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A community-based study of antibiotic consumption in an urban health training centre area of Ahmedabad city
For correspondence: Dr Rashmi Sharma, Department of Community Medicine, GMERS Medical College, Ahmedabad 380 060, Gujarat, India e-mail: drrashmi_psm@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Sharma R, Patel PN, Patel NR, Gajjar SA, Patel BP, Chandegara A, Bapat NK. A community-based study of antibiotic consumption in an urban health training centre area of Ahmedabad city. Indian J Med Res. 2026;163:327-33. doi: 10.25259/IJMR_452_2025
Abstract
Background and objectives
The rise of antibiotic resistance is a global health crisis, and the irrational use of antibiotics is the major contributing factor. Therefore, it is essential to understand the antibiotic usage in the community to estimate the prevalence of antibiotic usage and its association with various co-variates and to evaluate the consumption pattern of antibiotic usage in the catchment areas of the Urban Health Training Centre of a medical college in Ahmedabad City.
Methods
An observational, community-based cross-sectional study was conducted in 3 phases during May-Aug 2024. Estimated sample size was 315 individuals who were ill anytime in last three months or consumed drugs and were selected from 15 clusters identified by cluster sampling method. Information was gathered on a structured questionnaire, and statistical parameters such as prevalence, prevalence ratios, confidence interval, and chi-square test were calculated in MS Excel.
Results
The screening of 2278 participants yielded 349 eligible participants as per inclusion criteria and 117 (33.5%) of them consumed 152 antibiotics during the previous three months. Sociodemographic determinates like age, sex and qualification of treatment provider showed significant association with antibiotic usage. Use of antibiotics was higher 55 (42.6%) in children than in adults 62 (28.1%). As per AWaRe classification (WHO), 3/4th of the participants (59.9%) consumed the watch group, more than half (50.4%) consumed the Access group and 2 (1.7%) consumed the Reserve group of antibiotics. Antibiotics are prescription only drugs, still in 37.5% of cases, antibiotics, even those from the Watch group, were obtained without a prescription.
Interpretation and Conclusions
Overall, a concerning trend of antibiotic use without prescriptions was witnessed, specifically in the ‘Watch’ category of antibiotics. It highlights the need for improved prescribing practices and public education to prevent misuse of antibiotics.
Keywords
Antibiotic consumption
India
Prevalence
Urban
WHO AWaRe classification
Antibiotics are used for the prevention or treatment of microbial infections.1 Around 50% of antibiotic consumption is irrational, irresponsible, or without clinical need.2 Despite being ‘prescription-only drugs’, over-the-counter (OTC) sales and the use of antibiotics without proper medical supervision is common in India.3 The WHO has classified antibiotics into three categories Access, Watch, and Reserve (AWaRe) to regulate their usage by allowing the use of Access group antibiotics and reducing the use of the Watch and Reserve group antibiotics.4
Except for a few,5 most studies focusing on this subject are institution-based and therefore, do not cover OTC-based and without-prescription consumption of antibiotics. One of the biggest contributory factors for the development of anti-microbial resistance (AMR) is the irrational and irresponsible use of antibiotics.2 Therefore, prior to study the AMR, it is essential to study the magnitude and the pattern antibiotic consumption in the community. With this background, the present study has been undertaken in the community settings with the objectives to estimate the prevalence and covariates of antibiotic consumption in the study population and to evaluate the antibiotics consumption pattern by using the AWaRe classification.
Methods
An observational community-based, cross-sectional study was conducted at the catchment area under the Urban Health Training Center (UHTC) in Ognaj (population=1.65 lakhs), associated with a medical college of Ahmedabad. Ethical clearance was obtained from the local Institutional Ethics Committee (IEC). Participants were informed about the purpose of the study through the participant’s information sheet (PIS). Informed written consent from all adults and assent (<18 yr) was obtained. Data confidentiality was ensured throughout the process.
Sample size and sampling technique
The sampling technique used was the cluster sampling method.6 This method saves the time and resources and gives representation to all geographical units of the reference population. Number of clusters can be 30, 15 or 10, however, the design effect increases when number of clusters decrease. Due to the time constraints, we studied 15 clusters which increased the design effect. The initial sample size calculated was 304 based on the prevalence of antibiotic consumption as 76%7, at a 95% level of significance with a relative precision of 10%, a non-response rate of 20%, and a design effect of 2. Number of cases per cluster was 20.26 which was rounded off to 21 to increase the sample size to 315. Study units were polio immunisation booths (24) coded as A001 to X0024 under the micro plan used in Pulse Polio Immunisation. Out of these 24 units, 15 were selected as study clusters as per the method given below.
