Evaluation of the Association between Inhaler technique and Adherence in Asthma Control: Cross-Sectional Comparative Analysis Study between Amman and Baghdad

Purpose: Asthma is a chronic condition affecting millions of people all around the world. Asthma has no cure, but disease control is essential and highly recommended. However, the available tools for asthma control assessment don’t include factors such as inhaler technique and adherence. This study aimed to assess the correlation between inhaler techniques, adherence, and level of asthma control in two different healthcare settings; Jordan and Iraq. Patients and methods: A cross-sectional observational study was con-ducted over six months, from January to August 2018, in two public hospitals in Amman (Jordan) and Baghdad (Iraq). Asthmatic patients were interviewed to assess their inhaler technique, adherence, and asthma control. The researcher personally visited both public hospitals, conducting face-to-face interviews with patients at the hospital outpatient clinics. Validated questionnaires were used for patient assessment, including demographics, asthma history and medication use, the patient’s inhaler technique, adherence, and asthma control. Results: A total of 300 patients entered the study, with a mean age of 45.54 ± 13.71. The asthma control test showed very poor asthma control for patients living in both countries (Amman n=78 (52.0%) vs. Baghdad n=106 (70.0%)). An asthma knowledge assessment showed that most asthmatic patients in both countries didn’t follow their asthma medication plan (Amman n=78 (52.0%) vs. Baghdad n=93 (62.0%). Conclusion: In both Jordan and Iraq, asthma patients were found to be poorly controlled. Knowledge of patients was inadequate, probably leading to the poorly managed chronic disease. The results of this study highlight the significance of the pharmacist’s role in recognizing asthmatic patients requiring assistance. Furthermore, they underscore the pharmacist’s pivotal contribution to delivering patient education and counseling, ultimately resulting in enhanced asthma control. (AU)

Real-World Effectiveness of Four Types of COVID-19 Vaccines.

BACKGROUND: There is a scarcity of evidence regarding the real-world effectiveness of coronavirus disease 2019 (COVID-19) vaccines. This was the first study to evaluate the effectiveness of four types of vaccines against asymptomatic and symptomatic infection, and COVID-19 outcomes among the general population. METHODS: This was a matched comparison group quasi-experimental study conducted in Jordan between 1 January and 29 August 2021. In the first part of the study, 1200 fully vaccinated individuals were matched with 1200 unvaccinated control participants. In order to measure vaccine effectiveness, the infection rates of both vaccinated and unvaccinated groups were calculated. The second part of the study included measuring specific anti-SARS CoV-2 immune cells and antibodies. RESULTS: BNT162b2 (Pfizer, New York, NY, USA) showed a significantly higher effectiveness against asymptomatic COVID-19 infection (91.7%) and hospitalization (99.5%) than BBIBP-CorV (Sinopharm, Beijing, China) (88.4% and 98.7%, respectively) and ChAdOx1 nCoV-19 (AstraZeneca, Cambridge, UK) (84.3%, and 98.9%, respectively). The effectiveness rates of the Sputnik V (Gamaleya Research Institute, Moscow, Russia) vaccine against asymptomatic, symptomatic, and hospitalization were 100%, 100%, and 66.7%, respectively. The highest median anti-spike (S) IgG values were seen in individuals who received BNT162b2 (2.9 AU/mL) and ChAdOx1 nCoV-19 (2.8 AU/mL) vaccines. The levels of anti-S IgG were significantly decreased after 7 months of vaccination with BNT162b2 and BBIBP-CorV. There were significant decreases in the median number of neutralizing antibodies one month and seven months after receiving BNT162b2 (from 88.5 to 75.2 4 Bioequivalent Allergen Unit per milliliter/mL), BBIBP-CorV (from 69.5 to 51.5 BAU/mL), and ChAdOx1 nCoV-19 (from 69.2 to 58.BAU/mL) vaccines. The highest percentage of T cells specific to COVID-19 vaccine was found in individuals who received BNT162b2 (88.5%). CONCLUSION: All four vaccines evaluated in this study showed effectiveness against asymptomatic COVID-19 infection, symptomatic infection, hospitalization, and death. Furthermore, BNT162b2, BBIBP-CorV, and ChAdOx1 nCoV-19 induced high levels of immunology markers within one month of vaccination.

Therapeutic Drug Monitoring of Vancomycin in Jordanian Patients. Development of Physiologically-Based Pharmacokinetic (PBPK) Model and Validation of Class II Drugs of Salivary Excretion Classification System (SECS).

