Skliros et al.
BMC Family Practice 2010, 11:58
http://www.biomedcentral.com/1471-2296/11/58
RESEARCH ARTICLE Open Access
Self-medication with antibiotics in rural
population in Greece: a cross-sectional
multicenter study
Eystathios Skliros, Panagiotis Merkouris, Athanasia Papazafiropoulou*, Aristofanis Gikas, George Matzouranis,
Christos Papafragos, Ioannis Tsakanikas, Irene Zarbala, Alexios Vasibosis, Petroula Stamataki, Alexios Sotiropoulos
Abstract
Background: Self-medication is an important driver of antimicrobial overuse as well as a worldwide problem. The
aim of the present study was to estimate the use of antibiotics, without medical prescription, in a sample of rural
population presenting in primary care in southern Greece.
Methods: The study included data from 1,139 randomly selected adults (545 men/594 women, mean age ± SD:
56.2 ± 19.8 years), who visited the 6 rural Health Centres of southern Greece, between November 2009 and
January 2010. The eligible participants were sought out on a one-to-one basis and asked to answer an anonymous
questionnaire.
Results: Use of antibiotics within the past 12 months was reported by 888 participants (77.9%). 508 individuals
(44.6%) reported that they had received antibiotics without medical prescription at least one time. The major
source of self-medication was the pharmacy without prescription (76.2%). The antibiotics most frequently used for
self-medication were amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), cefaclor (9.7%), cefuroxim (7.9%),
cefprozil (4.7%) and ciprofloxacin (2.3%). Fever (41.2%), common cold (32.0%) and sore throat (20.6%) were the
most frequent indications for the use of self-medicated antibiotics.
Conclusion: In Greece, despite the open and rapid access to primary care services, it appears that a high proportion
of rural adult population use antibiotics without medical prescription preferably for fever and common cold.
Background with high yearly use of antibiotics [3]. It is noteworthy,
Since the introduction of penicillin, 60 years ago, antibio- that our country had one of the highest uses of antimi-
tics have played an important and crucial role in the crobial agents in ambulatory care [5].
treatment of infectious diseases, especially those caused Self-medication is an important driver of antimicrobial
by bacteria. However, the inappropriate use of those overuse, especially, in low- and middle-income countries,
drugs has led to the phenomenon of antimicrobial resis- where antibiotics are easily obtained over the counter
tance, which is becoming a worldwide public health pro- [1,6,7]. Studies showed that the prevalence of actual self-
blem [1,2]. Recent studies in Europe, including Greece, medication was high in eastern and southern Europe and
have showed high rates of outpatient antibiotic use and low in northern and western Europe [8-10]. This studies
resistance [2-5]. In particular, a shift from the old nar- showed that the most common reasons for self-
row-spectrum antibiotics to the new broad-spectrum medication were throat symptoms and bronchitis [8,10]
antibiotics was observed [3]. They also recorded seasonal while the main medication sources were pharmacies and
fluctuations with heightened winter peaks in countries medication leftover from previous prescriptions [8-10].
In Greece, the limited data concerning urban population
indicate that the prevalence of self-medication is high
* Correspondence: pathan@ath.forthnet.gr [11,12]. However, data about self-medication in rural
3rd Department of Internal Medicine and Center of Diabetes, General
Hospital of Nikaia “Ag. Panteleimon” - Piraeus, Greece, 3 D.Mantouvalou areas are lacking. Therefore, the aim of the present study
Street, GR-184 54 Nikaia, Greece
© 2010 Skliros et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Skliros et al. BMC Family Practice 2010, 11:58 Page 2 of 3
http://www.biomedcentral.com/1471-2296/11/58
was to evaluate the prevalence of self-medication with Discussion
antibiotics in rural population in Greece. Our results showed that the prevalence of self-medication
with antibiotics in rural population in southern Greece
Methods was high. Our results are comparable to those of
Population Jordan were 46% of patients reported antimicrobial self-
The study included data from 1,139 adults (545 men/594 medication [6]. However, antimicrobial drug self-medica-
women, mean age ± SD: 56.2 ± 19.8 years), who visited tion prevalence varies widely among different European
the 6 rural Health Centres of southern Greece, between regions. Studies in Denmark and Spain showed that self
November 2009 and January 2010. Physicians of the drug consumption was 3% and 11% respectively [14,15]. In
above Health Centres carried out the study. Physicians Malta and Lithuania the prevalence of self-medication was
asked each consecutive patient to fill an anonymous 19% and 22% respectively [7,16]. A prospective survey of
questionnaire and to return it at the practice. The refusal emergency department patients in the USA established
rates were low. The questionnaire included items relating that 17% of patients had taken leftover antibiotics without
to demographic characteristics, overall use of antibiotics consulting a physician, most commonly for a cough (11%)
and self-medication with antibiotics. In particular, infor- or sore throat (42%) [17]. A recent study in Europe
mation about the type of antibiotics, the sources of self- reported that Greece had one of the highest outpatient
medication, the symptoms for which the drugs were antibiotic uses in Europe with cephalosporins and macro-
reportedly used, and duration of use were collected. lides being the most frequently used antibiotics [3].
