Antibiotic use in Namibia: prescriber practices for common community infections

Analysis of policies for use of medically important antibiotics in animals in Namibia: implications for antimicrobial stewardship

BACKGROUND

In Namibia, overuse of medically important antibiotics in animals is common and is a considerable driver of antimicrobial resistance. The study aims to analyze policies, resistance patterns and consumption of these antibiotics used in animals in Namibia.

RESEARCH DESIGN AND METHODS

A scoping review and retrospective descriptive analysis of policies, resistance patterns and use of these antibiotics in Namibia was conducted, and assessed against the AWaRe (Access, Watch and Reserve) antimicrobial use guidance.

RESULTS

Of the forty-five antibiotic products registered for use in animals, 77.8% are Access antibiotics, 68.9% are broad-spectrum and 60% are over-the-counter antibiotics- mainly tetracyclines, penicillins and sulfonamides. There is misalignment of antibiotic use policies for animals and humans and no guideline for antibiotic use in animals. Most medically important antibiotics are indicated for control of gastrointestinal (77.7%), musculoskeletal (71.1%) and respiratory (46.7%) infections, and for growth promotion (4.4%). There is high resistance to AWaRe Access antibiotics- sulfonamides (19.5%-100%), tetracyclines (56%-100%) and penicillin (13.5%-100%).

CONCLUSION

Whilst Namibia banned the use of antibiotics in farming, current policy frameworks are inconsistent across sectors, and promote overuse of broad-spectrum important antibiotics in animals. A multi-sectoral one health approach is required to harmonize antibiotic use policies and reduce resistance.

Antimicrobial resistance among bacteria isolated from urinary tract infections in females in Namibia, 2016-2017

Background

The emergence of antimicrobial resistance (AMR) among bacterial pathogens demands a local understanding of the epidemiological situation. This information is needed both for clinical treatment decision-making purposes as well as for the revision of current care guidelines. Clinical AMR data from Namibia is sparse, whilst urinary tract infections remain not only widespread but they disproportionally affect females. This paper aims to describe the national antimicrobial resistance situation of major bacterial uropathogens in females within the 14 Namibian regions.

Method

Retrospective countrywide information on clinical urine cultures performed in females in Namibia in 2016–2017 was obtained from the national public health laboratory, Namibia Institute of Pathology (NIP). The data set included both microbiological findings as well as antimicrobial susceptibility test (AST) results. The AST was done as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Resistance to 3rd generation cephalosporins was indicative of Extended Spectrum-ß-lactamase (ESBL) production. Data analysis was done with WHONET using expert interpretation rules.

Results

In total, 22,259 urinary cultures were performed, of which 13,673 (61.4%) were culture positive. Gram-negative bacterial species accounted for 72.6% of the findings. The most common pathogens identified were Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis. Most of these were from young females, with a median age ranging from 28 to 32 years for the various pathogens. Resistance to ampicillin was 77.7% in E. coli and 84.9% in K. pneumoniae. In E. coli, resistance to 1^st line empiric therapy antibiotic, nitrofurantoin, was below 13%, except for one region that showed 59.2% resistance. Resistance to third generation cephalosporin (3GC) was used as a proxy for ESBL production. By year 2017, 3GC resistance was 22%, 31.4% and 8.3% for E. coli, K. pneumoniae and P. mirabilis, respectively.

Conclusion

We report high resistance to ampicillin, quinolones and sulfamethoxazole-trimethoprim amongst E. coli. Resistance rates to third-generation cephalosporins was also concerningly high at 22%. Resistance to carbapenems was low. However, superiority of nitrofurantoin was found, which provides rational support for the usefulness of nitrofurantoin as an empiric therapy regimen for the treatment of urinary tract infections in this setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-022-01066-2.

National standard treatment guidelines: their impact on medicine use indicators in a resource-limited setting

Objectives

Standard treatment guidelines improve patient care outcomes. Few studies assess the impact of standard treatment guidelines on population-level medicine use indicators in resource limited settings in sub-Saharan Africa, where the burden of disease is greatest. The objective of this study was to determine the immediate and long-term impact of the national standard treatment guidelines on medicine use indicators at the population-level in Namibia.

