Antibiotic Misuse during the COVID-19 Pandemic in Lebanon: A Cross-Sectional Study

Abstract

Background: Over the past 100 years, the discovery of antibiotics is regarded as one of the most significant advances in medical research and has saved millions of lives. However, the emergence of antimicrobial-resistant bacteria has significantly reduced the efficacy of antibiotics against infectious disorders. Antimicrobial resistance is mostly caused by antibiotic misuse for conditions that may be treated with self-care. During the COVID-19 pandemic, antibiotic use has been out of control among the general population. Aim: The objective of this study is to investigate the prevalence of antibiotic misuse during the COVID-19 pandemic in Lebanon. Methods: In January 2024, a descriptive cross-sectional study was conducted amongst students registered at the Islamic University of Lebanon. Individuals who have been infected with COVID-19 at least once were eligible for the study and were selected by a non-random snowball sampling technique. Descriptive and quantitative analyses were performed using SPSS 21. Results: Out of the 478 participants who completed the questionnaire, 40.2% (n = 192) received antibiotics during the COVID-19 infection. A physician’s prescription is mentioned by some participants (51%, n = 98), followed by a pharmacist’s (23.4%, n = 45), self-taken (14.5%, n = 28), and others as family or friends (10.9%, n = 21). Moreover, 59.3% (n = 114) of the respondents respected the antibiotic therapy’s rules, and 40.6% (n = 78) discontinued taking the antibiotic when they felt better. Conclusion: Our results showed that participants were likely to show unsatisfactory compliance and to use non-prescribed antibiotics. Campaigns are urgently needed to promote appropriate antibiotic use.

1. Introduction

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), which caused coronavirus disease 2019 (COVID-19), has aroused widespread alarm due to the infection’s rapid international spread and the clinical spectrum of the inflammatory sickness, which ranges from moderate to severe and resulted in death and multi-organ failure [1,2]. The World Health Organization (WHO) declared COVID-19 a global pandemic in March 2020 [3].

The management of critically ill patients has been made possible by the following publications of guidelines on the management of the condition, particularly the use of steroids. Although infection management has received significant attention, the guidelines initially placed little focus on antibiotics due to a lack of adequate data. When COVID-19 was first discovered in Wuhan in December 2019, more than 90% of hospitalized patients received antibiotics despite the lack of convincing bacterial infection proof [4]. Secondary bacterial problems associated with moderate and severe pneumonia cases might develop from COVID-19 infections and can be successfully treated with antibiotics; thus, antibiotics are not advised for all COVID-19 patients [5,6]. The WHO guidelines issued a strict warning against administering antibiotics in such situations and reported that the massive rise in antibiotic resistance is primarily attributable to the inappropriate use of antibiotics, including the prescription of unnecessary antibiotics or the use of antibiotics with an overly broad spectrum and the wrong dosage or duration [7,8].

Studies have shown that there has been a comparable rise in antibiotic usage with the growth in infectious illnesses, despite the fact that antibiotics neither treat nor prevent viral infections, including COVID-19 [9,10]. One of these studies reported that almost 80% of patients receiving antibiotics had no COVID-19 infection and were taking them ineffectively in an effort to stop the illness. Furthermore, even though only a small percentage (15%) of COVID-19 patients who were badly afflicted experienced bacterial co-infection, necessitating the need to start antibiotics, 75% of them ultimately received antibiotics [11]. Social media’s ability to spread panic and the fact that there is no recognized treatment for COVID-19-infected patients are both factors that helped to drastically increase the prevalence of self-treatment with medicine [12].

Unfortunately, self-treatment with medicine is on the rise across all societies globally, with some societies reporting prevalence rates of over 90% [13]. It has been shown that self-medicating with antibiotics can result in serious health issues, such as negative side effects, therapeutic failure, and, most importantly, antibiotic resistance [14,15]. The prevalence of self-treatment with medicine was as high as 82%, with 20% to 50% of antibiotics being misused, according to a systematic analysis that evaluated antibiotics consumption outside of authorized healthcare facilities in low- and middle-income countries in the Middle East [16]. There is limited published literature on antibiotic misuse during COVID-19 among the Lebanese population. This study aims to investigate the prevalence of antibiotic misuse during the pandemic in Lebanon.

