Antibiotic prescription pattern in a Ghanaian primary health care facility

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Antibiotic appropriateness at outpatient settings in Ethiopia: the need for an antibiotic stewardship programme

Background

Antibiotics are drugs of natural or synthetic origin used to treat various infections. The practice of excessive and inappropriate antibiotics use is the main global cause of bacterial resistance, which is one of the most serious global public health threats. It is estimated that about 50% of global antibiotic prescriptions are inappropriate. This study assesses the prevalence and pattern of inappropriate prescriptions of antibiotics amongst ambulatory care visits in Ethiopia.

Methods

A facility-based, cross-sectional study with a quantitative approach was conducted amongst randomly selected prescriptions issued for outpatients from May to June 2022 at Debre Markos Specialized Comprehensive Hospital, Northwest Ethiopia. Descriptive statistics, such as frequencies and percentages, were computed. For group comparisons, χ2 and independent sample t-tests were computed. The statistical significance of the association was considered at p<0.05.

Results

A total of 2640 antibiotics were prescribed for patients in the outpatient setting with various bacterial infections via 911 prescriptions, of which 49.5% were non-compliant with the national treatment guideline. Guideline non-compliant prescriptions increased remarkably amongst patients in the outpatient setting diagnosed with community-acquired pneumonia (38.8% versus 30.1%; p=0.006) and peptic ulcer disease (14.9% versus 9%; p=0.006). Moreover, inappropriate prescription was significantly higher amongst patients taking amoxicillin/clavulanic acid (33.2% versus 48.2%; p<0.001) and cephalexin (17.8% versus 24.3%; p=0.016).

Conclusion

Large proportions of antibiotic prescriptions for outpatients were non-compliant with the national treatment guideline, suggesting that prescribers need to give special attention to outpatients whilst ordering antibiotics such as amoxicillin/clavulanic acid and cephalexin. Antibiotic stewardship efforts to optimize outpatient antibiotic prescriptions and reduce the use of potentially inappropriate antibiotics are needed in Ethiopia.

Evaluating drug use patterns among paediatric outpatients in Burundi

Background

Rational prescribing is key to optimising therapeutic outcomes and avoiding risks associated with irrational use of medicines. Using WHO drug use indicators, this study evaluated drug use patterns among paediatric outpatient encounters at Primary Healthcare Centers (PHCs) in Bujumbura Mairie, Republic of Burundi.

Methods

Descriptive cross-sectional research assessed paediatric medicine use in 20 PHCs. From 8 February to 7 April 2023, 800 randomly selected paediatric encounters' 2022-year data were retrospectively collected. Data for specific facility indicators were prospectively collected. SPSS 23 was used to analyse data.

Results

800 outpatient child encounters were analysed, 48.4% female and 51.6% male. The mean number of medicines per encounter was 2.4(±0.99). The injection rate was 9.9%. Overall, 78.8% of generics and 85.2% of essential medicines were prescribed. Results show drug prescribing differences between private and government PHCs (p < 0.001). All PHCs studied had no standard treatment guidelines (STGs), while 50% had an essential medicine list (EML) and 85% of key medicines were available.

Conclusion

Poor prescribing practices were found indicating the need for interventions to promote good drug use practices. A large study at a national scale is required to provide a more comprehensive understanding of the overall drug use practices.

Overuse of Antibiotics: Who is to Blame? A Qualitative Study

Background

The irrational use of antibiotics seriously threatens global health. Clinicians undoubtedly play an essential role in consuming antibiotics in hospitals and communities, and their attitudes may help the health system's optimal treatment of antibiotics. In this study, we reported clinicians' experiences with antibiotics used in Isfahan, Iran.

Methods

In a qualitative study conducted from October 2020 to March 2021, the experiences of 13 clinicians with different clinical specialties were collected through one-to-one interviews. Participants were selected through purposive sampling until data saturation; data collection was conducted through semi-structured interviews. Conventional content analysis was used to analyze the transcribed interviews. The main category was recognized and subcategorized and coded by three researchers.

Results

Eight women and five men with a mean work experience of 12.54 ± 10.047 years participated in the study. All of them worried about the overuse of antibiotics and antibiotic resistance. Clinicians believe that the antimicrobial stewardship committee is not active in our country. Laboratory challenges, healthcare providers, the poor performance of the health system, and marketing and business were the main categories of the study. Subcategrories of main categories included inefficiency in the function of laboratories, harmful profit, challenges in medical education, ups and downs of disease treatment, the unacceptable performance of hospitals, failure to upgrade the health system, threats and opportunities, and jobbery.

