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Meta-analysis: Antibiotics for Prophylaxis against Hemodialysis Catheter–Related Infections.
Tonelli: University of Alberta, 7-129 Clinical Sciences Building, Edmonton, T6G 2G3 Alberta, Canada. James was supported by a KRESCENT award from the Kidney Foundation of Canada and an Alberta Heritage Foundation for Medical Research Award.
0.41 case of infection per 100 catheter-days), need for catheter removal, and hospitalization for infection. We used a structured questionnaire to collect data from a random sample of 540 households with at least one child aged < 5 years.
Tonelli and Hemmelgarn were supported by Population Health Investigator Awards from the Alberta Heritage Foundation for Medical Research. Tonelli, Manns, and Hemmelgarn were supported by New Investigator Awards from the Canadian Institutes for Health Research.
Symptoms commonly treated were cough (84%), fever (66%), nasal discharge (65%) and sore throat (60%).
Whether these strategies will lead to antimicrobial resistance and loss of efficacy over longer periods remains unclear. Because such use leads to the spread of bacterial resistance to antibiotics and related health problems, our findings have important implications for public education and the enforcement of regulations regarding the sale of antibiotics in Mongolia.
Les pharmacies étaient la principale source (86%) d'approvisionnement des antibiotiques non prescrits. Los antibióticos de venta sin receta se obtuvieron principalmente (86%) en las farmacias.
13 injections per person per year,16 and the prescription of antibiotics is widespread and often inappropriate.17 Moreover, after the establishment of a market-based economy in 1990, the number of private pharmacies rose sharply in Mongolia. Such studies are essential to obtain a clear understanding of the factors that underlie this practice and to develop measures to preventive antibiotic resistance and promote rational use. The aim of the present study was therefore to determine the prevalence of the administration of non-prescription antibiotics by caregivers to children younger than 5 years of age, and to identify factors associated with non-prescription use. About 39% of the country's population lives in this city, and 8.8% of its inhabitants are aged between 0 and 4 years. Because of the absence of relevant data, we estimated a sample size of approximately 400 for an assumed prevalence of self-medication of 50%, a 95% confidence level and a 5% margin of error.23 In a recent government survey, a non-response rate of 15% was assumed in the sampling design24 and with this in mind, we adjusted the sample size by 30% to compensate for potential problems of non-response or incomplete survey reports.
In the second stage, we selected households from each sampled subdistrict by probability proportional to size, using a list of households that had children aged < 5 years.
Because coverage under the National Expanded Programme on Immunization is approximately 97% in Mongolia,25 we used the list of households from its records.
For households with more than one child aged < 5 years, we selected one of the children at random from the list before visiting the household.
We excluded households from the survey if parents or caregivers were not present at the time of the interview or if they refused to participate, if they were medical professionals, or if they did not understand what the word "antibiotics" meant. If mothers or caregivers reported that their child had taken antibiotics without a prescription, they were asked for further details concerning self-medication with antibiotics.

