Measuring antibiotic prescribing in hospitalised children in resource-poor countries: a systematic review

Application of the anatomical chemical system/defined daily doses: Challenges and way forward for resource-limited countries

WHAT IS KNOWN AND OBJECTIVE

The Anatomical Therapeutic Chemical Classification/Defined Daily Doses (ATC/DDD) methodology is a WHO gold standard for ensuring systematic Drug Utilization Research (DUR) and has been mainly used in the developed world. This article examines the challenges and way forward for using this methodology in resource-limited countries.

CONTENT

The ATC/DDD is superior over other methods employed in DUR as it offers a unified medicines regulation and management system at all care levels. The ATC/DDD allows access to standardized and validated information on DUR by: assessing patterns of utilization, defining optimal use levels, identification of gaps, aggregating and analysing statistics for reporting adverse drug reactions, as well as assisting in developing rational medicines use interventions and monitoring their outcomes.

WHAT IS NEW AND CONCLUSION

Application of the ATC/DDD methodology is crucial for improved patient management, optimal consumption of national pharmaceutical budgets and policy formulation in resource-limited countries.

Antimicrobial Prescribing during Infant Hospital Admissions in a Birth Cohort in Dhaka, Bangladesh

Empirical antimicrobial use is common in hospitalized infants and may contribute to antimicrobial resistance in low- and middle-income countries. In this observational birth cohort study nested in a randomized controlled trial in Dhaka, Bangladesh, inpatient antimicrobial prescription data were extracted from serious adverse event forms completed for hospitalizations of infants (0-12 months of age). The primary outcome was the proportion of inpatient admissions where systemic antimicrobials were prescribed. Infant and hospitalization-related factors associated with antimicrobial prescriptions were determined. Among 1254 infants, there were 448 admissions to 32 facilities from 2014 to 2016. Antimicrobials were prescribed in 73% of admissions with a mean antimicrobial exposure rate of 0.25 antimicrobials per day of admission [95% confidence intervals (95% CIs): 0.24-0.27]. The most common antibiotics were aminoglycosides (29%), penicillins (26%) and third-generation cephalosporins (25%). In all, 58% of antibiotics were classified as 'access', 38% 'watch' and 1% 'reserve' using the World Health Organization (WHO) Essential Medicines List classification. WHO-recommended antimicrobial regimens were used in 68% of neonatal sepsis and 9% of lower respiratory tract infection (LRTI) admissions. 'Watch' antimicrobials were used in 26% of neonatal sepsis and 76% of LRTI admissions. Compared with private facilities, antimicrobial prescription rates were lower at government [rate ratio (RR) 0.71; 95% CI: 0.61-0.83] and charitable facilities (RR 0.39; 95% CI: 0.28-0.53), after adjustment for household wealth index and parental education. Younger infant age, older maternal age and longer admission were associated with higher prescription rates. These findings highlight the need for paediatric antimicrobial stewardship programs in Bangladesh.

Antibiotic prescribing in inpatient and outpatient settings in Iran: a systematic review and meta-analysis study

Background

Antibiotic prescribing is common worldwide. There are several original studies about antibiotic prescribing in the healthcare setting of Iran reporting different levels of prescribing. The aim of this systematic review and meta-analysis was to determine the prevalence of antibiotic prescribing in both inpatient and outpatient settings in Iran, an example of a developing country.

Methods

To identify published studies on antibiotic prescribing, databases such as ISI, Scopus, PubMed, Google Scholar, and Electronic Persian were searched in Iran till January 2020. Eligible studies were those analyzing original data on the prescription and use of antibiotics in outpatient or inpatient settings in Iran. Moreover, all studies that used an intervention to improve antibiotic prescribing were included. The quality of the included studies was assessed using self-administered quality assessment criteria. The meta-analysis of prevalence of antibiotic prescribing was conducted based on the meta-analysis of observational studies in epidemiology guidelines. To calculate pooled rates, the random-effects model was used.

