A study on the relationship between improved patient knowledge and compliance with antibiotic use

Catharina Colette Beukes Supervisor: Professor A.G.S. Gous

Background:

Antibiotic resistance is fast becoming a major health challenge. Patients need to be educated on the origin of this medical crisis and need to change their attitude toward antibiotic use. Health professionals need to help patients improve antibiotic compliance and identify problem areas.

Objectives:

The aim of this study was to determine whether a better understanding of resistance formation and patient education on responsible use of antibiotics will improve patient compliance towards antibiotic use. To achieve the aim of the study:

Determined the patients compliance on antibiotic use by the self-pill count feedback method. Determined whether the provision of more antibiotic information to the patient correlated to better compliance and Other reasons for non-compliance were also recorded. Compared the findings of the study with other similar antibiotic compliance studies.

Methodology:

The study was conducted at a private hospital in Gauteng. Patients receiving antibiotic prescriptions were divided into two groups. Group A received a leaflet with their antibiotic prescription with information on how to use antibiotics responsibly. Group B did not receive any additional information on antibiotic use. Both these groups were contacted via e-mail and asked to complete a survey to test their knowledge and attitude towards antibiotics.

Antibiotics: Wise-up and take responsibility

Antibiotics are the first line of defence against many infections, however, overusing or misusing antibiotics can cause treatment failure in future. What are antibiotics? Antibiotics are used for treating many less serious to life-threatening diseases caused by bacterial infections. Taking antibiotics when you don't need to, can lead to antibiotic-resistance. Antibiotics are only effective against bacterial infections, certain fungal infections and some kinds of parasites. Most infections result from either bacteria or viruses. Antibiotics are not effective against viral infections! Common bacterial infections cause severe upper-respiratory-tract infections e.g. pneumonia, wound and skin infections and urinary tract infections. Common colds, influenza, most ear infections and stomach flu are caused by viral infections. These can be treated by anti-viral drugs or by treating the symptoms. How does antibiotic resistance develop? Penicillin was introduced in the first part of the 20th century and since then scientists have developed many more antibiotics to help stop the spread of infectious disease. Antibiotics have saved millions of lives but because of frequent use, often for conditions or infections that aren't caused by bacteria, the bacteria have become resistant to many commonly used antibiotics. Resistance develops when an antibiotic fails to kill all of the bacteria it targets. The surviving bacteria adapt and become more resistant to that particular drug. Doctors then needs to prescribe stronger antibiotics, but the bacteria quickly learn to defend themselves against the more potent drugs as well, creating a cycle in which increasingly powerful drugs are required to treat infections. Experts are working to develop new antibiotics and to keep pace with antibiotic-resistant strains of bacteria, but bacteria adapt quickly. Antibiotic-resistant bacteria continue to be a global health concern and using antibiotics wisely is an important part of preventing the development of resistance. Consequences of antibiotic resistance As an increasing amount of bacteria become resistant to first line treatments, the consequences become severe. Illnesses last longer, and the risk of complications and death increases. The inability to properly treat a particular infection leads to longer periods in which a person is contagious and able to spread the resistant bacterial strains to others. Because of first line treatment failures, doctors have to resort to less-conventional antibiotics, many of which are much more costly and have more side-effects. Many other factors need to be considered, including the increased costs associated with prolonged illnesses, direct expense for additional laboratory tests, treatments and hospitalization, and the indirect costs from loss of income or time away from family. Safeguard effective antibiotics: What you can do Finishing your prescribed course of antibiotics is utmost importance. Using antibiotics too often or incorrectly is a major cause of the increase in resistant bacteria. Here are some things you can do to promote proper use of antibiotics: Understand when antibiotics should be used. Don't expect to take antibiotics every time you're sick. Antibiotics are effective in treating bacterial infections, but they're not useful against viral infections, such as colds, acute bronchitis, or the flu. And even some common minor bacterial ailments, such as mild ear infections, don't benefit much from antibiotics. Don't pressure your doctor for antibiotics if you have a viral illness. Talk to your doctor about ways to relieve the symptoms of your viral infection. Take antibiotics exactly as prescribed. Follow your doctor's instructions when taking prescribed medication, including how many times a day and for how long. Never stop treatment a few days early if you start feeling better a complete course of antibiotics is needed to kill all of the harmful bacteria. A shortened course of antibiotics often only kills the most vulnerable bacteria, while allowing relatively resistant bacteria to survive. Never take antibiotics without a prescription. You might be tempted to use leftover medication the next time you get sick. This might be the incorrect antibiotic for you infection and an incomplete course. Protect yourself from infection in the first place. Good hygiene can go a long way in preventing infection. Wash your hands thoroughly with soap and water, especially after using the toilet, changing a diaper or handling raw meat or poultry. Keep food preparation areas clean. Antibiotic resistance is a pressing, global health problem. Nearly all bacterial infections are becoming resistant to commonly used antibiotics. When you abuse antibiotics, the resistant micro-organisms that you help create can cause new and hard-to-treat infections. That's why the decisions you make about antibiotic use unlike almost any other medicine you take extend far beyond your reach. Responsible antibiotic use protects the health of your family, neighbours and ultimately the global community.