Symptoms were self-reported and based on codes in the International classification of primary care,27 and antibiotics were defined as antibacterials for systemic use.28 Parents and caregivers also reported whether they took antibiotics themselves without a prescription and whether they kept antibiotics at home. It was pre-tested on a small pilot population and revised on the basis of feedback from the pilot test.
The chief investigator provided training in the content of the questionnaire and the purpose of the study to a team of experienced interviewers.
Interviewers visited households and explained the purpose of the study to parents or caregivers and asked them to participate. Sample weights were used to minimize bias in the selection of a given child in a household. We included in the model only responses for households in which the main caregiver was the mother, as mothers clearly accounted for the largest proportion of persons responsible for dealing with children's illnesses. The dependent variable was whether a child had received non-prescribed antibiotics in the previous 6 months. Explanatory variables used in the analysis were sociodemographic variables, distance to a family practice facility, availability of antibiotics at home, mother's knowledge regarding upper respiratory tract infections and antibiotic use, tendency to demand antibiotics, and mother's own self-medication with antibiotics. Mothers were considered to have a tendency to demand antibiotics if they responded affirmatively to two of the three questions about their expectations for antibiotics use. About one-fifth (21%) of the 503 children had taken antibiotics without a prescription, and both prescribed and non-prescribed antibiotics were used concomitantly in 21%.
Amoxicillin was the most commonly used non-prescribed antibiotic (58%), followed by ampicillin (25%), erythromycin (6%), chloramphenicol (5%) and trimethoprim-sulfamethoxazole (5%). Additionally, 8% of the children were treated with two non-prescribed antibiotics simultaneously, and 5% were given parenteral antibiotics if they had a sore throat with fever and cough or shortness of breath. Of the non-prescribed antibiotics, 31% were given on the advice of pharmacists, 35% on the advice of family members and 8% on the advice of friends. Reasons for not seeking a physician's advice included the belief that the illness was not severe (70%) and previous experience with the doctor always prescribing the same antibiotics for similar conditions (15%). Past experiences and familiarity with a drug were the main reasons for selecting a particular antibiotic (82%). Many respondents gave incorrect answers about antibiotic use for colds or flu (83%), a cough (81%), sore throat (74%) or purulent nasal discharge (64%).
There was also a lack of understanding of antibiotic use for clear nasal discharge (runny nose) and middle ear fluid: about half the respondents answered incorrectly. Most participants (96%) incorrectly believed that most colds and cases of flu were caused by bacteria, and 76% incorrectly believed that antibiotics would accelerate recovery from these illnesses. In both developed and developing countries, self-medication with antibiotics is common for illnesses presumed to be caused by a virus.11,13,31,32 Although this practice is well known, few previous studies have used research methods that allow their findings to be compared with those from earlier studies. It is also associated with the emergence and spread of antimicrobial resistance.39 These problems require appropriate measures by policy-makers to develop pertinent policies as well as to ensure their implementation. When younger children become ill, parents may be more careful and concerned and more likely to visit a doctor, whereas when the children are older, parents may have more knowledge about common illnesses and be more inclined to administer medical treatments themselves. In particular, caregivers who had medicated themselves with antibiotics were more likely to give antibiotics to their children without a prescription. Most respondents in our study believed that antibiotics were needed for colds or flu, purulent nasal discharge and cough, even though these are typical manifestations of upper tract respiratory infections, most of which are caused by viruses. Previous interventions have included the distribution of educational materials to hospitals and pharmacies, and the communication of information through the media.9,42,45 The use of non-prescribed medications for children might be a consequence of poor oversight of community pharmacies, and the widespread availability of medicines has probably contributed to an increase in this phenomenon.

Interventions in other developing countries that have reduced over-the-counter antibiotic sales suggest, however, that this situation can be changed. In Chile, the prohibition of over-the-counter sales of antibiotics and a simultaneous public education campaign had an immediate and significant impact on the acquisition of antibiotics from pharmacies.1 Similarly, sales of antibiotics without prescription in Zimbabwe decreased when the law against over-the-counter sales was strictly enforced. Fear of losing their license was a factor mentioned by some pharmacists for their compliance.46 This study has several limitations.
To minimize this possibility we limited the recall period to the previous 6 months, and attached a list of the most commonly used antibiotics to the questionnaires.
Another limitation is that findings from this urban sample cannot be generalized to the whole population of Mongolia.
This would overestimate the prevalence of non-prescription antibiotic use since this study was done in the capital city, where access to pharmacies and information are higher than in rural settings.
To better study this issue, future research should focus on both urban and rural areas, and should involve both prescribers and pharmacists.
Additionally, seasonal variations in illnesses should also be taken into consideration, because they may have affected disease patterns and antibiotic use. As shown in a multi-country study in Europe, the attitudes and behaviour of health personnel may also reinforce self-medication with antibiotics,14 although these factors were not examined in the current study. In the future, questions relating to the prescription of antibiotics, the doctor-patient relationship, patient satisfaction and perceived accessibility of health care should be included in survey instruments. The information obtained with these items will result in a better understanding of the determinants of non-prescription antibiotic use in Mongolia.
Despite these limitations, our findings shed light on the relative importance of demand-side determinants related with non-prescription antibiotic use for children and the interventions needed to prevent this misuse. Some determinants of this practice were the child's age, caregivers' misconceptions about the efficacy of antibiotics for upper respiratory tract infections, caregivers' own experience with self-medication, and the availability of antibiotics at home. Interventions aimed at preventing the unsanctioned use of antibiotics should be directed primarily at reducing the availability of non-prescribed antibiotics and educating the general public to dispel misconceptions about the use of antibiotics. Assessment of hepatitis B vaccine-induced seroprotection among children 5-10 years old in Ulaanbaatar, Mongolia. Antimicrobial resistance module for population-based surveys, Demographic and Health Survey.
Grigoryan L, Haaijer-Ruskamp FM, Burgerhof JG, Mechtler R, Deschepper R, Tambic-Andrasevic A et al. Caregivers' practices, knowledge and beliefs of antibiotics in paediatric upper respiratory tract infections in Trinidad and Tobago: a cross-sectional study.
Assessment of self-medication practices in Assendabo town, Jimma zone, southwestern Ethiopia. Social factors influencing the acquisition of antibiotics without prescription in Kerala State, south India. Low sale of antibiotics without prescription: a cross-sectional study in Zimbabwean private pharmacies.

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