Antimicrobial drugs in the home, United Kingdom.A total of 6% of 6,983 households in the United Kingdom had leftover antimicrobial antimicrobial /an·ti·mi·cro·bi·al/ (-mi-kro´be-al) 1. killing microorganisms or suppressing their multiplication or growth. 2. an agent with such effects. drugs, and 4% had standby antimicrobial drugs. Respondents with leftover drugs were more educated, more knowledgeable about antimicrobial drugs, younger, and female. Of respondents with leftover drugs, 44% kept them in case of future need, and 18% had taken these drugs without medical advice. ********** Antimicrobial drug resistance is increasing worldwide and is related to use of these drugs (1,2). Use of leftover drugs may increase antimicrobial drug resistance in the community by exerting selective pressure in the commensal commensal /com·men·sal/ (kom-men´sil) 1. living on or within another organism, and deriving benefit without harming or benefiting the host. 2. a parasite that causes no harm to the host. flora (3,4). Retention and use of leftover antimicrobial drugs are widespread in countries that sell antimicrobial drugs without a prescription (i.e., over-the-counter) (5,6). In countries in which over-the-counter antimicrobial drug sales are restricted, studies on use of leftover drugs have been few and mostly questionnaire-based, relying on respondent recall (7,8). A large survey of British household drug practices showed that 2% of medicines were leftover or standby drugs (9), but no information was obtained about the households containing them. To inform antimicrobial drug education campaigns (10,11) and research examining the relationship between antimicrobial drug prescribing and resistance (12), we conducted a household survey to identify antimicrobial drugs present and the characteristics of respondents who kept them. Methods The survey formed part of the Office for National Statistics' Omnibus omnibus: see bus. Survey in the United Kingdom in February, March, June, and July 2003. A representative sample of households was selected by using previously published methods (9). Households were invited by letter to participate in a study about their views and experiences on a variety of subjects. For households with >1 adult member, 1 person [greater than or equal to] 16 years of age was selected by a random number tables. At the household visit, respondents were informed that the survey was sponsored by the department of health and was about drugs for treating infections. Respondents were asked to show the interviewer all drugs in the household that had been prescribed for infections, even if the person for whom they were prescribed was not present (temporarily or permanently), and asked whether the drugs were currently being used for an infection for which they were prescribed, had been prescribed for a previous infection (leftover drugs), or were being kept for use in the future (standby drugs). The amount of unused drug was noted and prescription details were recorded and coded by their listing in the British National Formulary The British National Formulary (BNF) contains a wide spectrum of information on prescribing and pharmacology, among others indications, side effects and costs of the prescription of all medications available on the National Health Service. . Antimicrobial drugs included all antifungal antifungal /an·ti·fun·gal/ (-fung´gal) 1. destructive to fungi, or suppressing their reproduction or growth; effective against fungal infections. 2. an agent that so acts. and antibacterial antibacterial /an·ti·bac·te·ri·al/ (-bak-ter´e-al) destroying or suppressing growth or reproduction of bacteria; also, an agent that does this. an·ti·bac·te·ri·al adj. drugs. Respondents were asked a series of questions about their use of antimicrobial drugs and whether they agreed or disagreed with a series of statements from education campaigns (10,11) about the usefulness of these drugs for coughs and colds, viruses, bacteria, and normal flora Normal flora The mixture of bacteria normally found at specific body sites. Mentioned in: Sputum Culture, Wound Culture ; the importance of completing courses of drug therapy, and antimicrobial drug resistance. Ethical approval was not required for this ongoing national survey, but respondents were able to refuse participation in any part of the survey at any time and were told that all information was anonymous and strictly confidential. To enable comparison with nationally prescribed antimicrobial drugs, the number of community-prescribed drugs in England was obtained from prescribing analysis and cost data (PACT) (13). Sampling weights