scholarly journals Pharmacy Students’ Knowledge and Perceptions about Antimicrobial Stewardship

2019 ◽  
pp. 1-8 ◽  
Author(s):  
Nehad J Ahmed ◽  
Khalil Y Abujheisha ◽  
Mohamed F. Balaha
Keyword(s):  
Public Health ◽  
Saudi Arabia ◽  
Antibiotic Resistance ◽  
Antimicrobial Stewardship ◽  
Bacterial Resistance ◽  
Background Knowledge ◽  
Antibiotic Use ◽  
Pharmacy Students ◽  
Antimicrobial Use ◽  
Global Public Health

Introduction: Antibiotic resistance is considered one of the serious threats to global public health. Antimicrobial stewardship programs should be implemented by all hospitals to improve antimicrobial use. It is important that pharmacy students have a sound knowledge of antimicrobial stewardship. Objective: The aim of this study was to determine pharmacy students’ knowledge and perceptions about antimicrobial stewardship. Methodology: The study included a questionnaire that was used to assess the background knowledge of pharmacy students and their perceptions on antimicrobial stewardship. Results and Discussion: Out of 103 students who completed the survey, 25 students (24.27%) reported that they know what antimicrobial Stewardship is, and only 39 students were familiar with antimicrobial stewardship programs in Saudi Arabia. Most of the students (95.14%) reported that they need more antimicrobial stewardship training. Conclusion: Our results, therefore, recommend that pharmacy students should have more training on bacterial resistance, antibiotic use and antimicrobial stewardship.

scholarly journals Increasing Voluntary Public Health Reporting to the NHSN Antimicrobial Use Option

2020 ◽  
Vol 41 (S1) ◽  
pp. s296-s297
Author(s):  
Heather Dubendris ◽  
Amy Webb ◽  
Melinda Neuhauser ◽  
Arjun Srinivasan ◽  
Wendy Wise ◽  
...  
Keyword(s):  
Public Health ◽  
Antimicrobial Stewardship ◽  
Self Report ◽  
Antimicrobial Use ◽  
Health Departments ◽  
Public Health Reporting ◽  
Use Stage ◽  
Education And Development ◽  
Health Registry ◽  
Over Time

Background: The CDC NHSN launched the Antimicrobial Use Option in 2011. The Antimicrobial Use Option allows users to implement risk-adjusted antimicrobial use benchmarking within- and between- facilities using the standardized antimicrobial administration ratio (SAAR) and to evaluate use over time. The SAAR can be used for public health surveillance and to guide an organization’s stewardship or quality improvement efforts. Methods: Antimicrobial Use Option enrollment grew through partner engagement, targeted education, and development of data benchmarking. We analyze enrollment over time and discuss key drivers of participation. Results: Initial 2011 Antimicrobial Use Option enrollment efforts awarded grant Funding: to 4 health departments. These health departments partnered with hospitals, which encouraged vendors to build infrastructure for electronic antimicrobial use reporting. CDC supported vendors through outreach and education. In 2012, with CDC support, Veterans’ Affairs (VA) Informatics, Decision-Enhancement, and Analytic Sciences Center and partners began implementation of Antimicrobial Use Option reporting and validation of submitted data. These early efforts led to enrollment of 64 facilities by 2014 (Fig. 1). As awareness of the antimicrobial use option grew, we focused on facility engagement and development of benchmark metrics. A second round of grant Funding: in 2015 supported submission to the Antimicrobial Use Option from additional facilities by Funding: a vendor, a healthcare system, and an antimicrobial stewardship network. In 2015, CMS recognized the Antimicrobial Use Option as a choice for public health registry reporting under Meaningful Use Stage 3, resulting in an increase in participating hospitals. Antimicrobial Use Option enrollment increased in 2015 (n = 120), coinciding with national prioritization of antimicrobial stewardship. In 2016, the SAAR, was released in NHSN. We leveraged the SAAR to encourage participation from additional facilities and began quarterly calls to encourage continued participation from existing users. In 2016, the Department of Defense began submitting data to the Antimicrobial Use Option, resulting in 207 facilities enrolled in 2016, which grew to 616 in 2017. As of November 2019, 12 vendors self-report submission capabilities and 1,470 facilities, of ~6,800 active NHSN participants, are enrolled in the Antimicrobial Use Option. Two states have passed requirements regulating Antimicrobial Use Option reporting with Tennessee’s requirement going into effect in 2021. Conclusions: The Antimicrobial Use Option offers evidence that collaboration with partners, and leveraging of benchmarking metrics available to a national surveillance system can lead to increased voluntary participation in surveillance of high-priority public health data. Moving forward, we will continue expanding analytic capabilities and partner engagement.Funding: NoneDisclosures: None

