A retrospective audit of antibiotic prescriptions in primary health-care facilities in Eastern Region, Ghana

Audit of antibiotic utilization patterns and practice for common eye infections at the ambulatory clinic of a teaching hospital in Ghana: Findings and implications

BACKGROUND

Antimicrobial resistance (AMR) is a serious public health issue which is exacerbated by increased inappropriate use of antibiotics for common eye infections. This cross sectional survey was to assess the appropriate use of antibiotics for eye infections in an ambulatory clinic in Ghana and possible determinants.

METHOD

The medical records of all patients who sought eye care between January 2022 to December 2022 and were prescribed antibiotics were extracted from the hospital's electronic database. Descriptive, bivariate and multivariate analyses were then conducted.

RESULTS

A total of 1925 patient medical records were extracted, whose median age was 40 years (IQR 26-69), and were mostly females (58.91%, n = 1134/1925). The eye condition commonly treated with antibiotics was bacteria conjunctivitis (33.51%, n = 645/1925). The most prescribed antibiotic was gentamycin (22.96%, n = 442/1925) followed by ciprofloxacin (16.78%, n = 321/1925). These were mostly topical dosage forms (82.13%, n = 1581/1925). Systemic antibiotics prescribed were mostly from the WHO 'Access' class (83.33%, n = 280/338). The appropriate choice of antibiotic prescribed was 42.44% (n = 817/1925) and this was positivity associated with age (p<0.001), number of antibiotics prescribed (p <0.001), the prescription of topical dosage forms (p <0.001), and WHO 'Access' antibiotic class (p <0.034).

CONCLUSION

The level of appropriateness of antibiotic prescriptions for eye infections was sub-optimal. Antimicrobial stewardship programs, including prescriber education on guidelines and prescription audit to address associated factors, must now be instigated in this hospital to improve future antibiotic use and prevent the rise of AMR.

A Systematic Review on Antimicrobial Resistance in Ghana from a One Health Perspective

BACKGROUND

Antimicrobial resistance (AMR) poses a global health threat, with lower-middle-income countries bearing a disproportionate burden. Surveillance of AMR under a One Health framework is needed to elucidate the associations among clinical, animal, and environmental AMR. This review aimed to describe the state of AMR in Ghana, focusing on One Health.

METHOD

This review utilized the PRISMA guidelines and major databases to systematically search and analyze AMR in Ghana published from 1 January 2014 to 1 May 2023.

RESULTS

Out of the 48 articles that met the inclusion criteria, 28 studies were conducted on humans, 14 studies involved animals, and 6 studies focused on the environment. A total of 48 different pathogens were identified across the human, animal, and environmental sectors, with the most common being Escherichia coli (67%, n = 32), Klebsiella spp. (52%, n = 25), Pseudomonas spp. (40%, n = 19), and Salmonella spp. (38%, n = 18). Generally, a high prevalence of antibiotic resistance was observed among various bacterial species across the sectors. These bacteria exhibited resistance to commonly used antibiotics, with resistance to ampicillin and tetracycline exceeding 80%, and multidrug resistance (MDR) ranging from 17.6% in Shigella spp. to 100% in Acinetobacter spp.

CONCLUSION

This review reaffirms the significant challenge of AMR in Ghana, with a high prevalence observed in the human, animal, and environmental sectors. Key pathogens (e.g., Staphylococcus aureus and Escherichia coli) found across the sectors emphasize the urgent need for a One Health approach to tackle AMR in Ghana.

Modeling pediatric antibiotic use in an area of declining malaria prevalence

In malaria-endemic areas of Sub-Saharan Africa, overlap of clinical symptoms between malarial and non-malarial febrile illnesses can lead to empiric use of antibiotics among children. Our study aimed to illustrate the potential impact of decreasing malaria prevalence from malaria control efforts on antibiotic use. We constructed a probabilistic decision tree model representing antibiotic prescription in febrile children < 5 years. This model was used to predict change in absolute antibiotic use compared to baseline under levels of decreasing malaria prevalence. Model parameters were based on data from a hospital study in Ghana and validated via literature review. The baseline prevalence of malaria diagnoses was 52% among all hospitalized children. For our main results, we reported outcomes for a scenario representing a 50% decrease in malaria prevalence. Compared to baseline, absolute antibiotic prescription decreased from a baseline of 639 doses (95% CI 574-694) to 575 (95% CI 502-638). This reflected a 10% (95% CI 7%-13%) decrease in absolute antibiotic use. Our findings demonstrate that effective malaria control can reduce pediatric antibiotic use. However, until substantial progress is made in developing accurate diagnostics for non-malarial febrile illnesses, further reductions in antibiotic use will remain a challenge.

Injectable antibiotic use in India: public-private share in volume and cost

Background

Consumption of injectable antibiotics is not widely studied, despite injectables constitute a major share of antibiotic cost. This study aimed to understand the share of oral and injectable antibiotic consumption and cost at the national level in India, and the public and private sector shares in the provision and cost of injectables in Kerala state.

Methods

We used the PharmaTrac private sector sales dataset and the Kerala Medical Services Corporation public sector procurement dataset. Using WHO Access, Watch, Reserve (AWaRe) and Anatomical Therapeutic Chemical (ATC) Classifications, we estimated the annual total and per-capita consumption, and the annual total, per defined daily dose (DDD), and per-capita spending on injectables.

Results

Although 94.9% of total antibiotics consumed at the national level were oral preparations, 35.8% of total spending were on injectables. In Kerala , around 33% of total antibiotic spending in the private sector were for injectables, compared to around 25% in the public sector. The public sector used fewer injectable antibiotic formulations (n=21) compared the private sector (n=69). The cost per DDD was significantly higher in the private sector as compared to the public sector. Despite only accounting for 6.3% of the cost share, the public sector provided 31.4% of injectables, indicating very high efficiency. Across both sectors, Watch group antibiotics were significantly more consumed and at a significantly higher cost than Access group antibiotics, for example in nearly double the quantity and at 1.75 times the price per DDD in the private sector. Reserve group antibiotics made up the lowest consumption share (0.61% in the private sector), but at the highest cost per DDD (over 16 times that of Access).

Conclusions

Public sector showed higher cost efficiency in antibiotic provisioning compared to private sector. Appropriate antibiotic use cannot be achieved through drug price control alone but requires extensive engagement with private providers through structured stewardship programs.

Social and cultural determinants of antibiotics prescriptions: analysis from a public community health centre in North India

This paper explores the socio cultural and institutional determinants of irresponsible prescription and use of antibiotics which has implications for the rise and spread of antimicrobial resistance (AMR). This study describes the patterns of prescription of antibiotics in a public facility in India and identifies the underlying institutional, cultural and social determinants driving the irresponsible use of antibiotics. The analysis is based on an empirical investigation of patients' prescriptions that reach the in-house pharmacy following an outpatient department (OPD) encounter with the clinician. The prescription analysis describes the factors associated with use of broad-spectrum antibiotics, and a high percentage of prescriptions for dental outpatient department prescribed as a precautionary measure. This paper further highlights the need for future research insights in combining socio-cultural approach with medical rationalities, to further explore questions our analysis highlights like higher antibiotic prescription, etc., Along with the recommendations for further research.

A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications

Background and objectives: There are concerns with the current prescribing practices of antibiotics in ambulatory care in Tanzania, including both the public and private sectors. These concerns need to be addressed as part of the national action plan (NAP) of Tanzania to reduce rising antimicrobial resistance (AMR) rates. Issues and concerns include high rates of prescribing of antibiotics for essentially self-limiting conditions. Consequently, there is a need to address this. As a result, the aims of this narrative review were to comprehensively summarize antibiotic utilization patterns particularly in ambulatory care and their rationale in Tanzania and to suggest ways forward to improve future prescribing practices. Materials and Methods: We undertook a narrative review of recently published studies and subsequently documented potential activities to improve future prescribing practices. Potential activities included instigating quality indicators and antimicrobial stewardship programs (ASPs). Results: Published studies have shown that antibiotics are being excessively prescribed in ambulatory care in Tanzania, in up to 95% to 96.3% of presenting cases depending on the sector. This is despite concerns with their appropriateness. High rates of antibiotic prescribing are not helped by variable adherence to current treatment guidelines. There have also been concerns with extensive prescribing of 'Watch' antibiotics in the private sector. Overall, the majority of antibiotics prescribed across the sectors, albeit inappropriately, were typically from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. The inappropriate prescribing of antibiotics in ambulatory care is linked to current knowledge regarding antibiotics, AMR, and ASPs among both prescribers and patients. Recommended activities for the future include improved education for all groups, the instigation of updated quality indicators, and the regular monitoring of prescribing practices against agreed-upon guidelines and indicators. Education for healthcare professionals on ASPs should start at undergraduate level and continue post qualification. Community advocacy on the rational use of antibiotics should also include social media activities to dispel misinformation. Conclusion: The quality of current prescribing practices of antibiotics in ambulatory care is sub-optimal in Tanzania. This needs to be urgently addressed.

