Annals of Clinical and Medical
Case Reports
ISSN 2639-8109 Volume 12
Review Article
Antibiotic Prescription and Consumption in Brazil: Impact in the Global Health
Pellegrino FLPC1*, Aguiar-Alves F2, Assumpção DV1, Alves MS3 and Dias RCS4
1
Laboratórios Integrados de Pesquisa em Bactérias Resistentes aos Antimicrobianos e em Desenvolvimento Galênico-LIPE, Departamento de Farmácia, Faculdade de Ciências Biológicas e da Saúde, Universidade do Estado do Rio de Janeiro-Campus Zona Oeste
(UERJ-ZO), Rio de Janeiro, RJ, Brasil
2
Gregory School of Pharmacy, Palm Beach Atlantic University, FL, USA
3
Departamento de Ciências Farmacêuticas, Faculdade de Farmácia, Universidade Federal de Juiz de Fora, Juiz de Fora, MG, Brasil
4
Instituto Biomédico, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brasil
*
Corresponding author:
Flávia Lúcia Piffano Costa Pellegrino,
Integrated Research Laboratories on Antimicrobial
Resistant Bacteria and Galenic Development-LIPE.
Department of Pharmacy, Faculty of Biological and
Health Sciences, State University of Rio de Janeiro,
West Zone Campus (UERJ-ZO). Avenida Manuel
Caldeira de Alvarenga, 1203, Campo Grande, Rio
de Janeiro city. Rio de Janeiro State. Brazil
Received: 02 Jan 2024
Accepted: 01 Feb 2024
Published: 06 Feb 2024
J Short Name: ACMCR
1. Abstract
Despite the antibiotic sale prohibition without medical prescription since 2010, excessive and often inappropriate antibiotic prescription and self-medication, are still common practices in Brazil.
Indiscriminate antibiotic use is directly involved with the dissemination of resistant bacteria causing serious infections increasingly
difficult to treat. The present review work exposes data about the
prescription and consumption of antibiotics in Brazil in the last
decade and reveals a worrisome panorama about antibiotic use in
the country.
2. Introduction
Antibiotics have been excessively and misused in human and veterinary Medicine and in agriculture. This use plus the globalization
together have contributed to resistant bacteria dissemination that
are easily transferred among people and animals and are rapidly
spreading across continents. World Health Organization guidelines
recommend farmers and the food industry stop using antimicrobials routinely to promote growth and prevent disease in healthy
animals; the measure is important to maintain the effectiveness of
antimicrobials used in antibiotic therapy of infections in humans
and to contain the advance of antimicrobial resistance [1]. Conscious antibiotic prescriptions benefit inpatients and community.
Evaluating and re-evaluating indication, dose, route, and duration
United Prime Publications LLC., https://acmcasereport.org/
Copyright:
©2024 Pellegrino FLPC. This is an open access article
distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially
Citation:
Pellegrino FLPC, Antibiotic Prescription and
Consumption in Brazil: Impact in the Global Health.
Ann Clin Med Case Rep. 2024; V12(15): 1-4
of antibiotic treatment, reviewing the patient’s outcomes before
switching the antibiotic and being attentive to antibiotic safety and
efficacy, are examples of principles that must be adopted to reach
an optimal prescription. If an antibiotic is prescribed inappropriately, it will likely be consumed wrongly; if used by self-medication, probably it will be consumed unnecessarily [2]. The present
review shows data about antibiotic use in Brazil.
3. Methods
This review was performed to collect, select, and analyze data
from articles published in MEDLINE, Scopus, Web of Science
(ISI Web of Knowledge) and Science Direct, between 2011 and
2019. Keywords employed were that who best fit in the theme:
antibiotic prescription, antibiotic consumption, indiscriminate antibiotic use, bacterial resistance, and Brazil. After the search, were
select the papers directly related to the subject whose data were
relevant and exposed the real situation regarding antibiotic use in
Brazil. Finally, one references list of the original articles was completed and the articles were used to write the manuscript.