scholarly journals Antimicrobial Stewardship: Development and Pilot of an Organisational Peer-to-Peer Review Tool to Improve Service Provision in Line with National Guidance

Antibiotics ◽  
2021 ◽  
Vol 10 (1) ◽  
pp. 44
Author(s):  
Olaolu Oloyede ◽  
Emma Cramp ◽  
Diane Ashiru-Oredope
Keyword(s):  
Public Health ◽  
Peer Review ◽  
Antimicrobial Stewardship ◽  
Service Provision ◽  
Good Practice ◽  
Survey Method ◽  
Global Public Health ◽  
Inappropriate Use ◽  
National Guidance ◽  
New Antibiotics

Antimicrobial resistance continues to be a considerable threat to global public health due to the persistent inappropriate use of antibiotics. Antimicrobial stewardship (AMS) programs are essential in reducing the growth and spread of antibiotic resistance, in an environment which lacks incentives for the development of new antibiotics. Over the years, a variety of resources have been developed to strengthen antimicrobial stewardship. However, the differences in resources available present a challenge for organisations/teams to establish the best resources to utilise for service provision. A peer review tool was formulated using four national documents on AMS and tested through three phases with feedback. A survey method was used to collect feedback on the validity, feasibility, and impact of the AMS peer review tool. Feedback received was positive from the earlier pilots. The tool was found to be useful at identifying areas of good practice and gaps in antimicrobial stewardship across various pilot sites. Feedback suggests the tool is useful for promoting improvements to AMS programs and highlights that the content and features of the tool are appropriate for evaluating stewardship.

scholarly journals 152. Applying A Difference-in-Difference Analysis to Assess Effect of Antimicrobial Stewardship Strategies on Changes in Antimicrobial Use

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S86-S86
Author(s):  
Ann F Chou ◽  
Yue Zhang ◽  
Makoto M Jones ◽  
Christopher J Graber ◽  
Matthew B Goetz ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Clinical Pharmacist ◽  
Antibiotic Use ◽  
Feedback Mechanism ◽  
Health Care Facilities ◽  
Antimicrobial Use ◽  
Time Points ◽  
The Difference ◽  
The Impact ◽  
Over Time

Abstract Background About 30–50% of inpatient antimicrobial therapy is sub-optimal. Health care facilities have utilized various antimicrobial stewardship (AS) strategies to optimize appropriate antimicrobial use, improve health outcomes, and promote patient safety. However, little evidence exists to assess relationships between AS strategies and antimicrobial use. This study examined the impact of changes in AS strategies on antimicrobial use over time. Methods This study used data from the Veterans Affairs (VA) Healthcare Analysis & Informatics Group (HAIG) AS survey, administered at 130 VA facilities in 2012 and 2015, and antimicrobial utilization from VA Corporate Data Warehouse. Four AS strategies were examined: having an AS team, feedback mechanism on antimicrobial use, infectious diseases (ID) attending physicians, and clinical pharmacist on wards. Change in AS strategies were computed by taking the difference in the presence of a given strategy in a facility between 2012–2015. The outcome was the difference between antimicrobial use per 1000 patient days in 2012–2013 and 2015–2016. Employing multiple regression analysis, changes in antimicrobial use was estimated as a function of changes in AS strategies, controlling for ID human resources in and organizational complexity. Results Of the 4 strategies, only change in availability of AS teams had an impact on antimicrobial use. Compared to facilities with no AS teams at both time points, antibiotic use decreased by 63.9 uses per 1000 patient days in facilities that did not have a AS team in 2012 but implemented one in 2015 (p=0.0183). Facilities that had an AS team at both time points decreased use by 62.2 per 1000 patient days (p=0.0324). Conclusion The findings showed that AS teams reduced inpatient antibiotic use over time. While changes in having feedback on antimicrobial use and clinical pharmacist on wards showed reduced antimicrobial use between 2012–2015, the differences were not statistically significant. These strategies may already be a part of a comprehensive AS program and employed by AS teams. In further development of stewardship programs within healthcare organizations, the association between AS teams and antibiotic use should inform program design and implementation. Disclosures All Authors: No reported disclosures

scholarly journals Perceptions of Antibiotic Use and Resistance: Are Antibiotics the Dentists’ Anxiolytics?

