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Aqua Zole Metronidazole - mg - 60 Count. Recent systematic reviews indicate that antibiotics can be purchased without a prescription in many developing countries across the world, despite regulations prohibiting this practice [ 14 , 15 ]. Online purchases have become an important source of antibiotics without a prescription in the US and United Kingdom UK as well [ 16 , 17 ]. Another study found that In the present COVID era or in an analogous scenario with high rates of unemployment and quarantine restrictions, persons seeking antibiotics online may increase as some avoid in-person visits.
Patients consuming antibiotics purchased online without a valid prescription are at additional risk of using the incorrect medication, dose, or duration as well as receiving a poor-quality product lacking official validation of contents. Recent studies have shown that veterinarian-prescribed antibiotics or antibiotics intended solely for animal use have become a source for self-medication including among members of the US Armed Forces and some underrepresented ethnic communities [ 18 , 19 ].
Access to these antibiotics intended for animal use appears to be more so driven by OTC availability in street-side businesses i. In contrast to antibiotics obtained for dogs and cats, the purchase of fish antibiotics in the US does not require pet prescription information, and the products are not FDA-regulated [ 20 ]. There are an estimated The statement highlights ornamental fish antibiotics have not been approved, conditionally approved, or indexed by the FDA, and the illegality of marketing them for human use [ 20 ].
The availability and use of fish antimicrobials was recently highlighted in the global news after a man in the US died from ingesting chloroquine phosphate for fish aquariums in an attempt to prevent COVID [ 22 ].
The online availability of OTC fish antibiotics and the intent of consumers purchasing these antibiotics has not been quantified.
The purpose of this study was to assess online availability of OTC fish antibiotics and describe their intended use for self-medication through publicly available comments and product purchase reviews.
The authors conducted a prospective, cross-sectional assessment of all website and online vendors selling fish antibiotics between August and September of The primary objective of this study was to identify the proportion of comments and reviews on online fish antibiotics associated with human consumption. The secondary objectives were to evaluate the traffic and attention received by reviews and comments associated with human consumption versus comments not associated with human consumption.
Additionally, the authors sought to evaluate the physical appearance of commonly sought online fish antibiotics and compare them with FDA-approved equivalents. Vendor websites were included if product information e.
Online vendors who do not provide shipment to the US were excluded. Other antimicrobials e. Investigators screened the fish antibiotics sold on every website and the top 9 antibiotics that could be commonly used for human consumption were determined. Of note, these antibiotics were officially sold for the intended treatment of ornamental fish and domestic fish tanks.
The cost and quantity supplied of fish antibiotics was recorded. The reviews and comments left by consumers who purchased fish antibiotics were read and categorized as either related or unrelated to human consumption Fig 1.
To determine if possibly purchased for human consumption, the following criteria were used to evaluate reviews and comments: a Explicitly stated purchased antibiotics were for human consumption.
If the verbiage was ambiguous or non-descript e. Discordant reviews were discussed and allocated based on consensus. One fish antibiotic erythromycin was not analyzed because fish erythromycins being sold were powder-formed and it was hard to compare them with FDA-approved equivalents using pill identification programs.
Descriptive statistics were used to estimate the prevalence of human related consumption. Data were checked for normality and t-test analyses were conducted to compare traffic between the human consumption-related and non-human consumption-related reviews.
The authors identified 24 website vendors with online ordering available for OTC fish antibiotics. Nine vendor websites S1 Table were included and 15 websites were excluded due to the consumer reviews not existing or not being publicly available. Nine fish antibiotics were selected and analyzed based on their common use in the treatment of human infections and the possibility of having negative repercussions as a result of self-medication Table 1.
Consumer review traffic and proportion of reviews related to human consumption are shown in Table 2. Among consumer reviews, 55 2. Human-consumption related reviews constituted Fish antibiotics with a high percentage of human consumption-related reviews are as follows, erythromycin 8. Select reviews demonstrating potential human consumption are shown in Fig 2. Among the 8 antibiotics purchased and compared to FDA-approved equivalents, all products were deemed consistent with human generic equivalents based on physical appearance.
