key: cord-0847620-rjy5h0eo authors: Elsayed, Asmaa A.; Darwish, Samar F.; Zewail, Moataz B.; Mohammed, Marwa; Saeed, Haitham; Rabea, Hoda title: Antibiotic misuse and compliance with infection control measures during COVID‐19 pandemic in community pharmacies in Egypt date: 2021-02-15 journal: Int J Clin Pract DOI: 10.1111/ijcp.14081 sha: 20887087779d06fe67049b8d8c52f129d1b2e13f doc_id: 847620 cord_uid: rjy5h0eo BACKGROUND: Globally, antibiotics misuse by the public has been reported in the era of COVID‐19, despite the discouraging instructions of the World Health Organization, especially for mild cases. OBJECTIVE: Is to describe this antibiotic misuse and its contributing factors. Also, to measure the pharmacists' application of infection preventive practices during the pandemic. METHODS: A cross‐sectional study was conducted among randomly selected Egyptian community pharmacists (Center, East, Delta, and Upper Egypt) using a questionnaire and direct interviews from 1 to 30 August 2020. The questionnaire consisted of two parts, the first covered pharmacist's demographic data and their application of basic infection preventive practices (eg, wearing face masks, regular hand sanitization, etc), and the other part was related to antibiotic dispensing patterns. Data were descriptively analyzed and the impact of participant experience on the responses was evaluated using the χ(2) test. RESULTS: From 480 randomly selected Egyptian community pharmacists, 413 (87%) consented to participate in the study. 86.7% of the participants were keen to wear face masks (n = 358) and 86.2% kept regular hand sanitization (n = 356); whereas, 46.9% (n = 194) maintained adequate antibiotic stock supply during the pandemic. Nearly 67% (n = 275) of the pharmacists reported that patients were more likely to be given antibiotics for showing any sign or symptom of COVID‐19 infection, and 82% (n = 74 278) of the dispensed antibiotics were given upon physician recommendation. Azithromycin, Ceftriaxone, and Linezolid were the major antibiotics dispensed to COVID‐19 presumptive patients Azithromycin was given to ~40% of presumptive patients showing only mild or moderate symptoms for 5‐10 days. Additionally, antibiotic combinations were given to 74% (n = 62 479) of home‐isolated patients for a maximum of 2 weeks. CONCLUSIONS: Pharmacists applied suitable sanitation and infection control protocols. Meanwhile, antibiotics were dispensed heavily during this pandemic without proper clinical indication and for long durations supporting the idea of antibiotic misuse. A cross-sectional study aimed to assess community pharmacist role and antibiotic misuse during the current pandemic. Data were gathered using a questionnaire addressed to Egyptian community pharmacists who were actively practicing during 1-30 August 2020, targeting one pharmacist in each pharmacy. Investigators (authors) were trained to guide the participants in filling the questionnaire. To standardize the impact of participated pharmacist response, answers to each question were provided as multiple-choice questions in most cases and they were filled online using a pre-prepared form to prevent bias in response and facilitate the analysis of data. Regarding the preventive actions taken by the pharmacist to prevent the disease spread inside the pharmacy, the items were recorded according to what the investigator see in the pharmacy (floor marks, masks, gloves, and other precautions). The development of this questionnaire was based on the existing literature, especially the WHO, the National Institute for Health and Care Excellence (NICE), and the Egyptian Ministry of Health and Population (version 1.4) guidance. 5, 6, 8, 10 In order to test the content and the face validity of this questionnaire, a draft consisting of 36 pilot questions was randomly distributed to 9 community pharmacists, following which modifications were made to develop this final version by deleting and merging some questions. • Antibiotic misuse is a common problem in our daily practices. • There was an antibiotic misuse related to COVID-19 expressed mainly as prescribing and dispensing antibiotics without indication. closed-ended, and optional questions. The internal consistency of the questionnaire items was tested using Cronbach's alpha (=0.732). For sample size calculations, the total population was 70 000 community pharmacies in Egypt, with a confidence interval of 95% and a limit of precision of 5%. As there were no similar studies related to COVID-19, the calculations were based on the assumption that the probability of dispensing antibiotics to a presumptive patient is 50%, and the calculated sample size was 383. Only public community pharmacies were included. For the included pharmacies, only the working pharmacists could participate. The participating pharmacist should be working in the selected pharmacy from the start of the pandemic. Hospital or private pharmacies were not included, also pharmacy technicians were not allowed to participate in this study. Newly working pharmacists were not allowed to participate, also pharmacy undergraduates were excluded. The study divided Egypt into four major regions, selected