Recently, an alarming issue in human health has come to light: the misuse of unused antibiotics. Antibiotics are potent drugs used to treat bacterial infections, but improper administration or storage can cause bacteria to develop resistance. This is why it is essential to complete the entire course of any prescribed antibiotic. Inadequate use of antibiotics can eventually lead to the development of antibiotic-resistant bacteria, so it is also important to be aware of the risks associated with stockpiling antibiotics. ¹ The primary risk associated with the misuse of unused antibiotics is the development of drug-resistant bacteria. If bacteria are repeatedly exposed to a particular antibiotic, they will develop resistance over time. In addition, if left untreated, this could lead to additional, more difficult diseases that may also be resistant to other drugs, ultimately leaving the infected significantly worse off than before they took the antibiotics. ²

Antibiotic resistance can frequently be traced directly to leftover or unfinished medications that have been hidden in homes or sold illegally online without a valid prescription. To combat this issue, it is crucial that governments around the world implement appropriate regulation systems so that appropriate safety precautions are taken whenever possible. ¹ In a study on the knowledge, attitude, and practice of antibiotic use and misuse among adults attending Primary Healthcare Centres (PHCs) in Arar, several factors have been proposed to explain the increase in antibiotic resistance, including self-medication, cultural factors, behavioral factors, lack of health education, socioeconomic status, education level, and patients‘/parents' pressure on physicians and pharmacists. In this study, 479 applicants participated, and the knowledge score (62.6±25.6) regarding the safe use of antibiotics was relatively high. ³

A similar study involving 141 participants in the city of Buraidah and the use of antibiotics found that 75.2% of the participants believe that antibiotics can be used to treat influenza and the common cold, 46.1% believe it is beneficial for fever, and 22.2% believe it is beneficial for headache. Additionally, 30% of participants believed that antibiotics should be kept at home and used when a family member becomes ill. In addition, 67% of study participants stated that antibiotic resistance is only an issue for those who take it and has no bearing on others. ⁴ A second study conducted in Kuwait with 680 participants revealed that 187 (27.5%) of the study population had taken antibiotics without a doctor's prescription within the past year. The majority of them, 166 (88.8%), were also prescribed antibiotics during this period. Ninety-seven (51.9%) of the self-medicated respondents indicated that they had given an antibiotic to another person without a doctor's prescription. 119 (63.6%) reported using antibiotics that were initially prescribed for an infection that recurred, and 21 (11.2%) for a different type of infection. In Kuwait, 59 (31.6% of respondents who self-medicated) purchased antibiotics directly from private pharmacies. Family members (n=50; 26.7%) and friends (n=7; 3.5%) were also sources of antibiotics. ⁵ A study was conducted to determine the prevalence of antibiotic self-medication in Saudi Arabia. More than one-third of respondents (43.4%) indicated that they sometimes self-medicate with antibiotics. Tonsillitis and pharyngitis (76.7%) are the most frequently reported conditions for which antibiotics were self-prescribed. They also discovered that the most common source of antibiotic self-medication was a previous prescription (36.6%). ⁶ Likewise, a study was conducted to evaluate the knowledge and attitudes of Saudi citizens regarding antibiotic use and self-medication. 63.6% of participants reported purchasing antibiotics from pharmacies without a prescription, and 71.1% reported not finishing the antibiotic course because they felt better. In addition, 44.7% of those who used antibiotics (prescribed or non-prescribed) reported keeping antibiotics from incomplete courses of treatment for future use. ⁷ Another study evaluates the general population's knowledge and attitudes regarding antibiotic use in Jeddah, Saudi Arabia. Almost half of those who used antibiotics did so without a prescription, obtaining them from a retail pharmacy (63.9%), a private clinic (15.3%), or someone else's supply (20%). In addition, they discovered that the majority of antibiotic prescriptions were for fever, pain, and/or inflammation (58.2%), followed by respiratory illnesses (21.2%). ⁸ According to a study conducted in China, 48.1% of participants kept antibiotics at home for their children. Regarding the origins of antibiotics, 63.1% of participants who kept antibiotics at home obtained them through a previous prescription, whereas 35.3% reported purchasing their antibiotics from pharmacies. ⁹ For the factors associated with keeping antibiotics at home, the study found that those with a higher level of education were more likely to do so, while those with a medical background were more likely to do so. ⁹