A Narrative Review of Antibiotic Prescribing Practices in Primary Care Settings in South Africa and Potential Ways Forward to Reduce Antimicrobial Resistance

There are concerns with the current prescribing of antibiotics in both the private and public primary care settings in South Africa. These concerns need to be addressed going forward to reduce rising antimicrobial resistance (AMR) rates in South Africa. Concerns include adherence to current prescribing guidelines. Consequently, there is a need to comprehensively summarise current antibiotic utilization patterns from published studies as well as potential activities to improve prescribing, including indicators and antimicrobial stewardship programs (ASPs). Published studies showed that there was an appreciable prescribing of antibiotics for patients with acute respiratory infections, i.e., 52.9% to 78% or more across the sectors. However, this was not universal, with appreciable adherence to prescribing guidelines in community health centres. Encouragingly, the majority of antibiotics prescribed, albeit often inappropriately, were from the 'Access' group of antibiotics in the AWaRe (Access/Watch/Reserve) classification rather than 'Watch' antibiotics to limit AMR. Inappropriate prescribing of antibiotics in primary care is not helped by concerns with current knowledge regarding antibiotics, AMR and ASPs among prescribers and patients in primary care. This needs to be addressed going forward. However, studies have shown it is crucial for prescribers to use a language that patients understand when discussing key aspects to enhance appropriate antibiotic use. Recommended activities for the future include improved education for all groups as well as regularly monitoring prescribing against agreed-upon guidelines and indicators.

Trends and Patterns of Antibiotic Prescriptions in Primary Care Institutions in Southwest China, 2017-2022

Purpose

To explore the prescription patterns and usage trends of antibiotics within primary care institutions located in underdeveloped regions of China from 2017 to 2022.

Methods

A retrospective analysis of antibiotic prescriptions was conducted from 25 primary care institutions in Guizhou Province during the period of 2017-2022. Antibiotic prescriptions were categorized into appropriate and inappropriate use. Appropriate use is further categorized into preferred medication, and antibiotics can be used or substituted. Inappropriate use is further categorized into unnecessary use, incorrect spectrum of antibiotics and combined use of antibiotics. Factors associated with inappropriate use were investigated using generalized estimation equations. Holt-Winters and SARIMA models were employed to predict the number of inappropriate antibiotic prescriptions as the alternative model.

Results

A total of 941,924 prescriptions were included, revealing a decreasing trend in both the number and inappropriate rates of antibiotic prescriptions from 2017 to 2022. Diseases of the respiratory system (70.66%) was the most frequent target of antibiotic use, with acute upper respiratory infections of multiple and unspecified sites representing 52.04% of these cases. The most commonly used antibiotics were penicillins (64.44%). Among all prescriptions, inappropriate antibiotic prescriptions reached 66.19%. Physicians aged over 35, holding the title of associate chief physician and possessing more than 11 years of experience were more likely to prescribe antibiotics inappropriately. The phenomenon of inappropriate antibiotic use was commoner among children aged five or younger. By comparing model parameters, it was determined that the SARIMA model outperforms the Holt-Winters model in predicting the number of inappropriate antibiotic prescriptions among primary care institutions.

Conclusion

The number and inappropriate rates of antibiotic prescriptions in southwest China exhibited a downward trend from 2017 to 2022, but inappropriate prescription remains a serious problem in primary care institutions. Therefore, future efforts should focus on strengthening physician education, training, and clinical practice. Additionally, physicians' awareness of common misconceptions about inappropriate antibiotic use must be improved, and the prescribing behavior of physicians who fulfill patients' expectations by prescribing antibiotics needs to be modified.

Stop antibiotic resistance - A roller coaster ride through "antibiotic stewardship," "prescription auditing" and "AWaRe" assessment tool

The emergence of superbugs and highly resistant organisms like methicillin-resistant staphylococci, vancomycin-resistant enterococci, carbapenem-resistant enterobacteriaceae demands the monitoring of antibiotic prescription and usage in various domains. The impact of antibiotic resistance is huge that it increases mortality, morbidity, and economic costs. The issue has to be addressed at various levels and that is why regulatory bodies implement antibiotic stewardship programs. These programs give a list of guidelines like infection control, tracking antibiotic use, prescription auditing, and involvement of health professionals like pharmacists, nurses, etc., A comparison of the list of guidelines given by the Centre for Disease Control and Prevention and Indian Council of Medical Research gives an idea about the measures to be taken at various levels to reduce the burden of antibiotic resistance. Prescription auditing is one of the major components of antibiotic stewardship. The auditing can be done either prospectively or retrospectively using WHO core prescribing indicators and antibiotic-specific indicators. An AWaRe assessment tool was also used to evaluate antibiotic consumption in countries and hospitals. The antibiotics are classified into access, watch and reserve categories. The aim of implementing the AWaRe tool is to increase the rational use of access antibiotic and reduce the consumption of watch and reserve antibiotics. This review focuses on the importance of prescription auditing, AWaRe tool and antibiotic stewardship in decreasing the threat of antibiotic resistance.

Impact of Point-of-Care Rapid Diagnostic Tests on Antibiotic Prescription Among Patients Aged <18 Years in Primary Healthcare Settings in 2 Peri-Urban Districts in Ghana: Randomized Controlled Trial Results

BACKGROUND

Inappropriate antibiotic prescriptions are a known driver of antimicrobial resistance in settings with limited diagnostic capacity. This study aimed to assess the impact of diagnostic algorithms incorporating rapid diagnostic tests on clinical outcomes and antibiotic prescriptions compared with standard-of-care practices, of acute febrile illness cases at outpatient clinics in Shai-Osudoku and Prampram districts in Ghana.

METHODS

This was an open-label, centrally randomized controlled trial in 4 health facilities. Participants aged 6 months to <18 years of both sexes with acute febrile illness were randomized to receive a package of interventions to guide antibiotic prescriptions or standard care. Clinical outcomes were assessed on day 7.

RESULTS

In total, 1512 patients were randomized to either the intervention (n = 761) or control (n = 751) group. Majority were children aged <5 years (1154 of 1512, 76.3%) and male (809 of 1512, 53.5%). There was 11% relative risk reduction of antibiotic prescription in intervention group (RR, 0.89; 95% CI, .79 to 1.01); 14% in children aged <5 years (RR, 0.86; 95% CI, .75 to .98), 15% in nonmalaria patients (RR, 0.85; 95% CI, .75 to .96), and 16% in patients with respiratory symptoms (RR, 0.84; 95% CI, .73 to .96). Almost all participants had favorable outcomes (759 of 761, 99.7% vs 747 of 751, 99.4%).

CONCLUSIONS

In low- and middle-income countries, the combination of point-of-care diagnostics, diagnostic algorithms, and communication training can be used at the primary healthcare level to reduce antibiotic prescriptions among children with acute febrile illness, patients with nonmalarial fevers, and respiratory symptoms.

CLINICAL TRIALS REGISTRATION

NCT04081051.

Prevalence of antibiotics prescription amongst patients with and without COVID-19 in low- and middle-income countries: a systematic review and meta-analysis

Antimicrobial resistance (AMR) poses a substantial risk to public health. In low-income and middle-income (LMICs) nations, the impact of AMR is significantly more severe. The absence of data from low-income countries (LMICs) causes this topic to be frequently overlooked. Additionally, the COVID-19 pandemic could make the AMR issue even worse. Earlier guidelines recommended antibiotic use in patients with COVID-19, even in those without bacterial coinfection. This study aims to investigate the proportion of antibiotic prescriptions in LMICs among patients with and without coronavirus disease-2019 (COVID-19), the proportion of inappropriate antibiotics, and multi-antibiotic prescribing. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We retrieved data through online databases, including PubMed, Scopus, and ScienceDirect. Amongst COVID-19 patients, the meta-analytic estimate of antibiotic prescription was 0.80 (95% CI: 0.72-0.88), whereas antibiotic use among patients with non-COVID-19 infections was 0.54 (95% CI: 0.49-0.58). Half of those prescribed antibiotics (0.52, 95% CI: 0.32-0.72) are inappropriate prescriptions. In addition, we found that one-third of antibiotics prescriptions consisted of more than one antibiotic (0.32, 95% CI: 0.21-0.43). In conclusion, antibiotics are highly prescribed across LMICs, and their use is increased in patients with COVID-19. Amongst those prescriptions, inappropriate and multiple use was not uncommon. This study has several limitations, as it included two studies in an ambulatory setting, and some of the studies included in the analysis were conducted on a small scale. Nevertheless, our findings suggest that urgent action to improve prescribing practices is essential.

Healthcare seeking outside healthcare facilities and antibiotic dispensing patterns in rural Burkina Faso: A mixed methods study

OBJECTIVE

Optimising antibiotic use is important to limit increasing antibiotic resistance. In rural Burkina Faso, over-the-counter dispensing of antibiotics in community pharmacies and non-licensed medicine retail outlets facilitates self-medication. We investigated its extent, reasons and dispensing patterns.

METHODS

In an exploratory mixed-method design conducted between October 2020 and December 2021, this study first explored illness perceptions, the range of healthcare providers in communities, antibiotics knowledge and reasons for seeking healthcare outside healthcare facilities. Second, frequencies of illness and healthcare utilisation in the last 3 months were quantitatively measured.

