Prescribing indicators at primary health care centers within the WHO African region: a systematic analysis (1995-2015)

Comparing pharmacy practice in health facilities with and without pharmaceutically trained dispensers: a post intervention study in Tanzania

Background

The critical shortage of comprehensively trained healthcare staff in Tanzania affects the capacity to deliver essential health services, attain universal health coverage and compromises health outcomes. There is a specific lack of suitably trained pharmaceutical professionals, thus, an increase in the use of unqualified or poorly trained staff. Following the introduction of a one-year pharmacy dispenser course intervention, this study explored the impact that the new cadre of graduates had on pharmacy practice compared to healthcare facilities with non-pharmacy trained dispensers (NPTDs).

Methods

A post intervention assessment was conducted in 2021 using questionnaires formulated to measure indicators of Good Pharmacy Practice, comparing 29 public health facilities employing pharmacy-trained dispensers (PTD) with 32 public health facilities with NPTDs in Dodoma, Shinyanga and Morogoro regions of Tanzania. Data were collected by experienced pharmacists or pharmaceutical technicians and subsequently aggregated and statistically analysed.

Results

The dispensing times for medicines were found to be the same for PTDs and the NPTDs (2 min). There were no statistically significant differences in the adequacy of labelling elements between PTDs and NPTDs. Patients' level of knowledge of the medicines dispensed to them, from both PTDs and NPTDs, showed no difference. Moreover, no differences were observed in storage practice and documentation performance, records of dispensed medicines, handling of medicines and the dispensing area cleanliness between both groups. Overall, facilities with PTDs averaged a higher availability of tracer medicines (77%) than those with NPTDs (70%), however, availability of health commodities in all health facilities in the three regions was low and there was no statistically significant difference between both groups.

Conclusion

The study showed no significant difference in performance of pharmacy practice between PTDs and NPTDs despite the former undertaking a one-year training course intended to improve knowledge and skills. Practice application not only depends on effective training but on the working environment. Clear job descriptions, appropriate tools and references to guide, Standard Operating Procedures, acceptance by management of the training undertaken to actively encourage recruits to apply these new skills could improve PTDs performance. Training and knowledge alone do not seem to lead to better practice and performance.

Antibiotic prescribing patterns and carriage of antibiotic-resistant Escherichia coli and Enterococcus species in healthy individuals from selected communities in Lusaka and Ndola districts, Zambia

Objectives

This study assessed antibiotic prescribing patterns in primary healthcare facilities and antimicrobial resistance (AMR) profiles of commensal Escherichia coli and enterococci isolated from pregnant women and children under 5 years of age.

Materials and methods

This cross-sectional study was conducted in Lusaka and Ndola districts of Zambia. Prescription pattern data were obtained from hospital pharmacies. Identification and antimicrobial susceptibility profiles of E. coli and enterococci were determined by conventional methods, while confirmation of both pathogens and AMR genes were determined by PCR. Data were analysed using WHONET and SPSS version 25.0.

Results

Most prescribed antibiotics at the primary healthcare facilities belonged to the Access group of the WHO Access, Watch and Reserve (AWaRe) classification. All the primary healthcare facilities adhered to the AWaRe framework of ≥60% prescribed antibiotics belonging to the Access group. However, resistance was highest in the Access group of antibiotics. E. coli resistance to ampicillin ranged from 71% to 77% and to co-trimoxazole from 74% to 80%, while enterococcal resistance to tetracycline was 59%-64%. MDR was highest in E. coli (75%) isolates, while XDR was highest in enterococcal isolates (97%). The identified AMR genes in E. coli included blaCTX-M, sul2 and qnrA, while those of enterococci included erm(B), erm(C) and erm(A).

Conclusions

Resistance was highest in the prescribed WHO Access group of antibiotics. These findings highlight the need to use local susceptibility data to formulate country-specific treatment guidelines in line with WHO AWaRe classification and enforce regulations that prohibit easy access to antibiotics.

Evaluation of Rational Medicines Use Based on World Health Organization Core Indicators: A Cross-Sectional Study in Five Health Districts in Mauritania

Introduction

The rational use of medicines is essential for preventing adverse medicine reactions, achieving therapeutic outcomes, and optimizing treatment costs. While the irrational use of medicines is frequently reported in sub-Saharan Africa, to the best of our knowledge no formal studies have taken place in Mauritania thus far. The main objective of this study was therefore to analyze the rational use of medicines in public and private not-for-profit health facilities, in five health districts in Mauritania.

Methods

We conducted a cross-sectional study to assess the rational use of medicines. We used the standard indicators derived from the methodologies of the World Health Organization (WHO) and International Network for Rational Use of Drugs (INRUD). Data were prospectively collected from 1050 prescriptions/patients, in thirty-one public and private not-for-profit health posts/centers in 5 health districts. The data were analyzed using the Statistical Package for the Social Sciences. P value less than 0.05 at 95% confidence interval considered for significance of relationships for associations in statistical test.

Results

The average number of medicines per prescription was 2.21; 83.1% (1931/2325) of medicines were prescribed by generic name, but only 54% (1253/2325) were on the National Essential Medicine List (NEML). Antibiotics were prescribed in 62.4% (655/1050) of the consultations, and injectable medicines were prescribed in 15.6% (164/1050) of the consultations. The average consultation time was 16.32 minutes, and the average dispensing time was 97 seconds. Dispensed medicines were correctly labeled, and 83% (871/1050) of patients met the correct administration schedule. The NEML, and the "restricted NEML" for 76 commonly-used medicines, were available in all surveyed health facilities, but the National Therapeutic Guidelines were available in only 60.26% of them.

Conclusion

Our findings indicate a possible excess of antibiotics prescriptions, and a likely lack of knowledge of the National Therapeutic Guidelines. There is a need to investigate in more detail the prescription patterns versus disease-specific therapeutic guidelines, and to qualitatively investigate the factors that contribute to the observed irrational prescribing. Moreover, training local staff in the rational use of medicines seems important.

Antibiotic consumption in the first months of life: A cross-sectional study

INTRODUCTION

The factors and patterns associated with antibiotic consumption in infants are unclear. Our aim was to assess the cumulative incidence of antibiotic consumption from birth to 16 months and identify factors associated with antibiotic consumption among infants aged 4-16 months.

MATERIAL AND METHODS

We conducted a cross-sectional study in 2016 in a sample of 18 882 women from Galicia, Spain, who had given birth to a live child between September 1, 2015 and August 31, 2016. We calculated the cumulative incidence of antibiotic consumption based on maternal reports regarding the infant's consumption from birth to 14 months obtained through interviews; we did not estimate consumption at ages 15 and 16 months due to the small sample size. To assess which factors were associated with antibiotic consumption, we carried out a nested case-control study matching cases and controls for birth month on a 1:1 ratio.

RESULTS

The cumulative incidence of antibiotic consumption among infants aged 0-14 months increased from 7.5% to 66.0%. The case-control study included data for 1852 cases and 1852 controls. Daycare attendance (OR: 3.8 [95% CI: 3.2-4.6]), having older siblings (OR: 1.8 [95% CI: 1.6-2.1]), health care visits to private clinics (OR: 1.6 [95% CI: 1.4-2.0]), and passive smoking (OR: 1.3 [95% CI: 1.1-1.6]) were associated with an increased probability of antibiotic consumption. Maternal age between 30-39 years or 40 years and over at the time of birth was associated with a decreased probability of antibiotic consumption (OR: 0.8 [95% CI, 0.7-1.0] and OR: 0.6 [95% CI: 0.5-0.8], respectively).

CONCLUSIONS

Some of the factors associated with antibiotic consumption in infants are modifiable and should be considered in the development of public health measures aimed at reducing antibiotic consumption.

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.

A combined strategies intervention on the World Health Organization prescribing indicators: A quasi-randomised trial

BACKGROUND

Irrational medicine use is a global problem that may potentiate antimicrobial resistance.

AIM

This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators.

SETTING

The study was conducted in public-sector healthcare facilities in Eswatini.

METHODS

A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times.

RESULTS

At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up.

CONCLUSION

In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing.Contribution: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use.

Assessing the impact of COVID-19 on prescription patterns and antibiotic use: Insights from three military health facilities

BACKGROUND

The COVID-19 pandemic disrupted health systems globally and there are suggestions it impacted antibiotics prescribing patterns in clinical practice.

OBJECTIVES

This study aimed to assess the effects of the COVID-19 pandemic on the prescribing patterns in three Nigerian military health facilities and investigate the factors associated with antibiotic prescriptions.