Conclusions

The participants of this study believed that excessive use of antibiotics is a serious challenge in our country. Physicians were concerned about antibiotic resistance and believed that the pattern of antibiotic resistance was not routinely reported. Therefore, in our region, we should make more efforts to collect data in this field and provide this information to physicians. Also, this study confirmed many obstacles to implementing the antimicrobial stewardship program, and the infrastructure needs strengthening. There is also a need for cultural changes and the views of physicians.

Tackling antimicrobial resistance in primary care facilities across Pakistan: Current challenges and implications for the future

Antibiotics are gradually becoming less effective against bacteria worldwide, and this issue is of particular concern in economically-developing nations like Pakistan. We undertook a scoping review in order to review the literature on antimicrobial use, prescribing, dispensing and the challenges associated with antimicrobial resistance in primary care (PC) settings in Pakistan. Furthermore, this review aims to identify potential solutions to promote appropriate use of antimicrobials in Pakistan. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist, a comprehensive scoping review was conducted to review the literature of antimicrobials used, prescribed and dispensed in PC settings in Pakistan. Google Scholar and Pub-Med were searched for the period 2000-2023. Papers were analyzed on the basis of eligibility i.e., included antimicrobial use, prescribing and dispensing practices by general population at homes, by prescribers in outpatient departments of hospitals and by pharmacists/dispensers in community pharmacies, respectively. Two researchers analyzed the articles thoroughly and disagreements were resolved through discussion with a third reviewer. Both quantitative and qualitative research studies were eligible for inclusion. Additionally, the selected papers were grouped into different themes. We identified 4070 papers out of which 46 studies satisfied our eligibility criteria. The findings revealed limited understanding of antimicrobial resistance (AMR) by physicians and community pharmacists along with inappropriate practices in prescribing and dispensing antibiotics. Moreover, a notable prevalence of self-medication with antibiotics was observed among the general population, underscoring a lack of awareness and knowledge concerning proper antibiotic usage. Given the clinical and public health implications of AMR, Pakistan must prioritize its policies in PC settings. Healthcare professionals (HCPs) need to reduce inappropriate antibiotic prescribing and dispensing, improve their understanding of the AWaRe (access, watch and reserve antibiotics) classification and guidance, monitor current usage and resistance trends, as well as implement antimicrobial stewardship (ASP) activities starting in targeted locations.

Adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Adherence to evidence-based standard treatment guidelines (STGs) enable healthcare providers to deliver consistently appropriate diagnosis and treatment. Irrational use of antimicrobials significantly contributes to antimicrobial resistance in sub-Saharan Africa (SSA).  The best available evidence is needed to guide healthcare providers on adherence to evidence-based implementation of STGs. This systematic review and meta-analysis aimed to determine the pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines among prescribers in SSA.

METHODS

The review followed the JBI methodology for systematic reviews of prevalence data. CINAHL, Embase, PubMed, Scopus, and Web of Science databases were searched with no language and publication year limitations. STATA version 17 were used for meta-analysis. The publication bias and heterogeneity were assessed using Egger's test and the I2 statistics. Heterogeneity and publication bias were validated using Duval and Tweedie's nonparametric trim and fill analysis using the random-effect analysis. The summary prevalence and the corresponding 95% confidence interval (CI) of healthcare professionals' compliance with evidence-based implementation of STG were estimated using random effect model. The review protocol has been registered with PROSPERO code CRD42023389011. The PRISMA flow diagram and checklist were used to report studies included, excluded and their corresponding section in the manuscript.

RESULTS

Twenty-two studies with a total of 17,017 study participants from 14 countries in sub-Saharan Africa were included. The pooled prevalence of adherence to evidence-based implementation of antimicrobial treatment guidelines in SSA were 45%. The pooled prevalence of the most common clinical indications were respiratory tract (35%) and gastrointestinal infections (18%). Overall prescriptions per wards were inpatients (14,413) and outpatients (12,845). Only 391 prescribers accessed standard treatment guidelines during prescription of antimicrobials.

CONCLUSIONS

Healthcare professionals' adherence to evidence-based implementation of STG for antimicrobial treatment were low in SSA. Healthcare systems in SSA must make concerted efforts to enhance prescribers access to STGs through optimization of mobile clinical decision support applications. Innovative, informative, and interactive strategies must be in place by the healthcare systems in SSA to empower healthcare providers to make evidence-based clinical decisions informed by the best available evidence and patient preferences, to ultimately improving patient outcomes and promoting appropriate antimicrobial use.

Antibiotic prescription among children with common cold at a district hospital in Uganda

BACKGROUND

Most childhood infections are of viral origin making antibiotics unnecessary. They are, however, the most frequently prescribed drugs dispensed to children, resulting in inappropriate antibiotic prescriptions, which are one of the main drivers of antibiotic resistance.