Antibiotics ◽  
2021 ◽  
Vol 10 (6) ◽  
pp. 735
Author(s):  
Julie Dormoy ◽  
Marc-Olivier Vuillemin ◽  
Silvia Rossi ◽  
Jean-Marc Boivin ◽  
Julie Guillet
Keyword(s):  
Public Health ◽  
Antibiotic Resistance ◽  
Qualitative Method ◽  
Oral Surgery ◽  
Antibiotic Use ◽  
Public Health Issue ◽  
Clinical Factors ◽  
Structured Interviews ◽  
Health Crisis ◽  
The Public

Background: Antibiotic resistance is a global health crisis. The aim of this study was to explore dentists’ perceptions of antibiotic resistance. Methods: A qualitative method was used. Seventeen dentists practising in the Nancy (Lorraine, France) region were surveyed. They were general practitioners or specialised in oral surgery, implantology, or periodontology. The practitioners took part in semi-structured interviews between September 2019 and July 2020. All of the interviews were transcribed in full and analysed thematically. Results: Four major themes have been selected: attitudes of the dentists in regard to the guidelines, clinical factors that influence prescriptions, non-clinical factors that influence prescriptions, and the perception of antibiotic resistance. The dentists stated that they were very concerned regarding the public health issue of antibiotic resistance. However, they often prescribe according to their own interests and habits rather than according to the relevant guidelines. Conclusions: Although dentists are generally well aware of antibiotic resistance, they often do not adequately appreciate the link between their prescribing habits and the phenomenon of antibiotic resistance. Regular updating of practitioners’ knowledge in this regard is necessary, but patients and the general public should also be made more aware of the issue.

scholarly journals Socio-economic disparities in the dispensation of antibiotics in Sweden 2016–2017: An intersectional analysis of individual heterogeneity and discriminatory accuracy

2021 ◽  
pp. 140349482098149
Author(s):  
Maria Wemrell ◽  
Cecilia Lenander ◽  
Kristofer Hansson ◽  
Raquel Vicente Perez ◽  
Katarina Hedin ◽  
...  
Keyword(s):  
Public Health ◽  
Antibiotic Use ◽  
Individual Heterogeneity ◽  
Global Public Health ◽  
Swedish Population ◽  
Medical Practitioners ◽  
Demographic Groups ◽  
Discriminatory Accuracy ◽  
Intersectional Analysis ◽  
Socio Economic Variables

Aims: Antimicrobial resistance presents an increasingly serious threat to global public health, which is directly related to how antibiotic medication is used in society. Actions aimed towards the optimised use of antibiotics should be implemented on equal terms and according to the needs of the population. Previous research results on differences in antibiotic use between socio-economic and demographic groups in Sweden are not entirely coherent, and have typically focused on the effects of singular socio-economic variables. Using an intersectional approach, this study provides a more precise analysis of how the dispensation of antibiotic medication was distributed across socio-economic and demographic groups in Sweden in 2016–2017. Methods: Using register data from a nationwide cohort and adopting an intersectional analysis of individual heterogeneity and discriminatory accuracy, we map the dispensation of antibiotics according to age, sex, country of birth and income. Results: While women and high-income earners had the highest antibiotic dispensation prevalence, no large differences in the dispensation of antibiotics were identified between socio-economic groups. Conclusions: Public-health interventions aiming to support the reduced and optimised use of antibiotics should be directed towards the whole Swedish population rather than towards specific groups. Correspondingly, an increased focus on socio-economic or demographic factors is not warranted in interventions aimed at improving antibiotic prescription patterns among medical practitioners.

scholarly journals Assessing Robustness of Antimicrobial Stewardship in Colorado Hospitals and Barriers to Improvement

