Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda

Readiness of and barriers for community pharmacy professionals in providing and implementing vaccination services

BACKGROUND

Community pharmacy professionals are essential for healthcare delivery, particularly for administering vaccination services. However, there is a lack of substantial evidence documenting their role in vaccination within Ethiopia.

OBJECTIVES

This study aimed to assess community pharmacy professionals' readiness to provide vaccination services, identify barriers hindering the implementation of these services, and determine factors influencing the provision of vaccination services by community pharmacy professionals.

METHODS

A cross-sectional study was conducted among community pharmacy professionals in Debre Markos and Injibara Town from April 15 to May 13, 2024. The data were collected using a structured questionnaire, and descriptive statistics were used to analyze the findings.

RESULTS

The study revealed that a significant majority of community pharmacy professionals perceived that they had adequate vaccine knowledge and were easily accessible to the community. However, barriers such as lack of regulation, time constraints, workload concerns, patient trust issues, and infrastructure challenges hinder the implementation of vaccination services. Factors influencing the provision of vaccination services included the need for enhanced education and training, financial reimbursement, patient demand, infrastructure improvements, collaboration with other healthcare providers, and pharmacists' special interest in vaccination.

CONCLUSIONS

Community pharmacy professionals exhibit readiness to provide vaccination services. However, significant barriers such as regulatory constraints, time pressures, workload concerns, patient trust issues, and infrastructure challenges hinder their full participation. Addressing these barriers and leveraging pharmacists' expertise is essential for optimizing service delivery and improving public health outcomes. Advocating for policy changes, developing comprehensive training programs, establishing clear guidelines, investing in infrastructure improvements, conducting public awareness campaigns, and fostering collaboration with other healthcare providers are recommended to facilitate the provision and implementation of vaccination services by community pharmacy professionals in Ethiopia.

Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study

BACKGROUND

Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda.

METHODS

This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis.

RESULTS

Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS.

CONCLUSION

There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.

A case for routine microbial diagnostics: Results from antimicrobial susceptibility testing in post-traumatic wound infections at a Ugandan tertiary care hospital

The global spread of antimicrobial resistance (AMR) poses an increasing challenge for clinicians in Uganda, where microbiological diagnostics are not routinely available or accessible. The aim of this study was to determine pathogen prevalence and antibiotic resistance patterns in patients with wound infections following trauma at a national referral hospital in Kampala, Uganda. In addition, the suitability of currently used empirical treatment options in this setting was evaluated. This prospective, observational study analysed antimicrobial prescriptions, culture results and antimicrobial sensitivity testing (AST) of wound swabs and blood samples from patients with clinical signs of wound infections on the trauma ward. A total of 124 patients (n = 99, 79.8% male) with a median age of 30 years (IQR 23-39) were enrolled between October 2021 and January 2022. Wound infections were classified as nosocomial in 69% of the cases. Pathogens were isolated from 122 wound swabs, yielding 238 bacterial isolates. The most prevalent pathogens were gram-negative bacteria including Escherichia coli (n = 48, 20.2%) and Acinetobacter spp. (n = 43, 18.1%). Empiric treatment consisted of ceftriaxone and gentamicin which was administered to 67.2% (n = 78) and 62.1% (n = 72) of patients, respectively. High rates of antimicrobial resistance could be demonstrated across gram-negative and gram-positive species towards the most common empiric antibiotics. Following the AST results, over 95% (n = 111) of patients required a change of treatment. Our findings demonstrate that current empiric treatment for wound infections is missing its target in hospitalized patients in Kampala. To address the growing problem of AMR in Uganda, there is a pressing need to enhance diagnostic capacity and implement structured antimicrobial stewardship programs.

Perceived antimicrobial dispensing practices in medicine outlets in Ghana: A maximum difference experiment design

INTRODUCTION

Antimicrobials are consumed among patients globally, but in developing and middle-income countries, these drugs can be obtained without a prescription from pharmacies and licensed drug stores due to inadequate regulation in the pharmaceutical sector. This study aimed to assess antimicrobial dispensing practices in medicine sales outlets (i.e., pharmacies and licensed drug stores) to provide quantitative evidence for policy discussions to enhance patient safety and care quality in Ghana's pharmaceutical industry.

METHOD

The data for this study were obtained from a cross-sectional survey conducted in the Greater Accra region between July and August 2022. The survey was conducted through interviewer-administered questionnaires, and 200 staff members from medicine sales outlets were randomly selected using a two-stage cluster and random sampling technique. The maximum difference experiment model, rooted in random utility theory, was used to analyze their antimicrobial dispensing practices.

RESULT

We found that medicine sales outlet staffs were highly concerned about following the drug act and not dispensing antimicrobials without a prescription, and usually refer a patient to get a prescription from a doctor if the patient has complications (like high fever, generalized malaise, fatigue as symptoms, sinusitis). Stronger concerns were also observed for medicine outlet staff not dispensing antimicrobials without a prescription if the patient is pediatric or geriatric with a severe infection. They also evaluated patients and dispensed antimicrobials based on symptoms, not their age or gender. However, they tended not to dispense antibiotics if the patient had a mild fever and requested it without a prescription.

CONCLUSION

Our results provide insight into the need for a national surveillance system for monitoring antimicrobial prescribing and dispensing practices at medicine sales outlets. Therefore, the selection of antimicrobials for treating infectious diseases may be informed by evidence-based antimicrobial prescribing and dispensing surveillance data and will help policymakers to know the pattern of commonly consumed antimicrobials in the medicine sales outlets.

Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania

BACKGROUND

Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic.

METHODS

Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms =  415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs  = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed.

RESULTS

Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client's symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.

CONCLUSION

Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda

The medicines retail sector is an essential element of many health systems in Africa and Asia, but it is also well known for poor practice. In the literature, it is recognised that improvements in the sector can only be made if more effective forms of governance and regulation can be identified. Recent debate suggests that interventions responsive to structural constraints that shape and underpin poor practice is a useful way forward. This paper presents data from a mixed-methods study conducted to explore regulation and the professional, economic and social constraints that shape rule breaking among drug shops in one district in Uganda. Our findings show that regulatory systems are undermined by frequent informal payments, and that although drug shops are often run by qualified staff, many are unlicensed and sell medicines beyond their legal permits. Most shops have either a small profit or a loss and rely on family and friends for additional resources as they compete in a highly saturated market. We argue that in the current context, drug shop vendors are survivalist entrepreneurs operating in a market in which it is extremely difficult to abide by policy, remain profitable and provide a service to the community. Structural changes in the medicines market, including removing unqualified sellers and making adjustments to policy are likely prerequisite if drug shops are to become places where individuals can earn a living, abide by the rules and facilitate access to medicines for people living in some of the world's poorest countries.

An Evaluation of Antibiotic Prescription Rationality at Lower Primary Healthcare Facilities in Three Districts of South-Western Uganda

Purpose

Antimicrobial resistance is now one of the leading five causes of death globally. This study evaluated the rationality of antibiotic prescriptions at lower primary care levels in three districts of Southwestern Uganda.

Methods

This prospective cross-sectional study reviewed 9899 antibiotic prescriptions at 39 health centers following a drug delivery cycle by National Medical Stores in three phases (19 days each on average). Phase 1 started 3 days after delivery, mid-way (Phase 2) and towards the end (Phase 3). The proportion of rationally prescribed antibiotics was determined using a modified criterion by Badar and in reference to Uganda Clinical Guidelines (UCG). Using multivariate logistic regression, the factors associated with rational prescription were determined with 95% confidence intervals.

