Editor-in-Chief Hatice Kübra Elçioğlu Vice Editors Levent Kabasakal Esra Tatar Online ISSN 2630-6344 Publisher Marmara University Frequency Bimonthly (Six issues / year) Abbreviation J.Res.Pharm. Former Name Marmara Pharmaceutical Journal
Journal of Research in Pharmacy 2013 , Vol 17 , Num 2
The role of patient education in adherence to antibiotic therapy in primary care
Nefise Bilge Göktay2, Suna Telefoncu2, S.Beril Kadıoğlu1, Çağlar Macit1, Nazlı Şencan1, Philip Martin Clark1
1Yeditepe Unıversıty, Clınıcal Pharmacy, Istanbul, Türkiye
2Communıty Pharmacy, İstanbul, Turkey
DOI : 10.12991/201317379


AMAÇ: Uyunç, tedavide daha iyi sonuçlara ulaşmada belirgin bir role sahiptir. Bilgilendirilen hastalar kendilerine reçetelenen ilaçlar hakkında bilinçli oldukları için, hasta eğitimi ile uyunç birbiri ile ilişkilidir. Bu çalışmanın amacı antibakteriyel ajan reçetelenmiş hastalarda uyuncu ölçmek ve hasta eğitiminin uyunç üzerindeki etkisini değerlendirmektir.

MATERYAL ve METOT: Bu çalışma, prospektif ve kontrollü bir çalışma olup, Ocak 2010 – Temmuz 2010 tarihleri arasında antibiyotik reçete edilmiş hastalarla gerçekleştirildi. Hastalara biri tedavinin başında; ikincisi antibiyotik tedavisinin sona erdiği günün sonunda olmak üzere iki farklı anket yapıldı. İlk anket hastaların sosyo-demografik bilgilerini, hastalıkları ve ilaçları hakkında bilgiye ihtiyaçları olup olmadığına dari sorular, ikinci ankette ise, antibiyotik tedavisi bittikten bir gün sonra antibiyotik ajanları nasıl kullandıkları ile ilgili sorular içermektedir. Uyunç ve dozların doğru zamanda alınıp alınmadığı, tablet sayımı ve kişinin kendi beyanatına dayalı rapor metotlarıyla değerlendirilmiştir.

BULGULAR ve SONUÇ: Bu çalışmada, çalışma ve kontrol grupları arasında eczacı tarafından verilen bilgiye göre doz alımı, doz zamanlaması, alım ve zamanlama uyuncu (AZU) açısından istatistiksel fark bulunamadı. Hekim tarafından bilgilendirilen ve bilgilendirilmeyen hastalar arasında, eczacıdan bilgi talebinde bulunma oranları açısından anlamlı fark saptanmadı. Diğer katılımcılarla karşılaştırıldığında, daha az miktarda ilaç ve daha kısa süreli tedavi reçete edilen katılımcılarda ilaç alım yüzdesinde artış görüldü. Bununla birlikte 30 yaşın üzerindeki yetişkin hastalar, genç hastalara göre daha yüksek uyunç gösterdi. Eczacıların hasta eğitimi üzerindeki güçlü rolünün altı çizildi.


The term compliance or adherence can be described as the extent of correlation between the patients’ obedience to the therapy and the advice of health providers. Thus, it is related to the patients’ drug-taking attitude[1,2]. Even when appropriate treatment is prescribed successful results may not be always achieved if patients use their medicines improperly. To attain good results in health status, adherence to the prescribed regimen is considered necessary[3].

Patients can be categorized as adherent or nonadherent. Adherent patients are generally cognizant of their medications and medical condition, and as a result they are more likely to achieve positive therapeutic outcomes. Correct dosing and timing of medication is an important constituent of adherence to the therapy[4]. By contrast, non-adherent patients do not use their drugs as prescribed by the physician; some use their drugs incompletely while others do not take any medication[5].

Adherence can be affected certain factors such as dose frequency, duration of treatment, pharmacological (adverse effects) and psychosocial factors (dissatisfaction of patient), medical errors such as misunderstood or lack of patient information[3-9].