Results

A total of 54 studies (39 outpatients and 15 inpatients) were included in this study. The median of antibiotic prescribing in the outpatient and inpatient settings accounted for 45.25% and 68.2% of patients, respectively. The results of meta-analysis also showed that the antibiotic prescribing accounted for 45% of prescriptions in outpatient settings and 39.5%, 66%, and 75.3% of patients in all wards, pediatrics wards, and ICU wards of inpatient settings, respectively. The most commonly prescribed antibiotic classes in outpatient settings were penicillins, cephalosporins, and macrolides, while in inpatient settings, these were cephalosporins, penicillins, and carbapenems. There were seven studies using interventions to improve antibiotic prescribing pattern. It should be mentioned that intervention in a study had a statistically significant effect on improving antibiotic prescribing (p < .05).

Conclusion

Prevalence of antibiotic prescribing in Iran is high. Our findings highlight the need for urgent action to improve prescription practices. It seems that developing a national plan to improve antibiotic prescribing is necessary.

Antibiotic prescriptions in Italian hospitalised children after serial point prevalence surveys (or pointless prevalence surveys): has anything actually changed over the years?

BACKGROUND

Point prevalence surveys have been used in several studies to provide immediate and easily comparable information about antibiotic use and showed that about one third of hospitalised children had on ongoing antimicrobial prescription during their hospital admission. The aim of this study, as part of the Global Antimicrobial Resistance, Prescribing and Efficacy in Neonates and Children project, is to describe antimicrobial prescriptions among hospitalised children in four tertiary care hospitals in Italy to show if something has changed over the years.

METHODS

Four tertiary care Italian's hospitals joined three Point Prevalence Surveys (PPSs) in three different period of the year. All children under 18 years of age with an ongoing antimicrobial prescription, admitted on the participating wards at 8 o'clock in the morning of the selecting day were enrolled.

RESULTS

A total of 1412 patients (475 neonates and 937 children) were admitted in the days of three PPSs. Overall, among the total admitted patients, 565 patients (40%) had an ongoing antimicrobial prescription in the days of the survey A total of 718 antibiotics were administered in the 485 admitted children and 133 in neonates. The most common indications for antibiotic therapy in children was Lower respiratory tract infections (244/718, 34%), while in neonates were prophylaxis for medical problems (35/133, 26.3%), newborn prophylaxis for newborn risk factors (29/133, 21.8%) and prophylaxis for surgical disease (15/133, 11.3%).

CONCLUSIONS

Based on our results, it appears that nothing has changed since the last PPS and that the quality improved targets, underlyined in previous studies, are always the same. Serial PPSs can be part of AMS strategies but they are not sufficient alone to produce changes in clinical practice.

Impact of clinical decision support on empirical antibiotic prescribing for children with community-acquired pneumonia

AIM

To assess the impact of a computerised clinical decision support system (CDSS) on antibiotic use in hospitalised children with a presumptive diagnosis of uncomplicated community-acquired pneumonia (CAP).

METHODS

Codes associated with lower respiratory tract infection were used to identify cases of presumed uncomplicated CAP requiring admission to a tertiary paediatric hospital. Random sampling of the periods between 1 October 2010 and 30 September 2012 (pre-CDSS) and 1 October 2012 and 30 September 2014 (post-CDSS) determined the sequence of case assessment by two independent investigators. Initial antibiotic therapy, associated CDSS approvals and documented signs of clinical deterioration prior to antibiotic decision-making were recorded.

RESULTS

Statistically significant differences between cases pre- and post-CDSS implementation were minimal. High fever was observed in 57.5% (77/134) cases pre-CDSS and 45.8% (49/107) cases post-CDSS (P = 0.07). Supplemental oxygen was used in 30.6% pre-CDSS and 54.2% post-CDSS cases (P < 0.001). Narrow-spectrum penicillins were prescribed most often, with no statistically significant change post-CDSS implementation (81.3% pre-CDSS, 77.6% post-CDSS, P = 0.47). Macrolides were used consistently throughout the study period (53.7% pre-CDSS, 61.7% post-CDSS; P = 0.21).

CONCLUSION

CDSS implementation did not reduce already low rates of broad-spectrum antibiotic use for uncomplicated CAP.

Metrics for quantifying antibiotic use in the hospital setting: results from a systematic review and international multidisciplinary consensus procedure

Background

Quantifying antibiotic use is an essential element of antibiotic stewardship since it allows comparison between different settings and time windows, and measurement of the impact of interventions. However, quantity metrics (QMs) and methods have not been standardized.

