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HANDLING OF ANTIBIOTICS MISUSE

Introduction
Antibiotics resistance is a growing global public health issue
 Between 2000 and 2010 global antibiotics consumption grew by more than 50%
based on data from 71 countries, including China
 Excessive consumption of antibiotics mainly leads to the development of antibiotics
resistance. China consumes the second largest amount of antibiotics in the world with
a prescription rate twice that recommended by the World Health Organization (WHO)
and rural areas have higher rates than urban areas
 In this regard, the Chinese government has introduced a number of regulations in the
last decade, but it has not played a significant role in rural areas
 The majority of people in southwest China live in rural areas where primary care
physicians usually provide the health services
 Most physicians there have non-degree training yet are allowed to prescribe
antibiotics in the national list due to personnel shortages. Previous studies reported a
high irrational antibiotics prescription use among primary care physicians
 In addition, studies performed in Italy and Germany exploring the patterns of
antibiotic prescriptions among primary care physicians found that the rate of
inappropriate antibiotic use was high
 Strengthening the knowledge and practice of rational use of antibiotics among
primary care physicians is one way to reduce antibiotic resistance. Thus, we need to
understand how antibiotics are unnecessarily used, for example prescribed with
incorrect choices for particular diseases, escalated (for example prescribing more
expensive and broad spectrum antibiotics when cheaper and more specific antibiotics
can give the same result) and used intravenously.

The aim of this study was to document the clinical patterns of antibiotics prescriptions in a
rural primary care setting where physicians are mostly non-degree trained. The secondary
objective was to determine the association between antibiotics use and various characteristics
of patients and physicians.

Antibiotics are important drugs. Many antibiotics can successfully treat infections caused by
bacteria (bacterial infections). Antibiotics can prevent the spread of disease. And antibiotics
can reduce serious disease complications.
But some antibiotics that used to be typical treatments for bacterial infections now don't work
as well. And some drugs don't work at all against some bacteria. When an antibiotic no
longer works against some strains of bacteria, those bacteria are said to be antibiotic resistant.
Antibiotic resistance is one of the world's most urgent health problems.

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The overuse and misuse of antibiotics are key factors leading to antibiotic resistance. The
general public, health care providers and hospitals all can help ensure correct use of the
drugs. This can lessen the growth of antibiotic resistance.

Types of Antibiotics
1. Azithromycin

This antibiotic is often given incorrectly for viral infections such as the common cold, sinus
infections, and acute bronchitis. It is an easy drug to prescribe with minimal side effects and
that often tends to cause it to be misused in order to placate a patient with a viral infection
who often wants an antibiotic irrespective of the fact that their illness is caused by a virus.
These patients would be better served with cough suppressants and drugs such as ibuprofen
or acetaminophen.

2. Amoxicillin

This antibiotic is often overprescribed for viral infections such as acute bronchitis, mild ear
infections, and viral pharyngitis. These patients would be better served with cough
suppressants and drugs such as ibuprofen or acetaminophen.

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3. Cephalexin

This antibiotic is overprescribed for skin conditions which may not even require an antibiotic
to be prescribed because they are non-infectious, will resolve on their own, or can be treated
with topical antibiotics.

4. Trimethoprim-sulfamethoxazole (TMP/SMX)

This antibiotic is overprescribed for urinary tract infections which may not be true infections
as many elderly, for example, chronically have bacteria in their urine. It is also unnecessarily
given for skin boils, which usually don’t require antibiotics once they’ve been adequately
drained.

5. Ciprofloxacin

This antibiotic is often overprescribed for urinary tract infections which really are not urinary
tract infections or when a simpler antibiotic such as TMP/SMX or nitrofurantoin would be
sufficient.

THE HISTORY AND BENEFITS OF ANTIBIOTICS

History of Antibiotics:-

 The management of microbial infections in ancient Egypt, Greece, and China is well-
documented.
 The modern era of antibiotics started with the discovery of penicillin by Sir Alexander
Fleming in 1928.Since then, antibiotics have transformed modern medicine and saved
millions of lives.
 Antibiotics were first prescribed to treat serious infections in the 1940s.Penicillin was
successful in controlling bacterial infections among World War II soldiers.
 However, shortly thereafter, penicillin resistance became a substantial clinical
problem, so that, by the 1950s, many of the advances of the prior decade were
threatened.
 In response, new beta-lactam antibiotics were discovered, developed, and deployed,
restoring confidence.
 However, the first case of methicillin-resistant Staphylococcus aureus (MRSA) was
identified during that same decade, in the United Kingdom in 1962 and in the United
States in 1968.
 Unfortunately, resistance has eventually been seen to nearly all antibiotics that have
been developed Vancomycin was introduced into clinical practice in 1972 for the
treatment of methicillin resistance in both S aureus and coagulase-negative
staphylococci.
 It had been so difficult to induce vancomycin resistance that it was believed unlikely
to occur in a clinical setting.
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 However, cases of vancomycin resistance were reported in coagulase-negative


staphylococci in 1979 and 1983.
 From the late 1960s through the early 1980s, the pharmaceutical industry introduced
many new

