Mubasher Rehman  ( Department of Microbiology, Hazara University Mansehra, KPK, Pakistan. )
Shehzad Ahmed  ( Department of Microbiology, Hazara University, Mansehra, KPK, Pakistan. )
Umair Ahmed  ( Department of Microbiology, Hazara University Mansehra, KPK, Pakistan. )
Kosar Tamanna  ( Department of Microbiology, Hazara University Mansehra, KPK, Pakistan. )
Muhammad Shehryar Sabir  ( Department of Microbiology, Hazara University, Mansehra, KPK, Pakistan. )
Zeeshan Niaz  ( Department of Microbiology, Hazara University Mansehra, KPK Pakistan )

Self-medication is the use of medicines by people on the basis of their own experience without consulting a doctor. People use medicines for pain management or to cure a disease and sometime this may be unnecessary. There are a lot of public and professional health concerns about misuse of medicines and globally physicians agree upon this rising issue that leads to antibiotic resistance. In developing countries, medicines without prescription are easily available which results in many adverse outcomes, especially bacterial resistance. Insufficient healthcare services and socioeconomic factors result in increased proportion of self-medication compared to drugs prescribed by physicians. The current narrative review was planned to focus on indicating prevalence rate of self-medication in different developed and under-developed countries, major risk factors and control of self-medication due to which antibiotic resistance rate can be minimised. The issue needs urgent attention of representative authorities for taking serious actions. Furthermore, arranging awareness seminars and implementing new policies/regulations to prevent the sale of any drug/antibiotic without prescription could play a vital role in bringing this alarming issue under control.

Keywords: Antibiotics, Bacterial resistance, Prevalence, Self-medication.

DOI: https://doi.org/10.47391/JPMA.1331

 

Introduction

 

Self-medication is globally a noteworthy general medical issue and can be defined as “the use of a drug by a patient on his own experience without proper consultation of medical practitioner”¹ or “utilising drugs without consulting medical specialist either for diagnosis or treatment”.² Due to self-medication practices, the use of antibiotics is on the rise. These antibiotics are usually advised by either lay-persons amongst family or by patients themselves based on information available on the internet or friends of the patient³ or using leftover from the stock of medicines at home or lack of time or reusing old prescriptions to buy medicine.⁴

If a self-medicating person chooses irrelevant antibiotics of not the recommended dose or therapy, it may be harmful. The major cause of antibiotic resistance is inadequate use of antibiotics.⁵ Promiscuous use of antibiotics may lead to a variety of complications, including nosocomial, waterborne and food-borne infections by the bacteria that are antibiotic-resistant, enteropathy or short-tempered bowel syndrome, diarrhoea etc., drug sensitivity, environment modification and devastation of flimsy competition occurring in different species of the microbial ecosystem.^6,7

A study conducted in Europe demonstrated that there is a significant difference in public point of view and their level of education about self-medication and antibiotic resistance. About 50% of respondents knew about antibiotic resistance and consciousness was minimal in nations with a higher prevalence of resistance.⁸ Another study, conducted in Spain, demonstrated that regulations and its implementation also differ for the prescription of antibiotics. For example, in Spain, because of poor implementation and control over the rules and regulations, self-medication with antibiotics is noted.⁹

There are myriad of public and professional problems regarding unreasonable use of medicine.⁴ The prevalence rate of self-medication is high and alarming all over the world, particularly among university students of developing countries as well as in the developed countries. In Asia, the highest prevalence rate of self-medication was recorded in Pakistan (95.5%),¹⁰ followed by Kuwait (92%),¹¹ India (87%),¹² Nepal (59%),¹³ Dubai (56%),¹⁴ Saudi Arabia (34%),¹⁵ while the lowest rate was found in southern China (47.8%) university students.¹⁶ In Europe the highest prevalence rate was recorded in Croatia (88%),¹⁷ followed by Greece (75%),¹⁸ other European countries (68%)¹⁹ and Turkey (45%).²⁰ In Africa, the highest prevalence rate was recorded in Ethiopia (51.4%),²¹ followed by northern Nigeria (38.8%).²² In the United States, 54% of young children were reported to be self-medicated,²³ while in Australia 55% respondents were found to be self-medicated in a survey.²⁴

Studies have revealed that the prevalence rate is high in women living alone, people with low socioeconomic status (SES), patients suffering from chronic diseases, in teenagers and students.^18,25,26 In Pakistan and many other developing countries, pharmacies mostly sells drugs without any prescription.²⁷ The reasons behind high prevalence of self-medication are easy availability of medicine over the counter (OTC) and unawareness of harmful effects of different drugs. Due to sub-standard basic healthcare units and affordability problems, people usually prefer self-medication instead of following proper diagnosis and treatment protocols.²⁸