Results

Seven of every 10 antibiotic prescriptions were irrational. Half the prescriptions were made by unauthorized personnel (nurses) and many of the pediatric prescriptions (916, 46.5%) did not bear body weight measurements to guide appropriate dosing. Also, the proportion of rational prescriptions in reference to UCG, 2016 was very low (3387, 34.2%). However, a high proportion of antibiotic prescriptions were legibly written (9462, 95.7%), prescribed by generic names (9083, 91.8%) and had a diagnosis (9677, 97.8%) indicated. Multivariate logistic analysis showed that; availability of medicines (phase 1) (phase 2 AOR=1.14, 95% CI:1.02-1.28, phase 3, AOR=1.23, 95% CI:1.1-1.38), legibly written prescription (AOR=0.61, 95% CI: 0.47-0.78), indication of a date on the prescription (AOR=0.56, 95% CI0.38-0.81) and being a medical officer were factors associated with rational antibiotic prescription.

Conclusion

We observed a high rate of irrational prescription in the study sites and the majority of these were by unauthorized personnel. A review of antibiotic use policies and focused interventions is crucial in these settings.

Crossover-Use of Human Antibiotics in Livestock in Agricultural Communities: A Qualitative Cross-Country Comparison between Uganda, Tanzania and India

Antibiotic use in animal agriculture contributes significantly to antibiotic use globally and is a key driver of the rising threat of antibiotic resistance. It is becoming increasingly important to better understand antibiotic use in livestock in low-and-middle income countries where antibiotic use is predicted to increase considerably as a consequence of the growing demand for animal-derived products. Antibiotic crossover-use refers to the practice of using antibiotic formulations licensed for humans in animals and vice versa. This practice has the potential to cause adverse drug reactions and contribute to the development and spread of antibiotic resistance between humans and animals. We performed secondary data analysis of in-depth interview and focus-group discussion transcripts from independent studies investigating antibiotic use in agricultural communities in Uganda, Tanzania and India to understand the practice of antibiotic crossover-use by medicine-providers and livestock-keepers in these settings. Thematic analysis was conducted to explore driving factors of reported antibiotic crossover-use in the three countries. Similarities were found between countries regarding both the accounts of antibiotic crossover-use and its drivers. In all three countries, chickens and goats were treated with human antibiotics, and among the total range of human antibiotics reported, amoxicillin, tetracycline and penicillin were stated as used in animals in all three countries. The key themes identified to be driving crossover-use were: (1) medicine-providers' and livestock-keepers' perceptions of the effectiveness and safety of antibiotics, (2) livestock-keepers' sources of information, (3) differences in availability of human and veterinary services and antibiotics, (4) economic incentives and pressures. Antibiotic crossover-use occurs in low-intensity production agricultural settings in geographically distinct low-and-middle income countries, influenced by a similar set of interconnected contextual drivers. Improving accessibility and affordability of veterinary medicines to both livestock-keepers and medicine-providers is required alongside interventions to address understanding of the differences between human and animal antibiotics, and potential dangers of antibiotic crossover-use in order to reduce the practice. A One Health approach to studying antibiotic use is necessary to understand the implications of antibiotic accessibility and use in one sector upon antibiotic use in other sectors.

Antibiotic prescription rationality and associated in-patient treatment outcomes in children under-five with severe pneumonia at Bwizibwera health center IV, Mbarara District, South-Western Uganda

Background

Pneumonia is a major cause of morbidity and mortality in children under five. Antibiotic treatment must be started immediately in children with pneumonia. The irrational use of antibiotics may increase morbidity and mortality in children with pneumonia. Pneumonia accounted for approximately 16% of the 5.6 million under-five deaths word wide in 2016. In Uganda, it kills approximately 2,400 children per year. Early diagnosis and appropriate case management with rational use of antibiotics remain the most effective intervention to reduce pneumonia-related mortality. This study aimed at determining antibiotic prescription rationality and associated in-patient treatment outcomes in children aged 2–59 months with severe community-acquired pneumonia at Bwizibwera Health Centre IV from 1^st May 2018 to 30^th April 2019.

Methods

We conducted a retrospective cohort study design; data were collected from in-patient records of all children aged 2–59 months with severe community-acquired pneumonia who met the eligibility criteria for a period of one year. Data abstraction template was used for data collection. Health care records of children aged 2–59 months who had other co-morbidities and were on medication that could influence or impact on in-patient treatment outcomes from 1st May 2018 to 30th April 2019 were excluded. Data was entered and analyzed using Epi-info v 7.2 and STATA v 13.0 respectively, Descriptive statistics were reported and Chi-square test was used to compare the proportions.

Results

Of the total records of children retrieved and screened (N = 847), 229 prescription records of children fulfilled inclusion criteria, 57 (24.9%) had rational prescriptions with good outcomes and 172 (75.1%) had irrational prescriptions with 10 (4.4%) having unfavorable outcomes. The majority (73.7%) of those who received rational prescription were on treatment with a combination of benzyl penicillin plus gentamycin while (26.3%) were on ampicillin plus gentamycin. The majority (32.4%) of patients with good treatment outcomes were aged 6 – 11 months. This age category also doubled as the group that experienced the highest percentage (40.0%) of unfavorable outcomes. There were no statistically significant associations between patient characteristics and treatment outcomes.

Conclusion

In conclusion, the majority of children had irrational antibiotic prescriptions and 40 percent of children aged 6–11 Months had unfavorable treatment outcomes with 20 percent death. This study also found out that majority of antibiotic prescription among children under five was irrational and it’s against Uganda clinical guideline for treatment of severe pneumonia among children under five.

Community pharmacists' perception and exposure to drug promotion in Pakistan: a cross-sectional study

OBJECTIVE

Drug promotion is a factor that promotes the irrational use of drugs and sometimes negatively influences the prescribing/dispensing pattern. So there was a need to assess the views about accepting gifts and attitudes/influence towards drug promotion among community pharmacists in Punjab, Pakistan.

SETTING

Adopting a preused questionnaire, we conducted a cross-sectional multiple-site survey study. We distributed questionnaires to pharmacists in the community pharmacies to investigate the exposure, scepticism and acceptance to drug promotion as well as their perception about the appropriateness of gifts and to check if they had been taught about dealing with medical representatives. Data were analysed in simple percentages, and the χ² test was used to evaluate association with demographics. All the analysis was done using SPSS V.23.0.

RESULTS

A total 86.9% (463/533) pharmacists completed the survey. One out of four pharmacists reported being taught about the ethics of drug promotion (26.8%) and about how to interpret drug promotional material (25.0%) and were significantly associated with higher age (age 31%-35 years, 81.9%; p<0.05). More than two-thirds of the respondents found it appropriate to accept stationery (73.4%) and textbooks (70.6%) as gifts, and only 17.5% felt it was appropriate to accept direct money. Less than half of the pharmacists (47.3%) perceived drug companies were useful for gaining knowledge about new drugs. Majority (76.2%) thought these drug promotions play a role in the irrational prescribing of antibiotics and 18.6% dispensed antibiotics due to these promotions.

CONCLUSION

The majority of pharmacists participating in this study felt it was appropriate to receive small value gifts from pharmaceutical companies. Only a small proportion of the respondents was given ethical training and education about drug promotion. Improving the syllabus and updating the pharmacist's knowledge after graduation, as part of continued pharmacy education, will eventually improve the healthcare professionals' capability to act for the patients' welfare.

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.

Antibiotic stories: a mixed-methods, multi-country analysis of household antibiotic use in Malawi, Uganda and Zimbabwe

BACKGROUND

As concerns about the prevalence of infections that are resistant to available antibiotics increase, attention has turned toward the use of these medicines both within and outside of formal healthcare settings. Much of what is known about use beyond formal settings is informed by survey-based research. Few studies to date have used comparative, mixed-methods approaches to render visible patterns of use within and between settings as well as wider points of context shaping these patterns.