METHODS

This was a two-year cross-sectional retrospective study. Three hospitals and a total of 11,590 prescriptions were purposively and conveniently sampled respectively. The World Health Organisation (WHO) and International Network of Rational Use of Drugs (INRUD) prescribing indicators were used to assess for polypharmacy, injection use, use of antibiotics, use of generic drugs and prescriptions from essential drug lists for the periods of the pandemic and before the pandemic. Indicators from both periods were compared for statistical significance using the independent t-test. Generalized linear modelling was applied to assess the factors associated with antibiotic prescriptions. The relationship between the receipt of antibiotics and independent variables was presented using incident risk ratios (IRR).

RESULTS

Our findings showed that all five WHO/INRUD prescribing indicators were above the reference limit for the two-year study period. The study found there was a significant statistical difference between the COVID- and non-COVID-19 periods, with polypharmacy and antibiotic use indicators elevated during the pandemic compared to the latter. COVID-19 (IRR = 1.09), comorbidity (IRR = 1.74), pregnancy (IRR = 0.93), out-of-pocket payments (IRR = 1.10) and the inpatient department (IRR = 1.51) were associated with antibiotic prescriptions.

CONCLUSIONS

This provides insight on impact of the pandemic on prescription patterns and advocates for stewardship programs in clinical settings to ensure the rational use of drugs.

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

Background

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

Methods

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

Results

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

Conclusions

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

Exploring knowledge, perceptions, and practices of antimicrobials, and their resistance among medicine dispensers and community members in Kavrepalanchok District of Nepal

BACKGROUND

Inappropriate use of antimicrobials is a global public health issue, particularly in developing countries, including Nepal, where over-the-counter sales and self-medication of antimicrobials are common.

OBJECTIVES

To explore knowledge, perceptions, and practices of antimicrobials and their resistance among medicine dispensers and community members in Nepal.

METHODS

The study was conducted in three rural and five urban municipalities of the Kavrepalanchok district from May 2021 to August 2021. Data were collected using two qualitative approaches: In-Depth Interviews (IDIs) and Focus Group Discussions (FGDs). Data were analyzed using thematic analysis that combined deductive and inductive approaches to identify codes under pre-specified themes.

RESULTS

A total of 16 In-depth interviews with medicine dispensers and 3 focus group discussions with community members were conducted. Knowledge regarding antimicrobial resistance varied among dispensers. Those with a prior educational background in pharmacy often had good knowledge about the causes and consequences of antimicrobial resistance. Meanwhile, consumers were less aware of antimicrobial resistance. Community members perceived antimicrobials as effective medicines but not long-term solution for treating diseases. They reported that dispensing without a prescription was common and that both consumers and dispensers were responsible for the inappropriate use of antimicrobials. On the contrary, several dispensers said that self-medication was common among the consumers, especially among more educated groups. The medicine dispensers and consumers expressed concerns about the weak enforcement of policies regarding pharmacy drug use and dispensing practices.

CONCLUSION

Promoting and strengthening the appropriate use of antimicrobials among medicine dispensers and community members is crucial. Bold policies and collective implementation of regulations could help combat antimicrobial resistance.

Trends in antihypertensive use among privately insured hypertensive clients in Ghana

The objective of the study was to describe the patterns of antihypertensive medicines (AHM) in a selected national population in Ghana. The claims data for all privately insured patients in Ghana over three years to 2018 were analysed. The classes of medicines used, the dose by time, gender and age, and generic status were examined. In addition, the use in Defined Daily Dose (DDD) per 1000 population per day was estimated. Classes of AHM prescribed were CCB, ARB, ACEI, diuretics, and BB. Amlodipine, nifedipine, losartan, lisinopril, and bendroflumethiazide accounted for 74% of all use. The most widely used single CCB was amlodipine 3.92 DDD/1,000 population/day in 2016, 3.92 DDD/1,000 population/day in 2017, and 4.92 DDD/1,000 population/day in 2018. In those aged 51-60 years, use of CCB in women (74.0 DDD/1,000 population/day) was almost twice that of men (38.3 DDD/1,000 population/day). The top ten medicines accounted for 93% of all single medicine products in 2018. Most single medicine products was generic (76.5% in 2016; 79.9% in 2017 and 83.1% in 2018) whiles most fixed combination products were branded (73.0% in 2016; 89.7% in 2017 and 91.3% in 2018). The patterns of AHM use are clinically expected although the Ghana Standard Treatment guidelines are not directive about lines of treatment.

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

INTRODUCTION

As health reforms move Ireland from a mixed public-private system toward universal healthcare, it is important to understand variations in prescribing practice for patients with differing health cover and socioeconomic status. This study aims to determine how prescribing patterns for patients aged ≥ 65 years in primary care in Ireland differ between patients with public and private health cover.

METHODS

This was an observational study using anonymised data collected as part of a larger study from 44 general practices in Ireland (2011-2018). Data were extracted from electronic records relating to demographics and prescribing for patients aged ≥ 65 years. The cohort was divided between those with public health cover (via the General Medical Services (GMS) scheme) and those without. Standardised rates of prescribing were calculated for pre-specified drug classes. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex, and hospitalisations.

RESULTS

Overall, 42,456 individuals were included (56% female). Most were covered by the GMS scheme (62%, n = 26,490). The rate of prescribing in all drug classes was higher for GMS patients compared to non-GMS patients, with the greatest difference in benzodiazepine anxiolytics. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. The number of unique medications prescribed to both GMS and non-GMS cohorts increased over time. The increase was steeper in the GMS group where the mean number of medications prescribed increased by 0.67 medications/year. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.

CONCLUSION

Our study found a significantly larger number of medications were prescribed to patients with public health cover, compared to those without. Increasing medication burden and polypharmacy among older adults may be accelerated for those of lower socioeconomic status. These findings may inform planning for moves towards universal health care, and this would provide an opportunity to evaluate the effect of expanding entitlement on prescribing and medications use.

Implications of the South African National Drug Policy on prescribing patterns: a case study of the Limpopo province

BACKGROUND

The South African National Drug Policy (SA-NDP) was introduced to promote rational medicine use (RMU). This study evaluates the quality of prescribing in the public healthcare sector in South Africa's Limpopo province following the World Health Organization's (WHO) rational prescribing standards. In addition, the prescribing practices in South Africa were compared to other African countries.

METHODS

A prospective cross-sectional survey of patients' prescriptions was conducted in Limpopo, South Africa, from October to December 2018. Findings were compared with the WHO reference values (WHO-RV), and the International Network of Rational Use of Drugs (IRDP) tool was used to measure the degree of rational prescribing. The optimal IRDP value was defined as 1. Study findings were compared with results from a previous study conducted in Limpopo and studies from Ethiopia and Eritrea.

RESULTS

Six hundred prescriptions were reviewed. The mean (SD) age was 43.9 ± 24.4 years (females = 56.5%). The average number of drugs prescribed (4.3, IRDP = 0.47) was higher than the WHO-RV (< 2). Generic prescribing (43%, IRDP = 0.43) and medicines prescribed from the essential medicines list (EML) (90%, IRDP = 0.90) were less than the WHO-RV (100%, respectively). Antibiotics (28%, IRDP = 1) and the number of injections prescribed (8%, IRDP = 1) were below the WHO-RV (< 30% and < 20%, respectively). The number of medicines prescribed was higher compared to previous years (4.3 vs. 3.4). Antibiotic prescribing declined (28% vs. 63.4%). Generic prescribing (43% vs. 41.7%) and medicines prescribed from the EML (90% vs. 93.1%) did not improve. A higher number of medicines were prescribed in this study compared to Ethiopia (1.7) and Eritrea (1.8), and a lower number of antibiotics were prescribed compared to Ethiopia (58.2%) and Eritrea (54.5%). Generic prescribing was low compared to Ethiopia (95.6%) and Eritrea (94.9%). All studies showed reduced injection prescribing (6.6-15.9%) and similar prescribing from the EML (90-95%).

CONCLUSIONS

There is an increased potential for drug-drug and adverse reactions with the increased number of prescribed medicines; however, the patient's clinical needs may warrant using multiple medicines. There is a need for generic prescribing to reduce medicine expenditure.

Head-to-head comparison of the WHO STEPwise approach with immediate unattended and delayed unattended automated blood pressure measurements during household-based screening: a diagnostic accuracy study in Lesotho

Background

WHO introduced the STEPwise approach to surveillance (STEPS) to monitor trends in non-communicable diseases. For arterial hypertension, the STEPS protocol takes the average of the last two out of three standard blood pressure measurements (SBPM). This study assesses the diagnostic accuracy of SBPM, same-day and next-day unattended automated measurement (uABP), with 24 h ambulatory measurement (24 h-ABPM) as reference.