2. Methods

2.1. Study Design and Participants

This cross-sectional research was carried out in January 2024. The Islamic University of Lebanon extended an invitation to all enrolled students to take part in this study. Participants in the study had to have had at least one COVID-19 infection. The goal was a non-random sample. The snowball method was used to recruit students in two phases. During the initial phase, all enrolled students at the university’s several campuses (Beirut, Baalbek, Tyre, Mount Lebanon) received an online questionnaire from the administrative or IT department. The students were encouraged to complete the questionnaire and share it with their families and community. Using the sample size calculator “Raosoft”, with a margin of error of 5%, confidence level of 95%, response distribution of 50%, and supposing a population size of 20,000, the sample size must be a minimum of 377 participants.

2.2. Instrument

The questionnaire was divided into three sections and contained 31 items: the participants’ sociodemographic information, lifestyle and past medical history, and antibiotic-related healthcare-seeking behaviors (Supplementary Data: questionnaire). Information on gender, age, education level, working field, monthly income, BMI, smoking, and medical history was gathered through sociodemographic questions. The behaviors included using antibiotics for self-treatment, using prescription drugs, reasons for antibiotic usage, and whether the COVID-19 vaccine was taken. Participants were also asked to list the antibiotic brands or chemicals that they had used. The questions on antibiotic use behaviors were adapted from previous studies [17]. The questionnaire was pre-tested on a pilot population (n = 15) to determine whether the data would provide reliable information, then translated into Arabic, then backtranslated into English to validate the translation. Students were also asked to state the chemical or brand names of antibiotics they had used. The survey was self-administrated and was made available online in both Arabic and English via a WhatsApp application. The internal consistency of COVID-19 and antibiotics (part 3 of the questionnaire) was determined by Cronbach’s alpha and was 0.729, which indicates very good reliability.

2.3. Ethical Considerations

A letter of information explaining the study’s objectives, confidentiality, and voluntary participation was sent out with the questionnaire. The continued filling of the questionnaire is considered a consent form. The questionnaire respects the total anonymity of the participants. The Hiram Hospital’s scientific and ethical committee gave its approval to the study protocol.

2.4. Statistical Analysis

To summarize the data on participant demographics and to provide the prevalence of antibiotic use, a descriptive analysis was carried out. Pretesting was done on the questionnaire. SPSS 21 software was used to examine the data once it was automatically saved online and downloaded in Excel format. Every result was double-checked to find any mistakes or discrepancies. According to the results, participants were classified into 2 groups: presenting with the use of antibiotics during COVID-19 infection or not. A bivariate analysis was performed to identify the variables affecting the use of antibiotics using Student’s t-test for continuous variables and χ² test for categorical variables. At α < 0.05, statistical significance was established. The odds ratios (ORs) and accompanying 95% confidence intervals (CIs) were estimated using bivariate analysis. With SPSS 21, all statistical analyses were completed.

3. Results

3.1. Socio-Demographic Characteristics

A total of 478 participants completed the questionnaire after discarding the participants that were not infected by COVID-19 infection or not proven by biological testing. The majority of respondents were women (71.8%, n = 343), and the mean age was 26.6 years [SD 9.44 years]. Most of the respondents (n = 401, or 83.9%) held a university degree, while 10.3% held a higher technical degree (n = 49). Of the total, 242 were employed in the health sector (50.6%), and 65.7% of the respondents (n = 314) had a monthly income of less than 10,000,000LL = 110$ (1$ = 90,000LL). While 59.6% (n = 285) of the individuals indicated they engaged in physical activity for more than two hours per week, 38.5% (n = 184) of the participants reported smoking. The mean BMI was 24.4 [SD 5]; according to the international classification of the BMI, 6.9% (n = 33) were classified as underweight (BMI < 18.5), 54.8% (n = 262) were classified as normal weight (BMI = 18.5 < 25), 27% (n = 129) were classified as overweight (BMI = 25 < 30), and 11.3% (n = 54) were classified as obese (BMI > 30) (

Table 1. Sociodemographic and other characteristics of participants.