DESIGN

This article analyses findings from mixed-methods anthropological studies of antibiotic use in a range of rural and urban settings in Zimbabwe, Malawi and Uganda between 2018 and 2020. All used a 'drug bag' survey tool to capture the frequency and types of antibiotics used among 1811 households. We then undertook observations and interviews in residential settings, with health providers and key stakeholders to better understand the stories behind the most-used antibiotics.

RESULTS

The most self-reported 'frequently used' antibiotics across settings were amoxicillin, cotrimoxazole and metronidazole. The stories behind their use varied between settings, reflecting differences in the configuration of health systems and antibiotic supplies. At the same time, these stories reveal cross-cutting features and omissions of contemporary global health programming that shape the contours of antibiotic (over)use at national and local levels.

CONCLUSIONS

Our findings challenge the predominant focus of stewardship frameworks on the practices of antibiotic end users. We suggest future interventions could consider systems-rather than individuals-as stewards of antibiotics, reducing the need to rely on these medicines to fix other issues of inequity, productivity and security.

Addressing antimicrobial resistance by improving access and quality of care-A review of the literature from East Africa

Universal access to healthcare, including quality medicines, is a fundamental human right but is still out of reach for many in low- and middle-income countries (LMICs). An existing framework capturing variability of access to healthcare in low-resource settings includes the 5 dimensions: availability, accessibility, affordability, adequacy, and acceptability. This framework encompasses key components, including health infrastructure and means to access it as well as service organisation, costs, and factors that influence users' satisfaction. However, in reality, the effectiveness of accessed healthcare is measured by the likelihood of a positive outcome. We therefore propose an expansion of this framework to include an additional dimension, "aspects of quality," incorporating quality, which critically influences the ability of the accessed services to generate optimal health outcomes. Within this framework, we explore literature from East Africa likely relevant to a range of LMIC contexts, mainly focusing on the provision of widely used antimicrobials such as antimalarials and antibiotics. We argue that major inadequacies exist across all 6 dimensions of access and quality of drugs and their provision. While the global focus is on curbing excessive antimicrobial use to tackle the antimicrobial resistance (AMR) crisis, major constraints around access shape patients' health-seeking decisions leading to potentially problematic practices that might exacerbate the AMR problem. We advocate for a holistic approach to tackling these inadequacies, encompassing all dimensions of access and quality of healthcare in order to improve health outcomes while simultaneously counteracting the AMR crisis.

Antibiotic use among children under five years with diarrhea in rural communities of Gulu, northern Uganda: a cross-sectional study

Background

Diarrhea is the second leading cause of mortality in children under 5 years of age globally, and the risk of death increases with practices such as restriction of fluid intake and inappropriate use of antibiotics. We determined the prevalence of antibiotic use in managing diarrhea in children under 5 years of age in rural communities of Gulu district, northern Uganda.

Method

A cross-sectional study among children under 5 years with diarrhea, from households selected using multi-stage sampling. A researcher administered questionnaire was used to obtain data from caregivers of these children.

Results

Of the 856 children recruited, 318 (37.1%, 318/856) had experienced diarrhea, where 263 (82.7%, 263/318) had diarrhea with acute respiratory infections (ARIs), and 55 (17.3%, 55/318) had diarrhea without ARIs. The majority (89.6%, 285/318) of the children had non-bloody diarrhea. A high proportion (82.8%) of the children with non-bloody diarrhea also had ARIs. Bloody diarrhea was reported for 33 (10.4%) children including those with ARIs, and only 6 of these (18.2%) children had bloody diarrhea without ARIs. Of the 318 children with diarrhea, over half (52%, CI: 46–57) were administered antibiotics. Of the 55 children who had diarrhea without ARIs, over a third (38%, CI: 26–51) were administered antibiotics. Similarly, of the 263 children with diarrhea and ARIs, 54% (CI: 48–60) were treated with antibiotics. The determinants of antibiotic use included; children living in peri-urban settings (AOR: 3.41, CI: 1.65–7.08, P = 0.001), getting treatment from health facility (AOR: 1.76, CI: 1.06–2.93, P = 0.029), and having diarrhea with ARIs (AOR: 3.09, CI: 1.49–6.42, P = 0.003).

Conclusion

Antibiotic use is common among children under 5 years with diarrhea in rural communities of northern Uganda.

Antibiotic Practices, Perceptions and Self-Medication Among Patients at a National Referral Hospital in Uganda

Background

Antimicrobial resistance (AMR) is a major global health concern with increasing reports of microorganisms resistant to most of the available antibiotics. There are limited data on antibiotic practices, perceptions and self-medication among Ugandans, necessitating this study.

Methods

A cross-sectional study was conducted among patients at Kiruddu National Referral Hospital, Kampala, Uganda. A pre-tested interviewer administered a questionnaire that was used to collect data after an informed consent. Chi-square tests and logistic regression were used to assess associations between outcome and exposure variables. A P<0.05 was statistically significant.

Results

A total of 279 patients (response rate=71%) with a median age of 32 years participated in the study. The majority were females (55.6%, n=155) and from the outpatient department (74.9%, n=209). Overall, 212 (76%) participants had taken an antibiotic in the past 6 months, and some 22.2% (n=47) of the participants had practiced self-medication. Male participants (adjusted odds ratio (aOR)=2.13, 95% confidence intervals (CI): 1.01 to 4.50, P=0.046) and Muslims (aOR=4.37, 96% CI:1.54 to 12.44, P=0.006) were more likely to self-medicate. Employees (aOR=0.06, 95% CI:0.01 to 0.51, P=0.010) and patients with tertiary education (aOR=0.14, 95% CI: 0.02 to 0.81, P=0.028) were less likely to practice self-medication. About 33% (n=70) of the participants had not completed treatment dosage during their last course of antibiotic treatment because of feeling better (60%, n=42), lack of money to purchase the medication (15.7%, n=11) and side effects (10%, n=7). Whereas 169 participants (79.7%) believed that not completing treatment would have an impact on their personal health, only 96 participants (45.3%) believed that this behaviour could affect the health of others.

Conclusion

Antibiotic misuse is significant among patients in Uganda. Continuous health education programs aimed at informing the public on antimicrobial resistance, and its dangers are recommended to curtail this challenge.

No prescription? No problem: drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries: a systematic review of qualitative studies

BACKGROUND

Non-prescription dispensing of antibiotics, one of the main sources of antibiotic misuse or over use, is a global challenge with detrimental public health consequences including acceleration of the development of antimicrobial resistance, and is facilitated by various intrinsic and extrinsic drivers. The current review aimed to systematically summarise and synthesise the qualitative literature regarding drivers of non-prescribed sale of antibiotics among community drug retail outlets in low and middle income countries.

METHODS

Four electronic databases (PubMed, CINAHL, Scopus and Google Scholar) and reference lists of the relevant articles were searched. The Joanna Briggs Institute's Critical Appraisal Checklist for qualitative studies was used to assess the quality of included studies. The enhancing transparency in reporting the synthesis of qualitative research statement was used to guide reporting of results. Data were coded using NVivo 12 software and analysed using both inductive and deductive thematic analysis.

RESULTS

A total of 23 articles underwent full text review and 12 of these met the inclusion criteria. Four main themes were identified in relation to facilitators of non-prescribed sale of antibiotics among community drug retail outlets: i) the business orientation of community drug retail outlets and tension between professionalism and commercialism; ii) customers' demand pressure and expectation; iii); absence of or a lax enforcement of regulations; and iv) community drug retail outlet staff's lack of knowledge and poor attitudes about antibiotics use and scope of practice regarding provision.

CONCLUSIONS

This review identified several potentially amendable reasons in relation to over the counter dispensing of antibiotics. To contain the rise of antibiotic misuse or over use by targeting the primary drivers, this review suggests the need for strict law enforcement or enacting new strong regulation to control antibiotic dispensing, continuous and overarching refresher training for community drug retail outlet staff about antibiotic stewardship, and holding public awareness campaigns regarding rational antibiotic use.