AIM

The study aimed to determine the prevalence of antibiotic prescriptions and identify its associated factors among children below 5 years with common cold who attend the outpatient department in Tororo General Hospital.

SETTING

The study was carried out in Tororo General Hospital, Eastern Uganda.

METHODS

A cross-sectional survey using consecutive sampling was performed among children below 5 years with common cold attending the outpatient department. Data were collected using an interviewer-administered, structured questionnaire and analysed using STATA version 14.0. Prevalence of antibiotic prescriptions was calculated. Bivariate analysis using chi-square test and multivariate analysis using logistic regression was performed to establish factors associated with antibiotic prescription.

RESULTS

The prevalence of antibiotic prescriptions for common cold among children below 5 years was 23.3%. Factors associated with antibiotic prescription for common cold were duration of symptoms of more than 5 days (OR, 95% CI: 4.49; 1.16-17.23, p = 0.029) and being attended to by a clinical officer (OR, 95% CI: 0.19; 0.04-0.91, p = 0.038).

CONCLUSION

There is inappropriate antibiotic prescription among children with common cold in Tororo General Hospital. There is need for antibiotic stewardship programmes to promote optimal antibiotic use in primary care facilities.Contribution: The study's findings can be used to develop context-specific antibiotic stewardship programmes tailored to promote judicious use of antibiotics in primary care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIALS REGISTRATION

NCT04081051.

Antibiotic usage in a South African paediatric medical ward following the introduction of an antibiotic prescription chart

Introduction

the global rise in antibiotic resistance (ABR), coupled with a dry pipeline for the discovery of new antibiotics requires the conservation of currently available antibiotics. Antimicrobial stewardship (AMS) interventions are being implemented to optimize antibiotic use including the use of antibiotic prescription charts. This study reviewed the use of antibiotics before and after the introduction of an antibiotic prescription chart in a paediatric medical ward of an academic tertiary hospital in Johannesburg.

Methods

a cross-sectional retrospective review of patient records was conducted for patients admitted to a paediatric medical ward of an academic tertiary hospital over two study periods; before and after the introduction of an antibiotic prescription chart. Data were captured on a Microsoft® Excel (2010) spreadsheet and analyzed using Stata/IC 15.1 (StataCorp, USA).

Results

antibiotic use decreased significantly by 7.04% following the introduction of the antibiotic prescription chart (p=0.027). Fields often left unfilled on the antibiotic prescription chart include age (100%), a record of renal function (GFR/CrCl) (97.46%), time of antibiotic prescribing (83.62%) and a record of culture and sensitivity results (80.17%).

Conclusion

the findings of this study show an improvement in antibiotic use, the frequency of culture and sensitivity testing and documentation of relevant parameters after the introduction of the antibiotic prescription chart. The use of an antibiotic prescription chart is a practical way to achieve optimal antibiotic use and to encourage proper detailing of the clinical components necessary for antibiotic selection in a hospital setting in a developing country.

Assessment of drug use in primary health centers in Lagos State, Nigeria

Introduction

rational drug use prevents wastage of resources, loss of confidence in healthcare system and drug-related morbidity and mortality. This study aims to assess drug use in Primary Health Centers (PHCs) in Lagos State, Nigeria using the World Health Organization in collaboration with the International Network of Rational Use of Drugs core drug use indicators.

Methods

the study was conducted between February to October 2021 as a comparative observational survey of selected PHCs. It included a retrospective and prospective cross-sectional design for prescribing and patient care indicators assessing 2640 prescriptions and clients respectively. Data were analyzed and presented as frequency with percentage or mean with standard deviation, as applicable. The performances of the types of PHCs were compared using two-sample t-test. A 2-tailed p-value < 0.05 was considered statistically significant.

Results

average number of drugs per prescription, drugs prescribed by the generic name, percentage of encounters with prescribed antibiotics and injections were 3.6 ± 0.9%, 76.5 ± 18.5%, 63.3 ± 19.1% and 21.1 ± 24.1% respectively with no significance difference between the comprehensive and basic PHCs. For all the facilities, the average consultation and dispensing times were 10.5 ± 6.0 minutes, 244.9 ± 179.2 seconds respectively. In this study, the percentage of patients' knowledge of the correct dosage was 72.4 ± 38.3%. There is statistically significant difference in availability of key drugs in stock between the comprehensive and basic PHCs (p-value 0.0001).

Conclusion

irrational drug use practices exist in comprehensive and basic PHCs. There is a need to implement interventions aimed at strengthening good prescribing and patient-care practices across the PHCs in Lagos State.

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.

Good versus poor prescribers: the comparison of prescribing competencies in primary care

Aim:

To compare the competencies of primary care physicians (PCPs) with poor and good prescribing performance in frequently encountered indications.

Background:

Primary care centers are one of the mostly visited health facilities by the population for different health issues.