Antibiotics are efficient, potent, safe and life saving agents used to facilitate the healing of bacterial infections[8]. Their introduction has led to an obvious reduction in mortality[10]. Unnecessary and/or inappropriate usage of these drugs is a common cause of the development and spread of resistance to them[11]. Adherence to antibiotic therapy is improved substantially when verbal and written information is provided in concert[2].

Clinical pharmacy is a synthesis of public health and science which aims to achieve optimum medical treatment, patient wellness and an advanced state of health[12]. Because clinical pharmacists are active supporters of rational drug use, they can correct inappropriate or incorrectly prescribed therapies, in consultation with the doctor[12]. It has been demonstrated that clinical pharmacy services support patient care and facilitate successful and effective medication use[13].

The aim of this study is to investigate whether patient education, as a clinical pharmacy related practice, given to patients prescribed antibiotics for any type of infections at the beginning of the treatment in a community pharmacy, is effective on adherence or not.


Study population and study center
This study was a prospective, controlled trial and conducted in a community pharmacy in Acıbadem between the dates of January, 2010 and July, 2010. Consecutive patients that had been prescribed oral antibiotic therapy for any type of infectious diseases were asked to participate in the trial. A total of 60 patients were included in study.

Eligibility criteria
In this study, out-patients who had been diagnosed with various infectious diseases by practitioners or specialists, and to whom oral antibiotic therapy had been prescribed, were enrolled.

Inclusion criteria
Inclusion criteria were to have a prescription including an oral antibacterial agent, and to have given consent to be followedup and to answer the questionnaires. Outpatients aged ≥18 were included.

Exclusion criteria
Exclusion criteria were to have possible drug interactions between the prescribed drugs; having possible allergic reactions to prescribed antibacterial agents. (These patients were redirected to their doctors.) Outpatients aged under 18 were excluded.

Study group
All patients in the study group were instructed to take their medication according to their physician’s recommendations.

The pharmacist gave additional instructions about drug usage both orally as well as in writing, with instruction and warning stickers on each container. Moreover, patients were reminded to take their tablets/capsules regularly at the same time everyday and to finish the whole blister or bottle of antibacterial medications, as recommended by the doctor; They were told that if any of the pills were left unused, the treatment might not be as effective against bacteria particularly in case of an acute recurrence of the complaint. Thus, the importance of the potential occurrence of antibacterial resistance was briefly emphasized. Finally, in case, if an adverse effect, patients were instructed to call their doctor and pharmacist immediately.

Control group
Patients in the control group were informed only about the dosage regimen prescribed by the doctor. As in study group, the pharmacist gave instructions about drug usage both orally and as well as in writing with stickers on each drug container in control group. However, no extra information was given about the prescribed dosage regimen in terms of the risks involving resistance if it developed.

Data collection
Patients were informed about the study orally in the first instance. Patients agreed to participate in the study signed the informed written consent before the first questionnaire. Verbal approval was obtained from patients who did not want to sign the consent form. Then, patients answered the first questionnaire which was administered by the pharmacist. In this questionnaire the datas of the socio-demographic characteristics of patient, the health center/organization and specialty of prescribing physician, diagnosis and prescribed drugs, whether or not the physician had informed the patient about drug usage the uninformed patient by the physician was asked if he/she needed more information about usage of drugs, whether or not the physician asked the patient if he/she had a chronic disease requiring medication, apart from the prescribed antibacterial and adjuvant drugs. whether or not the physician asked the patient if he/she had any drug allergy to some sort of medicines. whether or not a bacterial culture had been performed, the time spent for the clinical examination of the patient were collected.

The day after the end of the antibacterial treatment, patients were contacted by phone and asked to help complete a second questionnaire. In this questionnaire, the number of remaining pills in the blister or box, whether the patient omitted to take his/her medication or deliberately missed a dose, how many pills the patient took per day and at what time, regularly or irregularly. whether patient felt much better or not after the antibiotic therapy, whether the patient read the prospectus/ printed instructions and directions about his/her antibacterial agent or not.

Phone calls had to be repeated up to 2-3 times because the patient could frequently not be reached at that time of the first call.

