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Medrano PG, Weerasinghe N, Nagahawatte A, Vanderburg S, Park LP, Wijayaratne GB, Devasiri V, Dilshan B, Sheng T, Kurukulasooriya R, Anderson J, Nicholson BP, Woods CW, Bodinayake CK, Tillekeratne LG. Prevalence and predictors of antibiotic prescription among patients hospitalized with viral lower respiratory tract infections in Southern Province, Sri Lanka. PLoS One 2024; 19:e0304690. [PMID: 38861513 PMCID: PMC11166322 DOI: 10.1371/journal.pone.0304690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/16/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Antimicrobial overprescription is common for lower respiratory tract infections (LRTI), as viral and bacterial infections generally present with similar clinical features. Overprescription is associated with downstream antimicrobial resistance. This study aims to identify the prevalence and predictors of antibiotic prescription among patients hospitalized with viral LRTI. METHODS A prospective cohort study was conducted among patients aged ≥1 year hospitalized with viral LRTI in a tertiary care hospital in Southern Province, Sri Lanka from 2018-2021. Demographic, clinical, and laboratory data were recorded. Nasopharyngeal and blood samples were collected for multiplex polymerase chain reaction testing for 21 respiratory pathogens and procalcitonin (PCT) detection, respectively. Demographic and clinical features associated with antibiotic prescription were identified using Chi Square and t-tests; significant variables (p<0.05) were further included in multivariable logistic regression models. The potential impact of biomarker testing on antibiotic prescription was simulated using standard c-reactive protein (CRP) and PCT cut-offs. RESULTS Of 1217 patients enrolled, 438 (36.0%) had ≥1 respiratory virus detected, with 48.4% of these patients being male and 30.8% children. Influenza A (39.3%) and human rhinovirus/ enterovirus (28.3%) were most commonly detected. A total of 114 (84.4%) children and 266 (87.8%) adults with respiratory viruses were treated with antibiotics. Among children, neutrophil percentage (median 63.6% vs 47.6%, p = 0.04) was positively associated with antibiotic prescription. Among adults, headache (60.6% vs 35.1%, p = 0.003), crepitations/crackles (55.3% vs 21.6%, p<0.001), rhonchi/wheezing (42.9% vs 18.9%, p = 0.005), and chest x-ray opacities (27.4% vs 8.1%, p = 0.01) were associated with antibiotic prescription. Access to CRP and procalcitonin test results could have potentially decreased inappropriate antibiotic prescription in this study by 89.5% and 83.3%, respectively. CONCLUSIONS High proportions of viral detection and antibiotic prescription were observed among a large inpatient cohort with LRTI. Increased access to point-of-care biomarker testing may improve antimicrobial prescription.
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Affiliation(s)
- Perla G. Medrano
- Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | | | - Ajith Nagahawatte
- Duke Global Health Institute, Durham, North Carolina, United States of America
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - Sky Vanderburg
- University of California, San Francisco, California, United States of America
| | - Lawrence P. Park
- Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | | | | | | | - Tianchen Sheng
- Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | | | - Jack Anderson
- Duke University, Durham, North Carolina, United States of America
| | - Bradly P. Nicholson
- Institute for Medical Research, Durham, North Carolina, United States of America
| | - Christopher W. Woods
- Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
| | - Champica K. Bodinayake
- Duke Global Health Institute, Durham, North Carolina, United States of America
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
| | - L. Gayani Tillekeratne
- Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
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Alwis I, Rajapaksha B, Jayasanka C, Dharmaratne SD. Morbidity profile and pharmaceutical management of adult outpatients between primary and tertiary care levels in Sri Lanka: a dual-centre, comparative study. BMC PRIMARY CARE 2024; 25:200. [PMID: 38844839 PMCID: PMC11155019 DOI: 10.1186/s12875-024-02448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 05/23/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Outpatient care is central to both primary and tertiary levels in a health system. However, evidence is limited on outpatient differences between these levels, especially in South Asia. This study aimed to describe and compare the morbidity profile (presenting morbidities, comorbidities, multimorbidity) and pharmaceutical management (patterns, indicators) of adult outpatients between a primary and tertiary care outpatient department (OPD) in Sri Lanka. METHODS A comparative study was conducted by recruiting 737 adult outpatients visiting a primary care and a tertiary care facility in the Kandy district. A self-administered questionnaire and a data sheet were used to collect outpatient and prescription data. Following standard categorisations, Chi-square tests and Mann‒Whitney U tests were employed for comparisons. RESULTS Outpatient cohorts were predominated by females and middle-aged individuals. The median duration of presenting symptoms was higher in tertiary care OPD (10 days, interquartile range: 57) than in primary care (3 days, interquartile range: 12). The most common systemic complaint in primary care OPD was respiratory symptoms (32.4%), whereas