4. Results
Oral antibiotic sales data in the private sector in São Paulo state,
from 2008 to 2012, showed a positive contribution to the Brazilian antimicrobial policy with the implementation of new resolutions that prohibited the sale of antimicrobials without retaining
1
Volume 12 Issue 15 -2024
a medical prescription, reducing antibiotic consumption. Oral antibiotic consumption was reduced from 8.44 defined daily doses
per 1,000 inhabitants per day (DID) in 2008 to 8.06 DID in 2012
[3]. However, the fact does not seem to be repeated in other states
of Brazil. Based on Brazilian studies, published between 2011 to
2019, is possible to affirm that Brazil has serious problems with
the prescription and consumption of antibiotics. Unclear, illegible,
and inappropriate antibiotic prescribing (unnecessary prescribing
or wrong choice or dose and longtime of antibiotic use), were reported in all national territory, including in remote regions, such as
the Amazon Basin [4]. In 18 private community pharmacies from
Rio Grande do Norte, 29.3% of prescriptions had one or more illegible items, 91.3% had one or more missing items, and 29.0%
had both illegible and missing items. Legibility of the antibiotic
prescriptions interferes in the wrong antibiotic use. The evaluation was done between May and November 2014. Dosing schedule
(18.81%) and patient identification (12.14%) were the most commonly unreadable items in prescriptions and the lack of complete
patient identification occurred in 90.53% of the prescriptions. It
is estimated that 40.3% of users have used antibiotics without a
prescription and that 46.49% did not receive any guidance on the
administration of the drug [5].
Insufficient prescription of antibiotics and the lack of patient guidance about how to use the drug was detected, when physician
prescriptions in basic health units from Brasília, Campinas, Florianópolis, Minas Gerais, Porto Alegre, Salvador, and São Paulo
were evaluated. Only 74.8% of antibiotic users (8,803) were correctly oriented about how to use the drug [6]. Analyzing antibiotic
prescriptions to treat upper respiratory tract infections in Primary
Health Centers of São Paulo state, over 12 months, about 13% of
them occurred inappropriately to treat flu and other viruses. Penicillin (73.1%) was the most used antibiotic, followed by cephalosporins (10.6%), sulfonamides (7.5%) and macrolides (4.3%).
Amoxicillin was the drug of choice for respiratory infections in
pediatrics [7]. Overprescribing and inappropriate use of antibiotics
in children has been reported in Brazil8. A study by the Federal
University of Rio Grande, conducted between May and December 2000, raised information about antibiotic use in 501 children
in 18 community-based outpatient clinics of Rio Grande, Southern region of Brazil. Pieces of information were obtained through
questions answered by the children’s parents. About 201 (41.1%)
children (29 days to 18 years of age) had received at least one
antimicrobial course in the previous 2 months. For 7 months, the
frequency of antibiotic use varied between once (41%) to three
times (2.7%). Amoxicillin was the most used antibiotic (54%), but
broad-spectrum antimicrobial agents were also used in 15.3% of
interventions. Antibiotics were prescribed by a physician (96%
pediatricians) to treat acute respiratory infections (91%), although
at least 39.5 percent were conditions of presumed viral etiology
[8].
United Prime Publications LLC., https://acmcasereport.org/
Review Article
Antibiotic consumption without prescription was described in a
study that analyzed riverside dwellers more than 18 years old, in
the Brazilian Amazon Basin, randomly selected, from April to July
2016. A total of 74 people (21.3% of 346) used an antibiotic and
two-thirds of the patients managed to use the antibiotic without
a medical prescription. Unfortunately, one-third of the antibiotics
were used for non-bacterial infections [4]. About 20-50% of the
world’s population is affected by periodontal diseases. Frequently,
in cases of dental emergencies, dentists or family doctors prescribe
antibiotics, characterizing indiscriminate or over-prescription,
since in many cases of dental outpatients, antibiotics use is unnecessary. Studies point out that antibiotics have been overprescribed
in dental practices, contributing to the increase of antimicrobial
resistance [9]. There are few works that discuss the indiscriminate
use of antimicrobial agents in dental treatment, although self-medication has already been related in Brazilian literature [10]. In general, beta-lactams, macrolides, lincosamides and tetracyclines are
the most prescribed drugs by dentists for treatment or prophylaxis,
but in dental emergencies, the self-medication rates are alarming.