In a study conducted in Saudi Arabia measuring the knowledge of health-related students about antibiotics, 50.0% of participants believed antibiotics could be used safely without consulting a physician. ¹⁰ The majority of participants in the same study believed that antibiotics can be used instead of anti-inflammatory drugs to treat pain and inflammation. ¹⁰ In the previous study, the majority of participants believed that antibiotics could be used to treat viral infections, ¹⁰ and a similar study conducted in Qatar found that nearly half of participants believed antibiotics could be used to treat viral illness. ¹¹ This study also found that 82% of participants used antibiotics without a prescription, 37% used antibiotics prescribed for another family member, and 27% used antibiotics prescribed to them for a similar condition. ¹¹

According to research conducted in Saudi Arabia, certain risk factors may be more prevalent in Saudi Arabia than in other countries. As presented by a Riyadh hospital, one of the risk factors is the misuse of antibiotics. Unoptimized antibiotic dosage is another risk factor for the development of bacterial resistance. In addition, one of the most significant risk factors is travel to Saudi Arabia's holy cities, which presents an opportunity for the spread of infectious diseases. ¹² Another study that examined the use of antibiotics in tertiary hospital settings found that factors such as bed occupancy rate, average length of stay, and number of admissions had no bearing on the development of antimicrobial resistance (AMR), and the same was true for the number of bacteria and percentage of isolates in the group. ¹³ In a study examining participants' knowledge and attitudes regarding antibiotics, it was discovered that between 20 and 50% of the study population shared leftover antibiotics with family members. ¹⁴ In a separate study, the researchers discovered that a relative's leftover antibiotics, the use of leftover antibiotics from a similar episode of disease, and the presence of a runny nose, sore throat, and fever were all examples of situations in which leftover antibiotics were administered. ¹⁵

In 2022, 231 parents participated in a cross-sectional study conducted in six rural primary health centers in Peru to investigate the causes of limited awareness and self-medication of children with antibiotics. The largest knowledge gap was observed among 183 parents (79%) who were unaware that antibiotics are ineffective against viral infections. More than half of the parents (n=120, 52%) admitted giving their children antibiotics without a doctor's prescription. ¹⁶

From September to December of 2018, a cross-sectional survey of medical students from three universities in Colombia was conducted. 532 medical students participated in the study. In the past year, 49.1% of individuals utilized antibiotics. Only 18.2% of those surveyed were familiar with the term “antimicrobial stewardship,” and only 69.3% knew that empiric antibiotic therapy contributes to antibiotic resistance. 11.6% believe that antibiotics should be discontinued as soon as the patient's symptoms improve, while 24.6% believe that prescribing broad-spectrum antibiotics is the most effective way to ensure that the patient is treated. In terms of their actions, 28.5% of respondents are aware that resistance is a multifaceted problem, but they take no action because they believe that individual actions will have little impact. ¹⁷

Similarly, another cross-sectional study was conducted to investigate rural population knowledge, attitudes, and practices regarding self-medication in south-western Saudi Arabia in 2019. 58% of the 500 responses were from women, while 42% were from men. Pain (38.1%), influenza (26.3%), cough (24%), and allergies (24%) were treated with self-medication. 85% of patients did not consult a physician, were unaware of medicine information inserts, and did not check the expiration date. ¹⁸