According to the United Arab Emirates Ministry of Economy’s national antibiotics policy and manual of antimicrobial treatment, antimicrobials should only be sold or provided by prescription from an approved therapeutic expert or dental specialist. For sensible usage, antimicrobials are characterised into three groups. Group I: Basic use; all physicians may recommend them; they are safe, effective and relatively cheap. Group II: For confined use; prescription by doctors only; they are expensive, toxic and new agents. Group III: Use in essential human services; they share the characteristics of Group I with a few oversights.²⁹

There are different reasons for self-medication, like occasional pain,³⁰ sore throat, diarrhoea, fever, cough, vomiting, headache, allergy, inability to sleep, gastric pain, constipation, and eye diseases and other common infections.¹⁰

The current narrative review was planned to focus on the comparison of self-medication problem in developing and the developed countries while putting together the basic reasons behind self-medication. It also planned to take a look as the consequences of self-medication, its relation with antibiotic resistance, and steps to control this problem.

 

Why people self-medicate?

 

Studies indicated that top two factors for self-medication are prior familiarity and non-seriousness of illness. People preferering to maintain their own health with non-expert advices also contribute towards high prevalence of problems originating due to self-medication.^21,31,33 Other factors accountable for the rising drift of self-medication are feeling sympathy towards members of the family when they are ill, shortage of time, absence of health facilities, low SES, unawareness, misbelief, widespread advertisments, remaining stock of medicines at home and reusing old prescriptions to buy medicine.^34,35

Though OTC medicines are planned for self-medication and can be useful if used properly while having enough information about usage, in unique groups, particularly in kids, elderly patients, pregnant and lactating mothers, irrational use of drugs can cause severe damage if the user lacks knowledge regarding side-effects, efficacy as well as their antagonistic effects.³⁶

 

Role of Self-Medication in Antibiotics Resistance

 

Two factors need to be focussed on while understanding the resistance phenomena: the antibiotics and resistance gene.³⁷ To conventional antibiotics, bacteria show progressive resistance at both clinical and non-clinical sites. About a decade ago, the main concern was toward gram-positive bacteria, especially methicillin-resistant staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus spp. But currently, microbiologists strongly agree that multi-drug ressitant (MDR) gram-negative bacteria are highly fatal to public health. Not only gram-negative bacteria resistance is increasing more rapidly^38,39 but along with it there are insufficient development of new antibiotics against gram-positive bacteria.^40-42

The leading cause for development of resistance to antibiotic and human pathogens is self-medication.^43,44  Amoxicillin has the highest percentage of self-medication usage among antibiotics (22.4%) and Ampiclox has the lowest percentage (3.3%) (Table 1).⁴⁵

Some of the common antibiotic-resistant pathogens are toxin producing clostridium difficile, MRSA, glycopeptides-resistant staphylococcus aureus, and β-lactamase- and carbapenemase-producing coliforms.^46,47 In 2008 a database listed bacterial genome sequences in which more than 20,000 potential resistant genes (r genes) of 400 different sorts were predicted.⁴⁸

The potential reasons behind the development of microbial resistance include regular and irrational use of antibiotics, and ignorance of patient regarding adequate dosage limit, their side-effects and overdose.⁴³ Common reasons for self-medication evaluated by different studies are chill and upper respiratory tract symptoms usually caused by viruses.^49,50 Many patients use antibiotics to treat viral infections although antibiotics don’t work against them since many developing countries have poor antibiotic administering rule which ultimately results in the emergence of antibiotic resistance.^51,52 The phenomenon of antibiotic resistance, its development and the transfer of drug resistance to other bacteria have been studied (Figure 1).

Antibiotic resistance has transformed into serious worldwide health problem and people are still not aware of the risks or damages that occur at the personal as well as at public/community level. According to the Centers for Disease Control and Prevention (CDC)⁵³ in developed countries like the United States, annually many patients admitted in hospitals are infected by antibiotic-resistant pathogens and approximately 23,000 die due to the absence of therapeutic choices available along with vague and fatal effects resulting in troubled diagnosis. For example, in children suffering from meningitis who may suffer neurological damage, antibiotic as a firstline of therapy is not of much significance. An infection of antibiotic-resistant pathogen can slow the healing process and persuade more therapeutic expenses.⁵⁴ In under-developed countries where the healthcare system is not as much advanced, the costs become comparatively higher. A study estimated that in India more than 58,000 infants died in 2013 because of antibiotic-resistant bacterial infections, although it produces over 40% of world’s antibiotics.⁵⁵ A report presented at a medical conference in Pakistan said antibiotic resistance will possibly kill 10 million people per annum up to 2050 which is an alarming condition for the country. Another study reported that 95% of the infections in hospitalised patients are detected as resistant against a wide range of antibiotics.⁵⁶