A study showed that about 40% of 223 patients consulted in an
Urgency Service of a Dental School in the South of Brazil for a
period of two years, had taken antibiotics before the dentist’s appointment and that 16% received a prescription after the consultation. Amoxicillin was the most frequently prescribed antibiotic
[10]. Data about antibiotic prescriptions in Brazil are shown in
(Table 1).
Self-medication and unnecessary antibiotic consumption have occurred in Brazil. A study based on data from the PNAUM (National Survey on Access, Use and Promotion of Rational Use of
Medicines), showed a prevalence rate of 16,1% of self-medication
in Brazil between September 2013 and February 2014. Of 8,545
drugs used in self-medication by Brazilian, 2.3% were antibacterial agents. When compared with analgesics (33.4%), although it
seems low, the self-medication of antibiotics is unacceptable because their use without prescription can be life-threatening for the
patient [11]. Of 136 adults that consumed antibiotics (one antibiotic per person), between May and August 2015, in the Metropolitan Region of Manaus, 19% used with no prescription, because
self-medication or by recommendation of relatives, neighbors,
or pharmacy employees. Cephalexin (39.7%) and amoxicillin
(29.4%) were the antibiotics most used. There were 10 cases of
self-medication with amoxicillin, six with cephalexin and four
with tetracycline. Amoxicillin was the most self-medicated antibiotic, and consumption was higher among healthy women [12].
The habitual use of antibiotics among 655 residents of Goiás State,
predominantly female between 20 and 59 years old, revealed that
the main antibiotic indication was made by a physician or dentist
(81.8%), while the other 18.2% were by a pharmacy employee or
self-medication (9.1% each). The most used antibiotic was amoxicillin (40.1%), to treat infections of the oropharynx (29.5%), dental
2
Volume 12 Issue 15 -2024
Review Article
issues (13.6%), or urinary/kidney infections (13.6%). About 5% of
patients did not complete the treatment due to symptoms improvement, and the antibiotic inappropriate use to treat fever, influenza
illness, or allergy; 20.5% of that people recommended the same
antibiotic to family and friends [13]. Epidemiologic aspects related
to antibiotic use were evaluated in 1,044 children of Pelotas, Rio
Grande do Sul: only 45% had an antibiotic prescription. Children
with brown, yellow, or indigenous skin color had taken 2.5 times
more antibiotics than white ones; children of mothers with 12 or
more years of schooling used 83.0% fewer antibiotics than those
of mothers with up to 4 years of schooling [14]. Relevant aspects
associated with antibiotics consumption by the Brazilian population have been summarized in (Table 2).
Table 1: Antibiotic prescriptions data in Brazil
Place
N
Prescriber
Most prescribed
Antibiotic
Prescription
Indication
With prescription/
Self-medication
Reference
Primary Health
Centers, SP
160
Physician
AMX (NR)
Pharyngitis (31.88%)
100%/NA
7
Households, AM
4,001
Physician
CEL (39.7%)
Respiratory I (NR)
81.8%/19%
12
Households visited,
GO
655
Physician/
dentist
AMX (40,1%)
Oropharyngeal I
(29.5%)
81.8%/9.1%
13
Five maternity
wards, RS
1,044
Physician
NR
Respiratory I (60%)
44.8%/NR
14
Riverside-dwellers,
AM
492
NR
AMX (27.3%)
Tonsillitis (NR)
33,8%/66,2%
4
N: Number of individuals studied. I: Infections. AMX: Amoxicillin; CEP: First-generation cephalosporins; CEL: Cephalexin; CEZ: Cefazolin. NR: not
reported. NA: not applicable. GO: Goiás; RS: Rio Grande do Sul; SP: São Paulo; AM: Amazonas: SC: Santa Catarina
Table 2: Aspects associated with the consumption of antibiotics by Brazilian population.