the two governorates with the largest population to represent each region, and divided each governorate into four major areas. Pharmacies were discovered by releasing an online form to collect all pharmacies that want to participate, also through using global positioning system search engines to find the largest number of pharmacies that are not registered through the online form for each area. For each given area, pharmacies were selected randomly (not all pharmacies) by giving each pharmacy a number then a random number is selected through using the randomization website (random.org). The investigators started to contact this random sample to conduct (phone calls or messages through emails and social applications) a personal visit to fill the questionnaire. Each investigator asked all the pharmacists working in the same pharmacy to participate in the study, if more than one pharmacist decided to participate, one of them was selected randomly. Continuous variables were expressed as mean ± SD, while the categorical data were expressed as a percent. All participants were categorized into four groups according to years of experience as follow: the first group (pharmacist with experience <5 years), second group (pharmacist with experience <10 years), third group (pharmacist with experience <15 years), and fourth group (pharmacist with experience ≥15 years). The effect of different community pharmacist experience levels as a factor was compared with the response of the different questions concerned with antibiotic dispensing patterns and application of infection control practices using the χ 2 test (P ≤ .05 were considered statistically significant). A total of 480 community pharmacists were visited and only 413 (87%) pharmacists successfully completed the study, with 50 pharmacists refused to participate in the current study, and 17 pharmacists were excluded for missing parts of the questionnaire. The participants were 283 (69%) males and 130 (31%) females and ranged in experience from 1 to 20 years (mean ± SD=7.9 ± 4.8 years). The included pharmacies were in different locations to cover a wide range of different communities in Egypt ( The measures taken by the community pharmacist to deal with the health risks faced in the current pandemic were described in Table 2 . cough, and shortness of breath ( Figure 3) . None of the patients were asked by the physician or the pharmacist to do allergy testing before parenteral antibiotic administration. (Table 4) . Azithromycin was the highest antibiotic prescribed by physicians for COVID-19 patients (n = 400, 36%), followed by ceftriaxone (n = 249, 23%), linezolid (n = 138, 13%), and finally levofloxacin TA B L E 3 Correlation between pharmacist's experience and Preventive measures and services provided by the pharmacies (n = 126, 11%). Also, azithromycin was the highest antibiotic dispensed by community pharmacists (n = 260, 48%) as shown in Table 5 . In terms of antibiotic dosage (Figure 4) In terms of antibiotic duration ( Figure 5) Upon asking community pharmacists about dealing with any recurrence cases after recovery, 332 (80.4%) pharmacists denied seeing a recurrence case, and 81 (19.6%) admitted dealing with recurrence cases. The majority reported dispensing the same antibiotic given previously for the patient (n = 42) or another antibiotic class (n = 30), while 9 pharmacists did not re-dispense antibiotics as the patients suffered from mild symptoms. Many studies investigated antibiotic consumption patterns inside hospitals during the pandemic, 13, 14 with no previous study focused on community antibiotic consumption during COVID-19. In such hard times, pharmacists have a huge responsibility towards their community being the nearest health care providers for their neighbors, so pharmacists tried to adopt and implement new services for their patients. 17 The majority of the respondents tried to provide patient counseling through social media groups with fewer responses for distributing posters and flyers with COVID-19 information to raise public awareness. The WHO and NICE recommendations support that only symptoms are enough to suspect infected cases, 5,10 so the majority of the pharmacists relied on patient symptoms to identify COVID-19 presumptive cases, but the process of case identification and proper clinical knowledge when possible. As previously mentioned, antibiotics are easily accessible as over-the-counter drugs (OTC) or upon patient request, and this can be one of the major causes behind the massive antibiotic misuse happening among the population. 