 

Prevention of bacterial resistance

 

To handle the problem of antibiotic resistance, it is essential to discuss the misuse of antibiotics⁵⁷ and to make strict strategies to curb the resistance percentage. Restraining the misuse of antibiotics at the local level can diminish the number of resistant bacterial strains and ultimately prevent the whole world from such a crisis.⁵⁸

Medical specialists can play an important role in this regard by providing awareness to the people about the potential risks of antibiotics misuse. Physicians ought to likewise instruct their patients and parental figures about the psychosomatic factors that can help them in increasing adherence to medicine, for example, improving inspiration, patient education, defining wellbeing objectives and expanding social help and support. When a patient has a disease that should be treated with antibiotics, the physician ought to give appropriate guidelines on its utilisation, like dose, frequency of dosage, duration of treatment and harmful effects of its misuse.⁵⁹

Better information and awareness among the non-medical population regarding allopathic medicines, particularly an understanding of the dosage of antibiotics, can help in reducing microbial resistance issues worldwide.⁵⁹ Medical specialists and pharmacists can also play an  important role in reducing antibiotic resistance rate if enough information is provided to patients during checkup and sale of medicines.⁵¹

 

Trends of Self-Medication Around the World

 

Different studies reveal that self-medication is a common practice, especially in the developing countries or in communities having low SES. Self-medication also has some advantages, but many disadvantages which can cause severe damages and can even be lethal.^60,61 In under-developed countries where healthcare services are not readily available, the preferable choice for people become self-medication.⁶² Self-medication is highly prevalent worldwide and its rate is alarming, especially among university students (Figure 2).^11,63

 

Self-Medication in Pakistan

 

The prevalence rate of self-medication is significantly high in Pakistan, especially among university students; 76% in Karachi University students²⁸ and 95.5% in COMSATS Institute of Information Technology, Abbottabad10 which was significantly (p<0.0001) higher from that of Karachi, although the subjects knew the harmful effects better.²⁸ The common factors which were the main cause of self-medication were previous experiences (50.10%) with similar symptoms and trivial nature of the problem (48.30%).^28,64 Here is a need to teach the juveniles to move towards safe practices by adopting strict strategies that may help control the issue.²⁸ In Pakistan, the government spends very less percentage of its GDP on health which is the key reason behind the high prevalence rate of self-medication. According to one report, Pakistan is only spending $36.2 per capita on health which is against the World Health Organisation (WHO)’s low-income countries standard ($86).⁶⁵

Headache, fever and flu-like symptoms were the most common symptoms that led to self-medication (Figure 3) and, hence, painkillers, antipyretics, anti-allergics and antibiotics were among the most commonly used drugs.

These drugs are usually obtained from medical stores or from friends.²⁸

 

Advantages and Disadvantage of Self-Medication

 

Self-medication can only be beneficial if it is used for minor health problems, such as headache, mouth ulcers, cough etc., and the users have enough knowledge about disease condition, drug efficacy, side-effects etc. At the community level, it can reduce the workload on healthcare centres where facilities or healthcare personnel are

insufficient.^66-68 Besides, self-medication has many potential risks. Regular user usually has no or limited knowledge of principles of therapy, or of specific usage of medicinal product. This results in certain potential risk at individual and community levels, like inappropriate selection of drug may lead to progression of disease, organ failure and, most importantly, bacterial resistance. Delay in diagnosis and treatment of a serious medical condition can cause health and financial loss and sometime even death.^66,69 Unwillingly, repeated use of similar drugs with different trade names, incorrect route of administration and failure to recognise contraindications, interactions, warnings and precautions can cause severe damages and some infections can even be lethal.⁶⁶

 

Controlling Potential Risks Related with Self-Medication

 

Role of medical specialist

Doctors should give enough time to patients, comprehensively guide them about the pros and cons of prescribed drug and its usage along with detailed information about the illnesses they have.⁷⁰ Minimum information that should be provided to the patients must be given (Table 2).

