DTI Drug Target Insights 2023; 17: 114-119 ISSN 1177-3928 | DOI: 10.33393/dti.2023.2614 ORIGINAL RESEARCH ARTICLE Drug Target Insights - ISSN 1177-3928 - www.aboutscience.eu/dti © 2023 The Authors. This article is published by AboutScience and licensed under Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Commercial use is not permitted and is subject to Publisher’s permissions. Full information is available at www.aboutscience.eu Prevalence of antibiotic misuse in cases of pneumonia and diarrhea in Saudi Arabia Ebtehaj Saud Almughais1, Fatmah Fahad Alreshidi1, Hussain Gadelkarim Ahmed2 1Department of Family and Community Medicine, College of Medicine, University of Hail, Hail - Saudi Arabia 2Department of Histopathology and Cytology, FMLS, University of Khartoum, Khartoum - Sudan ABSTRACT Background: Antibiotic misuse is a major public health issue with long-term repercussions. Objective: The purpose of this investigation was to evaluate the effects of pneumonia and diarrhea, with an emphasis on antibiotic misuse. Methodology: This study included 410 participants (217 fathers and 193 mothers), of whom 239 purchased antibiotics for their children without a prescription, whereas 171 had a prescription or were unsure if one was required. Results: Antibiotics were used incorrectly by 58.1% of respondents. About 51.2% of participants said they were taking two antibiotics at the same time. Around 30% of people admitted to using antibiotics inefficiently. The most prevalent reason for use was “viral and bacterial,” followed by “viral,” and then “bacterial,” with 35%, 21%, and 20%, respectively. In addition, 22.4% of patients have used antibiotics for an unknown reason. Conclusion: Saudi parents of children with pneumonia and diarrhea abuse antibiotics. Saudi legislation banning medications without a prescription has helped reduce antibiotic abuse, but more community-based education and awareness are needed. Keywords: Antibiotic abuse, Antibiotic misuse, Diarrhea, Pneumonia, Saudi Arabia Received: May 31, 2023 Accepted: September 7, 2023 Published online: October 9, 2023 Corresponding author: Hussain Gadelkarim Ahmed Department of Histopathology and Cytology FMLS, University of Khartoum, Khartoum - Sudan hussaingad5@gmail.com Introduction Abuse of antibiotics is a major global public health hazard, needing concerted efforts to control its spread (1). Antimi- crobial resistance threatens global food, health, and devel- opment. Antibiotic resistance is caused by antibiotic misuse. Maximizing antibiotic use improves medical outcomes, reduces toxicity, and prevents resistance (2). Antibiotic resis- tance genes (ARGs) have plagued antibiotic treatment and antimicrobial chemotherapy worldwide due to overuse and misuse (3). Like any health issue, affluence and antibiotic usage vary depending on the type of antibiotic abuse and the country’s health level. Understanding the social and economic factors could help create antibiotic misuse prevention programs and policies (4). Because of the country’s high rates of antimicrobial administration without a prescription, antimicrobial abuse and misuse have reached pandemic proportions in Saudi Arabia. Implementation of the regulation in Saudi Arabia’s public pharmacies led to a slight decrease in the use of anti- microbials without prescriptions (5). Most antibiotics are mis- used or overused in Saudi Arabia for the treatment of upper respiratory tract infections (URTIs), which are predominantly viral infections (6). The current study investigates antibiotic usage in Saudi Arabia after the restriction on antibiotic sales without a prescription, with pneumonia and diarrhea being the most common indicators of antibiotic misuse. Materials and methods Between May 2022 and December 2022, 410 local inhab- itants participated in a community-based survey in Hail, which is located in northern Saudi Arabia. When select- ing participants at random, no consideration was paid to their age, social standing, degree of education, or monthly income. To be eligible, a child’s parents had to show that they had