Vancomycin is a commonly used antibiotic for multi-drug resistant gram-positive infections treatment, especially methicillin-resistant Staphylococcus aureus (MRSA). Despite that, it has wide individual pharmacokinetic variability and nephrotoxic effect. Vancomycin trough concentrations for 57 Jordanian patients were measured in plasma and saliva through immunoassay and liquid chromatography-mass spectrometry (LC-MS/MS), respectively. Plasma levels were within accepted normal range, with exception of 6 patients who showed trough levels of more than 20 µg/ml and vancomycin was discontinued. Bayesian dose-optimizing software was used for patient-specific pharmacokinetics prediction and AUC/MIC calculation. Physiological-based pharmacokinetic (PBPK) vancomycin model was built and validated through GastroPlus™ 9.8 using in-house plasma data. A weak correlation coefficient of 0.2478 (P=0.1049) was found between plasma and saliva concentrations. The suggested normal saliva trough range of vancomycin is 0.01906 to 0.028589 (µg/ml). Analysis of variance showed significant statistical effects of creatinine clearance and albumin concentration on dose-normalized Cmin plasma and saliva levels respectively, which is in agreement with PBPKmodeling. It can be concluded that saliva is not a suitable matrix for TDM of vancomycin. Trough levels in plasma matrix should always be monitored for the safety of patients.

The Role of Clinical Pharmacy in Preventing Prescribing Errors in the Emergency Department of a Governmental Hospital in Jordan: A Pre-Post Study.

Background: Clinical pharmacists have a vital role in intercepting prescribing errors (PEs) but their impact within a Jordanian hospital emergency department (ED) has never been studied. Objective: To evaluate the impact of clinical pharmacy services on PEs and assess predictors of physicians' acceptance of clinical pharmacists' interventions. Setting: This study was conducted in the ED of the largest governmental hospital in Jordan. Method: This was a pre-post study conducted in October and November 2019 using a disguised observational method. There were 2 phases: control phase (P0) with no clinical interventions, and active phase (P1) where clinical pharmacists prospectively intervened upon errors. The clinical significance of errors was determined by a multidisciplinary committee. The SPSS software version 24 was used for data analysis. Main Outcome Measure: PEs incidence, type, severity, and predictors for physicians' acceptance. Results: Of 18003 patients, 8732 were included in P0 and 9271 in P1. PEs incidence decreased from 24.6% to 5.4%. Contraindication, drug selection, and dosage form error types were significantly reduced from 32.6%, 9.1%, and 3.7% (P0) to 12.6%, 0.0%, and 0.0% (P1), respectively. Albeit not statistically significant, drug-drug interaction, drug frequency, and allergy error types were reduced from 4.9%, 3.1%, and 0.1% to 4.5%, 2.5%, and 0.0%, respectively. Significant and serious errors were significantly reduced from 68.7% and 3.0% (P0) to 8.9% and 1.8% (P1), respectively. During P1, most errors were minor (89.3%, 1574/1763), and lethal errors ceased. Predictors for physicians' acceptance were: significant errors (OR 3.1; 95% CI 2.6-4.3; P = 0.03) and non-busy physicians (OR 2.1; 95% CI 1.6-2.7; P = 0.04). Conclusion: Clinical pharmacists significantly reduced PEs in the ED by 76%; most of interventions were significant. Policymakers are advised to implement active clinical pharmacy in the ED.

Pharmacy students' attitude towards providing pharmaceutical care to patients with anxiety and their knowledge of psychotropic medicines in Jordan.

OBJECTIVES: To describe pharmacy students' attitude towards providing pharmaceutical care (PC) to patients with anxiety and their knowledge of psychotropic medicines (PM). METHODS: A cross-sectional emailed survey was sent to all 200 pharmacy students (fourth and fifth year) in one Jordanian university. Statistical analysis included descriptive statistics and chi-square test. KEY FINDINGS: A total of 134 responses were received (response rate 67%). About two-thirds of students (87, 64.9%) would like to give enough time to patients with anxiety to discuss their medications. Only half of students knew correctly that alprazolam (53.7%) and diazepam (50.0%) are categorized as anxiolytics. Undertaking a course in psychiatry was significantly associated with better students' knowledge in PM (P < 0.05). CONCLUSION: Despite positive attitudes towards providing PC to patients with anxiety, policy makers should include courses on psychiatric pharmacotherapy in pharmacy curricula to improve pharmacy students' knowledge of PM.