2021 ◽  
Vol 1 (S1) ◽  
pp. s15-s15
Author(s):  
Daniel Dodson ◽  
Matthew Kronman ◽  
Sarah Parker ◽  
Christopher Czaja
Keyword(s):  
Public Health ◽  
Antimicrobial Stewardship ◽  
Pediatric Patients ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Defined Daily Dose ◽  
Health Departments ◽  
Web Based ◽  
Public Health Departments ◽  
Core Elements

Background: Adherence to core elements of antimicrobial stewardship programs (ASPs) is increasing nationally but the robustness of programs and inclusion of pediatrics is poorly understood. We describe the details of ASP in Colorado hospitals and identify steps by which academic centers and public health departments can assist community ASPs. Methods: We invited ASP leaders at the 102 acute-care hospitals (ACHs) and critical-access hospitals (CAHs) in Colorado to participate in a web-based survey regarding their ASPs. Questions related to adherence to Centers for Disease Control and Prevention (CDC) core elements, barriers to improvement, desired resources, and extension to pediatrics. Enrollment began in August 2020. Hospital types were compared using the Fisher exact test. Results: As of January 1, 2021, 31 hospitals (30% of targeted hospitals) completed the web-based survey including 19 ACH and 12 CAH. Hospitals were distributed across the state. Median number of beds was 52 (range, 11–680). Of the responding hospitals, 87% were adherent to all CDC core elements. However, if action was defined as prospective audit and feedback or prior authorization, tracking was defined as measuring antibiotic use in days of therapy (DOT) or defined daily dose (DDD) quarterly, and reporting was defined as providing unit- or provider-specific antibiotic use reports annually. Overall adherence fell to 35% including 81% for action, 58% for tracking, and 58% for reporting. CAHs were less likely to adhere to these strict criteria than ACHs (Figure 1). In the 27 hospitals (87% of hospitals) caring for pediatric patients, adherence to a strict action for at least 1 pediatric population was 59%. Reported barriers to improved ASP were available time and personnel, information technology support, perceived concerns about provider attitudes, and education gaps (Figure 2). CAHs were less likely to use the NHSN antibiotic use or resistance modules or have a data analyst than ACHs (Figure 3). Pediatric pharmacy expertise and guidelines were often not available in hospitals caring for pediatric patients. Desired ASP resources included assistance with data analysis, access to stewardship expertise and education, and treatment guidelines, including for pediatrics. Conclusions: Adherence to CDC core elements of an ASP was excellent but fell dramatically when stricter criteria were used and was worse in pediatric patients. Academic centers and public health departments can assist community hospitals by providing educational resources, assistance in analyzing data including using the NHSN ED: /AR modules, and ASP expertise and clinical care guidelines including those for pediatrics.Funding: NoDisclosures: None

scholarly journals Antimicrobial use in COVID-19 patients in the first phase of the SARS-CoV-2 pandemic: Rapid review and evidence synthesis

2021 ◽  
Author(s):  
Wenjuan Cong ◽  
Ak Narayan Poudel ◽  
Nour Alhusein ◽  
Hexing Wang ◽  
Guiqing Yao ◽  
...  
Keyword(s):  
Antibiotic Resistance ◽  
Critical Illness ◽  
Antimicrobial Resistance ◽  
Early Phase ◽  
Data Extraction ◽  
Antibiotic Use ◽  
Rapid Review ◽  
Antibiotic Prescribing ◽  
Antimicrobial Use ◽  
Secondary Infections