Methods

This diagnostic accuracy study was done within a population-based household survey on cardiovascular risk factors in two districts in Northern Lesotho. Adults (aged ≥ 18 years) with elevated SBPM (defined as ≥140/90 mmHg), and 2:1 age- and sex-matched participants with normal SBPM during the survey were recruited. Following SBPM, first uABP readings were obtained on survey day. Afterwards, participants received a 24 h-ABPM device. Second uABP readings were taken 24 h later, after retrieval of the 24 h-ABPM. The main outcome was overall diagnostic accuracy of all screening measurements (SBPM, first uABP, and second uABP), determined using area under the receiver operating characteristic curve (AUROC), with 24 h-ABPM as a reference.

Findings

Between November 2, 2021 and August 31, 2022, 275 participants (mean age 58 years (SD: 16 years), 163 (59%) female) were enrolled, 183 of whom had elevated and 92 had normal SBPM. Mean difference between systolic daytime 24 h-ABPM and screening measurements was highest for SBPM (mean difference: -13 mmHg; 95% CI: -14 to -11). Mean difference between diastolic daytime 24 h-ABPM and diastolic SBPM was -2 mmHg (95% CI: -4 to -1), whereas no difference was found for mean diastolic first uABP (mean difference: -1 mmHg; 95% CI: -2.0 to 0.3); and mean diastolic second uABP (mean difference: 1.0 mmHg; 95% CI: -0.4 to 2.3). White coat hypertension was highest with SBPM (55 [20%]), followed by first uABP (27 [9.8%]), and second uABP (18 [6.5%]). Using systolic daytime 24 h-ABPM as a reference, the uABPs had higher AUROC (first uABP: 87% [95% CI: 83-91]; second uABP: 88% [95% CI: 84-92]); SBPM: (79% [95% CI: 74-85]). This difference was significant between first uABP and SBPM (P = 0.0024), and between second uABP and SBPM (P = 0.0017).

Interpretation

uABP had better diagnostic performance than SBPM. Integration of uABP into STEPS protocol should be considered.

Funding

Swiss Agency for Development and Cooperation under the ComBaCaL project, and the World Diabetes Foundation.

Prescribing Pattern and Associated Factors in Community Pharmacies: A Cross-Sectional Study Using AWaRe Classification and WHO Antibiotic Prescribing Indicators in Dire Dawa, Ethiopia

BACKGROUND

Antimicrobials are drugs that are more likely to trigger the development of resistance naturally. Thus, they need to be prescribed, dispensed, and administered with greater caution. To underline the significance of their proper usage, antibiotics are divided as AWaRe: Access, Watch, and Reserve. Timely evidence on medicine use, prescribing patterns, and the factors affecting prescribing of antibiotic and their use percentage from AWaRe classification would help decision-makers to draft guidelines that can enable more rational use of medicines.

METHODS

Prospective and cross-sectional study was conducted among seven community pharmacies in Dire Dawa to assess current prescribing practices related World Health Organization (WHO) indicators and AWaRe classification including antibiotic use and associated factors. Using stratified random sampling techniques, 1200 encounters were reviewed between 1 October and 31 October 2022, and SPSS version 27 was used for the analysis.

RESULTS

The average of medications per prescription was 1.96. Antibiotics were included in 47.8% of encounters, while 43.1% were prescribed from the Watch groups. In 13.5% of the encounters, injections were administered. In multivariate models, patient age, gender, and the number of medications prescribed were significantly associated to prescription of antibiotics. Antibiotics were about 2.5 times more likely to be prescribed to patients under the age of 18 years than to subjects 65 years and older [adjusted odds ratio (AOR): 2.51, 95% confidence interval (CI): 1.88-5.42; P < 0.001]. Men were also more likely than women to receive an antibiotic prescription (AOR: 1.74, 95% CI: 1.18-2.33; P = 0.011). Subjects who received more than two drugs were 2.96 times more likely to receive an antibiotic drug (AOR: 2.96, 95% CI: 1.77-6.55; P < 0.003). The probability of prescribing antibiotics was increased by 2.57 for every one-unit increase in the number of medications [crude odds ratio (OR): 2.57; 95% CI: 2.16-3.47; P < 0.002].

CONCLUSION

According to the present study, the amount of prescriptions with antibiotics at community pharmacies is much higher than the WHO standard (20-26.2%). The antibiotics prescribed from Access group were 55.3%, which is slightly lower than WHO recommended level (60%). The prescribing of antibiotics was significantly correlated to the patient's age, gender, and number of medications. The preprint version of the present study is available on Research Square with the following link: https://doi.org/10.21203/rs.3.rs-2547932/v1 .

WHO/INRUD prescribing indicators among tertiary regional referral hospitals in Dar es Salaam, Tanzania: a call to strengthen antibiotic stewardship programmes

Background

Antibiotic prescribing should be guided by national essential medicines lists (NEMLs) and treatment guidelines; however, there are inadequate data on antibiotic utilization patterns in tertiary hospitals in Tanzania. This study aimed to determine antibiotic prescribing patterns in tertiary hospitals in Dar es Salaam, Tanzania.

Methods

A retrospective cross-sectional study was conducted in three regional referral hospitals. About 200 prescription records from 2020 to 2022 were analysed at each hospital for prescribing patterns using WHO/ International Network of Rational Use of Drugs (INRUD) indicators (1993) and the AWaRe 2021 classification. Factors associated with receiving an antibiotic prescription were assessed using a logistic regression model. Facilities were ranked on prescribing practices using the index of rational drug prescribing (IRDP).

Results

A total of 2239 drugs were prescribed, of which 920 (41.1%) were antibiotics. An average of 3.7 ± 1.5 (optimal: 1.6-1.8) total medicines and 1.53 ± 0.78 antibiotics were prescribed per patient. About 88.0% (528) of the prescriptions contained antibiotics (optimal: 20.0%-26.8%), while 78.2% (413) of all antibiotic prescriptions contained injections (optimal: 13.4%-24.1%). Furthermore, 87.5% (462) of the antibiotics were prescribed in generic names (optimal: 100%), while 98.7% (521) conformed to the NEML (optimal: 100%). Metronidazole was the most frequently prescribed antibiotic (39.2%; n = 134), followed by ceftriaxone (37.1%, n = 127) and amoxicillin/clavulanic acid (8.5%, n = 29).

Conclusions

We found substantial empirical prescribing and overuse of antibiotics exceeding WHO recommendations. Antibiotic overuse varied across the hospitals. Being male, having underlying conditions such as diabetes mellitus, and/or being treated at Temeke hospital were associated with receiving an antibiotic prescription. We recommend strengthening antibiotic stewardship programmes in the studied facilities.

Using Culture Sensitivity Reports to Optimize Antimicrobial Therapy: Findings and Implications of Antimicrobial Stewardship Activity in a Hospital in Pakistan

Background: There are concerns with inappropriate prescribing of antibiotics in hospitals especially broad spectrum in Pakistan and the subsequent impact on antimicrobial resistance rates. One recognized way to reduce inappropriate prescribing is for empiric therapy to be adjusted according to the result of culture sensitivity reports. Objective: Using culture sensitivity reports to optimize antibiotic prescribing in a teaching hospital in Pakistan. Methods: A retrospective observational study was undertaken in Ghurki Trust Teaching Hospital. A total of 465 positive cultures were taken from patients during the study period (May 2018 and December 2018). The results of pathogen identification and susceptibility testing from patient-infected sites were assessed. Additional data was collected from the patient's medical file. This included demographic data, sample type, causative microbe, antimicrobial treatment, and whether empiric or definitive treatment as well as medicine costs. Antimicrobial data was assessed using World Health Organization's Defined Daily Dose methodology. Results: A total of 497 isolates were detected from the 465 patient samples as 32 patients had polymicrobes, which included 309 g-negative rods and 188 g-positive cocci. Out of 497 isolates, the most common Gram-positive pathogen isolated was Staphylococcus aureus (Methicillin-sensitive Staphylococcus aureus) (125) (25.1%) and the most common Gram-negative pathogen was Escherichia coli (140) (28.1%). Most of the gram-negative isolates were found to be resistant to ampicillin and co-amoxiclav. Most of the Acinetobacter baumannii isolates were resistant to carbapenems. Gram-positive bacteria showed the maximum sensitivity to linezolid and vancomycin. The most widely used antibiotics for empiric therapy were cefoperazone plus sulbactam, ceftriaxone, amikacin, vancomycin, and metronidazole whereas high use of linezolid, clindamycin, meropenem, and piperacillin + tazobactam was seen in definitive treatment. Empiric therapy was adjusted in 220 (71.1%) cases of Gram-negative infections and 134 (71.2%) cases of Gram-positive infections. Compared with empiric therapy, there was a 13.8% reduction in the number of antibiotics in definitive treatment. The average cost of antibiotics in definitive treatment was less than seen with empiric treatment (8.2%) and the length of hospitalization also decreased. Conclusions: Culture sensitivity reports helped reduced antibiotic utilization and costs as well as helped select the most appropriate treatment. We also found an urgent need for implementing antimicrobial stewardship programs in hospitals and the development of hospital antibiotic guidelines to reduce unnecessary prescribing of broad-spectrum antibiotics.