USE OF ANTIBIOTICS IN COMMON INFECTIONS

Antibiotics are crucial for successfully managing various bacterial infections, such as acute
bacterial sinusitis, tuberculosis, pneumonia, bacterial gastroenteritis, septicemia, etc.

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The most common condition for prescribing antibiotics includes upper respiratory tract
infections, acute bronchitis and cough, accounting for almost two-thirds of the total
prescriptions. Interestingly, 80% of these prescriptions are not according to the standard
guidelines for prescribing antibiotics and often exceeds the recommended period.

India is the largest consumer of antibiotics globally. The share of BRICS countries in global
antibiotic consumption was 76% between the period 2000 to 2010, of which India's
contribution was 23%. There has been a 22% increase in per-capita antibiotic consumption in
India between 2008 to 2012. India has witnessed an increased use of lincosamides, 3rd
generation cephalosporins, carbapenems, and glycosides in the recent past.

ANTIBIOTIC USE IN NOSOCOMIAL INFECTIONS:-

Nosocomial infections or hospital-acquired infections are common in developing countries,


accounting for 75% of the global cases. It resulted in an increased overall cost of treatment,
antibiotics use and improved hospital stay.

The most common nosocomial infections site includes urinary tract infections (UTI),
respiratory tract infections, surgical and soft tissue infections, gastroenteritis and
meningitis. The common organisms include S. pneumonia, Enterococcus, S. aureus, E. coli,
Pseudomonas, and Acinetobacter.

The use of inappropriate broad-spectrum antibiotics in healthcare settings is a leading cause


of nosocomial infections globally. Penicillin-resistant pneumococci, multi-drug-resistant
tuberculosis, methicillin-resistant and S. aureus (MRSA) are the most common antibiotic-
resistant bacteria examples in hospital settings.

For example, in a study among 3439 patients in a maternity hospital in Saudi Arabia, over
90% of the bacterial isolates were multi-drug resistant. The same study reported an antibiotic
misuse rate as high as 57%.

Hospitals need to adopt various control programs through which infection rates can be
compared and controlled with a well-managed surveillance team. Healthcare workers,
especially nurses, should be well-trained to adopt best practices to avoid the spread of
nosocomial infections.

Until the arrival of a culture report, physicians generally prescribe empirical therapy to
prevent the infection's progression. Once the information is received, physicians should
prescribe the most effective antibiotic, It will help in preventing antibiotic resistance.
Suppose the culture is negative, and the physician still suspects it, they may implement
bacterial infection, PCR and data sequencing techniques to determine the infection's
aetiology.

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Most commonly Antibiotics Used in Paediatrics

1. Amoxicillin:-

Amoxicillin is at the top of the list of most commonly prescribed pediatric


medications. It is an antibiotic that is inexpensive and well-tolerated by most
children. It’s available by the brand name Amoxil, but there are many generic
options that are less expensive. This medication is given orally. Young children
usually take it in liquid form and older children and adults take it in tablet or
capsule form. It is used to treat:

 Strep throat
 Ear infections
 Sinus infections
 Childhood pneumonia

2. Clavulanic Acid:-

Known by the brand name Augmentin, this medication combines the antibiotic amoxicillin
with potassium clavulanate. Potassium clavulanate is a type of enzyme that helps the
antibiotic fight bacteria that might be resistant to antibiotics alone. It is used to treat the same
illnesses as amoxicillin alone, but may also be prescribed to kill bacteria in infected bites and
infections of the mouth.]

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1. Albuterol

Albuterol is a type of drug called a bronchodilator. These drugs are used to treat respiratory
issues by widening the air passages of the lungs (bronchi). It is commonly prescribed to
relieve the symptoms of asthma. It is often administered by a metered-dose inhaler or in a
nebulizer. It is also available as a syrup, but this form of the medication is not used very often
anymore.

