Assessment of Community Pharmacists’ Knowledge, Attitude and Practice Regarding Non-Prescription Antimicrobial Use and Resistance in Thailand

Background: An estimated two-thirds of global sales of antimicrobials occur over the counter without a prescription. Furthermore, antimicrobials are the most commonly sold medicines in developing countries. The overuse, misuse, or inappropriate use of antimicrobials are major contributing factors to the emergence of antimicrobial resistance. This does not only lead to failure of therapy, increased morbidity and mortality, and rise in healthcare costs, but it puts these countries on a fast track to the pre-antibiotic era. Thailand is experiencing soaring antimicrobial resistance. A few studies suggest that inadequate knowledge, incorrect attitudes and malpractices of healthcare professionals and patients regarding the use of antimicrobials and reducing the emergence of antimicrobial resistance may be fuelling this crisis. Pharmacists in particular, may have a key role in rationalising the use of antimicrobials in community and reducing the emergence of resistance. Aim This study aims to assess pharmacists’ knowledge, attitudes and practices regarding antimicrobials use over the counter and antimicrobial resistance. Methods A cross-sectional descriptive study was conducted using online self-administered questionnaire for pharmacists in Bangkok and Chonburi province in Thailand between May and July 2017. The self-administered questionnaire was developed following a review the literature relating to pharmacists and healthcare professionals using the Knowledge, Attitude and Practices (KAP) model regarding antimicrobial use and resistance. The questionnaire was validated by an expert panel and its validity and reliability was tested in a pilot study. Statistic Package for the Social Science (SPSS) software version 24 was used for statistical analysis. The Cronbach’s alpha and Interclass correlation coefficients (ICC) were used to test of reliability. Kolmogorov-Smirnov Test was used for normal distribution testing. Descriptive data were examined by the median, interquartile range (IQR), Chi-squared test. Mann-Whitney U Test and Kruskal-Wallis test were used to describe associations between demographics with knowledge, attitude and practice of participants. Relationships between knowledge, attitude and practice dimensions were analysed by regression equations and Spearman’s correlation coefficient statistic. Qualitative data were coded and presented as percentages. Results 372 pharmacists completed the questionnaire obtaining a response rate of 71.4%. The community pharmacists age average was 32.02 (± 5.81) years. Most participants hold a bachelor degree in pharmacy (77.2%), and work at individual/ independent drug stores (62.6%). The average experience in community pharmacy is 5.46 (± 4.31) years. 69.4% of the participants work in Bangkok and 30.6% work in Chonburi. More than 90% of pharmacists have good knowledge, attitude and practice in antimicrobial use and resistance. However, there is only a slight correlation between attitude and practice score at rho = 0.149, p-value 0.004. The most commonly encountered infections are respiratory infections and Aminopenicillin is the main drug provided in pharmacies. The main reported reason of pharmacists to provide antimicrobials without a prescription was their confidence in their competency. Conclusion Respiratory infections were the most commonly encountered infections in community in Thailand, with Aminopenicillin being the most commonly dispensed antibiotic. Community pharmacists in Thailand report competence as the main reason for them providing antimicrobials without a prescription. This study shows that over 90% of them have good knowledge, attitude, and practice regarding antimicrobial use and resistance. Pharmacists in Thailand could sustain their competence through continuing education, adherence to antimicrobials guidelines, collaboration with other healthcare providers, and raising public awareness regarding antimicrobial use and resistance. Pharmacy associations could support pharmacists to improve pharmacy services through research, training, campaigning, professional standards and guidelines, and increasing inter-professional collaboration in fighting antimicrobial resistance. Further, government and policy makers could enhance pharmacists’ role in ensuring the appropriate use of antimicrobial and combatting antimicrobial resistance through the provision of national databases and surveillance programmes, research funding and healthcare regulations

Lack of interchangeability between visual analogue and verbal rating pain scales: a cross sectional description of pain etiology groups

BACKGROUND: Rating scales like the visual analogue scale, VAS, and the verbal rating scale, VRS, are often used for pain assessments both in clinical work and in research, despite the lack of a gold standard. Interchangeability of recorded pain intensity captured in the two scales has been discussed earlier, but not in conjunction with taking the influence of pain etiology into consideration. METHODS: In this cross-sectional study, patients with their pain classified according to its etiology (chronic/idiopathic, nociceptive and neuropathic pain) were consecutively recruited for self-assessment of their actual pain intensity using a continuous VAS, 0–100, and a discrete five-category VRS. The data were analyzed with a non-parametric statistical method, suitable for comparison of scales with different numbers of response alternatives. RESULTS: An overlapping of the VAS records relative the VRS categories was seen in all pain groups. Cut-off positions for the VAS records related to the VRS categories were found lower in patients with nociceptive pain relative patients suffering from chronic/idiopathic and neuropathic pain. When comparing the VAS records transformed into an equidistant five-category scale with the VRS records, systematic disagreements between the scales was shown in all groups. Furthermore, in the test-retest a low percentage of the patients agreed to the same pain level on the VAS while the opposite hold for the VRS. CONCLUSION: The pain intensity assessments on VAS and VRS are in this study, not interchangeable due to overlap of pain records between the two scales, systematic disagreements when comparing the two scales and a low percentage intra-scale agreement. Furthermore, the lower VAS cut-off positions relative the VRS labels indicate different meaning of the rated pain intensity depending on pain etiology. It is also indicated that the scales have non-linear properties and that the two scales probably have different interpretation. Our findings are in favor of using the VRS in pain intensity assessments but if still the VAS is preferred, the VAS data should be analyzed as continuous using statistical methods suitable for ordinal data. Furthermore, our findings indicate a risk to over or under estimate the patient's perceived pain when interpreting condensed VAS data