RESULTS

Participants distinguished between natural and magico-religious illnesses, according to origins. For illnesses considered to be 'natural', healthcare was mainly sought at healthcare facilities, private pharmacies and informal drug outlets. For illnesses considered as magico-religious, traditional healers were mainly visited. Antibiotics were perceived in the community as medicines similar to painkillers. Healthcare-seeking outside healthcare facilities was reported by 660/1973 (33.5%) participants reporting symptoms, including 315 (47.7%) to informal vendors. Healthcare seeking outside facilities was less common for 0-4-year-olds (58/534, 10.9% vs. 379/850, 44.1% for ≥5-year-olds) and decreased with improving socio-economic status (108/237, 45.6% in the lowest quintile; 96/418, 23.0% in the highest). Reported reasons included financial limitation, and also proximity to informal drug vendors, long waiting times at healthcare facilities, and health professionals' non-empathetic attitudes towards their patients.

CONCLUSION

This study highlights the need to facilitate and promote access to healthcare facilities through universal health insurance and patient-centred care including reducing patients' waiting time. Furthermore, community-level antibiotic stewardship programmes should include community pharmacies and informal vendors.

Appropriateness of antimicrobial selection for treatment of pneumonia in selected public hospitals of Eastern Ethiopia: A cross-sectional study

Objective

Inappropriate antimicrobial use leads to drug resistance and poor clinical outcomes. Considering the lack of data regarding the drug use patterns in the treatment of pneumonia in selected study areas, the authors felt compelled to assess the appropriateness of antimicrobial usage in the treatment of pneumonia at Hiwot Fana Specialized Comprehensive University Hospital and Jugal Hospital from May 1 to 31, 2021.

Methods

A cross-sectional retrospective study was conducted using the medical cards of 693 admitted patients with pneumonia. The collected data were analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were used to identify the factors associated with an initial inappropriate antibiotic use. A p value of 0.05 was used to determine the statistical significance of the association using an adjusted odds ratio with 95% confidence interval.

Results

Of the total participants, 116 (16.74%, 95% confidence interval: 14.1-19.6) of them received an initial inappropriate antimicrobial regimen. Ceftriaxone plus azithromycin was the most prescribed antimicrobial agent. Patients who were younger than 5 years (adjusted odds ratio = 1.71; 95% confidence interval: 1.00-2.94), between 6 and 14 years (adjusted odds ratio = 3.14; 95% confidence interval: 1.64-6.00), and older than 65 years (adjusted odds ratio = 2.97; 95% confidence interval: 1.07-2.66), with comorbid conditions (adjusted odds ratio = 1.74; 95% confidence interval: 1.10-2.72) and prescribed by medical interns (adjusted odds ratio = 1.80; 95% confidence interval: 1.14-2.84) were associated with an initial inappropriate antimicrobial use.

Conclusion

Around one out of every six patients had received initial inappropriate treatments. Adherence to the recommendation of guidelines and attention to extreme-aged groups and comorbidity may improve antimicrobial use.

Factors influencing receipt of an antibiotic prescription among insured patients in Tanzania: a cross-sectional study

OBJECTIVES

There are limited data on factors influencing antibiotic prescription among insured patients. We assessed for correlates of an antibiotic prescription among insured patients.

DESIGN

A cross-sectional study.

SETTING

The study was conducted at the National Health Insurance Fund offices, Dar es Salaam, Tanzania.

DATA SOURCE

We captured data from the claim forms, containing inpatient and outpatient treatment information for insured patients, for the month of September 2019.

OUTCOME VARIABLE

Receipt of an antibiotic prescription.

EXPOSURE VARIABLES

Age, sex, diagnosis, prescriber qualification, health facility level, ownership and department were exposure variables. Predictors of receipt of an antibiotic prescription were determined by Poisson regression analysis.

RESULTS

Of 993 analysed patients, the mean (±SD) age was 36.3 (±23.2) years, 581 (58.5%) were females and 535 (53.9%) were adults. The prevalence of antibiotic prescription was 46.4% (95% CI 42.8% to 50.0%). Strong predictors of an antibiotic prescription were being a child (1.7, 95% CI 1.3 to 2.2); acute upper respiratory tract infection (URTI) of multiple and unspecified sites (1.6, 95% CI 1.3 to 1.4); chronic rhinitis, nasopharyngitis and pharyngitis (4.0, 95% CI 2.4 to 6.4); being attended by a clinical officer (1.9, 95% CI 1.2 to 3.0); attending a health centre (1.5, 95% CI 1.1 to 2.0); attending a public facility (1.2, 95% CI 1.0 to 1.4) and visiting an inpatient department (2.0, 95% CI 1.2 to 3.4).

CONCLUSIONS

Among insured patients, being a child, acute URTI, being attended by a clinical officer or dental therapist, being attended by an assistant medical/dental officer, attending a health centre or a district hospital, attending a public health facility and visiting an inpatient department predicted an antibiotic prescription. Incorporation of these findings in revisions or establishment of targeted antimicrobial stewardship programmes may lead to better antibiotic prescribing practices that are critical for combating antibiotic resistance.

A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications

OBJECTIVE

Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider.

METHODS

A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines.

RESULTS

The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files.

CONCLUSIONS

It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.

High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study

BACKGROUND

Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance.

METHODS

Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year.

RESULTS

The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions.

CONCLUSIONS

Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.

Pushy Patients Or Pushy Providers? Effect Of Patient Knowledge On Antibiotic Prescribing In Tanzania

Antimicrobial resistance is one of the most serious threats to global health, but little progress has been made in reversing its spread. Inappropriate use of antibiotics in humans is a major driver of antimicrobial resistance, and rates are high and growing in lower- and middle-income countries. Antibiotics are thought to be subject to supplier-induced demand, whereby providers prescribe them to patients who do not know they are unnecessary. We conducted a randomized field experiment in 227 private health facilities in Tanzania, with standardized patients presenting uncomplicated upper respiratory tract infection symptoms. Standardized patients were randomly assigned to express knowledge (informed) or not (uninformed) that antibiotics were not required to treat them. There was a very high rate of inappropriate antibiotic prescription, with 86.0 percent of informed standardized patients and 94.8 percent of uninformed standardized patients prescribed an antibiotic, for an adjusted difference of 7.8 percentage points between the groups. This small effect suggests that broader health systems factors are at play and that interventions should be aimed at systems, health facilities, and providers.

Diarrhea-Causing Bacteria and Their Antibiotic Resistance Patterns Among Diarrhea Patients From Ghana

Diarrheal disease remains a major global health problem particularly in children under 5 years and the emergence of antibiotic-resistant strains of causative pathogens could slow control efforts, particularly in settings where treatment options are limited. This surveillance study conducted in Ghana aimed to determine the prevalence and antimicrobial susceptibility profile of diarrhea-causing bacteria. This was a cross-sectional study carried out in five health facilities in the Ga West Municipality of Ghana between 2017 and 2021. Diarrheic stool samples from patients were collected and cultured on standard differential/selective media and isolates identified by standard biochemical tests, MALDI-TOF assay, and serological analysis. The antibiogram was determined using Kirby-Bauer disk diffusion and Microscan autoScan4 MIC panels which were used for extended-spectrum beta-lactamase (ESBL) detection. Bacteria were isolated from 97.5% (772/792) of stool samples, and 167 of the isolates were diarrheagenic and met our inclusion criteria for antimicrobial resistance (AMR) analysis. These included Escherichia coli (49.1%, 82/167), Salmonella species (23.9%, 40/167), Vibrio species (16.8%, 28/167), and Shigella species (10.2%, 17/167). Among 24 Vibrio species, we observed resistances to cefotaxime (21/24, 87.5%), ceftriaxone (20/24, 83.3%), and ciprofloxacin (6/24, 25%), including four multi-drug resistant isolates. All 13 Vibrio parahaemolyticus isolates were resistant to cefazolin. All 17 Shigella isolates were resistant to tetracycline with resistance to shigellosis drugs such as norfloxacin and ciprofloxacin. Salmonella isolates were highly susceptible to norfloxacin (40/40, 100%) and tetracycline (12/34, 35%). Two ESBL-producing E. coli were also identified with marked susceptibility to gentamicin (66/72, 91.7%) and amikacin (57/72, 79.2%) prescribed in the treatment of E. coli infections. This study showed the different bacteria implicated in diarrhea cases in Ghana and the need for differential diagnoses for better treatment outcomes. Escherichia coli, Shigella, Salmonella, and Vibrio have all been implicated in diarrhea cases in Ghana. The highest prevalence was E. coli and Salmonella with Shigella the least prevalent. Resistance to commonly used drugs found in these isolates may render bacteria infection treatment in the near future nearly impossible. Routine antimicrobial susceptibility testing, effective monitoring, and nationwide surveillance of AMR pathogens should be implemented to curb the increase of antimicrobial resistance in Ghana.

Use of WATCH antibiotics prior to presentation to the hospital in rural Burkina Faso

Background

In low- and middle-income countries, the prevalence of antimicrobial resistance (AMR) is increasing. To control AMR, WHO recommends monitoring antibiotic use, in particular Watch antibiotics. These are critically important antibiotics, with restricted use because at risk of becoming ineffective due to increasing AMR. We investigated pre-hospital antibiotic use in rural Burkina Faso.

Methods

During 2016–2017, we collected data from patients aged > 3 months presenting with severe acute fever to the rural hospital of Nanoro Health District, Burkina Faso, including antibiotic use in the two weeks prior to consultation or hospitalization. We analysed reported antibiotic use by applying the WHO Access, Watch, Reserve classification.