Incidence, nature, severity, and causes of dispensing errors in community pharmacies in Jordan.

Background Medication dispensing is a core function of community pharmacies, and errors that occur during the dispensing process are a major concern for pharmacy profession. However, to date there has been no national study of medication dispensing errors in Jordan. Objective The study aimed to investigate the incidence, nature, severity, causes and predictors of medication dispensing errors. Setting The study was conducted in randomly selected community pharmacies across Jordan. Method A mixed method approach was taken, incorporating prospective disguised observation of dispensing errors and interviews with pharmacists regarding the causes of errors. A multidisciplinary committee evaluated the severity of errors. Proportionate random sampling was used to include 350 pharmacies from across all regions of Jordan. SPSS (Version 24) was used for data analysis. Main outcome measure Incidence, nature, severity, causes and predictors of medication dispensing errors. Results The overall rate of medication dispensing errors was 24.6% (n = 37,009/150,442), of which 11.5% (n = 17,352/150,442) were prescription related errors and 13.1% (n = 19,657/150,442) pharmacist counselling errors. The most common type of prescription-related errors were wrong quantity (37.9%, n = 6584/17,352), whereas the most common pharmacist counselling error was wrong drug (41.9%, n = 8241/19,657). The majority of errors were caused by poor handwriting (30.7%, n = 75,651/37,009), followed by high workload (17.3%, n = 22,964/37,009). More than half of errors (52.6%) were moderate in severity, followed by minor errors (38.8%), and 8.6% of errors were rated as serious. Predictors of medication dispensing errors were: Sundays (OR 2.7; 95% CI 2.15-3.94; p = 0.02), grade A pharmacies (dispensing ≥ 60 prescriptions a day (OR 3.6; 95% CI 2.89-4.78; p = 0.04)), and prescriptions containing ≥ 4 medication orders (OR 4.1; 95% CI 2.9-6.4; p = 0.001). Conclusion Medication dispensing errors are common in Jordan and our findings can be generalised and considered as a reference to launch training programmes on safe medication dispensing and independent prescribing for pharmacists.

Saliva versus Plasma Therapeutic Drug Monitoring of Gentamicin in Jordanian Preterm Infants. Development of a Physiologically-Based Pharmacokinetic (PBPK) Model and Validation of Class II Drugs of Salivary Excretion Classification System.

Gentamicin has proven to be a very successful treatment for bacterial infection, but it also can cause adverse effects, especially ototoxicity, which is irreversible. Therapeutic drug monitoring (TDM) in saliva is a more convenient non-invasive alternative compared to plasma. A physiologically-based pharmacokinetic (PBPK) model of gentamicin was built and validated using previously-published plasma and saliva data. The validated model was then used to predict experimentally-observed plasma and saliva gentamicin TDM data in Jordanian pediatric preterm infant patients measured using sensitive LCMS/MS method. A correlation was established between plasma and saliva exposures. The developed PBPK model predicted previously reported gentamicin levels in plasma, saliva and those observed in the current study. A good correlation was found between plasma and saliva exposures. The PBPK model predicted that gentamicin in saliva is 5-7 times that in plasma, which is in agreement with observed results. Saliva can be used as an alternative for TDM of gentamicin in preterm infant patients. Exposure to gentamicin in plasma and saliva can reliably be predicted using the developed PBPK model in patients.

The development of a population physiologically based pharmacokinetic model for mycophenolic mofetil and mycophenolic acid in humans using data from plasma, saliva, and kidney tissue.

BACKGROUND: Mycophenolic acid (MPA) is used widely to prevent graft rejection in kidney-transplant patients. Therapeutic drug monitoring (TDM) in plasma requires an invasive procedure that is inconvenient, especially in pediatric patients. TDM in saliva is a more convenient non-invasive alternative compared with plasma. METHODS: A population physiologically based pharmacokinetic (Pop-PBPK) model of mycophenolate mofetil (MMF) and MPA with enterohepatic recycling was built and verified using previously published plasma, saliva, and kidney biopsy data in healthy and kidney-transplant adult patients. The verified model was then used to predict experimentally observed plasma and saliva MMF and MPA TDM data in Jordanian pediatric kidney transplant patients measured using LC-MS/MS. A correlation was established between plasma and saliva exposures in pediatrics. RESULTS: The developed LCMS was sensitive to both MMF and MPA in plasma and saliva. The developed Pop-PBPK model predicted well the previously reported MMF and MPA levels in plasma, saliva, and kidney tissue and those observed in the current study (more than 75% of observed data points were within 90% predictive interval of population simulations). A statistically significant correlation was found between plasma and saliva exposures for both MMF (Pop-PBPK predicted and observed) and MPA (Pop-PBPK predicted). CONCLUSION: Both MPA and MMF can be classified as class III compounds in the Salivary Excretion Classification System. Saliva is an alternative body fluid to plasma that can be used for TDM of MPA and MMF in kidney-transplant patients in pediatrics. Exposure to MPA and MMF in plasma, saliva, and kidney tissue was reliably predicted using the developed Pop-PBPK model.

