PATTERN OF SELF-MEDICATION WITH ANTIBIOTICS IN DENPASAR CITY, INDONESIA.

(1)

PATTERN OF SELF-MEDICATION WITH ANTIBIOTICS

IN DENPASAR CITY, INDONESIA

Jesika Ginotodihardjo1_{, I Gusti Ayu Artini}2

1_{Student of Faculty of Medicine, Udayana University, Bali, Indonesia}

2_{Departement of Pharmacology, Faculty of Medicine, Udayana University, Bali, Indonesia}

Abstract

Introduction: Self-medication with antibiotics that commonly related to misperception and lack of knowledge make antibiotic resistance become hard to control. This study aimed to investigate the prevalence of self-medication with antibiotic as well as knowledge regarding antibiotic usage in Denpasar City, Indonesia. Methods: This cross sectional population based survey directly interviewed respondents using structured questionnaire in Bahasa. A hundred respondents were selected using non probability-convenience sampling method in November-December 2013. The data were analyzed descriptively, and then the proportion data were analyzed using Chi Square. Results:

Forty three percent of respondents did self-medication with antibiotic, and simplicity (43%) is the most popular reason, beside feel confident, cost saving, inaccessibility from health care, time saving, and recommended by others. Pharmacists were the most common source of drug (91%). Gender was found to be statistically significant with p<0.05, whereas age and education level were not significant (p>0.05). Conclusions:

The prevalence of self-medication with antibiotics in this study is quite high, but it needs further investigation to generalize this result to Denpasar population.

Keywords: Antibiotics, Resistance, Self-medication

Abstrak

Pendahuluan: Pengobatan mandiri menggunakan antibiotik yang pada umumnya berkaitan dengan persepsi yang salah dan kurangnya pengetahuan menyebabkan masalah resistensi antibiotik menjadi sulit dikendalikan. Studi ini bertujuan untuk mengetahui prevalensi pengobatan mandiri menggunakan antibiotik dan pengetahuan masyarakat mengenai penggunaan antibiotik di Kota Denpasar, Indonesia. Metode:

Penelitian ini menggunakan metode cross sectional. Responden diwawancara secara langsung menggunakan kuisioner dalam bahasa Indonesia. Seratus responden dipilih menggunakan metode pengambilan sampel non probabilitas-kenyamanan pada bulan November-Desember 2013. Data yang terkumpul dianalis secara deskriptif, dan data proporsi dianalisis menggunakan Chi Square. Hasil: Empat puluh tiga persen dari responden pernah melakukan pengobatan mandiri dengan antibiotik, dan praktis (43%) menjadi alasan terbanyak disamping merasa paham, hemat biaya, kesulitan mengakses layanan kesehatan, hemat waktu, dan direkomendasi oleh oranglain. Apotek menjadi sumber obat-obatan paling umum (91%). Jenis kelamin menunjukkan signifikansi secara statistik dengan p<0.05, sedangkan usia dan tingkat pendidikan tidak signifikan (p>0.05). Kesimpulan: Prevalensi pengobatan mandiri dengan antibiotik pada studi ini cukup tinggi, namun dibutuhkan penelitian lebih lanjut untuk dapat menggambarkan penduduk Denpasar secara umum.

(2)

1

PATTERN OF SELF-MEDICATION WITH ANTIBIOTICS

IN DENPASAR CITY, INDONESIA

Jesika Ginotodihardjo1, I Gusti Ayu Artini2 1

Student of Faculty of Medicine, Udayana University, Bali, Indonesia 2

Departement of Pharmacology, Faculty of Medicine, Udayana University, Bali, Indonesia

Abstract

Abstrak

(3)

2 Introduction

The antibiotic resistance has already

become a global problem and therefore

WHO has stated “Antibiotic

Resistance” as the topic in World Health Day on April 7th, 2011. WHO

defines the appropriate use of antibiotic

as cost effective use which can

maximizes clinical therapeutic effect

while minimizing both drug related

toxicity and the development of

antibiotic resistance.1

Many researches have been conducted

to identify the prevalence of antibiotic

resistance; one of them is

penicilin-non-susceptible Streptococcus pneumoniae

(PNSP) in Southeast Asian.