Higher consumption
by age group
N
Higher
consumption
by gender
Most used
antibiotic
Consumption
prevalence (%)
Clinical
indication
State
Year
Reference
Children 0-9 years old
160
Female
AMX
100%
Pharyngitis
SP
NR
7
Adults 18-39 years
old
492
Female
AMX
70,3%
Tonsillitis
AM
2016
4
Children 2 years old
1,044
Male
NR
10.50%
Respiratory I
RS
2015
14
Adults 20-59 years
old
655
Female
AMX
6,8%
Oropharyngeal I
GO
NR
13
Adults 25-34 years
old
4,001
Female
CEL
3.40%
Respiratory I
AM
2015
12
N: Number of individuals. AMX: Amoxicillin; CEP: First-generation cephalosporins; CEL: Cephalexin; CEZ: Cefazolin; NR: not reported. I: Infections. GO: Goiás; RS: Rio Grande do Sul; SP: São Paulo; AM: Amazonas: SC: Santa Catarina
5. Discussion and Conclusion
Unreadable prescriptions, prescriptions without guidance to the
patient, underdosing, overdosing, and wrong or inappropriate prescriptions are examples of problems with the prescription of antibiotics in Brazil, reported in national studies. When the patient
or pharmacist cannot clearly read what is written on the medical
prescription, the chance of errors in consumption increases and in
turn the improper use of the antibiotic as well [4,6].
The most frequent clinical indication for which antibiotics were
prescribed and consumed by the Brazilian population was respiratory tract infections, although, in many cases, the infection may
have been of viral origin [4,7,8, 12,13,14]. The mistaken use of anUnited Prime Publications LLC., https://acmcasereport.org/
tibiotics to treat undetermined fever, viral infections and allergies
and the recommendation of antibiotic use by family and friends
based on symptoms and without a medical prescription are strong
pieces of evidence of the indiscriminate use of antibiotics in Brazil. Antibiotic prescriptions to treat nonbacterial infections lead to
unnecessary consumption of antibiotics [12,13,14].
In fact, the discrete reduction in antibiotic consumption observed
in São Paulo state can be a positive consequence of Brazilian public policies measures by prohibition of the sale of antimicrobials
without medical prescription but it was not seen in other Brazilian states and, therefore, it does not represent the Brazilian realty [3]. The consumption of antibiotics without a prescription is a
3
Volume 12 Issue 15 -2024
dangerous practice that carries serious risks to human health. In
addition to the adverse effects that the antibiotic can cause in the
patient, overuse can lead the patient to become ill from overdose,
and underdoses can select resistant strains of bacteria among the
sensitive ones impairing the treatment of a later bacterial infection.
Amoxicillin was the most prescript consumed, and self-medicated
antibiotic in Brazil [4,7,8, 12,14]. This beta-lactam has been used
to treat most community-acquired infections, and the isolation of
Gram-positive and Gram-negative bacterial pathogens resistant to
amoxicillin is very common in our midst [6]. Although most prescribers are physicians, dentists also have been reported as professionals who prescribe antibiotics very often in Brazil [9].
If urgent actions to alert people about the impact of inadequate
prescriptions and of the indiscriminate consumption of antibiotics
will not be taken and this practice is not interrupted, consequences
to health human can be disastrous. Serious and resistant bacterial infections, difficult to treat, are already a reality in Brazil and
around the world. From One Health perspective, antibiotic prescription and consumption cause a huge impact on human, animal,
and global health. In fact, as the scientific literature has shown,
all of us, animals, plants, microorganisms, and natural environments, are interconnected and interconnected, so that every action
can impact and pose risks to the health of the entire globe. It is
noteworthy that changes in any habitat, such as pollution by antibiotics or by antibiotic-resistant microorganisms, can influence the
structures of their associated bacterial populations, contributing to
the spread of antimicrobial resistance among the various terrestrial
and aquatic [1]. Therefore, it is necessary to rethink surveillance
and control measures in relation to prescription and consumption
of antibiotics in Brazilian and world populations, both in Human
Medicine and in Veterinary Medicine, in hospital or community
environments, as well as in the management and disposal of these
wastes in attempt to preserve human health and the whole planet.