Methods:

In this cross-sectional study, we analyzed 6 125 487 prescriptions generated by 1431 PCPs which were selected by systematic sampling in 2016 in Istanbul. We defined PCPs as poor prescriber (n = 227) or good prescriber (n = 210) in terms of their prescribing performance per WHO/INRUD criteria. We compared solo diagnosis prescriptions of these two groups in ‘percentage of prescriptions in compliance with clinical guidelines’ and also rational prescribing indicators.

Findings:

Poor prescribers and good prescribers significantly differed in each of the prescribing indicators for their all solo diagnosis prescriptions. Hypertension had the highest difference of the average cost per encounter (Δ = 284.2%) between poor prescribers (US$43.99 ± 63.05) and good prescribers (US$11.45 ± 45.0), whereas headache had the highest difference between the groups in the percentage encounters with an antibiotic (14.9% vs. 1.5%). Detailed analysis of the prescribing performances showed significantly higher values of each WHO/INRUD indicators for all examined diagnoses. We found significantly higher percentages of guideline-compliant drugs in good prescribers compared to that in poor prescribers in hypertension (40.8% vs 34.8%), tonsillopharyngitis (57.9% vs 50.7%), and acute sinusitis (46.4% vs 43.6%).

Conclusion:

This study shows that the prescribing performances of PCPs are not rational enough in terms of drug selection and prescription content. Furthermore, even the physicians who have good prescribing practice appear as not satisfactorily rational in compliance with current pharmacotherapy competencies.

Effect of placebo versus prophylactic postoperative amoxicillin on post-(adeno) tonsillectomy morbidity in Tanzanian children: a two-centre, double-blind randomized controlled non-inferiority trial

INTRODUCTION

to date in Africa, there is limited evidence regarding the role of prophylactic antibiotics to prevent post (adeno) tonsillectomy ((A)TE) morbidity in children. As (A)TE is the most performed surgery in the pediatric population, the use of prophylactic antibiotics is likely a major factor in the development of AMR. In Tanzania, as in many other settings with limited resources antibiotics are misused and overprescribed. Potential reasons include limited stewardship and widespread use of postsurgical prophylactic antibiotics. Misuse of antibiotics might contribute significantly to the development of antimicrobial resistance (AMR).

METHODS

a two-centre, double-blinded randomized controlled non-inferiority trial. Subjects included children from 2-14 years of age with recurrent chronic tonsillitis and/or obstructive sleep apnoea due to adenotonsillar hypertrophy who were electively scheduled for (A)TE in two tertiary hospitals. Participants were randomly allocated to receive either placebo or amoxicillin for five days postoperatively. Primary outcome was non-inferiority of placebo compared with amoxicillin for postoperative haemorrhage (margin 5%; at 14 days) postoperative fever (margin 5%; at 7 days), and pain (margin 1 point; at 7 days). Secondary outcomes included the times required for resumption of normal diet and normal activities, and microbial recolonization of the tonsillar beds. Data were analysed according to intention-to-treat principle. Follow-up was 14 days.

RESULTS

between March 13, 2019 and September 20, 2019 270 children were enrolled. All children were randomly assigned to receive placebo (n = 136) or amoxicillin (n = 134). By 14^{t h}day post-operatively, total of 8 children were lost to follow-up in each arm. No major postoperative haemorrhage was registered. By 14^th day post-operatively, 22 (17.5%) children in the amoxicillin arm and 19 (14.8%) children in the placebo arm had reported minor haemorrhage (risk difference (RD) -2.6% (95%CI -10.2 - 5.0); p_{non-inferiority} = 0.045). By 7^th day post operatively, 8 (6.3%) children in amoxicillin arm and 4 (3.1%) children in placebo arm reported fever during the first week (RD -3.2% (95%CI -7.6 - 1.2); p_{non-inferiority} = 0.001). By 7^th day post operatively, mean pain score (mean (SD)) was 3.25 (1.53) in the amoxicillin arm and 3.56 (1.68) in the placebo arm (mean difference 0.31, (95% CI -0.02 - 0.65); p_{non-inferiority} < 0.001). No statistically significant differences between the two groups were found in any of the secondary outcomes. Findings shows, placebo is non-inferior to amoxicillin for post-operative morbidities in Tanzanian children undergoing (A)TE.

CONCLUSION

it is recommended that antibiotics should only be used when clinically necessary to treat a specific infection. Unnecessary use of antibiotics contributes to the development of antimicrobial resistance. Trial Registration: Pan African Clinical Trials Registry PACTR201905466349317. Retrospectively registered on 15 May 2019.