2. Cephalexin

Like many commonly prescribed pediatric medications, cephalexin is an antibiotic. It is sold


under the brand name Keflex and is also available as a generic. It can be taken in a capsule,
tablet, or oral suspension to treat things like ear infections, respiratory infections, urinary tract
infections, and skin infections like impetigo.

3. Azithromycin

Like many commonly prescribed pediatric medications, azithromycin is an antibiotic. It is


sold under the brand name Zithromax but is also available as a generic medication. It is
usually prescribed for ear infections. It is available as a tablet, in an oral suspension (liquid),
and in eye drops.

4. Fluticasone

Fluticasone is a steroid that is used in many different medications. Depending on what it is


combined with, it can be prescribed as a nasal spray, cream, and ointment. It can be used to
treat asthma, eczema, and allergies.

5. Ibuprofen

Ibuprofen is an NSAID (nonsteroidal anti-inflammatory drug) that is used to treat fevers,


pain, and inflammation. You probably already have children’s strength ibuprofen in your
medicine cabinet. It is available over the counter as Children’s Motrin or Advil. However, it
is also available in prescription strength for certain conditions.

6. Cefdinir

Sold by the brand name Omnicef, this antibiotic is used to treat sinus infections, ear
infections, and pneumonia. It is not usually the first type of antibiotic pediatricians will
prescribe for these conditions. It is more expensive than some more common antibiotics.

7. Montelukast Sodium/Singulair

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Singulair is used to treat asthma and relieve symptoms of seasonal allergies. It is a type of
drug called a leukotriene inhibitor. These medications are used to prevent or lessen the
body’s reaction to allergens. It is commonly referred to as Singulair even though it is
available as a generic drug.

8. Prednisone

Prednisone is a type of corticosteroid. Corticosteroids are a class of drug that reduces


inflammation in the body. Prednisone is used to treat asthma flare-ups, croup, and allergic
reactions to things like poison ivy. It is usually prescribed for a short period of time in small
dosages.

9. Nystatin

Nystatin is an anti-fungal medication that treats infections caused by fungi such as yeast. It
can be given by mouth to treat infections in the mouth such as thrush. It also comes topical
forms like creams, ointments, and powders to treat skin conditions like diaper rashes.

The team at Kernodle Pediatrics is dedicated to keeping your child happy and healthy from
birth to age 18. Our pediatric services range from routine preventative care to treating acute
illnesses.

Most commonly antibiotics used in pregnancy

PENICILLINS

Penicillins have been used in clinical practice since the 1940s, and as a group they are
probably the “safest” antibiotics in pregnancy. Each contains a thiazolidine beta-lactam ring,
and every type has a different side chain. Penicillins are bactericidal, acting through
inhibition of bacterial cell wall synthesis. When given to the mother, significant levels are
achieved in the fetus.18, 31, 33 Ratios of umbilical cord blood to maternal serum
concentrations for some of the penicillins are

CEPHALOSPORINS

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Cephalosporins are the most commonly prescribed antibiotics. Like penicillins, they contain
the four-member beta-lactam ring. They are also bactericidal, acting through inhibition of
bacterial cell wall synthesis. Cephalosporins have been classified as first-, second-, and third-
generation based on their spectrum of activity (Table 4). Although there have been no large
studies of the safety of cephalosporins in pregnancy, there have been no embryocidal effects
reported, and all of these drugs

MACROLIDES

The macrolides—erythromycin, clindamycin, azithromycin, and clarithromycin—are


bacteriostatic antibiotics that work by attaching to the 50S ribosome and inhibiting bacterial
protein synthesis (Table 5). Erythromycin covers most aerobic gram-positive cocci, and it is a
drug of choice for Legionella, Mycoplasma, and Chlamydia infection in pregnancy. Unlike
the vast majority of other antibiotics, erythromycin crosses the placenta minimally. For this
reason it is not first-line treatment

AMINOGLYCOSIDES

Aminoglycosides are bactericidal antibiotics that bind the 30S ribosome and inhibit bacterial
protein synthesis. Members of this class include streptomycin, gentamicin, tobramycin,
kanamycin, amikacin, and netilmicin (see Table 5). Gentamicin is the most widely used
aminoglycoside in pregnancy. It covers a wide range of aerobic gram-negative rods, though
resistance has developed by some strains of Pseudomonas aeruginosa. Gentamicin also has
some activity against S. aureus and is synergistic

AMINOCYCLITOL

Spectinomycin is an aminocyclitol antibiotic related to the aminoglycosides. It may be


beneficial in the treatment of N. gonorrhoeae infection in patients who are allergic to
penicillins and cephalosporins. Penicillinase-producing strains of gonorrhea resistant to
spectinomycin have been reported. There have been no teratogenic or adverse fetal effects
documented. Spectinomycin is listed as FDA category B.