Antibiotics' use in Thailand: Community pharmacists' knowledge, attitudes and practices

Thailand spends $203 million on antibiotics every year, and patients can still access antimicrobials over the counter without a prescription. Community pharmacy plays a pivotal role in improving access and ensuring the appropriate use of antimicrobials. However, little is known about current practices in this setting. This study aims to assess Thai community pharmacists’ knowledge, attitudes and practices (KAP) regarding antimicrobials’ use and resistance. A cross-sectional study was conducted in Bangkok and Chonburi province in 2017 using an online self-administered questionnaire. The questionnaire was completed by 372 community pharmacists (71.4% response rate). The most commonly encountered infections in the community were upper and lower respiratory tract infections. The most commonly dispensed antimicrobials were broad-spectrum antibiotics including aminopenicillins and fluoroquinolones. Thai pharmacists have a good knowledge, attitude, and practice regarding antimicrobials’ use and resistance. They dispense anti-microbials in line with local guidelines, although international guidelines may not indicate anti-biotics for viral self-limiting infections. While community pharmacy in Thailand could be the most accessible healthcare resource for patients, inappropriate provision of antimicrobials for self-limiting viral infections by pharmacists will increase antimicrobial resistance. This highlights the need for updated guidance and improved pharmacists’ training

Managing the symptoms of neuropathic pain: An exploration of patients' experiences

The debilitating effects of chronic neuropathic pain on everyday life are considerable but little is known about how individual sufferers manage these effects. Virtually nothing is known about what patients prefer, what measures they take themselves, when, or in what combinations. The aim of this study was to explore patients’ reports of how they managed their neuropathic pain symptoms. Three focus groups including 10 participants were used to generate qualitative data on both individual and shared experiences of managing their symptoms of neuropathic pain. Discussions were recorded and transcribed verbatim. Data were analysed using thematic analysis, identifying categories and broader themes of importance to patients. The most common management strategy was the use of conventional medications, often associated with poor effectiveness and unpleasant side-effects. Complementary and alternative medicine was ineffective but many found resting or retreating helpful. They exhibited a repeated cycle of seeking help to manage the pain, with each unsuccessful attempt followed by new attempts. Some had tried to accept their pain, but there was insufficient psychological, social, emotional and practical support to allow them to do this successfully. This exploratory study provides a basis from which to develop a larger study to validate and extend the findings. Other issues meriting research are the effectiveness of cognitive behavioural therapies for those with neuropathic pain; and an exploration and subsequent evaluation of different types of social, practical and emotional support needed to help live with neuropathic pain

Sleep patterns over 15-day period in rats with spinal cord injury

Study design: Experimental, controlled trial.Objectives: the purpose of this study was to evaluate over a 15-day period alterations in sleep pattern of rats after spinal cord injury (SCI).Setting: Federal University of São Paulo, Department of Psychobiology.Methods: in total, 20 male Wistar rats were used. the rats were divided in two groups: SHAM and SCI. the rats were submitted to the following procedures: electrode insertion surgery, 24 h duration baseline sleep recording, SCI (level T9) and subsequent sleep recording for 15 consecutive days.Results: the results showed a reduction in sleep efficiency in the light period for Days 1-3, 5, 10 and 12 after SCI in relation to the SHAM group, with alterations in total waking time and sleep stages. Limb movements were observed 4 days after SCI.Conclusion: the present findings suggest that SCI may be heavily involved in altering sleep pattern in SCI subjects and that the inactivity caused by SCI may be exacerbating this altered sleep pattern.Universidade Federal de São Paulo, Dept Psychobiol, BR-04020060 São Paulo, BrazilUniversidade Federal de São Paulo, Ctr Psychobiol & Exercise Res, BR-04020060 São Paulo, BrazilSanta Casa, Dept Pathol, São Paulo, BrazilUniversidade Federal de São Paulo, Dept Psychobiol, BR-04020060 São Paulo, BrazilUniversidade Federal de São Paulo, Ctr Psychobiol & Exercise Res, BR-04020060 São Paulo, BrazilWeb of Scienc

Machine learning suggests sleep as a core factor in chronic pain

Patients with chronic pain have complex pain profiles and associated problems. Subgroup analysis can help identify key problems. We used a data-based approach to define pain phenotypes and their most relevant associated problems in 320 patients undergoing tertiary pain management. Unsupervised machine learning analysis of parameters "pain intensity," "number of pain areas," "pain duration," "activity pain interference," and "affective pain interference," implemented as emergent self-organizing maps, identified 3 patient phenotype clusters. Supervised analyses, implemented as different types of decision rules, identified "affective pain interference" and the "number of pain areas" as most relevant for cluster assignment. These appeared 698 and 637 times, respectively, in 1000 cross-validation runs among the most relevant characteristics in an item categorization approach in a computed ABC analysis. Cluster assignment was achieved with a median balanced accuracy of 79.9%, a sensitivity of 74.1%, and a specificity of 87.7%. In addition, among 59 demographic, pain etiology, comorbidity, lifestyle, psychological, and treatment-related variables, sleep problems appeared 638 and 439 times among the most important characteristics in 1000 cross-validation runs where patients were assigned to the 2 extreme pain phenotype clusters. Also important were the parameters "fear of pain," "self-rated poor health," and "systolic blood pressure." Decision trees trained with this information assigned patients to the extreme pain phenotype with an accuracy of 67%. Machine learning suggested sleep problems as key factors in the most difficult pain presentations, therefore deserving priority in the treatment of chronic pain.Peer reviewe