Misconceptions About Antibiotics, and Why They Persist

Among scientists and medical professionals, the proper use of antibiotics is well established. Antibiotics are powerful drugs that are used to treat bacterial infections. Their discovery and widespread implementation in the 1940s has revolutionized medicine and saved countless lives. Prescription of antibiotics is very common. Despite antibiotics being ubiquitous in hospitals, pharmacies, and doctors’ offices, general public knowledge of the proper usage of them is alarmingly low across the world. Improper use of antibiotics is both common and dangerous. Behaviors of patients and consumers can contribute to a problem that is growing globally, and that is drug resistance in bacteria and other microbes.

If bacteria are exposed to a drug, like an antibiotic, they are killed, or at least stopped from reproducing. Bacteria, however, evolve very quickly. Over the course of a treatment, some bacteria could evolve to be more resistant to the drug- that is, more difficult to kill. This is accounted for when courses of antibiotics are prescribed, and bacteria evolving resistance happens in relatively few bacterial cells when looking at the scope of the whole infection. Usually, the course of antibiotics is enough to kill off even those most stubborn bacteria and avoid creating an infection that will be resistant to the drug altogether. That being said, it is recommended to take caution when prescribing antibiotics, as unnecessary use of them can lead to more resistant, and thus more dangerous, bacterial infections. So can improper use of antibiotics, like taking them without a prescription, demanding them from doctors when they may not be needed, and not finishing the entire prescribed course of drugs.

Because patients misusing antibiotics can be such a threat to public health, it is necessary to understand the source of the public’s misunderstandings. If we can understand why the public is doing these things, and why they have misconceptions about antibiotic use, we can more effectively combat antibiotic resistance and the dangers it poses.

Studies show that people everywhere on Earth, of all income levels, self-medicate with antibiotics, without the guidance of a doctor or pharmacist (Mallah). The frequency of self-medication depends on the country, ranging from 3.1% in European countries to 82% in Qatar (Sun). Self-medication leads to a variety of problems. The general global public does not have a good understanding of what antibiotics are used to treat. It is common across the world for people to seek out and take antibiotics for illnesses that are not bacterial infections, or even to take them as painkillers (Sun, Antwi). This is not good for antibiotic resistance because it means exposing the body, and the bacteria that reside there naturally, to antibiotics unnecessarily, which can generally be seen as a risky move.

Another risky behavior when it comes to antibiotics is not finishing the prescribed course, which can cause some more difficult-to-kill cells to reproduce and become a more dangerous infection. While this behavior is very dangerous, and could put one at risk in a more immediate way, it is very common. A narrative literature review found that patients rarely complete the full prescribed course of drugs (Antwi). This behavior leads to other risky behaviors, like keeping antibiotics in the home or unnecessarily seeking out antibiotics in the future (Sun, Antwi).

To understand how to combat self-medication, risky behaviors, and misinformation surrounding antibiotics, it is necessary to understand what is driving people to do these things. One important note is that in many countries, over-the-counter (OTC) antibiotics are available. The World Health Organization in Europe found that one third of people who take antibiotics do so without a prescription (WHO). Studies have urged policymakers to crack down on regulations allowing OTC antibiotics (Nafisah). The widespread accessibility of antibiotics in many places across the world has contributed to antibiotic overconsumption, and thus antibiotic resistance (Nafisah). Non-prescription antibiotics are abundant across the world. A study on them found that “The overall pooled proportion of non-prescription supply of antibiotics was 62%” worldwide (Auta). It is simply not the global norm that antibiotics require a prescription. This one reason why behaviors like self-medication and keeping antibiotics in the home vary between countries. They are more difficult to do in places where antibiotics are more strictly regulated. Promisingly, while research on the subject is scarce, it seems that some intervention strategies to enforce prescription-only access to antibiotics could be effective (Jacobs). If robust enforcement and education strategies are implemented in these regions, consumption of and resistance to antibiotics will hopefully decrease as well (Nafisah, Seppala).