MONOBACTAM

Aztreonam is a monobactam antibiotic, and is the first and only agent in this class to become
clinically available. Although it is a beta-lactam, like the penicillins, it is resistant to
hydrolysis by beta-lactamase and has not been found to induce beta-lactamase production.
Aztreonam covers most aerobic gram-negative rods, but is ineffective against gram-positives
and anaerobes. Its spectrum is thus similar to the aminoglycosides, and it remains effective in
an anaerobic environment

SULFONAMIDES

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Sulfonamides are the oldest class of antibiotics, introduced in the 1930s. They are
bacteriostatic and interfere with bacterial synthesis of folate. Their action is potentiated by
trimethoprim, which inhibits bacterial dihydrofolate reductase. The primary use of
sulfonamides in pregnancy is the treatment of uncomplicated urinary tract infection. While
they were once active against most gram-positive cocci and gram-negative rods, many strains
have become resistant, so susceptibility should be

NITROFURANTOIN

Nitrofurantoin is used primarily for the treatment of urinary tract infections during
pregnancy. This drug has not been reported to be associated with teratogenic or adverse fetal
effects. While nitrofurantoin may cause hemolytic anemia in women with glucose-6-
phosphate dehydrogenase deficiency,43 it has not been reported to do so in the fetus.
Nitrofurantoin has also been associated with a pneumonitis if given for protracted periods. In
the authors’ experience of over 1000 pregnant women

TETRACYCLINES

Tetracyclines are bacteriostatic antibiotics that reversibly bind the 30S ribosome and inhibit
bacterial protein synthesis. They have a broad spectrum of activity against many gram-
positive and gram-negative aerobes and anaerobes, including chlamydia, mycoplasma, and
the spirochetes. Tetracyclines cross the placenta and deposit in fetal decidual teeth causing
yellow-brown discoloration if given after 5 months gestation.21, 27, 30, 46 Despite earlier
reports, they do not lead to an increase in

ANTITUBERCULOUS AGENTS

The incidence of tuberculosis in pregnancy is increasing, and it has been reported to be as


high as 0.1% in endemic areas of the United States.34 The American Thoracic Society and
Centers for Disease Control have recommended that initial treatment for pregnant women
with tuberculosis consist of isoniazid and rifampin. Ethambutol is also suggested if there is
concern for isoniazid resistance.

CUSTOMIZED TREATMENT OF INFECTION


An increasing trend of personalized medicine is observed in almost all the therapeutic
categories, including infection management. Delivering personalized medications reduces the
incidences of antibiotic resistance. While developing the strategy for treating bacterial
infections, the physicians should assess the risk of developing a particular condition and
forms a tailor-made treatment plan. The duration of therapy may be determined by using
biomarkers. Therapeutic drug monitoring also helps in ensuring the success of treatment and
reducing antibiotic resistance. The standard drug categories used in managing infections are
Cephalosporin and Aminoglycoside, fluoroquinolones, and glycopeptide antibiotics.

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GUIDANCE ON PRESCRIBING ANTIBIOTICS


Antibiotics are considered life-saving agents in managing various bacterial infections.
However, there is an unmet need to curb the inappropriate, ineffective, and unnecessary
antibiotics use. Different international guidelines are in place to monitor antibiotics' use and
reduce the development of antibiotic resistance. Following are some of the rules outlined by
global guidelines that need to be followed while prescribing antibiotics:

Need: As antibiotics are available at low cost and are relatively safer, these are the most
misused drugs. The physicians need to understand that antibiotics are for treating infection
and significantly reducing the duration of illness. Physicians should not prescribe antibiotics
without comprehensively evaluating the patient’s symptoms.

Cause of infection: The doctor should recommend diagnostic testing to determine the cause
of infection. Antibiotics do not work in viral infections.

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Narrow spectrum antibiotics: The doctors should aim to prescribe the antibiotics with a
narrow spectrum. It will prevent antibiotic resistance and have fewer effects on normal flora.

Recommended duration: The duration of antibiotic treatment should be according to the


international and local guidelines.

Reason for prescription: The doctors should set out the reason for prescribing a particular
antibiotic.