AbstractBackgroundAs the numbers of people with COVID-19 continue to increase globally, concerns have been raised regarding the widespread use of antibiotics for the treatment of COVID-19 patients and its consequences for antimicrobial resistance during the pandemic and beyond. The scale and determinants of antibiotic use in the early phase of the pandemic, and whether antibiotic prescribing is beneficial to treatment effectiveness in COVID-19 patients, are still unknown. Unwarranted treatment of this viral infection with antibiotics may exacerbate the problem of antibiotic resistance, while antibiotic resistance may render presumptive treatment of secondary infections in COVID-19 patients ineffective.MethodsThis rapid review was undertaken to identify studies reporting antimicrobial use in the treatment of hospitalised COVID-19 patients. The review was conducted to comply with PRISMA guidelines for Scoping Reviews (http://www.prisma-statement.org/Extensions/ScopingReviews) and the protocol was registered with the Open Science Framework (OSF): http://osf.io/vp6t5. The following databases: Web of Science, EMBASE, PubMed, CNKI & VIP were searched to identify the relevant studies from 1 Dec 2019 up to 15 June 2020; no limits were set on the language or the country where studies were conducted. The search terms used were: ((“Covid-19” or “SARS-CoV-2” or “Coronavirus disease 2019” or “severe acute respiratory syndrome coronavirus-2”) and ((“antibiotic prescribing” or “antibiotic use” or “antibiotic*”) or “antimicrobial *” or “antimicrobial therapy” or “antimicrobial resistance” or “antimicrobial stewardship”)). A total of 1216 records were identified through database searching and 118 clinical studies met the inclusion criteria and were taken into data extraction. A bespoke data extraction form was developed and validated through two independent, duplicate extraction of data from five Records. As all the included studies were descriptive in nature, we conducted descriptive synthesis of data and reported pooled estimates such as mean, percentage and frequency. We created a series of scenarios to capture the range of rationales for antibiotic prescribing presented in the included studies.ResultsOur results show that during the early phase of the pandemic, 8501 out of 10 329 COVID-19 patients (82·3%) were prescribed antibiotics; antibiotics were prescribed for COVID-19 patients regardless of reported severity, with a similar mean antibiotic prescribing rate between patients with severe or critical illness (75·4%) and patients with mild or moderate illness (75·1%). The top five frequently prescribed antibiotics for hospitalised COVID-19 patients were azithromycin (28·0 % of studies), ceftriaxone (17·8%), moxifloxacin (14·4%), meropenem (14·4%) and piperacillin/tazobactam (12·7%). The proportion of patients prescribed antibiotics without clinical justification was 51·5% vs 41·9 % for patients with mild or moderate illness and those with severe or critical illness respectively. Comparison of patients who were provided antibiotics with a clinical justification with those who were given antibiotics without clinical justification showed lower mortality rates (9·5% vs 13·1%), higher discharge rates (80·9% vs 69·3%) and shorter length of hospital of stay (9·3 days vs 12·2 days). Only 9·7% of patients in our included studies were reported to have secondary infections.ConclusionsAntibiotics were prescribed indiscriminately for hospitalised COVID-19 patients regardless of severity of illness during the early phase of the pandemic. COVID-19 related concerns and lack of knowledge drove a large proportion of antibiotic use without specific clinical justification. Although we are still in the midst of the pandemic, the goals of antimicrobial stewardship should remain unchanged for the treatment of COVID-19 patients.

scholarly journals First report of Klebsiella quasipneumoniae harboring blaKPC-2 in Saudi Arabia

2019 ◽  
Vol 8 (1) ◽  
Author(s):  
Sharif Hala ◽  
Chakkiath Paul Antony ◽  
Mohammed Alshehri ◽  
Abdulhakeem O. Althaqafi ◽  
Asim Alsaedi ◽  
...  
Keyword(s):  
Public Health ◽  
Saudi Arabia ◽  
Tertiary Hospital ◽  
Whole Genome ◽  
Drug Resistant ◽  
Global Public Health ◽  
Gulf Region ◽  
Carbapenem Resistant ◽  
The Impact ◽  
Klebsiella Spp

