Assessment of adherence to pneumonia guidelines and its determinants in an ambulatory care clinic in Ghana: findings and implications for the future

BACKGROUND

Adherence to local standard guidelines is seen as a pragmatic way to measure and improve the quality of future prescribing in ambulatory care to reduce morbidity, mortality and healthcare costs.

OBJECTIVES

To evaluate adherence to the Ghana Standard Treatment Guidelines (STGs) for the empirical antibiotic treatment of ambulatory care patients with community-acquired pneumonia (CAP) in a region in Ghana and factors associated with it.

METHODS

A cross-sectional survey was conducted using a checklist to collect data from the hospital electronic database, which included sociodemographic details, payment type and clinical information of all ambulatory patients attending Keta Municipal Hospital, diagnosed and managed for CAP from September 2018 to January 2019. Prescriptions were assessed for adherence to the Ghana STG based on choice of antibiotics. A χ2 test and multiple logistic regression were subsequently conducted.

RESULTS

A total of 1929 patient records with diagnosis of CAP within the study period at the ambulatory clinic were identified. The overall rate of adherence to the Ghana STG was 32.50% (n = 627). From the patient records collected, 62.50% were female, 41.84% were children (0-12 years), and 97.15% had a valid national health insurance status. Adherence was associated with the duration of antibiotic prescribing, number of additional antibiotics prescribed and some patients' clinical characteristics.

CONCLUSIONS

The rate of adherence to Ghana STG among the study population was low. Efforts must be made to train and encourage prescribers to follow empirical guidelines to reduce inappropriate selection of antibiotics in the ambulatory care settings.

Changes in Availability, Utilization, and Prices of Medicines and Protection Equipment for COVID-19 in an Urban Population of Northern Nigeria

Objective

Measures are ongoing to prevent the spread of COVID-19 and treat it with medicines and personal protective equipment (PPE). However, there has been considerable controversy surrounding treatments such as hydroxychloroquine with misinformation fuelling prices hikes and suicides. Shortages have also appreciably increased costs of PPE, potentially catastrophic among lower- and middle-income countries such as Nigeria with high copayment levels. Consequently, a need to investigate changes in availability, utilization, and prices of relevant medicines and PPE during the pandemic in Nigeria.

Methods

Exploratory study among community pharmacists with a survey tool comprising four sections including questions on changes in consumption, prices, and shortages of medicines and PPE from the beginning of March 2020 to the end of June 2020. In addition, suggestions from community pharmacists and co-authors on ways to reduce misinformation.

Findings

30 out of 34 pharmacists participated giving a response rate of 88.2%. Significant increases were seen (3-fold or more increase) in the consumption of hydroxychloroquine (100%), vitamins/immune boosters (96.7%) and antibiotics (46.7%) as well as PPE (100%). Considerable price increases (50% increase or greater) also seen for antimalarials (96.7%), antibiotics (93.3%), vitamins/immune boosters (66.7%), and PPE (100%). Shortages are also seen for hydroxychloroquine and vitamins/immune boosters but most severe for PPE (80% of pharmacies).

Conclusion

Encouraging to see increases in the utilization of vitamins/immune boosters and PPE. However, a considerable increase in the utilization and prices of antimicrobials is a concern that needs addressing including misinformation. Community pharmacists have a key role in providing evidence-based advice and helping moderate prices.

A point prevalence survey of antimicrobial utilisation patterns and quality indices amongst hospitals in South Africa; findings and implications

Objectives: Antimicrobial use is growing, driven mainly by rising demands in developing countries. Knowing how antimicrobials are prescribed is important. Consequently, we undertook a point prevalence survey (PPS) quantifying antimicrobial consumption among 18 public sector hospitals across South Africa.Method: A purpose-built web-based application was used to collect PPS data.Results: Out of 4407 adult patients surveyed, 33.6% were treated with an antimicrobial. The most frequently prescribed groups were a combination of penicillins including β-lactamase inhibitors. Amoxicillin combined with an enzyme inhibitor accounted for 21.4% total DDDs. In the medical and surgical wards, Access antimicrobials (54.1%) were mostly used, while in the ICU, Watch antimicrobials (51.5%) were mostly used. Compliance with the South African Standard Treatment Guidelines and Essential Medicines List was 90.2%; however, concerns with extended use of antimicrobials for surgical prophylaxis (73.2% of patients).Conclusion: The web-based PPS tool was easy to use and successful in capturing PPS data since the results were comparable to other PPS studies across Africa. High use of amoxicillin combined with an enzyme inhibitor, possibly because it was among the broad-spectrum antimicrobials in the Access group. The findings will assist with future targets to improve antimicrobial prescribing among public sector hospitals in South Africa.