Assessment of Prescribing Practices and Factors Related to Antibiotic Prescribing in Community Pharmacies

Background and Objectives: Overprescribing of antibiotics is one of the important contributors of antimicrobial resistance globally. A high proportion of antibiotics prescribed in community settings are unnecessary or inappropriate. This study assesses the prescribing practices and factors related to antibiotic prescribing in community pharmacies in United Arab Emirates (UAE). Materials and Methods: A cross-sectional study utilizing a quantitative approach was carried out in the community pharmacies of Ras Al Khaimah (RAK), UAE. Six hundred and thirty prescription encounters from 21 randomly selected community pharmacies were investigated using World Health Organization (WHO) core prescribing indicators. Factors related to antibiotic prescribing were identified using logistic regression analyses. Results: In 630 prescription encounters, a total of 1814 drugs were prescribed. Out of these, the most commonly prescribed drug class was antibiotics (43.8% prescriptions) and the antibiotic was amoxicillin/clavulanic-acid (22.4%). The average number of drugs per prescription was 2.88, which was higher than the WHO recommended value of 1.6-1.8. In addition, more than half of the prescriptions (58.6%) had drugs by generic names and the majority of the drugs prescribed (83.8%) were from the essential drug list, which were lower than the optimal values of 100%. The majority of the antibiotics prescribed in the study were from the WHO's Access group antibiotics. Multivariable logistic regression analysis identified patient age (children-OR: 7.40, 95% CI: 2.32-23.62, p = 0.001 and adolescent-OR: 5.86, 95% CI: 1.57-21.86, p = 0.008), prescriber qualification as general practitioner (OR: 1.84, 95% CI:1.30-2.60, p = 0.001), and number of drugs per prescription (OR: 3.51, 95% CI: 1.98-6.21, p < 0.001) as independent factors associated with antibiotic prescribing. Conclusions: This study reveals considerable variations from the WHO recommendations for the different prescribing indicators in the community pharmacies of RAK, UAE. In addition, the study reports overprescribing of antibiotics in the community setting, indicating the need for interventions to promote rational use of antibiotics in a community setting.

Perceptions of and Preparedness for the Application of Pharmacoeconomics in Practice, among Final Year Bachelor of Pharmacy Students in South Africa: A National Cross-Sectional Study

For the improvement of access to health, many countries including South Africa, have adopted universal healthcare. However, this requires skills to apply health technology assessments for the facilitation of investment decisions. This study aimed to ascertain final year Bachelor of Pharmacy (BPharm) students' perceptions of the relevance of pharmacoeconomics in pharmacy practice, and their level of preparedness to apply pharmacoeconomic principles, using a quantitative, cross-sectional, and descriptive design. Data were collected using a self-administered questionnaire over 12 months, and included student demographics, knowledge about pharmacoeconomics and its applicability in practice, as well as students' satisfaction with the appropriateness of the curriculum content. Five of nine universities offering pharmacy education took part. The overallstudent response rate was 38.1% (189/496), with 26.2% (45/172) of students signifying a good understanding of basic pharmacoeconomic concepts. Pharmacoeconomics application in South Africa was perceived to be relevant by 87.5% (140/160); however, 47.0% (79/168) felt they were not prepared to apply pharmacoeconomic principles in medicine management, and 86.7% (137/158) wanted to acquire additional pharmacoeconomic knowledge. Whilst students' perceptions of the relevance of pharmacoeconomics were positive, results indicated a gap in knowledge, understanding, and application. Addressing this gap may increase students' preparedness to apply pharmacoeconomic principles and better equip them for the practical application of pharmacoeconomics post qualification. Consequently, we have started this process.

Prevalence and Correlates of Polypharmacy, and Drug Utilization Pattern in a Semi-urban Population: Results from the Pars Cohort Study

BACKGROUND

Although polypharmacy is considered a major predictor of irrational use of drugs, little is known about polypharmacy in developing regions. We aimed to indicate the prevalence and correlates of polypharmacy and to determine the medication profile at the population level in southern Iran.

METHODS

In this cross-sectional study, we analyzed data from participants of the Pars Cohort Study (PCS) (aged above 40 years, N=9269). Polypharmacy was defined as using five or more medications concurrently. A Poisson multivariable model was applied to estimate the adjusted prevalence ratios (APRs) of various risk factors. The Anatomical Therapeutic Chemical (ATC) classification system was used for classifying medications.

RESULTS

Prevalence of polypharmacy was 10.4%, (95% CI: 9.75; 11.08) and it was higher among females (15.0%), older adults (age≥65 years) (16.0%), and individuals with more than two chronic conditions (31%). Being female, educated, married, and not having a low socio-economic class were independently associated with a higher likelihood of polypharmacy. The most prevalent medications among female participants were sex hormones and modulators of the genital system (58.4%), drugs for acid-related disorders (14.6%), and anti-anemic preparations (13.6%,). On the other hand, males were using acid-related disorders (14.6%), anti-inflammatory and anti-rheumatic products (7.8%), and beta-blocking agents (6.3%).

CONCLUSION

The prevalence of polypharmacy in our sample was relatively low, especially among males. Cardiovascular drugs, acid suppressants, hormonal contraceptives, and anti-anemic preparations are drug classes with the highest contribution to polypharmacy.

Knowledge, attitudes and practices of healthcare professionals on the use of an electronic stock visibility and management tool in a middle-income country: Implications for access to medicines

Background

The Stock Visibility System (SVS) is a mobile application and web-based management tool used at public primary health care (PHC) facilities in South Africa to capture and monitor medicines availability, providing visibility at national level. Medicine stock-outs are prevalent despite the implementation of SVS, compromising patient care. This study aimed to assess the knowledge, attitudes and practices (KAP) of healthcare professionals (HCPs) on the use of the SVS at PHC level to provide future guidance.

Method

A cross-sectional study using a structured self-administered questionnaire among 206 HCPs at 21 randomly selected PHC facilities located in a health district in KwaZulu-Natal Province, South Africa. Closed-ended questions were used to collect data on socio-demographic characteristics, knowledge on the SVS and practices on its use. A Likert scale was used to determine attitudes towards the SVS. Cronbach's alpha (α) was used to assess the internal consistency of the questionnaire and independent samples t-test and one-way analysis of variance (ANOVA) was used to test statistical difference in the mean scores for KAP and socio-demographic variables. Association between knowledge and practices, and attitude and practices was determined using odds ratios (OR) and Chi-square.

Results

The majority (99.5%) of HCPs had previous training on SVS. Nearly two thirds (62.1%; 128/206) generally had good knowledge about the SVS and 76.7% (158/206) had positive attitudes towards the SVS while only 17.0% had a good practice score. There was no statistically significant association between KAP of HCPs on the use of the SVS, and sociodemographic variables (HCP qualification, age and sex). There was a significant association between the knowledge and practice scores (aOR: 5.44; 95% CI: 1.92-15.4; p = 0.001). Although positive attitudes, was associated with good practices, it was not statistically significant (OR: 1.21; 95% CI: 0.46-3.22; p = 0.702).

Conclusions

HCPs in this district had poor practices when using SVS despite good knowledge and positive attitudes towards SVS and the higher the HCPs knowledge of SVS, the more desirable the practices on SVS. This underscores the need for continuous training of HCPs to ensure a constant and efficient supply of medicines to meet the health needs of the population.

Overdue Assignment: A Case Study on Academic Writing Development for Postgraduate Health Professional Trainees in Kenya

OBJECTIVES

Though essential for research capacity building, development of authorial identity for thesis projects and publications has been overlooked in African postgraduate residency programs. This study aims to explore authorial identity among postgraduate health professional trainees at two universities in Kenya. It also evaluated the effect of Age of Acquisition of English on confidence in writing.

METHODS

This exploratory case study utilized quantitative and qualitative data. Pre- and post-workshop surveys were generated from learning objectives and evaluated confidence in writing and plagiarism awareness, both important attributes of authorial identity. As confidence in writing might be influenced by the English Age of Acquisition, the questionnaire also included items from the Language Experience and Proficiency Questionnaire. Pre- and post-workshop responses were analyzed using planned comparisons. Focus group discussions further explored authorial identity among participants and were analyzed thematically.

