بحث منشور الى المدرس عطور طالب Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics

Medical Science

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics

ISSN 2321 – 7359 EISSN 2321 – 7367

The International Weekly Journal for Medicine

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page16

1. INTRODUCTION

Rational use of medicines refers to the correct, proper and appropriate use of medicines. Rational use requires that

patients receive the appropriate drug, in the proper dose, for an adequate period of time, and at the lowest cost to

them and their community (WHO, 2010). World Health Organization (WHO) estimates that more than half of all drugs

prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. This incorrect

use may take the form of overuse, underuse and misuse of drugs. Incorrect use of drugs occurs in all countries,

causing harm to people and wasting resources (WHO, 2010).

Generally, antibiotics are drugs used to prevent or treat infections caused by pathogenic – disease-producing

microorganisms (antimicrobial drugs). In current practice, antibiotics used interchangeably with antibacterial drugs (a

class of drugs used to treat bacterial infections only, where they destroy bacteria (bactericidal) or prevent bacteria

from multiplying (bacteriostatic). Antibiotics are among the most frequently used drugs worldwide. The success of

antibiotics in saving lives and decreasing severity and duration of infectious diseases has encouraged their extensive

use. Antibiotics are not effective against the viruses that cause many illnesses including influenza and most upper

respiratory tract infections, including the common cold, or fungal infections like those caused by yeast (Abrams et al.,

2009).

Irrational use of antibiotics is very common, and it accelerates the development of adverse drug effects,

emergence of newer strains of bacteria that are resistant to many antibiotics, health care costs and reduces the

number of available effective drugs for serious or antibiotic-resistant infections (Abrams et al., 2009; Richard A.

Lehne, 2001). Antibiotic resistance occurs when antibiotics no longer work against disease-causing bacteria. These

infections are difficult to treat and can lead to longer lasting illnesses, extended hospital stays, and the need for more

expensive and toxic medications. Some resistant infections can even cause death. i.e., ineffective antibiotics will lead

to increased morbidity, health-care use and eventually premature mortality (Livermore, 2003). Furthermore,

antibiotics are required for other treatments, such as surgery and cancer chemotherapy, which would become

unavailable with the disappearance of effective antibiotics. Unfortunately, while resistance to older antibiotics is

increasing, the development of new generations of antibiotics is stalling (Kaplan and Laing, 2004). Therefore, efficient

use of existing antibiotics is needed to ensure the availability in the long term of effective treatment of bacterial

infections. Efficient use includes both restrictive and appropriate use (Sarahroodi and Arzi, 2009).

Appropriate use of antibiotics comprises – take antibiotics only when prescribed by a physician. Many patients

take antibiotics without medical prescription (as Self-medication). Do not prescribed antibiotics to patients who do

not need them like colds, flu and other viral infections. These antibiotics not only of no benefit, they become less

effective against the bacteria they are intended to treat. Follow all directions when taking antibiotics and take the

entire prescribed regimen (full course) even if you feel better before finishing them or take it for only a few days

before their illness completely cured. Taking the full course of antibiotics is the only way to kill all of the harmful

bacteria. A shortened course of antibiotics, on the other hand, often wipes out only the most vulnerable bacteria

while allowing relatively resistant bacteria to survive. Do not used antibiotics routinely with mild symptoms. Routine

use of antibiotics with mild symptoms, not help you to get better more quickly, is the primary cause of the increase in

the number of drug-resistant bacteria and even some common bacterial illness, such as mild ear infections; do not

benefit much from antibiotics. Throw away any unused antibiotics; do not save antibiotics for future use since partial

and incomplete treatment regimens are ways that bacteria develop resistance to antibiotics. Do not share your

medication and do not take antibiotics prescribed for someone else; specific antibiotics are prescribed for specific

bacteria, since not all antibiotics are able to cure all bacterial infections (Pechere, 2007).

Self-medication is a common problem worldwide and defined as obtaining and consuming drugs without the

advice of a physician either for diagnosis, prescription or surveillance of treatment (Montastruc et al., 1997). Two

thirds of all antibiotics are sold without prescription, through unregulated private sectors. Self-medication with

antibiotics has the potential to produce harmful effects on the society, as well as, on individual patients (Awad et al.,

2005). Overuse and misuse of antibiotics is a particularly serious global problem. It is now evident that both

developing countries as well as, developed countries are experiencing many aspects of inappropriate use of

medications in their health care facilities (Otoom and Sequeira, 2006).