Results

Of 920 febrile participants (63.0% ≤ 14 years), pre-hospital antibiotic use was reported by 363 (39.5%). Among these 363, microbiological diagnoses were available for 275 (75.8%) patients, of whom 162 (58.9%) were non-bacterial infections. Use of more than one antibiotic was reported by 58/363 (16.0%) participants. Of 491 self-referred patients who did not previously visit a primary health care center, 131 (26.7%) reported antibiotic use. Of 424 antibiotics reported, 265 (62.5%) were Access and 159 (37.5%) Watch antibiotics. Watch antibiotic use was more frequent among patients > 14 year olds (51.1%) compared to those 0–14 year old (30.7%, p < 0.001) and among referrals from the primary health care centers (42.2%) compared to self-referred patients (28.1%, p = 0.004). Most frequently reported Watch antibiotics were ceftriaxone (114, 71.7%) and ciprofloxacin (32, 20.1%).

Conclusion

The reported frequent use of Watch group antibiotics among febrile patients prior to presentation to the hospital in rural Burkina Faso highlights the need to develop targeted interventions to improve antibiotic use in community settings as part of strengthening antibiotic stewardship in low- and middle-income countries. This should include facilitating referral, access to qualified prescribers and diagnostic tools in rural primary health care centers.

Trial registration ClinicalTrials.gov identifier: NCT02669823. Registration date was February 1, 2016.

Exploring the economic impact of inappropriate antibiotic use: the case of upper respiratory tract infections in Ghana

BACKGROUND

Antibiotic consumption is increasing worldwide, particularly in low and middle-income countries (LMICs). Access to lifesaving antibiotics in LMICs is crucial while minimising inappropriate use. Studies assessing the economic impact of inappropriate antibiotic use in LMICs are lacking. We explored the economic impact of inappropriate antibiotic use using the example of upper respiratory tract infections (URIs) in Ghana, as part of the ABACUS (AntiBiotic ACcess and USe) project.

METHODS

A top-down, retrospective economic impact analysis of inappropriate antibiotic use for URIs was conducted. Two inappropriate antibiotic use situations were considered: (1) URIs treated with antibiotics, against recommendations from clinical guidelines; and (2) URIs that should have been treated with antibiotics according to clinical guidelines, but were not. The analysis included data collected in Ghana during the ABACUS project (household surveys and exit-interviews among consumers buying antibiotics), scientific literature and stakeholder consultations. Included cost types related to health care seeking behaviour for URIs. Additionally, cost saving projections were computed based on potential effects of future interventions that improve antibiotic use.

RESULTS

Health care costs related to inappropriate antibiotic use for URIs were estimated to be around 20 million (M) USD annually, including 18 M USD for situation 1 and 2 M USD for situation 2. Travel costs and lost income due to travel, together, were estimated to be around 44 M USD for situation 1 and 18 M USD for situation 2. Possible health care cost savings range from 2 to 12 M USD for situation 1 and from 0.2 to 1 M USD for situation 2.

CONCLUSIONS

This study indicates that inappropriate antibiotic use leads to substantial economic costs in a LMIC setting that could have been prevented. We recommend investment in novel strategies to counter these unnecessary expenditures. As the projections indicate, this may result in considerable cost reductions. By tackling inappropriate use, progress can be made in combatting antibiotic resistance.

Management of febrile illness in rural Guinea over a seven-year period: A retrospective study

INTRODUCTION

Febrile illnesses constitute a major clinical challenge in tropical settings. We aimed to assess the frequency, presentation and management of febrile illness at two health facilities in Forécariah, Guinea, with a focus on appropriateness of antibiotic prescription.

MATERIALS AND METHODS

This was a retrospective study conducted in patient files in a health center and a district hospital. Proportions of antibiotic prescription were determined by age group and syndromes as well as appropriateness of antibiotic prescription using the WHO model list (2019).

RESULTS

From 2014 to 2020, 23,583 of 62,185 (38.0%) visits were related to febrile illness. Most patients with fever were female (56.1%) and evaluated at the health center (81.0%). Gastrointestinal (40.6%) and respiratory syndromes (36.8%), and undifferentiated fever (30.0%) were the most common presentations. Malaria was confirmed in 61.3% of the cohort. Overall, the rate of antibiotic prescription was high (14,834/23,583, 62.9%), mostly among patients aged <5 years (5,285/7,566, 69.9%), those with respiratory (7,577/8,684, 87.3%) and gastrointestinal (6,324/9,585, 66.0%) syndromes. Moreover, 7,432/14,465 (51.4%) patients with malaria were also prescribed an antibiotic. Penicillin (42.0%), cotrimoxazole (26.3%) and quinolones (18.7%) were the most frequently prescribed antibiotics. Overall, appropriateness of antibiotic prescription was low (38.3%), and even more so in patients with respiratory (29.1%) and gastrointestinal (25.8%) syndromes.

CONCLUSIONS

Febrile illness is a major cause of consultation in rural Guinea. Rate of antibiotic prescription was high, even in confirmed malaria and was often considered inappropriate. There is a pressing need to investigate the etiological spectrum and improve the diagnostic approach of febrile illness in Guinea.

Analyzing gut microbiota composition in individual Anopheles mosquitoes after experimental treatment

The microbiota of Anopheles mosquitoes influences malaria transmission. Antibiotics ingested during a blood meal impact the mosquito microbiome and malaria transmission, with substantial differences between drugs. Here, we assessed if amoxicillin affects the gut mosquito microbiota. We collected Anopheles larvae in Burkina Faso, kept them in semi-field conditions, and offered a blood meal to adult females. We tested the impact of blood supplementation with two alternative amoxicillin preparations on microbiota composition, determined by high-throughput sequencing in individual gut samples. Our analysis detected four major genera, Elizabethkingia, Wigglesworthia, Asaia, and Serratia. The antibiotic treatment significantly affected overall microbiota composition, with a specific decrease in the relative abundance of Elizabethkingia and Asaia during blood digestion. Besides its interest on the influence of amoxicillin on the mosquito microbiota, our study proposes a thorough approach to report negative-control data of high-throughput sequencing studies on samples with a reduced microbial load.

The prevalence and pattern of antibiotic prescription among insured patients in Dar es Salaam Tanzania

Introduction

high prevalence of antibiotic prescriptions may contribute to the problem of antibiotic resistance. Understanding the pattern of antibiotic prescriptions in a country may inform monitoring and stewardship activities, which are crucial in the fight against antibiotic resistance. We aimed to determine the prevalence and describe the pattern of antibiotic prescriptions among National Health Insurance Fund (NHIF) insured patients receiving treatment at health facilities in Ilala Municipality, Dar es Salaam, Tanzania.

Methods

a cross-sectional analysis of claim forms of NHIF insured patients. A data extraction form was used to capture data for September, 2019 submitted to the Ilala NHIF offices.

Results

among 993 insured patients (mean [±SD] age 36.3 [±23.2] years; 581 [58.5%] females; 535 [53.9%] adults) a total of 357 (46.4%, 95% CI, 42.8-50.0) received an antibiotic prescription. Of the 357 patients who received an antibiotic prescription, 71(19.9%) received more than one antibiotic prescription. The most common antibiotic prescribed was amoxicillin/clavulanate (17.1%) followed by amoxicillin (16.5%) whereas the most commonly prescribed antibiotic class was the penicillins (51.3%) followed by the nitroimidazoles (14.0%). Among patients who received more than one antibiotic, the most commonly co-prescribed antibiotics were Ampicillin/Cloxacillin plus Metronidazole (11.4%) followed by Amoxicillin plus Metronidazole (7.1%). According to 2019 WHO Access, Watch, Reserve (AWaRe) Classification of antibiotics, 60.8% of patients received the access antibiotics, 33.3% received the watch antibiotics whereas 17.4% of patients received antibiotics that were not recommended. No patient received an antibiotic from the reserve group.

Conclusion

the prevalence of antibiotic prescriptions in Tanzania is high and some antibiotics not recommended by the WHO are still prescribed. We recommend revision of the current Tanzania treatment guideline on antibiotics to reflect WHO recommendations, and further research to address local factors influencing antibiotic prescriptions is warranted.

Prescription of Antimicrobials in Primary Health Care: Scoping Review

Objective:

To map the available evidence about the prescription of antimicrobials in Primary Health Care.

Methods:

A Scoping Review has been proposed based on the procedures recommended by the Joanna Briggs Institute.

Results:

This review included a total of 16 studies. The articles compiled demonstrated that this theme is the center of discussion, in a linear manner, over the past 12 years. Among the studies, 37.5% occurred in Brazil, and regarding the prescription of antimicrobials analyzed in studies, amoxicillin was the most prescribed, the physician was the prescribing professional in 12 studies, and the prescriptions were mostly intended for the general population (children, adolescents, adults and the elderly).

Conclusion:

This review ratifies the premise of rational use of antimicrobials promoted by the World Health Organization through the goals of sustainable development when understanding that these drugs have been considerably prescribed in the daily routine of Primary Health Care and there is no specific system to control and monitor their rational use.

Are antibiotic prescription practices in Eastern Uganda concordant with the national standard treatment guidelines? A cross-sectional retrospective study

OBJECTIVES

To evaluate the antibiotic prescription patterns of health workers in Eastern Uganda and more specifically whether they are not in accordance with the Uganda standard treatment guidelines and other indicators of appropriate antimicrobial drug prescription.