Data analysis
The initially measured variable was adherence to prescribed antibiotic regimens. In the absence of a clear consensus in the literature on the definition of measures of adherence, and for the sake of convenience the researchers considered it appropriate to divide adherence into two categories:

1. Self-administration Adherence
2. Timing Adherence

To assess self-administration adherence, patients in both groups were asked to count the pills that were left over in the box. According to patient-derived data, the following formula was used:

Pill Count = Pills taken by the patient / Pills prescribed by physician x 100

Patients with a pill count of 100% were defined as adherent in terms of administration. A pill count under 100% was considered as non-compliant in self-administration.

Timing adherence was evaluated according to patients’ answers to the 4th question in the second questionnaire. In the 4th question, patients were asked whether he/she took his/her antibiotic pills at the correct times regularly or not. If the answer was ‘YES’, patients were defined as timing adherent. On the other hand, if the answer was ‘NO’, patients were considered non-adherent.

Patients who were adherent in both administration and timing categories were named ATA (Administration and Timing Adherent).

Statistical analysis
SPSS software (version 17.0 SPSS Inc., Chicago, IL) was used for statistical analysis and graphics in this trial. The Kolmogorov- Simirinov test was performed for analysis of normality. Chi-square and Fisher’s exact tests were used to compare categorical data of binary groups. Normally distributed continuous data was compared with student t-test as an average value; groups of continuous data not showing normal distribution was compared with Mann-Whitney U test as a median value. During the analysis of the correlation, Spearman’s rho correlation analysis was used because compared parameters were not normally distributed. A p value of less than 0.05 was regarded as significant .

There were some situations that limited the study listed below.

1. In the current study, the results of the survey do not reflect the data of socio-demographic characteristics of different populations since the survey was done only in one pharmacy.

2. The method used in this trial was based on a self-reported questionnaires. Fakat hastalar telefon görüşmeleri esnasında ilaç kutularında kalan ilaç sayısı sorularak verdikleri bilgiler yine subjektif olarak doğrulanmaya çalışılmıştır.


The mean age of patients enrolled in study group was 37.77±16.52, in the control group it was 34.96±16.10. In the study group, 24 of the patients (77.4%) were female, and 7 (22.6%) were male. The groups were homogenous in terms of age and sex. (p=0.516 Student t-test, p=0.195 Chi Square test respectively) Due to the number of categories, the educational status of the groups was not statistically comparable but the distribution of both groups was observed to be similar, as shown in Figure 1.

Click Here to Zoom
FIGURE 1: Comparative percentages of patients’ education status of study and control groups

Forty nine patients (81.7%) were examined by a specialist in ophthalmology; ear, nose and throat; internal medicine; obstetrics; dermatology; pulmonary medicine, general surgery, dentistry, urology, or infectious diseases.

The remaining eleven (18.3%) were examined by a general practitioner. Most of the patients were diagnosed primarily with upper respiratory tract infections, and secondarily with genito-urinary infections. The frequencies of patients’ diagnosis are shown in Figure 2.

Click Here to Zoom
FIGURE 2: Distribution of infections according to anatomical locations (n=60)

Administration adherence was found to be %100 in patients who had been suffering with chest and skin infections; timing adherence was observed to be %100 in eye infections. All of the patients failed to reach 100% in ATA, but patients that had genitourinary infections achieved the highest percentage %77.8. Anatomical locations of these infections according to types of adherent patients are shown in Table 1.

TABLE 1: Percentages of the types of adherent patients in terms of anatomical localizations of the infections

The mean administration adherence for all patients (n=60) was 85.60%±28.17. In terms of the three adherence parameters (administration, timing and ATA), patients in the study group were more adherent to therapy than those in the control group but this difference was not found to be statistically significant. (see Table 2)

TABLE 2: Comparison of the adherence parameters between study and control groups

Our analysis showed that there was a statistically significant negative correlation between administration adherence and the mean number of tablets/capsules in the medicine container, and also between adherence and the number of days of therapy. The length of clinical examination did not significantly affect the adherence (Table 3). Similar data was also obtained when examination time, pill number and length of therapy were compared with ATA (Table 4).

TABLE 3: Correlation between administration adherence and time taken for clinical examination, amount in tablets/capsules in the medicine container, and the number of days of therapy

TABLE 4: The effect of examination time, number of tablets/capsules in the container and number of days of therapy on administration and timing adherent patients

A number of factors that may affect compliance were evaluated as seen in Table 5. Timing-adherence and ATA were found significantly more common in patients aged >30 than in younger adults. However, significant differences were not observed in terms of administration adherence alone.