The study was conducted in accordance with the 2004 Substantial variation in the prevalence rates of antimi-
amendment of the Declaration of Helsinki, the guide- crobial drug self-medication among the European
lines for Good Epidemiological Practice [13], and local regions suggests that socioeconomic factors play a role,
regulatory requirements. The protocol was approved by as do disparities in health care systems such as reimbur-
the local ethics committee in each study area. sement policies, access to health care, and drug dispen-
sing policies [18]. Another factor is the acquisition of
Statistical Analysis antimicrobial drugs from pharmacies without prescrip-
Statistical analysis was preformed using programs avail- tion, which occurred most frequently in eastern and
able in the SPSS statistical package (SPSS 15.0, Chicago, southern European countries [18].
USA). All variables were tested for normal distribution Although most of the responsibility regarding inap-
of the data. Data are shown as mean ± SD. A chi-square propriate antibiotic use belongs to the physicians’ pre-
test was used for categorical variables. P < 0.05 (two- scribing practices, several studies found that patients,
tailed) was considered statistically significant. too, contribute to inappropriate antibiotic usage [15,18].
Self-medication with antibiotics is possible via several
Results sources: a) they are legally available over the counter, b)
Use of antibiotics within the past 12 months was antibiotics initially prescribed by physicians are saved
reported by 888 participants (77.9%). 508 individuals and subsequently used without medical consultation, c)
(44.6%) reported that had received antibiotics without antibiotics are obtained through friends or relatives, and
medical prescription at least one time in the past 12 d) they can be acquired via Internet [15,18].
months. The major source of self-medication was the In the present study the major source of self-
pharmacy without prescription (76.2%) followed by left- medication was the pharmacy. It must be mentioned
over medications at home (15.3%) and drugs obtained that in Greece law still allows patients to obtain antibio-
from relatives or friends (7.2%). tics from the pharmacists without any medical prescrip-
The most frequently self-medicated antibiotics were tion. A study by Contopoulos-Ioannidis et al., reported
amoxicillin (18.3%), amoxicillin/clavulanic acid (15.4%), that 77% of Greek pharmacists offered antibiotics with-
cefaclor (9.7%), cefuroxim (7.9%), cefprozil (4.7%) and out a medical prescription [19]. The same study showed
ciprofloxacin (2.3%). Fever (41.2%), common cold that most of pharmacists offered expensive broad-spec-
(32.0%) and sore throat (20.6%) were the most frequent trum antibiotics. Antibiotics were most frequently
indications for their use. offered for treatment of patients with symptoms that
Only 9.1% (57/630) of the participants who did not were suggestive of a common cold [19].
report self-medication with antibiotics, had stored drugs
at home compared to 49.2% (250/508) of the partici- Conclusions
pants who reported self medication (P < 0.001). Finally, In Greece, despite the open and rapid access to primary
31.5% of the participants reported earlier discontinua- care services, it appears that a high proportion of rural
tion of antibiotics when symptoms improved. adult population prefers to use antibiotics without
Skliros et al. BMC Family Practice 2010, 11:58 Page 3 of 3
http://www.biomedcentral.com/1471-2296/11/58
medical prescription. The high prevalence of self- medication with antibiotics in Europe: the impact of beliefs, country
wealth and the healthcare system. J Antimicrob Chemother 2008,
medication with antibiotics in rural population in 61:1172-1179.