METHOD

Data on variables of the patients was obtained from the health management information system records of the outpatient department registers of Soroti and Mbale Regional Referral Hospitals from 2016 to 2018.

RESULTS

The prevalence of non-adherence to treatment guidelines when prescribing antibiotics was 82.6% (95%CI: 81.4% - 83.7%). Guidelines were likely to be adhered to when prescribing antibiotics for individuals aged 13 - 19 years compared to their counterparts aged 0 - 12 years (13 - 19 years: adjusted odds ratio (AOR) =0.55, 95%CI: 0.40-0.74). When prescribing antibiotics for males, health workers were twice as likely not to adhere to guidelines compared to when prescribing for females (AOR=2.09, 95%CI: 1.61-2.72). When prescribing cephalosporins and nitroimidazoles, health workers were likely not to adhere to guidelines compared to when prescribing penicillin (cephalosporins: AOR=1.92, 95%CI: 1.28 - 2.86; nitroimidazoles: AOR=1.70 95%CI: 1.09-2.65). Health workers were most likely not to follow guidelines when prescribing antibiotics in combinations with another antibiotic (2 antibiotics: AOR=1.27, 95%CI: 1.03 - 1.56) CONCLUSION: Non-adherence to treatment guidelines for an indicated diagnosis and inappropriate antibiotic prescription is significantly prevalent in Eastern Uganda. Health workers were more likely not to follow guidelines when prescribing for male patients, children up to 12 years of age and when prescribing cephalosporins, nitroimidazoles or antibiotics in double combination.

Assessment of medicine use based on WHO drug-use indicators in public health facilities of the South Indian Union Territory

OBJECTIVE

To assess medicine use based on World Health Organization (WHO) core drug-use indicators in selected public health facilities of the South Indian Union Territory.

METHODS

A prospective cross-sectional study was conducted for period of one year (from March 2019 to February 2020) in 10 selected public health facilities based on the WHO document How to investigate drug use in health facilities. Total 900 prescriptions were analysed to study prescribing, patient care and health facility indicators. The results were compared with the WHO standard measures.

RESULTS

The overall average number of drugs per prescription was 3.2. Percentage of prescriptions with antibiotics and injections were found to be 36.6 and 11.4%, respectively. Percentage of drugs prescribed by generic name was 74.6%. Percentage of drugs prescribed from the National List of Essential Medicine was 93.3%. Average consultation and dispensing time were found to be 3.9 minutes and 49.3 seconds, respectively. The percentage of drugs dispensed in this study was 98.5 and 61.6% of medicines were properly labelled; 76.7% of patients had correct knowledge of each medicine dispensed to them. Mean availability of key essential medicine was 73.4%.

CONCLUSION

Indicators such as percentage of drugs prescribed from the National List of Essential Medicine, availability of copy of essential medicine list and percentage of drugs dispensed were found to be as per WHO optimal value. Indicators such as average number of drugs per prescription, average consultation and dispensing time and percentage of medicines labelled were found below optimal value and need to be improved.

Antibacterial prescription and the associated factors among outpatients diagnosed with respiratory tract infections in Mbarara Municipality, Uganda

Background

Respiratory tract infections (RTI) are the second most frequent diagnosis after Malaria amongst Outpatients in Uganda. Majority are Non pneumonia cough and flu which are self-limiting and often do not require antibacterials. However, antibiotics are continuously prescribed for these conditions and are a major contributor to antimicrobial resistance and wastage of health resources. Little is known about this problem in Uganda hence the impetus for the study.

Objectives

To determine the antibacterial prescribing rate and associated factors among RTI outpatients in Mbarara municipality

Methodology

This was a retrospective cross-sectional study on records of RTI outpatients from 1st April 2019 to 31st March 2020 (prior to the novel corona virus disease pandemic) in four selected public health facilities within Mbarara municipality. A pretested data caption tool was used to capture prescribing patterns using WHO/INRUD prescribing indicators. We used logistic regression to determine factors associated to antibacterial prescribing.

Results

A total of 780 encounters were studied with adults (18-59 years) forming the largest proportion of age categories at (337, 43.15%) and more females (444, 56.85%) than men (337, 43.15%). The antibacterial prescribing rate was 77.6% (606) with Amoxicillin the most prescribed 80.4% (503). The prescribing pattern showed an average of 2.47 (sd 0.72) drugs per encounter and the percentage of encounters with injection at 1.5% (24). Drugs prescribed by generic (1557, 79%) and drugs prescribed from essential medicine list (1650, 84%) both not conforming to WHO/INRUD standard; an indicator of possible irrational prescribing. Female gender (adjusted odds ratio [aOR] = 1.51, 95% confidence interval [CI]: (1.06–2.16); 18–59 years age group (aOR = 1.66, 95% CI: 1.09–2.33) and Individuals prescribed at least three drugs were significantly more likely to have an antibacterial prescribed (aOR= 2.72, 95% CI: 1.86–3.98).

Conclusion

The study found a high antibacterial prescribing rate especially among patients with URTI, polypharmacy and non-conformity to both essential medicine list and generic name prescribing. This prescribing pattern does not comply with rational drug use policy and needs to be addressed through antimicrobial stewardship interventions, prescriber education on rational drug use and carrying out more research to determine the appropriateness of antibacterial prescribed.

To Push or To Pull? In a Post-COVID World, Supporting and Incentivizing Antimicrobial Drug Development Must Become a Governmental Priority

The COVID-19 pandemic has refocused attention worldwide on the dangers of infectious diseases, in terms of both global health and the effects on the world economy. Even in high income countries, health systems have been found wanting in dealing with the new infectious agent. However, the even greater long-term danger of antimicrobial resistance in pathogenic bacteria and fungi is still under-appreciated, especially among the general public. Although antimicrobial drug development faces significant scientific challenges, the gravest challenge at the moment appears to be economic, where the lack of a viable market has led to a collapse in drug development pipelines. There is therefore a critical need for governments across the world to further incentivize the development of antimicrobials. Most incentive strategies over the past decade have focused on so-called "push" incentives that bridge the costs of antimicrobial research and development, but these have been insufficient for reviving the pipeline. In this Perspective, we analyze the current incentive strategies in place for antimicrobial drug development, and focus on "pull" incentives, which instead aim to improve revenue generation and thereby resolve the antimicrobial market failure challenge. We further analyze these incentives in a broader "One Health" context and stress the importance of developing and enforcing strict protocols to ensure appropriate manufacturing practices and responsible use. Our analysis reiterates the importance of international cooperation, coordination across antimicrobial research, and sustained funding in tackling this significant global challenge. A failure to invest wisely and continuously to incentivize antimicrobial pipelines will have catastrophic consequences for global health and wellbeing in the years to come.

Irrational drug use and its associated factors at Debre Markos Referral Hospital's outpatient pharmacy in East Gojjam, Northwest Ethiopia

Objectives:

Half of all drugs are used irrationally around the world, and about half of patients take their medications correctly. Inappropriate use of drugs leads to antibiotic resistance, medication therapy problems, and an increase in drug costs. This study aimed to assess irrational drug use and its associated factors at the outpatient pharmacy of Debre Markos Referral Hospital.

Methods:

A hospital-based cross-sectional study was used. Systematic random sampling was used as a sampling technique. The data were collected with a structured checklist. The data were entered into EPI Data Version 3.1 and analyzed using SPSS version 20. Descriptive statistics and logistic regression analysis were used for data analysis.

Results:

The average number of drugs per patient encounter was 2.14. The prevalence of antibiotics use per encounter was 39.3%. Polypharmacy was detected in 62.2% of prescriptions, and injections were prescribed in 13% of prescriptions. The percentage of drugs prescribed with a generic name was 95.5%. In multivariable logistic regression, comorbidities, professionals’ training, and prescribers’ experience were significantly associated with polypharmacy. Patient age, comorbidity, presence of chronic disease, professionals training, and type of diseases were significantly associated with antibiotic prescribing.

Conclusion:

Our findings revealed there were practices of polypharmacy and antibiotics overuse. Continuous seminars and training on rational prescribing and periodic prescription surveys are recommended to prevent irrational drug use.

Residual antimicrobial agents in food originating from animals

BACKGROUND

The agricultural food products industry in Bangladesh depends on utilizing antimicrobials indiscriminately as growth promoters and for controlling infectious diseases. Thus, there is always a risk of antimicrobial agent accumulation in food sources that originate from agricultural production.

METHODS

In the present study, we collected data from published articles between January, 2013 and December, 2019 on antimicrobial residues in human food sources such as meat, milk, eggs, and fishes.