Dear Pretoria East Hospital Pharmacy Patient, We would like to follow-up on the use of your antibiotics received at our pharmacy on ________. A questionnaire survey has been compiled to measure patients adherence to antibiotic prescription instructions and also the information received from the pharmacist or assistant that issued your prescribed antibiotics. We would appreciate it if you could take 3 minutes to answer the 11 questions. This survey aims to determine how we can improve our service to patients and ensure that patients receive the necessary information regarding the medication they need to take. All patient information will be kept confidential and will only be used for the purposes of the study. No names are asked in this questionnaire and all data will be saved anonymously.

Your consent to partake in this study will be given by completing the questionnaire below and returning it to the sender. Your participation would be greatly appreciated.
Please first answer the questions, next 'copy' the text with the given answers. Click on the reply button, then 'paste' the completed questionnaire before clicking on the send button.

1. Have you finished you antibiotic course? Yes No If you answered 'No', please specify how many of the tablets or how much of the suspension do you have left over?
2. Did you finish the antibiotics in the prescribed time? Yes No 3. The following might be possible reasons for not finishing the prescribed antibiotics. Choose the most appropriate option. You felt better before the antibiotic course was finished The antibiotics made you feel worse The antibiotic course was too long You did not know for how long to take your antibiotics You did not receive the whole antibiotic course You had trouble taking the antibiotics because of tablet size or flavour You forgot to take the antibiotic Other reasons or when answering Yes to question 1. Please explain when choosing 'Other reasons':

4. Do you know what happens when one does not finish a course of antibiotics? Yes No If your answer is 'Yes', what do you think would happen?

5. What have you done with left-over antibiotics in the past? Kept it for future use Threw it away Gave it to someone that needed antibiotics 6. What would you do with left-over antibiotics in future?
7. Would you ask your doctor for antibiotics when you have a common cold? Yes No Have you asked your doctor for antibiotics when having a common cold in the past?

8. Did you receive an 'Antibiotics: wise-up and take responsibility' brochure from your pharmacist? Did you read the brochure? (answer from dropdown menu) YesNo 9. What is the most important lesson you learned by reading the 'Antibiotics: wise-up and take responsibility' brochure?
10. In what way would you change your use of antibiotics, if you would change anything? 11. Would you prefer to receive more information on responsible antibiotic use? YesNo

Results:

274 Patients

138 Received additional antibiotic information

136 Received no additional antibiotic information

39 responses = 39 participants

99 no response

40 responses = 40 participants

96 no response

32 read the additional information = Group Aa

71 adult patients 28 child patients

40 did not receive additional information = Group B

71 adult patients 25 child patients

24 adult participants 8 child participants

31 adult participants 9 child participants

7 did not read the additional information= Group Ab

4 adult participants 3 child participants

Participant response rate

A total of 79 patients participated in the study. Group A with 39 participants and Group B with 40 participants completed the questionnaire and reported on their antibiotic usage and knowledge

% of patient prescriptions
10 12 14 0 2 4 6 8

Patient age distribution

Age group

014 ye ar 15 s -1 9y ea rs 20 -2 9y ea rs 30 -3 9y ea rs 40 -4 9y ea rs 50 -5 9y ea rs 60 -6 9y ea rs 70 -7 9y ea rs 80 -8 9y ea rs

Male

Female

1. Have you finished your antibiotic course?

Question 1. Have you finished your antibiotic course?

Sample (N) 79 Group Aa Group Ab Group B Total

Yes 31 5 34 70

% 96.88% 71.43% 85% 88.61%

No 1 2 6 9

% 3.12% 28.57% 15% 11.39%

Group total 32 (100%) 7 (100%) 40 (100%) 79 (100%)

Group Aa, who was provided additional information on antibiotic use and read through the brochure, showed a better compliance to the antibiotic regimen prescribed.

 2. Did you complete the antibiotics in the prescribed time?

Question 2. Did you complete the antibiotics in the prescribed time?