Patients commonly demand antibiotics from their doctors when they or their children are sick (Antwi, Sun). It is easy to understand why this is so. People take antibiotics when they are properly prescribed, and then they feel better. When they get sick, they want to feel better that quickly again, so they demand antibiotics. And unfortunately, most of the time, doctors oblige without further discussion or running diagnostic tests (Antwi). This is more likely to happen in less economically developed regions, but does happen in higher income countries as well (Sun). Doctors acquiescing to their patients’ wishes for drug prescriptions is an alarming trend. General practitioners (GPs) need to be more firm with these patients and be patient in explaining why antibiotics aren’t always the answer. It has been found that having a satisfying experience with a GP when sick will decrease the likelihood of a patient demanding antibiotics for treatment (Sun). This means that much of the intervention for this problem must be done on an individual level, between doctor and patient.

One big reason people self-medicate with antibiotics is a simple lack of understanding. As stated previously, many people don’t understand antibiotics well. Higher combined knowledge about antibiotics leads to better antibiotic use behaviors (Sun). The Antwi narrative literature review also notes a “superficiality” of knowledge possessed by most of the public (Antwi). Because so many people see antibiotics as a powerful drug that can be used to treat any infection, or as painkillers, they self-medicate if they get the opportunity. Keeping antibiotics in the home is also a big risk factor for self-medication. People across the globe routinely keep antibiotics in their homes, ranging from 6.5% in China to 80.5% in Pakistan (Sun).

Several studies have investigated the impact of knowledge about antibiotic resistance on antibiotic use. The Sun literature review claims that even when people are aware of antibiotic resistance, and agree that the issue is serious, they are no more likely to use antibiotics properly than anybody else (Sun). This finding seems surprising, but knowledge about antibiotic resistance does not necessarily equate to knowledge about best practices. The two pieces of knowledge are both important, but they are distinct. Just because a person hears about antibiotic resistance does not mean they know how to prevent it. Often, information about the growing problem is presented in a way that is designed to cause panic. Maybe the idea behind this is to spur action, but really, it only turns it into a looming, shadowy monster that people do not know how to fight. It is more effective to include information about causes of antibiotic resistance, and how individuals’ actions can help lessen the severity of the problem. Communicating to the public that self-medication is dangerous, and that antibiotics can only be used to help certain types of infections, will be much more effective in preventing antibiotic resistance than preaching about how dangerous antibiotics are.

We know that knowledge about best antibiotic practices is not widespread. Though many people globally are aware that there is some issue happening with antibiotics, the knowledge held by the general public about antibiotic resistance is patchy at best. One study found that some people think the problem of antibiotic resistance is sensationalized in the media (Antwi). One finding stated that more than half of respondents did not agree that antibiotic resistance is a serious worldwide problem (Antwi). While people may notice that use of particular antibiotics ceases, they usually don’t know the reason for this, and hold a wide array of ideas on what the reason might be (Antwi). This goes to show that reporting on this issue often takes a tone of fear mongering rather than informing. Sensationalizing the issue does not only leave people with fear and a lack of knowledge about what to do, but it can cause some to disregard the problem altogether. If the public thinks that antibiotic resistance is something the media has latched onto to grab their attention, they will not change their behavior. Furthermore, they won’t tune in when scientists take the podium to try and explain what individuals can do to combat antibiotic resistance. Media attention to the issue has to shift to focus on solutions if there is any hope of helping the public understand and combat this growing problem.

Overall higher education does not mean that you are more likely to use antibiotics correctly (Antwi). Misuse carries across countries, education levels, and economic standings (Mallah, Sun, Antwi). Misinformation is deeply rooted in communities. Specific, clear information campaigns are necessary to change the behavior of the public. Barriers to healthcare are another major reason for self-medication. There are countless reasons why a person may not see a doctor and get the proper diagnosis and treatment for every illness. A fairly obvious, and very important, reason is financial limitations. Many people who self-medicate or buy OTC antibiotics, which are often improperly regulated and can be dangerous, do so because of a lack of financial resources. Some studies found that a high level of income leads to less self-medication (Antwi). One literature review analyzing how income level affects antibiotic misuse found that in lower income countries, wealthier individuals still had higher odds of non-adherence to antibiotic regulations than those with low income in upper middle wealth countries (Mallah). This could have to do with widespread antibiotic access being more common in lower and middle income countries (Jacobs). Poor people are also more likely to use cheap, OTC, and counterfeit antibiotics (Antwi). There are also other barriers to accessing medical care, like perceived long wait times or difficulty accessing transportation to get to a doctor or hospital (Sun). When they have a minor illness, many people don’t want to waste time at the doctor’s office, so they use the antibiotics that they may be keeping in their home or purchasing OTC (Antwi).