Review Article
5.
Lima SIVC, Diniz RS, Egito EST, Azevedo PRM, Oliveira AG,
Araujo IB. Rationality of antimicrobial prescriptions in community
pharmacy users. PLoS One. 2015; 10(10): e0141615.
6.
Lima MG, Álvares J, Junior AAG, Costa EA, Guibu IA, Soeiro
OM, et al. Indicators related to the rational use of medicines and its
associated factors. medicines and its associated factors. Rev Saude
Publica. 2017; 51(suppl 2): 23s.
7.
Fiol FSD, Lopes LC, Barberato-Filho S, Motta CCB. Evaluation of
the prescription and use of antibiotics in Brazilian children. Braz J
Infect Dis. 2013; 17(3): 332-37.
8.
Zhang L, Mendoza R, Costa MM, Ottoni EJ, Bertaco AS, Santos JC,
et al. A. Antibiotic use in community-based pediatric outpatients in
southern region of Brazil. J Trop Pediatr. 2005; 51(5): 304-9.
9.
Segura-Egea JJ, Gould K, Şen BH, Jonasson P, Cotti E, Mazzoni
A, et al. Antibiotics in Endodontics: a review. Int Endod J. 2017;
50(12): 1169-84.
10. Haque M, Sartelli M, Haque SZ. Dental Infection and Resistance-Global Health Consequences. Dent J (Basel) 2019; 7(1): 22.
11. Arrais PS, Fernandes ME, Pizzol TD, Ramos LR, Mengue SS, Luiza
VL, et al. Prevalence of self-medication in Brazil and associated
factors. Rev Saude Publica. 2016; 50(suppl 2): 13s.
12. Pereira JQ, Silva MT, Galvão TF. Use of antibiotics by adults: a population-based cross-sectional study. Sao Paulo Med J. 2018; 136(5):
407-13.
13. Braoios A, Pereira ACS, Bizerra AA, Policarpo OF, Soares NC, Barbosa AS. The use of antimicrobial drugs by the population in the
city of Jataí, State of Goias, Brazil. Cien Saude Colet. 2013; 18(10):
3055-60.
14. Bertoldi AD, MielkeI GI, Guttier MCI, Neumann NA, Dalabona C,
Boing AC, et al. Use of antibiotics in the health care unit: 2015 Pelotas Birth Cohort. Rev Saude Publica. 2019; 53: 92.
References
1.
Hernando-Amado S, Coque TM, Baquero, F, Martinez JL. Defining
and combating antibiotic resistance from One Health and Global
Health perspectives. Nat Microbiol. 2019; 4(9): 1432-42.
2.
Amorim WW, Passos LC, Gama RS, Souza RM, Graia LT, Macedo JC, et al. Physician and patient-related factors associated with
inappropriate prescribing to older patients within primary care: a
cross-sectional study in Brazil. Sao Paulo Med J. 2021; 139(2): 10716.
3.
Kliemann BS, Levin AS, Moura ML, Boszczowski I, Lewis JJ. Socioeconomic determinants of antibiotic consumption in the state of
São Paulo, Brazil: the effect of restricting over-the-counter sales.
PLoS One. 2016; 11(12): e0167885.
4.
Muri-Gama AS, Figueras A, Secoli SR. Inappropriately prescribed
and over-the counter antimicrobials in the Brazilian Amazon Basin:
We need to promote more rational use even in remote places. PLoS
One. 2018; 13(8): e0201579.
United Prime Publications LLC., https://acmcasereport.org/
4