CAUSES OF THE ANTIBIOTIC RESISTANCE CRISIS

As early as 1945, Sir Alexander Fleming raised the alarm regarding antibiotic overuse when
he warned that the “public will demand [the drug and] … then will begin an era … of
abuses.” The overuse of antibiotics clearly drives the evolution of resistance Epidemiological
studies have demonstrated a direct relationship between antibiotic consumption and the
emergence and dissemination of resistant bacteria strains. In bacteria, genes can be inherited
from relatives or can be acquired from nonrelatives on mobile genetic elements such as
plasmids. This horizontal gene transfer (HGT) can allow antibiotic resistance to be
transferred among different species of bacteria. Resistance can also occur spontaneously
through mutation. Antibiotics remove drug-sensitive competitors, leaving resistant bacteria
behind to reproduce as a result of natural selection. Despite warnings regarding overuse,
antibiotics are overprescribed worldwide.

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In the U.S., the sheer number of antibiotics prescribed indicates that a lot of work must be
done to reduce the use of these medications.An analysis of the IMS Health Midas database,
which estimates antibiotic consumption based on the volume of antibiotics sold in retail and
hospital pharmacies, indicated that in 2010, standard units (a unit equaling one dose, i.e., one
pill, capsule, or ampoule) of antibiotics were prescribed per person in the The number of
antibiotic prescriptions varies by state, with the most written in states running from the Great
Lakes down to the Gulf Coast, whereas the West Coast has the lowest use In some states, the
number of prescribed courses of treatment with antibiotics per year exceed the population,
amounting to more than one treatment per person per year

In many other countries, antibiotics are unregulated and available over the counter without a
prescription. This lack of regulation results in antibiotics that are easily accessible, plentiful,
and cheap, which promotes overuse. The ability to purchase such products online has also
made them accessible in countries where antibiotics are regulated.

Factors contributing to antibiotic misuse


Antimicrobial resistance (AMR) is a pressing global health concern, especially in resource-
constrained countries, such as Bangladesh. This study aimed to identify the factors
contributing to antibiotic misuse by assessing knowledge, attitude, and practice (KAP). A
cross-sectional study was conducted from August 20 to August 30, 2022, among 704 parents
of school-going children in Dhaka South City. Descriptive statistics were used to analyze the
KAP, and multivariate models, including linear and ordinal logistic regression, were used to
explore the associations between these factors. The findings revealed that approximately 22%
of the participants were male and 78% were female. Most parents (58%) had completed
higher secondary education. Approximately 45% of the respondents demonstrated moderate
knowledge, 53% had uncertain attitudes, and 64% exhibited antibiotic misuse. Factors such
as parental age, education level, employment status, income, child’s age, and family type
significantly influenced KAP. These findings emphasize the importance of targeted education
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and awareness initiatives to enhance knowledge and responsible antibiotic use among
parents, contributing to global efforts against antibiotic resistance. The government should
enforce laws and regulations regarding the misuse of antibiotics

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HANDLING OF ANTIBIOTICS MISUSE

ANTIBIOTIC-RESISTANT BACTERIAL INFECTIONS

Antibiotic-resistant infections are already widespread in the U.S. and across the globe. 1 A
2011 national survey of infectious-disease specialists, conducted by the IDSA Emerging
Infections Network, found that more than 60% of participants had seen a pan-resistant,
untreatable bacterial infection within the prior year. 7 Many public health organizations have
described the rapid emergence of resistant bacteria as a “crisis” or “nightmare scenario” that
could have “catastrophic consequences.”8 The CDC declared in 2013 that the human race is
now in the “post-antibiotic era,” and in 2014, the World Health Organization (WHO) warned
that the antibiotic resistance crisis is becoming dire. 15 MDR bacteria have been declared a
substantial threat to U.S. public health and national security by the IDSA and the Institute of
Medicine, as well as the federal Interagency Task Force on Antimicrobial Resistance. 1

Among gram-positive pathogens, a global pandemic of resistant S. aureus and Enterococcus


species currently poses the biggest threat. 5,16 MRSA kills more Americans each year than
HIV/AIDS, Parkinson’s disease, emphysema, and homicide combined. 1,12 Vancomycin-
resistant enterococci (VRE) and a growing number of additional pathogens are developing
resistance to many common antibiotics.1 The global spread of drug resistance among
common respiratory pathogens, including Streptococcus pneumoniae and Mycobacterium
tuberculosis, is epidemic.16