Variables	Classification	Frequency (N)	Percentage (%)
Gender	Male Female	135 343	28.2 71.8
Diploma	University degree Higher technical	401 43	83.9 10.3
Working field	Health sector	242	50.6
Monthly income	<10,000,000 10,000,000–20,000,000 >20,000,000	314 66 98	65.7 13.8 20.5
Physical activities	Inactive (no physical activity) Moderately to very active (equal or more than two hours per week)	193 285	40.4 59.6
Smoking	Yes No	184 294	38.5 61.5
BMI	Mean ± SD Underweight (BMI < 18.5) Normal weight (BMI = 18.5 < 25) Overweight (BMI = 25 < 30) obese (BMI > 30)	24.4 ± 5 33 262 129 54	6.9 54.8 27 11.3
Chronic diseases	Cardiovascular diseases Pulmonary diseases (BPCO, Asthma) Diabetes Others	16 13 03 12	36.4 29.5 6.8 27.3

).

3.2. COVID-19 Infection

Among 80.3% of the participants (n = 384) who declared taking a COVID-19 vaccine, the majority (70.3% (n = 270)) declared taking two doses, and 23.9% (n = 92) took three doses. When asked about the severity of their COVID-19 infection, participants considered it to be mild in 28.2% of the cases (n = 135), moderate in 50.2% of the cases (n = 240), and severe in 21.5% of the cases (n = 103).

However, among the responders, 31.4% (n = 150) reported seeing a doctor to address the COVID-19 infection, and 7.7% (n = 37) reported being admitted to the hospital. Moreover, among the subjects, 40.2% (n = 192) were receiving antibiotic medication during the COVID-19 infection. Furthermore, the majority of participants who took antibiotics during their COVID-19 infection took one antibiotic, whereas the remaining participants took two (76.1%, n = 146 and 23.9%, n = 46, respectively); antibiotic treatment was prescribed by several people. A physician’s prescription is mentioned by some participants (51%, n = 98), followed by a pharmacist’s (23.4%, n = 45), self-taken (14.5%, n = 28), and others as family or friends (10.9%, n = 21). Furthermore, the findings indicated that the primary rationale for using antibiotics was either to lessen symptoms or as a preventative measure (n = 143 for 74.5% and n = 49 for 25.5%, respectively). However, 59.3% (n = 114) of the respondents respected the antibiotic therapy’s role, and 40.6% of the respondents (n = 78) discontinued taking the antibiotic when they felt better (

Table 2. COVID-19 infection.

Variables	Classification	Frequency (N)	Percentage (%)
COVID-19 vaccine	Yes No One dose Two doses Three doses	384 94 22 270 92	80.3 19.7 5.7 70.3 23.9
Perception of COVID-19 infection’s severity	Mild Moderate Severe	135 240 103	28.2 50.2 21.5
Doctor’s consultation	Yes No	150 328	31.4 68.6
Hospital admission	Yes No	37 441	7.7 92.3
Antibiotic treatment	Yes No One antibiotic Two antibiotics	192 286 146 46	40.2 59.8 76.1 23.9
Name of antibiotic	Azithromycin Augmentin Tavanic Don’t remember	37 22 12 121	19.3 11.5 6.2 63
Prescription of antibiotic	Physician Pharmacist Self-taken Others (family, friends…)	98 45 28 21	51 23.4 14.5 10.9
Rationale for using antibiotics	To lessen symptoms As a preventative measure	143 49	74.5 25.5
Symptoms as rationale for taking antibiotics	Fever Difficulty in breathing Chest pain Others: headache, muscle pain, back pain…	96 28 23 45	50 14.6 12 23.4
Respect the antibiotic therapy’s role	Respect antibiotic therapy’s role Discontinued the antibiotic treatment when felt better	114 78	59.3 40.6

).