Efforts to Identify and Combat Antimicrobial Resistance in Uganda: A Systematic Review

The global burden of antimicrobial resistance is on the rise, resulting in higher morbidity and mortality in our communities. The spread of antimicrobial resistance in the environment and development of resistant microbes is a challenge to the control of antimicrobial resistance. Approaches, such as antimicrobial stewardship programmes and enhanced surveillance, have been devised to curb its spread. However, particularly in lower- and middle-income countries, the overall extent of antimicrobial resistance and knowledge on ongoing surveillance, stewardship or investigation efforts, are often poorly understood. This study aimed to look at the efforts that have been undertaken to detect and combat antimicrobial resistance in Uganda as a means of establishing an overview of the situation, to help inform future decisions. We conducted a systematic literature review of the PubMed database to assess these efforts. A search combining keywords associated with antimicrobial resistance were used to find relevant studies between 1995 and 2020 on surveillance of antimicrobial resistance in Uganda, and susceptibility of microbes to different drugs. The search yielded 430 records, 163 of which met the inclusion criteria for analysis. The studies were categorized according to country and region, the type of antimicrobial resistance, context of the study, study design and outcome of the study. We observed that antibacterial resistance and antimalarial resistance had the most published studies while antiviral and antifungal resistance were represented by very few studies each. Most studies were conducted in humans and hospital settings, with few in veterinary and One Health contexts, and only one that included environmental sampling. The majority of studies have focused on surveillance, susceptibility testing or resistance genes; none of our included papers had a policy or stewardship focus. The results from our work can inform public health policy on antimicrobial stewardship as it contributes to understanding the status of antimicrobial resistance surveillance in Uganda, and can also help to guide future research efforts. Notably, a One Health approach needs to be followed with respect to surveillance of antimicrobial resistance to better understand the mechanisms of resistance transfer across the human-animal–environment interface, including additional investigation in antiviral and antifungal resistance.

Motivating antibiotic stewardship in Bangladesh: identifying audiences and target behaviours using the behaviour change wheel

BACKGROUND

South Asia is a hotspot for antimicrobial resistance due largely to over-the-counter antibiotic sales for humans and animals and from a lack of policy compliance among healthcare providers. Additionally, there is high population density and high infectious disease burden. This paper describes the development of social and behavioural change communication (SBCC) to increase the appropriate use of antibiotics.

METHODS

We used formative research to explore contextual drivers of antibiotic sales, purchase, consumption/use and promotion among four groups: 1) households, 2) drug shop staff, 3) registered physicians and 4) pharmaceutical companies/medical sales representatives. We used formative research findings and an intervention design workshop with stakeholders to select target behaviours, prioritise audiences and develop SBCC messages, in consultation with a creative agency, and through pilots and feedback. The behaviour change wheel was used to summarise findings.

RESULTS

Workshop participants identified behaviours considered amenable to change for all four groups. Household members and drug shop staff were prioritised as target audiences, both of which could be reached at drug shops. Among household members, there were two behaviours to change: suboptimal health seeking and ceasing antibiotic courses early. Thus, SBCC target behaviours included: seek registered physician consultations; ask whether the medicine provided is an antibiotic; ask for instructions on use and timing. Among drug shop staff, important antibiotic dispensing practices needed to change. SBCC target behaviours included: asking customers for prescriptions, referring them to registered physicians and increasing customer awareness by instructing that they were receiving antibiotics to take as a full course.

CONCLUSIONS

We prioritised drug shops for intervention delivery to all drug shop staff and their customers to improve antibiotic stewardship. Knowledge deficits among these groups were notable and considered amenable to change using a SBCC intervention addressing improved health seeking behaviours, improved health literacy on antibiotic use, and provision of information on policy governing shops. Further intervention refinement should consider using participatory methods and address the impact on profit and livelihoods for drug shop staff for optimal compliance.

Health Workers' Practices in Assessment and Management of Children with Respiratory Symptoms in Primary Care Facilities in Uganda: A FRESH AIR Descriptive Study

INTRODUCTION

Globally, acute lower respiratory infections are the leading cause of mortality among children under 5 years. Following World Health Organization primary care guidelines, pneumonia is diagnosed based on cough/difficult breathing and fast breathing. We aimed to describe the practices of healthcare workers in primary care health facilities in Uganda in the management of young children with respiratory symptoms especially regarding asthma as opposed to pneumonia.

METHODS

Health workers were observed during clinical consultations with children 1-59 months of age presenting with cough and/or difficult breathing at recruitment. Afterward, an exit interview with the caregiver was conducted. Health center availability of clinical guidelines, equipment and supplies for management of children with respiratory symptoms was assessed systematically.

RESULTS

A total of 218 consultations with 50 health workers at six health centers were included. Median consultation time was 4 min. Health workers asked history relevant to distinguishing asthma from pneumonia in 16% of consultations. The respiratory rate was counted in 10%. Antibiotics were prescribed to 32% of all the children and to 39% of children diagnosed with pneumonia. Caregivers reported being informed of findings and possible diagnosis in 5% of cases. Medicine and equipment needed for diagnosing and treating asthma were generally unavailable.

CONCLUSION

Clinical practices among Ugandan health workers in primary care are insufficient to distinguish between main causes of respiratory symptoms, especially asthma as opposed to pneumonia, in children under five. Irrational use of antibiotics is widespread. Clear communication with caregivers is lacking. This could be due to lack of relevant competencies, medicines, time and supplies.

LAY SUMMARY

Globally, the most frequent cause of death for children under five is infections in the lower airways. The World Health Organization recommends that in local health clinics this is defined as cough/difficult breathing and fast breathing. This article focuses on the practices of local health workers in Uganda and how they in practice diagnose and treat children under five with these symptoms. In addition, we try to estimate how much the caregivers of the children understand from the consultation. This is done by observing the healthcare workers (HCWs) and by interviewing the caregivers. In general, we found that the consultations were too short, that too few of the health workers looked for important signs for lower airways disease such as fast breathing and that antibiotics were prescribed in too many of the consultations. Also, the length and quality of the consultations and the supplies at the local health clinics were not sufficient to diagnose and treat asthma, which can often be mistaken for an infection. We believe that it is an important problem that too few children with asthma are being diagnosed correctly and that antibiotics are being prescribed too frequently, the latter being an important cause of antibiotic resistance. Relevant action must be taken to improve this.

Emerging organic contaminants in shallow groundwater underlying two contrasting peri-urban areas in Uganda

This study investigated the occurrence and seasonal variation in concentrations of emerging organic contaminants (EOCs) in shallow groundwater underlying two peri-urban areas of Bwaise (highly urbanised) and Wobulenzi (moderately urbanised) in Uganda. Twenty-six antibiotics, 20 hydrocarbons, including 16 polycyclic aromatic hydrocarbons (PAHs), and 59 pesticides were investigated. Ampicillin and benzylpenicillin were the most frequently detected antibiotics in both areas, although at low concentrations to cause direct harm to human health, but could lead to a proliferation of antibiotic resistance genes. The most frequently detected hydrocarbons in Bwaise were naphthalene and xylene while anthracene and fluoranthene were the most frequent in Wobulenzi, also at low concentrations for ecological impact at long-term exposure. Molecular diagnostic ratios indicated pyrogenic and pyrolytic sources of PAHs in both areas. Cypermethrin (for vermin control) was the most frequent pesticide in Bwaise while metalaxyl (attributed to agriculture) was the most frequent in Wobulenzi. Banned organochlorines (8) were also detected in both areas in low concentrations. The pesticide concentrations between the two areas significantly differed (Z = - 3.558; p < 0.01), attributed to contrasting land-use characteristics. In Wobulenzi (wet season), the total pesticide concentrations at all the locations exceeded the European Community parametric guideline value while 75% of the detected compounds exceeded the individual pesticide guideline value. Thus, the antibiotic and pesticide residues in shallow groundwater underlying both Bwaise and Wobulenzi pose potential adverse ecological effects at long-term exposure. Monitoring of EOCs in both highly and moderately urbanised catchments should be strengthened towards mitigating associated risks.