S.pneumoniae as the major pathogen of

pneumonia, meningitis, and otitis media

in children and adult, had been altered

to be penicillin resistance more than

40% PNSP in Singapore (2000), and

21% in Jakarta (1996).2

Many factors contribute to

inappropriate use of antibiotics that

subsequently lead to resistance; one of

them is a patient-related factor

including self-medication and poor

adherence to dosage regiment.1

Self-medication with antibiotics (SMA) that

commonly related to misperception and

lack of knowledge make this resistance

become hard to control. The habit of

community to use antibiotic

inappropriately makes this topic

become interesting to be explored

further. This study aimed to investigate

the prevalence of SMA as well as people’s knowledge regarding their antibiotic usage.

Methods

This descriptive cross sectional study

was conducted in Denpasar City on

November until December 2013 to

assess self-medication with antibiotic as

well as respondents’ knowledge about

antibiotic. The respondents were

selected using non

probability-convenient sampling. Respondents

included in this study were non-health

care provider, age over 17 years old,

lived at Denpasar area, and had history of antibiotic usage. Respondents’ habit and knowledge related to antibiotic

were directly interviewed using

structured questionnaire in Bahasa. The

questionnaire was pre-tested to a

number of respondents, and resulted in

some revisions.

There were 14 questions related to last

antibiotic usage, conditions of usage,

(4)

3

antibiotic, and respondents’ knowledge including antibiotic function and target,

antibiotic usage immediately after fever,

and antibiotic resistance. Demographic

information such as date of birth,

gender, address, last education

achievement, and job were also

recorded.

The collected data were stored and

analyzed descriptively. Proportion data

were analyzed using Chi Square.

Results

Demographic characteristic

Data from 100 respondents who have

past history of using antibiotics was

successfully collected. Respondents’

age ranged from 18 to 62 years old.

Most respondents were female and

already passed the senior high school.

The complete demographic data were

presented in Table 1.

There was no significant difference

(p>0.05) in self-medication pattern

between younger respondents (<33

years old) with the older ones (≥33

years old), and also between lower

education level (elementary, junior high

school) with the higher (senior high

school and collage). Statistically

significant data was found in gender

with p<0.05.

Pattern of antibiotic usage

Almost half of respondents were found

to do self-medication for their last

antibiotic usage with various reasons.

As shown in Table 2, most of

respondents who did SMA, obtained

antibiotic from pharmacy, and the rest

got from remaining drugs of past

treatment. The types of antibiotic used

by respondents were presented in Table

3.

Knowledge of antibiotic

Some figures were presented below

regarding respondents’ knowledge

about antibiotic usage. Figure 1 shows

the respondents’ knowledge about

antibiotic function. Most of respondents

agreed that antibiotic was used to

eradicate the infection. The target of

antibiotic also was recorded and

presented in Figure 2.

Knowledge about antibiotic resistance

and immediate antibiotic usage in fever

are presented in Figure 3. Both SMA

and non-SMA respondents stated that

they have already known that

inappropriate use of antibiotic would

lead to bacterial resistance. More than

half of respondents agreed not to use

antibiotic immediately after getting

(5)

4

Table 1. Demographic characteristics of respondents

Demographic characteristics SMA

n(%)

Non SMA n(%) Gender

Female 15 (33) 38 (70)

Male 31 (67) 16 (30)

Age in years

< 20 3 (7) 5 (9)

20 – 29 26 (56) 24 (44)

30 – 39 8 (17) 16 (30)

40 – 49 6 (13) 5 (9)

50 – 59 3 (7) 3 (6)

≥ 60 0 (0) 1 (2)

Highest education achievement

Elementary school 2 (4) 5 (9)

Junior high school 3 (7) 5 (9)

Senior high school 30 (65) 36 (67)

Collage 11 (24) 8 (15)

Table 2. Pattern of SMA in respondents

Pattern of SMA n (%)

Reasons

Simplicity 20 (43)

Feel confident 12 (26)

Cost saving 9 (20)

Inaccessibility from health care 3 (7)

Time saving 1 (2)

Recommended by others 1 (2)

Source of antibiotics

Last medication 4 (7)

Pharmacy 42 (91)

Table 3. Type of antibiotic, which were used in SMA

Types of Antibiotic n (%)

Amoxicillin 60 (60)

Unknown 36 (36)

Ciprofloxacin 2 (2)

Cefadroxil 1 (1)

(6)

5

Figure 1. Knowledge about antibiotic function among respondents

Figure 2. Knowledge about antibiotic target among respondents

Figure 3. Knowledge about resistance and immediate antibiotic usage in fever

Discussion

Almost half of respondents did

self-medication with antibiotics, which most

of them bought it in pharmacy without

doctor’s prescription or prior

consultation. Unfortunately, this habit

was not supported with appropriate

knowledge.

