An evaluation of rational prescribing in hospital outpatient practice in Sierra Leone and assessment of affordability of a prescription as an outcome

Antibiotic use and consumption among medical patients of two hospitals in Sierra Leone: a descriptive report

BACKGROUND

Although one of the main drivers of antimicrobial resistance is inappropriate antibiotic prescribing, there are limited resources to support the surveillance of antibiotic consumption in low-income countries. In this study, we aimed to assess antibiotic use and consumption among medical patients of two hospitals in different geographic regions of Sierra Leone.

METHODS

This is a cross-sectional study of adult (18 years or older) patients receiving medical care at two hospitals (34 Military Hospital-MH and Makeni Government Hospital-MGH) between March 2021 and October 2021. After admission to the medical or intensive care unit, patients were sequentially recruited by a nurse from each hospital. Demographic and clinical characteristics and information on the dose of antibiotics, their routes, and frequency of administration and duration were collected using a questionnaire adapted from previous studies and encrypted in EpiCollect software (Epic, Verona WI). A physician reviews and verifies each completed questionnaire. Data analysis was done using STATA version 16.

RESULTS

The mean age of the 468 patients evaluated in this study was 48.6 years. The majority were women (241, 51.7%) and treated at MGH (245, 52.0%). Clinical diagnosis of bacterial infection was made in only 180 (38.5%) patients. Regardless of the diagnosis, most (442, 94.9%) patients received at least one antibiotic. Of a total 813 doses of antibiotics prescribed by the two hospitals, 424 (52.2%) were administered in MH. Overall, antibiotic consumption was 66.9 defined daily doses (DDDs) per 100 bed-days, with ceftriaxone being the most commonly used antibiotic (277, 34.1%). The ACCESS and WATCH antibiotics accounted for 18.9 DDDs per 100 bed-days (28.2%) and 48.0 DDDs per 100 bed-days (71.7%), respectively. None of the patients were prescribed a RESERVE antibiotics. The antibiotic consumption was lower in MH (61.3 DDDs per 100 bed-days) than MGH (76.5 DDDs per 100 bed-days).

CONCLUSION

Antibiotic consumption was highest with ceftriaxone, followed by levofloxacin and metronidazole. Given the high rate of consumption of antibiotics in the WATCH category of the AWaRe classification, there is a need to initiate surveillance of antibiotic consumption and establish hospital-based antibiotic stewardship in these settings.

Antibiotic use and consumption in Freetown, Sierra Leone: A baseline report of prescription stewardship in outpatient clinics of three tertiary hospitals

Objective

As there are no country-representative data on bacterial sensitivities to guide antimicrobial stewardship (AMS) interventions, an AMS programme was established in the outpatient clinics of three tertiary hospitals in Freetown, Sierra Leone.

Methods

The study employed a cross-sectional design to collect antibiotic prescribing data from 370 pregnant women and lactating mothers, 314 children and 229 regular patients in the outpatient clinics of the Princess Christian Maternity Hospital (PCMH), Ola During Children's Hospital and Connaught Hospital (CH), respectively, in April 2022. All data were analysed using Stata Version 16.

Results

Of 913 patients, most were female (n=635, 69.5%), treated at PCMH (n=370, 40.5%) and had a bacterial infection (n=661, 72.4%). The indication for prescribing antibiotics was inappropriate in 252 (27.6%) patients. Of the 1236 prescriptions, 393 (31.8%) were made at CH. The duration of antibiotic use was not stated in 230 (18.6%) prescriptions. Overall antibiotic consumption was 55.3 defined daily doses per 1000 outpatient-days.

Conclusion

Gaps in antibiotic prescriptions were identified in the outpatient clinics of three national referral hospitals in Sierra Leone. In order to combat antimicrobial resistance, AMS interventions are needed to reduce the prescription of antibiotics for inappropriate indications or without specified duration.

Improving the availability of prescription drugs in Lebanon: a critical analysis of alternative policy options

The economic downfall in Lebanon and the destruction of the Beirut Port have had a crippling effect on all players in the health sector, including hospitals, healthcare providers, and the pharmaceutical and medical supply industry. The outbreak of COVID-19 has further aggravated the crisis. To address the challenges facing the pharmaceutical industry, Lebanon must create a stable and secure source of prescription drug production. Two alternative approaches are presented to address the crisis: (1) amending the subsidy system and supporting local pharmaceutical production, and (2) promoting the prescription and use of generic drugs. Investing in local production is promising and can lead to establishing trust in the quality of drugs produced locally. These efforts can be complemented by promoting the prescription and use of generic drugs at a later stage, after having had established a well-operating system for local drug production.

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.

Adherence to Prescribing Indicators at a District Hospital in Ghana: Do We Match WHO Standards?