Social and cultural norms also contribute to the misuse of antibiotics. Workplace norms often involve not taking time off for minor illnesses (Sun). This can cause people to take whatever medication they have lying around, which is often antibiotics, due to the common occurrence of people not taking all of their prescribed course. This stigma around taking time off and “powering through” is detrimental not only to workers’ recovery, but to the antibiotic resistance problem. Similarly, in some places, like Saudi Arabia, infections are stigmatized and people often want to treat themselves without medical, and thus social, attention (Sun). Problems like these encourage people to use whatever they can access to feel better.

There is a lot that needs to change if people are to use antibiotics more effectively and safely. Understanding where misconceptions come from, and why people are misusing these drugs, is a vital first step. There are deeply rooted misunderstandings of these drugs in the public. To combat this misinformation, it is important to educate people, but also to remove the barriers that many people face when they get sick that cause them to self-medicate or hoard antibiotics. The problem must be addressed by the root causes.

Works Cited

Alsuwayt, B., Shiromwar, S. (2020). Understanding of the Antibiotic Misuse among the General Public of Rafha City of Saudi Arabia. Journal of Pharmaceutical Research International, 32(21), 123-130. https://doi.org/10.9734/JPRI/2020/v32i2130762

Antwi, AN., Stewart, A., Crosbie, M. (2020). Fighting antibiotic resistance: a narrative review of public knowledge, attitudes, and perceptions of antibiotics use. Perspectives in Public Health, 140(6), 338-350. https://doi.org/10.1177/1757913920921209

Auta, A., Hadi, M.A., Oga, E., Adewuyi, E.O., Abdu-Aguye, S.M., Adeloye, D., Strickland-Hodge, B., Morgan, D.J. (2018). Global access to antibiotics without prescription in community pharmacies: A systematic review and meta-analysis. J Infect, 78(1), 8-18. https://doii.org/10.1016/j.jinf.2018.07.001

Jacobs, T., Robertson, J., van dem Ham, H., Iwamoto, Kl, Pederson, H., Mantel-Teeuwisse A. (2019). Assessing the impact of law enforcement to reduce over-the-counter (OTC) sales of antibiotics in low- and middle-income countries; a systematic literature review. BMC Health Services Research, 19, 536. https://doi.org/10.1186/s12913-019-4359-8

Mallah, N., Orsini, N., Figueiras, A., Takkouche, B. (2022). Income level and antibiotic misuse: a systematic review and dose-response meta-analysis. The European Journal of Health Economics, 23, 1015-1035. https://doi.org/10.1007/s10198-021-01416-8

Nafisah, S., Nafesa, S., Alamery, A., Alhumaid, M., AlMuhaidib, H., Al-Eidan, F. (2017). Over-the-counter antibiotics in Saudi Arabia, an urgent call for policy makers. Journal of Infection and Public Health, 10(5), 522-526. https://doi.org/10.1016/j.jiph.2016.09.016.

Seppala, H., Klaukka, T., Vuopio-Varkila, J., Muotiala, A., Helenius, H., Lager, K., Huovinen, P., Finnish Study Group for Antimicrobial Resistance. (1997). The Effect of Changes in the Consumption of Macrolide Antibiotics on Erythromycin Resistance in Group A Streptococci in Finland. The New England Journal of Medicine, 337, 441-446. https://doi.org/10.1056/NEJM199708143370701

Sun, R., Yau, T., Zhou, X., Harbarth, S., Lin, L. (2021). Non-biomedical factors affecting antibiotic use in the community: a mixed-methods systematic review and meta-analysis. Clinical Microbiology and Infection, 28(3), 345-354. https://doi.org/10.1016/j.cmi.2021.10.017

World Health Organization. (2022). 1 in 3 use antibiotics without prescription, WHO/Europe’s study shows. WHO. https://www.who.int/europe/news/item/21-11-2022-1-in-3-use-antibiotics-without-prescription--who-europe-s-study-shows