0 20 40 60

SMA non SMA

Percentage of respondents (%)

Ant

ibi

o

tic

fun

ct

io

ns

others

pain relieve

increase immunity

decrease fever

eradicate infection

0 20 40 60

SMA non SMA

Ant

ibi

o

tic

ta

rg

et

both

viral

bacteria

0 20 40 60 80 100 120

antibiotic usage in fever (SMA) antibiotic usage in fever (non SMA) Inappropriate use of antibiotic lead to

resistency (SMA)

Inappropriate use of antibiotic lead to resistency (non SMA)

it

em

s

o

f

k

no

w

ledg

e

Yes

(7)

6

Many studies have been done to

evaluate SMA pattern in Indonesia and

also in other countries, like China and

Sudan.3,4,5 Poverty, lack of information,

and poor regulation that related to drug

distribution may contribute to self-

medication with antibiotics.3 Female,

older age, and having higher education

were also stated as risk factors.4,5

Actually, antibiotic in Indonesia is

categorized as “obat keras” which

means it could not be accessed easily

without doctor’s prescription.3,6,7 The

commonly used antibiotics like

amoxicillin in developing countries are

10- to 30-folds cheaper than that in the

developed countries.8,9 That condition

makes antibiotics become more

reachable.

Respondents’ previous experiences regarding similar illness increase their

confident to do self-medication, and

start to ignore the role of doctors.7

Inappropriate use of antibiotic for

viral-related illness eradication especially for

common cold, which is a self limiting

disease, contribute in antibiotic

resistance related to self-medication. 6,10-14

Adequate information, expert

explanation, and better regulation in

drug distribution should be done to

prevent further misperception and

inappropriate self-medication especially

with antibiotics.

However, this study has some

limitations, including inadequate

number of respondents and the

sampling technique. These would limit

the generalization of the study results to

Denpasar population. The information

given by respondents might potentially

result in bias. Further studies with larger

number of respondents are suggested to

determine the prevalence and factors

that potentially affect self-medication

with antibiotic in Denpasar, especially

for rural area.

Conclusion

The prevalence of self-medication with

antibiotic is quite high in Denpasar.

Misperception and lack of knowledge

appear and result in inappropriate use of

antibiotic. Gender as one of

demographic characteristics is

statistically significant in this study.

Further education about antibiotic as

well as correction of drug regulation

should be done to prevent further

(8)

7 References

1. WHO. WHO Global Strategy for

Containment of Antimicrobial

Resistance. 2001. Available at:

http://whqlibdoc.who.int/hq/2001/W

HO_CDS_CSR_DRS_2001.2.pdf.

Cited in November,21 2013.

2. Lestari ES, Severin JA, Verbrugh

HA, Antimicrobial Resistance

Among Pathogenic Bacteria in

Southeast Asia. Southeast Asian

Journal of Tropical Medicine and

Public Health. 2012; 43(2):

385-423.

3. Widayati A, Suryawati S, Crespigny

C, Hiller JE. Self Medication with

Antibiotics in Yogyakarta City

Indonesia: A Cross Sectional

Population-based Survey. BMC

Research Notes. 2011; 4: 491.

4. Pan H, Cui B, Zhang D, Farrar J,

Law F, Thein WB. 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(7).

5. Awad A. Self-Medication with

Antibiotics and Antimalarials in the

Community of Khartoum State,

Sudan. Journal of Pharmacy

&Pharmaceutical Sciences. 2005;

8(2): 326-331.

6. Undang-Undang Obat Keras.

Direktorat Jendral Pelayanan

Kefarmasian dan Alat Kesehatan.

1949. Available at:

http://www.dikti.go.id/files/atur/seh

at/UU-419-1949OrdonansiObat

Keras.pdf. Cited in November,22

2013.

7. Shojania KG, McDonald KM,

Wachter RM, Owens DK. Closing

the Quality Gap: A Critical Analysis

of Quality Improvement Strategies:

Antibiotic Prescribing Behavior.

2006; 4(9): 45-48.

8. Abdulah R. Antibitoic Abuse in

Developing Countries.

Pharma-ceutical Regulatory Affairs. 2012;

1(2).