Knowledge, Awareness and Practice with Antimicrobial Stewardship Programmes among Healthcare Providers in a Ghanaian Tertiary Hospital

Antimicrobial resistance (AMR) is a significant problem in global health today, particularly in low- and middle-income countries (LMICs) where antimicrobial stewardship programmes are yet to be successfully implemented. We established a partnership between AMR pharmacists from a UK NHS hospital and in Ho Teaching Hospital with the aim of enhancing antimicrobial stewardship knowledge and practice among healthcare providers through an educational intervention. We employed a mixed-method approach that included an initial survey on knowledge and awareness before and after training, followed by qualitative interviews with healthcare providers conducted six months after delivery of training. This study was carried out in two phases in Ho Teaching Hospital with healthcare professionals, including pharmacists, medical doctors, nurses and medical laboratory scientists. Ethical approval was obtained prior to data collection. In the first phase, we surveyed 50 healthcare providers, including nurses (33%), pharmacists (29%) and biomedical scientists (23%). Of these, 58% of participants had engaged in continuous professional development on AMR/AMS, and above 95% demonstrated good knowledge on the general use of antibiotics. A total of 18 participants, which included four medical doctors, five pharmacists, four nurses, two midwives and three biomedical scientists, were interviewed in the second phase and demonstrated greater awareness of AMS practices, particularly the role of education for patients, as well as healthcare professionals. We found that knowledge and practice with AMS was markedly improved six months after the training session. There is limited practice of AMS in LMICs; however, through AMR-focused training, we demonstrated improved AMS skills and practice among healthcare providers in Ho Teaching Hospital. There is a need for continuous AMR training sessions for healthcare professionals in resource-limited settings.

Evaluation of more than one billion outpatient prescriptions and eight-year trend showing a remarkable reduction in antibiotic prescription in Turkey: A success model of governmental interventions at national level

PURPOSE

To present the antibiotic prescription trend between 2011-2018 at primary healthcare in Turkey in order to evaluate the effects of interventions at national level for providing rational prescription of antibiotics.

METHODS

Electronic prescription data of the family physicians collected from January 1, 2011 to December 31, 2018 in 81 provinces of Turkey were recorded through the Prescription Information System and screened for the antimicrobial drugs. The interventions to promote rational antibiotic use during 2011-2018 in Turkey includes reminding the legislation to stop access of antibiotics without prescription, monitoring of antibiotic prescription behaviors of primary healthcare physicians, and education of healthcare workers and the public on the appropriate use of antibiotics.

RESULTS

A total of 1 054 261 396 prescriptions for outpatients of all age groups were recorded during this period. Of the prescriptions written by family physcians, 34.94% were containing at least one antibiotic in 2011, which declined to 24.55% in 2018. Antibiotics constituted 13.99% of all the items in prescriptions in 2011 and 10.47% in 2018. Percentage of total antibiotic expenditure to the total drug expanditure decreased from 14.14% to 4.12% during 2011-2018. The most commonly prescribed antibiotics were amoxicillin and enzyme inhibitor combination, cefdinir, and cefuroxime during 2011-2018, with an increasing trend for prescription of first-line antibiotic, amoxicillin, in recent years.

CONCLUSIONS

Governmental interventions at national level have contributed to reducing antibiotic prescription and increasing preference of first-line antibiotics at primary healthcare level in Turkey over a course of 8 years. Turkey's model of governmental interventions may set an example for other countries with high consumption of antibiotics, and contribute to the actions against antimicrobial resistance worldwide.

An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda

Ensuring access to effective antibiotics and rational prescribing of antibiotics are critical in reducing antibiotic resistance. In this study, we evaluated antibiotic prescribing practices in a rural district in Uganda. It was a cross-sectional study that involved a retrospective review of 500 outpatient prescriptions from five health facilities. The prescriptions were systematically sampled. World Health Organization core medicine use prescribing and facility indicators were used. Percentage of encounters with one or more antibiotics prescribed was 23% (10,402/45,160). The mean number of antibiotics per prescription was 1.3 (669/500). About 27% (133/500) of the diagnoses and 42% (155/367) of the prescriptions were noncompliant with the national treatment guidelines. Prescribing antibiotics for nonbacterial infections such as malaria 32% (50/156) and noninfectious conditions such as dysmenorrhea and lumbago 15% (23/156) and nonspecific diagnosis such as respiratory tract infection 40% (59/133) were considered noncompliant with the guidelines. On average, 68% (51/75) of the antibiotics were available on the day of the visit. Inappropriate prescribing practices included excessive use of antibiotics and failure to diagnose and prescribe in compliance with treatment guidelines. There is a need to strengthen antibiotic use in the health facilities through setting up stewardship programs and interventions to promote adherence to national treatment guidelines.