based on the 2001 census data for Great Britain Great Britain, officially United Kingdom of Great Britain and Northern Ireland, constitutional monarchy (2005 est. pop. 60,441,000), 94,226 sq mi (244,044 sq km), on the British Isles, off W Europe. The country is often referred to simply as Britain. were applied to household and respondent data to allow for any oversampling Creating a more accurate digital representation of an analog signal. In order to work with real-world signals in the computer, analog signals are sampled some number of times per second (frequency) and converted into digital code. or undersampling by region, Carstair's deprivation quintile quin·tile n. 1. The astrological aspect of planets distant from each other by 72° or one fifth of the zodiac. 2. Statistics The portion of a frequency distribution containing one fifth of the total sample. , age group, and sex. Multivariable logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. (ignoring sampling weights) was used to investigate independent associations between respondent characteristics and the presence of leftover antimicrobial drugs prescribed for the respondent. Results Of 10,981 selected households, 25% refused to participate and 10% could not be contacted. Respondents in 7,120 (65%) households completed the questionnaire and 6,983 (64%) agreed to the drug survey. A total of 19% of the 6,983 households had an antimicrobial drug leftover (6%), kept for standby use (4%), or currently in use (11%) (Table 1). Six percent of leftover drugs had been prescribed for [less than or equal to] 3 days, 16% for 4-5 days, 61% for [greater than or equal to] 6 days, and 17% were to be taken as required. No specific class of oral antimicrobial drugs was kept more often as leftover drugs relative to PACT prescription rates (Figure 1). [FIGURE 1 OMITTED] Four percent of respondents had leftover antimicrobial drugs that had been prescribed. The most educated respondents were twice as likely as those least educated to have leftover antimicrobial drugs (5.4% with a university degree vs. 2.4% with no formal degree) (Table 2). Respondents most knowledgeable about antimicrobial drugs (6.1% if all 11 questions were answered correctly) were twice as likely as those least knowledgeable (3.1% if [greater than or equal to] 5 were answered incorrectly) to keep them (Table 2, Figure 2). Level of education and knowledge of antimicrobial drugs were independently associated with being more likely to have leftover drugs (Table 2). Younger respondents and women were more likely to have leftover drugs (Table 2, Figure 2). Thirty-eight percent of respondents' leftover drugs had been dispensed dis·pense v. dis·pensed, dis·pens·ing, dis·pens·es v.tr. 1. To deal out in parts or portions; distribute. See Synonyms at distribute. 2. To prepare and give out (medicines). 3. >1 year earlier, and 48% of these drugs had more than half of the original amount remaining (Table 1). Of those who had kept a leftover antimicrobial drug prescribed in the past year, 44% did so for future need (Table 1). Of those with a leftover drug, 18% had taken antimicrobial drugs without advice compared with 4% of respondents who did not have a leftover drug (p<0.0005). [FIGURE 2 OMITTED] When directly questioned, 38% of respondents (95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. 36.4-38.8%) recalled that they had been prescribed a drug in the past year. Younger age in women (50% if 16-24 years of age, 43% if 25-44 years of age, and 44% if 45-54 years of age) and lower level of education (33% with a degree and 40% with no formal qualifications on leaving school at the minimum age [16 years]) were independently associated with being prescribed an antimicrobial drug. Discussion This large survey of household antimicrobial drugs, which was conducted in a country with restricted over-the-counter sales, showed an association between keeping leftover antimicrobial drugs and higher education higher education Study beyond the level of secondary education. Institutions of higher education include not only colleges and universities but also professional schools in such fields as law, theology, medicine, business, music, and art. and knowledge about these drugs, younger age, and being female. The strength of this study is that we asked a large representative sample to show us their antimicrobial drugs rather than relying on respondent memory. However, we may not have been shown all antimicrobial drugs, and some of the leftover drugs may have been misclassified as standby drugs. The characteristics of respondents in households with standby drugs were similar