(1) Background: Rational use of medicines (RUM) and their assessment are important to ensure optimal use of resources and patient care in hospitals. These assessments are essential to identifying practice gaps for quality improvement. (2) Methods: Assessment of adherence to WHO/International Network for Rational Use of Drugs core prescribing indicators among outpatients in 2021 was conducted at the University Hospital of the Kwame Nkrumah University of Science and Technology in the Ashanti Region of Ghana. We reviewed electronic medical records (EMR) of 110,280 patient encounters in the year which resulted in 336,087 medicines prescribed. (3) Results: The average number of medicines prescribed per encounter was three, with generics being prescribed in 76% of prescriptions. Injections were prescribed in 7% of encounters while 90% of medicines were from Ghana's Essential Medicines List, 2017. (4) Conclusions: With the exception of patient encounters with injections, none of the prescribing indicators assessed in this study met WHO optimum levels, providing targets for quality improvement in RUM. Implementing prescribing guides and policies, regular audits and feedback as well as continuous professional development training may help to improve prescribing practices in the hospital.

The Pattern of Medicine Use in Ethiopia Using the WHO Core Drug Use Indicators

Introduction

Rational medicine use is an appropriate prescribing, dispensing, and patient use of medicines for the diagnosis, prevention, and treatment of diseases. It is affected by several factors. Irrational use of medicine is a widespread problem at all levels of care. This review is aimed at assessing the medicine use pattern in health facilities of Ethiopia using the medicine use pattern developed by WHO/INRUD.

Methods

Relevant literature was searched from Google Scholar, PubMed, Hinari, Web of Science, and Scopus using inclusion and exclusion criteria. A systematic review was used to summarize the medicine use pattern in health facilities of Ethiopia, and that WHO core drug use indicators were employed.

Result

From 188 searched studies, 30 literatures were reviewed. The average number of drugs per encounter was 2.11. The percentage of encounters with antibiotics and injection was 57.16% and 22.39%, respectively. The percentage of drugs prescribed by generic name and from an essential drug list was 91.56% and 90.19%, respectively. On average, patients spent 5.14 minutes for consultation and 106.52 seconds for dispensing. From prescribed drugs, 67.79% were dispensed, while only 32.25% were labeled adequately. The availability of key essential medicines was 64.87%. The index of rational drug use value was 7.26. Moreover, the index of rational drug prescribing, index of rational patient-care drug use, and index of rational facility-specific drug use were 3.74, 2.51, and 1.01, respectively.

Conclusion

Ethiopian health facilities were faced with antibiotic overprescribing, short consultation, and dispensing times, poor labeling of medicines, poor availability of key drugs, and nonadherence to the essential drug list. Routine, multidisciplinary awareness creation, and regulation should be implemented to promote rational medicine use at a national level.

Drug use pattern using WHO core drug use indicators in public health centers of Dessie, North-East Ethiopia

Background

Rational drug use requires that patients receive and take medication appropriately. Though the process of diagnosis and pharmaceutical care is complex, World Health Organization (WHO)/international network for rational use of drugs (INRUD) core drug use indicators investigate drug use to minimize the hazardous effect of the drug and enhance the wise use of scares resources. This study assessed drug use patterns in health centers of Dessie town using WHO/INRUD indicators.

Methods

A cross-sectional study was conducted in public health centers of Dessie town. Data were retrospectively collected from 1500 prescriptions dispensed from January 1, 2018, to December 31, 2018 using WHO data collection tool to assess prescribing indicators. For patient care and health facility indicators, 600 patients and 3 health centers were prospectively reviewed. Systematic random sampling was used to select samples. Data were analyzed using the Statistical Package for the Social Sciences version 20.

Results

The average number of drugs per encounter was 2.1. The percentage of encounters with antibiotics and injection was 44% and 13.9%, respectively. The percentage of drugs prescribed by generic name and from an essential drug list was 98% and 100%, respectively. On average, patients spent 4.7 min for consultation and 105 s for dispensing. From 1305 prescribed drugs, 92% were dispensed, while only 4% were labeled adequately. More than half (54.8%) of patients had adequate knowledge of their medication. None of the health centers had an essential drug list. The availability of key essential medicines was 64.10%.

Conclusion

This study demonstrated irrational drug use practices in all healthcare facilities. Polypharmacy, antibiotics over-prescribing, short consultation and dispensing times, inadequate labeling of medicines, inadequate level of patients' knowledge about prescribed medicines, and unavailability of key drugs in stock were found to be the major problems. Continuous refreshment trainings on rational use of drugs and WHO recommendations should be given for prescribers and pharmacists. Further, we recommend studies involving large number of facilities to estimate overall prescribing practices.

Appropriateness and affordability of prescriptions to diabetic patients attending a tertiary hospital in Eastern Uganda: A retrospective cross-sectional study

Background

Irrational prescription of drugs can lead to high cost of treatment thus limiting access to essential medicines. We assessed the affordability and appropriateness of prescriptions written for diabetic patients in Eastern Uganda.

Methods

We collected secondary data from the health management information system registers of patients who attended the outpatient medical clinic at Mbale regional referral hospital from January 2019 to December 2019. The average cost of the prescriptions was calculated and adjusted odds ratios for predictors for unaffordability estimated using logistic regression. Computed scores for indicators of rational drug prescription were used to assess the extent of rational prescribing.