it was dermatological symptoms (30.2%) in tertiary care. The self-reported prevalence of noncommunicable diseases (NCDs) was 37.9% (95% CI: 33.2-42.8) in tertiary care OPD and 33.2% (95% CI: 28.5-38.3) in primary care; individual disease differences were significant only for diabetes (19.7% vs. 12.8%). The multimorbidity in tertiary care OPD was 19.0% (95% CI: 15.3-23.1), while it was 15.9% (95% CI: 12.4-20.0) in primary care. Medicines per encounter at primary care OPD (3.86, 95% CI: 3.73-3.99) was higher than that at tertiary care (3.47, 95% CI: 3.31-3.63). Medicines per encounter were highest for constitutional and respiratory symptoms in both settings. Overall prescribing of corticosteroids (62.7%), vitamin supplements (45.8%), anti-allergic (55.3%) and anti-asthmatic (31.3%) drugs was higher in the primary care OPD, and the two former drugs did not match the morbidity profile. The proportion of antibiotics prescribed did not differ significantly between OPDs. Subgroup analyses of drug categories by morbidity largely followed these overall differences. CONCLUSIONS The morbidities between primary and tertiary care OPDs differed in duration and type but not in terms of multimorbidity or most comorbidities. Pharmaceutical management also varied in terms of medicines per encounter and prescribed categories. This evidence supports planning in healthcare and provides directions for future research in primary care.
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Affiliation(s)
- Inosha Alwis
- Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | | | - Chanuka Jayasanka
- Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Samath D Dharmaratne
- Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Jayawardhana Y, Premaratne A, Kalpani S, Jayasundara S, Jayawardhane G, Jayawarna C, Gamage S, Jayawardhana K, Johnsan R, Jayasundara C, Liyanapathirana V. Investigating the drivers for antibiotic use and misuse amongst medical undergraduates-perspectives from a Sri Lankan medical school. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001740. [PMID: 36963066 PMCID: PMC10027203 DOI: 10.1371/journal.pgph.0001740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/23/2023] [Indexed: 03/22/2023]
Abstract
Medical undergraduates are a unique group who gain the theoretical knowledge on prescribing antibiotics but are not authorized to prescribe till full licensure. This unique situation may result in self-medication and unauthorized prescription of antibiotics. This cross-sectional study was conducted among medical students of the Faculty of Medicine, University of Peradeniya, Sri Lanka in 2021 to identify patterns and drivers for antibiotic use and misuse among medical undergraduates. A validated, self-administered Google forms-based online questionnaire was used to gather information on antibiotic use, misuse, and associated factors: demographics, knowledge and perceptions. Two scores; a practice score and a knowledge score were calculated to compare with the associated factors. The study population consisted of 347 medical students with a mean age of 24 (SD1.7) years and 142/347 (40.9%) were male participants. The patterns of misuses identified included; use of antibiotics without a prescription (161/347, 46.4%), keeping left-over antibiotics for future use (111/347, 32.0%), not completing the course of antibiotics (81/347, 23.3%), use of left-over antibiotics (74/347, 21.3%), prescribing to animals (61/347, 17.6%), prescribing antibiotics to family members or friends (51/347, 14.7%), antibiotic self-medication (25/347, 7.2%) and not following the dosage regime prescribed (24/347, 6.9%). The practice score ranged from 33% to 100% (median 87%, IQR 80.0-93.3) and did not differ significantly with either the gender or the year of study. The knowledge score ranged from 4% to 100% (median 87%, IQR: 71.5-95.4) differing significantly according to the year of study. Antibiotic prescription by medical undergraduates was perceived as unacceptable (329/347, 94.8%) by the majority. Individual misuse patterns were associated favourably or unfavourably with gender, year of study, having a health care worker at home and knowledge score. The knowledge score increased with the advancement in training at the medical school while the practice score remained indifferent, highlighting the need to identify the additional drivers of antibiotic misuse among medical undergraduates.
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Affiliation(s)
| | - Avanthi Premaratne
- Department of Microbiology, Faculty of Medicine, University of Peradeniya, Sri Lanka, Sri Lanka
| | - Sudeepa Kalpani
- Faculty of Medicine, University of Peradeniya, Sri Lanka, Sri Lanka
| | | | | | | | - Sarala Gamage
- Faculty of Medicine, University of Peradeniya, Sri Lanka, Sri Lanka
| | | | - Radshana Johnsan
- Faculty of Medicine, University of Peradeniya, Sri Lanka, Sri Lanka
| | | | - Veranja Liyanapathirana
- Department of Microbiology, Faculty of Medicine, University of Peradeniya, Sri Lanka, Sri Lanka
- * E-mail:
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Skosana PP, Schellack N, Godman B, Kurdi A, Bennie M, Kruger D, Meyer JC. A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications. Hosp Pract (1995) 2022; 50:306-317. [PMID: 35980901 DOI: 10.1080/21548331.2022.2114251] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider. METHODS A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines. RESULTS The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files. CONCLUSIONS It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.