Sample (N) 79 Group Aa Group Ab Group B Total

Yes 30 5 33 68

% 93.75% 71.43% 82.50% 86.08%

No 2 2 7 11

% 6.25% 28.87% 17.50% 13.92%

Group total 32 (100%) 7 (100%) 40 (100%) 79 (100%)

3: The following might be possible reasons for not finishing the prescribed antibiotics. Choose the most appropriate option.
You felt better before the antibiotic course was finished The antibiotics made you feel worse The antibiotic course was too long 5 1 3 31% 6% 19%

You did not know for how long to take your antibiotics
You did not receive the whole antibiotic course

0
0

0%
0% 6% 19% 19% 100%

You had trouble taking the antibiotics because of tablet size 1 You forgot to take the antibiotic Other reasons or when answering Yes to question 1. N = 16 3 3

The patient felt better before the antibiotic course was finished The antibiotics made the patient feel wose 31% The antibiotic course was too long 19% 6% 6% 19% The patient had trouble taking the antibiotics because of tablet size or flavour The patient forgot to take the antibiotic Other reasons

19%

Reported reasons for patient non-compliance

Participants gave various reasons for not being compliant. Most patients stopped taking their antibiotics as soon as they felt better.

4: Do you know what happens when one does not finish a course of antibiotics? What do you think will happen?

79 Participants

58 Participants Know why one complete antibiotics 73.42%

21 Participants Dont know why one complete antibiotics 26.58%

18 Antibiotics will stop working

19 Resistance will develop

15 The infection will not clear up

5 No answer

1 Patient will become immune to the antibiotic

18 Participant s
Group B

3 Participants : Group Ab

79 Participants

73.42%

58 Participants Know why one complete antibiotics 73.42%

26.58%

21 Participants Dont know why one complete antibiotics 26.58%

18 Antibiotics will stop working

19 Resistance will develop

15 The infection will not clear up

5 No answer

1 Patient will become immune to the antibiotic

18 Participants Group B

3 Participants: Group Ab

12 Group Aa

13 Group Aa

4 Group Aa

3 Group Aa

0 Group Aa

1 Group Ab

1 Group Ab

2 Group Ab

0 Group Ab

0 Group Ab

5 Group B

5 Group B

9 Group B

2 Group B

1 Group B

79 Participants

73.42%

58 Participants Know why one complete antibiotics 73.42%

26.58%

21 Participants Dont know why one complete antibiotics 26.58%

18 Antibiotics will stop working 31.03%

19 Resistance will develop 32.76%

15 The infection will not clear up 25.86%

5 No answer 8.62%

1 Patient will become immune to the antibiotic 1.72%

18 Participants Group B 85.71%

3 Participants: Group Ab 14.29%

12 Group Aa

13 Group Aa 68.84%

4 Group Aa 26.67%

3 Group Aa 60%

0 Group Aa 0%

66.67%

1 Group Ab 5.56%

1 Group Ab 5.26%

2 Group Ab 13.33%

0 Group Ab 0%

0 Group Ab 1%

5 Group B 27.77%

5 Group B 26.31%

9 Group B 60%

2 Group B 40%

1 Group B 100%

79 Participants

73.42%

58 Participants Know why one complete antibiotics 73.42%

26.58%

21 Participants Dont know why one complete antibiotics 26.58%

18 Antibiotics will stop working 31.03%

19 Resistance will develop 32.76%

15 The infection will not clear up 25.86%

5 No answer 8.62%

1 Patient will become immune to the antibiotic 1.72%

18 Participants Group B 85.71%

3 Participants: Group Ab 14.29%

12 Group Aa 66.67%

13 Group Aa 68.84%

4 Group Aa 26.67%

3 Group Aa 60%

0 Group Aa 0%

1 Group Ab 5.56%

1 Group Ab 5.26%

2 Group Ab 13.33%

0 Group Ab 0%

0 Group Ab 1%

5 Group B 27.77%

5 Group B 26.31%

9 Group B 60%

2 Group B 40%

1 Group B 100%

When compared to Group Ab, who received additional information on antibiotic use and did not read through the brochure, and Group B, who received no additional information on antibiotic use, a much higher percentage of Group Aa was able to give valid reasons as to why one should complete an antibiotic course.

5: What have you done with leftover antibiotics in the past?