already purchased antibiotics for their child’s pneumonia or diarrhea. Antibiotic misusers are parents who give antibi- otics to their children without first obtaining a doctor’s pre- scription or doing a culture and sensitivity test. Individuals whose antibiotic use could be proven were considered not to be misusing the medications. A poll found that 239 par- ents bought antibiotics for their children without a prescrip- tion, whereas 171 had a prescription or were unsure if they needed one (including 217 fathers and 193 mothers). https://doi.org/10.33393/dti.2023.2614 https://creativecommons.org/licenses/by-nc/4.0/legalcode mailto:hussaingad5@gmail.com Almughais et al Drug Target Insights 2023; 17: 115 © 2023 The Authors. Published by AboutScience - www.aboutscience.eu Data analysis The data was analyzed using SPSS, which generated cross- tabulations, frequencies, and statistically significant results. We utilized a 95% confidence interval (CI) chi-square test to determine significance. Data with a p-value less than 0.05 was considered significant. Results This study comprised parents aged 20 to 60 years; 217/410 (52.9%) fathers and 193/410 (47.1%) mothers were polled. A total of 239/410 (58.1%) respondents admitted to using anti- biotics inappropriately; an additional 12/410 (3.1%) were unsure. About 210 (51.2%) of the 410 participants reported using two antibiotics at the same time, while 17 (4.4%) were unsure; 123/410 people (30%) said they didn’t use antibiotics enough, while 28/410 (6.8%) weren’t sure. The most common category was “viral and bacterial,” followed by “viral,” and then “bacterial,” with relative frequencies of 35% (144/410), 22% (89/410), and 20% (85/410). Furthermore, approximately 92/410 (22.4%) patients have used antibiotics for an unknown reason, as indicated in Table I, Figures 1 and 2. TABLE I - Distribution of study participants based on their antibiotic use status Variable Yes No Don’t know Total Antibiotic misuse 239 159 12 410 Antibiotic double use 210 183 17 410 Antibiotic complete use 259 123 28 410 Treatment indication Viral Bacterial Viral and bacterial Unknown Frequencies 89 85 144 92 About 176 out of 299 participants (59%) chose the wrong antibiotic to treat pneumonia, while 114 out of 299 (38%) chose the right antibiotic and 9 out of 299 (3%) were not sure. Approximately 68/112 (60.7%) children used the antibi- otic incorrectly for diarrhea, 42/112 (37.5%) used it appro- priately, and only 2/112 (1.8%) were uncertain. Only 114/299 (38%) of the 299 children with pneumonia had used the right antibiotics, as indicated in Table II. In comparison to 117/193 (60%) mothers, around 122/217 (56.2%) fathers purchased improper antibiotics. The relative risk (RR) and 95% CI for moms purchasing unsuitable antibiotics were RR (95% CI) = 1.0783 (0.9157 to 1.2697), p = 0.3662. Antibiotic abuse was most prevalent in the 35–44 age range, followed by 25–34 and 45 years, with 100/239 (42%), 88 (37%), and 42 (17.6%), respectively. Fig. 1 - Description of the parti- cipants by antibiotic use status. Fig. 2 - Indications of antibiotic use by study participants. Antibiotic misuse in pneumonia and diarrhea116 © 2023 The Authors. Drug Target Insights - ISSN 1177-3928 - www.aboutscience.eu/dti Antibiotic misuse was reported by 58% of married peo- ple, 75% of divorcees, and 25% of widows. The probability that children of divorced parents will abuse antibiotics is RR (95% CI) = 1.2305 (0.9179 to 1.6495), p = 0.1654, and the z statistic is 1.387. Around 132/203 (65%) of those with ≥5 family members reported antibiotic abuse, compared to 107/207 (51.7%) of those with <5 family members. The RR of antibiotic abuse was 1.2580 (1.0656 to 1.4850), with a 95% CI of 1.0656 to 1.4850 (p < 0.001) (see Tab. III, Fig. 3). The status of antibiotic use in relation to the parents’ level of education, occupation, and income was summa- rized in Table IV and Figure 4. About 151/275 (55%) parents with a college degree used antibiotics wrongly, compared to 68/107 (64%) parents with a secondary education and 20/28 (71%) parents with a primary