3.3. Determinants of Antibiotic Misuse

No significant relationship was seen between antibiotic use and gender, BMI, education level, and working in the health field. However, results showed that there was a significant relationship between smoking and severity of symptoms (OR 2.077, 95% CI, 1.336% to 3.229%, p < 0.001) and antibiotic use (OR 1.802, 95% CI, 1.238% to 2.624%, p < 0.002). Similarly, those with COVID-19 infection symptoms that were severe took far more antibiotics (OR 2.318, 95% CI 1.489% to 3.610%, p = 0.000). Furthermore, a nearly significant correlation was seen between the usage of antibiotics and the individuals who were not vaccinated (OR 0.640, 95% CI 0.407% to 1.008%, p = 0.053) (

Table 3. Association between COVID-19 vaccine, smoking, and severity of COVID-19 infection with ATB use.

		Antibiotic Use		p-Value
		Yes	No
COVID-19 vaccine	Yes No	146 46	238 48	0.053
Smoking	Yes No	90 102	94 192	0.002 *
Perception of COVID-19 infection’s severity	Mild to Moderate Severe	134 58	241 45	0.000 *
Work in health sector	Yes No	90 102	152 134	0.179
Education level	University Level Others	155 37	246 40	0.123

* <0.05.

).

Data on the perceived severity of COVID-19 infection (not actual disease severity) and its correlations with gender, smoking status, and hospital admission are displayed in

Table 4. Association between gender, smoking, and hospital admission with severity of COVID-19 infection.

Severity of COVID-19		Perception of COVID-19 Infection’s Severity		p-Value
		Mild to Moderate	Severe
Gender	Male Female	114 261	21 82	0.046
Smoking	Yes No	130 245	54 49	0.001 *
Hospital admission	Yes No	15 360	22 81	0.000 *

* <0.05.

. Gender and perceived severity were found to be significantly correlated (p-value = 0.046). This shows that men may view their COVID-19 infection as more severe than women do. Additionally, there is a statistically significant correlation between perceived severity and smoking status (p-value = 0.001). Smokers may be more prone to believe that their infection is serious. The largest statistical correlation was found between perceived severity and hospital admission (p-value = 0.000).

No significant relationship was seen between nonprescription antibiotic use and gender. Nevertheless, results showed that there was a significant relationship between nonprescription ATB use and education level (p < 0.031) and working in the health sector (p < 0.004). Furthermore, a significant correlation was seen between respecting antibiotic therapy’s roles and working in the health sector (p = 0.053) (

Table 5. Association between nonprescription ATB, respecting ATB therapy’s role, and some other characteristics.

		Nonprescription Antibiotic Use			Respecting Antibiotic Therapy’s Role
		Physician Prescription ATB Use	Nonprescription ATB Use	p-Value	Yes	No	p-Value
Gender	Male Female	26 72	28 66	0.616	21 55	33 83	0.902
Education Level	University Level Others	85 13	70 24	0.031 *	61 15	94 22	0.895
Working field: Health Sector	Yes No	56 42	34 60	0.004 *	24 52	66 50	0.001 *

* <0.05.

).