Chemical testing was not performed. Details regarding the physical products are available in Table 3 and Fig 3 3a-3h. Erythromycin was not purchased because it was only available in a powder formulation. Pill and capsule identification of 8 fish antibiotics. Reported self-medication with fish antibiotics documented in a viral tweet from drew significant market attention. Amazon has since discontinued the sale of fish antibiotics, although antiparasitic and antifungal fish medications remain available for purchase at the time of this publication.
In the present study, there were numerous readily available websites selling fish antibiotics online. The findings of this study confirm that fish antibiotics can be freely purchased online without prescription in the US. Though, as anticipated, most customers are assumed to have bought the fish antibiotics for pets, 2. These human consumption-related reviews contributed to Although the percentage of human consumption associated reviews is low, these reviews generate significantly more traffic compared to other reviews and comments.
A number of studies have shown that purchasing behavior, intentions, and attitudes towards products can be influenced by the consumer ratings and reviews [ 24 — 26 ], and the most important factors affecting sales and attitudes are the valence and the volume of reviews [ 25 — 27 ]. This suggests that human-consumption related reviews may encourage more people to use antibiotics marketed for fish for self-medication. Some social media platforms and websites also reported people were using fish antibiotics as a cheap alternative for self-medication and showed that this issue was reaching the lay public [ 21 , 23 , 30 , 31 ].
In analyzing these human consumption related reviews, the authors felt that, consistent with other literature, multiple factors may contribute to patient self-medication with antibiotics, including affordability of physician visits, convenience of ordering and delivery to home, embarrassment associated with potential diagnosis, and lack of knowledge of antibiotic use and misuse.
Surprisingly, one vendor customer service agent publicly expressed that fish antibiotics can be used in humans. There are certainly many potential hazards of self-medicating with fish antibiotics.
As stated in a report issued by the FDA in [ 20 ], the safety and effectiveness of the antibiotics that are available in pet stores, or online had not been evaluated and have not been approved by the FDA. Recently, the FDA also released a statement to warn the public not to use chloroquine phosphate intended for fish [ 32 ] as treatment for COVID in humans because these products sold for aquarium use have not been evaluated by the FDA [ 33 ].
All 8 fish antibiotics purchased had consistent physical findings with FDA-approved equivalents using pill identification, which is something that has drawn online attention in the lay public among advocates for self-treating using fish antibiotics [ 23 , 30 , 31 ]. The authors were unable to obtain further information regarding supply chain of the fish antibiotics from the vendors or suppliers. Inappropriate use of antibiotics may cause a variety of adverse effects, including serious complications such as allergic reactions, organ dysfunction, or Clostridioides difficile infection [ 34 — 39 ].
Perhaps most concerning is that self-medication infers self-diagnosis, significantly increasing the risk for delayed, masked, or missed diagnoses [ 40 ]. This is largely concerning among communicable diseases, such as sexually transmitted infections STIs , that may lend themselves to self-medication. In the present study, several product reviews of metronidazole specifically alluded to management of STIs including trichomoniasis and bacterial vaginosis. Inappropriate use of antibiotics without medical guidance may also increase the risk of the selection of resistant bacteria [ 41 , 42 ].
While using fish antibiotics for self-medication may not contribute on a large scale to antimicrobial resistance, it certainly may impact the individual who chooses to self-medicate.
Antibiotic consumption may can also impact future antibiotic choice if the patient ultimately seeks care for a particular infection [ 43 , 44 ]. Some strategies may be needed to decrease self-medication and account for this use.
Efforts on continuing public awareness of rational use of antibiotics appears warranted and necessary. The Centers for Disease Control and Prevention advocates for antibiotic awareness among patients and providers to improve antibiotic use and combat continued emergence of antibiotic resistance [ 45 ]. Upon knowledge of self-medication, clinicians should strive to determine patient specific motivators for self-medication and barriers to seeking care.
These simple interventions may have long-term benefits for the patient to perhaps enhance medication access for the patient or manage other underlying reasons for self-medication.
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