Role of the pharmacist in improving inhaler technique and asthma management in rural areas in Jordan.

INTRODUCTION: Pharmacists can have a valuable role in educating patients on correct inhaler technique leading to improved asthma management. Rural areas can benefit from the role of the pharmacist considering the barriers found in attending primary health-care facilities. OBJECTIVES: This study aimed to assess the impact of inhaler technique education delivered by pharmacists on patients' inhaler technique, Asthma Control Test (ACT) score, forced expiratory volume in the first 1 second (FEV1%), and reliever use (puffs/day). METHODS: A pre-post interventional study was conducted over 6 months from February 2017 to July 2017 in rural areas in Jordan. Asthma patients visiting respiratory clinics and using metered dose inhaler (MDI) or turbuhaler (TH) controlled medication were randomly recruited. Inhaler technique was assessed via published checklists. The ACT, FEV1%, and reliever use (puffs/day) were assessed. Patients were educated on inhaler technique via demonstration with return demonstration education. All assessments were repeated 3 months post education. RESULTS: A total of 103 (TH, n=44; MDI, n=59) patients were recruited (mean age=46.5±13.5), 74% females. Patients reported an overuse of their reliever (5.1±4.2 puffs/day). Only 2 patients (1.9%) had well-controlled asthma, while the rest had either moderately (19.4%) or poorly (78.6%) controlled asthma. Patients using the MDI achieved 3.03±4.30 ACT score improvement (p<0.001), which is a clinically significant improvement in control. Patients using the TH achieved a statistically significant improvement of 2.07±4.72 (p=0.031). FEV1% improved significantly for MDI users (p=0.005) but not for TH users (p=0.097). Reliever use decreased significantly for MDI and TH users. CONCLUSION: Asthmatic patients living in rural areas in Jordan reported poor inhaler technique, ACT scores, and FEV1% scores and high use of reliever medications. Pharmacist-led educational intervention resulted in improved inhaler technique scores, ACT scores, and FEV1% scores and lowered reliever use over time.

Saliva versus Plasma Therapeutic Drug Monitoring of Pregabalin in Jordanian Patients.

The objective is using saliva instead of plasma for pregabalin therapeutic drug monitoring (TDM) since saliva reflects the free non-protein bound drug concentration, simple and noninvasive sampling, cheaper and does not require the expertise of drawing blood. Forty four patients participated in this study, two samples of saliva and another two of blood were taken from each patient; first sample of both saliva and blood is the trough sample and was taken just before the first dose of the day and second sample is the peak sample and was taken 1 h after taking the first dose of the day. Descriptive statistics and t-testing after log transformation were done using Excel, p-value=0.05 was adopted for significant difference. Optimized effective intestinal permeability of pregabalin was estimated by PK-Sim program version 7. This study for the first time revealed that pregabalin is excreted in saliva and classified as class 1 based on Salivary Excretion Classification System (SECS). A good correlation of 0.71-0.83 between Cmin and Cmax of plasma and saliva pregabalin was observed respectively which indicate that saliva sampling is a good alternative matrix for pregabalin TDM. C/D-ratios were calculated to demonstrate pharmacokinetic variability of Pregabalin; the results showed that C/D-ratio was higher in women, elderly and in those patients who had Scr.≥0.9 mg/dl. Proposed pregabalin therapeutic ranges are 0.7 to 1.84 µg/ml in plasma and 0.055 to 0.145 µg/ml in saliva, for neuropathic pain, diabetic neuropathy and disc prolapse patients.

Saliva Versus Plasma Bioequivalence of Azithromycin in Humans: Validation of Class I Drugs of the Salivary Excretion Classification System.