RESULTS

Liver contained the highest percentage of antimicrobial residues (74%; 95% CI: 59.66-85.37) against the in vitro enteric pathogen Escherichia coli in layer chickens. Similar results were demonstrated in liver (68%; 95% CI: 53.30-80.48) and kidney (66%, 95% CI: 51.23-78.79) of layer chickens against Bacillus cereus and Bacillus subtilis. Amongst all antibiotics, the highest concentrations of ciprofloxacin were detected in kidney (48.57%; 95% CI: 31.38-66.01), followed by liver (47.56; 95% CI: 40.88-54.30) of broiler chickens. Ciprofloxacin was also present in liver (46.15%; 95% CI: 33.70-58.96) of layer chickens. The percentage of ciprofloxacin in thigh and breast meat in broiler bird were 41.54% (95% CI: 34.54-48.79) and 37.95% (95% CI: 31.11-45.15) respectively. Enrofloxacin was the second most dominant antimicrobial agent and was present in the liver of both types of poultry (Broiler and Layer chickens: 41.54%; 95% CI: 29.44-54.4 and 437.33%; 95% CI: 30.99-44.01). The prevalence rates of enrofloxacin in thigh and breast meat of broiler chickens were 24.10% (95% CI: 18.28-30.73) and 20.51% (95% CI: 15.08-26.87), respectively. Tetracycline, a commonly used antibiotic in livestock, was present in the liver (49.23%; 95% CI: 36.60-61.93) of layer chickens. In case of aquaculture food products, the highest amount of amoxicillin (683.2 mg/kg) was detected in Tilapia fish (Oreochromis niloticus), followed by 584.4 mg/kg in climbing perch (Anabas testudineus) and 555.6 mg/kg in Rui fish (Labeo rohita). Among the five types of fishes, Rui fish (0.000515 mg/kg) contained the highest concentrations of chloramphenicol antibiotic residues.

CONCLUSIONS

The presence of antimicrobial residues in meat, milk, egg, and fish is a serious public health threat due to the potential induction of antimicrobial resistance. It can negatively impact the food supply chain, especially with the current strain that it is already facing with the current COVID-19 pandemic. The findings of the present study highlight the ongoing risk of residual antimicrobial agents in food of animal origin in Bangladesh and countries with similar practices. This can draw the attention of public health officials to propose plans to mitigate or stop this practice.

Amoxicillin Utilization Pattern at Governmental Hospitals in Eastern Ethiopia

INTRODUCTION

Penicillin is among the highly used antibiotics in most parts of the world, with amoxicillin being the most frequently utilized drug in the category. However, amoxicillin use has been found to deviate from standard treatment guidelines (STGs).

OBJECTIVE

This study aimed to evaluate amoxicillin utilization patterns based on Ethiopian STGs criteria at four governmental hospitals in Harar town: Hiwot Fana Specialized University Hospital, Jugel Hospital, South East Command III Hospital, and Federal Harar Police Hospital in Eastern Ethiopia in 2016.

METHODS

A hospital-based retrospective cross-sectional study was employed using medication records of patients who received amoxicillin in 2016 at four governmental hospitals from May 15 to June 30, 2018. A total of 502 medication records were proportionally allocated based on the ratio of consumption data of each hospital. Simple random sampling was employed to collect the required sample from the sampling frame. The collected data were entered into SPSS version 21 and analyzed using descriptive analysis.

RESULTS

Amoxicillin was used in all age groups, including pregnant and lactating women. The majority (96.2%) of patients were from the outpatient departments. Complete blood count was the most laboratory investigation carried out in 24.9% whereas microbiological culture was not recorded at all. Top three indications include nonspecific upper respiratory tract infections (15.1%), pneumonia (13.5%) and dental problems (10.6%). Non-steroidal anti-inflammatory drugs (56.2%) were frequently co-administered agents. An appropriate utilization was made considering indication, dose, frequency and therapy duration in 23.9% as per the Ethiopian STG. The wrong indication (65.4%) was the prime reason for inappropriateness, followed by dose (14.6%) and duration of therapy (12.2%).

CONCLUSION

Amoxicillin utilization was appropriate in less than a quarter of patients. The wrong indication was the main reason for inappropriateness, predisposing to resistance development. Further studies identifying factors related to misuse and sensitivity tests should be the next steps.

Drug Therapy Problems and Predictors Among Patients Admitted to Medical Wards of Dilla University Referral Hospital, South Ethiopia: A Case of Antimicrobials

Purpose

To assess antimicrobial use-related problems and associated factors among patients admitted to medical wards of Dilla University Referral Hospital.

Patients and Methods

A hospital-based prospective observational study design was employed to assess the antimicrobial use-related problems among adult patients admitted to Dilla University Referral Hospital from 5 March to 4 September 2018. The antimicrobial therapy was reviewed to assure compliance with the recommendations of the national guidelines or evidence-based international clinical guidelines and drug therapy problem was identified. The logistic regression model was fit to determine the association between the different factors and the occurrence of drug therapy problems. Odds ratio was used to show a comparison of factors contributing to drug therapy problems. Statistical significance was considered at p-value <0.05.

Results

In this follow-up to 229 participants, the prevalence of antimicrobial therapy-related problem was 70.74%. “Noncompliance to therapy” was the most frequent DTP experienced by 68 (29.69%) of the patients followed by “needs additional drug therapy” seen among 31 (13.54%) patients. “Adverse drug reaction” was the least and experienced by 7 (3.06%) patients. Others include: dosage too low among 22 (9.61%), dose too high among 17 (8.30%), unnecessarily prescribed antimicrobials among 17 (7.42%) and ineffective antimicrobials among 8 (3.49%) patients. Compared with those who used less than four drugs, the use of four to six (AOR: 4.024) and seven and above (AOR: 13.516) drugs were determinants for antimicrobial use problems. Additionally, infectious cases not addressed by the national guideline (AOR: 3.328) and the unavailability of appropriate lab values results within 48 hours of hospital admission (AOR: 1.285) were determinants for antimicrobial use problems.

Conclusion

Antimicrobial use problem was prevalent with 0.94-problems-per-patient. Polypharmacy, coverage of national guidelines and availing laboratory values within 48 hours of hospital admission were independent determinants of antimicrobial use problems.

Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.

METHODS AND FINDINGS

We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.

CONCLUSIONS

Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.

TRIAL REGISTRATION

PROSPERO registration number: CRD42019123269.

Inappropriate Antibiotic Use Among Inpatients Attending Madda Walabu University Goba Referral Hospital, Southeast Ethiopia: Implication for Future Use

BACKGROUND

Ethiopia is one of the countries where the healthcare system is not yet developed to the required level; hence, it is not uncommon that drugs, particularly antimicrobials, are inappropriately used for infections by any causative agents, with or without prescription, in combination or not, and, of more concern, without sensitivity tests. So, it was considered important to assess the magnitude of inappropriate antimicrobial use among inpatients attending Madda Walabu University Goba Referral Hospital, southeast Ethiopia.

METHODS

A health institution-based cross-sectional study was conducted from September 2018 to April 2019. Patient folders from collaborating wards were reviewed for antibiotic use. Inappropriateness of a drug or its dosage, or both, was considered in reference to the Ethiopian national treatment guideline. The information obtained was analyzed using SPSS version 20. Patterns of prescription of antimicrobials for the hospitalized patients were analyzed using simple descriptive statistics.

RESULTS

A total of 801 antibiotics were written as prescriptions to 471 clients, 228 (47.6%) of whom had received two or more antibiotics at the time of the study. Of the total prescribed antibiotics, 142 (30.1%) had an inappropriate prescription. Genitourinary tract infections accounted for 42 (30.4%) of the inappropriate prescriptions due to the wrong dose and drugs. Cephalosporins were the most extensively prescribed class of antibiotics, 24.4% of which were inappropriately prescribed. Intravenous formulations made up the largest proportion of prescriptions, at 335 (41.8%). The most commonly prescribed antimicrobials were cephalosporins, 178 (38%); nitroimidazoles, 115 (24.5%); and macrolides, 53 (11.3%), while ceftriaxone was prescribed in 249 (53%) and metronidazole in 123 (26.2%) cases.

CONCLUSION

Low dose, inadequate duration and empiric use of antibiotics were major causes of inappropriate use in the study area. Therefore, local antimicrobial sensitivity tests, antibiotic stewardship and following the national treatment guideline are recommended to overcome inappropriate antimicrobial use.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

Introduction: Antibiotics are indispensable to maintaining human health; however, their overuse has resulted in resistant organisms, increasing morbidity, mortality and costs. Increasing antimicrobial resistance (AMR) is a major public health threat, resulting in multiple campaigns across countries to improve appropriate antimicrobial use. This includes addressing the overuse of antimicrobials for self-limiting infections, such as upper respiratory tract infections (URTIs), particularly in lower- and middle-income countries (LMICs) where there is the greatest inappropriate use and where antibiotic utilization has increased the most in recent years. Consequently, there is a need to document current practices and successful initiatives in LMICs to improve future antimicrobial use.Methodology: Documentation of current epidemiology and management of URTIs, particularly in LMICs, as well as campaigns to improve future antimicrobial use and their influence where known.Results: Much concern remains regarding the prescribing and dispensing of antibiotics for URTIs among LMICs. This includes considerable self-purchasing, up to 100% of pharmacies in some LMICs. However, multiple activities are now ongoing to improve future use. These incorporate educational initiatives among all key stakeholder groups, as well as legislation and other activities to reduce self-purchasing as part of National Action Plans (NAPs). Further activities are still needed however. These include increased physician and pharmacist education, starting in medical and pharmacy schools; greater monitoring of prescribing and dispensing practices, including the development of pertinent quality indicators; and targeted patient information and health education campaigns. It is recognized that such activities are more challenging in LMICs given more limited resources and a lack of healthcare professionals.Conclusion: Initiatives will grow across LMICs to reduce inappropriate prescribing and dispensing of antimicrobials for URTIs as part of NAPs and other activities, and these will be monitored.