Methods

An interrupted time-series modeling of the impact of national standard treatment guidelines implemented in Namibia in 2011, on population-level medicine use indicators. Antibiotic, generic and polypharmacy prescribing indicators were abstracted from the national Pharmaceutical Information System, over an eight-year period, 2007– 2015. This generated 15-quarterly time points. The impact was estimated by changes in trends of the indicators, immediately and after the intervention using R-software. The immediate impact was reflected by level change while long term impact was determined by trends/quarterly change after standard treatment guideline implementation.

Key findings

Data points from 522 Pharmaceutical Information System reports from 38 health facilities were included. The eight-year period estimates were, 2.9 ± 0.1 medicines prescribed per outpatient, 48.1 ± 2.5% of prescriptions had an antibiotic and 74.0 ± 4.2% of medicines were prescribed by generic name. Of the 13 regions, 61.3% and 53.8% had a decline in the average medicines per prescription and prescriptions with antibiotics respectively, as well as 53.8% of the regions had an increase in prescribing of generic medicines immediately after implementation of the standard treatment guidelines. Thereafter, quarterly trends in the three indicators did not significantly improve after the intervention at national and in all regions, except for generic prescribing in Oshikoto region, 4.5% (95% CI: 2.6 – 6.3%, P < 0.001).

Conclusion

Whilst national standard treatment guidelines immediately improved medicine use indicators, it is discouraging that the improvement over time was marginal across regions and was not sustained at the national level. Robust point of care interventions is needed for sustained and effective implementation of standard treatment guidelines.

Systematic review of patient-oriented interventions to reduce unnecessary use of antibiotics for upper respiratory tract infections

BACKGROUND

Antibiotics are prescribed frequently for upper respiratory tract infections (URTIs) even though most URTIs do not require antibiotics. This over-prescription contributes to antibiotic resistance which is a major health problem globally. As physicians' prescribing behaviour is influenced by patients' expectations, there may be some opportunities to reduce antibiotic prescribing using patient-oriented interventions. We aimed to identify these interventions and to understand which ones are more effective in reducing unnecessary use of antibiotics for URTIs.

METHODS

We conducted a systematic review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), CINAHL, and the Web of Science. We included English language randomized controlled trials (RCTs), quasi-RCTs, controlled before and after studies, and interrupted time series (ITS) studies. Two authors screened the abstract/titles and full texts, extracted data, and assessed study risk of bias. Where pooling was appropriate, a meta-analysis was performed by using a random-effects model. Where pooling of the data was not possible, a narrative synthesis of results was conducted.

RESULTS

We included 13 studies (one ITS, one cluster RCTs, and eleven RCTs). All interventions could be classified into two major categories: delayed prescriptions (seven studies) and patient/public information and education interventions (six studies). Our meta-analysis of delayed prescription studies observed significant reductions in the use of antibiotics for URTIs (OR = 0.09, CI 0.03 to 0.23; six studies). A subgroup analysis showed that prescriptions that were given at a later time and prescriptions that were given at the index consultation had similar effects. The studies in the patient/public information and education group varied according to their methods of delivery. Since only one or two studies were included for each method, we could not make a definite conclusion on their effectiveness. In general, booklets or pamphlets demonstrated promising effects on antibiotic prescription, if discussed by a practitioner.

CONCLUSIONS

Patient-oriented interventions (especially delayed prescriptions) may be effective in reducing antibiotic prescription for URTIs. Further research is needed to investigate the costs and feasibility of implementing these interventions as part of routine clinical practice.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016048007.

Knowledge, attitude and practice of Gambian health practitioners towards antibiotic prescribing and microbiological testing: a cross-sectional survey

Background

Inappropriate antibiotic use is the leading cause of antibiotic resistance worldwide. At the same time, the practice of antibiotic prescribing in Africa is less well documented when compared to developed countries. The objective of the study was to assess the knowledge, attitude, and practice (KAP) of health practitioners towards antibiotic prescribing and microbiological testing in The Gambia.

Methods

A KAP survey was conducted in The Gambia from March to May 2016. Self-administered paper-based questionnaires were distributed to health practitioners working in 12 health facilities.