Abstract Background Nosocomial infections caused by multi-drug resistant Enterobacteriaceae are a global public health threat that ought to be promptly identified, reported, and addressed accurately. Many carbapenem-resistant Enterobacteriaceae-associated genes have been identified in Saudi Arabia but not the endemic Klebsiella pneumoniae carbapenemases (KPCs), which are encoded by blaKPC-type genes. KPCs are known for their exceptional spreading potential. Methods We collected n = 286 multi-drug resistant (MDR) Klebsiella spp. isolates as part of screening for resistant patterns from a tertiary hospital in Saudi Arabia between 2014 and 2018. Antimicrobial susceptibility testing was carried out using both VITEK II and the broth microdilution of all collected isolates. Detection of resistance-conferring genes was carried out using Illumina whole-genome shotgun sequencing and PacBio SMRT sequencing protocols. Results A Carbapenem-resistant Enterobacteriaceae (CRE) Klebsiella quasipneumoniae subsp. similipneumoniae strain was identified as a novel ST-3510 carrying a blaKPC-2 carbapenemase encoding gene. The isolate, designated as NGKPC-421, was obtained from shotgun Whole Genome Sequencing (WGS) surveillance of 286 MDR Klebsiella spp. clinical isolates. The NGKPC-421 isolate was collected from a septic patient in late 2017 and was initially misidentified as K. pneumoniae. The sequencing and assembly of the NGKPC-421 genome resulted in the identification of a putative ~ 39.4 kb IncX6 plasmid harboring a blaKPC-2 gene, flanked by transposable elements (ISKpn6-blaKPC-2–ISKpn27). Conclusion This is the first identification of a KPC-2-producing CRE in the Gulf region. The impact on this finding is of major concern to the public health in Saudi Arabia, considering that it is the religious epicenter with a continuous mass influx of pilgrims from across the world. Our study strongly highlights the importance of implementing rapid sequencing-based technologies in clinical microbiology for precise taxonomic classification and monitoring of antimicrobial resistance patterns.

Qualitative Map of Salmonella Contamination on Young Chicken Carcasses†

2010 ◽  
Vol 73 (9) ◽  
pp. 1596-1603 ◽  
Author(s):  
T. P. OSCAR ◽  
G. K. RUTTO ◽  
J. B. LUDWIG ◽  
S. PARVEEN
Keyword(s):  
Public Health ◽  
Antibiotic Resistance ◽  
Public Health Problem ◽  
Global Public Health ◽  
Culture Methods ◽  
Chi Square ◽  
Conventional Culture ◽  
Chicken Carcass ◽  
Young Chicken ◽  
Chi Square Analysis

Salmonella contamination of poultry is a global public health problem. The objective of this study was to map the distribution of Salmonella on the young chicken carcass, to improve poultry inspection and food safety. Young chickens (n = 70) in the Cornish game hen class were obtained at retail over a 3-year period. Carcasses were aseptically sectioned into 12 parts, and then Salmonella was isolated from whole-part incubations by conventional culture methods. Isolates were characterized for serotype and antibiotic resistance, and by pulsed-field gel electrophoresis (PFGE). Salmonella incidence was 21.5% (181 of 840) for parts and 57.1% (40 of 70) for carcasses. The number of contaminated parts per carcass ranged from 0 to 12, with a mean of 4.5 among contaminated carcasses. Chi-square analysis indicated that Salmonella incidence differed (P < 0.05) among parts, with rib back (38.6%) and sacral back (34.3%) being the most contaminated. Among the 40 contaminated carcasses, there were 37 different patterns of contamination among parts. Of the 33 carcasses with more than one contaminated part, 12.1% contained two serotypes, 33.3% contained two or more antibiotic resistance profiles, and 100% contained two or more PFGE patterns. The most common serotype was Typhimurium (94.5%), and most (97.2%) isolates were resistant to multiple antibiotics. These results indicated a diverse pattern of Salmonella contamination among carcasses and that multiple subtypes of Salmonella were often present on contaminated carcasses. Thus, whole-carcass incubation succeeded by characterization of multiple isolates per carcass is needed to properly assess and manage this risk to public health.

An overview of self-medication: a major cause of antibiotic resistance and a threat to global public health

2020 ◽  
pp. 1-22
Author(s):  
Mubasher Rehman ◽  
Shehzad Ahmed ◽  
Umair Ahmed ◽  
Kosar Tamanna ◽  
Muhammad Shehryar Sabir ◽  
...  
Keyword(s):  
Antibiotic Resistance ◽  
Health Care Services ◽  
Bacterial Resistance ◽  
Developed Countries ◽  
Resistance Rate ◽  
Adverse Outcomes ◽  
Global Public Health ◽  
Self Medication ◽  
Care Services ◽  
Professional Health

Self-medication is the use of medicines by people on 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 miss usage 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 health care services and socioeconomic factors result in increased proportion of self-medication as compared to drugs prescribed by physicians. This review article is focused 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 minimized. 

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