Influence of pharmaceutical services organization on the availability of essential medicines in a public health system

Objective: To evaluate the influence of organizational structure and technical-management activities on the availability of essential medicines in the primary healthcare. Materials & methods: Cross-sectional, exploratory and evaluative study. The availability was evaluated according to parameters established by the WHO. Results: The average availability of standardized essential medicines was 83.3 and 73.3% for medicines purchased centrally by the Brazilian government. Among the therapeutic groups evaluated, the lowest average availability were for the tuberculostatics (24.1%) and psychotropic/special control medicines (30.3%). Conclusion: The availability of essential medicines was positively influenced by the presence of the pharmacist and by the computerized system deployed, and negatively associated with essential medicines purchased centrally by the federal government, especially in the smaller municipalities.

Development of a web-based application to improve data collection of antimicrobial utilization in the public health care system in South Africa

Objective

Determining antimicrobial utilization patterns in hospitals can be a challenge given personnel and resource constraints with paper-based systems. A web-based application (APP) was developed in South Africa to address this, building on a recent point prevalence survey (PPS) using a paper-based system. Consequently, there was a need to test and evaluate the ease of use of a newly developed app and potential time saving versus paper-based methods for PPS. The findings can be used to further refine the APP.

Methods

The developed app was tested in a large academic public hospital in a PPS in South Africa. During data collection, the app was evaluated for functionality on 35 variables and subsequently refined. After data collection, the app was evaluated in terms of its time-saving potential and ease of use.

Results

181 patient’s files were surveyed across 13 wards in the hospital, with the antimicrobial usage findings similar to the previous paper-based study in the same hospital. The median age for males was 45.5 years and 42 years for females. Overall 80 out of 181 (44%) patients received antibiotics. Whilst 38% (12 out of 31) of patients in the adult surgical ward received antimicrobials, the prevalence was the highest (78%) in the pediatric medical wards. All the data collectors were confident in using the app after training and found the tool is not complex at all to use. In addition, the time taken to plan for the study and to collect data was considerably reduced. Reduced time spent in data collection and analysis is important for timely instigation of quality improvement programs in resource limited settings.

Conclusions

All data collectors would recommend the app for future PPSs. Several concerns with data entry were identified, which have now been addressed. The app development has been successful and is now being deployed across South Africa as part of a national PPS as well as wider.

Potential approaches for the pricing of cancer medicines across Europe to enhance the sustainability of healthcare systems and the implications

Introduction: There are growing concerns among European health authorities regarding increasing prices for new cancer medicines, prices not necessarily linked to health gain and the implications for the sustainability of their healthcare systems.Areas covered: Narrative discussion principally among payers and their advisers regarding potential approaches to the pricing of new cancer medicines.Expert opinion: A number of potential pricing approaches are discussed including minimum effectiveness levels for new cancer medicines, managed entry agreements, multicriteria decision analyses (MCDAs), differential/tiered pricing, fair pricing models, amortization models as well as de-linkage models. We are likely to see a growth in alternative pricing deliberations in view of ongoing challenges. These include the considerable number of new oncology medicines in development including new gene therapies, new oncology medicines being launched with uncertainty regarding their value, and continued high prices coupled with the extent of confidential discounts for reimbursement. However, balanced against the need for new cancer medicines. This will lead to greater scrutiny over the prices of patent oncology medicines as more standard medicines lose their patent, calls for greater transparency as well as new models including amortization models. We will be monitoring these developments.

The Prevalence of Medication Errors Among Nursing Students: A Systematic and Meta-analysis Study

BACKGROUND

Health promotion and preserving patients' safety are the main purposes of care in health-therapeutic systems. With regard to nursing profession, nursing students are exposed to medications errors (MEs) during clinical activities, which can be considered as a threat to patients' safety. The study aimed to determine the prevalence of MEs among nursing students using a systematic and meta-analysis approach.