Objectives

To propose a set of QMs for antibiotic use in inpatients (IQMs) that are accepted globally by professionals in a range of disciplines. The study was conducted within the Driving Reinvestment in Research and Development and Responsible Antibiotic Use (DRIVE-AB) project.

Methods

A systematic literature review using MEDLINE identified articles on measuring inpatient antibiotic use, published up to 29 January 2015. A consensually selected list of national and international web sites was screened for additional IQMs. IQMs were classified according to the type of numerator used and presented to a multidisciplinary panel of stakeholders. A RAND-modified Delphi consensus procedure, which consisted of two online questionnaires and a face-to-face meeting, was performed.

Results

The systematic literature review and web site search identified 168 eligible articles from which an initial list of 20 IQMs, composed of 20 different numerators and associated denominators was developed. The consensus procedure resulted in a final set of 12 IQMs. Among this final set, DDDs per 100(0) patient-days and days of therapy per patient-days were most frequently found in the review. The panel recommended that antibiotic use should be expressed in at least two metrics simultaneously.

Conclusions

Our consensus procedure identified a set of IQMs that we propose as an evidence-based global standard.

Interventions to reduce childhood antibiotic prescribing for upper respiratory infections: systematic review and meta-analysis

BACKGROUND

Antibiotics are overprescribed for children with upper respiratory infections (URIs), leading to unnecessary expenditures, adverse events and antibiotic resistance. This study assesses whether interventions antibiotic prescription rates (APR) for childhood URIs can be reduced and what factors impact intervention effectiveness.

METHODS

MEDLINE, Embase, Google Scholar, Web of Science, Global Health, WHO website, United States CDC website and The Cochrane Central Register of Controlled Trials (CENTRAL) were searched by December 2015. Cluster or individual-patient randomised controlled trials (RCTs) and non-RCTs that examined interventions to change APR for children with URIs were selected for meta-analysis. Educational interventions for clinicians and/or parents were compared with usual care.

RESULTS

Of 6074 studies identified, 13 were included. All were conducted in high-income countries. Interventions were associated with lower APR versus usual care (OR 0.63 (95% CI 0.50 to 0.81, p<0.001). A patient-clinician communication approach was the most effective type of intervention, with a pooled OR 0.41 (95% CI 0.20 to 0.83; p<0.001) for clinicians and 0.26 (95% CI 0.08 to 0.91; p=0.04) for parents. Interventions that targeted clinicians and parents were significant, with a pooled OR of 0.52 (95% CI 0.35 to 0.78; p=0.002). Insignificant effects were observed for targeting clinicians and parents alone, with a pooled OR of 0.88 (95% CI 0.67 to 1.16; p=0.37) and 0.50 (95% CI 0.10 to 2.51, p=0.40), respectively.

CONCLUSIONS

Educational interventions are effective in reducing antibiotic prescribing for childhood URIs. Interventions targeting clinicians and parents are more effective than those for either group alone. The most effective interventions address patient-clinician communication. Studies in low-income to middle-income countries are needed.

Antibiotics usage in infants during the first 18 months of life in Benin: a population-based cohort study

Data centered on antibiotics usage and their determinants in African pediatric populations are limited. In order to define the determinants of antibiotics prescriptions (ABPr), we analyzed the data of a birth cohort in Benin. From 2007 to 2009, 538 infants were followed from birth to 18 months in three different health centers. The following determinants were assessed: infants' clinical findings at consultations, mothers' and children's characteristics at birth, and health parameters recorded at scheduled follow-up of general health parameters. Multilevel logistic models were performed for analysis. Among the 4394 consultations, fever represented 53.7 % of consultations, 64.1 % of which were non-malarial fevers. Antibiotics were prescribed during 44.2 % of the consultations and the proportion of ABPr differed significantly among health centers (p < 10(-3)). Nearly 40 % of ABPr were related to children without fever. During the first semester of life, the percentage of ABPr was twice lower than after (27.4 vs. 54.7, p < 10(-3)). Respiratory and enteric symptoms were positively associated with ABPr (p < 10(-3)). Malaria was significantly associated with a lower ABPr after the first semester [odds ratio (OR) = 0.55, 95 % confidence interval (CI) = 0.44-0.67, p < 10(-3)]. No maternal and child at-birth characteristics were associated with ABPr. ABPr was positively associated with a low breastfeeding score (p < 10(-3)). Studies on the rational use of antibiotics in this population should give priority to children more than 6 months of age, without malaria, and with respiratory and/or enteric symptoms. Our data also advocate for studies specifically designed to assess and improve healthcare providers' compliance to guidelines on antibiotics usage.