AIM: The aim of this study was to compare human pharmacokinetics and bioequivalence metrics in saliva versus plasma for azithromycin as a model class I drug of the Salivary Excretion Classification System (SECS). METHODS: A pilot, open-label, two-way crossover bioequivalence study was done, and involved a single 500-mg oral dose of azithromycin given to eight healthy subjects under fasting conditions, followed by a 3-week washout period. Blood and unstimulated saliva samples were collected over 72 h and deep frozen until analysis by a validated liquid chromatography with mass spectroscopy method. The pharmacokinetic parameters and bioequivalence metrics of azithromycin were calculated by non-compartment analysis using WinNonlin V5.2. Descriptive statistics and dimensional analysis of the pharmacokinetic parameters of azithromycin were performed using Microsoft Excel. PK-Sim V5.6 was used to estimate the effective intestinal permeability of azithromycin. RESULTS AND DISCUSSION: No statistical differences were shown in area under the concentration curves to 72 h (AUC0-72), maximum measured concentration (C max) and time to maximum concentration (T max) between test and reference azithromycin products (P > 0.05) in the saliva matrix and in the plasma matrix. Due to the high intra-subject variability and low sample size of this pilot study, the 90% confidence intervals of AUC0-72 and C max did not fall within the acceptance range (80-125%). However, saliva levels were higher than that of plasma, with a longer salivary T max. The mean saliva/plasma concentration of test and reference were 2.29 and 2.33, respectively. The mean ± standard deviation ratios of saliva/plasma of AUC0-72, C max and T max for test were 2.65 ± 1.59, 1.51 ± 0.49 and 1.85 ± 1.4, while for the reference product they were 3.37 ± 2.20, 1.57 ± 0.77 and 2.6 ± 1.27, respectively. A good correlation of R = 0.87 between plasma and saliva concentrations for both test and reference products was also observed. Azithromycin is considered a class I drug based on the SECS, since it has a high permeability and high fraction unbound, and saliva sampling could be used as an alternative to plasma sampling to characterize its pharmacokinetics and bioequivalence in humans when adequate sample size is used.

Inter-professional education unveiling significant association between asthma knowledge and inhaler technique.

OBJECTIVES: To explore whether an association exists between health care professionals' (HCPs) asthma knowledge and inhaler technique demonstration skills. METHODS: HCPs' asthma knowledge and inhaler technique demonstration skills were assessed at baseline at an inter-professional educational workshop focusing on asthma medication use. Asthma knowledge was assessed via a published questionnaire. Correct inhaler technique for the three inhalers, the Accuhaler, Turbuhaler and pressurized Metered Dose Inhaler (pMDI) was assessed using published checklists. RESULTS: Two hundred HCPs agreed to participate: 10 specialists (medical doctors specialized in respiratory diseases) (5%), 46 general practitioners (23%), 79 pharmacists (39%), 15 pharmacists' assistants (8%), 40 nurses (20%) and 10 respiratory therapists (5%). Backwards stepwise multiple regression conducted to determine predictors of HCPs' inhaler technique, showed that out of many independent variables (asthma knowledge score, profession, age, gender, place of work, years in practice and previous personal use of the study inhaler/s), asthma knowledge score was the only variable showing significant association with inhaler technique (R(2)=0.162, p<0.001). CONCLUSION: This study revealed significant associations between asthma knowledge and inhaler technique scores for all HCPs. Providing inter-professional workshops for all HCPs involved integrating education on asthma knowledge and practice of inhaler technique skills are looked-for.

Inter-professional education unveiling significant association between asthma knowledge and inhaler technique

Objectives: To explore whether an association exists between health care professionals’ (HCPs) asthma knowledge and inhaler technique demonstration skills. Methods: HCPs’ asthma knowledge and inhaler technique demonstration skills were assessed at baseline at an interprofessional educational workshop focusing on asthma medication use. Asthma knowledge was assessed via a published questionnaire. Correct inhaler technique for the three inhalers, the Accuhaler, Turbuhaler and pressurized Metered Dose Inhaler (pMDI) was assessed using published checklists. Results: Two hundred HCPs agreed to participate: 10 specialists (medical doctors specialized in respiratory diseases) (5%), 46 general practitioners (23%), 79 pharmacists (39%), 15 pharmacists’ assistants (8%), 40 nurses (20%) and 10 respiratory therapists (5%). Backwards stepwise multiple regression conducted to determine predictors of HCPs’ inhaler technique, showed that out of many independent variables (asthma knowledge score, profession, age, gender, place of work, years in practice and previous personal use of the study inhaler/s), asthma knowledge score was the only variable showing significant association with inhaler technique (R2=0.162, p<0.001). Conclusion: This study revealed significant associations between asthma knowledge and inhaler technique scores for all HCPs. Providing inter-professional workshops for all HCPs involved integrating education on asthma knowledge and practice of inhaler technique skills are looked-for (AU)

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Inhaler technique training and health-care professionals: effective long-term solution for a current problem.