However, most plans regarding antibiotic misuse are directed toward optimizing physicians’ prescriptions, while

other potential sources of antibiotic misuse are neglected. The problem of inappropriate antibiotic use is not the

physician's alone – it is shared by the other health professionals' drug sellers/pharmacists, health workers, community

and the pharmaceutical companies as well, all should be taken into consideration in attempting to curb the problem

(Bin Abdulhak et al., 2011).

Many agencies and organizations, including the Centers for Disease Control and Prevention (CDC) and the WHO,

have recognized antibiotic resistance as one of the most pressing public health issues of our time. This has resulted in

massive surveillance and research efforts, particularly in the area of antibiotic overuse. Nurses have been largely

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page17

absent from relevant educational and research efforts. Although advanced practice nurses frequently receive

continuing education concerning appropriate antibiotic use, most nurses do not. Their exposure to the subject is

limited to public service announcements and the lay literature, inadequate sources for any practicing professional

(Ann Marie Hart, 2006).

Misconceptions and lack of basic knowledge about antibiotic use have been reported by several studies across

populations in both developed and developing countries (Larson et al., 2009; Grigoryan et al., 2007; Andre et al.,

2010; Azevedo et al., 2009; Sawalha, 2008; You et al., 2008; Ling et al., 2011; Aris Widayati et al., 2012). Different

studies in neighbourhood countries from 2008 to 2012 showed unsatisfactory knowledge of proper antibiotic use,

antibiotics could be easily obtained without a medical prescription and misconceptions regarding antibiotic use exist

in the community (Mayadah et al., 2012; Abobakr et al., 2009; Nehad et al., 2012; Sarahroodi et al., 2010).

2. OBJECTIVES OF THE STUDY

1. To assess and evaluate the nurses' knowledge about the rational use of antibiotics.

2. To identify their awareness about the consequences of incorrect use of antibiotics.

3. METHODOLOGY

This study was a cross-sectional involving 110 nurses from General Basrah hospital and Al-sader teaching hospital in

Basrah governorate south of Iraq. The study was conducted from January to April 2013. Participation in the study was

voluntary and anonymous. The present study, as we believes, is the first study of its kind to be implemented in

Basrah. The data obtained through the administration of questionnaire designed to gather information such as socio-

Table 1

Demographic characteristics of the respondents (N = 110)

Variable Number Percentage

Age

< 25 years 24 21.8%

26 – 35 years 30 27.3%

36 – 45 years 38 34.5%

> 46 years 18 16.4%

Gender

Male 47 42.7%

Female 63 57.3%

Years of education

12 years and less 60 55%

13 years and more 50 45%

Years of nursing experience

10 years and less 38 34.5%

11– 20 years 44 40%

21 years and more 28 25.5%

Table 2

Respondents' knowledge score for correct answers about appropriate use of antibiotics

Score level Number Percentage

Poor (< 50%) 61 55.5%

Fair (50 – 69 %) 34 30.9%

Good (70% and over) 15 13.6%

Total 110 100%

Table 3

Respondents' knowledge about antibiotic use against bacteria and other organisms

Variable

Total

N=110

N %

Number of nurses who answered the correct answer 51 46%

Number of nurses who answered the wrong answer 59 54%

Total 110 100%

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page18

demographic data, level of knowledge on correct, proper and appropriate use of antibiotics and consequences of

incorrect use of antibiotics. The knowledge index for appropriate use of antibiotics calculated for each nurse by

summing the number of correct answers then dividing by the total score of the questions multiplied by 100. The main

index for all nurses was calculated and an arbitrator cut – off point is 50 %. Poor knowledge level considered if the

percentage of correct answers below the cut – off point. Fair knowledge level considered if the 50 – 69 % of answers

are correct and good knowledge level considered if the percentage of correct answers 70% and over. The collected

data was transferred to a Microsoft excel worksheet to obtain the results which has been expressed as numbers and

percentages.

4. RESULTS

Socio-demographic characteristics of the 110 nurses in the present study was 57.3% were females and 42.7% were

males, the majority of them 34.5% at age 36 – 45 years old, 55% of nurses 12 and less years of education. 40% of the

nurses were having 11 – 20 years of experience (Table 1). The findings of the table 2 presented that 55.5% of nurses

was poor knowledge, followed by 30.9% of nurses was fair knowledge, while 13.6% of nurses was good knowledge.