Greece emphasizes the role of the primary care physi- 11. Mitsi G, Jelastopulu E, Basiaris H, Skoutelis A, Gogos C: Patterns of
cian who should advise patients about the correct use of antibiotic use among adults and parents in the community: a
questionnaire-based survey in a Greek urban population. Int J Antimicrob
the prescribed antibiotics. Another important interven- Agents 2005, 25:439-443.
tion to reduce the major problem of self-medication 12. Poulakou G, Katsarolis I, Matthaiopoulou I, Tsiodras S, Kanavaki S, Hatzaki D,
with antibiotics in Greece should be legislative changes Roilides E, Sofianou D, Kavaliotis I, Kansouzidou A, Kafetzis DA, Paraskakis I,
Foustoukou M, Daikos GL, Syriopoulou V, Pangalis A, Leveidiotou S,
banning unregulated sale of antibiotics without medical Giamarellou H, Hellenic Study Group for the Susceptibility of Streptococcus
prescription. Finally, efforts like the European Antibiotic pneumoniae: Nationwide surveillance of Streptococcus pneumoniae in
Awareness Day [20] emphasize the importance of using Greece: patterns of resistance and serotype epidemiology. Int J
Antimicrob Agents 2007, 30:87-92.
antibiotics responsibly by reducing their unnecessary use 13. International Epidemiological Association (IEA): Good epidemiological
and encourage people to follow their doctor’s instruc- practice (GEP): IEA guidelines for proper conduct in epidemiologic
tions on how to take antibiotics in the appropriate way, research. 2007 [http://www.ieatemp.com/goodEpiPractice.aspx], Accessed
27 November 2009.
especially in children. 14. Muscat M, Monnet DL, Klemmensen T, Grigoryan L, Jensen MH,
Andersen M, Haaijer-Ruskamp FM: Patterns of antibiotic use in the
community in Denmark. Scand J Infect Dis 2006, 38:597-603.
Authors’ contributions 15. Väänänen MH, Pietilä K, Airaksinen M: Self-medication with antibiotics–
AG, GM, CP, IT, IZ, AV and PS participated in the collection of the data. ES, does it really happen in Europe? Health Policy 2006, 77:166-171.
PM, AP and AS participated in the design of the study and performed the 16. Borg MA, Scicluna EA: Over-the-counter acquisition of antimicrobial drugs
statistical analysis and drafted the manuscript. All authors read and approved in the Maltese general population. Inter J Antimicrob Agents 2002,
the final manuscript. 20:253-257.
17. Richman P, Garra G, Eskin B, Nashed A, Cody R: Oral antibiotic use without
Competing interests consulting a physician: a survey of ED patients. Am J Emerg Med 2001,
The authors declare that they have no competing interests. 19:57-60.
18. Grigoryan L, Haaijer-Rysjamp FM, Burgerhof JG, Mechtler R, Deschepper R,
Received: 24 February 2010 Accepted: 8 August 2010 Tambic-Andrasevic A, Andrajati R, Monnet DL, Cunney R, Di Matteo A,
Published: 8 August 2010 Edelsein H, Valinteliene R, Alkerwi A, Scicluna E, Grzesiowski P, Bara AC,
Tesar T, Cizman M, Campos J, Lundborg CS, Birkin J: Self-medication with
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Edelsein H, Valinteliene R, Alkerwi A, Scicluna E, Grzesiowski P, Bara AC,
• Convenient online submission
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antimicrobial drugs in Europe. Emerg Infect Dis 2006, 12:452-459. • Thorough peer review
9. Grigoryan L, Burgerhof JG, Haaijer-Ruskamp FM, Degener JE, Deschepper R, • No space constraints or color figure charges
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• Immediate publication on acceptance
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10. Grigoryan L, Burgerhof JG, Degener JE, Deschepper R, Lundborg CS, • Research which is freely available for redistribution
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