Antibiotic Use for the Treatment of Upper Respiratory Infections in a Diverse Community
Analysis
We dichotomized the likelihood of use and perceived effectiveness of treatments (measured on 5-point scales) into categorical variables. For example, “very likely” and “somewhat likely” were collapsed into one category to compare with a second category combining “neutral”, “somewhat unlikely,” and “very unlikely.” These categorical variables were then analyzed using chi-square tests.
To relate beliefs and practices regarding antibiotic access and use to countries of origin, we classified respondents into 1 of 3 groups as an indication of cultural background. These groups were: subject and subject’s mother were both born in the United States (US); subject or subject’s mother was born outside the mainland United States in a country or territory where there are regulations limiting antibiotic access (REGS); and subject or subject’s mother was born in a country with over-the-counter antibiotics (OTC). Our categorization of specific countries is shown in Table 1. Access to antibiotics in the countries and territories of the second group (REGS) are diverse. Although all of those countries have regulations limiting antibiotic access, the degree of enforcement is variable.17 We determined antibiotic regulations through telephone and E-mail contact with embassies and Ministries of Health.
We computed bivariate analyses among the likelihood of seeking care, the use of antibiotics as a usual treatment for URIs, and the perceived effectiveness of antibiotics in relation to patient demographic characteristics. Similarly, we used bivariate analyses to relate the likelihood of seeking care, usual treatment, and perceived effectiveness of antibiotics to country of origin classification. We then determined if usual use, demographics, or country of origin classification correlated with positive reports of obtaining antibiotics without physician prescriptions.
Results
Of the 221 subjects approached, 29 refused participation or returned incomplete surveys, resulting in 192 usable surveys (87%). Table 2 shows the demographic characteristics of the sample. The majority of subjects (59%) were surveyed in primary care sites, 29% in an emergency department, and 12% in community centers.
Our results indicate that the majority of respondents were likely to seek care from a physician for both scenarios (Table 3). Slightly more than half (58%) of the respondents were somewhat or very likely to seek care for the scenario with clear nasal discharge, while 84% of the respondents were likely to seek care with discolored nasal discharge (P <.001). Our data also indicate that antibiotics were the usual treatment for URIs with both scenarios, although significantly more often when discolored nasal discharge was present. Antibiotics were also believed to be effective treatments for URIs by the majority of respondents for both scenarios (79% in the clear discharge scenario and 88% in the discolored discharge scenario, P = .02). The use of other treatments did not differ significantly between the 2 scenarios.
Twenty-six percent of respondents reported the use of antibiotics for URIs in the last year that were not prescribed for that condition by a physician. Non-prescription antibiotics were obtained from a variety of sources. In nonmutually exclusive categories, 61% used antibiotics left over from a previous illness; 46% obtained antibiotics from a family member; 31% obtained them directly from a pharmacist without a prescription; and 21% obtained them outside the United States. When asked if antibiotics should be available over the counter, 31% of subjects indicated they should.
Individuals who report using antibiotics for the URI scenario with clear nasal discharge were significantly more likely than those who did not to report having used antibiotics not prescribed for a cough or cold in the last year (35% vs 11%, P = .001). Similarly, individuals who believe that antibiotics are somewhat or very effective for the clear discharge scenario are more likely to feel that antibiotics should be available without a prescription (35% vs 17%, P = .04).
On the basis of their birthplace or the birthplace of their mothers, subjects were categorized into 3 groups that reflected control of antibiotic access in different countries (Table 1). Subjects in the OTC group were more likely than either the REGS group or the USA group to report using antibiotics for a cough or cold that were not prescribed by a physician (40%, 30%, and 20%, respectively, P = .049). Subjects in the OTC group were also significantly more likely to seek care for the URI scenario with clear nasal discharge than the REGS group or the USA group, (80%, 56%, and 51%, P = .01). Belief in the effectiveness of antibiotics for the same scenario was very high (79%) and did not differ significantly among the groups.
Discussion
Our study contributes additional evidence to the findings that patient knowledge of appropriate treatments for URIs is inconsistent with available evidence of treatment effectiveness.5,18 Our results have important implications in terms of the individual misuse of antibiotics for URIs. Nearly one third of the respondents believed antibiotics should be available over the counter. Of greater importance, a substantial proportion of individuals obtained antibiotics through a method other than a physician prescription for the condition; subjects not only used their own leftover medication, but they also used friends’ and family members’ leftover pills, obtained antibiotics directly from pharmacists, or from sources outside the United States. We found that those individuals who have used antibiotics for URIs in the past were much more likely to obtain them on their own rather than from a physician.