738 participants of all ages, genders, nationalities, and socioeconomic backgrounds, residing in various regions of the kingdom of Saudi Arabia, responded to the online questionnaire (see Table 1). ²¹ 76.42% (n=564) knew what an antibiotic was a chemical substance used to treat infections, 14.09% (n=104) thought it was used to relieve pain, 3.25% (n=24) thought it was used to reduce fever, and 6.23% (n=46) had no idea. When asked when they begin using antibiotics, 95.66% (n=706) of the participants responded, after consulting a physician, 3.25 % (n=24) said when they felt ill for any reason, and 1.08% (n=8) replied after first attempting herbal medicine. When asked for which symptoms people most frequently use antibiotics, the following responses were provided: 38.08% (n=281) reported a sore throat, 32.11 (n=237) a fever, 27.10% (n=200) a cold, and 2.71% (n=20) a cough. 28.32% (n=209) of participants selected allergy as the most common side effect of antibiotics, followed by 21.82% (n=161) who selected stomachache, 7.87% (n=58) who selected rash, and 5.01% (n=37) who selected difficulty breathing. The remaining participants chose multiple adverse effects. When asked to define antibiotic resistance, 68.43% (n=505) of respondents said it is a microorganism's adaptability against antibiotics, 3.6% (n=27) said it is a decrease in antibiotic efficacy due to manufacturing errors, and 27.19% (n=206) said they had no idea.

When asked if they take antibiotics when experiencing any new non-specific symptom, the following responses were given by the participants: 46.07% (n=340) strongly disagreed, 29.95% (n=221) disagreed, 12.47% (n=92) were neutral, 7.32% (n=54) agreed, and 4.2% (n=31) strongly agreed. 71.54% (n=528) of the participants strongly agreed, 20% (n=149) agreed, 4.61% (n=34) were neutral, 1.76% (n=13) disagreed, and 1.90% (n=14) strongly disagreed when asked if they only use antibiotics with a prescription. 71.41% (n=527) of participants responded with strong agreement to the question, 21% (n=155) with agreement, 4.61% (n=34) with a neutral response, 2.44% (n=18) with disagreement, and 0.54% (n=4) with strong disagreement. When asked if they stored the antibiotics according to the label's instructions, 91.19% (n=673) said yes, while 8.8% (n=65%) said no.

When asked if limiting antibiotic prescriptions was a good idea, 91.33% (674 of 674) of participants agreed, while 8.67% (n=64) disagreed. When asked whether prescribing antibiotics encourages their misuse, 82.79% of the respondents (n=611) said “yes,” while 17.21% said “no.” When asked what they believed could be done to reduce antibiotic resistance, 35.64 % (n=263) said antibiotics should only be taken when prescribed by a doctor, 18.56% (n=137) said living a healthy lifestyle would increase immunity, lower the risk of infection, and reduce the need for antibiotics, and 11.92% (n=88) said antibiotics should only be used in life-threatening situations. Only 20.05% (n=148) of the respondents have participated in an antibiotics campaign, but 88.08% (n=650) believe that antibiotics campaigns can alter community habits.

There is no correlation between average household income and the storage and reuse of antibiotics (p>0.30). A statistically significant correlation existed between age and the use of unused antibiotics (p=0.0019). The remaining 311 participants did not use any leftover antibiotics: 33 (22.4%) were under 20 years of age, 77 (52.38%) were 20—29 years of age, 18 (12.24%) were 30—40 years of age, and 19 (12.93%) were older than 40 years of age. There was no statistically significant correlation between gender and the use of leftover antibiotics (p>0.05); among the 147 participants who used leftover antibiotics, 79 were male (53.74%) and 68 were female (46.26%). There was a statistically significant correlation between having children and reusing antibiotics; among the 147 participants who reused antibiotics, 30 (20.41%) had children, while 117 (79.59%) did not. There was no statistically significant correlation between the number of children and the use of leftover antibiotics. Eight (26.67%) of the 30 participants who used leftover antibiotics and had one or two children, nine (30%) had three or four children, and 13 (43.33%) had more than four children. There was no statistically significant correlation between the level of education and the use of unused antibiotics. Among the 147 participants who used leftover antibiotics, 102 (69.39%) had a college degree or higher, while 45 (30.61%) did not complete high school. There was no statistically significant correlation between occupation and the use of leftover antibiotics; 45 (30.61%) of the 147 participants who used leftover antibiotics were healthcare workers, while 102 (69.39%) were non-healthcare workers. We also found no statistical significance between chronic illness and knowledge of antibiotics or attitude toward unused antibiotics. Additional answers are depicted in Figure 1.