A cross-sectional study on the prevalence of antibiotic use prior to laboratory tests at two Ghanaian hospitals

There has been a significant rise in global antibiotic use in recent years. Development of resistance has been linked to easy accessibility, lack of regulation of sale, increased tendency to self-medicate and the lack of public knowledge. The increase in antibiotic misuse, including self-medication, has not been well documented in developing countries. Antibiotic use prior to visiting health facilities has been found to be prevalent in developing countries. It has been identified by some studies to increase the likelihood of missed diagnoses and influence the outcome of bacteriological tests. This study is aimed at determining the prevalence of prior antibiotic use through a cross-sectional survey of patients undergoing laboratory tests at two health facilities in Ghana. Face-to-face questionnaires were used to interview 261 individuals chosen by random sampling of patients visiting the bacteriology laboratory of the hospitals within a two-month period. The questionnaire investigated participant demographic characteristics, knowledge about antibiotics and the nature of antibiotic use. Antibiotic property detection bioassay was performed on patient’s urine sample using a disk diffusion method to accurately determine antibiotic use within 72 hours. Culture results were used as an index to evaluate the effect of prior antibiotic use on bacteriological tests. Out of a 261 participants enrolled, 19.9% (95% CI, 14.9–24.9) acknowledged using antibiotics prior to their visit to the laboratory during the study period. On the contrary, 31.4% (95% CI, 25.7–37.5) of participants’ urine samples were positive for antimicrobial activity. Participants within the age ranges of 20–30, 31–40 and 41–50 years had significantly lower odds of urine antimicrobial activity. Participants who had urine antimicrobial activity were more likely to have no growth on their culture plates than participants who had no urine antimicrobial activity [OR 2.39(1.37–4.18), p = 0.002]. The most commonly used antibiotics were the penicillins, fluoroquinolones and metronidazole. Although, majority of the participant (54.8%) had knowledge of antibiotics, most of them had inadequate information on their proper use. The commonest indications for antibiotic use were aches and pains (30.3%), diarrhoea (43.3%) and urinary tract infections (28.0%). Prior antibiotic use was found to increase the likelihood of obtaining a culture negative result and can affect the outcome of bacteriological tests.

Leveraging donor support to develop a national antimicrobial resistance policy and action plan: Ghana's success story

BACKGROUND

To mitigate the increasing trend of antimicrobial drug resistance (AMR), the Global Action Plan (GAP) on AMR was adopted at the 68th World Health Assembly in May 2015. Subsequently, member countries were encouraged to mirror the five key strategic objectives of GAP to develop their respective National Action Plans (NAPs) by 2017. Country-specific data on AMR is, however, critical for a comprehensive NAP that will inform policy and also anchor all the objectives of GAP. Systematic reviews have been suggested by some authors to generate relevant data to inform NAP development.

OBJECTIVES

This article highlights Ghana's success story in the development of its AMR policy documents and how it could further be implemented through donor support.

METHODS

Literature and desk review of the activities of Ghana's National Platform on Antimicrobial Resistance leading to the development of the NAP and AMR policy was done.

RESULTS

Ghana launched its NAP together with the accompanying policy document in April 2018. Country-specific data, which guided these documents, were obtained by leveraging donor support activities through the National Platform on Antimicrobial Resistance.

CONCLUSION

Ghana's success story on the development of AMR policy documents is pivoted on a strong political will and the leveraging of donor support for specific activities.

Rational prescribing of antibiotics in children under 5 years with upper respiratory tract infections in Kintampo Municipal Hospital in Brong Ahafo Region of Ghana

OBJECTIVE

The aim of the study was to assess the rational use of antibiotics in children with URTIs in the Kintampo Municipal Hospital in Ghana.

RESULTS

A total of 839 medicines were prescribed, 237 were antibiotics. The mean number of medicines prescribed per patient encounter was 3.1. The percentage of patient encounters with antibiotics was 28.2 and 0.4% for injections. The percentage of medicines prescribed by generic was 93.8% and from the essential medicines list was 94.9%. Ninety-two of patients received amoxicillin. Polypharmacy was common as prescriptions with five to six medicines per patient encounter was found. Some prescribers are not following the WHO/INRUD requirement of prescribing medicines in their generic and from the essential medicine list of the country.

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.

Retrospective Assessment of Antibiotics Prescribing at Public Primary Healthcare Facilities in Addis Ababa, Ethiopia

Background. Antibiotic overprescribing is the major driving force for the emergence of antibiotics resistance. The aim of this study was to assess antibiotics prescribing at primary healthcare facilities in Addis Ababa, Ethiopia. Methods. The study was conducted in six public health centers found in Addis Ababa City. Data was collected retrospectively from a total of 900 prescriptions and selected medical charts of patients in the health centers in 2016. Data was entered and analyzed using EPI Info 7 and SPSS 20, respectively. Descriptive statistics and logistic regression analysis were used to analyze the data. Results. One or more antibiotics were prescribed in 56.0% of the prescriptions. Antibiotics accounted for 46.0% of the total cost of medicines prescribed. Amoxicillin was the most frequently (44.8%) prescribed antibiotic and upper respiratory tract infection was the most common (24.5%) diagnosis for prescribing antibiotics. Laboratory investigation was done for only about 27% of the cases for which antibiotics were prescribed. Conclusion. There was a high rate of antibiotics prescribing in the health centers often empirically which might exacerbate the antimicrobial resistance situation in the country. Large-scale study should be conducted to fully understand the prescribing pattern and identify the associated factors thereby design and implement appropriate interventions.

Physicians' knowledge, attitudes, and perceptions concerning antibiotic resistance: a survey in a Ghanaian tertiary care hospital

Background

Understanding the knowledge, attitudes and practices of physicians towards antibiotic resistance is key to developing interventions aimed at behavior change. The survey aimed to investigate physicians’ knowledge and attitudes towards antibiotic resistance in a tertiary-care hospital setting in Ghana.

Methods

We conducted a cross-sectional respondent-driven survey using a 40-item, anonymous, voluntary, traditional paper-and-pencil self-administered questionnaire among 159 physicians at Korle-Bu Teaching Hospital. Single and multi-factor analysis were conducted to assess the study objectives.

Results

The survey was completed by 159 of 200 physicians (response rate of 79.5%). Of physicians, 30.1% (47/156) perceived antibiotic resistance as very important global problem, 18.5% (29/157) perceived it as very important national problem and only 8.9% (14/157) thought it as a very important problem in their hospital. Methicillin resistant Staphylococcus aureus was the most known about antibiotic resistant bacteria of public health importance followed by extended-spectrum beta-lactamase-producing Enterobacteriaceae, carbapenem resistant Enterobacteriaceae (CRE) and vancomycin resistant enterococci (VRE). In multiple logistic regression analysis, senior physicians were nearly 3 times more likely to know about CRE than junior physicians. The odds of knowing about VRE increased over 4.5 times from being a junior to becoming senior physician. Among junior physicians, age had no associated effect on their knowledge of VRE or CRE.

Conclusions

Physicians in this survey showed variable knowledge and perceptions on antibiotic resistance. Introducing educational programs on antibiotic resistance would be a useful intervention and should focus on junior physicians.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-2899-y) contains supplementary material, which is available to authorized users.

Antibiotics use among Palestine refugees attending UNRWA primary health care centers in Jordan - A cross-sectional study

The irrational use of antibiotics is increasing in Jordanian refugee camps and consequently so too is bacterial resistance. About one-third of health expenditures at UNRWA health centers in Jordan are attributed to antibiotics.

OBJECTIVE

We studied knowledge, attitude and behaviour of Palestine refugees attending UNRWA health centers in Jordan regarding antibiotic use in order to plan public health interventions accordingly.

METHODS

A cross-sectional, interviewer-administered survey among 250 adult Palestine refugees at four different health centers was conducted.

RESULTS

Irrational antibiotic use was widespread: 63% of patients share antibiotics at home, 38% use left-over antibiotics and 60% purchase antibiotics directly from the pharmacy without prescription (OTC) .¹ At the same time, knowledge about antibiotics side effects, resistance, and target agent was low. 90% of patients trust their doctor, however long waiting hours prevent them from seeking medical advice, which significantly increased self-medication.

CONCLUSIONS

Our findings suggest a strong need for public education about antibiotics. In addition, health institutional level improvements such as shorter waiting hours and strict regulations prohibiting dispensing without prescription are necessary to combat growing bacterial resistance.

Treatment practices of households and antibiotic dispensing in medicine outlets in developing countries: The case of Ghana

INTRODUCTION

Antibiotic resistance, associated with inappropriate drug use, is a global public health threat. The pharmaceutical sectors in developing countries are poorly regulated leading to antibiotic sales and use without a prescription. The study documents the treatment of acute illnesses in households and the antibiotic dispensing practices of medicine sales outlets in Eastern region, Ghana.

METHOD

Twice-weekly illness recall visits were made to 12 households in three rural communities over eight consecutive weeks. Detailed fieldnotes were taken and analysed using a thematic approach. Quantitative counts of health events and treatment were also conducted. Dispensing practices were systematically observed and documented in three rural and three urban medicine outlets for analysis.