Results

Out of 241 questionnaires distributed, 216 (89.6%) were returned. One third of respondents reported making a request for microbiological tests or using results as a guide in less than 25% of patients with possible infectious disease. Thirty-two percent of the participants reported that '25-50%' of antibiotic prescriptions in their departments were inappropriate. Only 16.1% of the participants had some training on antibiotic prescribing in the last 12 months. Respondents agreed with the options 'inadequate supervision' (82.6%) and 'insufficient laboratory support' (82.5%) as the main causes of inappropriate antibiotic use in their settings.

Conclusions

There are deficits related to antibiotic prescriptions in The Gambia. Availability and use of microbiological services and training should be emphasized.

Compliance to guidelines for the prescribing of antibiotics in acute infections at Namibia's national referral hospital: a pilot study and the implications

BACKGROUND

Sub-optimal antibiotic prescribing remains a public health concern in Namibia. The objective was to determine the level and predictors of compliance to guidelines in the prescribing of antibiotics in acute infections at a national referral hospital in Namibia to improve future prescribing.

METHODS

An analytical cross-sectional survey design. The clinical records of patients receiving care were reviewed. Prescribing practices were assessed using a self- administered questionnaire with reference to Namibia Standard Treatment Guidelines (NSTG).

RESULTS

The majority of prescriptions (62%) complied with the NSTGs; however, lower than national targets (95%). Most prescriptions were empiric and prescribers typically made reference to the NSTG (58%). Diagnosed infections were principally respiratory infections (58%) and penicillins were the most used antibiotics. Good concurrence between signs and symptoms with the diagnosis indicated on the prescription - OR=5.2 (95% CI: 1.4, 19.2), a diagnosis of upper respiratory tract (p=0.001), oral-dental OR=0.1(95% CI: 0.03,0.3) and urogenital infections OR=0.3(95% CI: 0.1,0.95) and the prescribing of penicillins (p=0.001) or combination antibiotics and amphenicols were independent predictors of compliance to the NSTGs. The main behaviours associated with antibiotic prescribing were patient influences, clinical state, and access to guidelines.

CONCLUSIONS

Compliance with NSTGs is suboptimal. Prescribing of combination antibiotics, penicillins and diagnosis of oral dental, genitourinary and ear, nose and throat infections were important predictors for NSTG compliance. There is a need to implement antibiotic indicators and stewardship programmes, and ensure access to NSTGs, to improve future antibiotic prescribing in Namibia.

An analysis of policies for cotrimoxazole, amoxicillin and azithromycin use in Namibia's public sector: Findings and therapeutic implications

BACKGROUND

Despite Namibia's robust medicine use systems and policies, antibiotic use indicators remain suboptimal. Recent medicine use surveys rank cotrimoxazole, amoxicillin and azithromycin (CAA) among the most used medicines. However, there is rising resistance to CAA (55.9%-96.7%). Unfortunately, to date, there have been limited studies evaluating policies to improve antibiotic use in Namibia.

AIM

To evaluate public sector pharmaceutical policies and guidelines influencing the therapeutic use of CAA antibiotics in Namibia.

METHODS

Evaluate Namibia's pharmaceutical policies and guidelines for CAA use through quantitative text analysis. The main outcome variables were the existence of antibiotic policies, therapeutic indications per antibiotic and the type/level of healthcare facility allowed to use the antibiotic.

RESULTS

Policies for antibiotic use were limited, with only the draft Namibia Medicines Policy having a statement on antibiotic use. Several essential antibiotics had no therapeutic indications mentioned in the guidelines. Twenty-nine antibiotics were listed for 69 therapeutic indications; CAA (49.3%) antibiotics and ATC J01C/J01D (48%) having the highest indications per antibiotic. For CAA antibiotics, this suggested use was mainly for acute respiratory infections (n=22, 37.2%). Published policies (58.6%-17/29) recommended antibiotics for use at the primary healthcare (PHC) level, with CAA antibiotics recommended mostly for respiratory tract infections and genitourinary infections.

CONCLUSIONS

Policy and guidelines for antibiotic use in Namibia are not comprehensive and are skewed towards PHCs. Existing policies promote the wide use of CAA antibiotics, which may inadvertently result in their inappropriate use enhancing resistance rates. This calls for the development of more comprehensive antibiotic guidelines and essential medicine lists in tandem with local antimicrobial resistance patterns. In addition, educational initiatives among all key stakeholder groups.