Antibiotic prescription practices among prescribers for children under five at public health centers III and IV in Mbarara district

INTRODUCTION

Rational use of medicines requires that patients receive medications appropriate to their clinical needs. Irrational prescription of antibiotics has been reported in many health systems across the world. In Uganda, mainly nurses and assistant medical officers (Clinical officers) prescribe for children at level III and IV primary care facilities (health center II and IV). Nurses are not primarily trained prescribers; their antibiotic prescription maybe associated with errors. There is a need to understand the practices of antibiotic prescription among prescribers in the public primary care facilities. We therefore determined antibiotic prescription practices of prescribers for children under five years at health center III and IV in Mbarara district, South Western Uganda.

METHODS

This was a retrospective descriptive cross-sectional study. We reviewed outpatient records of children <5 years of age retrospectively. Information obtained from the outpatient registers were captured in predesigned data abstraction form. Health care providers working at health centers III and IV were interviewed using a structured questionnaire. They provided information on socio-demographic, health facility, antibiotic prescription practices and availability of reference tools. Data was analyzed using STATA software version 13∙0.

RESULTS

There were 1218 outpatients records of children under five years reviewed and 35 health care providers interviewed. The most common childhood illness diagnosed was upper respiratory tract infection. It received the most antibiotic prescription (53%). The most commonly prescribed oral antibiotics were cotrimoxazole and amoxicillin, and ceftriaxone and benzyl penicillin were the commonest prescribed injectable antibiotics. Up to 68.4% of the antibiotic prescription was irrational. No prescriber or facility factors were associated with irrational antibiotic prescription practices.

CONCLUSION

Upper respiratory tract infection is the most diagnosed condition in children under five years with Cotrimoxazole and Amoxicillin being the most commonly prescribed antibiotics. Antibiotics are being prescribed irrationally at health centers III and IV in Mbarara District. Training and support supervision of prescribers at health centers III and IV in Mbarara district need to be prioritized by the district health team.

Post-Vaccination Streptococcus pneumoniae Carriage and Virulence Gene Distribution among Children Less Than Five Years of Age, Cape Coast, Ghana

In 2012, Ghana introduced PCV13 into its childhood immunization program. To monitor the pneumococcus after PCV13 vaccination, we analyzed serotypes, antibiotic resistance, and virulence genes of pneumococcal carriage isolates among children under five years of age. We obtained nasopharyngeal swabs from 513 children from kindergartens and immunization centers in Cape Coast, Ghana. Pneumococcal serotypes were determined by multiplex-PCR and Quellung reaction. Antibiotic resistance and virulence genes prevalence were determined by disc diffusion and PCR respectively. Overall, carriage prevalence was 29.4% and PCV13 coverage was 38.4%. Over 60% of the isolates were non-PCV13 serotypes and serotype 23B was the most prevalent. One isolate showed full resistance to penicillin, while 35% showed intermediate resistance. Resistance to erythromycin and clindamycin remained low, while susceptibility to ceftriaxone, levofloxacin and vancomycin remained high. Penicillin resistance was associated with PCV13 serotypes. Forty-three (28.5%) strains were multidrug-resistant. Virulence genes pavB, pcpA, psrP, pilus-1, and pilus-2 were detected in 100%, 87%, 62.9%, 11.9%, and 6.6% of the strains, respectively. The pilus islets were associated with PCV13 and multidrug-resistant serotypes. PCV13 vaccination had impacted on pneumococcal carriage with a significant increase in non-PCV13 serotypes and lower penicillin resistance. Including PcpA and PsrP in pneumococcal protein-based vaccines could be beneficial to Ghanaian children.

Prescribing Pattern of Antibiotics Using WHO Prescribing Indicators Among Inpatients in Ethiopia: A Need for Antibiotic Stewardship Program

Background

Irrational prescribing of antibiotics is a universal public health problem, leading to antibiotic resistance. Understanding the prescribing pattern of antibiotics is crucial to tackling irrational prescription. Yet, comprehensive studies regarding the prescribing pattern of antibiotics among inpatients and the need for an Antibiotic Stewardship Program (ASP) are lacking in Ethiopia. This study aimed to evaluate prescribing patterns of antibiotics and the need for an ASP.

Methods

A hospital-based prospective observational study was carried out from February 2019 to December 2019. This study was conducted among patients admitted to Aksum University Comprehensive Specialized Hospital, Ethiopia. Data were collected using a data abstraction format generated by World Health Organization (WHO) prescribing indicators. Data analysis was carried out using SPSS version 25.0.