Medical specialists have an important role in preventing the risks of self-medication. Information, therapeutic advice and education are the three main aspects on which medical specialists must work on daily basis).^70,71

 

Information

 

Whenever medical specialists are recommending medicine, they should give admissible advices and clearly identify the purpose for which it is suggested so that the given instructions and advices are helpful for better understanding. The advices, facts and figures which are given to the patient should be brief, so that the patient may easily understand the administration of medicine.⁷¹

 

Therapeutic advice

 

In both acute and chronic treatments, absence of proper therapeutic advice is a significant issue and reflects an inadequately understandable or deficient explanation of the treatment purpose. If the patients are not well instructed, they struggle to take medication properly.⁷⁰ However, if limitation and way of using drugs are well explained, like dosage, time difference between first and second dosage, time period of the entire course, how to use it, etc., then the patients feel more inclined towards taking medicines accurately. Wrong and irrational self-medication as well as with non-compliance might be decreased if patients are educated, well aware and know why these advices and supervision have been provided by medical specialists.⁷¹

 

Education

 

Suitable and proper health education must be provided to patients. By acquiring a professional attitude, people may subsequenlt encourage their friends, family and relatives.⁷¹

 

Role of Pharmacist

 

Pharmacists play a crucial part in educating people indulging in self-medication. They may guide customers regarding the proper use of medicine as well as indicating, solving and avoiding drug-related problems for acquiring maximum patient outcomes and quality of life.^68,72,73

A pharmacist should be a good communicator and must communicate straightforward and briefly with the patient.⁷⁴ Pharmacist must ask key questions from patients and provide an appropriate information, like efficacy, how to take medicine, how to store the medicine and how to deal with safety issues.^71,75

To obtain essential information, the pharmacist must take necessary detail regarding patient age, gender, allergies, diseases etc., and about medicine that is either prescribed or not. This will help pharmacist to decide whether to prescribe a drug or refer the patient to some specialist.⁷⁴

There must be a referral protocol for the pharmacologist. Protocol for public health workers is required for circulation of drugs^71,75,76 and a pharmacist should be selective in providing information and drugs to patient.⁷⁴

To identify health problems and risks in the community, a pharmacist must participate in health screening programmes. He should attend and arrange seminars to raise awareness of issues related to health and disease prevention. Pharmacists should also provide advice to individuals regarding health, which can help them in maintaining their health on their own.^71,75

Finally, a pharmacist essentially certifies that the items the customer is purchasing are of excellent quality.^71,75

 

Suggestions and Recommendations

 

Self-medication in Pakistan and in other under-developed countries has not been studied extensively and it is essential for researchers to report more data. Health regulatory authorities must take serious actions against medical stores selling drugs without doctor’s prescription. Furthermore, it is recommended for the patients to avoid using any medicines without prescription of a medical specialist. There is also a need to explore new strategies to combat antibiotic resistance by adopting alternative strategies like phage therapy as well as by immunotherapy.

Strategies to augment the existing policies for prevention of antimicrobial resistance may include improving the self hygiene and immunisation which ultimately reduce the need for antibiotics; nosocomial infection control and antibiotic stewardship must also be improved; modifying the inducements that encourage the overuse and miss-use of antibiotic and reassuring antibiotic stewardship; decreasing and ultimately phasing out the use of sub-therapeutic antibiotic in agriculture; encouraging health professionals, policy-makers, and the community at large about the proper use of antibiotics; and to ensure political commitment to encounter the threat generated by antibiotic resistance.

 

Conclusion

 

Self-medication being a serious issue would be safe if a person has proper and adequate familiarity with its dosage, efficacy and side-effects However, due to limited knowledge, it can cause serious side-effects, such as allergic reactions, skin problems and bacterial resistance. In less advanced countries, such as Pakistan and India, people have very limited knowledge regarding risks associated with self-medication, which leads to a high prevalence rate and the emergence of new cases of antibiotic resistance frequently. Many studies have reported self-medication as the root cause of antibiotic resistance. To curb the menace, multidimensional approaches need to be adopted, like proper awareness, education, and strictness regarding pharmaceutical advertising. Healthcare commission should implement protocols and strict legislation related to sale of drugs without prescription, and the government should spend higher percentage of its GDP on the health sector.

 

Acknowledgement: A special gratitude to Dr. Muhammad Nasir Riaz (Lecturer in Microbiology at Hazara University Mansehra and a PhD candidate at Viral Immunology system programs, The Kirby institute, UNSW Sydney) for his expert advice and support throughout the writing. 

Disclaimer: None.

Conflict of Interest: None.