9. Hadi U, Duerink DO, Lestari ES,

Nagelkerke NJ, Werter S, Keuter M,

Suswandojo E, Rahardjo E, Broek

P, Gyssens IC. Survey of Antibiotic

Use of Individuals Visiting Public

Healthcare Facilities in Indonesia.

International Journal of Infectious

Diseases. 2008; 12: 622-629.

10.Widayati A, Suryawati S, Crespigny

C, Hiller JE. Knowledge and Beliefs

about Antibiotics among People in

(9)

8

Sectional Population-based Survey.

Antimicrobial Resistance and

Infection Control. 2012; 1:38.

11.Mohanna M. Self-Medication with Antibiotic in Children in Sana’a City, Yemen. Oman Medical

Journal. 2010; 25: 41-43.

12.Aditya S, Rattan A. Self-Medication

among Dental Undergraduate

Students with Antibiotics: Looking

beyond The Known. Asian Journal

of Pharmaceutical and Clinical

Research. 2013; 6(4).

13.Osemene KP, Lamikanra A. A

Study of The Prevalence of

Self-Medication Practice among

University Students in

South-western Nigeria. Tropical Journal of

Pharmaceutical Research. 2012; 11:

683-689.

14.Grigoryan L, Ruskamp FMH,

Burgerhof JGM, Mechtler R,

Deschepper R, Andrasevic AT,

Andrahati R, Monnet DL, Cunney

R, Matteo AD, Edelstein H,

Valinteliene R, Alkerwi A, Scicluna

EA, Grzesiowski P, Bara AC, Tesar

T, Cizman M, Campos J, Lundborg

CS, Birkin J. Self-Medication with

Anti-microbial Drugs in Europe.

Emerging Infectious Diseases.

(10)

1

PATTERN OF SELF-MEDICATION WITH ANTIBIOTICS

IN DENPASAR CITY, INDONESIA

Jesika Ginotodihardjo1, I Gusti Ayu Artini2 1

Student of Faculty of Medicine, Udayana University, Bali, Indonesia 2

Departement of Pharmacology, Faculty of Medicine, Udayana University, Bali, Indonesia

Abstract

Abstrak

(11)

2 Introduction

The antibiotic resistance has already

become a global problem and therefore

WHO has stated “Antibiotic

Resistance” as the topic in World Health Day on April 7th, 2011. WHO

defines the appropriate use of antibiotic

as cost effective use which can

maximizes clinical therapeutic effect

while minimizing both drug related

toxicity and the development of

antibiotic resistance.1

Many researches have been conducted

to identify the prevalence of antibiotic

resistance; one of them is

penicilin-non-susceptible Streptococcus pneumoniae

(PNSP) in Southeast Asian.

S.pneumoniae as the major pathogen of

pneumonia, meningitis, and otitis media

in children and adult, had been altered

to be penicillin resistance more than

40% PNSP in Singapore (2000), and

21% in Jakarta (1996).2

Many factors contribute to

inappropriate use of antibiotics that

subsequently lead to resistance; one of

them is a patient-related factor

including self-medication and poor

adherence to dosage regiment.1

Self-medication with antibiotics (SMA) that

commonly related to misperception and

lack of knowledge make this resistance

become hard to control. The habit of

community to use antibiotic

inappropriately makes this topic

become interesting to be explored

further. This study aimed to investigate

the prevalence of SMA as well as people’s knowledge regarding their antibiotic usage.

Methods

This descriptive cross sectional study

was conducted in Denpasar City on

November until December 2013 to

assess self-medication with antibiotic as

well as respondents’ knowledge about

antibiotic. The respondents were

selected using non

probability-convenient sampling. Respondents

included in this study were non-health

care provider, age over 17 years old,

lived at Denpasar area, and had history of antibiotic usage. Respondents’ habit and knowledge related to antibiotic

were directly interviewed using

structured questionnaire in Bahasa. The

questionnaire was pre-tested to a

number of respondents, and resulted in

some revisions.

There were 14 questions related to last

antibiotic usage, conditions of usage,

(12)

3

antibiotic, and respondents’ knowledge including antibiotic function and target,

antibiotic usage immediately after fever,

and antibiotic resistance. Demographic

information such as date of birth,

gender, address, last education

achievement, and job were also

recorded.

The collected data were stored and

analyzed descriptively. Proportion data

were analyzed using Chi Square.

Results

Demographic characteristic

Data from 100 respondents who have

past history of using antibiotics was

successfully collected. Respondents’

age ranged from 18 to 62 years old.