Results

A total of 1653 antibiotics were prescribed for 822 inpatients. Overall, 52.3% of patients had at least one oral and/or injectable antibiotic prescribed, for a mean duration of 4.2 (SD=2.3) days. The average number of prescribed antibiotics per patient was 2.01 (SD=1.9). The majority (97.6%) of antibiotics were prescribed by their generic name, and all prescribed antibiotics were from the national Essential Medicine List (EML). Frequently prescribed injectable and oral antibiotics were ceftriaxone (24.5%) and azithromycin (12.9%), respectively. Culture and sensitivity testing were not performed in any of the cases. During the study period, 65.2% of key antibiotics were available in stock.

Conclusion

In this study, more than half of patients were on at least one antibiotic, and all antibiotics were prescribed from the national EML. However, all antibiotics were prescribed empirically. This result shows that the prescribing pattern of antibiotics in the hospital deviates from and is non-compliant with the standard endorsed by WHO. This study provides evidence for the necessity and a way forward for the establishment of an ASP in the hospital that may help to introduce the prescribing of antibiotics with the aid of culture and sensitivity tests, and to develop institutional guidelines.

Unnecessary antimicrobial prescribing for upper respiratory tract infections in children in Pietermaritzburg, South Africa

Background

Acute upper respiratory tract infections (URTIs) are contagious diseases of the upper airways, but they are self-limiting in nature. Therefore, antimicrobial-use for the majority of the URTIs is considered inappropriate. Unfortunately, globally, antimicrobials are still being prescribed for the treatment of URTIs, especially in children. However, there is insufficient evidence on the causes of this phenomenon in South Africa.

Objective

To investigate whether the parents/guardians accompanying children with URTIs expected/influenced physicians and/or nurses to prescribe antibiotics.

Methods

This was a prospective descriptive and explorative questionnaire-based study. Participants were guardians who accompanied children aged five years and below, diagnosed with acute URTIs.

Findings

Three hundred and six parents/guardians participated in this study. Seventy six percent (n=233) of participants received antibiotics for URTIs for their children, and 67% (n=156) of these did not make requests for antimicrobial therapy. On overall, there was a statistically significant (p < 0.0001) chance (with OR of 5.9; 95% CI, 2.4 – 14.2) for receiving antibiotics for URTIs without a request.

Conclusion

Physicians and other healthcare providers need education on rational prescribing of antimicrobials, and to implement evidence-based standard treatment guidelines, to reduce inappropriate use of antibiotics in children with self-limiting URTIs.

Patterns of Antibiotic Prescription in Colombia: Are There Differences between Capital Cities and Municipalities?

The use of antibiotics is the most important modifiable risk factor for the development of microorganism resistance. A cross-sectional study of outpatients receiving antibiotic prescriptions registered in a population database in Colombia was conducted. The characteristics of the consumption in capital cities and small municipalities was studied and the AWaRe classification was used. AWaRe classifies antibiotics into three stewardship groups: Access, Watch and Reserve, to emphasize the importance of their optimal use and potential harms of antimicrobial resistance. A total of 182,397 patients were prescribed an antibiotic; the most common were penicillins (38.6%), cephalosporins (30.2%) and fluoroquinolones (10.9%). ‘Access’ antibiotics (86.4%) were the most frequently prescribed, followed by ‘Watch’ antibiotics (17.0%). Being 18 or older, being male, living in a municipality, having one or more comorbidities and urinary, respiratory or gastrointestinal disorders increased the probability of receiving ‘Watch’ or ‘Reserve’ antibiotics. Penicillin and urinary antiseptic prescriptions predominated in cities, while cephalosporin and fluoroquinolone prescriptions predominated in municipalities. This analysis showed that the goal set by the WHO Access of mainly using Access antibiotics is being met, although the high use of Watch antibiotics in municipalities should be carefully studied to determine if it is necessary to design specific campaigns to improve antibiotics use.

Assessment of Antibiotic Prescribing Patterns at Outpatient Pharmacy Using World Health Organization Prescribing Indicators

Background: Overuse of antibiotics is a common problem in health care, which leads to unnecessary expenditure on drugs, raised risk of adverse reactions, and the development of antimicrobial resistance. Inappropriate prescribing habits lead to ineffective and unsafe treatment, worsening of disease and increment of health care costs. The aim of this study was to assess antibiotic prescribing patterns using World Health Organization prescribing indicators at the outpatient Pharmacy Department of University of Gondar referral hospital, Gondar, Northwest Ethiopia. Methods: A retrospective cross-sectional study was conducted. One-year prescription data was collected from prescription and prescription registration books retained at the pharmacy store. World Health Organization/International Network of Rational Use of Drugs prescribing indicators were utilized to measure rational use of drugs with due focus on antibiotics prescribing patterns. The collected data was analyzed using SPSS version 20. Results and Discussion: A total of 968 drugs were prescribed from 600 patient encounters. The average number of drugs per encounter was 1.6. The percentage of encounters in which an antibiotics and injections were prescribed was 69.7% and 6.3% respectively. Amoxicillin (28.5%) followed by ciprofloxacin (12%) and metronidazole(11.1%) were the most commonly prescribed antibiotics. The percentage of drugs prescribed from essential drugs list and by generic name was 95.3% and 96%, respectively. Rate of antibiotics prescribing showed deviation from the standard recommended by World Health Organization whereas polypharmacy, injectable prescribing pattern, uses of brand names, and prescription of drugs from the National Essential Drugs List were not found to be a significant problem though there were slight deviations from the standard. Conclussion: Interventions aimed at improving the antibiotic prescribing patterns need to be implemented so as to prevent the inappropriate use of antibiotics and avoid further complications.