METHODS

8 studies (in 9 groups) in English and Persian from inception to March 2019, were collected. Searched was conducted in SID, MagIran, IranMedex, Google Scholar, Web of Science, PubMed and Scopus. The meta-analysis method and the random effects model were used to analyze the data. In addition, the I2 statistic was used to examine heterogeneity among studies. The analyses were conducted using Stata, version 11.

RESULTS

Analysis of 8 studies (in 9 groups) with a total sample size of 688 showed that the overall MEs' prevalence among nursing students was 39.68% (95% CI: 22.07-57.29) and the prevalence of lack of reporting MEs was 48.60% (95%CI: 27.33-69.86). There were no relationships between the prevalence of MEs and lack of reporting MEs in nursing students with the sample size and the mean age of students.

CONCLUSIONS

Considering the relatively high prevalence of MEs and lack of MEs reporting among nursing students and the importance of their effect on the level of patients' safety, measures such as educations, monitoring by clinical trainers, and examining and eliminating the causes of MEs are essential.

Key Issues Surrounding Appropriate Antibiotic Use for Prevention of Surgical Site Infections in Low- and Middle-Income Countries: A Narrative Review and the Implications

BACKGROUND

There is a concern with the growing use of antimicrobials across countries increasing antimicrobial resistance (AMR) rates. A key area within hospitals is their use for the prevention of surgical site infections (SSI) with concerns with timing of the first dose, which can appreciably impact on effectiveness, as well as duration with extended prophylaxis common among low- and middle-income countries (LMICs). This is a concern as extended duration increases utilization rates and AMR as well as adverse events. Consequently, there is a need to document issues of timing and duration of surgical antibiotic prophylaxis (SAP) among LMICs together with potential ways forward to address current concerns.

METHODS

Narrative review of timings and duration of SAP among LMICs combined with publications documenting successful approaches to improve SAP to provide future direction to all key stakeholder groups.

RESULTS

There were documented concerns with the timing of the first dose of antibiotics, with appropriate timing as low as 6.7% in Egypt, although as high as 81.9% in Turkey. There was also an extensive duration of SAP, ranging from long duration times in all patients in a study in Nigeria with a mean of 8.7 days and 97% of patients in Egypt to 42.9% of patients in Pakistan and 35% in Turkey. Successful interventions to improve SAP typically involved multiple approaches including education of all key stakeholder groups, monitoring of usage against agreed guidelines,as well as quality targets. Multiple approaches typically improved timing and duration as well as reduced costs. For instance, in one study appropriateness increased from 30.1% to 91.4%, prolonged duration reduced to 5.7% of patients, and mean costs of antibiotics decreased 11-fold.

CONCLUSION

There are considerable concerns with the timing and duration of SAP among LMICs. Multiple interventions among LMICs can address this providing future directions.

Medication safety in primary care-from measurement to action

Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.

Rapid Assessment of the Potential Paucity and Price Increases for Suggested Medicines and Protection Equipment for COVID-19 Across Developing Countries With a Particular Focus on Africa and the Implications

Background: Countries across Africa and Asia have introduced a variety of measures to prevent and treat COVID-19 with medicines and personal protective equipment (PPE). However, there has been considerable controversy surrounding some treatments including hydroxychloroquine where the initial hype and misinformation led to shortages, price rises and suicides. Price rises and shortages were also seen for PPE. Such activities can have catastrophic consequences especially in countries with high co-payment levels. Consequently, there is a need to investigate this further. Objective: Assess changes in utilisation, prices, and shortages of pertinent medicines and PPE among African and Asian countries since the start of pandemic. Our approach: Data gathering among community pharmacists to assess changes in patterns from the beginning of March until principally the end of May 2020. In addition, suggestions on ways to reduce misinformation. Results: One hundred and thirty one pharmacists took part building on the earlier studies across Asia. There were increases in the utilisation of principally antimalarials (hydroxychloroquine) and antibiotics (azithromycin) especially in Nigeria and Ghana. There were limited changes in Namibia and Vietnam reflecting current initiatives to reduce inappropriate prescribing and dispensing of antimicrobials. Encouragingly, there was increased use of vitamins/immune boosters and PPE across the countries where documented. In addition, generally limited change in the utilisation of herbal medicines. However, shortages have resulted in appreciable price increases in some countries although moderated in others through government initiatives. Suggestions in Namibia going forward included better planning and educating patients. Conclusion: Encouraging to see increases in the utilisation of vitamins/immune boosters and PPE. However, concerns with increased utilisation of antimicrobials needs addressing alongside misinformation, unintended consequences from the pandemic and any appreciable price rises. Community pharmacists and patient organisations can play key roles in providing evidence-based advice, helping moderate prices through improved stock management, and helping address unintended consequences of the pandemic.