Source of Funding: None

 

References

 

1.      AESGP. Association of the European Self medication Industry. [Online] 2004 [Cited 2015 December 15]. Available from URL: http://www.aesgp.be/researchproject/finalreport.pdf.

2.      Montastruc JL, Bagheri H, Geraud T, Lapeyre-Mestre M. Pharmacovigilance of self-medication. Therapie 1997;52:105-10.

3.      Sawalha AF. A descriptive study of self-medication practices among Palestinian medical and nonmedical university students. Res Social Adm Pharm 2008;4:164-72. doi: 10.1016/j.sapharm.2007.04.004.

4.      Nepal G, Bhatta S. Self-medication with Antibiotics in WHO Southeast Asian Region: A Systematic Review. Cureus 2018;10:e2428. doi: 10.7759/cureus.2428.

5.      Zdziarski P, Simon K, Majda J. Overuse of high stability antibiotics and its consequences in public and environmental health. Acta Microbiol Pol 2003;52:5-13.

6.      Becattini S, Taur Y, Pamer EG. Antibiotic-Induced Changes in the Intestinal Microbiota and Disease. Trends Mol Med 2016;22:458-78. doi: 10.1016/j.molmed.2016.04.003.

7.      Nuermberger EL, Bishai WR. Antibiotic resistance in Streptococcus pneumoniae: what does the future hold? Clin Infect Dis 2004;38(Suppl 4):s363-71. doi: 10.1086/382696.

8.      Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg CS, Monnet DL, et al. Self-Medication with Antibiotics and Resistance (SAR) Consortium. Determinants of self-medication with antibiotics in Europe: the impact of beliefs, country wealth and the healthcare system. J Antimicrob Chemother 2008;61:1172-9. doi: 10.1093/ jac/dkn054.

9.      Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg CS, Monnet DL, et al. Attitudes, beliefs and knowledge concerning antibiotic use and self-medication: a comparative European study. Pharmacoepidemiol Drug Saf 2007;16:1234-43. doi: 10.1002/ pds.1479.

10.    Ullah H, Khan SA, Ali S, Karim S, Baseer A, Chohan O, et al. Evaluation of self-medication amongst university students in Abbottabad, Pakistan; prevalence, attitude and causes. Acta Pol Pharm 2013;70:919-22.

11.    Abahussain E, Matowe LK, Nicholls PJ. Self-reported medication use among adolescents in Kuwait. Med Princ Pract 2005;14:161-4. doi: 10.1159/000084633.

12.    Verma RK, Mohan L, Pandey M. Evaluation of self medication among professional students in North India: proper statutory drug control must be implemented. Asian J Pharm Clin Res 2010;3:60-4.

13.    Shankar PR, Partha P, Shenoy N. Self-medication and non-doctor prescription practices in Pokhara valley, Western Nepal: a questionnaire-based study. BMC Fam Pract 2002;3:e17. doi: 10.1186/ 1471-2296-3-17.

14.    Abasaeed A, Vlcek J, Abuelkhair M, Kubena A. Self-medication with antibiotics by the community of Abu Dhabi Emirate, United Arab Emirates. J Infect Dev Ctries 2009;3:491-7. doi: 10.3855/jidc.466.

15.    Alghadeer S, Aljuaydi K, Babelghaith S, Alhammad A, Alarifi MN. Self-medication with antibiotics in Saudi Arabia. Saudi Pharm J 2018;26:719-24. doi: 10.1016/j.jsps.2018.02.018.

16.    Pan H, Cui B, Zhang D, Farrar J, Law F, Ba-Thein W. Prior knowledge, older age, and higher allowance are risk factors for self-medication with antibiotics among university students in southern China. PLoS One 2012;7:e41314. doi: 10.1371/journal.pone.0041314.

17.    Aljinović-Vucić V, Trkulja V, Lacković Z. Content of home pharmacies and self-medication practices in households of pharmacy and medical students in Zagreb, Croatia: findings in 2001 with a reference to 1977. Croat Med J 2005;46:74-80.

18.    De Sanctis V, Soliman A, Bernasconi S, Bianchin L, Bona G, Bozzola M, et al. Primary Dysmenorrhea in Adolescents: Prevalence, Impact and Recent Knowledge. Pediatr Endocrinol Rev 2015;13:512-20.

19.    Bretagne JF, Richard-Molard B, Honnorat C, Caekaert A, Barthélemy P. Gastroesophageal reflux in the French general population: national survey of 8000 adults. Presse Med 2006;35:23-31. doi: 10.1016/s0755-4982(06)74515-8.