Kept it for future use Threw it away Gave it to someone that needed antibiotics

6. What would you do with left-over antibiotics in future?

Patients kept left-over antibiotics for future use n=19

Past behaviour

9 Patients received a brochure and read the leaflet Group Aa Future behaviour

3 Patients received a brochure but did not read the leaflet Group Ab Future behaviour

Patients did not receive a leaflet Group B Future behaviour

2patients will throw away their left-over antibiotics in future

7 patients will complete their antibiotic courses in future

2 patients will still keep their left-over antibiotics for future use

1 patient will throw away the left-over antibiotics in future

1 patient will complete the antibiotic course in future

6 patients will still keep their left-over antibiotics for future use

Participants kept left-over antibiotics for future use

Patients kept left-over antibiotics for future use n=19

Past behaviour

9 Patients received a brochure and read the leaflet Group Aa

3 Patients received a brochure but did not read the leaflet Group Ab

7 Patients did not receive a leaflet Group B

77.78% +ve change in behaviour n=7

Future behaviour

0% +ve change in behaviour

n=0

Future behaviour

14.29% +ve change in behaviour n=1

Future behaviour

2patients will throw away their left-over antibiotics in future

7 patients will complete their antibiotic courses in future

2 patients will still keep their left-over antibiotics for future use

1 patient will throw away the left-over antibiotics in future

1 patient will complete the antibiotic course in future

6 patients will still keep their left-over antibiotics for future use

Patients kept left-over antibiotics for future use n=19

Past behaviour

9 Patients received a brochure and read the leaflet

Group Aa

3 Patients received a brochure but did not read the leaflet Group Ab

7 Patients did not receive a leaflet

Group B

77.78% +ve change in behaviour n=7

Future behaviour

0% +ve change in behaviour

n=0

Future behaviour

14.29% +ve change in behaviour n=1

Future behaviour

2patients will throw away their left-over antibiotics in future

7 patients will complete their antibiotic courses in future

2 patients will still keep their left-over antibiotics for future use

1 patient will throw away the left-over antibiotics in future

1 patient will complete the antibiotic course in future

6 patients will still keep their left-over antibiotics for future use

Participants threw away left-over antibiotic 49

Past behaviour

17 Participans received a leaflet Group Aa Future behaviour

4 Participant received a leaflet but did not read the leaflet Group Ab Future behaviour

28 Participants received no leaflet Group B

12 participants will complete the antibiotic course in future

5 participants will throw away left-over antibiotics

4 Participants will throw away left-over antibiotics

2 Participants will complete the antibiotic course in future

26 Participants will throw away left-over antibiotic

Participants threw away left-over antibiotics

Participants threw away leftover antibiotic 49

Past behaviour

17 Participans received a leaflet Group Aa

4 Participant received a leaflet but did not read the leaflet Group Ab

28 Participants received no leaflet Group B

Future behaviour
70.59% +ve change in behaviour n=12 0% +ve change in behaviour n=0

Future behaviour
7.14% +ve change in behaviour n=2

12 participants will complete the antibiotic course in future

5 participants will throw away leftover antibiotics

4 Participants will throw away leftover antibiotics

2 Participants will complete the antibiotic course in future

26 Participants will throw away leftover antibiotic

Participants threw away leftover antibiotic 49

Past behaviour

17 Participans received a leaflet

Group Aa Future behaviour

70.59% +ve change in behaviour n=12

4 Participant received a leaflet but did not read the leaflet Group Ab

28 Participants received no leaflet Group B

Future behaviour
7.14% +ve change in behaviour n=2

0% +ve change in behaviour n=0

12 participants will complete the antibiotic course in future

5 participants will throw away leftover antibiotics

4 Participants will throw away leftover antibiotics

2 Participants will complete the antibiotic course in future

26 Participants will throw away leftover antibiotic

Past behaviour

Participant will give left-over antibiotic to someone who might need antibiotics 3

3 Participants received a leaflet Group Aa

Future behaviour

3 Participants will complete the course of antibiotics in future

Participants gave left-over antibiotics to someone in need of antibiotics

Past behaviour

Participant will give left-over antibiotic to someone who might need antibiotics 3

3
Participants received a leaflet Group Aa

100% +ve change to behaviour n=3

Future behaviour

Participants will complete the course of antibiotics in future

Past behaviour

Participant will give left-over antibiotic to someone who might need antibiotics 3

3
Participants received a leaflet

Group Aa

100% +ve change to behaviour n=3

Future behaviour

Participants will complete the course of antibiotics in future

Participant always complete the antibiotic course with no left-over antibiotics 10

5 Participants received a leaflet Group Aa

Future behaviour

5 Participants did not receive a leaflet Group B

100% +ve participant behaviour

100% +ve participant behaviour

5 Participants will complete the antibiotic course in future

Participants always complete an antibiotic course

5 Participants will complete the antibiotic course in future

78% of Group Aa intended to change their future behaviour with regards to left-over antibiotics. These patients are committed to being completely compliant in future.