TABLE 5: Comparison of the factors that may affect adherence

The percentages of physicians who provided their patients with information about their medications, and patients’ self-reported request for information from the community pharmacist are shown in Table 6. There was no significant difference between the patients informed and uninformed by the physicians interms of the rates of information request from the community pharmacist. (p=0.136, Chi Square test)

TABLE 6: The proportion of patients who require education about their medication from the pharmacist; and patients informed by physicians


Pharmacists may be able to play a role in providing pharmaceutical care to patients receiving antibiotic treatments and; can help to ensure patients use their medications appropriately and enhance rational antibiotic use. The rates of the information request of the patients were independent from the rates of information given by the physicians. This issue underlines the importance of patient education given by the pharmacists.

The results of our study suggest that patients under the age of 30, who are receiving multiple-dose, long term antibiotic regimens could benefit from more comprehensive patient education aimed at increasing their adherence to therapy.

Further researches in this field may demonstrate the benefit and importance of the clinical pharmacist in antibacterial therapy, by comparing adherence and clinical outcomes of patients where clinical pharmacy services are offered compared to routine practice.


1) Barber N, Willson A. Churchill’s Clinical Pharmacy Survival Guide. Edinburgh Churchill Livingstone Edinburgh. 1999.

2) Segador J, Gil-Guillen VF, Orozco D, Quirce F, Carratalá MC, Fernández-Parker A, Merino J. The effect of written information on adherence to antibiotic treatment in acute sore throat. Int J Antimicrob Agents 2005; 26:56-61.

3) Claxton AJ, Cramer J, Pierce C. A systematic review of the associations between dose regimens and medication compliance. Clin Ther 2001; 23:1296-310.

4) Kardas P. Patient compliance with antibiotic treatment for respiratory tract infections. J Antimicrob Chemother 2002; 49:897-903.

5) Pechere JC, Hughes D, Kardas P, Cornaglia G. Noncompliance with antibiotic therapy for acute community infections: a global survey. Int J Antimicrob Agents 2007; 29:245-53.

6) Cals JW, Hopstaken RM, Le Doux PH, Driessen GA, Nelemans PJ, Dinant GJ. Dose timing and patient compliance with two antibiotic treatment regimens for lower respiratory tract infections in primary care. Int J Antimicrob Agents 2008; 31:531-6.

7) Jackson C, Lawton RJ, Raynor DK, Knapp P, Conner MT, Lowe CJ, Closs SJ. Promoting adherence to antibiotics: a test of implementation intentions. Patient Educ Couns 2006; 61:212-8.

8) Hawkings NJ, Butler CC, Wood F. Antibiotics in the community: a typology of user behaviours. Patient Educ Couns 2008; 73:146-52.

9) Niederman MS. Principles of appropriate antibiotic use. Int J Antimicrob Agents 2005; 26 Suppl 3:S170-5.

10) Davey P, Pagliari C, Hayes A. The patient’s role in the spread and control of bacterial resistance to antibiotics. Clin Microbiol Infect 2002; 8 Suppl 2:43-68.

11) http://www.acponline.org/patients_families/diseases_ conditions/antibiotic_resistance/.

12) The definition of clinical pharmacy. 2008. (Accessed at http://www.accp.com/docs/positions/commentaries/ Clinpharmdefnfinal.pdf.)

13) Hand K. Antibiotic pharmacists in the ascendancy. J Antimicrob Chemother 2007; 60 Suppl 1:i73-6.

14) Once-daily dosage secures better compliance with antibiotic therapy of respiratory tract infections than twicedaily dosage. 2003. (Accessed at http://www.jarcet. com/articles/Vol3Iss2/Kardas.htm.)

15) Ngoh LN. Health literacy: a barrier to pharmacist-patient communication and medication adherence. J Am Pharm Assoc (2003) 2009; 49:e132-46; quiz e47-9.

16) Kardas P, Devine S, Golembesky A, Roberts C. A systematic review and meta-analysis of misuse of antibiotic therapies in the community. Int J Antimicrob Agents 2005; 26:106-13.

Marmara University