to those of respondents with leftover drugs. The number of antimicrobial drugs found was twice that found by a recent survey in Sweden that relied on respondent recall; in that study, the respondents also reported a lower number of antimicrobial drug prescriptions (8). Persons may keep leftover antimicrobial drugs because too much was prescribed for their initial infection. Most community-acquired infections are respiratory or urinary, for which many prescribed courses of antimicrobial drugs are longer than necessary (14). If the standard duration of treatment could be shortened and package size reduced to contain enough drug for 3 to 5 days, the temptation to keep antimicrobial drugs might be diminished. Our finding supports this suggestion because prescriptions for [greater than or equal to] 6 days constituted 61% of leftover drugs, whereas prescriptions for [less than or equal to] 3 days constituted 6% of leftover drugs. Evidence shows that repeated treatment with antimicrobial drugs exerts greater selective pressure on normal bacterial flora The bacterial flora is the whole system of bacteria in body cavities that have contact with the outside world. Every place shows another biochemical environment:
Our results show that any public education campaign to reduce retention and use of leftover antimicrobial drugs must be directed at well-educated groups rather than the less educated, who are prescribed more antimicrobial drugs. One explanation may be that well-educated people are confident that they can make their own decisions about antimicrobial drug use, and this may be particularly relevant when their infection is less severe or becomes asymptomatic a·symp·to·mat·ic adj. Exhibiting or producing no symptoms. Asymptomatic Persons who carry a disease and are usually capable of transmitting the disease but, who do not exhibit symptoms of the disease are said to be . Furthermore, they do not discard these drugs because 44% of those with leftover antimicrobial drugs admitted keeping them in case of future need. Antimicrobial drug education campaigns should reinforce the message that leftover drugs should be returned to the pharmacist pharmacist /phar·ma·cist/ (fahr´mah-sist) one who is licensed to prepare and sell or dispense drugs and compounds, and to make up prescriptions. phar·ma·cist n. or that these drugs should only be taken after the advice of a health professional. Our finding of high levels of leftover antimicrobial drugs suggests that prescription does not equate e·quate v. e·quat·ed, e·quat·ing, e·quates v.tr. 1. To make equal or equivalent. 2. To reduce to a standard or an average; equalize. 3. to use. This will be an important source of bias in epidemiologic studies epidemiologic study A study that compares 2 groups of people who are alike except for one factor, such as exposure to a chemical or the presence of a health effect; the investigators try to determine if any factor is associated with the health effect examining risk factors for antimicrobial drug resistance (12) that include dose and duration of antimicrobial drug treatment in their analysis of exposure (1,4). Acknowledgments We thank the staff at the Office for National Statistics who were involved in the household survey, in particular, Amanda Wilmot, Alessio Fiacco, and Laura Rainford, and staff at the Department of Health, who provided the PACT data, in particular, Candida candida Any of the parasitic imperfect fungi (see fungus) that make up the genus Candida, which resemble yeasts and occur especially in the mouth, vagina, and intestinal tract. Ballantyne, Anne Custance, and Anne Emery emery: see corundum. emery Granular rock consisting of a mixture of the mineral corundum (aluminum oxide, Al2O3) and iron oxides such as magnetite (Fe3O4) or hematite (Fe2O3). . This study was supported by a grant from the Department of Health, England, whose staff had no involvement in the design, collection, analysis, or interpretation of data in this study or in writing this paper or submitting it for publication. References (1.) Donnan PT, Wei L, Steinke DT, Phillips G, Clarke R, Noone A, et al. Presence of bacteriuria bacteriuria /bac·te·ri·uria/ (bak-ter?e-u´re-ah) [bacteri- +-uria ] the presence of bacteria in the urine. Bacteriuria The presence of bacteria in the urine. caused by trimethoprim-resistant bacteria in patients prescribed antibiotics: multilevel model Multilevel models are known by several names: hierarchical linear models, generalized linear mixed models, nested models, mixed models (in biostatistics), random coefficient or random-effects models (in econometrics), random parameter models, and split-plot designs. with practice and individual patient data. BMJ BMJ n abbr (= British Medical Journal) → vom BMA herausgegebene Zeitschrift . 