Gram-negative pathogens are particularly worrisome because they are becoming resistant to
nearly all the antibiotic drug options available, creating situations reminiscent of the pre-
antibiotic era.1,5,16 The emergence of MDR (and increasingly pan-resistant) gram-negative
bacilli has affected practice in every field of medicine. 1 The most serious gram-negative
infections occur in health care settings and are most commonly caused by Enterobacteriaceae
(mostly Klebsiella pneumoniae), Pseudomonas aeruginosa, and Acinetobacter.5,16 MDR
gram-negative pathogens are also becoming increasingly prevalent in the community. 16 These
include extended-spectrum beta-lactamase-producing Escherichia coli and Neisseria
gonorrhoeae.1

The CDC assessed antibiotic-resistant bacterial infections according to seven factors: clinical
impact, economic impact, incidence, 10-year projection of incidence, transmissibility,
availability of effective antibiotics, and barriers to prevention. 5 The threat level of each
bacteria was then classified as “urgent,” “serious,” or “concerning” (Table 1).16 In general,
threats that are urgent or serious require more monitoring and prevention activities, whereas
those considered concerning require less.5 A summary of information regarding the resistant
bacteria mentioned above follows. Information regarding other strains of resistant bacteria
that have been identified as threats by the CDC

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CONCLUSION

Rapidly emerging resistant bacteria threaten the extraordinary health benefits that have been
achieved with antibiotics.14 This crisis is global, reflecting the worldwide overuse of these
drugs and the lack of development of new antibiotic agents by pharmaceutical companies to
address the challenge.14 Antibiotic-resistant infections place a substantial health and
economic burden on the U.S. health care system and population.1 Coordinated efforts to
implement new policies, renew research efforts, and pursue steps to manage the crisis are
greatly needed.2,7 Progress in these areas, as well as new agents to treat bacterial infections,
will be discussed in Part 2 of this article.

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REFERENCES
 Louie JP, Bell LM. Appropriate use of antibiotics for common infections in an era
of increasing resistance. Emerg Med Clin North Am. 2002 Feb;20(1):69-91.
 Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV.
Duration of antibiotic treatment for common infections in English primary care:
cross-sectional analysis and comparison with guidelines. BMJ. 2019 Feb
27;364:l440.
 Farooqui HH, Selvaraj S, Mehta A, Heymann DL. Community-level antibiotic
utilization in India and its comparison vis-à-vis European countries: Evidence from
pharmaceutical sales data. PLoS One. 2018;13(10):e0204805.
 Danish Health and Medicines Authority. Guidelines on prescribing antibiotics.
Available at: https://www.sst.dk/-/media/Udgivelser/2019/Guideline-on-
prescribing-antibiotics.ashx?
la=da&hash=5AD3BEEB829F508CD25C02C0730017EE371D053F. Accessed on
21st February 2021.
 Center for Infectious Disease Research and Policy. Overuse and overprescribing of
antibiotics. Available at: https://www.cidrap.umn.edu/asp/overuse-overprescribing-
of-antibiotics#:~:text=Risks%20of%20antibiotic%20overuse%20or,problems
%20that%20previously%20may%20have. Accessed on 21st February 2021.
 Khan HA, Ahmad A, Mehboob R. Nosocomial infections and their control
strategies. Asian Pacific J Trop Biomed. 2015;5(7):509-14.
 Bilal NE, Gedebou M, Al-Ghamdi S. Endemic nosocomial infections and misuse of
antibiotics in a maternity hospital in Saudi Arabia. APMIS. 2002 Feb;110(2):140-7
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594576/
 https://www.mayoclinic.org/healthy-lifestyle/consumer-
health/in-depth/antibiotics/art-20045720
 https://www.formularywatch.com/view/no-silver-bullet-
for-paying-for-gene-therapies
 https://venusremedies.com/blog/inappropriate-use-
antibiotic#:~:text=Increased%20infection%20severity%3A
%20Inappropriate%20use,increases%20the%20cost%20of
%20treatment.
 https://www.nature.com/articles/s41598-024-52313-y
 https://www.sciencedirect.com/science/article/abs/pii/
S0889854505703260
 https://www.kernodle.com/pediatrics_blog/commonly-
prescribed-pediatric-medications/
#:~:text=Amoxicillin,options%20that%20are%20less
%20expensive.
 http://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar-threats-
2013-508.pdf.5
 https://www.cidrap.umn.edu/asp/overuse-overprescribing-of-
antibiotics#:~:text=Risks%20of%20antibiotic%20overuse
%20or,problems%20that%20previously%20may%20have.

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