History taking and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia: a simulated-client survey

Background

Self-care is one of the growing tasks of community pharmacy professionals. They are highly engaged in consultations in response to specific drug request (product-based presentation) or symptoms clients describe (symptom-based presentation).

Purpose

This study was aimed at assessing the appropriateness of patient assessment and response to an adult diarrheal case among community drug retail outlets in Gondar town, north-west Ethiopia.

Methods

A descriptive cross-sectional study design based on simulated-client method of visit was conducted from 03 August to 21 September, 2020. An adult female diarrheal case scenario was developed and used to guide data collectors to interact with professionals in a standardized and consistent way. All 60 dispensaries in the town during the data collection were included in the study. A pretested data collection tool was used to record the conversation between simulated clients and providers. The data were analyzed using SPSS version 20.

Results

With regard to patient history, age of the patient, whether diarrhea is watery or bloody and onset and duration of diarrhea were the three most commonly requested questions with 59 (98.3%), 55 (91.7%) and 46 (76.7%), respectively. Past-medical and medication history are enquired in none of the visits. Medication was dispensed in 57 (95%) of the visits and no referral to a health facility was recommended in majority (90%) of cases. The most commonly recommended medications were ciprofloxacin 30 (52.6%) and metronidazole 20 (35.1%). ORS was considered in only 6 (10.5%) dispensaries.

Conclusion

Patient assessment, final decisions and treatment recommendations for an adult diarrheal case are inadequate, irrational and illegal. Educational interventions coupled with incentive mechanisms for cognitive pharmaceutical service and strict regulatory enforcement are needed to reduce the problem.

Non-prescription dispensing of antibiotic agents among community drug retail outlets in Sub-Saharan African countries: a systematic review and meta-analysis

BACKGROUND

The development of antimicrobial resistance, which is partially attributable to the overuse and/or misuse of antibiotics in health care, is one of the greatest global public health challenges. In Sub-Saharan African (SSA) countries, non-prescribed dispensing of antibiotics in community drug retail outlets (CDROs) has been flagged as one of the contributing factors for the widespread misuse of antibiotics in the community.

OBJECTIVE

The current review aimed to estimate the proportion of non-prescription antibiotics requests or consultations that resulted in provision of antibiotics without a valid prescription among CDROs in SSA region, and describe the type of antibiotics dispensed.

METHODS

A literature search was conducted using PubMed, CINAHL, Scopus and Google Scholar. We also searched reference lists of relevant articles. Random effect model meta-analysis was employed to determine the pooled proportion of over the counter sale of antibiotics. Subgroup and meta-regression was undertaken to explore the potential cause of heterogeneity in effect size across studies.

RESULTS

Of 671 total citations retrieved, 23 met the inclusion criteria (seven cross-sectional questionnaire-based surveys and 16 cross-sectional client-based studies). The overall pooled proportion of non-prescription antibiotics requests or consultations that resulted in supply of antibiotics without prescription was 69% (95% CI 58-80). Upper respiratory tract infections and/or acute diarrhoea were the most frequently presented case scenarios, and amoxicillin and co-trimoxazole were the most frequently dispensed antibiotics to treat those symptoms.

CONCLUSIONS

Non-prescribed dispensing of antibiotics was found to be a common practice among CDROs in several SSA countries. Ease of access to and overuse of antibiotics can potentially accelerate the emergence of resistance to antibiotics available in the region. Our review highlights the need for a stringent enforcement of existing policies and/or enacting new regulatory frameworks that would regulate antibiotic supply, and training and educational support for pharmacy personnel (e.g. pharmacists, pharmacy assistants) regarding judicious use of antibiotics and the importance of antimicrobial stewardship.

Previous Traditional Medicine Use for Sore Throat among Children Evaluated for Rheumatic Fever in Northern Uganda

Timely diagnosis of group A streptococcal (GAS) sore throat coupled with appropriate antibiotic treatment is necessary to prevent serious post-streptococcal complications, including rheumatic fever (RF) and rheumatic heart disease (RHD). Traditional medicine (TM) is a known common adjunct to formal medical care in sub-Saharan Africa. A better understanding of health-seeking behavior for sore throat both within and outside the formal medical system is critical to improving primary prevention efforts of RF and RHD. A prospective mixed-methods study on the use of TM for sore throat was embedded within a larger epidemiological study of RF in Northern Uganda. Children presenting with symptoms of RF were interviewed about recent TM use as well as health services use for sore throat. One hundred children with a median age of 10 years (interquartile range: 6.8-13 years) completed the TM interview with their parent/guardian as part of a research study of RF. Seventeen, or 17%, accessed a TM provider for sore throat as part of the current illness, and 70% accessed TM for sore throat in the past (73% current or past use). Of the 20 parents who witnessed the TM visit, 100% reported use of crude tonsillectomy. Penicillin was the most frequently prescribed medication by TM providers in 52% of participants who were seen by a TM provider. The use of TM among children presenting with symptoms of sore throat in northern Uganda is common and frequently used in tandem with diagnostic services offered through the formal healthcare system. Engagement with TM practitioners may provide an important avenue for designing effective primary prevention and management strategies of RF and reduce the global burden of RHD.

'I know those people will be approachable and not mistreat us': a qualitative study of inspectors and private drug sellers' views on peer supervision in rural Uganda

BACKGROUND

Peer supervision improves health care delivery by health workers. However, in rural Uganda, self-supervision is what is prescribed for licensed private drug sellers by statutory guidelines. Evidence shows that self-supervision encourages inappropriate treatment of children less than 5 years of age by private drug sellers. This study constructed a model for an appropriate peer supervisor to augment the self-supervision currently practiced by drug sellers at district level in rural Uganda.

METHODS

In this qualitative study, six Key informant interviews were held with inspectors while ten focus group discussions were conducted with 130 drug sellers. Data analysis was informed by the Kathy Charmaz constructive approach to grounded theory. Atlas ti.7 software package was used for data management.

RESULTS

A model with four dimensions defining an appropriate peer supervisor was developed. The dimensions included; incentives, clearly defined roles, mediation and role model peer supervisor. While all dimensions were regarded as being important, all participants interviewed agreed that incentives for peer supervisors were the most crucial. Overall, an appropriate peer supervisor was described as being exemplary to other drug sellers, operated within a defined framework, well facilitated to do their role and a good go-between drug sellers and government inspectors.

CONCLUSION

Four central contributions advance literature by the model developed by our study. First, the model fills a supervision gap for rural private drug sellers. Second, it highlights the need for terms of reference for peer supervisors. Third, it describes who an appropriate peer supervisor should be. Lastly, it elucidates the kind of resources needed for peer supervision.

Regulatory inspection of registered private drug shops in East-Central Uganda-what it is versus what it should be: a qualitative study

Background

Regulatory inspection of private drug shops in Uganda is a mandate of the Ministry of Health carried out by the National Drug Authority. This study evaluated how this mandate is being carried out at national, district, and drug shop levels. Specifically, perspectives on how the inspection is done, who does it, and challenges faced were sought from inspectors and drug sellers.