Table 3 shows that about 46% of nurses who answered correctly that antibiotics are effective against bacteria only

and 54% of them believed wrongly that antibiotics are effective against bacteria and other organisms. Table 4 shows

that about 57% from nurses who answered correctly that antibiotics are effective against bacteria only with 12 and

less years of education and 43% from them with 13 and more years of education while 53% of nurses who believed

wrongly that antibiotics are effective against bacteria and other organisms with 12 and less years of education and

47% from them with 13 and more years of education. Table 5 shows that about 47% from nurses who answered

correctly that antibiotics are effective against bacteria only with 11– 20 years of experience while 27.5% of them with

10 and less years of experience and 25.5% of them with 21 and more years of experience. Table 6 presents the

Table 4

Respondents' knowledge about antibiotic use against bacteria and other organisms regarding years of education

Variable

Years of education

Total

N=110

12 yrs and less 13 yrs and more %

N % N %

Number of nurses who answered the

correct answer

29 57% 22 43% 51 100%

Number of nurses who answered the wrong answer 31 53% 28 47% 59 100%

Total 60 -- 50 -- 110 --

Table 5

Respondents' knowledge about antibiotic use against bacteria and other organisms regarding years of experience

Variable

Years of experience

Total

N=110

10 yrs and less 11– 20 yrs 21 yrs and more %

N % N % N %

Number of nurses who answered the correct answer 14 27.5% 24 47% 13 25.5% 51 100%

Number of nurses who answered the wrong answer 24 41% 20 34% 15 25% 59 100%

Total 38 -- 44 -- 28 -- 110 --

Table 6

Respondents' awareness about medical causes for antibiotics use (N=110)

Medical causes Number percentage

Urinary tract infection 66 60%

Tonsillitis 62 56%

Gastroenteritis (diarrhea & vomiting) 55 50%

Ear infections 42 38%

Bronchitis or chest infections 38 35%

Sore throat 33 30%

Flu or Cold 27 25%

Runny nose 11 10%

Toothache 11 10%

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page19

conditions that indicate the use of antibiotics according to nurses' knowledge. 60%, 56%, 50%, 38%, 35%, 30% of

nurses believed that the antibiotics are effective against urinary tract infection, tonsillitis, gastroenteritis, ear

infections, bronchitis or chest infections and sore throat respectively. Table 7 shows misconceptions of nurses

regarding antibiotics use. 85% of nurses believed that, antibiotics help to get better more quickly, 67% supposed that,

antibiotics will always be effective in the treatment of same infection in the future, 58% believed that, antibiotics

should be stopped as soon as the patient feels better before complete drug course, 52% believed that, it is very

important to store antibiotics at home for necessary, while 30% of them used antibiotics routinely even with mild

symptoms. Table 8 show that 69% of nurses understand that antibiotics have many side effects and 61% of nurses

understand that inappropriate use of antibiotics cause antibiotics resistance. Table 9 reveal that 82% of nurses were

practiced antibiotic self-medication – use antibiotics and instruct antibiotics as well for patients, relatives, and friends

without consulting a physician. 84 (93%) from 90 nurses, who practiced antibiotic self-medication, use and instruct

antibiotics to patients without return to the physicians opinion depending on their previous experience.

5. DISCUSSION

Knowledge by itself is not enough to change behaviour, but does play an important role in shaping beliefs and

thoughts regarding a particular behaviour. Knowledge and thoughts influence persons’ behaviors and outcomes.

Improvements in knowledge are often correlated with better health practices. Antibiotics are powerful medicines that

fight bacterial infections – like urinary tract infection, many wound and skin infections, severe sinus infections that

last longer than 2 weeks, some ear infections, and some tonsillitis (tonsillitis caused by strep bacteria). Antibiotics are

ineffective and should not be used to treat viral infections – like bronchitis, colds, flu (influenza), most cough, most

ear infections, most tonsillitis and sore throats, and viral gastroenteritis. All these viral infections will usually go away

on its own and not required antibiotics treatment. If antibiotics used to treat viral infections may do more harm to

people and community than benefit (Livemore, 2003). Such antibiotic-taking behavior can result in insufficient

antibiotic exposure for eradicating infectious bacteria and potentially create an environment that promotes antibiotic

resistance. Using antibiotics when not required can lead to the development of many adverse effects and bacterial

strains that are resistant to drugs. The findings of the present study revealed that more than half of nurses (55.5%)

had poor knowledge regarding antibiotic use followed by 30.9% and 13.6% of nurses was fair and good knowledge

respectively. Poor knowledge regarding antibiotics guides to extensive irrational use, and consequently leads to

adverse drug effects and antibiotic resistance that has reached to levels places the human race in a real danger.