When asking what antibiotics are and when they should be used, having 738 participants from all regions of Saudi Arabia helped us gain a deeper understanding of the various backgrounds and educational levels of the participants. Providing an analysis of the impact of media and awareness campaigns, when asked when they typically begin using antibiotics, 95.66% (n=706) of respondents said after consulting with a physician. This majority may indicate a high level of awareness, but it may also indicate that the health ministry is effectively implementing and monitoring the restrictive system. Another study conducted in Saudi Arabia in 2021 revealed that 82% of participants who were able to obtain antibiotics did so without a prescription. ¹⁰

Another study conducted in Kuwait with 680 participants revealed that 27.5% of the study population had taken antibiotics without a prescription in the previous year. 97 (51.9%) of the self-medicated respondents reported giving an antibiotic to another individual without a prescription. 119 (63.6%) reported using antibiotics initially prescribed for a recurrent infection, while 21 (11.2%) reported using antibiotics for a different type of infection. Family members (n=50; 26.7%) and friends (n=7; 3.5%) were also sources of antibiotics. In Kuwait, 59 (31.6%) of respondents who self-medicated purchased antibiotics directly from private pharmacies (3). When asked when they first used antibiotics, 95.66% (n=706) of the participants in our study said after consulting a doctor, 3.25% (n=24) when they felt ill for any reason, and 1.08% (n=8) after trying herbal medicine for the first time. ¹

A study revealed that 81.4% of the respondents believed that antibiotic resistance occurs when the body develops a resistance to antibiotics and ceases to function properly. ¹⁹ When asked what they believe could be done to decrease antibiotic resistance, 88.08% (n=650) of respondents believe that antibiotics campaigns can alter community habits. Community-wide attitude shifts can be easily implemented with the aid of campaigns, resulting in a decline in antibiotic resistance. There was a statistically significant correlation between participant age and the use of unused antibiotics (p=0.0019). 33 (22.4%) of the 147 participants who used unused antibiotics were younger than 20 years old, 77 (52.38%) were 20—29 years old, 18 (12.24%) were 30—40 years old, and 19 (12.93%) were older than 40 years old. We can attribute the increase in the use of leftover antibiotics in the 20—29 age group to multiple factors, including the high proportion of participants in this age group (51.08%). There were numerous perspectives on antibiotic use (n=377), resulting in unregulated use.

There was a statistically significant relationship between having children and reusing antibiotics; of the 147 participants who reused antibiotics, 30 (20.41%) had children, while 117 (79.59%) did not. This statistic indicates that participants with children were more hesitant than those not having any, either because they feared the side effects of reusing antibiotics or because they were more cautious when it came to their children. There was no statistically significant correlation between occupation and the use of leftover antibiotics; 45 (30.61%) of the 147 participants who used leftover antibiotics worked in healthcare, while 102 (69.39%) did not. This statistic indicates that although healthcare professionals have greater access to information about antibiotics, they continue to use unused antibiotics, which may contribute to an increase in antimicrobial resistance.

A 2022 cross-sectional study revealed that 79% of 183 parents were unaware that antibiotics are ineffective against viral illnesses. ¹⁶ 76.42% (n=564) of those surveyed in our study were aware that antibiotics are chemical substances used to treat bacterial infections; 14.09% (n=104) believed it was used to relieve pain; 3.25 % (n=24) believed it was used to reduce fever; and 6.23% (n=46) had no idea. A similar study involving 141 participants in the city of Buraidah and the use of antibiotics found that 75.2% of participants believed that antibiotics can be used to treat influenza and the common cold, 46.1% believed that antibiotics are beneficial for fever, and 22.2% believed that antibiotics are beneficial for headache. In addition, 30% of participants believed that antibiotics should be kept at home and administered to sick family members. In addition, 67% of study participants stated that antibiotic resistance is only a concern for those who take it and has no effect on others. ¹⁵ Antibiotics were used to treat pain (38.3%) and cough (24%) in another cross-sectional study conducted in south-western Saudi Arabia in 2019. According to our study, participants used antibiotics for the following reasons: 38.08% (n=281) reported a sore throat, 32.11 (n=237) reported a fever, 27.10% (n=200) reported a cold, and 2.71 (n=20) reported a cough.