Utilisation, Availability and Price Changes of Medicines and Protection Equipment for COVID-19 Among Selected Regions in India: Findings and Implications

Background: COVID-19 has already claimed a considerable number of lives worldwide. However, there are concerns with treatment recommendations given the extent of conflicting results with suggested treatments and misinformation, some of which has resulted in increased prices and shortages alongside increasing use and prices of personal protective equipment (PPE). This is a concern in countries such as India where there have been high patient co-payments and an appreciable number of families going into poverty when members become ill. However, balanced against pricing controls. Community pharmacists play a significant role in disease management in India, and this will remain. Consequently, there is a need to review prices and availability of pertinent medicines during the early stages of the COVID-19 pandemic in India to provide future direction. Objective: Assess current utilisation and price changes as well as shortages of pertinent medicines and equipment during the early stages of the pandemic. Our Approach: Multiple approach involving a review of treatments and ongoing activities across India to reduce the spread of the virus alongside questioning pharmacies in selected cities from early March to end May 2020. Our Activities: 111 pharmacies took part, giving a response rate of 80%. Encouragingly, no change in utilisation of antimalarial medicines in 45% of pharmacies despite endorsements and for antibiotics in 57.7% of pharmacies, helped by increasing need for a prescription for dispensing. In addition, increased purchasing of PPE (over 98%). No price increases were seen for antimalarials and antibiotics in 83.8 and 91.9% of pharmacies respectively although shortages were seen for antimalarials in 70.3% of pharmacies, lower for antibiotics (9.9% of pharmacies). However, price increases were typically seen for PPE (over 90% of stores) as well as for analgesics (over 50% of pharmacies). Shortages were also seen for PPE (88.3%). Conclusion: The pandemic has impacted on utilisation and prices of pertinent medicines and PPE in India but moderated by increased scrutiny. Key stakeholder groups can play a role with enhancing evidenced-based approaches and reducing inappropriate purchasing in the future.

Health-Care professionals' knowledge and practice regarding disposal of medicines in primary health-care facilities in South Africa: Impact and implications

Objective:

Professional nurses, pharmacists, and medical practitioners are responsible for disposing of medicines within health-care facilities. South African regulations stipulate that medicines should not be disposed of through sewage systems because of the potential impact on patients and the environment. Consequently, our objective was to determine knowledge and practices among health-care professionals (HCPs) in South Africa and the information they provide to patients regarding the safe disposal of unused/expired/damaged medicines to provide future guidance with identified concerns.

Methods:

A descriptive study was conducted among 165 HCPs at 16 primary health-care clinics in two subdistricts of the city of Tshwane in Gauteng Province through self-administered questionnaires.

Findings:

Only 23.5% of HCPs stated that they participated in destroying medicines within their facilities. More than half (65.1%) also reported that they always counsel patients regarding the safe storage of their medicines in their homes, with 27.9% indicating they counsel patients on the safe disposal of their medicines during consultations. More than half (65.1%) also reported that patients never asked about the disposal of medicines. Of concern is that incineration (31.9%), flushing down the toilet (20.6%), and flushing down the sink (9.9%) were regarded by HCPs as correct disposal methods, while 9.6% stated that they did not know the correct methods. In addition, 71.1% reported never receiving training regarding the safe disposal of medicine.

Conclusion:

There is an urgent need to educate HCPs regarding appropriate medicine waste disposal in South Africa. This can start with including this topic in the curriculum of HCPs, including pharmacists, and continuing post qualification.