RESULTS

A total of 57 postgraduate trainees from nine medical specialties participated in the study. Both confidence in writing and plagiarism awareness improved significantly after the workshop: confidence in writing pre-test (M = 3.20, SD = 0.59) and post-test (M = 3.97, SD = 0.61), t(56) = 6.93, P < .001, d = 0.9; plagiarism awareness pre-test (M = 3.01, SD 0.72) and post-test (M = 3.92, SD 0.65), t(56) = 6,8, P < .001, d = 0.9. The average English Age of Acquisition was 4.98 years and showed no correlation with confidence in writing. Participants recognized that authentic authorship requires hard work and suggested plagiarism is driven by inadequate writing instruction. They proposed that changing perceptions of research and writing could overcome a graduation requirement mindset among trainees.

CONCLUSIONS

Interactive workshops using procedural and enculturation approaches may be useful to develop authorial identity among postgraduate health professionals in Kenya. Further research is needed on evaluating workshop effectiveness using direct indicators of learning and other curricular reforms to promote authorship.

Pilot drug and therapeutic committee programme in Sierra Leone: A descriptive mixed method study

AIMS

Irrational medicine use is a global crisis, but incidences are proportionately higher in low- and middle-income countries such as Sierra Leone. This study explores the structure, functions and challenges of drug and therapeutics committees (DTCs), an intervention towards irrational medicine use recently piloted in Sierra Leone.

METHODS

A 2-phase mixed-method study design was used in this study. Firstly, a cross-sectional survey was conducted on all pharmacists who have worked for at least 1 year in DTC-piloted hospitals, using an online questionnaire to assess DTCs' structure, indicators and challenges. In phase 2, all eligible pharmacists were invited for a semistructured online interview using the WhatsApp messaging application to get deeper insights into the key issues that emerged from the survey; however, only 5 of the 7 consented to participate. MS Excel 2019 and NVivo version 12 were respectively used for data management and analysis.

RESULTS

A total of 6 survey responses and 5 interviews were included in the analysis. Participants are pharmacists from the 7 hospitals in Sierra Leone where DTC was piloted. Most DTCs are comprised of a minimum of 10 members consisting of both medical and hospital administrative staff. The main functions of DTCs are ensuring rational medicines use, monitoring and reporting adverse drug reactions. All 7 hospitals with established pilot DTCs have different subcommittees operating at varying functionality levels, ranging from effective to nonfunctional. The main challenges in DTC functions and maintenance are funding (n = 6), DTC decision implementation (n = 4), and unmotivated members (n = 4). Strategies suggested to improve DTCs at public hospitals and nationwide include resource allocation, monitoring and evaluating DTC functions and its members' capacity building.

CONCLUSION

DTCs present a compelling opportunity towards achieving rational medicines use at the hospital level in Sierra Leone. Nonetheless, the lack of funding and operational resources are significant limitations that must be noted by policymakers before expanding DTC programmes to other hospitals in Sierra Leone.

Prescription pattern and associated factors among pregnant women attending antenatal clinics in University of Gondar, North West Ethiopia

Background

An inappropriate use of drug during pregnancy may harm the fetus. There is no enough study on drug use among pregnant women at the University of Gondar referral hospital. Most studies are carried out in developed countries but not in developing countries. Thus, the aim of this study was to evaluate prescription of drug and associated factors among pregnant women attending antenatal care service in University of Gondar referral hospital.

Methods

Institution based cross sectional study was used among 334 pregnant women who attended antenatal care units of the University of Gondar referral hospital. Data were collected from the pregnant women medical records and registration logbook and analyzed using SPSS version 23. Multivariate logistic regression used to analyze the association of the independent variables with drug use. P-values <0.05 were considered significant.

Result

A total of 334 pregnant women's medical records showed a total of 631 drugs prescribed. The average numbers of drugs per pregnant women was 1.88. All pregnant women (100%) were prescribed with iron folat. Most pregnant women 185 (55.2%) were in the third trimester followed by third trimester 91 (27.25%). Moreover, 23.77%, 42.95%, 33%, and 7% pregnant women encountered with drugs from category A, B, C and D respectively. From the bivariate regression analysis, Age of women, maternal illness, trimester at the first visit, and gravidity were significantly associated with exposure to prescribed drug use during pregnancy.

Conclusion

The present study showed the deviation of drug use pattern from the WHO optimal levels proposing the hospitals had inappropriate use of drug. Implementing corrective measures are required to achieve the recommended standards of appropriate drug use.

Antibiotic Use and Stewardship Indicators in the First- and Second-Level Hospitals in Zambia: Findings and Implications for the Future

Introduction: There are increasing concerns with growing rates of antimicrobial resistance (AMR) across Africa, including in Zambia, enhanced by inappropriate utilization of antibiotics across the sectors. There is a need in hospitals to document current prescribing patterns via point prevalence surveys (PPS) alongside recognized indicators to improve future use. The findings can subsequently be used to develop and instigate appropriate antimicrobial stewardship programs (ASPs) to improve the quality of future antimicrobial prescribing across Zambia. This includes encouraging the prescribing of 'Access' over 'Watch' and 'Reserve' antibiotics where pertinent. Methods: A PPS was undertaken using the WHO methodology among 10 first- and second-level public hospitals across the 10 provinces of Zambia. A sampling process was used to select the hospitals. Results: The prevalence of antibiotic use among the in-patients was 307/520 (59.0%), with a high rate of empiric prescribing of ceftriaxone at 36.1% of all antibiotics prescribed (193/534). The reason for antibiotic use was recorded in only 15.7% of occasions and directed treatment prescribed in only 3.0% of occasions. Compliance with the national standard treatment guidelines (STGs) was also low at only 27.0% of occasions. Conclusion: High empiric prescribing, limited documentation of the rationale behind antibiotic prescribing, high use of 'Watch' antibiotics, and limited compliance to STGs among surveyed hospitals requires the urgent instigation of ASPs across Zambia to improve future prescribing.

Assessment of WHO core drug use indicators at a tertiary care Institute of National importance in India

Rational prescribing of medicines is an important aspect of drug prescribing which helps in safe and efficacious and cost-effective drug treatment for patients. WHO Prescription indicators are intended to evaluate the services provided to the population concerning the rational use of medicines. The study aims to study prescription practices and rational use of medicines in the department of Internal medicine, using WHO prescribing indicators in a tertiary care teaching institute of national importance. A total of 50 prescriptions were digitally photographed and analysed for prescription practices and rational drug use, using standard WHO core prescribing indicators. A total of 301 drugs with multiple and diverse diagnoses were used. Statistical analysis was done using SPSS 22 version. The average number of drugs per prescription was 3.48%. It was found that only 13.79% of prescriptions have generic names, whereas 27.58% of patient encounters had at least one drug from the National List of Essential Medicine, 6.8% of prescriptions have antibiotics and 0.7% of prescriptions were injections. The number of prescriptions with fixed drug combinations was 27.55%. Indicators such as percentage of the National List of Essential Medicine, fixed drug combinations and prescribing with a generic name are used. Hence, we will suggest regular prescription audit practices and conducting CMEs and training workshops for clinicians for the rational use of medicines in all healthcare settings to succeed in the rational use of medicine.

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.

A national, multicentre web-based point prevalence survey of antimicrobial use in community healthcare centres across South Africa and the implications

OBJECTIVE

Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community healthcare centers (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider.

METHODS

A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilization data, with utilization assessed against World Health Organization (WHO) and South African guidelines.

RESULTS

The overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients' files.

CONCLUSIONS

It's encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.

Evaluation of rational prescribing in a hospital paediatric outpatient clinic in Nigeria

BACKGROUND

Irrational prescribing is a continuing public health issue in low/middle-income countries. This study evaluated the drug use pattern of medicines in paediatrics aged below 12 years attending the outpatient paediatric clinic of Bingham University Teaching Hospital, Nigeria.

METHOD

An observational cross-sectional study was conducted using patients' medical records who attended the outpatient paediatric clinic from 1 January to 30 April 2022. The WHO prescribing indicators and guidelines for investigating drug use in health facilities were used.

RESULT

A total of 800 prescriptions containing 2723 drugs were analysed, with a mean number of drugs per prescription of 3.4. A total of 651 patients (81.3%) had at least one antibiotic, and the number of encounters with injection was 17.5% (140 patients). Prescribing by generic name was done for 1406 (51.6%) drugs; of the 2723 drugs prescribed, 2441 (89.6%) were from the WHO Pediatric Essential Medication List. In addition, 80% of the prescriptions contained antimalaria. Analgesics/antipyretics were the most frequently prescribed medicine (87.9%).

CONCLUSION

The findings of this study deviated from the WHO recommended standards. There is a need to target paediatric clinics further and enforce national strategies to tackle non-standard prescribing practices among the paediatric population.

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.

Patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities in Bugisu, Eastern Uganda

Objectives

To describe patterns and contextual determinants of antibiotic prescribing for febrile under-five outpatients at primary and secondary healthcare facilities across Bugisu, Eastern Uganda.

Methods

We surveyed 37 public and private-not-for-profit healthcare facilities and conducted a retrospective review of antimicrobial prescribing patterns among febrile under-five outpatients (with a focus on antibiotics) in 2019–20, based on outpatient registers. Multilevel logistic regression analysis was used to identify determinants of antibiotic prescribing at patient- and healthcare facility-levels.

Results

Antibiotics were prescribed for 62.2% of 3471 febrile under-five outpatients. There were a total of 2478 antibiotic prescriptions of 22 antibiotic types: amoxicillin (52.2%), co-trimoxazole (14.7%), metronidazole (6.9%), gentamicin (5.7%), ceftriaxone (5.3%), ampicillin/cloxacillin (3.6%), penicillin (3.1%), and others (8.6%). Acute upper respiratory tract infection (AURTI) was the commonest single indication for antibiotic prescribing, with 76.3% of children having AURTI as their only documented diagnosis receiving antibiotic prescriptions. Only 9.2% of children aged 2–59 months with non-severe pneumonia received antibiotic prescriptions in line with national guidelines. Higher health centre levels, and private-not-for-profit ownership (adjusted OR, 4.30; 95% CI, 1.91–9.72) were significant contextual determinants of antibiotic prescribing.

Conclusions

We demonstrated a high antibiotic prescribing prevalence among febrile under-five outpatients in Bugisu, Eastern Uganda, including prescriptions for co-trimoxazole and ampicillin/cloxacillin (which are not indicated in the management of the common causes of under-five febrile illness in Uganda). Study findings may be linked to limited diagnostic capacity and inadequate antibiotic availability, which require prioritization in interventions aimed at improving rational antibiotic prescribing among febrile under-five outpatients.

High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study

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.

Analysis of policies for use of medically important antibiotics in animals in Namibia: implications for antimicrobial stewardship

BACKGROUND

In Namibia, overuse of medically important antibiotics in animals is common and is a considerable driver of antimicrobial resistance. The study aims to analyze policies, resistance patterns and consumption of these antibiotics used in animals in Namibia.

RESEARCH DESIGN AND METHODS

A scoping review and retrospective descriptive analysis of policies, resistance patterns and use of these antibiotics in Namibia was conducted, and assessed against the AWaRe (Access, Watch and Reserve) antimicrobial use guidance.

RESULTS

Of the forty-five antibiotic products registered for use in animals, 77.8% are Access antibiotics, 68.9% are broad-spectrum and 60% are over-the-counter antibiotics- mainly tetracyclines, penicillins and sulfonamides. There is misalignment of antibiotic use policies for animals and humans and no guideline for antibiotic use in animals. Most medically important antibiotics are indicated for control of gastrointestinal (77.7%), musculoskeletal (71.1%) and respiratory (46.7%) infections, and for growth promotion (4.4%). There is high resistance to AWaRe Access antibiotics- sulfonamides (19.5%-100%), tetracyclines (56%-100%) and penicillin (13.5%-100%).

CONCLUSION

Whilst Namibia banned the use of antibiotics in farming, current policy frameworks are inconsistent across sectors, and promote overuse of broad-spectrum important antibiotics in animals. A multi-sectoral one health approach is required to harmonize antibiotic use policies and reduce resistance.

Evaluation of Drug Use Pattern in Pediatric Outpatient Clinics in a Tertiary Teaching Hospital Using WHO Drug-Prescribing Indicators

Purpose

The main aim of the study is to assess physicians’ prescribing patterns using the World Health Organization (WHO) prescribing indicators among pediatric outpatient clinics, and to identify areas in need of intervention regarding the rational use of medicines among pediatric outpatients in Jordan.

Methods

This is a descriptive observational cross-sectional study that was conducted at the outpatient pediatric clinics at Jordan University Hospital (JUH). During the study period, prescriptions were collected over a period of two months. Prescribing patterns were assessed using the five WHO drug prescribing indicators.

Results

A total of 1011 prescriptions/encounters were assessed. More than half of the encounters were for male patients (n= 595, 58.9%), and the median age of patients was eight years (IQR = 7.9). The average number of drugs prescribed per encounter was 1.8 ± 1.3; however, a specific individual clinic, the respiratory clinic, witnessed an average of 2.1 drugs prescribed per encounter. All of the prescribed drugs were prescribed by generic name (100%). Only 47.7% of the drugs were from the essential drug list of the JUH. Overall, antibiotics were prescribed in 19.5% of the encounters, but at higher rates in some clinics such as respiratory clinics (50.8%). Injectables were prescribed in 9.5% of the 1011 encounters; however, they were prescribed at higher rates in endocrinology and neurology clinics, in 44.8% and 31.3% of encounters, respectively.

Conclusion

This study revealed some adequate prescribing habits with an optimal prescribing pattern of generics and number of drugs per encounter among pediatric patients. However, the prescribing patterns of the essential drug list, antibiotics, and injectables, in specific clinics, failed to meet WHO standards. The findings of this study shed light on the need to establish national strategies to improve prescribing practices among the pediatric population.

Systematic review and meta-analysis of medicine use studies in Ethiopia using the WHO patient care indicators with an emphasis on the availability of prescribed medicines

OBJECTIVE

To collate the findings of studies on patient care indicators in Ethiopia using the WHO/International Network for Rational Use of Drugs indicators with a focus on the availability of medicines to patients.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase, Global Index Medicus, Google Scholar, Medline (via PubMed) and Web of Science.

ELIGIBILITY CRITERIA

Medicine use studies employing the WHO patient care indicators across health facilities in Ethiopia.

DATA EXTRACTION AND SYNTHESIS

Descriptive summary of the indicators and a random-effects meta-analysis were performed for quantitative synthesis of findings on the percentage of medicines actually dispensed. Meta-regression was performed to assess the moderator effects of different attributes of the studies.

RESULTS

A total of 25 studies conducted in 155 health facilities with 11 703 patient exit interviews were included. The median value of average consultation time was 5.1 min (25th-75th: 4.2-6.6) and that of average dispensing time was 78 s (25th-75th: 54.9-120.0). The median percentage of medicines with adequate labelling was 22.4% (25th-75th: 5.6%-50.0%). A concerning trend of decreasing dispensing times and adequacy of labelling were observed in more recent studies. The median percentage of patients with adequate knowledge of dosage schedules of medicines was 70.0% (25th-75th: 52.5%-81.0%). In the meta-analysis, the pooled estimate of medicine availability was 85.9% (95% CI: 82.1% to 89.0%). The multivariable meta-regression showed that geographical area and quality of study were statistically significant predictors of medicine availability.

CONCLUSION

Short consultation and dispensing times, inadequate labelling, inadequate knowledge of patients on medicines and suboptimal availability of medicines were identified in health facilities of Ethiopia. Studies aimed at further exploration of the individual indicators like problems of inadequate labelling and patients' knowledge of dispensed medicines are crucial to determine the specific reasons and improve medicine use.

PROSPERO REGISTRATION NUMBER

CRD42020157274.

A nationwide assessment of community pharmacists’ attitudes towards dispensing errors: A cross-sectional study

Objectives

Dispensing errors (DEs) are common causes of preventable harm to patients. Interestingly, very little is known about their prevalence and types in the community pharmacy setting in Lebanon due to the lack of an effective reporting system. Therefore, this study aims to explore the perceptions of community pharmacists about the types of these errors in Lebanon, the factors behind their occurrence, the reasons for underreporting, and the current practices for reducing them.

Methods

A cross-sectional survey was conducted through a self-administered questionnaire, using a scale of 0–4, distributed among a sample of community pharmacists in Lebanon.

Results

A total of 171 pharmacists responded to the survey, of whom 68% reported that DEs were common, and 52% believed that they were increasing. The main reported contributing factors to DEs were unreadable and incomplete prescriptions (≈3.0 ± 1.0 out of 5), workload, multitasking, interruptions, similarity in names of medications, and fatigue (≈2.5 ± 1.0). Moreover, the perceived strategies to limit the risks of DEs were collaboration with physicians, improving handwriting, double-checking, proper patient counselling, encouraging reporting, and issuance of guidelines (≈3.2 ± 1.0). Finally, the main reasons for underreporting DEs were the lack of obligation to report and the lack of reporting systems (59% and 56%, respectively).

Conclusions

DEs may be very prevalent in Lebanon because they are unmonitored by the authorities. Electronic prescription and fair reporting systems are highly recommended, along with follow-up studies.

Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

BACKGROUND

World Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India.

METHODS

After obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed.

RESULTS

A total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs.