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Affiliation(s)
- Phumzile P Skosana
- Division of Clinical Pharmacy, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Natalie Schellack
- Department of Pharmacology, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa
| | - Brian Godman
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Centre of Medical and Bio-allied Health Sciences Research, Ajman University, United Arab Emirates
| | - Amanj Kurdi
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK.,Department of Pharmacology, College of Pharmacy, Hawler Medical University, Erbil, Iraq
| | - Marion Bennie
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Danie Kruger
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Johanna C Meyer
- Division of Public Health Pharmacy and Management, School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
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Amponsah OKO, Nagaraja SB, Ayisi-Boateng NK, Nair D, Muradyan K, Asense PS, Wusu-Ansah OK, Terry RF, Khogali M, Buabeng KO. High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10286. [PMID: 36011917 PMCID: PMC9407799 DOI: 10.3390/ijerph191610286] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/13/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance. METHODS Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year. RESULTS The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions. CONCLUSIONS Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.
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Affiliation(s)
- Obed Kwabena Offe Amponsah
- Department of Pharmacy Practice, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | | | - Nana Kwame Ayisi-Boateng
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Divya Nair
- International Union against TB and Lung Disease (The Union), 75006 Paris, France
| | - Karlos Muradyan
- Tuberculosis Research and Prevention Center, Yerevan 0014, Armenia
| | - Phanuel Seli Asense
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Osei Kwaku Wusu-Ansah
- University Hospital, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
| | - Robert Fraser Terry
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organisation, 1211 Geneva, Switzerland
| | - Mohammed Khogali
- Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organisation, 1211 Geneva, Switzerland
| | - Kwame Ohene Buabeng
- Department of Pharmacy Practice, Kwame Nkrumah University of Science and Technology, Kumasi 00233, Ghana
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Sri Ranganathan S, Wanigatunge C, Senadheera GPSG, Beneragama BVSH. A national survey of antibacterial consumption in Sri Lanka. PLoS One 2021; 16:e0257424. [PMID: 34520501 PMCID: PMC8439449 DOI: 10.1371/journal.pone.0257424] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/31/2021] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Optimizing the use of antibacterial medicines is an accepted strategy to combat the antibacterial resistance. Availability of reliable antibacterial consumption (ABC) data is a prerequisite to implement this strategy. OBJECTIVES To quantify and describe the national ABC in Sri Lanka and to examine any differences in the consumption between public and private sector. METHODS The methodology for this survey was adapted from World Health Organization (WHO) methodology for a global programme on surveillance of antimicrobial consumption. Aggregate data on national consumption of systemic antibacterials (J01- Anatomical Therapeutic Chemical Classification (ATC) for 2017 were retrospectively extracted from all available data sources and classified using ATC classification. Quantity of consumption was converted to Defined Daily Doses (DDDs). Data are presented as total consumption and comparison between the public and private sector. Selected key quality indicators of ABC were compared between these two sectors. FINDINGS From the available data sources, the total ABC in 2017 was 343.46 million DDDs. Private sector consumption accounted for 246.76 million DDDs compared to 97.96 million DDDs distributed to entire public sector by the Ministry of Health. Beta-lactam-penicillins antibacterial group accounted for 58.79% in public sector compared to 27.48% in private sector while macrolides, quinolones and other beta-lactam antibacterials accounted for 60.51% in the private compared to 28.41% in public sector. Consumption of Reserve group antibacterials was negligible, and limited to private sector. Watch category antibacterials accounted for 46%, 24% and 54% of the total, public and private sector consumption, respectively. CONCLUSIONS A disproportionately higher use of broad spectrum and Watch category antibacterials was observed in the private sector which needs further study. This national consumption survey highlights the need and provides the opening for establishment of ABC surveillance in Sri Lanka.
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Affiliation(s)
| | - Chandanie Wanigatunge
- Department of Pharmacology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Jayewardenepura, Sri Lanka
| | - G. P. S. G. Senadheera
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Allied Health Sciences, University of Sri Jayewardenepura, Sri Jayewardenepura, Sri Lanka
| | - B. V. S. H. Beneragama
- National focal point for combating antimicrobial resistance in Sri Lanka, Ministry of Health, Colombo, Sri Lanka
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