20.    Buke C, Hosgor-Limoncu M, Ermertcan S, Ciceklioglu M, Tuncel M, Köse T, et al. Irrational use of antibiotics among university students. J Infect 2005;51:135-9. doi: 10.1016/j.jinf.2004.12.001.

21.    Abay SM, Amelo W. Assessment of self-medication practices among medical, pharmacy, and health science students in gondar university, ethiopia. J Young Pharm 2010;2:306-10. doi: 10.4103/0975-1483.66798.

22.    Fadare JO, Tamuno I. Antibiotic self-medication among university medical undergraduates in Northern Nigeria. J Public Health Epidemiol 2011;3:217-20

23.    Kogan MD, Pappas G, Yu SM, Kotelchuck M. Over-the-counter medication use among US preschool-age children. JAMA 1994;272:1025-30.

24.    Stosic R, Dunagan F, Palmer H, Fowler T, Adams I. Responsible self-medication: perceived risks and benefits of over-the-counter analgesic use. Int J Pharm Pract 2011;19:236-45. doi: 10.1111/ j.2042-7174.2011.00097.x.

25.    Lee CH, Chang FC, Hsu SD, Chi HY, Huang LJ, Yeh MK. Inappropriate self-medication among adolescents and its association with lower medication literacy and substance use. PLoS One 2017;12:e0189199. doi: 10.1371/journal.pone.0189199.

26.    Locquet M, Honvo G, Rabenda V, Van Hees T, Petermans J, Reginster JY, et al. Adverse Health Events Related to Self-Medication Practices Among Elderly: A Systematic Review. Drugs Aging 2017;34:359-65. doi: 10.1007/s40266-017-0445-y.

27.    Shah SS, Naqvi BS, Fatima M, Khaliq A, Sheikh AL, Baqar M. Quality of drug stores: Storage practices & Regulatory compliance in Karachi, Pakistan. Pak J Med Sci 2016;32:1071-6. doi: 10.12669/pjms.325.9705.

28.    Abuga K, Ongarora D, Karumbi J, Olulo M, Minnaard W, Kibwage I. Sub-Standard Pharmaceutical Services in Private Healthcare Facilities Serving Low-Income Settlements in Nairobi County, Kenya. Pharmacy 2019;7:167. doi: 10.3390/pharmacy7040167.

29.    UAE Ministry of Economy, International Monetary Fund. United Arab Emirates: Statistical Appendix. [Online] 2006 [Cited 2015 December 15]. Available from URL: https://www.imf.org/external/pubs/ ft/scr/2006/ cr06256.pdf

30.    Gualano MR, Bert F, Passi S, Stillo M, Galis V, Manzoli L, et al. Use of self-medication among adolescents: a systematic review and meta-analysis. Eur J Public Health 2015;25:444-50. doi: 10.1093/eurpub/ cku207.

31.    Omolase CO, Adeleke OE, Afolabi AO, Afolabi OT. Self medication amongst general outpatients in a nigerian community hospital. Ann Ib Postgrad Med 2007;5:64-7. doi: 10.4314/aipm.v5i2.64032.

32.    Health for the whole person: The complete guide to holistic medicine, 1st ed. In: Hastings AC, Fadiman J, Gordon JS, eds. London, United Kingdom: Routledge & CRC Press, 2019; pp 548.

33.    Kuhn E, Kanuri N, Hoffman JE, Garvert DW, Ruzek JI, Taylor CB. A randomized controlled trial of a smartphone app for posttraumatic stress disorder symptoms. J Consult Clin Psychol 2017;85:267-73. doi: 10.1037/ccp0000163.

34.    Phalke VD, Phalke DB, Durgawale PM. Self-medication practices in rural Maharashtra. Indian J Community Med 2006;31:34-5. DOI: 10.4103/0970-0218.54933

35.    Lancet S. Factors resposible for self-medication. [Online] 2010 [Cited 2018 August 08]. Available from URL: http://www.thelancetstudent. com

36.    Aljadhey H, Assiri GA, Mahmoud MA, Al-Aqeel S, Murray M. Self-medication in Central Saudi Arabia. Community pharmacy consumers' perspectives. Saudi Med J 2015;36:328-34. doi: 10.15537/ smj.2015.3.10523.

37.    Levy SB. Balancing the drug-resistance equation. Trends Microbiol 1994;2:341-2.

38.    Cornaglia G. Fighting infections due to multidrug-resistant Gram-positive pathogens. Clin Microbiol Infect 2009;15:209-11. doi: 10.1111/j.1469-0691.2009.02737.x.