Implementation of antimicrobial stewardship programmes in African countries: a systematic literature review

OBJECTIVE

Antimicrobial stewardship is one of the strategic objectives of the WHO global action plan on antimicrobial resistance. This paper sought to review the extent of implementation of antimicrobial stewardship programmes (ASPs) in African countries and the reported outcomes.

METHODS

We searched five electronic databases, including PubMed, Scopus, Cochrane library, African Journal Online, CINAHL and Google scholar for papers published between 1990 and March 2019. We combined the names of countries in the five regions of Africa with antimicrobial stewardship terms. Studies of any design, employing any stewardship strategies were included. The quality of included studies was assessed using the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool for before and after studies.

RESULTS

Of 1752 titles identified, 13 studies met the criteria for inclusion. Seven of the studies were conducted in South Africa, three in Kenya and one each in Sudan, Tanzania and Egypt. Eleven studies were of high quality with low risk of bias. The included studies mainly assessed the outcome using process measures and these were associated with improved compliance with antibiotic guidelines, appropriateness of prescribing, reduction in antibiotic use and cost savings. Decrease in rate of surgical site infections and nonsignificant change in mortality and 30-day readmission rate were reported in two studies respectively.

CONCLUSION

Findings of this review show the paucity of data on implementation of ASPs in African countries. Although the continent is faced with challenges which impact on effective implementation of ASPs, the successes reported in the included studies show that other African countries can implement these programmes.

A closer look at the spectrum of drug-induced liver injury in sub-Saharan Africa

Introduction: Drug-induced liver injury (DILI) has become the most frequent cause of acute liver failure in high-income countries. However, little is known about the determinants of DILI in sub-Saharan Africa (SSA), where the prescription of antimicrobials and the use of potentially hepatotoxic traditional medicine are common. Areas covered: Based on an extensive literature search, we summarize current data available on the epidemiology and risk factors of DILI in SSA. We discuss the most likely causes of DILI in the region, including antimicrobial therapies and traditional medicine. We also highlight research gaps as well as barriers to diagnosis and management of the condition, and explore ways to address these important challenges. Expert opinion: DILI is underestimated in SSA and several factors challenge its early diagnosis, including lack of information on the causes of DILI in the region, sub-optimal knowledge about the condition among clinicians, and structural difficulties faced by health care systems. In order to better prevent the occurrence of DILI and its complications, it is crucial to enhance awareness among health care providers and patients, adapt drug prescription habits and regulations, and improve current knowledge on the main risk factors for DILI, including host genetic and environmental determinants.

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.

Improving antimicrobial stewardship in the outpatient department of a district general hospital in Sierra Leone

There is global concern over increasing antibiotic resistance rates due to poor antimicrobial stewardship, particularly in low-income and middle-income countries where there are limited diagnostic facilities, fewer doctors per capita and inadequate control over the production and sale of antibiotics. This quality improvement project was designed to improve the antimicrobial prescriptions practices of paramedical staff in the outpatient department of a rural district general hospital in Masanga, Sierra Leone, West Africa. At baseline, 57 of 66 (86%) of patients were prescribed at least one antimicrobial. On further review of 243 prescriptions for 128 patients, only 161 (66%) antimicrobials were deemed appropriate for the named diagnosis when compared with international guidelines or senior medical opinion, and 86 (35%) prescriptions had the correct drug, dose and course-length. A full, empirical antimicrobial guideline was written and introduced to local staff via a number of different methods, including: one-to-one feedback, announcements in general meetings and printed copies placed in each outpatient room. After the first cycle, the choice of appropriate antimicrobial had improved to 85% and the correct drug, dose and course-length to 53%. Unfortunately, 2 months after the second cycle, coinciding with the departure of the international internal medical physician, the rates had degraded to 65% and 43%, respectively. This study shows that implementing an empirical antimicrobial guideline can be effective at improving appropriate antibiotic prescription but that other measures are required for sustainable change. It is suggested that projects designed to change practice in low-resource countries should include national staff from the outset to improve longer term sustainability.

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

OBJECTIVE

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

RESULTS

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