Most respondents were female and

already passed the senior high school.

The complete demographic data were

presented in Table 1.

There was no significant difference

(p>0.05) in self-medication pattern

between younger respondents (<33

years old) with the older ones (≥33

years old), and also between lower

education level (elementary, junior high

school) with the higher (senior high

school and collage). Statistically

significant data was found in gender

with p<0.05.

Pattern of antibiotic usage

Almost half of respondents were found

to do self-medication for their last

antibiotic usage with various reasons.

As shown in Table 2, most of

respondents who did SMA, obtained

antibiotic from pharmacy, and the rest

got from remaining drugs of past

treatment. The types of antibiotic used

by respondents were presented in Table

3.

Knowledge of antibiotic

Some figures were presented below

regarding respondents’ knowledge

about antibiotic usage. Figure 1 shows

the respondents’ knowledge about

antibiotic function. Most of respondents

agreed that antibiotic was used to

eradicate the infection. The target of

antibiotic also was recorded and

presented in Figure 2.

Knowledge about antibiotic resistance

and immediate antibiotic usage in fever

are presented in Figure 3. Both SMA

and non-SMA respondents stated that

they have already known that

inappropriate use of antibiotic would

lead to bacterial resistance. More than

half of respondents agreed not to use

antibiotic immediately after getting

(13)

4

Table 1. Demographic characteristics of respondents

Demographic characteristics SMA

n(%)

Non SMA n(%) Gender

Female 15 (33) 38 (70)

Male 31 (67) 16 (30)

Age in years

< 20 3 (7) 5 (9)

20 – 29 26 (56) 24 (44)

30 – 39 8 (17) 16 (30)

40 – 49 6 (13) 5 (9)

50 – 59 3 (7) 3 (6)

≥ 60 0 (0) 1 (2)

Highest education achievement

Elementary school 2 (4) 5 (9)

Junior high school 3 (7) 5 (9)

Senior high school 30 (65) 36 (67)

Collage 11 (24) 8 (15)

Table 2. Pattern of SMA in respondents

Pattern of SMA n (%)

Reasons

Simplicity 20 (43)

Feel confident 12 (26)

Cost saving 9 (20)

Inaccessibility from health care 3 (7)

Time saving 1 (2)

Recommended by others 1 (2)

Source of antibiotics

Last medication 4 (7)

Pharmacy 42 (91)

Table 3. Type of antibiotic, which were used in SMA

Types of Antibiotic n (%)

Amoxicillin 60 (60)

Unknown 36 (36)

Ciprofloxacin 2 (2)

Cefadroxil 1 (1)

(14)

5

Figure 1. Knowledge about antibiotic function among respondents

Figure 2. Knowledge about antibiotic target among respondents

Figure 3. Knowledge about resistance and immediate antibiotic usage in fever

Discussion

Almost half of respondents did

self-medication with antibiotics, which most

of them bought it in pharmacy without

doctor’s prescription or prior

consultation. Unfortunately, this habit

was not supported with appropriate

knowledge.

0 20 40 60

SMA non SMA

Ant

ibi

o

tic

fun

ct

io

ns

others

pain relieve

increase immunity

decrease fever

eradicate infection

0 20 40 60

SMA non SMA

Ant

ibi

o

tic

ta

rg

et

both

viral

bacteria

0 20 40 60 80 100 120

antibiotic usage in fever (SMA) antibiotic usage in fever (non SMA) Inappropriate use of antibiotic lead to

resistency (SMA)

Inappropriate use of antibiotic lead to resistency (non SMA)

it

em

s

o

f

k

no

w

ledg

e

Yes

(15)

6

Many studies have been done to

evaluate SMA pattern in Indonesia and

also in other countries, like China and

Sudan.3,4,5 Poverty, lack of information,

and poor regulation that related to drug

distribution may contribute to self-

medication with antibiotics.3 Female,

older age, and having higher education

were also stated as risk factors.4,5

Actually, antibiotic in Indonesia is

categorized as “obat keras” which

means it could not be accessed easily

without doctor’s prescription.3,6,7 The

commonly used antibiotics like

amoxicillin in developing countries are

10- to 30-folds cheaper than that in the

developed countries.8,9 That condition

makes antibiotics become more

reachable.