Methods

Six key informant interviews (KIIs) were held with inspectors at the national and district level, while eight focus group discussions (FGDs) were conducted among nursing assistants, and two FGDs were held with nurses. The study appraised current methods of inspecting drug sellers against national professional guidelines for licensing and renewal of class C drug shops in Uganda. Transcripts were managed using Atlas ti version 7 (ATLAS.ti GmbH, Berlin) data management software where the thematic content analysis was done.

Results

Five themes emerged from the study: authoritarian inspection, delegated inspection, licensing, training, and bribes. Under authoritarian inspection, drug sellers decried the high handedness used by inspectors when found with expired or no license at all. For delegated inspection, drug sellers said that sometimes, inspectors send health assistants and sub-county chiefs for inspection visits. This cadre of people is not recognized by law as inspectors. Inspectors trained drug sellers on how to organize their drug shops better and how to use new technologies such as rapid diagnostic tests (RDTs) in diagnosing malaria. Bribes were talked about mostly by nursing assistants who purported that inspectors were not interested in inspection per se but collecting illicit payments from them. Inspectors said that the facilitation they received from the central government were inadequate for a routine inspection.

Conclusion

The current method of inspecting drug sellers is harsh and instills fear among drug sellers. There is a need to establish a well-recognized structure of inspection as well as establish channels of dialogue between inspectors and drug sellers if meaningful compliance is to be achieved. The government also needs to enhance both human and financial resources if meaningful inspection of drug sellers is to take place.

Treatment of Sick Children Seeking Care in the Private Health Sector in Uganda: A Cluster Randomized Trial

The main objective of this study was to assess whether training of private health providers and community sensitization on the importance of effective prompt care seeking and the need for referral could improve treatment of sick children in the private health sector in Uganda. Private providers were trained to diagnose and treat sick children according to the integrated community case management (iCCM) guidelines. In the control arm, routine services were offered. The outcomes were seeking care within 24 hours of onset of symptoms and appropriate case management for malaria, pneumonia, and diarrhea among children aged < 5 years. A total of 10,809 sick children (5,955 in the intervention arm and 4,854 in the control arm) presented for diagnosis and treatment. The percentage seeking care within 24 hours of onset of symptoms was 45.4% (95% CI 36.0–48.8) in the intervention arm versus 43.9% (95% CI 38.1–49.8) in the control arm (P = 0.04). Adherence to malaria rapid diagnostic test (mRDT) results was high, with 1,459 (94.3%) in the intervention arm versus 1,402 (83.0%) in the control arm (P = 0.04). Appropriate treatment of mRDT-positive children with artemisinin-based combination therapy was seen in 93.1% (95% CI 88.5–97.7) in the intervention arm versus 85.1% (95% CI 78.6–91.7) in the control arm (P = 0.03). Adherence to iCCM guidelines was very high: 89.1% of children with diarrhea in the intervention arm and 80.4% in the control arm were given oral rehydration salts and zinc (P = 0.01). Of the children with a respiratory rate > 40 breaths/minute, 1,596 (85.1%) in the intervention arm versus 104 (54.5%) in the control arm were given amoxicillin (P = 0.01). In conclusion, the intervention improved treatment of malaria, pneumonia, and diarrhea because of provider adherence to treatment guidelines. The policy implications of these findings are to initiate a dialogue at district and national levels on how to scale up the intervention in the private sector. NCT02450630 registered with ClinicalTrials.gov: May 9, 2015.

Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: a mixed-methods study

Background

Controlled prescription drug use disorders are a growing global health challenge in Sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic. Since compliance with these regulations in resource-limited countries is poor, there is need to understand its predictors in order to reduce the risk of prescription drug use disorders.

Methods

A mixed-methods study utilizing a structured questionnaire and a simulated client guide was undertaken in Kampala and Mbale towns in Uganda. The questionnaire recorded self-reported dispensing and verified stock control practices and their covariates from 101 private pharmacies. The guide recorded actual dispensing practices from 27 pharmacies. Snowball sampling was done to enrich the sample with pharmacies that stock opioids. The mean compliance with good dispensing and stock control practices was calculated. Multivariate logistic regression analyses were applied to identify predictors of compliance.

Results

The mean compliance with dispensing and stock control requirements was 82.9% and 23%, respectively. Twenty percent and 40% of the pharmacies dispensed pethidine without a prescription and with invalid prescriptions, respectively. Having a pharmacist on duty (OR = 5.17; p = 0.02), prior in-service training on narcotics regulations (OR = 3.51; p = 0.04), and previous narcotics audits by the regulator (OR = 5.11; p = 0.01) were independent predictors of compliance with stock control requirements. Pharmacies with a previous history of poor compliance with dispensing requirements were less likely to demonstrate good compliance (OR = 0.21; p = 0.01).

Conclusions

There is suboptimal compliance to controlled prescription drug regulations among Uganda’s pharmacies. A previous history of poor compliance to dispensing requirements predicted low compliance in subsequent assessments. Training and regulatory audits increased compliance in stock control but not dispensing. Expansion of training and audits to more pharmacies and/or incentives for compliance are necessary.

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.

The impact of law enforcement on dispensing antibiotics without prescription: a multi-methods study from Saudi Arabia

Background: Dispensing of antibiotics without a prescription (DAwP) has been widely practised among community pharmacies in Saudi Arabia despite being illegal. However, in May 2018, the law and regulations were enforced alongside fines. Consequently, we wanted to evaluate the impact of these changes.Methods: A study was conducted among 116 community pharmacies in two phases. A pre-law enforcement phase between December 2017 and March 2018 and a post-law enforcement phase one year later. Each phase consisted of a cross-sectional questionnaire-based survey and a simulated client method (SCM) approach. In the SCM, clients presented with either pharyngitis or urinary tract infections (UTI). In SCM, for each phase, all 116 pharmacies were visited with one of the scenarios.Results: Before the law enforcement, 70.7% of community pharmacists reported that DAwP was common with 96.6% and 87.7% of participating pharmacies dispensed antibiotics without a prescription for pharyngitis and UTI respectively. After the law enforcement, only 12.9% reported that DAwP is still a common practice, with only 12.1% and 5.2% dispensing antibiotics without prescriptions for pharyngitis and UTI respectively.Conclusion: law enforcement was effective. However, there is still further scope for improvement. This could include further educational activities with pharmacists, physicians and the public.

A cross-sectional survey of practices and knowledge among antibiotic retailers in Nairobi, Kenya

BACKGROUND

Antimicrobial resistance (AMR) driven by antibiotic consumption is a growing global health threat. However, data on antimicrobial consumption patterns in low- and middle-income countries (LMICs) is sparse. Here, we investigate the patterns of antibiotic sales in humans and livestock in urban Nairobi, Kenya, and evaluate the level of awareness and common behaviours related to antibiotic use and AMR amongst human and veterinary pharmacists.

METHODS

A total of 40 human and 19 veterinary drug store pharmacists were interviewed in Nairobi in 2018 using a standard questionnaire. Data recorded included demographic variables, types of antibiotics sold, antibiotic customers, antibiotic prescribing practices and knowledge of antibiotic use and AMR.

RESULTS

Our study shows that at the retail level, there is a considerable overlap between antibiotic classes (10/15) sold for use in both human and veterinary medicine. Whilst in our study, clinical training significantly influenced knowledge on issues related to antibiotic use and AMR and respondents had a relatively adequate level of knowledge about AMR, several inappropriate prescribing practices were identified. For example, we found that most veterinary and human drug stores (100% and 52% respectively) sold antibiotics without a prescription and noted that customer preference was an important factor when prescribing antibiotics in half of the drug stores.

CONCLUSION

Although more research is needed to understand the drivers of antibiotic consumption in both human and animal populations, these findings highlight the need for immediate strategies to improve prescribing practices across the pharmacists in Nairobi and by extension other low- and middle-income country settings.