39.    Tan TT. "Future" threat of gram-negative resistance in Singapore. Ann Acad Med Singap 2008;37:884-90.

40.    Baiden F, Owusu-Agyei S, Webster J, Chandramohan D. The need for new antibiotics. Lancet 2010;375:637-8. doi: 10.1016/S0140-6736 (10)60265-6.

41.    Richter MF, Hergenrother PJ. The challenge of converting Gram-positive-only compounds into broad-spectrum antibiotics. Ann N Y Acad Sci 2019;1435:18-38. doi: 10.1111/nyas.13598.

42.    Tacconelli E, Carrara E, Savoldi A, Harbarth S, Mendelson M, Monnet DL, et al. Discovery, research, and development of new antibiotics: the WHO priority list of antibiotic-resistant bacteria and tuberculosis. Lancet Infect Dis 2018;18:318-27. doi: 10.1016/S1473-3099(17)30753-3.

43.    Gowri S, Mehta D, Kannan S. Antibiotic use in dentistry: A cross-sectional survey from a developing country. J Orofac Sci 2015;7:90-4. DOI: 10.4103/0975-8844.164310

44.    Nathan C, Cars O. Antibiotic resistance--problems, progress, and prospects. N Engl J Med 2014;371:1761-3. doi: 10.1056/NEJMp 1408040.

45.    Zhu X, Pan H, Yang Z, Cui B, Zhang D, Ba-Thein W. Self-medication practices with antibiotics among Chinese university students. Public Health 2016;130:78-83. doi: 10.1016/j.puhe.2015.04.005.

46.    Haddad Kashani H, Schmelcher M, Sabzalipoor H, Seyed Hosseini E, Moniri R. Recombinant Endolysins as Potential Therapeutics against Antibiotic-Resistant Staphylococcus aureus: Current Status of Research and Novel Delivery Strategies. Clin Microbiol Rev 2017;31:e00071-17. doi: 10.1128/CMR.00071-17.

47.    Spellberg B, Gilbert DN. The future of antibiotics and resistance: a tribute to a career of leadership by John Bartlett. Clin Infect Dis 2014;59(Suppl 2):s71-5. doi: 10.1093/cid/ciu392.

48.    Liu B, Pop M. ARDB--Antibiotic Resistance Genes Database. Nucleic Acids Res 2009;37(Suppl 1):443-7. doi: 10.1093/nar/gkn656.

49.    Rakofsky JJ, Dunlop BW. Nothing to sneeze at: Upper respiratory infections and mood disorders. Curr Psychiatr 2019;18:29-34.

50.    Richman PB, Garra G, Eskin B, Nashed AH, Cody R. Oral antibiotic use without consulting a physician: a survey of ED patients. Am J Emerg Med 2001;19:57-60. doi: 10.1053/ajem.2001.20035.

51.    Barker A, Verhoeven K, Ahsan M, Alam S, Sharma P, Sengupta S, et al. ID: 25: Social determinants of patient antibiotic misuse in Haryana, India. J Investig Med 2016;64:935. Doi: 10.1136/jim-2016-000120.49

52.    Feller E. Why do doctors overprescribe antibiotics? R I Med J 2019;102:9-10.

53.    US Department of Health and Human Services, Centers for Disease Control and Prevention (CDC). Antibiotic resistance threats in the United States, 2013. Atlanta, Georgia: CDC Press; 2013.

54.    Smith RA, MacGeorge EL, Hackman NM, M'ikanatha NM. Campaign Preparation for Complex Initiatives: A Person-Centered Approach to Audience Segmentation of Parents' Antibiotic Stewardship. Health Commun 2018;33:1539-48. doi: 10.1080/10410236.2017.1384345.

55.    Laxminarayan R, Duse A, Wattal C, Zaidi AK, Wertheim HF, Sumpradit N, et al. Antibiotic resistance-the need for global solutions. Lancet Infect Dis 2013;13:1057-98. doi: 10.1016/S1473-3099(13)70318-9.

56.    Antibiotic resistance. News release. Dawn News. [Online] 2016 [Cited 2018 August 22]. Available from URL: https://www.dawn.com/ news/1296345

57.    McCullough AR, Parekh S, Rathbone J, Del Mar CB, Hoffmann TC. A systematic review of the public's knowledge and beliefs about antibiotic resistance-authors' response. J Antimicrob Chemother 2016;71:e2366. doi: 10.1093/jac/dkw163.

58.    Littmann J, Buyx A, Cars O. Antibiotic resistance: An ethical challenge. Int J Antimicrob Agents 2015;46:359-61. doi: 10.1016/j.ijantimicag.2015.06.010.