Respondents’ previous experiences regarding similar illness increase their

confident to do self-medication, and

start to ignore the role of doctors.7

Inappropriate use of antibiotic for

viral-related illness eradication especially for

common cold, which is a self limiting

disease, contribute in antibiotic

resistance related to self-medication. 6,10-14

Adequate information, expert

explanation, and better regulation in

drug distribution should be done to

prevent further misperception and

inappropriate self-medication especially

with antibiotics.

However, this study has some

limitations, including inadequate

number of respondents and the

sampling technique. These would limit

the generalization of the study results to

Denpasar population. The information

given by respondents might potentially

result in bias. Further studies with larger

number of respondents are suggested to

determine the prevalence and factors

that potentially affect self-medication

with antibiotic in Denpasar, especially

for rural area.

Conclusion

The prevalence of self-medication with

antibiotic is quite high in Denpasar.

Misperception and lack of knowledge

appear and result in inappropriate use of

antibiotic. Gender as one of

demographic characteristics is

statistically significant in this study.

Further education about antibiotic as

well as correction of drug regulation

should be done to prevent further

(16)

7 References

1. WHO. WHO Global Strategy for

Containment of Antimicrobial

Resistance. 2001. Available at:

http://whqlibdoc.who.int/hq/2001/W

HO_CDS_CSR_DRS_2001.2.pdf.

Cited in November,21 2013.

2. Lestari ES, Severin JA, Verbrugh

HA, Antimicrobial Resistance

Among Pathogenic Bacteria in

Southeast Asia. Southeast Asian

Journal of Tropical Medicine and

Public Health. 2012; 43(2):

385-423.

3. Widayati A, Suryawati S, Crespigny

C, Hiller JE. Self Medication with

Antibiotics in Yogyakarta City

Indonesia: A Cross Sectional

Population-based Survey. BMC

Research Notes. 2011; 4: 491.

4. Pan H, Cui B, Zhang D, Farrar J,

Law F, Thein WB. 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(7).

5. Awad A. Self-Medication with

Antibiotics and Antimalarials in the

Community of Khartoum State,

Sudan. Journal of Pharmacy

&Pharmaceutical Sciences. 2005;

8(2): 326-331.

6. Undang-Undang Obat Keras.

Direktorat Jendral Pelayanan

Kefarmasian dan Alat Kesehatan.

1949. Available at:

http://www.dikti.go.id/files/atur/seh

at/UU-419-1949OrdonansiObat

Keras.pdf. Cited in November,22

2013.

7. Shojania KG, McDonald KM,

Wachter RM, Owens DK. Closing

the Quality Gap: A Critical Analysis

of Quality Improvement Strategies:

Antibiotic Prescribing Behavior.

2006; 4(9): 45-48.

8. Abdulah R. Antibitoic Abuse in

Developing Countries.

Pharma-ceutical Regulatory Affairs. 2012;

1(2).

9. Hadi U, Duerink DO, Lestari ES,

Nagelkerke NJ, Werter S, Keuter M,

Suswandojo E, Rahardjo E, Broek

P, Gyssens IC. Survey of Antibiotic

Use of Individuals Visiting Public

Healthcare Facilities in Indonesia.

International Journal of Infectious

Diseases. 2008; 12: 622-629.

10.Widayati A, Suryawati S, Crespigny

C, Hiller JE. Knowledge and Beliefs

about Antibiotics among People in

(17)

8

Sectional Population-based Survey.

Antimicrobial Resistance and

Infection Control. 2012; 1:38.

11.Mohanna M. Self-Medication with Antibiotic in Children in Sana’a City, Yemen. Oman Medical

Journal. 2010; 25: 41-43.

12.Aditya S, Rattan A. Self-Medication

among Dental Undergraduate

Students with Antibiotics: Looking

beyond The Known. Asian Journal

of Pharmaceutical and Clinical

Research. 2013; 6(4).

13.Osemene KP, Lamikanra A. A

Study of The Prevalence of

Self-Medication Practice among

University Students in

South-western Nigeria. Tropical Journal of

Pharmaceutical Research. 2012; 11:

683-689.

14.Grigoryan L, Ruskamp FMH,

Burgerhof JGM, Mechtler R,

Deschepper R, Andrasevic AT,

Andrahati R, Monnet DL, Cunney

R, Matteo AD, Edelstein H,

Valinteliene R, Alkerwi A, Scicluna

EA, Grzesiowski P, Bara AC, Tesar

T, Cizman M, Campos J, Lundborg

CS, Birkin J. Self-Medication with

Anti-microbial Drugs in Europe.

Emerging Infectious Diseases.