CONCLUSION

While we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Prescription analysis and cost of antidepressant drugs in major depressive disorder outpatients at the tertiary care hospital of Pakistan: a prospective approach

OBJECTIVES

To assess prescribing care indicators, utilization pattern, cost per prescription, cost ratios, and percent cost variation of antidepressants (ADs).

METHOD

A prospective cross-sectional study was carried out at the tertiary care hospital of Peshawar, Pakistan among major depressive disorder (MDD) outpatients from July 2019 to February 2020. The ideal standards for World Health Organization (WHO) prescribing care indicators were used. The ePharma Guide was used to calculate the cost in Pakistani rupees (Rs) and United States dollar (USD) 2021 (exchange rate: 1 USD = 154.43 Rs).

RESULTS

A total of 296 MDD patients received 846 drugs (average 2.86; range:1-8), of which 366 were ADs (average number ADs/prescription; 1.23). About 23% (n = 68) of patients received more than one AD. Only 21 (5.7%) generic ADs were prescribed, and 346 (94.5%) ADs were prescribed from the hospital formulary list. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed ADs (67.5%). The average cost of ADs per prescription per month was 700.95 Rs (4.54 USD). Escitalopram (5.69 Rs; 0.04 USD) showed highest cost ratio and maximum percentage cost variation (468.97%).

CONCLUSION

This study observed low generic prescribing, a higher prescribing trend of SSRI, wide differences in cost ratio and percentage cost variation among ADs.

The prevalence and pattern of antibiotic prescription among insured patients in Dar es Salaam Tanzania

Introduction

high prevalence of antibiotic prescriptions may contribute to the problem of antibiotic resistance. Understanding the pattern of antibiotic prescriptions in a country may inform monitoring and stewardship activities, which are crucial in the fight against antibiotic resistance. We aimed to determine the prevalence and describe the pattern of antibiotic prescriptions among National Health Insurance Fund (NHIF) insured patients receiving treatment at health facilities in Ilala Municipality, Dar es Salaam, Tanzania.

Methods

a cross-sectional analysis of claim forms of NHIF insured patients. A data extraction form was used to capture data for September, 2019 submitted to the Ilala NHIF offices.

Results

among 993 insured patients (mean [±SD] age 36.3 [±23.2] years; 581 [58.5%] females; 535 [53.9%] adults) a total of 357 (46.4%, 95% CI, 42.8-50.0) received an antibiotic prescription. Of the 357 patients who received an antibiotic prescription, 71(19.9%) received more than one antibiotic prescription. The most common antibiotic prescribed was amoxicillin/clavulanate (17.1%) followed by amoxicillin (16.5%) whereas the most commonly prescribed antibiotic class was the penicillins (51.3%) followed by the nitroimidazoles (14.0%). Among patients who received more than one antibiotic, the most commonly co-prescribed antibiotics were Ampicillin/Cloxacillin plus Metronidazole (11.4%) followed by Amoxicillin plus Metronidazole (7.1%). According to 2019 WHO Access, Watch, Reserve (AWaRe) Classification of antibiotics, 60.8% of patients received the access antibiotics, 33.3% received the watch antibiotics whereas 17.4% of patients received antibiotics that were not recommended. No patient received an antibiotic from the reserve group.

Conclusion

the prevalence of antibiotic prescriptions in Tanzania is high and some antibiotics not recommended by the WHO are still prescribed. We recommend revision of the current Tanzania treatment guideline on antibiotics to reflect WHO recommendations, and further research to address local factors influencing antibiotic prescriptions is warranted.

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

Background:

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

Objective:

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

Methods:

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

Results:

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

Conclusion:

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

Assessment of medicine use based on WHO drug-use indicators in public health facilities of the South Indian Union Territory

OBJECTIVE

To assess medicine use based on World Health Organization (WHO) core drug-use indicators in selected public health facilities of the South Indian Union Territory.

METHODS

A prospective cross-sectional study was conducted for period of one year (from March 2019 to February 2020) in 10 selected public health facilities based on the WHO document How to investigate drug use in health facilities. Total 900 prescriptions were analysed to study prescribing, patient care and health facility indicators. The results were compared with the WHO standard measures.

RESULTS

The overall average number of drugs per prescription was 3.2. Percentage of prescriptions with antibiotics and injections were found to be 36.6 and 11.4%, respectively. Percentage of drugs prescribed by generic name was 74.6%. Percentage of drugs prescribed from the National List of Essential Medicine was 93.3%. Average consultation and dispensing time were found to be 3.9 minutes and 49.3 seconds, respectively. The percentage of drugs dispensed in this study was 98.5 and 61.6% of medicines were properly labelled; 76.7% of patients had correct knowledge of each medicine dispensed to them. Mean availability of key essential medicine was 73.4%.

CONCLUSION

Indicators such as percentage of drugs prescribed from the National List of Essential Medicine, availability of copy of essential medicine list and percentage of drugs dispensed were found to be as per WHO optimal value. Indicators such as average number of drugs per prescription, average consultation and dispensing time and percentage of medicines labelled were found below optimal value and need to be improved.

WHO/INRUD Core drug use indicators and commonly prescribed medicines: a National Survey from Sri Lanka

Background

Identification of internationally comparable indicators of medicines use are important for a country to implement strategies and regulations to improve usage of medicines. Sri Lanka established a new National Medicines Regulatory Authority in 2015 and this survey evaluated the medication use indicators in Sri Lanka, according to the International Network on Rational Use of Drugs (INRUD), prior to its implementation.

Methods

This descriptive-cross-sectional study was conducted in 80 pharmacies, representing all 25 districts of the country. Three pharmacy categories were included; privately owned pharmacies, ‘Rajya Osusala’ pharmacies operated by the State Pharmaceuticals Corporation (SPC) of Sri Lanka and SPC Franchisee pharmacy outlets. Selection of pharmacies from respective districts were done proportionate to estimated population. Data were collected to identify WHO/INRUD core drug use indicators and the commonly prescribed medicines.

Results

Total of 2328 prescriptions were included (‘Rajya Osusala 559; SPC Franchise 711; private pharmacies 1058). Altogether 7,255 medicines were prescribed, and the 3 most commonly prescribed medicines were atorvastatin, losartan and metformin. Average number of medicines per encounter was 3.1±1.9 (Median: 3; range 1-12) Highest average number of medicines per encounter was reported in prescriptions received at ‘Rajya Osusala’ pharmacies (3.6±2.2), significantly higher than in other categories of pharmacies (p<0.001). Percentage of medicines prescribed by generic name was only 35.5%, highest at the ‘Rajya Osusala’ pharmacies (40.6%), significantly higher than other categories of pharmacies. The overall percentage of medicines prescribed from essential medicine list (EML) was 68.8%, without any significant variation between different categories of pharmacies. The percentage of medicines actually dispensed and accurately labelled were 92.4 and 98.5% respectively.

Conclusions

The average number of medicines per encounter was higher than the WHO recommended value but the usage of antibiotic and injectable drugs were within recommended standards. Generic prescribing, was very much lower. The EML prescribing, labelling and percentage dispensed medicines fared much better although lower than the WHO recommended 100% compliance. This island wide study has provided national wide data before the implementation of key changes in regulation of medicines in Sri Lanka and a repeat survey will be useful to identify impact of the new legislations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-021-00535-5.

Access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda: a qualitative study

Background

Inappropriate use of antimicrobials in both humans and animals is a key driver of antimicrobial resistance (AMR). In addition, human behaviours such as poor disposal of antimicrobials in the environment can increase their exposure to microbes which can impact on humans and animals. However, evidence on access, use and disposal of antimicrobials for humans and animals at community level in Uganda is limited. This study therefore explored access, use and disposal of antimicrobials among humans and animals in Wakiso district, Uganda.

Methods

A qualitative study was conducted that involved focus group discussions (FGDs) and key informant interviews (KIIs). Participants of the FGDs were community health workers (CHWs) and farmers involved in animal husbandry, while key informants included: officials from the Ministry of Health; Ministry of Agriculture, Animal Industry and Fisheries; human and animal health professionals; district health officials; and members of the national AMR surveillance committee. Twelve FGDs were held (8 for CHWs and 4 for farmers) while 15 KIIs were conducted. Thematic analysis in NVivo (version 12) was performed.

Results

Five main themes emerged from the study: access to antimicrobials in humans; access to antimicrobials in animals; use of antimicrobials in humans; use of antimicrobials in animals; and disposal of antimicrobials. Community members mainly accessed antimicrobials for humans from public health facilities such as government health centres, as well as private facilities, including drug shops and clinics. Antimicrobials for animals were obtained from veterinary practitioners and drug shops (both for humans and veterinary). Examples of inappropriate use of antimicrobials in both humans and animals was evident, such as sharing antibiotics among household members, and giving human-prescribed antimicrobials to food-producing animals as growth promoters. While some CHWs returned unused antimicrobials to public health facilities for proper disposal, community members mainly disposed of antimicrobials with general household waste including dumping in rubbish pits.