59.    Ventola CL. The antibiotic resistance crisis: part 1: causes and threats. P T 2015;40:277-83.

60.    Geissler PW, Nokes K, Prince RJ, Odhiambo RA, Aagaard-Hansen J, Ouma JH. Children and medicines: self-treatment of common illnesses among Luo schoolchildren in western Kenya. Soc Sci Med 2000;50:1771-83. doi: 10.1016/s0277-9536(99)00428-1.

61.    Baral K, Dahal M, Shrestha S, Adhikari A. Self-medication: Prevalence among Undergraduates in Kathmandu Valley. J Adv Med Pharm Sci 2019;21:1-13. DOI: 10.9734/JAMPS/2019/v21i130122

62.    Chauhan RC, Manikandan, Purty AJ, Samuel A, Singh Z. Determinants of health care seeking behavior among rural population of a coastal area in South India. Int J Sci Rep 2015;1:118-22. DOI: 10.18203/issn.2454-2156.IntJSciRep20150218

63.    ABIMIP. Brazilian Association of the Non-Prescription Drug Industry. [Online] 2011 [Cited 2018 August 12]. Available from URL: http://www.abimip.org.br/uploads/material_de_apoio/1296056417_792.pdf

64.    Hanif A, Ashar SM, Rabnawaz R, Yasmeen S. Self-medication of Antibiotics among the Students of Hamdard University, Pakistan. J Public Health Dev Ctries 2016;2:145-8.

65.    Basharat R. Govt spends less GDP on Health: Survey. News release. The Nation. [Online] 2017 [Cited 2018 August 05]. Available from URL: http://nation.com.pk/26-May-2017/govt-spends-less-gdp-on-health-survey#

66.    Anwar M, Green JA, Norris P, Bukhari NI. Self-medication, home remedies, and spiritual healing: common responses to everydaysymptoms in Pakistan. Health Psychol Behav Med 2015;3:281-95. DOI: 10.1080/21642850.2015.1088387

67.    Beyene A, Getachew E, Doboch A, Poulos E, Abdurahman K, Alebachew M. Knowledge, Attitude and Practice of Self Medication among Pharmacy Students of Rift Valley University, Abichu Campus, Addis Ababa, Ethiopia. J Health Med Informat 2017;8:e269. doi: 10.4172/2157-7420.1000269

68.    World Health Organization. General Information WHO Drug Information. [Online] 2000 [Cited 2018 August 08]. Available from URL: https://apps.who.int/medicinedocs/es/d/Jh1462e/7.12.html

69.    Rather IA, Kim BC, Bajpai VK, Park YH. Self-medication and antibiotic resistance: Crisis, current challenges, and prevention. Saudi J Biol Sci 2017;24:808-12. doi: 10.1016/j.sjbs.2017.01.004.

70.    Park JY, Wu LT. Prevalence, reasons, perceived effects, and correlates of medical marijuana use: A review. Drug Alcohol Depend 2017;177:1-13. doi: 10.1016/j.drugalcdep.2017.03.009.

71.    Braithwaite I, Newton-Howes G, Oldfield K, Semprini A. Cannabis-based medicinal products and the role of the doctor: should we be cautious or cautiously optimistic? N Z Med J 2019;132:82-8.

72.    Yadav S, Rawal G. Self-medication practice in low income countries. Int J Pharmaceut Chem Anal 2015;2:139-42.

73.    Azami-Aghdash S, Mohseni M, Etemadi M, Royani S, Moosavi A, Nakhaee M. Prevalence and Cause of Self-Medication in Iran: A Systematic Review and Meta-Analysis Article. Iran J Public Health 2015;44:1580-93.

74.    Sanii Y, Torkamandi H, Gholami K, Hadavand N, Javadi M. Role of pharmacist counseling in pharmacotherapy quality improvement. J Res Pharm Pract 2016;5:132-7. doi: 10.4103/2279-042X.179580.

75.    Ramay BM, Lambour P, Cerón A. Comparing antibiotic self-medication in two socio-economic groups in Guatemala City: a descriptive cross-sectional study. BMC Pharmacol Toxicol 2015;16:11. doi: 10.1186/s40360-015-0011-3.

76.    Gyawali S, Shankar PR, Poudel PP, Saha A. Knowledge, Attitude and Practice of Self-Medication Among Basic Science Undergraduate Medical Students in a Medical School in Western Nepal. J Clin Diagn Res 2015;9:17-22. doi: 10.7860/JCDR/2015/16553.6988.