4. Discussion

In addition to posing a challenge to global healthcare systems, the COVID-19 pandemic has raised a number of related issues. The misuse of antibiotics is one of the most important of them. Antibiotic resistance is a threat to world health because antibiotics, which are meant to treat bacterial illnesses, are frequently prescribed excessively or overused [18]. This issue is made worse by the combination of COVID-19 and antibiotic abuse, posing a dual risk to public health [19]. This study aimed to investigate the prevalence of antibiotic misuse during the COVID-19 pandemic in Lebanon. When the participants were asked about the severity of their COVID-19 infection, 28.2% of the cases considered it mild, moderate in 50.2% of the cases, and severe in 21.5% of the cases; 40.2% (n = 192) were receiving antibiotic medication during the COVID-19 infection. Additionally, 76.1% of the participants took one antibiotic during their COVID-19 infection, whereas the remaining participants took two (23.9%). Antibiotic treatment was prescribed by a physician for 51% of the participants, while the rest (49%) used antibiotics without consulting a doctor. Another supply-side player in antibiotic misuse is the pharmacy. It is worth noting that community pharmacists are a main source of healthcare information in the context of limited physician access, and patients frequently seek their services directly. Thus, they could play a significant role in dispensing and recommending antibiotic use to patients. It is imperative that pharmacists possess knowledge about the problem of antibiotic resistance, and policymakers ought to encourage the execution of public education campaigns regarding antibiotic usage in this context [20,21]. Moreover, community pharmacists typically have a strong awareness of and negative views regarding selling antibiotics without a prescription. Their procedures do, however, have some noticeable flaws, especially when it comes to patient education about the possible adverse effects of giving antibiotics without a prescription [22].

The majority of antibiotic use worldwide takes place outside of hospitals, and non-prescription antibiotic access is widespread [23,24]. In our study, 23.4% took antibiotics after consulting a pharmacist. Concerning the severity of the infection, there was a significant correlation between perceived severity, smoking status, and hospital admission.

The results showed that there was a significant relationship between nonprescription ATB use and education level and working in the health sector. Furthermore, a significant correlation was seen between respect for antibiotic therapy’s role and working in the health sector. Antibiotic abuse is more common among those with less education, though this is not always the case. In this study, participants who work in the health sector were more likely to use antibiotics after consulting a doctor, but not all of them respected the prescription rules. When compared to parents, a higher percentage of doctors and pharmacists in a Korean study thought that antibiotics could treat the common cold in children or lessen its complications. This suggests that healthcare professionals may also have false beliefs about the efficacy of antibiotics, similar to the general public [24]. A previous review found that more than one-third of patients who were prescribed antibiotics did not appropriately follow through on their antibiotic prescription and that 25% of patients kept any leftover drugs for later use [25]. These findings point to a widespread pattern of inadequate antibiotic prescribing and usage practices [26]. Another study performed in China found that antibiotic use is significantly influenced by gender, with men less likely than women to keep antibiotics at home or in their dorms. Another significant factor is the parents’ educational level, with a university education or higher being linked to a higher chance of keeping antibiotics in the home or dorm. There are variations in antibiotic use according to the province of residency; people from less developed provinces are more likely to misuse antibiotics. A medical background offers protection against some antibiotic usage behaviors [27].

Numerous research studies have revealed that developing countries are experiencing a rise in antibiotic resistance [23]. Several strategies may be used to address the issue of antibiotic misuse, such as controlling and monitoring physician prescribing practices to prevent over-prescribing; implementing successful health education programs to teach patients to take antibiotics exactly as prescribed; prohibiting the sale of antibiotics in pharmacies without a prescription; and encouraging patients to dispose of leftover antibiotics. Since this study is cross-sectional, one of its limitations is that it is unable to determine a cause-and-effect link between any variables and the behaviors associated with antibiotic misuse.

5. Conclusions

The misuse of antibiotics poses a serious threat to world health. Overuse and incorrect use of antibiotics are common problems. Sometimes, despite their ineffectiveness, they are given for viral diseases like the flu and colds. Antibiotic-resistant microorganisms are a result of this usage. Evidently, misusing antibiotics for self-limiting illnesses among participants was high. No significant association was detected between the nonprescription antibiotic use and gender. However, the findings indicated a strong correlation between the usage of nonprescription ATB and employment in the health sector and educational level. Additionally, a strong association was observed between respect for antibiotic therapy’s role and employment in the health sector. It is critically necessary to launch a campaign to encourage doctors to prescribe antibiotics appropriately, to enforce laws against the sale of medicines without a prescription, and to inform the public about the treatment of self-limiting illnesses.