About 46% of nurses in this study knew that antibiotics are effective in bacterial infections, but more than half (54%)

of them had wrong knowledge regarding antibiotics’ effectiveness for other infections. More than half of nurses

(60%) answered correctly that urinary tract infection treated with antibiotics while 56% and 50% of them believed

wrongly that antibiotics are drugs of choice for treatment of tonsillitis and gastroenteritis. Antibiotics can treat most

urinary tract infections successfully because the most important cause of urinary tract infection is bacteria (viral or

fungal infections are rarely causes) (Nicolle, 2008) while the most important cause of tonsillitis and gastroenteritis is

viruses and the overwhelming majority of patients recover completely with or without medication.

Table 7

Respondents' misconceptions about antibiotics use (N=110)

Misconceptions Number percentage

Antibiotics help to get better more quickly 93 85%

Antibiotics will always be effective in the treatment of same

infection in the future

74 67%

Antibiotics should be stopped as soon as the patient feels

better

64 58%

Store antibiotics at home for necessary 57 52%

Antibiotics used routinely even with mild symptoms 33 30%

Table 8

Nurses' awareness about antibiotic side effects and antibiotic resistance

Variable

aware unaware

Total %

No % No %

Awareness about side effects of antibiotics 76 69% 34 31% 110 100%

Awareness about antibiotics resistance 68 61% 42 39% 110 100%

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page20

In 40% of patients with tonsillitis, symptoms have resolved in three days and within one week in 85%, regardless

of whether streptococcal infection is present or not. Tonsillitis caused by a virus will usually go away on its own.

Home treatments such as gargling with salt water, drinking warm tea, and taking pain medicine (such as

acetaminophen or ibuprofen) may help relieve discomfort. Antibiotics are not effective treatment for viral tonsillitis

and generally prescribed for tonsillitis caused by strep bacteria. A strep infection will usually go away on its own but

antibiotic treatment is needed because untreated strep throat can cause serious complications (Del Mar et al., 2006).

The most common cause of acute gastroenteritis in all ages is viruses, and is usually an acute and self-limiting disease

that does not require medication except symptomatic treatment and replacing lost fluids and electrolytes. Antibiotics

had not usually used for gastroenteritis, although they are sometimes recommended if symptoms are particularly

severe or if a susceptible bacterial cause is isolated or suspected (Grimwood and Forbes, 2009). In addition, 38%, 35%,

30% of nurses believed wrongly that the antibiotics are effective against other viral infections such as ear infections,

bronchitis or chest infections and sore throat respectively.

This study showed that, a great percentage of nurses had misconceptions about the use of antibiotics. 85% of

them expressed beliefs that antibiotics help to get better more quickly. 67% supposed that, antibiotics would always

be effective in the treatment of same infection in the future. 58% thought that, antibiotics should be stopped as soon

as the patient feels better before complete drug course. 52% believed that, it is very important to store antibiotics at

home for necessary, while 30% of them used antibiotics routinely even with mild symptoms. These wrong beliefs may

be due to lack of awareness and knowledge of respondents towards proper use of antibiotics. They must be aware

that to take all prescribed doses of an antibiotic and do not stop when symptoms are relieved. If medication stopped

too soon, symptoms of the current infection may recur and new infections that are caused by antibiotic-resistant

organisms and that are harder to treat may develop (Abrams et al., 2009).

Nurses must be attentive that not to take antibiotics left over from a previous illness or prescribed for someone

else. Even if infection is present, the likelihood of having the appropriate drug on hand, and in adequate amounts, is

extremely small. Thus, taking drugs not prescribed for the particular illness tends to maximize risks and minimize

benefits (Abrams et al., 2009). Accordingly, the relationships between knowledge and beliefs suggest that the more

appropriate nurses' knowledge about the use of antibiotics; the fewer misconceptions they will have regarding the

effectiveness of antibiotics. In contrast to those misconceptions, nurses in this study had a sufficient knowledge

regarding the risks of inappropriate use of antibiotics. (69%) of them understand that antibiotics have many side

effects and (61%) realized that inappropriate use of antibiotics could contribute to resistance to these drugs. Despite

of this, a good percentage of nurses still used antibiotics inappropriately (despite owning the correct information,

they fail to employ what they know properly – there is wrong behaviors). This result proves the lack of knowledge

about correct, proper and appropriate use of antibiotics.