Rapid Assessment of Price Instability and Paucity of Medicines and Protection for COVID-19 Across Asia: Findings and Public Health Implications for the Future

Background: Countries have introduced a variety of measures to prevent and treat COVID-19 with medicines and personal protective equipment (PPE), with some countries adopting preventative strategies earlier than others. However, there has been considerable controversy surrounding some treatments. This includes hydroxychloroquine where the initial hype and misinformation lead to shortages, price rises and suicides. Price rises and shortages have also been seen for PPE. Such activities can have catastrophic effects on patients where there are high co-payment levels and issues of affordability. Consequently, there is a need to investigate this further. Objective: Assess changes in the availability, utilization and prices of relevant medicines and PPE during the pandemic among a range of Asian countries. Our approach: Narrative literature review combined with interviews among community pharmacists to assess changes in consumption, prices and shortages of medicines and PPE from the beginning of March 2020 until end of May 2020. In addition, suggestions on ways to reduce misinformation. Results: 308 pharmacists took part from five Asian countries. There was an appreciable increase in the utilization of antimicrobials in Pakistan (in over 88% of pharmacies), with lower increases or no change in Bangladesh, India, Malaysia and Vietnam. Encouragingly, there was increased use of vitamins/immune boosters and PPE across the countries, as well as limited price rises for antimicrobials in India, Malaysia and Vietnam, although greater price rises seen for analgesics and vitamin C/immune boosters. Appreciable price increases were also seen for PPE across some countries. Conclusion: Encouraging to see increases in utilization of vitamins/immune boosters and PPE. However, increases in the utilization and prices of antimicrobials is a concern that needs addressing alongside misinformation and any unintended consequences from the pandemic. Community pharmacists can play a key role in providing evidence-based advice, helping to moderate prices, as well as helping address some of the unintended consequences of the pandemic.

Supporting antimicrobial stewardship in Ghana: evaluation of the impact of training on knowledge and attitudes of healthcare professionals in two hospitals

BACKGROUND

A Commonwealth Partnership for Antimicrobial Stewardship was created between the Scottish Antimicrobial Prescribing Group (SAPG), Ghana Police Hospital and Keta Municipal Hospital. During a scoping visit, requirements for implementing antimicrobial stewardship (AMS), areas for improvement and training needs were identified.

METHODS

A multidisciplinary team from SAPG and health psychologists from The Change Exchange developed and delivered multi-professional evidence-based teaching incorporating behavioural science, supported by partner pharmacists in each hospital. Four sessions were delivered over 2 days to 60 participants across both sites. Before and after the sessions, participants were asked to complete a knowledge quiz and a behaviours survey. Results were analysed using t-tests.

RESULTS

Comparison of the participants' pre- and post-test quiz scores (Keta Municipal Hospital 9.4 and 10.9, Ghana Police Hospital 9.2 and 11.1, respectively) demonstrated statistically significant improvement in knowledge of antimicrobial resistance and appropriate use of antibiotics. Comparison of survey responses before and after the education sessions indicated that the education had a positive impact on participants' attitudes towards the issue of antimicrobial resistance, their role in AMS and confidence in using the Ghana Standard Treatment Guidelines. Participants were also more likely to question colleagues about compliance with guidelines. Forty-eight participants (80%) completed a training evaluation and all responded positively.

CONCLUSIONS

The education sessions appeared to be successful in improving knowledge and behaviours of hospital staff. Cascade of an abbreviated version of the training by partner pharmacists and AMS teams in Ghana will ensure that all staff have the opportunity to develop skills and knowledge to support AMS.

A systematic review and meta-analysis of the use of renin-angiotensin system drugs and COVID-19 clinical outcomes: What is the evidence so far?

