Prescribing patterns of physicians working in both the direct and indirect treatment sectors in Iran; findings and implications

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications

Background

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia.

Methods

A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool.

Results

Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List.

Conclusions

There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.

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 in the Cost of Medicines, Consultation Fees and Clinic Visits in Malaysia's Private Primary Healthcare System: Employer Health Insurance Coverage

Objective

To examine trends in the cost of medicines, consultation fees and clinic visits among the employees covered by the employer health insurance in Malaysia's private primary healthcare system in Malaysia.

Designs

Retrospective cross-sectional study.

Setting

PMCare claims database from January 2016 to August 2019.

Participants

A total of 83,556 outpatient clinic visits involving 10,150 IIUM employees of the International Islamic University Malaysia (IIUM) to private general practitioners (GPs). During the study period, IIUM adopts the incentive structure of capping coverage at Ringgit Malaysia (RM) 45/outpatient visit (USD 10.58) to cover for consultation fees and medicine costs.

Main Outcome Measures

The monthly percentage change in the number of clinic visits, medicine costs, consultation fees and total costs between January 2016 and August 2019. A simple linear regression using Stata v15.1 was also performed to measure the association between the characteristics of the prescribed medicines and medicine charges.

Results

The number of clinic visits per patient increased by 17% from January 2016 to August 2019, with consultation fees increasing by 113.9% and total costs by 7.9% per clinic visit per patient. Conversely, the cost of medicines and the number of medicines prescribed per clinic visit per patient decreased by 39.7% and 6.3%, respectively.

Conclusion

Within the incentive structure of capping the total amount of coverage per clinic visit, medicine costs were reduced by decreasing the number of medicines prescribed, to offset the increased consultation fees. This may create perverse incentives that affect medicine use with negative consequences for the health system and health insurers.

Ongoing Strategies to Improve Antimicrobial Utilization in Hospitals across the Middle East and North Africa (MENA): Findings and Implications

Antimicrobial resistance (AMR) is an increasing global concern, increasing costs, morbidity, and mortality. National action plans (NAPs) to minimize AMR are one of several global and national initiatives to slow down rising AMR rates. NAPs are also helping key stakeholders understand current antimicrobial utilization patterns and resistance rates. The Middle East is no exception, with high AMR rates. Antibiotic point prevalence surveys (PPS) provide a better understanding of existing antimicrobial consumption trends in hospitals and assist with the subsequent implementation of antimicrobial stewardship programs (ASPs). These are important NAP activities. We examined current hospital consumption trends across the Middle East along with documented ASPs. A narrative assessment of 24 PPS studies in the region found that, on average, more than 50% of in-patients received antibiotics, with Jordan having the highest rate of 98.1%. Published studies ranged in size from a single to 18 hospitals. The most prescribed antibiotics were ceftriaxone, metronidazole, and penicillin. In addition, significant postoperative antibiotic prescribing lasting up to five days or longer was common to avoid surgical site infections. These findings have resulted in a variety of suggested short-, medium-, and long-term actions among key stakeholders, including governments and healthcare workers, to improve and sustain future antibiotic prescribing in order to decrease AMR throughout the Middle East.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

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.

Antimicrobial Prescribing Confidence and Knowledge Regarding Drug Resistance: Perception of Medical Students in Malaysia and the Implications

Worldwide, microbes are becoming more challenging by acquiring virulent skills to adapt and develop antimicrobial resistance (AMR). This is a concern as AMR increases morbidity, mortality, and costs. Consequently, physicians need to be trained on appropriate antimicrobial prescribing, starting as medical students. Objective: To evaluate medical students’ confidence in antimicrobial prescribing and AMR. Methods: Cross-sectional study assessing medical students’ knowledge, perception, and confidence in prescribing antimicrobials and AMR in a Malaysian University. A universal sampling method was used. Results: Most responding students believed that educational input regarding overall prescribing was sufficient. Regarding the principle of appropriate and accurate prescriptions, female medical students had less knowledge (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.25–0.99; p = 0.050). Year-IV and Year-V medical students had more excellent knowledge than Year-III students regarding confidence in potential antibiotic prescribing once qualified. Year-V students also showed an appreciably higher confidence in the broad principles of prescribing, including antibiotics for infectious diseases, compared to those in other years. Conclusion: Overall, medical students gain more knowledge and confidence regarding the potential prescribing of antimicrobials as their academic careers progress. This is important given concerns with the current excessive use of antimicrobials in Malaysia.

Antibiotic consumption at community pharmacies: A multicenter repeated prevalence surveillance using WHO methodology

Background:

Antibiotics are losing their effectiveness because of the rapid emergence of resistant bacteria. Unnecessary antimicrobial use increases antimicrobial resistance (AMR). There are currently no published data on antibiotic consumption in Pakistan at the community level. This is a concern given high levels of self-purchasing of antibiotics in Pakistan and variable knowledge regarding antibiotics and AMR among physicians and pharmacists.

Objective:

The objective of this repeated prevalence survey was to assess the pattern of antibiotic consumption data among different community pharmacies to provide a baseline for developing future pertinent initiatives.

Methods:

A multicenter repeated prevalence survey conducted among community pharmacies in Lahore, a metropolitan city with a population of approximately 10 million people, from October to December 2017 using the World Health Organization (WHO) methodology for a global program on surveillance of antimicrobial consumption.

Results:

The total number of defined daily doses (DDDs) dispensed per patient ranged from 0.1 to 50.0. In most cases, two DDDs per patient were dispensed from pharmacies. Co-amoxiclav was the most commonly dispensed antibiotic with a total number of DDDs at 1018.15. Co-amoxiclav was followed by ciprofloxacin with a total number of 486.6 DDDs and azithromycin with a total number of 472.66 DDDs. The least consumed antibiotics were cefadroxil, cefotaxime, amikacin, and ofloxacin, with overall consumption highest in December.