RESULT

Fever, abdominal, and respiratory symptoms were the most common causes of ill-health in the 12 households. Most (65%) medicine-use events involved self-treatment with pharmaceuticals; 40% of medicine-use events involved antibiotics, often without a prescription. Although the number of antibiotic transactions without prescription in rural medicine outlets (n = 139, 27.4%) was statistically significantly more than in urban pharmacies (n = 140, 13.5%); z = 6.7, p < .0001), the volume of antibiotics sold in pharmacies was higher. Penicillins were the most commonly dispensed antibiotics constituting 30% of antibiotic sales in urban medicine outlets and 46% in rural ones. The lack of controls in the dispensing of antibiotics, community knowledge and use of antibiotics in ways inconsistent with biomedical recommendations, poverty and perceived barriers to formal healthcare were factors that influenced the inappropriate use of antibiotics.

CONCLUSION

Self-medication, including antibiotic self-prescription, constitutes an integral part of healthcare in the study settings and the qualitative data provides a contextual understanding of over-the-counter antibiotic acquisition and use. Inappropriate antibiotic use is apparent in the study settings. Stricter regulation of the pharmaceutical sector, training of dispensers and evidence-based treatment guidelines, and public education are potential interventions.

Distribuição e custo de antimicrobianos na Atenção Primária

Resumo Objetivo: Analisar a distribuição e custos de antimicrobianos na Atenção Primária de uma capital da Região Nordeste do Brasil. Método: Estudo transversal, analítico, desenvolvido em Teresina, Piauí, Brasil. Os dados contemplam o período de junho de 2015 a julho de 2016. Calculou-se estatísticas descritivas e o Teste de Kruskal-Wallis para comparar as medianas das distribuições de dados independentes. Resultados: Foram distribuídos 1.651.516 antimicrobianos de 15 tipos diferentes dos quais a amoxicilina (500mg) foi o mais distribuído (75%) nos Centros de Atenção Psicossocial e nas Unidades Básicas de Saúde (47%). O custo total no período foi de 98.705,00 reais. Não houve diferenças estatisticamente significante entre as medianas dos custos em cada zona do município estudado. Conclusão: A distribuição desses medicamentos é realizada de forma irregular entre as unidades, de acordo com a demanda. O fornecimento não segue protocolo específico, e não se investiga um possível aumento na demanda ou redução.

Antibiotic use in a tertiary healthcare facility in Ghana: a point prevalence survey

Background

The global rise and spread of antibiotic resistance is limiting the usefulness of antibiotics in the prevention and treatment of infectious diseases. The use of antibiotic stewardship programs guided by local data on prescribing practices is a useful strategy to control and reduce antibiotic resistance. Our objective in this study was to determine the prevalence and indications for use of antibiotics at the Korle-Bu Teaching Hospital Accra, Ghana.

Methods

An antibiotic point prevalence survey was conducted among inpatients of the Korle-Bu Teaching Hospital between February and March 2016. Folders and treatment charts of patients on admission at participating departments were reviewed for antibiotics administered or scheduled to be administered on the day of the survey. Data on indication for use were also collected. Prevalence of antibiotic use was determined by dividing the number of inpatients on antibiotics at the time of survey by the total number of patients on admission.

Results

Of the 677 inpatients surveyed, 348 (51.4%, 95% CI, 47.6–55.2) were on treatment with antibiotics. Prevalence was highest among Paediatric surgery where 20/22 patients (90.9%, 95% CI, 70.8–98.9) were administered antibiotics and lowest among Obstetrics patients with 77/214 (36%, 95% CI, 29.5–42.8). The indications for antibiotic use were 245/611 (40.1%) for community-acquired infections, 205/611 (33.6%) for surgical prophylaxis, 129/611 (21.1%) for healthcare associated infections and 33/611 (5.4%) for medical prophylaxis. The top five antibiotics prescribed in the hospital were metronidazole 107 (17.5%), amoxicillin-clavulinic acid 82 (13.4%), ceftriaxone 17(12.1%), cefuroxime 61 (10.0%), and cloxacillin 52 (8.5%) respectively. Prevalence of meropenem and vancomycin use was 12(2%) and 1 (.2%) respectively. The majority of patients 181 (52%) were being treated with two antibiotics.

Conclusion

This study indicated a high prevalence of antibiotic use among inpatients at the Korle-Bu Teaching Hospital. Metronidazole was the most commonly used antibiotic; mainly for surgical prophylaxis. There is the need to further explore factors contributing to the high prevalence of antibiotic use and develop strategies for appropriate antibiotic use in the hospital.

Electronic supplementary material

The online version of this article (10.1186/s13756-018-0299-z) contains supplementary material, which is available to authorized users.

Situational analysis of antibiotic use and resistance in Ghana: policy and regulation

Background

Antibiotics have played an essential role in decreasing morbidity and mortality from infectious diseases. However, indiscriminate use and unrestricted access is contributing to the emergence of bacterial resistance. This paper reports on a situational analysis of antimicrobial use and resistance in Ghana, with focus on policy and regulation.

Methods

Relevant policy documents, reports, regulations and enactments were reviewed. PubMed and Google search engines were used to extract relevant published papers. Websites of stakeholders such as Ministry of Health (MOH) and its agencies were also reviewed. An interview guide was used to elicit responses from selected officials from these sectors.

Results

Laws and guidelines to control the use of antimicrobials in humans were available but not for animals. There was no National Antimicrobial Policy (NAP). A health practice regulatory law mandates Physicians, Physician Assistants, Midwives and trained Nurses to prescribe antimicrobials. However, antibiotics are widely prescribed and dispensed by unauthorised persons, suggesting weak enforcement of the laws. Antibiotics were also supplied to and from unapproved medicine outlets. The Standard Treatment Guidelines (STG), Essential Medicines List (EML) and the National Health Insurance Scheme Medicines List (NHISML) provide restrictions regarding levels of prescribing of antimicrobials. However, existing guidelines on antibiotic use are mostly not adhered to. The use of Automatic Stop Orders to avoid wastage in the hospitals is also not practiced. Data on use of antibiotics for individuals are not readily available in most facilities. Again, there are no standards or guidelines on veterinary use of antibiotics. Surveillance systems for consumption of antibiotics and resistance monitoring were not in place in most health facilities. However, there is an ongoing national action to create awareness on bacteria resistance, strengthening knowledge through research and surveillance and development of NAP in line with global action plan on antimicrobial resistance.

Conclusion

Absence of national antimicrobial policy, weak regulatory environment and non-adherence to practice standards may have contributed to increased and unregulated access to antimicrobials in Ghana, a catalyst for development and spread of antimicrobial resistance.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4910-7) contains supplementary material, which is available to authorized users.

Indicadores do uso de medicamentos na atenção primária de saúde: uma revisão sistemática

OBJECTIVE

To analyze the rational use of medicines in the context of primary health care (PHC) according to the indicators recommended by the World Health Organization (WHO).

METHOD

A systematic review of the literature was performed following PRISMA guidelines to synthesize the evidence produced by the application of drug use indicators in PHC in the period from 2011 to 2016. The following databases were searched: PudMed, SciELO and Google Scholar, Virtual Health Library/BIREME, and Portal de Periódicos CAPES, using the keywords "World Health Organization," "indicators," "drug utilization," and "rational use of drugs" in Portuguese and English. Original articles describing studies performed at the PHC level, using at least one of the three sets of indicators (prescription, service-related, or health care) were included.

RESULTS

Of the 16 studies included, 56.2% were prospective, 37.5% were developed at a local level, 62.5% employed convenience sampling, 56.2% lasted up to 6 months, and 43.8% were performed in Brazil. Prescription indicators were used most (87.5%), followed by service-related indicators (37.5%) and health care indicators (31.3%). None of the scenarios described in the articles fully met the WHO recommendations. The most frequent interventions suggested to resolve the problems related to the rational use of medications included continuing education for rational prescription (56.3%), use of updated lists of essential medicines, including generic drug names and reflecting the needs of the population (31.3%), and implementation of clinical protocols to standardize therapeutic management (31.3%).

CONCLUSIONS

Application of the WHO indicators revealed irrational practices of drug use in PHC in several countries.

Antibiotic prescription pattern in a Ghanaian primary health care facility

Introduction

A major challenge to the provision of health care worldwide is the irrational use of antibiotics. To help promote rational use of drugs, standard treatment guidelines (STG) and essential medicine lists and facility-specific formularies have been developed to be used by clinicians. This study assessed the prescription pattern of antibiotics and explored the use of STG by clinicians.

Methods

A prospective cross sectional study that made use of seven core drug use indicators was conducted from February, 2017 to July, 2017. Prescribing indicators were assessed using 388 prescriptions that were submitted for filling and dispensing at the pharmacy unit of the hospital. Clinicians were interviewed to assess their use of STG. Data were analyzed using SPSS version 20.0 with a p-value of < 0.05 considered as statistically significant.

Results

A total of 1351 drugs were prescribed for 388 patients. The average number of medicines per prescription was 3.5. Of the 388 prescriptions, 55.2% bore antibiotics, with amoxicillin (22.5%) and ciprofloxacin (18.4%) being the most prescribed antibiotics. Patients' knowledge about their medications was found to be significantly associated with the number of drugs per prescription (p = 0.001), age (p = 0.015) and educational level (p = 0.001). Only 41.7% of prescribers had copies of STG and used them.

Conclusion

The prescribing and dispensing practices in the hospital were generally not satisfactory with a low patronage of STG among prescribers. In order to improve the situation, clinicians should practice evidence based medicine rather than empirical treatment of conditions as well as use the STG in practice.