education. Reduced education increased the risk of antibiotic abuse: RR (95% CI) = 0.7187 (0.5915–0.8731), p = 0.0009, z statistic = 3.326. About 158/287 (55%) government employees, 41/63 (65%) self-employed, and 40/60 (67%) unemployed reported antibiotic abuse. The risk associated with self-employed and unemployed antibiotic usage is RR (95% CI) = 1.1962 (1.0146 to 1.4104), p = 0.0330, and the z statistic = 2.132. About 33/56 (59%), 83/139 (60%), 87/145 (60%), and 36/70 (51%) of parents with monthly incomes of less than 5,000, 5,000 to 9,000, 10,000 to 14,000, and >15,000 SAR, respectively, misused antibiotics. Table V summarizes the negative effects of using antibi- otics in various situations. Approximately 150/230 (65%) of the children of individuals who were exposed to antibiotic overuse later had negative effects; 129/210 (61.4%) of the TABLE II - Distribution of antibiotic use status in relation to pneu- monia and diarrhea Antibiotic misuse Yes No Unsure Total Pneumonia  Yes 176 114 9 299  No 38 33 0 71  Unsure 25 12 3 40 Total 239 159 12 410 Diarrhea  Yes 68 42 2 112  No 143 101 6 250  Unsure 28 16 4 48 Total 239 159 12 410 Fig. 3 - Description of status of antibiotic use for each of the categories of social and demo- graphic factors. TABLE III - Distribution of antibiotic use status in relation to sociodemographic characteristics of the parents Antibiotic misuse Yes No Don’t know Total Parent  Father 122 91 4 217  Mother 117 68 8 193 Total 239 159 12 410 Age (years)  ≤24 9 7 1 17  25–34 88 76 6 170  35–44 100 52 2 154  ≥45 42 24 3 69 Total 239 159 12 410 Social status  Married 226 152 12 390  Divorced 12 4 0 16  Widow 1 3 0 4 Total 239 159 12 410 Family members  <5 members 107 96 4 207  ≥5 members 132 63 8 203 Total 239 159 12 410 Almughais et al Drug Target Insights 2023; 17: 117 © 2023 The Authors. Published by AboutScience - www.aboutscience.eu 210 antibiotics that were used twice had negative effects; 194/299 (65%) of the 299 pneumonia patients experienced adverse symptoms. About 75/112 (67%) of the 112 children who had diarrhea experienced adverse symptoms. Discussion The findings of this study reveal that despite Saudi Arabia’s ban on acquiring antibiotics without a prescription, a considerable number of people continue to misuse antibi- otics. According to the Saudi Law Compendium, pharmacists are not permitted to provide therapeutic advice. The Saudi TABLE IV - Distribution of antibiotic use status in relation to educa- tion, occupation, and income of the parents Antibiotic misuse Yes No Don’t know Total Education  Primary 20 8 0 28  Secondary 68 33 6 107  Universal 151 118 6 275 Total 239 159 12 410 Occupation  Government employees 158 120 9 287  Self-employed 41 22 0 63  Unemployed 40 17 3 60 Total 239 159 12 410 Monthly income (SAR)  <5,000 36 29 5 70  5,000-9,000 87 55 3 145  10,000-14,000 83 53 3 139  ≥15,000 33 22 1 56 Total 239 159 12 410 Ministry of Health (MOH) revised the rule to include finan- cial penalties, license revocation, business closure, and a 6-month prison sentence for the pharmacist. In May 2018, antibiotic distribution regulations were validated (7,8). Substantial rates of antibiotic misuse (58.1%) and over- use (51%) were found in the present investigation, both of which have undesirable effects such as the emergence of Fig. 4 - Description of antibio- tic use status within educa- tion, occupation, and income categories. TABLE V - The distribution of antibiotic abuse based on drug adverse effects Side effects Yes No Unsure Total Antibiotic misuse  Yes 150 33 56 239  No 101 28 30 159  Unsure 3 4 5 12 Total 254 65 91 410 Antibiotic double use  Yes 129 31 50 210  No 120 29 34 183  Unsure 5 5 7 17 Total 254 65 91 410 Pneumonia  Yes 194 44 61 299  No 39 15 17 71  Unsure 21 6 13 40 Total 254 65 91 410 Diarrhea  Yes 75 12 25 112  No 156 43 51 250  Unsure 23 10 15 48 Total 254 65 91 410 Antibiotic misuse in pneumonia and diarrhea118 © 2023 The Authors. Drug Target Insights - ISSN 1177-3928 - www.aboutscience.eu/dti antimicrobial resistance and financial burdens. Antibiotic resistance is a major