ACCESSIBILITY AND USE OF ANTIBIOTICS AMONG PATIENTS VISITING COMMUNITY PHARMACIES IN BENIN CITY, NIGERIA

ntibiotic resistance is an increasing problem worldwide. Among contributory factors is increasing easy access to antibiotics which is a trend in developing countries. The objective of this study is to determine the accessibility and use of antibiotics. A descriptive cross-sectional study was conducted in eight community pharmacies in Benin City, Nigeria. A structured questionnaire was used for data collection. Administrative approval was obtained from the superintendent pharmacists, while informed consent was sought from all study participants. The data obtained from the study were analyzed using IBM SPSS version 22. Of the 450 participants in the study, most [329 (73.11%)] had used antibiotics in the last six months before their current visit to the pharmacy, 207 (46%) of them took the antibiotic without laboratory investigation. Many [274 (60.89%)] of the participants had an antibiotic among the medications they got from the pharmacy on their current visit. More than half [289 (64.22%)] of the participants sometimes got antibiotics without prescription. More Pharmacists recommended antibiotics for participants compared to doctors (44.11%: 24.44%), while more than half of the study population (62.89%) got their antibiotics from pharmacies. Many [295 (65.56%)] of the participants think that the country should regulate antibiotic use. This study has shown that community pharmacy is a major outlet where patients source antibiotics sometimes without a prescription, thus denoting that many patients self-medicate with antibiotics. The need for incorporating community pharmacists in developing guidelines for prescribing and using antibiotics is crucial.


INTRODUCTION
World Health Organization estimated that about 20-50% of antibiotics used worldwide are either used or prescribed inappropriately (WHO 2001;2015). The remarkable effectiveness of antibiotics leads to their widespread usage, and a persistent belief among the general public that antimicrobials are universally efficacious and should therefore be applied in the first instance to virtually all ailments. The belief in the universal applicability of antimicrobials has resulted in their exuberant use and so has applied a widespread, strong, and polarized selective pressure on the microbial world. This has resulted in the increasing rates of antibiotic or antimicrobial resistance (AMR) seen today (Carolyn et al., 2014). Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases. A growing list of infections such as pneumonia, tuberculosis, blood poisoning, gonorrhea, and foodborne diseases are becoming harder, and sometimes impossible, to treat as antibiotics become less effective (WHO 2017). Where antibiotics can be bought for human use without a prescription, the emergence and spread of resistance is made worse.
Similarly, in countries like those in low-and middle-income regions, without standard treatment guidelines, antibiotics are often over-prescribed by health workers and veterinarians and over-used by the public (WHO 2017;Carolyn et al., 2014). In developing countries, antibiotics can be readily purchased without any control; such countries usually experience more cases of AMR, in contrast to what occurs in western nations where tight regulations of antibiotic use are in place. Self-medication practices have a major pitfall, which is that users do not follow a prescribed course of drug dosage and usually stop the drug regimen once they are relieved of symptoms of illness (Ayukekbong et al., 2017).
In Nigeria, there is poor regulatory control of antibiotic sales, and purchases can be carried out without the prescription of a clinician. In addition, there is a preponderance of counterfeit drugs in the market which makes it difficult to achieve effective treatment of self-diagnosed illnesses thus increasing the propensity for more use of antibiotics (Olumide et al., 2018). This study aims to investigate the accessibility and use of antibiotics in community pharmacies in Benin City. obtained information of patient knowledge and attitude on different antibiotics used, different medical condition that warrant the usage of the antibiotics and assessment of patients knowledge on antibiotics resistance.

DATA ANALYSIS
The data obtained from the survey were entered into Microsoft excel and transferred in IBM SPSS version 22.
Descriptive statistical analysis was performed.

RESULTS
A total number of 450 respondents participated in the study, of which majority (55.33%) were between the ages of 18-29 years. There was almost equal proportions of male (44.67%) and female (49.78%) participants in the study.
About a third (33.33%) of the respondents were unemployed. While about half (47.56%) of the respondents had postsecondary education, other characteristics of the study participants are as shown in Table 1. More than half 274(60.89%) of the respondents visiting community pharmacies at the time of this study had an antibiotic as part of medications in their prescription. When asked if they used antibiotics before their current visit to the pharmacy, many [204(45.33%)] took antibiotics one month before, 207 (46%) of those who took antibiotic did not do any laboratory investigation warranting the use of antibiotic. About half [185(44.1%)] of those who had an antibiotic as a past medication history said a pharmacist recommended it for them compared to 110 (24.4%) of the participants who got a doctor's prescription. The source of the antibiotics they used was mostly from pharmacy outlets

DISCUSSION
This study investigated the accessibility and use of antibiotics by a section of the public who visit community pharmacies. Prevalence of antibiotic use from the study participants is high, it can be deduced from the results of this study that many participants are involved in the frequent usage of antibiotics, as about half of the participants had used antibiotics within a month of their current visit to the pharmacy, and also had an antibiotic among the medications they got from their current visit. This trend could be attributed to the fact that the presumed infection or disease that the respondents were treating still persisted. It can be inferred that either they were treating the condition with the wrong drug (antibiotic) or resistance to the antibiotic has occurred, this assumption is further strengthened with the fact that more than half of the participants did not conduct a laboratory investigation before taking the antibiotics (Kuehn, 2013). Studies on antibiotic use by the public have shown that using antibiotic to treat the wrong infection or disease condition is rampart. In Southwestern Nigeria, a study revealed high usage of antibiotics for treating menstrual symptoms by women (Amy et al., 2010), other regions of the country have reported high usage and self-medication with antibiotics. In Northwestern Nigeria among university undergraduates, authors in a study found that more than 60% of their participants used antibiotics irrationally, similar findings was reported in a rural setting (Olumide et al.,