6, 7 In the current study, most of the presumptive COVID-19 cases received antibiotic therapy among their medication. Pharmacists' responses showed that the majority of the dispensed antibiotics were done upon official physician prescription; however, the results emphasized that the problem of the patient's self-medication is still evident. Analyzing the data of the current study, the results conclude that more than 65% of the presumptive patients with COVID-19 administered an antibiotic due to suffering from only mild symptoms with no signs of pneumonia. Furthermore, neither the physician nor the pharmacist instructed patients to do a bacterial culture before antibiotic administration. Both pharmacists and physicians tend to recommend azithromycin, ceftriaxone, and linezolid more than the other types of antibiotics. Several factors are influencing antibiotic dispensing patterns, most importantly fear and seeking patient compliance. Therefore, the choice of antibiotics was not made according to a bacterial culture or the degree of symptoms severity, but rather broad-spectrum and newer antibiotics were preferred, which also reflect a type of antibiotic misuse. Many clinical studies investigated the safety and efficacy of azithromycin in COVID-19 patients. They claimed that azithromycin is not only an antimicrobial drug, but it may exhibit antiviral activity as well. It acts by decreasing viral cell entry and possesses immunemodulatory properties by inhibiting the release of proinflammatory cytokines, 23, 24 and this may explain why physicians heavily prescribed azithromycin for presumptive cases with no signs of bacterial pneumonia. Meanwhile, community pharmacists reported good adherence to recommend one type of antibiotic to each presumptive patient; however, physicians prescribed two or more antibiotics rather than antibiotic monotherapy to the majority of the presumptive patients. Ceftriaxone was commonly combined with azithromycin, clarithromycin, or levofloxacin, also linezolid was combined with azithromycin or levofloxacin. In case of severe symptoms, physicians may add meropenem and imipenem to the previously mentioned combinations. Unfortunately, the previous combinations were given without proper clinical evidence. The problem of self-medication (antibiotics) without a prescription is evident among the public. 6 Moreover, in the first months of F I G U R E 5 Antibiotic duration dispensed according to physician prescription and pharmacist recommendation the current crisis; social media presented azithromycin as a part of a therapeutic protocol for COVID-19. As a result of public panic buying and storing drugs from community pharmacies, many pharmacies suffered from azithromycin stock deficit early in the crisis. It is worth noting that the most common antibiotics-prescribingerrors were prescribing broad-spectrum antibiotics for the inappropriate duration, improper antibiotic combinations, and wrong dosing schedules, while pharmacist-related-errors were recommending broad-spectrum antibiotics for the inappropriate duration. This supports the need to develop a national evidence-based antibiotic stewardship to improve rational prescribing among physicians and pharmacists. The term recurrence, a re-appearance of COVID-19 symptoms, should be differentiated from the re-exposure to the virus or the symptoms of viral complications. 25 The COVID-19 subjects should be monitored to differentiate a recurrence of symptoms or appearance of the post-COVID-19 syndrome from reinfection, but few participants still reported the presence of recurrence cases (appearance of symptoms after their absence for a short time) with admitting re-selling antibiotics for the same previous duration. However, recurrence of the symptoms may be due to common cold or influenza. In general speaking, antibiotics have no role or benefit in treating viral pneumonia, also the prevalence of bacterial co-infections, especially CAP, in COVID-19 patients is very low. 13 In the current pandemic circumstances, the role of community pharmacists is highlighted. The current study reported that pharmacists managed to apply appropriate sanitation and infection control measures. The misuse of antibiotics during the COVID-19 pandemic may have many forms such as overuse of antibiotics, incorrect dose, incorrect combination, and wrong indication. Most importantly, this is a pilot study that investigates the antibiotic prescribing and dispensing patterns during the COVID-19 pandemic. The previous results emphasized the need to raise public awareness considering the complications of using antibiotics without a proper clinical indication. Hence, the antibiotic policy or guideline is needed to guide the use of antibiotics during the COVID-19 pandemic. The authors have declared no conflict of interest. The present study was approved by Beni-Suef University, Faculty of Pharmacy, and its ethics committee (REC-H-phBSU-20017). Pharmacist's anonymity and confidentiality were ensured. Written informed consent was taken from each participant. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. Asmaa A. Elsayed https://orcid.org/0000-0002-2862-5382 Haitham Saeed https://orcid.org/0000-0002-2040-9466 Pandemic preparedness of community pharmacies for COVID-19 Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia COVID-19: A promising cure for the global panic Community pharmacist in public health emergencies: Quick to action against the coronavirus 2019-nCoV outbreak Clinical management of COVID-19: interim guidance Antibiotic dispensing in Egyptian community pharmacies: an observational study Pattern of antibiotic abuse-a population based study in Management protocol for COVID-19 patients. Egyptian Ministry of Health. 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