2004;328:1297. (2.) Goossens H, Ferech M. Vander-Stichele-R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet lancet /lan·cet/ (lan´set) a small, pointed, two-edged surgical knife. lan·cet n. . 2005;365:579-87. (3.) Gustafsson I, Sjolund M, Torell E, Johannesson M, Engstrand L, Cars O, et al. Bacteria with increased mutation frequency Mutation frequency refers to the number or "frequency" of cells with a specific mutation in a given population during a point in time. The phrase is often used in relation to drug resistance in bacterial or viral cultures. Mutation frequency is related to the concept of mutation rate. and antibiotic resistance antibiotic resistance, n the ability of certain strains of microorganisms to develop resistance to antibiotics. antibiotic resistance are enriched in the commensal flora of patients with high antibiotic usage. J Antimicrob Chemother. 2003;52:645-50. (4.) Jonsson M, Qvarnstrom Y, Engstrand L, Swedberg G. Clarithromycin treatment selects for persistent macrolide-resistant bacteria in throat commensal flora. Int J Antimicrob Agents. 2005;25:68-74. (5.) Stratchounski LS, Andreeva IV, Ratchina SA, Galkin DV, Petrotchenkova NA, Demin AA, et al. The inventory of antibiotics in Russian home medicine cabinets. Clin infect infect /in·fect/ (in-fekt´) 1. to invade and produce infection in. 2. to transmit a pathogen or disease to. in·fect v. 1. Dis. 2003;37:498-505. (6.) Okumura J, Wakai S, Umenai T. Drug utilisation and self-medication in rural communities in Vietnam. Soc Sci Med. 2002;54:1875-86. (7.) Ceaser S, Wurtz R. "Leftover" antibiotics in the medicine cabinet. Ann Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 2000;133:74. (8.) Svensson E, Haaijer-Ruskamp FM, Lundborg CS. Self-medication with antibiotics in a Swedish general population. Scand J Infect Dis. 2004;36:450-2. (9.) Woolf M. Left-over medicines, a report on OPCS OPCS, n.pl See proanthocyanadins. omnibus survey data. OPCS Omnibus Survey Publications Report 4. London: Her Majesty's Stationery Office; 1995. (10.) Finch finch, common name for members of the Fringillidae, the largest family of birds (including over half the known species), found in most parts of the world except Australia. RG, Joshua MP, Davey PG, Baker LJ. Educational interventions to improve antibiotic use in the community: report from the International Forum on Antibiotic Resistance (IFAR IFAR International Fanconi Anemia Registry (research and support group) IFAR International Foundation for Art Research (research organization for visual art works) IFAR Institute for Aging Research ) colloquium col·lo·qui·um n. pl. col·lo·qui·ums or col·lo·qui·a 1. An informal meeting for the exchange of views. 2. An academic seminar on a broad field of study, usually led by a different lecturer at each meeting. , 2002. Lancet Infect Dis. 2004;4:44-53. (11.) Department of Health Standing Medical Advisory Committee on Antimicrobial Resistance. The path of least resistance Noun 1. path of least resistance - the easiest way; "In marrying him she simply took the path of least resistance" line of least resistance fashion - characteristic or habitual practice . Occasional report. London: The Stationery Office; 1998. (12.) Steinke D, Davey P. Association between antibiotic resistance and community prescribing: a critical review of bias and confounding confounding when the effects of two, or more, processes on results cannot be separated, the results are said to be confounded, a cause of bias in disease studies. confounding factor in published studies. Clin Infect Dis. 2001;33(Suppl 3):S193-205. (13.) Lovejoy AE, Savage I. Prescribing analysis and cost tabulation tab·u·late tr.v. tab·u·lat·ed, tab·u·lat·ing, tab·u·lates 1. To arrange in tabular form; condense and list. 2. To cut or form with a plane surface. adj. Having a plane surface. (PACT) data: an introduction. Br J Community Nurs. 2001;6:62-7. (14.) Lambert HP. Don't keep taking the tablets? Lancet. 1999;354:943-5. (15.) Magee JT. The resistance ratchet: theoretical implications of cyclic cyclic /cyc·lic/ (sik´lik) pertaining to or occurring in a cycle or cycles; applied to chemical compounds containing a ring of atoms in the nucleus. cy·clic or cy·cli·cal adj. 1. selection pressure. J Antimicrob Chemother. 