Results

The median cost per prescription was USD 11.34 (IQR 8.1, 20.2). Majority of the diabetic patients (n = 2462; 94.3%, 95% CI: 93.3–95.1%) could not afford the prescribed drugs. Predictors for unaffordability were if a prescription contained: ≥ 4 medicines (AOR = 12.45; 95% CI: 3.9–39.7); an injectable (AOR = 5.47; 95%CI: 1.47–20.32) and a diagnosis of diabetes mellitus with other comorbidities (AOR = 3.36; 95%CI: 1.95–5.78). Having no antidiabetic drug prescribed was protective for non-affordability (AOR = 0.38; 95%CI: 0.24–0.61). The average number of drugs per prescription was 2.8. The percentage prescription of drugs by generic name and from the essential medicine and health supplies list of Uganda were (6160/7461; 82.6%, 96% CI: 81.7%-83.4%) and (6092/7461; 81.7%, 95% CI: 80.8%-82.5%) respectively against WHO standard of 100%.

Conclusion

The majority of diabetic patients (94.3%) in Eastern Uganda cannot afford to buy prescribed medicines. The government should therefore ensure that essential medicines are readily accessible in public health facilities.

Prescribing for Patients Seeking Maternal and Child Healthcare in Sierra Leone: A Multiregional Retrospective Cross-Sectional Assessments of Prescribing Pattern Using WHO Drug Use Indicators

Purpose

Rational use of medicines is a necessary constrict towards increasing access for those that desperately need them in society. In this study, we assess medicines prescribing patterns in healthcare facilities implementing free healthcare policy for pregnant women, lactating mothers and children under the age of five in Sierra Leone.

Materials and Methods

Using WHO drug use indicators, we evaluated prescription records from the pharmacies of four hospitals; one from each of the four regions in Sierra Leone. To study prescribing indicators, we systematically sampled 1200 prescriptions overall (300/hospital) retrospectively spanning a year, from June 2017 to July 2018. In evaluating patients care indicators, we randomly sampled 120 (30/hospital) patients encounter prospectively. We used MS Excel 2016 and IMB SPSS in data analysis, and p< 0.05 was considered significant for associational analysis.

Results

The average drug per prescription was 3.6 (SD=1.3) overall, 3.5 (1.3) for children under five and 3.4 (1.4) for pregnant women/lactating mothers. Eighty-seven percent of prescriptions for under-five children contains antibiotics as opposed to 68.4% of prescriptions for pregnant women/lactating mothers. More injections were prescribed per encounter for pregnant women/lactating mothers 23.2% than for children under five 18.1%. Overall, generic prescribing and prescribing from the National Essential Medicines List were 74.9% and 73.8%, respectively. None of the studied health facilities dispensed all of the prescribed medicines. The most prescribed pharmacological class of drugs were antibiotics, and paracetamol was the most commonly prescribed drug.

Conclusion

Following WHO drug use indicators used in this study, drugs were irrationally prescribed within government hospitals providing free healthcare in Sierra Leone. Sustainability of the free healthcare scheme will require efficient medicine supply and management strategies. Therefore, the formulation of stewardship programs and/or an active Drug and Therapeutics Committee may be necessary to optimise drug use in these hospitals.

Knowledge, attitude and antibiotic prescribing patterns of medical doctors providing free healthcare in the outpatient departments of public hospitals in Sierra Leone: a national cross-sectional study

Background

Antibiotic resistance is a global health crisis and irrational prescribing behaviour has been identified as a contributing factor. The current study aimed to assess the knowledge of, attitudes towards and practices regarding antibiotic prescribing of medical doctors providing free healthcare services in the outpatient departments of public hospitals in Sierra Leone. In addition, we evaluated prescribing patterns of antibiotics.

Methods

The study has two parts. First, we conducted a cross-sectional survey using a self-administered questionnaire to assess doctor’s knowledge of, attitudes towards and practices regarding prescribing antibiotics. Second, using patient medical records, we used the World Health Organization methodology on how to assess drug use in health facilities to evaluate prescribing patterns of antibiotics in four selected public hospitals in Sierra Leone.

Results

Of 130 administered questionnaires, 119 were returned, for a response rate of 91.5%. The majority of doctors (n=83 [69.7%]) agreed that amoxicillin is safe in the first 3 weeks of pregnancy and considered antibiotic resistance a global (n=108 [90.7%]) and national (n=97 [81.5%]) public health crisis. Less than a quarter of medical doctors agreed that antibiotics may speed up the recovery when added to malaria (n=25 [21%]) or cold and cough (n=81 [68%]) therapies. Prescribing pattern results show that children &lt;5 y of age (adjusted odds ratio 5.199 [confidence interval 2.743 to 9.855], p&lt;0.0001) were more likely to be prescribed an antibiotic than pregnant women/lactating mothers. Penicillins were the most commonly prescribed pharmacological class of antibiotics, with amoxicillin being the most commonly prescribed penicillin.

Conclusions

Doctors demonstrated a sound knowledge of antibiotics and antibiotics resistance, with a positive attitude towards prescribing antibiotics. However, the prescribing pattern of antibiotics was irrational, necessitating the need for the establishment of audit and feedback programmes such as antimicrobial stewardship programmes.