Conclusion:

The study indicated high antibiotic usage among community pharmacies in Lahore, Pakistan particularly broad-spectrum antibiotics, which were mostly dispensed inappropriately. The National action plan of Pakistan on AMR should be implemented by policymakers including restrictions on the dispensing of antimicrobials.

Assessing smoking cessation services and pharmacotherapy in Namibia; findings and implications for future policy initiatives

BACKGROUND

: Tobacco smoking is a considerable barrier to reducing morbidity and mortality associated with non-communicable diseases (NCDs). However, few studies in sub-Saharan Africa have explored access to smoking cessation programs including smoking cessation pharmacotherapy (SCP). This needs to be addressed given the growing burden of NCDs across sub-Saharan Africa including Namibia.

METHODS

: Multi-facility cross sectional survey among physicians in both public and private sectors in Namibia.

RESULTS

: Of the 106 physicians recruited, 69% practiced in public health facilities and 92% were non-smokers. 67% offer smoking cessation services, with 64% of these offering SCP. This was mainly nicotine replacement therapy (53%) and bupropion SR (41%). Overall, all physicians had a low knowledge score of SCP (<50%). The mean knowledge score though was 77% lower among physicians in public versus private sectors (OR=0.23, 95%CI: 0.14-0.35, p<0.001). Principal barriers to prescribing SCP were inadequate knowledge and/or lack of smoking cessation guidelines. This is not surprising with SCP medicines not currently listed within the public medicine list in Namibia.

CONCLUSION

: Despite good attitudes towards SCP, there are concerns with physicians' knowledge and practices especially in the public sector. There is an urgent need to address this and integrate services to reduce NCDs in Namibia.

Community antibiotic prescribing for children in France from 2015 to 2017: a cross-sectional national study

OBJECTIVES

To assess recent community antibiotic prescribing for French children and identify areas of potential improvement.

METHODS

We analysed 221 768 paediatric (<15 years) visits in a national sample of 680 French GPs and 70 community paediatricians (IQVIA's EPPM database), from March 2015 to February 2017, excluding well-child visits. We calculated antibiotic prescription rates per 100 visits, separately for GPs and paediatricians. For respiratory tract infections (RTIs), we described broad-spectrum antibiotic use and duration of treatment. We used Poisson regression to identify factors associated with antibiotic prescribing.

RESULTS

GPs prescribed more antibiotics than paediatricians [prescription rate 26.1 (95% CI 25.9-26.3) versus 21.6 (95% CI 21.0-22.2) per 100 visits, respectively; P < 0.0001]. RTIs accounted for more than 80% of antibiotic prescriptions, with presumed viral RTIs being responsible for 40.8% and 23.6% of all antibiotic prescriptions by GPs and paediatricians, respectively. For RTIs, antibiotic prescription rates per 100 visits were: otitis, 68.1 and 79.8; pharyngitis, 67.3 and 53.3; sinusitis, 67.9 and 77.3; pneumonia, 80.0 and 99.2; bronchitis, 65.2 and 47.3; common cold, 21.7 and 11.6; bronchiolitis 31.6 and 20.1; and other presumed viral RTIs, 24.1 and 11.0, for GPs and paediatricians, respectively. For RTIs, GPs prescribed more broad-spectrum antibiotics [49.8% (95% CI 49.3-50.3) versus 35.6% (95% CI 34.1-37.1), P < 0.0001] and antibiotic courses of similar duration (P = 0.21). After adjustment for diagnosis, antibiotic prescription rates were not associated with season and patient age, but were significantly higher among GPs aged ≥50 years.

CONCLUSIONS

Future antibiotic stewardship campaigns should target presumed viral RTIs, broad-spectrum antibiotic use and GPs aged ≥50 years.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Evaluation of Medication Use Pattern Among Patients Presenting to the Emergency Department of Hiwot Fana Specialized University Hospital, Using WHO Prescribing Indicators

Background

Ensuring rational drug use requires ongoing evaluation of drug prescribing, dispensing, and use by patients. Health care providers working in an emergency department face unique challenges, including making urgent decisions, patient overload, and limited resources, which contribute to inappropriate drug use. Rational medication use should be an important aspect of emergency care to improve patient outcomes. Thus, this study was conducted to assess medication utilization patterns using World Health Organization (WHO) prescribing indicators in the emergency department.

Methods

A cross-sectional study design was implemented among patients presenting at the emergency department of Hiwot Fana Specialized University Hospital (HFSUH) from January to March 2018. The data were collected from the medical charts of a total of 342 patients using a pre-prepared structured format according to WHO recommendations. The data were analyzed using SPSS version 21 software and presented in tables and figures.

Results

The most commonly reported clinical diagnosis was found to be soft tissue laceration or abrasion, in 75 patients (21.9%), followed by dyspepsia, in 50 (14.6%), and severe pneumonia, in 44 (12.9%). A total of 810 drugs were prescribed for the 342 patients. The main category of drugs prescribed were analgesics, constituting 125 (29.2%), followed by antibiotics, 120 (28.0%). Regarding WHO prescribing indicators, the average number of drugs prescribed per encounter was 2.36, the number of encounters at which antibiotics were prescribed was 127 (37.13%), and injections were prescribed at 300 (87.7%) encounters. All of the drugs prescribed were from the National Essential Medicine List (NEML) of Ethiopia, and 780 (98.1%) of the drugs were prescribed by international nonproprietary name.

Conclusion

Overall, there were inflated use of antibiotics and injection drugs, whereas prescribing by international nonproprietary name and prescribing from NEML were according to the recommendations. Hence, the hospital should work to ensure the judicious use of antibiotics and injection drugs.