2005;56:427-30. Address for correspondence: Cliodna A.M. McNulty, Health Protection Agency Primary Care Unit, Microbiology microbiology: see biology. microbiology Scientific study of microorganisms, a diverse group of simple life-forms including protozoans, algae, molds, bacteria, and viruses. Department, Gloucestershire Royal Hospital An NHS district general hospital in Great Western Road, Gloucester, England. Gloucestershire Royal Hospital has more than 600 beds and 14 operating theatres. It serves western and southern Gloucestershire and parts of Herefordshire. , Great Western Rd, Gloucester GL1 3NN, UK; email: jill.whiting@hpa.org.uk Cliodna A.M. McNulty, * Paul Boyle, ([dagger]) Tom Nichols, ([double dagger double dagger n. A reference mark (  ) used in printing and writing. Also called diesis.Noun 1. ]) Douglas P. Clappison, ([section]) and Peter Davey ([paragraph]) * Health Protection Agency, Gloucester, United Kingdom; ([dagger]) University of Saint Andrews Saint Andrews, town (1991 pop. 11,302), Fife, E Scotland, on the North Sea. A summer resort, it is famous for its golf courses. It was the seat of an archbishop from 908 and the ecclesiastical capital of Scotland until the Reformation. St. , Saint Andrews, United Kingdom; ([double dagger]) Health Protection Agency, London, United Kingdom; ([section]) Southwold Surgery, Southwold, United Kingdom; and ([paragraph]) University of Dundee As the above opinion represents, there was a significant movement with the intention of decanting the entire university to Dundee, which the Royal Commission observed was now a "large and increasing town" - or indeed the establishment of a college along very similar lines to the present , Dundee, United Kingdom Dr McNulty is a consultant medical microbiologist microbiologist a specialist in microbiology. and head of the Health Protection Agency Primary Care Unit in Gloucester, UK. Her research interests include management of infectious disease Infectious disease A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. in primary care, guidance development, and facilitation Facilitation The process of providing a market for a security. Normally, this refers to bids and offers made for large blocks of securities, such as those traded by institutions. of education.
Table 1. Outcomes from household survey of antimicrobial drugs and
interviews of an adult member of the household about behavior in
relation to these drugs, United Kingdom, 2003 *
Antibacterial or antifungal
Data drugs % (95% CI)
Household-based (6,983 households)
Households with drug 18.9 (18.0-19.9)
Households with current drug 10.6 (9.9-11.4)
Households with leftover drug 6.2 (5.7-6.8)
Households with standby drug 3.7 (3.3-4.2)
Households with leftover or standby 9.6 (8.9-10.3)
drug
Antimicrobial drug-based (506 leftover,
292 standby)
Leftover drug >1 y old 38 (33-44)
Standby drug >1 y old 31 (26-37)
Leftover drug is more than half left 48 (43-53)
Respondent-based (7,120 respondents)
Respondent had a leftover drug that
was originally 3.9 (3.4-4.4) ([dagger])
prescribed
Respondent prescribed a drug in the 37.6 (36.4-38.8)
last year
Respondent kept leftover drug from 5.9 (5.0-7.0)
their most recent prescription
Respondent kept drug in case of future 44 (35-52)
need
Antibacterial drugs, %
Data (95% CI)
Household-based (6,983 households)
Households with drug 13.9 (13.1-14.8)
Households with current drug 7.9 (7.2-8.5)
Households with leftover drug 4.5 (4.0-5.0)
Households with standby drug 2.4 (2.1-2.8)
Households with leftover or standby 6.7 (6.1-7.3)
drug
Antimicrobial drug-based (506 leftover,
292 standby)
Leftover drug >1 y old 32 (27-38)
Standby drug >1 y old 29 (23-37)
Leftover drug is more than half left 50 (44-56)
Respondent-based (7,120 respondents)
Respondent had a leftover drug that
was originally 2.8 (2.4-3.3)
prescribed
Respondent prescribed a drug in the
last year
Respondent kept leftover drug from
their most recent prescription
Respondent kept drug in case of future
need
Antifungal drugs, %
Data (95% CI)
Household-based (6,983 households)
Households with drug 6.9 (6.3-7.6)
Households with current drug 3.6 (3.2-4.1)
Households with leftover drug 2.1 (1.8-2.5)
Households with standby drug 1.5 (1.2-1.8)
Households with leftover or standby 3.5 (3.1-4.0)
drug
Antimicrobial drug-based (506 leftover,
292 standby)
Leftover drug >1 y old 55 (46-63)
Standby drug >1 y old 36 (28-46)
Leftover drug is more than half left 44 (36-53)
Respondent-based (7,120 respondents)
Respondent had a leftover drug that
was originally 1.2 (1.0-1.5)
prescribed
Respondent prescribed a drug in the
last year
Respondent kept leftover drug from
their most recent prescription
Respondent kept drug in case of future
need
* Some prescriptions contained both antibacterial and antifungal drugs
and contribute to all 3 columns. CI, confidence interval.
