory disorders which common in children.
The present finding that about two-thirds (56.04) of participants stated their trust in doctors who were not prescribed antibiotics should be utilized in designing effective interventions to reduce patients' expectations from antibiotics and to increase knowledge about antibiotic resistance. Previously study was reported that patients satisfied with improved understanding of their diseases even if an antibiotic was not prescribed [25,26]. In the current study, 17.58% being did not complete prescribe an antibiotic as prescribed; most of them stopped treatment because they felt better. This misconception in the antibiotic use may put the patient at risk of relapse with resistant pathogenic bacteria. It is widely believed that inadequate dosing, incomplete courses, and indiscriminate drug use have contributed to the emergence and spread of antibiotics resistance [16,27,28[. The current finding was showed 37.36% of the study population had self-medicated which is considerably lower than that reported from other countries in the Middle East region that ranged between 53.6% and 96.7% [29][30][31]. Self-medication is a very important behavioral aspect that contributes to the misuse of antibiotics [12].
The reasons of antibiotic misuse in the present study according to the opinion of participant doctors were an empirical use, incorrect dose and low level of education 68.70%, 18. 26%, 13.04% respectively; and the responsibility about antibiotic misuse according to pharmacist 'opinion were refer to parents and doctors 10.71%, 89.29% respectively. As regarding to the littérateur, the reasons of antibiotic misuse are complex, and several contributing factors are evidently associated with the overuse of antibiotics in both the patient's (or parents of children) level and doctor's level. These factors include cultural factors, behavioral characteristics, socioeconomic status, and level of education [32]. Furthermore, doctors usually relate their pattern of over prescribing to patients'/parents' pressure [11]. Also, lack of health education is one of the major contributing factors in the overuse of antibiotics [12]. Lack of knowledge, inappropriate beliefs and practices are vulnerable for misusing antibiotics in children [32,33].
The World Health Organization identified three key issues for public involvement: improving access to medical facilities, decreasing unnecessary use of antimicrobials. The WHO also urged member countries to initiate educational interventions for patients and the general population aimed at rationalizing the use of antibiotics to combat resistance [16]. Thus, the control of antibiotic utilization needs multifaceted interventions involving knowledgeable and engaged healthcare practitioners and the public.

CONCLUSION
The present KAP-survey has generated information about the prescribing attitudes and practices of medical doctors and pharmacies and parents from public hospitals. The parent had lower formal education but they were aware of the risks associated with use of excessive antibiotics. More interaction with pediatricians and involvement of mass media can help to improve the antibiotics knowledge and practices among and thus, control the problem of antibiotic resistance. Stringent laws need to be enforced by the government to restrict the access of antibiotics to parents without a prescription. Revision and dissemination of local AM guidelines, addressing the general public and exploring the possibilities of internet-based trainings.