List of all 24 areas with their population was obtained and cumulative population was calculated (165535). Cumulative population was divided by number of clusters (15) and it gave the sampling interval of 11036. A random number (< sampling interval) was selected by a currency note (8280). The population belonging to this number was selected as first cluster. The first selected random number plus the sampling interval gave the location of second cluster (8280 +11036=19316). Likewise, all 15 clusters were selected.
Once clusters formed, survey was started from a central place. Direction to move and first house to start was identified by rotating a glass bottle and a random number again identified through currency note (only the last digit or second last digit if the last one was zero), respectively. Team moved in the area with the enrolment of eligible study subjects till the assigned number (21) was achieved. If the selected cluster could not yield this number, next nearest cluster was studied. Data was collected from May to August 2024 in three phases,
First phase
In this phase there were 21 participants per cluster as per the following inclusion criteria: (i) anyone (all ages) having illness episodes or had taken drugs in the prior three months and (ii) available at the time of the survey and willing to participate in the study were included. The first participant was randomly selected from the central point of the cluster followed by the selection of subsequent participants serially until the desired sample of 21 from each cluster was achieved. If 21 participants were not obtained in a selected cluster, areas from adjoining clusters were included. All participants were included if the last household had more than one eligible participant. Actually, number of respondents were to be 315 (21*15). However, we collected responses from 349 individuals. If the last household had more than one case with illness, then all such cases were included. Secondly post field visit scrutiny revealed that some of the forms were incomplete. Therefore, to compensate this loss we went back to cluster and collected additional responses (following the guidelines of cluster sampling method). Due to these two reasons, the number increased from 315 to 349.
Second phase
All selected eligible participants were further verified about antibiotic consumption including their various social and demographic characteristics such as age, sex, occupation, socioeconomic8 status, etc., by the investigators.
Third phase
Those having a confirmed history of antibiotic consumption in the past three months were interviewed through self-designed and pilot tested data collection tools, prepared by investigators and validated for face and content validation in a workshop conducted under the guidance of a senior faculty provided as mentor by the sponsoring organisation. Prescriptions, physical drugs, text messages, WhatsApp images, and bill details were checked for confirmation of antibiotic consumption and related information. Data quality was ensured through field-testing of questionnaires and frequent review meetings.
Statistical analysis
Statistical parameters such as proportions, period (3 months) and point prevalence per 100 persons (ill or consuming drugs detected during first phase of survey along with 95% confidence intervals). Prevalence Ratio were calculated. Statistical tests such as chi square were used with a level of significance of P<0.05.
Result
Profile of study participants
A total of 2278 individuals (from 549 families) were screened in 15 clusters which yielded 349 eligible participants (247 families) who reported 358 spells of illness (including 9 participants with two spells of illness) in the last 3 months. The period prevalence of illness in surveyed population was 15.3% (349/2278*100). Break up of these participants (349) revealed that they were from nuclear families (64.6%), above the poverty line (APL) (59.5%), and from social classes 1 to 4 (56%). There were more females (51.3%) with an overall literacy of 89.7%. Mean age of participants was 29.2±21.9 yr with a median of 30 yr (range: 11 months - 89 yr). Among adults (>18 yr), most were married 185 (84.1%). Out of 349 participants, 61 (17.5%) had one or more illness, including 2 participants on anti-tuberculosis treatment. Out of 349 cases with reported illnesses, 31 (8.9%) were hospitalised, and the rest took OPD/daycare-based treatment. Treatment was mainly provided through MBBS/BDS doctors 142 (40.6%), followed by specialist/super-specialist doctors 119 (34%); while the rest were treated by providers of alternative medicines or quacks.
Antibiotic use
Antibiotic consumption was obtained mainly through prescriptions in 89 (76%) cases and 72 (61.6%) of them could show it as well. Rest 28 (23.9%) obtained antibiotic without a prescription (through OTC, via health care workers/friends, self-medication, through teleconsultation, quacks, or previous prescription). 117 had confirmed records of consumption of antibiotic(s). Therefore, the overall period prevalence (3 months) of antibiotic consumption was 33.5% (117/349). The most common indication for consumption was fever (54.7%) followed by gastrointestinal tract symptoms (42.7%), and respiratory tract symptoms (41%). Less than one-fourth of the participants (22.2%) were investigated by laboratory tests (mostly Blood CBC and Urine routine including sugar, albumin and microscopy) before antibiotic consumption. The consumption was higher in males 66 (38.8%) than in females 51 (28.5%). The prevalence was higher 55 (42.6%) in children (<18 years) than in adults 62 (28.1%). Among children, it was further higher, 30 (52.6%) in under-fives, and among adults, it was slightly higher in the geriatric population 15 (34.9%) (Table I). Out of 117 who took antibiotics during the preceding 3 months, 68 (58.1%) had completed their antibiotic course while 36 (30.8%) were still (at the time of survey) on antibiotics. Rest (13 or 11.1%) had stopped the antibiotics due to the side effects or because they felt better.