Conflicting evidence exists about the effect of angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) on COVID-19 clinical outcomes. We aimed to provide a comprehensive/updated evaluation of the effect of ACEIs/ARBs on COVID-19-related clinical outcomes, including exploration of interclass differences between ACEIs and ARBs, using a systematic review/meta-analysis approach conducted in Medline (OVID), Embase, Scopus, Cochrane library, and medRxiv from inception to 22 May 2020. English studies that evaluated the effect of ACEIs/ARBs among patients with COVID-19 were included. Studies' quality was appraised using the Newcastle-Ottawa Scale. Data were analyzed using the random-effects modeling stratified by exposure (ACEIs/ARBs, ACEIs, and ARBs). Heterogeneiity was assessed using I2 statistic. Several subgroup analyses were conducted to explore the impact of potential confounders. Overall, 27 studies were eligible. The pooled analyses showed nonsignificant associations between ACEIs/ARBs and death (OR:0.97, 95%CI:0.75,1.27), ICU admission (OR:1.09;95%CI:0.65,1.81), death/ICU admission (OR:0.67; 95%CI:0.52,0.86), risk of COVID-19 infection (OR:1.01; 95%CI:0.93,1.10), severe infection (OR:0.78; 95%CI:0.53,1.15), and hospitalization (OR:1.15; 95%CI:0.81,1.65). However, the subgroup analyses indicated significant association between ACEIs/ARBs and hospitalization among USA studies (OR:1.59; 95%CI:1.03,2.44), peer-reviewed (OR:1.93, 95%CI:1.38,2.71), good quality and studies which reported adjusted measure of effect (OR:1.30, 95%CI:1.10,1.50). Significant differences were found between ACEIs and ARBs with the latter being significantly associated with lower risk of acquiring COVID-19 infection (OR:0.24; 95%CI: 0.17,0.34). In conclusion, high-quality evidence exists for the effect of ACEIs/ARBs on some COVID-19 clinical outcomes. For the first time, we provided evidence, albeit of low quality, on interclass differences between ACEIs and ARBs for some of the reported clinical outcomes.

A multicentre point prevalence survey of hospital antibiotic prescribing and quality indices in the Kurdistan regional government of Northern Iraq: the need for urgent action

BACKGROUND

Rationale antibiotic use is crucial to address antimicrobial resistance (AMR) threats. No study has been undertaken in the Kurdistan Regional Government (KRG) to document current antibiotic use/areas for improvement given the high AMR rates.

RESEARCH DESIGN AND METHODS

Point prevalence survey (PPS), using the Global PPS methodology, was conducted among the three major public hospitals in KRG/northern Iraq from September-December 2019. Prevalence and quality of antibiotic use were assessed using agreed indicators.

RESULTS

Prevalence of antibiotic use was high (93.7%; n = 192/205); third-generation cephalosporins were the most commonly prescribed antibiotics (52.6%; n = 140/266). Reasons for treatment were recorded for only 61.7% (n = 164/266) of antibiotics and high use (89.9%) of parenteral therapy was observed. All therapy was empirical, no stop/review dates were recorded, and no treatment guidelines were available. The majority of the prescribed antibiotics (62%; n = 165/266) were from the WHO Watch list.

CONCLUSION

Prevalence of antibiotic use was high not only versus other hospitals in the region but globally, coupled with significant evidence of sub-optimal prescribing. Swift action is needed to improve future prescribing to reduce AMR. One or two areas should initially be targeted for quality improvement including development of local guidelines, documentation of antibiotic indications, and/or stop/review dates.

Response to the Novel Corona Virus (COVID-19) Pandemic Across Africa: Successes, Challenges, and Implications for the Future

BACKGROUND

The COVID-19 pandemic has already claimed considerable lives. There are major concerns in Africa due to existing high prevalence rates for both infectious and non-infectious diseases and limited resources in terms of personnel, beds and equipment. Alongside this, concerns that lockdown and other measures will have on prevention and management of other infectious diseases and non-communicable diseases (NCDs). NCDs are an increasing issue with rising morbidity and mortality rates. The World Health Organization (WHO) warns that a lack of nets and treatment could result in up to 18 million additional cases of malaria and up to 30,000 additional deaths in sub-Saharan Africa.

OBJECTIVE

Document current prevalence and mortality rates from COVID-19 alongside economic and other measures to reduce its spread and impact across Africa. In addition, suggested ways forward among all key stakeholder groups.

OUR APPROACH

Contextualise the findings from a wide range of publications including internet-based publications coupled with input from senior-level personnel.

ONGOING ACTIVITIES

Prevalence and mortality rates are currently lower in Africa than among several Western countries and the USA. This could be due to a number of factors including early instigation of lockdown and border closures, the younger age of the population, lack of robust reporting systems and as yet unidentified genetic and other factors. Innovation is accelerating to address concerns with available equipment. There are ongoing steps to address the level of misinformation and its consequences including fines. There are also ongoing initiatives across Africa to start addressing the unintended consequences of COVID-19 activities including lockdown measures and their impact on NCDs including the likely rise in mental health disorders, exacerbated by increasing stigma associated with COVID-19. Strategies include extending prescription lengths, telemedicine and encouraging vaccination. However, these need to be accelerated to prevent increased morbidity and mortality.