The previous findings are in line with most other studies from elsewhere – Sweden, Hong Kong, Greece, Jordan,

Syria but in contrast to what reported by the European study (Andre et al., 2010). Majority of nurses (82%) practiced

self-medication with antibiotic as well as they instructed antibiotics for patients, relatives, and friends without

consulting a physician. This rate is similar to other studies including population in China and Greece but there are

some lower rates, reported from study in Palestinian and study in Iran by 53% of antibiotic self-medication and other

studies in Turkey (45.8%)(Buke et al., 2003), Jordan (40.7%), (Al-Azzam et al., 2007) and in Sudan (Sawalha, 2008).

93% of nurses, who practiced antibiotic self-medication said that, their previous experience in the field of nursing,

allow them to diagnose the disease and prescribe the necessary treatment without return to the physicians' opinion.

These nurses do not understand that, antibiotics should not used without physician advise because in most cases

there is no necessitate to use antibiotics and in other cases physician need to send the patient for laboratory

investigation before prescribing treatment to confirm the diagnosis and then choose the appropriate antibiotic and

determine the treatment period. In addition, antibiotics dosage (amount and frequency of administration) should be

individualized according to characteristics of the causative organism, the chosen drug, and the patient’s size and

condition (e.g., type and severity of infection, ability to use and excrete the chosen drug). Dosage often must be

reduced if the patient has renal impairment or other disorders that delay drug elimination. Most antibiotic drugs are

given orally or IV for systemic infections. The route of administration depends on the patient’s condition (e.g.,

Table 9

Nurses use of antibiotics without medical prescription

Questions

Answers

Yes (%) No % Total %

Are you using antibiotics without medical prescription (self-medication with

antibiotics)?

90 82% 20 18% 110 100%

Are you instructing antibiotics for patients, relatives, and friends? 90 82% 20 18% 110 100%

use antibiotics without a prescription as a result of their previous experience. 84 93% 6 7% 90 100%

Utoor T Jassim,

Assessment of Nurses' Knowledge and Awareness about the Rational Use of Antibiotics,

Medical Science, 2014, 6(19), 15-21, www.discovery.org.in

http://www.discovery.org.in/md.htm © 2014 discovery publication. All rights reserved

Page21

location and severity of the infection, ability to take oral drugs) and the available drug dosage forms. In serious

infections, the IV route is preferred for most drugs.

6. CONCLUSION

The present study indicate that a lack of general knowledge and awareness regarding appropriate and rational use of

antibiotics between the nurses. Since this may be due to a lack of educational background on this subject.

7. RECOMMENDATIONS

Increase knowledge and awareness of nurses and other health care providers about rational use of antibiotics by

develops and delivers education programs at all levels of the health system on how to monitor and improve

antibiotics use.

REFERENCES

1. Abobakr A, Jiri V, Mohammed A, Ales K. Self medication

with antibiotics by the community of Abu Dhabi Emirate,

UAE. J Infec Dev Ctries 2009, 3(7), 491-497

2. Abrams A, Penningto S, lammon C. Clinical Drug Therapy:

Rationales for Nursing Practice. 9th ed. New York,

Lippincott Williams & Wilkins, 2009, 467–485

3. Al-Azzam SI, Al-Husein BA, Alzubi F, Masadeh MM, Al-

Horani MAS. Self-medication with antibiotics in Jordanian

population. Int. J. Occup. Med. Environ. Health, 2007, 20,

373-380

4. Andre M, Vernby A, Berg J, Lundborg CS. A survey of public

knowledge and awareness related to antibiotic use and

resistance in Sweden. J Antimicrob Chemother, 2010, 65(6),

1292-1296

5. Ann Marie Hart. Against Antibiotic Overuse: Nurses can

help solve this urgent problem. American Journal of

Nursing, 2006, 106(1), 13

6. Aris Widayati, Sri Suryawati, Charlotte de Crespigny, Janet E

Hiller. Knowledge and beliefs about antibiotics among

people in Yogyakarta City Indonesia: a cross sectional

population-based survey. Antimicrobial Resistance and

Infection Control, 2012, 1, 38

7. Awad A, Eltayeb I, Matowe L, Thalib L. Self-medication with

antibiotics and Antimalarial in the community of Khartoum

State, Sudan. J. Pharm. Pharm. Sci. 2005, 8, 326-331

8. Azevedo MM, Pinheiro C, Yaphe J, Baltazar F. Portuguese

students’ knowledge of antibiotics: a cross-sectional study

of secondary school and university students in Braga. BMC

Publ Health, 2009, 9, 359

9. Bin Abdulhak, Mohamad A Al Tannir, Mohammed A

Almansor. Non-prescribed sale of antibiotics in Riyadh,

Saudi Arabia: A Cross Sectional Study. BMC Public Health,

2011, 11, 538

10. Buke AC, Ermertcan S, Hosgor-Limoncu M, Ciceklioglu M,

Eren S. Rational antibiotic use and academic staff. Int. J.