| Characteristics | Antibiotic consumers | Prevalence (%) | 95% confidence interval |
|---|---|---|---|
| Sex | |||
| Male (n=170) | 66 | 38.8 | 31.5-46.6 |
| Female (n=179) | 51 | 28.5 | 22.0-35.7 |
| Age (yr) | |||
| ≤5 (n=57) | 30 | 52.6 | 39.0-66.0 |
| 5 - 17 (n=72) | 25 | 34.7 | 23.9 - 46.9 |
| 18 – 60 (n=177) | 47 | 26.6 | 20.2-33.7 |
| ≥ 60 (n=43) | 15 | 34.9 | 21.0 -50.9 |
| Total (n=349) | 117 | 33.5 | 28.6 -38.7 |
The association between the prevalence of antibiotic consumption and socio-demographic variables like age, sex, and qualification of treatment provider was statistically significant. Similar analysis with other variables like education, occupation, family type, socioeconomic status, employment status, poverty status, marital status, presence of co-morbidities did not exhibit significant association. An association was seen between antibiotic consumption and the number of episodes of illnesses (Prevalence Ratio=2.4, P=0.004) (Table II).
| Characteristics | Antibiotics consumed in the last 3 months | Prevalence Ratio & (95% CI) | |
|---|---|---|---|
| Yes (n=117) | No (n=232) | ||
| Sex (Reference female) | |||
| Male | 66 | 104 | 1.6 (1.2 – 2.1)* |
| Female | 51 | 128 | |
| Age (yr) (Reference adults) | |||
| Children (<18 yr) | 55 | 74 | 1.5 (1.1 – 2.0)* |
| Adults (≥ 18 yr) | 62 | 158 | |
| Comorbidities (Reference morbidity: no) | |||
| Yes | 110 | 228 | 0.5 (0.3 – 0.8)* |
| No | 7 | 4 | |
| Episodes of illness (Reference single episode of illness) | |||
| 1 | 110 | 230 | 2.4 (1.6 – 3.5)* |
| 2 | 7 | 2 | |
| Modalities of treatment (Reference OPD/day care based) | |||
| IPD based | 19 | 44 | 0.88 (0.6-1.3) |
| OPD-based/Day-care | 98 | 188 | |
| Qualification of treatment providers (Reference non MBBS doctors) | |||
| MBBS/MD/MS/Specialist | 110 | 152 | 5.2 (2.5 – 10.8)* |
| Non-MBBS | 07 | 80 | |
P*<0.05
Pattern of antibiotics as per AWaRe classification
A total 152 antibiotics were consumed by 117 participants in the last three months. Consumption was highest for the Watch group of antibiotics (91 or 59.9%) followed by the Access Group (59 or 38.8%). There were only 2 used from the Reserve group. Out of 152 antibiotics, 57 (37.5%) were obtained without prescription. The tendency to obtain antibiotics without a prescription was highest in the Access group (49.2%) antibiotics, followed by the Watch group (30.8%). In the Reserve group, antibiotics were obtained always with a prescription. The prescription status of top 3 commonly consumed antibiotics in each of the groups is shown in Figure 1.
- Prescription status of top 3 common Antibiotics (as per WHO AWaRe classification) consumed (N=152). Here, A: Amoxycillin+ Clavulanic Acid, B: Metronidazole, C: Ornidazole, D: Cefixime, E: Azithromycin, F: Ofloxacin, G: Linezolide. *Consumption of only 1 Reserve category antiobiotic reported.
When viewed separately, in 55 children with 70 antibiotics, consumption from watch group 41(58.6%) was higher than from access group 29 (41.4%); no drug was used from the “Reserve” group. Oxazolidinones, nitrofuran, tetracycline, rifamycin family, and anti-TB group of antibiotics were consumed by adults only, however, cephalosporin, beta-lactamase, and penicillin group of antibiotics were consumed more in children compared to adults. There was no antibiotic consumed from the Reserve group in paediatric cases (Fig. 2). Consumption pattern of antibiotics as per the AWaRe classification in various age group is shown in Figure 3. Consumption of Watch group of antibiotics was quite common while that reserve group was seen only among elderly persons. It was the same antibiotic in 2 cases from this age group (Fig. 3).