([dagger]) This outcome is examined in more detail in Table 2.
Table 2. Characteristics of respondents who had a leftover
antimicrobial drug, United Kingdom, 2003 *
Outcome: respondent had
leftover drug originally Crude OR ([dagger])
prescribed for respondent % (95% CI) (95% CI)
Age group, y
16-24 3.8 (2.4-6.0) 0.89 (0.82-0.98)
25-44 4.5 (3.7-5.4)
45-54 4.1 (3.0-5.5)
55-64 3.9 (2.9-5.3)
65-74 2.9 (2.0-4.3)
[greater than or equal to] 75 2.1 (1.3-3.5)
Sex
Male 3.2 (2.6-4.0) 1
Female 4.4 (3.8-5.2) 1.38 (1.05-1.82)
Education
Degree 5.4 (4.1-7.1) 1
Other 4.3 (3.6-5.1) 0.78 (0.56-1.10)
No formal degree 2.4 (1.8-3.2) 0.43 (0.29-0-65)
No. questions regarding drugs
answered incorrectly
0 6.1 (4.7-7.8) 0.87 (0.79-0.95)
1 4.2 (3.1-5.5)
2 3.4 (2.6-4.5)
3 4.0 (2.9-5.4)
4 2.5 (1.6-3.8)
[greater than or equal to] 5 3.1 (2.1-4.5)
Carstair deprivation score
1st quintile (least deprived) 4.4 (3.4-5.9) 1.00 (0.91-1.11)
2nd quintile 3.9 (2.8-5.5)
3rd quintile 3.4 (2.6-4.6)
4th quintile 3.1 (2.3-4.1)
5th quintile (most deprived) 4.6 (3.6-5.8)
Prescribed a drug in the past
year
No 2.1 (1.7-2.6) 1
Yes 6.9 (5.9-8.0) 3.51 (2.66-4.65)
Outcome: respondent had
leftover drug originally Adjusted OR ([dagger])
prescribed for respondent p value (95% CI)
Age group, y
16-24 0.01 0.97 (0.88-1.06)
25-44
45-54
55-64
65-74
[greater than or equal to] 75
Sex
Male 1
Female 0.02 1.22 (0.94-1.57)
Education
Degree <0.0005 1
Other 0.74 (0.54-1.02)
No formal degree 0.44 (0.29-0.68)
No. questions regarding drugs
answered incorrectly
0 0.002 0.91 (0.84-0.98)
1
2
3
4
[greater than or equal to] 5
Carstair deprivation score
1st quintile (least deprived) 0.99 1.01 (0.92-1.10)
2nd quintile
3rd quintile
4th quintile
5th quintile (most deprived)
Prescribed a drug in the past
year
No 1
Yes <0.0005 3.50 (2.69-4.54)
Outcome: respondent had
leftover drug originally
prescribed for respondent p value
Age group, y
16-24 0.49
25-44
45-54
55-64
65-74
[greater than or equal to] 75
Sex
Male
Female 0.14
Education
Degree 0.001
Other
No formal degree
No. questions regarding drugs
answered incorrectly
0 0.02
1
2
3
4
[greater than or equal to] 5
Carstair deprivation score
1st quintile (least deprived) 0.89
2nd quintile
3rd quintile
4th quintile
5th quintile (most deprived)
Prescribed a drug in the past
year
No
Yes <0.0005
* CI, confidence interval; OR, odds ratio.
([dagger]) For age group, no. of questions regarding drugs answered
incorrectly used Carstair deprivation score; the odds ratio is between
adjacent categories.
The corresponding p value is a test for trend.
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