Antimicrob. Agents, 2003, 21, 63-66

11. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore

throat. In Del Mar, Chris B. Cochrane Database Syst Rev.,

2006, 18(4)

12. Grigoryan L, Burgerhof JG, Degener JE, Deschepper R,

Lundborg CS, Monnet DL, Scicluna EA, Birkin J, Haaijer-

Ruskamp FM. Attitudes, beliefs and knowledge concerning

antibiotic use and self-medication: a comparative European

study. Pharmacoepidemiol Drug Saf, 2007, 16(11), 1234-

1243

13. Grimwood K, Forbes. Acute and persistent diarrhea.

Pediatr. Clin. North Am. DA, 2009, 56(6), 1343–61

14. Kaplan W, Laing R. Priority medicines for Europe and the

world. Geneva, WHO, 2004

15. Larson E, Ferng YH, Wong J, Alvarez-Cid M, Barrett A,

Gonzalez MJ, Wang S, Morse SS. Knowledge and

misconceptions regarding upper respiratory infections and

influenza among urban Hispanic households: need for

targeted messaging. J Immigr Minor Health, 2009, 11(2),

71-82

16. Ling Oh A, Hassali MA, Al-Haddad MS, Syed Sulaiman SA,

Shafie AA, Awaisu A. Public knowledge and attitudes

towards antibiotic usage: a cross-sectional study among the

general public in the state of Penang, Malaysia. J Infect Dev

Ctries, 2011, 5(5), 338-47

17. Livermore DM. Bacterial resistance: Origins, epidemiology,

and impact. Clinical Infectious Diseases, 2003, 36, 11–23

18. Mayadah S, Ghadeer S Darwish, M. Wazaify. Knowledge,

attitudes and behavior regarding antibiotics use and misuse

among adults in the community of Jordan. A pilot study.

Saudi Pharmaceutical Journal, 2012, 20(2), 125–133

19. Montastruc JL, Bagheri H, Geraud T, Lapeyre-Mestre M.

Pharmacovigilance of self-medication. Therapie, 1997, 52,

105-10

20. Nehad M, Jyothi V, Istabraq Al Ayoubi. Antibiotics

Utilization and Adherence Pattern in Ajman/UAE. Journal of

Applied Pharmaceutical Science, 2012, 2(6), 213-216

21. Nicolle LE. Uncomplicated urinary tract infection in adults

including uncomplicated pyelonephritis. Urol Clin North

Am., 2008, 35(1), 1–12

22. Otoom SA, Sequeira RP. Health care providers' perceptions

of the problems and causes of irrational use of drugs in two

Middle East countries. Int. J. Clin. Pract. 2006, 60, 565-570

23. Pechère JC. Non-compliance with antibiotic therapy for

acute community infections: a global survey. International

Journal of Antimicrobial Agents, 2007, 29, 245–253

24. Richard A Lehne. Pharmacology for Nursing Care. 4th ed.

London, Saunders, 2001, 905–917

25. Sarahroodi S, Arzi A, Sawalha AF, Ashtarinezhad A.

Antibiotics Self-Medication among Southern Iranian

University Students. International Journal of Pharmacology,

2010, 6, 48-52

26. Sarahroodi S, Arzi A. Self-medication with antibiotics, Is it a

problem among Iranian College students in Tehran?. J.

Biol. Sci. 2009, 9, 829-832

27. Sawalha AF. Self-medication with antibiotics: a study in

Palestine. Int J Risk Saf Med., 2008, 20, 213-222

28. Sawalha AF. A descriptive study of self-medication practices

among Palestinian medical and nonmedical university

students. Journal of Social and Administrative Pharmacy,

2008, 4, 164-172

29. WHO: Medicines: rational use of medicines. Geneva, 2010

30. You JH, Yau B, Choi KC, Chau CT, Huang QR, Lee SS. Public

knowledge, attitudes and behaviour on antibiotic use: a

telephone survey in Hong Kong. Infection, 2008, 36(2), 153-

157