Antimicrobial dispensing practices and determinants of antimicrobial resistance: a qualitative study among community pharmacists in Pakistan

Background

There are concerns with the extent of dispensing of antibiotics among community pharmacists in Pakistan often without a prescription adding to antimicrobial resistance (AMR) rates.

Objective

To explore the determinants of AMR and the pattern of antimicrobial dispensing among community pharmacists.

Design

In this qualitative study design, a semistructured interview guide was developed based on an in-depth review of published papers. Audio-recorded interviews with transcripts were analysed by thematic content analysis.

Setting

Interviews were conducted among community pharmacists in Lahore, Pakistan.

Participants

In order to obtain individual points of view, in-depth face-to-face interviews with purposively selected pharmacists were conducted.

Results

A total of 12 pharmacists were interviewed for the study. After analysis, four major themes emerged: (1) knowledge and perception of community pharmacists about antimicrobials, (2) antimicrobial dispensing practices of community pharmacists, (3) determinants of AMR, (4) potential interventions to control AMR. Most of the pharmacists have limited knowledge about AMR, antimicrobial stewardship programmes and related guidelines. However, all the pharmacists strongly agreed that different appropriate actions should be taken in order to rationalise future antimicrobial use.

Conclusion

The results indicated that irrational antimicrobial dispensing and use is common among community pharmacists in Pakistan owing to lack of knowledge. The community pharmacists perceived that behaviour of patients and the societal environment contributed to irrational antimicrobial use and subsequent development of AMR. They suggested a need for a multidisciplinary framework in order to improve future antimicrobial use and reduce AMR in Pakistan.

Antibiotic prescription for under-fives with common cold or upper respiratory tract infection in Savannakhet Province, Lao PDR

Background

The irrational use of antibiotics has been identified as a major problem in healthcare, and it can lead to antimicrobial resistance, treatment failure, and increased healthcare costs. Although many studies worldwide have focused on the irrational use of drugs, reports on prescription practice in Lao PDR remained limited. This study aimed to examine the patterns of antibiotic prescription for under-fives with common cold or upper respiratory tract infection (URTI) at pediatric outpatient divisions.

Methods

One provincial hospital (PH) at Kaisone Phomvihane and four district hospitals (DHs) at Songkhone, Champhone, Atsaphangthong, and Xepon in Savannakhet Province were selected. Healthcare providers at these hospitals were interviewed and medical records of under-fives from 2016 were examined.

Results

Of the 54 healthcare providers interviewed, 85.2% had seen the standard treatment guideline, 77.8% adhered to this guideline, and 90.7% knew about antimicrobial resistance, while 18.5% participated in antimicrobial resistance activities. Medical records of 576 outpatients (311 boys and 265 girls) with common cold or URTI were examined, 154 at the PH and 422 at the DHs. Although antibiotics prescription proportions were similar between facilities at both levels (68.8% and 70.9% at the PH and DHs, respectively), antibiotics were exclusively prescribed for URTIs (96.4%), not for common cold (4.9%). First-line antibiotics recommended by WHO Model List of Essential Medicines for Children the 6th List were prescribed for 81.5% of patients; mainly, beta-lactam antibiotics were prescribed (87.2% of prescribed antibiotics). There were no cases in which two or more antibiotics were prescribed. The correct dose according to the National STG was 31.9% as a whole. The difference in the correct dose between the PH (52.8%) and the DHs (24.4%) was significant (p < 0.001).

Conclusions

This study demonstrated the patterns of antibiotic prescription for under-fives with common cold or URTI among healthcare providers from two different levels of facilities. Although an appropriate number of generic first-line antibiotics in the essential drug list were prescribed, the dosage and duration of antibiotic use were not appropriate. In order to further improve antibiotic prescription practices, regulation by the government is necessary; this could also decrease antimicrobial resistance and improve treatment outcomes.

Healthcare professionals' level of medication knowledge in Africa: a systematic review

AIMS

Understanding how much healthcare professionals (HCPs) know about medication can help in devising strategies to improve rational medication use. This study aimed to synthesize information on the level of medication knowledge of HCPs in Africa.

METHOD

We performed a systematic literature study in Embase and PubMed. We included original studies quantifying HCPs' medication knowledge, published between 2012 and 2016. We extracted disease focus, country, number and type of HCPs included and all medication-related knowledge questions and scored the quality of papers. The outcome measure was the percentage of HCPs who correctly answered medication knowledge questions.

RESULTS

We identified 64 studies from 12 African countries, comprising 13 911 HCPs, mostly nurses/midwifes and physicians. We extracted 306 medication-related knowledge questions, and only 52% (SD 28) of HCPs correctly answered them. Knowledge questions were mainly about medication prescribed for communicable diseases (70%), followed by non-communicable diseases (11%), and family planning/gynaecology (10%). Most papers concluded that there was a considerable medication knowledge gap among HCPs.

CONCLUSION

We found a low level of medication knowledge across different disease areas, countries and HCPs. This underlines the continuous need to strengthen the undergraduate and postgraduate education in (clinical) pharmacology and therapeutics in Africa.

'The disease isn't listening to the drug': The socio-cultural context of antibiotic use for viral respiratory infections in rural Uganda

To identify factors precipitating antibiotic misuse and discuss how to promote safe antibiotics use and curb antibiotic resistance. Antibiotic misuse is a significant problem globally, leading to increased antibiotic resistance. Many socio-cultural factors facilitate antibiotic misuse: patient and provider beliefs about antibiotics, inadequate regulation, poor health literacy, inadequate healthcare provider training, and sub-optimal diagnostic capability. This study investigates the influence of such factors on antibiotic use and community health in rural Uganda. Attention was paid to patient-provider dynamics, providers' concerns, and the role of drug shops in the communities and how these situations exacerbate antibiotic misuse. Using a grounded ethnographic approach, interviews, focus groups, and observations were conducted over six weeks. Five salient themes emerged from data analysis. Based on the study results and a review of past literature on antibiotic resistance, there is need for improved health literacy and education, continued focus on efficiency and affordability in healthcare, and recognition of the role of stewardship and government in providing better healthcare. The problem of antibiotic misuse is multifactorial. Proposed solutions must target multiple contributing factors and must ultimately modify the culture and beliefs surrounding antibiotic use and encourage proper use. Such a multi-pronged approach would be most effective and would decrease rates of antibiotic resistance.

Family planning provision in pharmacies and drug shops: an urgent prescription

Drug shops and pharmacies have long been recognized as the first point of contact for health care in developing countries, including family planning (FP) services. Drug shop operators and pharmacists should not be viewed as mere merchants of short-acting contraceptive methods, as this ignores their capacity for increasing uptake of FP services and methods in a systematic and collaborative way with the public sector, social marketing groups and product distributors. We draw on lessons learned from the rich experience of earlier efforts to promote a variety of public health interventions in pharmacies and drug shops. To integrate this setting that provides convenience, confidentiality, access to user-controlled contraceptive methods (i.e., pills, condoms and potentially Sayana Press®) and a gateway to clinic-based FP services, we propose three promising practices that should be encouraged in future interventions to increase access to quality FP services.

Private retail drug shops: what they are, how they operate, and implications for health care delivery in rural Uganda

Background

Retail drug shops play a significant role in managing pediatric fevers in rural areas in Uganda. Targeted interventions to improve drug seller practices require understanding of the retail drug shop market and motivations that influence practices. This study aimed at describing the operational environment in relation to the Uganda National Drug Authority guidelines for setup of drug shops; characteristics, and dispensing practices of private retail drug shops in managing febrile conditions among under-five children in rural western Uganda.

Methods

Cross sectional survey of 74 registered drug shops, observation checklist, and 428 exit interviews using a semi-structured questionnaire with care-seekers of children under five years of age, who sought care at drug shops during the survey period. The survey was conducted in Mbarara and Bushenyi districts, South Western Uganda, in May 2013.