public health concern that has received a great deal of attention in recent years from physicians and researchers. Misusing or overusing antibiotics can lead to resistance, which is caused by natural selection and the evolution of bacteria (9). Physicians are struggling to improve patient outcomes due to rising infection rates, multidrug-resistant bacteria, and antibiotic use. Optimizing antimicrobial use can enhance patient outcomes, avoid resistance, and reduce drug abuse and overuse (10,11). A recent study in Saudi Arabia evalu- ated the antibiotic consumption after the adoption of a new prescription-only antimicrobial dispensing policy in commu- nity pharmacies. Generally, non-prescription antimicrobial use has dropped slightly (5). Although effective prescription limitations must be implemented, community-based activi- ties are deemed essential. Approximately 30% of this study’s participants reported using an inadequate antibiotic dose, and 6.8% were unclear. Clinicians and other health providers should advise patients to finish the entire course of prescribed antibiotics, even if their symptoms have subsided, in order to stop the spread of antibiotic resistance and avoid a resurgence of illness (12). According to the findings of this investigation, many drugs were abused in cases of viral ailments. Furthermore, around 59% of patients were given the wrong drug to treat pneu- monia. The overuse of antibiotics to treat viral community- acquired pneumonia is a major public health issue. According to one study, antibiotics were given to 98.3% of patients who had viral pneumonia (13). Antibiotic overuse, especially for viral, self-limiting respiratory tract infections like sore throats, increases community-wide antimicrobial resistance. Approximately 80% of sore throats are viral and resolve with- out medicine. Although there are over-the-counter topical sore throat medicines, antibiotics are still administered inap- propriately (14). However, whereas viral illnesses are more prevalent in children, adults with viral respiratory tract infec- tions are more likely to overuse antibiotics (15). In this study, approximately 60.7% of children used the antibiotic incorrectly for diarrhea. Over a million people die annually from the consequences of infectious diarrhea, which affects more than four billion people worldwide. A consistent geographic surveillance system would help fight the worry- ing rise in worldwide resistance caused by antimicrobial over- use and misuse (16). However, there is a scarcity of data on how Saudi eating habits may be linked to diarrhea in young children. Diarrhea was shown to be common among children aged 0 to 2 years, and it was also discovered that exclusive breastfeeding was not often followed in Saudi Arabia (17). About 40.3% of Saudi mothers thought it was a major prob- lem in the Saudi community, but nearly 23% couldn’t iden- tify any critical sign of severe diarrhea, and 66% incorrectly stated that diarrhea is caused by teething (18). According to the current study, mothers, particularly divorced mothers, are more likely to abuse antibiotics. Antibiotic misuse is more common in families with five or fewer members, and additional research is needed in this context. Furthermore, the current study’s findings dem- onstrate that antibiotic overuse is inversely associated with education level. Furthermore, self-employed individuals receive more antibiotics that are misused than government employees. In this study, however, there was no correlation between monthly income and antibiotic misuse. Parents must accurately observe the use of antibiotics in their chil- dren. Although parental antibiotic awareness, attitude, and practice have received little attention, most parents were uninformed, pessimistic, and did not administer antibiotics to their children correctly. Children’s antibiotic use was influ- enced by their parents’ socioeconomic position, education, occupation, knowledge, and viewpoint (19). Saudi researchers sought to refute common beliefs among primary school parents regarding when and how to