CONCLUSION

There are multiple activities across Africa to reduce the spread of COVID-19 and address misinformation, which can have catastrophic consequences, assisted by the WHO and others, which appear to be working in a number of countries. Research is ongoing to clarify the unintended consequences given ongoing concerns to guide future activities. Countries are learning from each other.

Supporting global antimicrobial stewardship: antibiotic prophylaxis for the prevention of surgical site infection in low- and middle-income countries (LMICs): a scoping review and meta-analysis

BACKGROUND

The Scottish Antimicrobial Prescribing Group is supporting two hospitals in Ghana to develop antimicrobial stewardship. Early intelligence gathering suggested that surgical prophylaxis was suboptimal. We reviewed the evidence for use of surgical prophylaxis to prevent surgical site infections (SSIs) in low- and middle-income countries (LMICs) to inform this work.

METHODS

MEDLINE, Embase, Cochrane, CINAHL and Google Scholar were searched from inception to 17 February 2020 for trials, audits, guidelines and systematic reviews in English. Grey literature, websites and reference lists of included studies were searched. Randomized clinical trials reporting incidence of SSI following Caesarean section were included in two meta-analyses. Narrative analysis of studies that explored behaviours and attitudes was conducted.

RESULTS

This review included 51 studies related to SSI and timing of antibiotic prophylaxis in LMICs. Incidence of SSI is higher in LMICs, infection surveillance data are poor and there is a lack of local guidelines for antibiotic prophylaxis. Education to improve appropriate antibiotic prophylaxis is associated with reduction of SSI in LMICs. The random-effects pooled mean risk ratio of SSI in Caesarean section was 0.77 (95% CI: 0.51-1.17) for pre-incision versus post-incision prophylaxis and 0.89 (95% CI: 0.55-1.14) for short versus long duration. Reduction in cost and nurse time was reported in shorter-duration surgical antibiotic prophylaxis.

CONCLUSIONS

There is scope for improvement, but interventions must include local context and address strongly held beliefs. Establishment of local multidisciplinary teams will promote ownership and sustainability of change.

Compliance with South Africa's Antimicrobial Resistance National Strategy Framework: are we there yet?

Antimicrobial resistance (AMR) is a growing problem worldwide. South Africa has recently released its Antimicrobial Resistance National Strategy Framework (referred to as the Framework) to instigate antimicrobial stewardship programmes (ASPs). Consequently, there is a need to assess compliance with the Framework.

METHODS

Descriptive study design, collecting quantitative data, among pre-selected public healthcare facilities. One healthcare professional from each participating facility, involved in ASPs, was invited to participate.

RESULTS

Overall 26 facilities from 8 provinces participated. Average compliance to the Framework was 59.5% for the 26 facilities, with 38.0% for community health centres, 66.9% for referral hospitals and 73.5% for national central hospitals. For 7 facilities compliance was <50% while 5 facilities were >80% compliant.

CONCLUSION

Although some facilities complied well with the Framework, overall compliance was sub-optimal. With the introduction of universal healthcare in South Africa, coupled with growing AMR rates, ongoing initiatives to actively implement the Framework should be targeted at non-compliant facilities.

Availability and price changes of potential medicines and equipment for the prevention and treatment of COVID-19 among pharmacy and drug stores in Bangladesh; findings and implications

Objective: There are concerns with increased prices and drug shortages for pertinent medicines and personal protective equipment (PPE) to prevent and treat COVID-19 enhanced by misinformation. Community pharmacists and drug stores play a significant role in disease management in Bangladesh due to high co-payments. Consequently, a need to review prices and availability in the pandemic. Materials and Methods: Multiple approach involving a review and questionnaire among pharmacies and stores early March to end May 2020. Results and Discussion: 170 pharmacies and drug stores took part, giving a response rate of 63.9%. Encouragingly, no change in utilization of antimalarial medicines in 51.2% of stores despite global endorsements. However, increased utilisation of antibiotics (70.6%), analgesics (97.6%), vitamins (90.6%) and PPE (over 95%). Encouragingly, increases in purchasing of PPE. No increase in prices among 50% of the stores for antimalarials, with a similar situation for antibiotics (65.3%), analgesics (54.7%), and vitamins (51.8%). However, price increases typically for PPE (over 90% of stores). Shortages also seen for medicines and PPE, again greater for PPE. Conclusions: The pandemic has impacted on the supply and prices of medicines and PPE in Bangladesh. Key stakeholder groups can play a role addressing misinformation, with enhanced local production helping address future shortages and prices. Bangladesh Journal of Medical Science Vol.19(0) 2020 p. S 36-S 50