Results

Up to 90 and 79% of surveyed drug shops in Mbarara and Bushenyi, largely operate in premises that meet National Drug Authority requirements for operational suitability and ensuring medicines safety and quality. Drug shop attendants had some health or medical related training with 60% in Mbarara and 59% in Bushenyi being nurses or midwives. The rest were clinical officers, pharmacists. The most commonly stocked medicines at drug shops were Paracetamol, Quinine, Cough syrup, ORS/Zinc, Amoxicillin syrup, Septrin® syrup, Artemisinin-based combination therapies, and multivitamins, among others. Decisions on what medicines to stock were influenced by among others: recommended medicines from Ministry of Health, consumer demand, most profitable medicines, and seasonal disease patterns. Dispensing decisions were influenced by: prescriptions presented by client, patients’ finances, and patient preferences, among others. Most drug shops surveyed had clinical guidelines, iCCM guidelines, malaria and diarrhea treatment algorithms and charts as recommended by the Ministry of Health. Some drug shops offered additional services such as immunization and sold non-medical goods, as a mechanism for diversification.

Conclusion

Most drug shops premises adhered to the recommended guidelines. Market factors, including client demand and preferences, pricing and profitability, and seasonality largely influenced dispensing and stocking practices. Improving retail drug shop practices and quality of services, requires designing and implementing both supply-side and demand side strategies.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3343-z) contains supplementary material, which is available to authorized users.

Prescribing patterns and associated factors of antibiotic prescription in primary health care facilities of Kumbo East and Kumbo West Health Districts, North West Cameroon

Background

Inappropriate use of antibiotics is a global public health challenge and has been associated with antibiotic resistance. WHO reports show that efforts to promote rational antibiotic use in developing countries are poor. With the growing number of infections with antibiotic resistant bacteria, rational drug use becomes imperative and studies that promote rational drug use are highly necessary. Considering this, we investigated prescribing patterns and predictors of antibiotic prescription in primary health care facilities in Kumbo East (KE) and Kumbo West (KW) health districts in North West Cameroon, to contribute data which could influence policy on antibiotic use.

Methods and findings

A cross sectional retrospective study was conducted from April 2014 to April 2015 in 26 randomly selected primary care facilities. Questionnaires were administered to 59 antibiotic prescribers to determine factors that predict antibiotic prescribing. Data on antibiotic prescription were collected by review of consultation registers. Prescription rates and demographics, prescriber and institution factors were analyzed using ANOVA. The best predictor of prescription was determined using multiple linear regression analysis.

Results

A total of 30,096 prescriptions were reviewed. Overall antibiotic prescription rate was 36.71%, with a mean of 1.14 antibiotics prescribed per patient. Amoxicillin was the most prescribed (29.9%). The most prevalent indications for prescribing were respiratory tract infections (21.27%). All antibiotics prescribed were broad-spectrum. Antibiotics were prescribed for patients with malaria and also in situations where diagnosis was uncertain. Prescribing by generic name was 98.36% while 99.87% was from Essential Drug List. Use of laboratory results, patient turnout and Performance Based Financing (PBF) were significantly associated with antibiotic prescribing rates (p < 0.05). PBF moderated prescribing.

Conclusion

There was misuse of antibiotics in primary care facilities in study area. We recommend all primary care health facilities in study area to be included in the PBF scheme and that prescribing should only be done by physicians as the have adequate training.

Impact of introduction of rapid diagnostic tests for malaria on antibiotic prescribing: analysis of observational and randomised studies in public and private healthcare settings

Objectives To examine the impact of use of rapid diagnostic tests for malaria on prescribing of antimicrobials, specifically antibiotics, for acute febrile illness in Africa and Asia.Design Analysisof nine preselected linked and codesigned observational and randomised studies (eight cluster or individually randomised trials and one observational study).Setting Public and private healthcare settings, 2007-13, in Afghanistan, Cameroon, Ghana, Nigeria, Tanzania, and Uganda.Participants 522 480 children and adults with acute febrile illness.Interventions Rapid diagnostic tests for malaria.Main outcome measures Proportions of patients for whom an antibiotic was prescribed in trial groups who had undergone rapid diagnostic testing compared with controls and in patients with negative test results compared with patients with positive results. A secondary aim compared classes of antibiotics prescribed in different settings.Results Antibiotics were prescribed to 127 052/238 797 (53%) patients in control groups and 167 714/283 683 (59%) patients in intervention groups. Antibiotics were prescribed to 40% (35 505/89 719) of patients with a positive test result for malaria and to 69% (39 400/57 080) of those with a negative result. All but one study showed a trend toward more antibiotic prescribing in groups who underwent rapid diagnostic tests. Random effects meta-analysis of the trials showed that the overall risk of antibiotic prescription was 21% higher (95% confidence interval 7% to 36%) in intervention settings. In most intervention settings, patients with negative test results received more antibiotic prescriptions than patients with positive results for all the most commonly used classes: penicillins, trimethoprim-sulfamethoxazole (one exception), tetracyclines, and metronidazole.Conclusions Introduction of rapid diagnostic tests for malaria to reduce unnecessary use of antimalarials-a beneficial public health outcome-could drive up untargeted use of antibiotics. That 69% of patients were prescribed antibiotics when test results were negative probably represents overprescription.This included antibiotics from several classes, including those like metronidazole that are seldom appropriate for febrile illness, across varied clinical, health system, and epidemiological settings. It is often assumed that better disease specific diagnostics will reduce antimicrobial overuse, but they might simply shift it from one antimicrobial class to another. Current global implementation of malaria testing might increase untargeted antibiotic use and must be examined.

Treatment and prevention of malaria in pregnancy in the private health sector in Uganda: implications for patient safety

BACKGROUND

Malaria in pregnancy is a major public health problem in Uganda; and it is the leading cause of anaemia among pregnant women and low birth weight in infants. Previous studies have noted poor quality of care in the private sector. Thus there is need to explore ways of improving quality of care in the private sector that provides almost a half of health services in Uganda.

METHODS

A survey was conducted from August to October 2014 within 57 parishes in Mukono district, central Uganda. The selected parishes had a minimum of 200 households and at least one registered drug shop, pharmacy or private clinic. Data was collected using a structured questionnaire targeting one provider who was found on duty in each selected private health facility and consented to the study. The main variables were: provider characteristics, previous training received, type of drugs stocked, treatment and prevention practices for malaria among pregnant women. The main study outcome was the proportion of private health facilities who prescribe treatment of fever among pregnant women as recommended in the guidelines.

RESULTS

A total of 241 private health facilities were surveyed; 70.5 % were registered drug shops, 24.5 % private clinics and 5.0 % pharmacies. Treatment of fever among pregnant women in accordance with the national treatment guidelines was poor: 40.7 % in private clinics, decreasing to 28.2 % in drug shops and 16.7 % at pharmacies. Anti-malarial monotherapies sulphadoxine-pyrimethamine and quinine were commonly prescribed, often without consideration of gestational age. The majority of providers (>75 %) at all private facilities prescribed SP for intermittent preventive treatment but artemisinin-based combination therapy was prescribed: 8.3, 6.9 and 8.3 % respectively at drug shops, private clinics and pharmacies for prevention of malaria in pregnancy. Few facilities had malaria treatment guidelines; (44.1 % of private clinics, 17.9 % of drug shops, and 41.7 % at pharmacies. Knowledge of people at risk of malaria, P = 0.02 and availability of malaria treatment guidelines, P = 0.03 were the factors that most influenced correct treatment of fever in pregnancy.

CONCLUSION

Treatment of fever during pregnancy was poor in this study setting. These data highlight the need to develop interventions to improve patient safety and quality of care for pregnant women in the private health sector in Uganda.