Conclusions

There is a need to increase awareness among the population on proper access, use and disposal of antimicrobials for both humans and animals. Development of a drug disposal system at community level would facilitate improved waste management of antimicrobials. Together, these measures would help prevent the rate of progression of AMR in communities.

Antimicrobial Stewardship Activities in Public Healthcare Facilities in South Africa: A Baseline for Future Direction

Antimicrobial resistance (AMR) is a growing problem worldwide, including South Africa, where an AMR National Strategy Framework was implemented to instigate antimicrobial stewardship programmes (ASPs) and improve antimicrobial prescribing across sectors. To address the need to assess progress, a sequential mixed methodology with an explanatory research design was employed. In Phase 1, a self-administered questionnaire was completed by healthcare professionals (HCPs) from 26 public sector healthcare facilities across South Africa to assess compliance with the Framework. The results were explored in Phase 2 through 10 focus group discussions and two in-depth interviews, including 83 participants. Emerging themes indicated that public healthcare facilities across South Africa are facing many challenges, especially at entry level primary healthcare (PHC) facilities, where antimicrobial stewardship activities and ASPs are not yet fully implemented. Improved diagnostics and surveillance data are a major shortcoming at these facilities. Continuous education for HCPs is deficient, especially for the majority of prescribers at PHC level and health campaigns are nearly non-existent. Involvement and visibility of management at certain facilities is a serious shortfall. Consequently, it is important to call attention to the challenges faced with improving antimicrobial prescribing across countries and address these to reduce AMR, especially in PHC facilities, being the first point of access to healthcare for the vast majority of patients in developing countries.

Evidence-based public policy making for medicines across countries: findings and implications for the future

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

Rational Drug Use Evaluation Based on World Health Organization Core Drug Use Indicators in Ethiopia: A Systematic Review

Background

Rational use of medicines plays a vital role in avoiding preventable adverse drug effects, maximizing therapeutic outcomes with promoting patient adherence, and minimizing the cost of drug therapy. Irrational use of drugs is often observed in countries with weak health care systems. No review has been done that systematically expresses rational drug use practice based on the three WHO core drug use indicators in Ethiopia. Thus, this study was aimed to review systematically the prescribing, health-facility, and patient-care indicators based on WHO core drug use indicators in Ethiopia.

Methods

A systematic article search was conducted in different electronic databases including PubMed/ MEDLINE, the Cochrane Library, EMBASE, Web of Science, POPLINE, the Global Health, and Google scholar. Quality assessment was conducted using Newcastle-Ottawa quality assessment scale. Studies were synthesized and grouped in to prescribing, patient care and health facility indicators.

Results

From a total of 6239 articles, 21 studies were found suitable for the review. The highest average number of drugs per encounter was 2.5 while the lowest was 0.98. The percentage of generic drug use was ranged from 70.5% to 100%. The highest percentage of encounters with an antibiotic was 85%. The lowest percentage of drugs prescribed from essential drugs list was 81.4%. The highest percentage of drugs actually dispensed and adequately labeled was 96.16% and 96.25%, respectively.

Conclusion

This study showed that the practice of rational drug use varied across region of the country. The average number of drugs per prescription, percentage of drugs encounter with antibiotics, drugs prescribed by their generic name, average consultation time, average dispensing time, percentage of drugs adequately labeled, and availability of essential drugs showed deviation from the standard recommended by WHO. Thus, provision of regular training for prescribers and pharmacists, and ensuring the availability of essential drugs should be encouraged.

Antibiotic use on acute respiratory tract infection nonpneumonia and nonspecific diarrhea in Primary Health Care Centre in Banjarbaru City, South Kalimantan, Indonesia

OBJECTIVES

Acute respiratory tract infection (ARTI) nonpneumonia and nonspecific diarrhea are the most common cases in primary health care centre (PHCC) in Indonesia with the enormous use of antibiotics. The aims of this study were to analyze the antibiotic use and factors affected to the quality of antibiotic use in PHCC in Banjarbaru City, South Kalimantan, Indonesia.

METHODS

The study was conducted in four PHCCs, two in urban and two in rural areas. All of the patients visited these PHCCs since March to April 2018 were recruited as samples after signing informed consent. Data were analyzed using SPSS version 18.

RESULTS

There were no significant difference in antibiotic use between urban and rural PHCC, both on ARTI nonpneumonia and nonspecific diarrhea. The most prescribed antibiotics were amoxycillin and cephadroxil. Based on DDD/1,000 patients-day calculation, the quantity of antibiotics in urban PHCC was 3,544.4 and in rural PHCC was 3,478.6. Physicians with more than seven years of service, both in rural and urban PHCCs, were prescribe the antibiotics higher than who had been working for shorter period. There were no significant difference between physicians who had trained on rational drug use and had not trained yet in urban PHCC (p=0.874), while in rural PHCC there were a significant difference among them.

CONCLUSIONS

The quantitative analysis showed that the antibiotics use in DDD in urban PHCC was 3,544.416 and in rural PHCC was 3,478.693. Factors affected to the quality of antibiotic use were physician's years of service and rational drug use training's.

Assessment of medicine use among outpatients at healthcare facilities in Ethiopia using the WHO's prescribing indicators with a focus on antibiotics: a systematic review and meta-analysis

OBJECTIVES

To summarize studies on prescribing medicine to general outpatients through the WHO/International Network for Rational Use of Drugs (INRUD) prescribing indicators with a focus on antibiotic prescription.

METHODS

A systematic review and random-effects meta-analysis of studies on the WHO prescribing indicators with a focus on the percentage of encounters with antibiotics prescribed (PEAP) was performed. The databases PubMed, Web of Science, EMBASE and Global Index Medicus were searched.

RESULTS

Twenty-six studies with a total of over 34 000 prescription encounters were included in the systematic review, showing a mean of two medicines per encounter. In each meta-analysis, a range of 19 to 25 studies was included. The percentages of medicines prescribed with an international non-proprietary name (INN) and from the essential medicines list (EML) were 91% and 96% of the total number of medicines, respectively, while 19% of encounters contained injections. Studies with over 25 000 prescription encounters reported an average PEAP of 58% and PEAP showed an increasing trend over the years included in this review. Multivariable meta-regression showed that PEAP increased with the average number of medicines per encounter (estimate = 0.83, P value = 0.0005). The number of medicines, study design and year of prescription explained over 40% of the variation in PEAP across studies.

CONCLUSIONS

Patterns of medicine use within and close to the WHO reference values were reported for the number of medicines, INN prescribing, prescription of injections and compliance with the EML, on average. Prescription of antibiotics requires attention as amounts much higher than the reference values were prescribed, which were even higher with polypharmacy and increasing over the years included in this review.

Evaluation of Rational Use of Medicine Using WHO/INRUD Core Drug Use Indicators at Teda and Azezo Health Centers, Gondar Town, Northwest Ethiopia

Background

Despite medicines are a major contributor to the health and well-being of the community, irrational use of medicines is being a serious public health crisis with significant harmful implications for patients, healthcare systems, and communities as a whole.

Objective

This study was aimed at evaluating the rational use of medicine using the World Health Organization/Network of Rational Use of Drugs (WHO/INRUD) core drug use indicators at Teda and Azezo health centers of Gondar town, northwest Ethiopia.

Methods

A cross-sectional study was conducted among 1200 prescription papers retrospectively, and 60 patients prospectively at two health centers of Gondar town, northwest Ethiopia from May 01/2019 to April 30/2020. The data were collected using a standard data collection checklist. Data were analyzed using SPSS^® version 24. The data were analyzed descriptively by using mean, frequency, and proportion.

Results

Prescribing indicators: From a total of 2595 prescribed medicines, 94% of them were prescribed by generic name; percent encounters with injection was 9.5±0.28%, percent encounters with antibiotics was 73.85±0.35%, and 100% of medicines were prescribed from the essential medicine list of Ethiopia. Patient care indicators: Only 16.7% of the patients knew the correct dosage of their medications, and 17.5% of dispensed medicines were adequately labeled. From the prescribed medications, only 77.17% were actually dispensed. Average consultation and dispensing time were 5.35 minutes and 40.24 seconds, respectively. Facility-specific indicators: Only 83.5% of key medicines were available in the health centers.

Conclusion

According to the WHO/INRUD core drug use indicators, rational medicine use is not achieved in terms of most components of the prescribing, patient care, and facility-specific indicators. Therefore, both health centers should work towards promoting the rational use of medicines.