Lessons from the failure of implementing the 'Better Care Better Value' prescribing indicator for renin-angiotensin system drugs in England: a qualitative study of general practitioners' perceptions using behavioural change framework

OBJECTIVES

To explore reasons for the lack of uptake of 'Better Care Better Value (BCBV)' prescribing indicators for renin-angiotensin-aldosterone system (RAAS) inhibitors and identify learning lessons to inform the implementation of future prescribing policies.

DESIGN

In-depth, semistructured interviews to explore: general practitioners' (GPs) experiences in prescribing RAAS, perceptions of the BCBV policy and potential barriers to policy implementation and suggestions for improving future policy implementation. Interviews were audio recorded, transcribed verbatim and analysed thematically, then mapped onto behavioural change frameworks (the Capability, Opportunity, Motivation and Behaviour) model and Behaviour Change Wheel (BCW)).

SETTING

Primary care setting in England PARTICIPANTS: Interviews were conducted with 16 GPs recruited from a purposive sample of 91 GP practices in three English counties.

RESULTS

Four factors/barriers, related mainly to GPs' psychological capability and reflective motivation, emerged as the possible barriers for the BCBV's lack of uptake, including: lack of the policy awareness, negative attitude to the policy, lack of incentives and GPs' reluctance to switch patients from angiotensin receptor blockers (ARBs) to ACE inhibitors (ACEIs). The participating GPs proposed interventions to improve future BCBV implementation and they were related to six intervention/policy functions of the BCW, addressing the four identified barriers: education/communication (increase GPs' awareness) and environmental restructuring/regulations (provide GPs with reminding alerts); incentivisation/fiscal (provide GPs with financial incentives); enablement/guidelines-regulations (provide GPs with benchmarking against peers) and enablement/regulations and education/guidelines (facilitate switching from ARBs to ACEIs).

CONCLUSIONS

The main reason underpinning the low uptake of the BCBV indicator appears to be lack of a proactive implementation strategy. This case study demonstrated that passively disseminating policy without an effective implementation strategy results in low uptake. Furthermore, multifaceted implementation strategies are necessary to influence complex clinical decision making in a time-limited environment, such as prescribing behaviours. These findings suggest that effective policy implementation requires the application of a systematic comprehensive behaviours change framework.

Real-world evaluation of the impact of statin intensity on adherence and persistence to therapy: A Scottish population-based study

Aim

To assess associations between statin intensity and adherence, persistence and discontinuation of statin therapy in Scotland.

Method

Retrospective cohort study, using linked electronic health records covering a period from January 2009 to December 2016. The study cohort included adult patients (≥18 years) newly initiating statins within Greater Glasgow and Clyde, Scotland. Study outcomes comprised adherence, discontinuation and persistence to treatment, stratified by three exposure groups (high, moderate and low intensity). Discontinuation and persistence were calculated using the refill‐gap and anniversary methods, respectively. Proportion of days covered (PDC) was used as a proxy for adherence. Kaplan‐Meier survival curves and Cox proportional hazard models were used to evaluate discontinuation, and associations between adherence/persistence and statin intensity were assessed using logistic regression.

Results

A total of 73 716 patients with a mean age of 61.4 ± 12.6 years were included; the majority (88.3%) received moderate intensity statins. Discontinuation rates differed between intensity levels, with high‐intensity patients less likely to discontinue treatment compared to those on moderate intensity (prior cardiovascular disease [CVD]: HR 0.43 [95% CI 0.34‐0.55]; no prior CVD: 0.80 [0.74‐0.86]). Persistence declined over time, and high‐intensity patients had the highest persistence rates. Overall, 52.6% of patients were adherent to treatment (PDC ≥ 80%), but adherence was considerably higher among high‐intensity patients (63.7%).

Conclusion

High‐intensity statins were associated with better persistence and adherence to treatment, but overall long‐term persistence and adherence remain a challenge, particularly among patients without prior CVD. This needs addressing.