- Consumption of antibiotics in adults vs. children (N=152). Access=Amoxycillin+Clavulanic acid, Metronidazole, Ornidazole, Isoniazid, Amoxicillin, Doxycycline, Nitrofurantoin, Penicillin, Sulbacaum+Cefoperazone. Watch=Cefixime, Azithromycin, Ofloxacin, Levofloxacin, Cefpodoxime, Cefpodoxime + Clavulinic acid, Cefpodxime, Cefuroxime, Ethambutol, Pyrizinamide, Rifampicin, Meropenem, Rifaximin, Ceftriaxone, Ciprofloxacin, Norfloxacin+Tinidazole. Reserve=Linezolid. Here, A: Cephalosporin, B: Fluoroquinolones, C: Anaerobic, D: Macrolide, E: Anti-TB, F: Beta-lactamase, G: Penicillin, H: Nitrofuran, I: Oxazolidinones, J: Tetracycline, K: Rifamycin Family, L: Carbapenem.
- Age wise antibiotic consumption as per WHO AWaRe classification (n=152 antibiotics in 117 individuals).
Discussion
Studies have reported an increase in antibiotic consumption in India.9-11 A trend analysis of antibiotic consumption in India (2000–2015), showed an increasing trend of antibiotic consumption, especially for Cephalosporins and broad-spectrum penicillin.1 Period prevalence varies in different studies depending on the recall period. The current study reported a period prevalence lower than even the point prevalence of 71.9% from a study of India12 and 53.0% from a study of Thailand.13 It is understandable as these studies12,13 were the centre-based Higher antibiotic consumption (57.1%) was reported in the geriatric population in another study13 than observed in the current study.
Young children are at a higher risk of infections due to their fragile physiology, greater bacterial exposure, and lack of immunity.14 Present study also found high antibiotic consumption among children. In the current study, higher consumption was observed in males than in females in contrast to earlier studies where females had a higher antibiotics consumption.5 Females are relatively less exposed to external environments than males.15 In the current study, association with occupation, family type, socioeconomic status, employment status, poverty, and marital status did not exhibit significant association. A significant association found between antibiotic consumption and the number of episodes, is in agreement with another study where antibiotic consumption was higher among those with fair health status than with those with good health status.5 Doctors trained in modern medicine are expected to get basic investigations such as complete blood count (CBC) or urine routine tests done, to pinpoint the diagnosis and justify the prescription of antibiotics. An important finding in the current study is that though 110 patients were prescribed antibiotics by doctors trained in modern medicine, however, before advising the antibiotics only in 22% cases, basic investigations were conducted.
Overall, a concerning trend of antibiotic use without prescriptions is seen, especially among medications in the Watch category and more so among children.16 All antibiotics were prescription only drugs, still in 37.5% of cases, antibiotics, even those from the Watch group, were obtained without a prescription. Antibiotics from the Access category are key to treating the majority of infections without risking the development of drug resistance17 however, the more use of antibiotics from the Watch category than the Access category in our study is another matter of concern. Most commonly used antibiotic from the Access group in the current study (with or without prescription) was amoxycillin in combination with clavulanic acid. Another study5 also found it as the most common antibiotic being used. A trend analysis (2000–2015) also found an increase in consumption of cephalosporins and broad-spectrum penicillin.12 Linezolid the only antibiotic from the Reserve category used in the current study was also found to be most commonly available in 29.3% of community pharmacies in Nepal.17 Procuring the antibiotics without a prescription is not the only thing to blame in this regard as in the current study, out of 95 prescriptions by qualified treatment providers, 68.4% prescribed the antibiotics from the Watch and Reserve categories. Two important factors of increased antibiotic consumption in India are the role of the private sector (comparatively less regulated) and the tendency of self-medication. The current study has reported a self-medication (9.1%) which was lesser than reported by a Brazilian study (19%).5
The strength of this study was that being a community-based study for antibiotic consumption using WHO AWaRe classification and scrutinising available prescriptions. Limitations of this study were (i) antibiotic consumption and its association with other characteristics may have been underreported due to the recall bias or the inability to share the medical records, (ii) as a limitation of cross-sectional study, the association between characteristics and prevalence does not imply causation, (iii) use of cluster sampling method with 15 clusters may have resulted in a selection bias, however, we compensated for this by considering the design effect as 2 and accordingly doubled the sample size, (iv) recall period of 3 months in present study was not comparable with other studies with different recall periods and (v) antibiotic consumption is not uniform throughout the year, therefore, the influence of seasonal factors does influence antibiotic consumption leading to measurement bias. The findings of this study emphasise the urgency of addressing behaviour and systemic gap contributing to antibiotic misuse. Community awareness regarding self-medication and adherence to treatment protocol is required. Training cum sensitisation sessions regarding the rational use of antibiotics and restricted prescription of antibiotics from the Watch group is recommended to policymakers.
Acknowledgment
Authors acknowledge the State Health System Resource Centre (SHSRC), Gujarat for providing technical guidance.
Financial support & sponsorship
The study received funding support from the State Health System Resource Centre (SHSRC), Gujarat (No. SHSRC/KMD/F.N.358/2024/3107-3109).
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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