Larissa Grigoryan, MD, PhD Family and Community Medicine Non-Prescription Antimicrobial Use in a Primary Care Population: Evidence for Action Larissa Grigoryan, MD, PhD Family and Community Medicine

Acknowledgements Roger Zoorob, MD, MPH Susan Nash, PhD Department of Family and Community Medicine Baylor College of Medicine, Houston, TX Barbara Trautner, MD, PhD Section of Infectious Diseases Department of Medicine and Surgery Michael E. DeBakey Veterans Affairs Medical Center

Background Non-prescription antibiotic use is common among Latin American immigrants to US* 19%-26% obtained non-prescription antibiotics in surveys Non-prescription use of antibiotics may foster development of resistance Very short courses, inappropriate drug and dose choice, and unnecessary therapy Other potential problems Adverse drug reactions, drug interactions, effect on microbiota, masking of underlying infectious processes and superinfection *Mainous et al, Emerg Infect Dis 2005; Landers et al, J Am Acad Nurse Pract 2010

Objectives To estimate the prevalence of non-prescription antibiotic use in adult patients from public and private primary care clinics. To examine patient characteristics associated with non-prescription use

Methods Multistage sampling design: Sample size needed is 296 1 private and 2 public family practice clinics Race/ethnicity stratified sampling to reflect racial/ethnic makeup of the population of Harris County, TX Systematic random sampling of adults Sample size needed is 296 94% response rate

Measures Self-administered standardized questionnaire Use of antibiotics during the past 12 months (prescribed or non-prescribed) Name of medicine, symptom or disease Intended non-prescription use and storage of antibiotics Demographic characteristics

Respondent characteristics (n= 400) Results Respondent characteristics (n= 400) Age, years 48 ±15 Female sex 274 (68%) Hispanic or Latino 168 (42%) African American or Black 80 (20%) Non-Hispanic 152 (38%) Private insurance 177 (45%) Medicare 50 (12%) Medicaid 75 (19%) Uninsured 90 (23%) Self-pay 4 (1%) Less than high education 43 (11%) High school or GED 112(28%) Some college and above 245 (61%) Presence of a chronic disease 138(34%)

Respondent characteristics (n= 400) Results Respondent characteristics (n= 400) Income ≤ $20,000 141/372 (38%) > $20,000 but ≤ $40,000 73/372 (15%) > $60,000 but ≤ $100,000 46 (12%) > $100,000 55 (15%) Employed 232/363 (64%) Not working 111/363 (31%) Retired 20/363 (5%) Public clinic patients 200 (50%) Private clinic patients Completed in Spanish 80 (20%)

Antibiotic use stratified by race/ethnicity * in the previous 12 months

Types of non-prescribed antibiotics taken, n=22 *including bactrim, tetracycline, ofloxacin, and amoxicillin clavulanate

Sources of non-prescribed antibiotics taken, n=22 A store or pharmacy in the US (40%) Obtained from another country (24%) From a relative or friend (20%) “Leftover” from previous prescriptions (12%) Veterinary antibiotics (4%)

Types of stored antibiotics, n=40 *including cephalexin, cefaclor, metronidazole, and nitrofurantoin

Intended non-prescription use 5 10 15 20 25 30 Other infections/diseases Diarrhea Flu Bronchitis Runny nose/cold Sinus infection Fever Cough UTI Ear infection/ear pain Sore throat Toothache Would use non-prescription antibiotics - %

Predictors of intended non-prescription use Multivariate analyses OR (95% CI) P value Age, years 0.98 (0.96-0.99) 0.02 Education 0.057 Less than high school 1 (reference) High school or GED 0.39 (0.18-0.85) Some college and above 0.60 (0.28-1.28) 0.18 Private clinic patients Public clinic patients 1.92 (1.11-3.31) Sex, race/ethnicity, insurance status, presence of a chronic disease, employment status, income and survey language were not significant

European Commission Antimicrobial Project

Use of prescribed and non-prescribed antibiotics in Europe and the United States Rates per 1000 respondents Source: L. Grigoryan et al, Emerg Infect Dis. 2006 Mar; 12(3): 452-9.

Conclusions The problem of non-prescription use is not confined to Latino communities in the US. Community antimicrobial stewardship must include a focus on non-prescription antimicrobials. An integrated approach involving policy makers, prescribers and the general public is needed using both educational and regulatory measures.

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