AJHSE-OWSD-2(2)
Isabel et al., 2021 | 160 2018; Abdulraheem et al., 2016). This trend is common in Low and Middle-Income Countries (LMICs). In Congo, about 67.8% of patients visiting pharmacies bought antimicrobials without a prescription, either on demand by patient or given by the dispensers (Aimerance et al., 2020). In a systematic review of 85 studies, 59 of which was done in LMICs, found that more than 60% of antibiotics were dispensed without a prescription in 49 (83%) of the studies (Wertheim et al., 2017).
Several factors are responsible for increase public usage of antibiotics in Nigeria and other LMICs. Overthe-counter sale of antibiotics, the cost of medical consultation, low satisfaction with medical practitioners, misconceptions regarding the efficacy of antibiotics, severity of illness, economic status, past successful antibiotic use and educational level are some contributory factors. High perceived appropriateness of self-medication with antibiotics and attitudes favouring antibiotic use for minor ailments are also predisposing factors for use of selfmedication (Cliodna et al., 2007;Larissa et al.,2008). The perceived availability of antibiotics from pharmacies without a prescription has been the main enabling factor at the individual level, in this study, it seems that more participants visit community pharmacies more than hospitals, as majority of the participants got antibiotics from pharmacies or on pharmacist's recommendation compared to the hospital, even patent medicine dealers have more patronage than hospitals as seen in this study. According to Nigeria's legislation, antibiotics and other antibacterial should only be dispensed with prescription. However, a combination of factors ranging from a shortage of licensed prescribers, pressure to meet up in community pharmacies with some employed dispensers who lack pharmacotherapeutics and appropriate dispensing training, poor access to quality medicines in some areas, to proliferation of under-regulated patent medicine vendor, drug markets and hawkers among others, means that Nigeria suffers severe access problems whilst simultaneously facing a crisis of irrational drug use. Drug misuse extends to the agricultural sector where antimicrobials are liberally used therapeutically and for growth promotion. All of these druguse problems are exacerbating resistance and complicating infectious disease management. Enforcement of the laws regulating the sale of antibiotics will help in curtailing the health danger posed by antibiotic resistance and some of its causes (Goossens et al., 2006;Jones et al., 2008;FDA 2013). It is noteworthy that majority of the respondents in this study are quite knowledgeable regarding the issue of antimicrobial (antibiotic) resistance and the fact that it is a serious issue in Nigeria, thus calling out that their use should be regulated.
Dispensing regulations for prescribed antibiotics in pharmacies is another enabling factor. Dispensing antibiotics per package size can produce leftovers, which, in a previous study, have been shown to substantially contribute to self-medication, with 36% of those who self-medicated using leftovers (Larissa et al., 2008;Nga et al., 2021;Olumide et al., 2018). In this study, some participants used left over antibiotics. To reduce self-medication with leftovers antibiotics, it is suggested that prescribed antibiotics should not be dispensed according to the package size.
Dispensing exact numbers of antibiotic tablets in pharmacies as implemented in some countries such as the UK, the Netherlands, Czech Republic and Israel, as well as in the USA, could be promoted in other countries (Larissa et al., 2008). While in other countries like Bangladesh, Ghana, and Vietnam, unused antibiotics could be returned and refunded (Nga et al., 2021).
Participants in this research used antibiotics for ailments such as urinary tract infections, malaria, typhoid fever, cough (upper respiratory tract infections and fever, with the highest usage for malaria infection likely with antimalarial drug. Previous studies show a wide range of illnesses that patients use antibiotics for as self-medication to include gastrointestinal, respiratory, genitourinary, skin, fever, typhoid, malaria and dental illnesses (Olumide et al.,2018;Abdulraheem et al.,2016;Aimerance et al., 2020). Results from this study on high usage of antibiotics for AJHSE-OWSD-2(2) Isabel et al., 2021 | 161 malaria treatment is quite disturbing, it further explains the serial use of antibiotics by the participants (Cliodna et al.,2007). Aside exposing the misconception that antibiotics treat varied disease conditions including malaria, the frequent use for malaria exposes patients and the public to resistance, since malaria is an infection that is recurring and some patients will have need to treat malaria very often. The objective of permanently changing public perception, and behavior of antimicrobial usage is necessary in the light of the growing AMR crisis. However, such an initiative will require coordination at local, national, and global levels to ensure a consistent "message" and also culturally appropriate local implementation (Carolyn et al., 2014). Such behavioral campaign should target ways to lessen the demand for the immediate application of antimicrobials for non-acute use, discouraging the public from irrational use of antibiotics by enlightening them on the dangers of antimicrobial resistance, and encourage the use of appropriate diagnostics. These measures in addition to promoting appropriate prescribing through regulation will in the long run preserve the limited antibiotics available.

CONCLUSION
This study reveals a high use of antibiotics without a prescription, partly due to easy access from community pharmacy outlets. The need for regulation of antibiotic prescription in Nigeria is crucial in slowing the rate of resistance.
Participant's use of antibiotics for malaria treatment is a public health concern with respect to tackling antimicrobial resistance; measures to increase public behavioral change towards antibiotic use can help to forestall this menace.