7: Would you ask your doctor for antibiotics when you have a common cold?
Yes No Have you asked your doctor for antibiotics when having a common cold in the past?

Participants who do not put pressure on doctors to prescribe antibiotics in viral infections
Group N=79 Group Aa Group Ab 22/32 4/7 68.75% 57.14% 32/32 4/7 100% 57.14% Past % Future %

Group B

32/40

80%

32/40

80%

80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Group Aa Group Ab Group B Past

Pressure from participants to get antibiotics prescriptions for viral infections

80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Group Aa Group Ab Group B Past Future

Pressure from participants to get antibiotics prescriptions for viral infections

100.00% 80.00% 60.00% Past 40.00% 20.00% 0.00% Group Aa Group Ab Group B Future

Pressure from participants to get antibiotics prescriptions for viral infections

Group Aa showed a 100% change in attitude when it comes to pressurizing medical practitioners into prescribing antibiotics for minor illness, colds and flu.

9: In what way would you change your use of antibiotics, if you would change anything?
N =32 15 Statement # Nr. 1 Statement Nothing Participants did complete course in prescribed time and have not asked for antibiotics from a medical practitioner (1 overlap statement Nr 4 and 1 overlap with Nr 5)

10 2

Nr. 2 Nr. 3

One should always complete the course One should only use antibiotics when it is necessary One should use antibiotics for bacterial infections and not for viral infections One should not pressure a medical practitioner for an antibiotic prescription when having a flu

Nr. 4

(1 overlap statement Nr 2)

Nr. 5

(1 overlap with statement Nr 2)

No answer provided

o Participants who already showed responsible use of antibiotics chose statement Nr 1, with no changes needed in their antibiotic use. o 56.25% of participants in Group Aa gained knowledge and based on that will use antibiotics more responsible in future.

o 87.50% of Group Aa learned something by reading the leaflet concerning responsible antibiotic use.
o 9.38% of Group Aa did not learn anything new

10: What is the most important lesson you learned by reading the 'Antibiotics: wise-up and take responsibility' brochure?
N =32 12 Statemen t# Nr. 1 Statement Antibiotics has no effect on viruses and should only be used for bacterial infections, not colds and flu All bacteria need to be killed by the antibiotic and the course should be completed to reduce antibiotic resistance One should not over use antibiotics Nothing learned Patients will become immune to antibiotics (1overlap with statement Nr 2)

12

Nr. 2

(1overlap with statement Nr 1) (2overlap with statement Nr 3) (2 overlap with statement Nr 2)

7 3 1

Nr. 3 Nr. 4 Nr. 5

The majority of Group Aa admitted to learning something by reading the leaflet handed to them and also showed most interest in wanting more antibiotic information from their pharmacist in future.

11: Would you prefer to receive more information on responsible antibiotic use?
Answer Group Gender/Age Group Female Yes Group Aa Group Ab Group B 12 1 11 Male 7 1 8 Children 7 3 4

Total: 54 (68.35%)
No Group Aa Group Ab Group B Total: 25 (31.64%) Total: 100%

Total: 24 (70.59%)
2 1 7 Total: 10 (29.41%) 100%

Total: 16 (64%)
3 1 5 Total: 9 (36%) 100%

Total: 14 (70%)
1 0 5 Total: 6 (30%) 100%

11: Would you prefer to receive more information on responsible antibiotic use?
Answer Group Gender/Age Group Female Yes Group Aa Group Ab Group B Total: 54 12 1 11 Total: 24 (70.59%) Group Aa Group Ab Group B Total: 25 (31.64%) Total: 100% 2 1 7 Total: 10 (29.41%) 100% Male 7 1 8 Total: 16 (64%) 3 1 5 Total: 9 (36%) 100% Children 7 3 4 Total: 14 (70%) 1 0 5 Total: 6 (30%) 100%

(68.35%)
No

Participants from Group Aa showed most willingness to learn more about antibiotic use with females and children making out the largest portion of the group. Male participants tended to be less eager to learn more about responsible antibiotic use.

Conclusion:

The main objective of the study was to determine whether a better understanding to antibiotic resistance will lead to better compliance. The hypothesis H = Ma > Mb, where Ma represents Group A and Mb represents Group B of the study, proved to be true. Participants from Group A showed a better understanding of the formation of antibiotic resistance. This group intended to change their negative behaviour and showed a higher compliance rate than Group B.