When addressing the decision to stop antibiotics once the patient is symptom-free, studies have yielded variable results; however, 71.1% of patients did not complete their antibiotic treatment because they felt better. ⁷ A 2018 survey revealed that 11.6% of respondents believed that antibiotics should be discontinued as soon as symptoms subside. While our research yielded similar results to the first study, with 71.41% (n=527) of respondents stating that they complete the course as instructed; the first study had a larger sample size. ¹⁸ The presence of expired pharmaceuticals in the home can increase the risk of toxicity, suicide, and accidental poisoning of children, ¹⁹ whereas the presence of unused antibiotics indicates antibiotic misuse and may increase the likelihood of antibiotic resistance. ²⁰

Storage at an improper temperature could have negative consequences. Low-stability medications, such as penicillin and cephalosporin, are easily weakened or rendered ineffective by improper storage temperature conditions. They may hinder the recovery from infections. In our study, 91.19% (n=673) of the participants stored the antibiotics in accordance with the label's instructions, while 8.81% (n=65) did not. Our study demonstrates that participants with a higher level of education keep and utilize unused antibiotics, corroborating a Chinese study which found that individuals with a higher level of education are more likely to keep antibiotics at home. In contrast to their findings, our study reveals that medical personnel were less likely to retain unused antibiotics than non-medical personnel. Among the 147 participants who used leftover antibiotics, 102 (69.39%) had a bachelor's degree or higher and 45 (30.61%) did not. 45 (30.61%) of the 147 participants who used leftover antibiotics were healthcare professionals, while 102 (69.39%) were not. ⁹

In a study, the prevalence of antibiotic self-medication in Saudi Arabia was determined. Over one-third of respondents, or 43.4% reported that they self-medicate with antibiotics on occasion. ⁶ While our study demonstrates that the majority of participants (71.54%; n = 528) only used antibiotics when prescribed, there were a number of participants who used antibiotics off-label. Tonsillitis and pharyngitis account for 76.7% of all instances of antibiotic self-medication. ⁶ Our study reveals that 38.08 percent (n=281) of individuals who self-medicate with leftover antibiotics do so for sore throat, 32.11% (n=237) for fever, 27.10% (n=200) for the common cold, and 2.71% (n=20) for cough. Another study assessed the knowledge and attitudes of the general population in Jeddah, Saudi Arabia, regarding the use of antibiotics. Nearly half of antibiotic users obtained them without a prescription from a retail pharmacy (63.9%), a private clinic (15.3%), or someone else's supply (20%). This study was published in 2018, prior to the 2019 announcement of penalties for violating Saudi Arabia's restrictive regulations. The regulations, which were announced for the first time in 2015, stipulated that pharmacists who sell antibiotics without a written prescription will be subject to a 100,000 SAR fine, license revocation, or six months in jail. In addition, they discovered that fever, pain, or inflammation were the most common reasons for taking antibiotics (58.2%), followed by respiratory illnesses (21.2%). ⁸ In a study conducted in Saudi Arabia to evaluate the knowledge of health science students regarding antibiotics, 50% of participants believed antibiotics could be used without consulting a doctor (8). 71.54% (n=528) of the participants in our study believed antibiotics should only be used when prescribed, with 48% (n=204) of these respondents being healthcare professionals.

While it is understandable that people may believe storing unused antibiotics will be useful in the event of an emergency, there are numerous risks associated with doing so. Although the Saudi Ministry of Health has implemented stringent measures to reduce antimicrobial resistance caused by antibiotic misuse by restricting the dispensing of antibiotics from pharmacies without a prescription, a sizeable proportion (20%) of our sample participants, regardless of age, level of education, or profession, have continued to store excess antibiotic pills after an infection treatment and re-use them. This calls for further revision of the current measures to fill those gaps and reduce this practice, such as selling/distributing the exact number of pills required to treat the current infection per prescription and increasing awareness of the consequences of using antibiotics excessively without consulting a doctor. This may also have an economic benefit, as more antibiotic pills will be available for additional prescriptions.

Ethical approval was received from the institutional review board of The Majmaah University for research committee (MUREC) (HA-01-R-088) with the ethical number MUREC-f uly.28/COM-2022/1O-2. Information from the questionnaire will be kept confidential and only used for statistical purposes.