INTRODUCTION: The aims of this study were (1) to assess the ability of a range of health-care professionals (HCPs: specialists [physicians specializing in management of airways disease], general practitioners, pharmacists, pharmacist assistants, nurses, and respiratory therapists) in Jordan to demonstrate the correct use of some commonly used inhalers using standardized checklists, with highest scores indicating optimal use, and (2) to evaluate the short-term and long-term effectiveness of a single educational intervention on the HCPs' skills in using inhalers. METHODS: HCPs' inhaler technique was assessed at baseline. All HCPs were then invited to attend a workshop on asthma management with particular reference to inhaler use. At the workshop, HCP skills in inhaler technique were optimized. Inhaler technique was assessed before and after training. All participants were assessed on their inhaler technique at follow-up (after 4 months). RESULTS: Two hundred HCPs (10 specialists, 46 general practitioners, 79 pharmacists, 15 pharmacist assistants, 40 nurses, and 10 respiratory therapists) participated in the study. Specialists scored highest on baseline inhaler technique demonstration skills. All HCPs scored poorly in demonstrating the correct use of the dry powder inhalers when compared with pressurized metered-dose inhalers (MDIs) (range of mean scores ± SD: MDI, 7.24 ± 0.97 to 8.70 ± 0.67; Diskus, 4.83 ± 0.51 to 6.30 ± 1.7; Turbuhaler, 4.90 ± 0.32 to 6.40 ± 1.7). Participants attending the workshop showed improved inhaler skills (mean scores before and after training: MDI, 4.77 ± 1.60 vs 8.77 ± 0.52; Diskus, 4.40 ± 2.60 vs 8.85 ± 0.41; Turbuhaler, 4.96 ± 2.05 vs 8.63 ± 0.67). Four months after the workshop, the inhaler technique of 129 participants was again assessed. Those who had attended the workshop (n = 48) scored significantly higher mean scores for all devices (score = 7.64) than nonattendees (n = 81, score = 5.99, P < .001), by one-way analysis of covariance. CONCLUSIONS: With the exception of specialists, HCPs in Jordan need to be updated on their inhaler technique skills, specifically the newer dry powder inhalers. A single effective educational workshop on inhaler technique can significantly improve HCPs' long-term ability to demonstrate these skills.

Awareness of antibiotic use and antimicrobial resistance in the Iraqi community in Jordan.

INTRODUCTION: Antimicrobial resistance is a serious global health concern. It has considerable implications on societies' health and resources. In Jordan, there is a large Iraqi community due to the ongoing turmoil in Iraq. Unfortunately, health awareness and practices of this community are under-investigated due to scarcity of research. This paper assesses the awareness of antibiotic use and antimicrobial resistance in the Iraqi community residing in Amman, Jordan. Their level of interaction with health care professionals regarding antibiotics and differences in their antibiotic use between Iraq and Jordan are also discussed. METHODOLOGY: A cross-sectional questionnaire-based survey involving randomly selected Iraqis residing in Amman, Jordan was conducted. RESULTS: The study involved 508 participants. Sixty-two percent of participants agreed with buying antibiotics without a prescription, 29% agreed with obtaining antibiotics from friends or relatives, and 46% agreed with keeping leftover antibiotics for future use. Furthermore, 60% disagreed with not completing an antibiotic course and almost 90% of the sample listed viral diseases as an indication for antibiotics. Forty-four percent of participants abided by physicians' instructions on antibiotic use. Half of the participants believed that pharmacists provided instructions on antibiotics all the time, whereas physicians were perceived to do so by 29% of participants. CONCLUSIONS: Gaps exist in knowledge of antibiotic use and reasons for antimicrobial resistance among Iraqis residing in Jordan. These gaps should serve in planning educational campaigns to raise the community's awareness of responsible antibiotic use. Law enforcement to restrict access to antibiotics is also pivotal to tackle their misuse.