Systematic review of drug utilization studies & the use of the drug classification system in the WHO-SEARO Region

BACKGROUND & OBJECTIVES

Information available on drug consumption is inadequate in most low and middle income countries. This systematic review was conducted to analyse published work on drug utilization research/studies (DUR) in the SEARO region of WHO for study objectives, methodology, results and recommendations and to identify the need for improving DUR and the use of the ATC/DDD system.

METHODS

A literature search for DUR was carried out in biomedical databases (PubMed, Scirus, Scopus and Google Scholar) up to May 2012. Publications were selected if those were in the English language, describing DUR or prescription practices, and study conducted in the WHO-SEARO countries.

RESULTS

A total of 318 publications were included in the review. Of these, 67 per cent were from India and 13 per cent were from Thailand. Majority of the publications were hospital based; only 16 per cent were community based. The ATC/DDD system was used in only 20 per cent of the publications, of which 73 per cent publications used DDD indicators. Several publications focused on antibiotics (31%). Publications that recommended the need for a policy or intervention to improve prescription practices/rational drug use amounted to 35 per cent.

INTERPRETATION & CONCLUSIONS

Drug utilization studies using ATC/DDD system need to be promoted and carried out on an ongoing basis. DUR is important for rational use of drugs. Its relevance to policy making and resource allocation needs to be emphasized.

Improving antibiotic prescribing for children in the resource-poor setting

Antibiotics are a critically important part of paediatric medical care in low- and middle-income countries (LMICs), where infectious diseases are the leading cause of child mortality. The World Health Organization estimates that >50% of all medicines are prescribed, dispensed or sold inappropriately and that half of all patients do not take their medicines correctly. Given the rising prevalence of antimicrobial resistance globally, inappropriate antibiotic use is of international concern, and countries struggle to implement basic policies promoting rational antibiotic use. Many barriers to rational paediatric prescribing in LMICs persist. The World Health Organization initiatives, such as 'Make medicines child size', the Model List of Essential Medicines for Children and the Model Formulary for Children, have been significant steps forward. Continued strategies to improve access to appropriate drugs and formulations, in conjunction with improved evidence-based clinical guidelines and dosing recommendations, are essential to the success of such initiatives on both a national and an international level. This paper provides an overview of these issues and considers future developments that may improve LMIC antibiotic prescribing.

Systematic Review of Antibiotic Resistance Rates Among Gram-Negative Bacteria in Children With Sepsis in Resource-Limited Countries

BACKGROUND

Gram-negative antimicrobial resistance (AMR) is of global concern, yet there are few reports from low- and low-middle-income countries, where antimicrobial choices are often limited.

METHODS

This study offers a systematic review of PubMed, Embase, and World Health Organization (WHO) regional databases of Gram-negative bacteremia in children in low- and low-middle-income countries reporting AMR since 2001.

RESULTS

Data included 30 studies comprising 71 326 children, of whom 7056 had positive blood cultures, and Gram-negative organisms were isolated in 4710 (66.8%). In neonates, Klebsiella pneumoniae median resistance to ampicillin was 94% and cephalosporins 84% in Asia; 100% and 50% in Africa. Large regional variations in resistance rates to commonly prescribed antibiotics for Salmonella spp. were identified. Multidrug resistance (resistance to ampicillin, chloramphenicol, and cotrimoxazole) was present in 30% (interquartile range [IQR], 0-59.6) in Asia and 75% (IQR, 30-85.4) in Africa.

CONCLUSIONS

There is a need for an international pediatric antimicrobial resistance surveillance system that collects local epidemiological data to improve the evidence base for the WHO guidance for childhood Gram-negative bacteremia.