give their children URTI medications. Antibiotics were unnecessary for nasal congestion (62.5%) and fever (74%). Compared to 39.4% for ear pain and 26% for throat discomfort, 61% of respondents correctly identified URTI as a virus, while only 20% believed antibiotics could not immediately treat it (20). Recent systematic reviews and meta-analyses included only 57 of 702 publications. ASM was highest in the Middle East (34%), Africa (22%), Asia (20%), and South America (17%). ASM is more prevalent in children who live far from a hos- pital or whose families are poor due to having multiple chil- dren. Parents may overuse antibiotics when their children develop fevers or recurrent coughs. Antimicrobial phar- maceutical sales should be rigorously restricted to reduce self-medication. Bert et al revealed that antibiotic self-medication (ASM) among children was highest in the Middle East (34%), Africa (22%), Asia (20%), and South America (17%) and lowest in Europe (8%). ASM risk in children is increased by a long dis- tance from the hospital, a low income, and several children. Antibiotics are sometimes abused by parents due to fever and cough. Self-medication can be reduced by focusing on antimicrobial drug control (21). Participants in the current study indicated that their chil- dren experienced negative side effects because of antibiotic usage for both pneumonia and diarrhea. Antibiotic abuse increases antimicrobial resistance and causes gastrointesti- nal, neurologic, and mental issues. Amoxicillin-clavulanate hepatotoxicity can be deadly. Overprescribing antibiotics for self-limiting infections increases patient readmission rates (22). However, in an era when new agents are required to combat multiresistant bacteria, balancing the dangers and advantages of existing antimicrobials is an intriguing challenge. The past decade has significantly influenced global antibi- otic stewardship. High-level policy conversations, regulations, and legislation have focused on antibiotic use improvements, and antibiotic stewardship infrastructure has grown rap- idly in hospitals, nursing homes, and ambulatory settings (23). Antibiotic stewardship programs (ASPs) effectively reduced antibiotic misuse, decrease antibiotic resistance, and improve treatment outcomes. The Saudi MOH devised a national antimicrobial stewardship plan to implement ASPs in hospitals, but little is known about its success or factors. According to a statewide cross-sectional poll that included all MOH hospitals, the utilization of ASP was only verified in 26% of hospitals (24). Almughais et al Drug Target Insights 2023; 17: 119 © 2023 The Authors. Published by AboutScience - www.aboutscience.eu Even though this study was an important update on anti- biotic abuse after Saudi Arabia banned antibiotics without a prescription, it had some limitations, such as a cross-sectional design and a low level of acceptability for data collection. Conclusion Antibiotic misuse is still prevalent among parents caring for children with pneumonia and diarrhea in Saudi Arabia. Even though laws in Saudi Arabia that say antibiotics can’t be given out without a prescription have helped cut down on antibiotic abuse, it is thought that more community-based education and awareness efforts are needed. Acknowledgments The authors are grateful to the study’s participants for providing samples. Disclosures Conflict of interest: The authors declare no conflict of interest. Financial support: This study was funded by the Deputy for Research and Innovation, Ministry of Education, through the Initiative of Institutional Funding at the University of Ha’il in Saudi Arabia. The project’s ID was IFP-22 048. Informed consent: Participants in this study provided both written and verbal informed consent. Ethical approval: The research plan received approval from the uni- versity’s ethics board. HERC 0137/CM.UOH/5/20 is the approval number. Data availability: The data presented in this study is available on request from the corresponding author. References 1. 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