Antibacterial prescription and the associated factors among outpatients diagnosed with respiratory tract infections in Mbarara Municipality, Uganda

Prescription patterns of antibiotics and associated factors among outpatients diagnosed with respiratory tract infections in Jinja city, Uganda, June 2022-May 2023

BACKGROUND

Most respiratory tract infections (RTIs) are viral and do not require antibiotics, yet their inappropriate prescription is common in low-income settings due to factors like inadequate diagnostic facilities. This misuse contributes to antibiotic resistance. We determined antibiotic prescription patterns and associated factors among outpatients with RTIs in Jinja City, Uganda.

METHODS

We conducted a retrospective observational study that involved data abstraction of all patient records with a diagnosis of RTIs from the outpatient registers for the period of June 1, 2022, to May 31, 2023. An interviewer-administered questionnaire capturing data on prescribing practices and factors influencing antibiotic prescription was administered to drug prescribers in the health facilities where data were abstracted and who had prescribed from June 1, 2022, to May 31, 2023. We used modified Poisson regression analysis to identify factors associated with antibiotic prescription.

RESULTS

Out of 1,669 patient records reviewed, the overall antibiotic prescription rate for respiratory tract infections (RTIs) was 79.8%. For specific RTIs, rates were 71.4% for acute bronchitis, 93.3% for acute otitis media, and 74.4% for acute upper respiratory tract infections (URTIs). Factors significantly associated with antibiotic prescription included access to Uganda Clinical Guidelines (Adjusted prevalence ratio [aPR] = 0.61, 95% CI = 0.01-0.91) and Integrated Management of Childhood Illness guidelines (aPR = 0.14, 95% CI = 0.12-0.87, P = 0.002), which reduced the likelihood of prescription. Prescribers without training on antibiotic use were more likely to prescribe antibiotics (aPR = 3.55, 95% CI = 1.92-3.98). Patients with common cold (aPR = 0.06, 95% CI = 0.04-0.20) and cough (aPR = 0.11, 95% CI = 0.09-0.91) were less likely to receive antibiotics compared to those with pneumonia.

CONCLUSION

The study reveals a high rate of inappropriate antibiotic prescription for RTIs, highlighting challenges in adherence to treatment guidelines. This practice not only wastes national resources but also could contribute to the growing threat of antibiotic resistance. Targeted interventions, such as enforcing adherence to prescription guidelines, could improve prescription practices and reduce antibiotic misuse in this low-income setting.

The epidemiology of antibiotic-resistant clinical pathogens in Uganda

Background

Antibiotic resistance (ABR) is a global challenge, and its control depends on robust evidence primarily derived from surveillance systems.

Methods

We utilised a national surveillance data set to demonstrate how such evidence can be systematically generated. In doing so, we characterised the ABR profiles of priority clinical pathogens, identified associated factors, and drew inferences on antibiotic usage in Uganda.

Results

Of the 12 262 samples collected between 2019-21, we analysed 9033 with complete metadata. ABR was steadily increasing at a rate of 0.5% per year, with a surge in 2021 and the highest and lowest levels of penicillin and carbapenems detected in the northern (odds ratio (OR) = 2.26; P < 0.001) and the northeast (OR = 0.28; P < 0.001) regions of Uganda respectively. ABR was commonly observed with Escherichia coli (OR = 1.18; P < 0.001) and Klebsiella pneumoniae (OR = 1.25; P < 0.001) among older and male patients (61-70 years old) (OR = 1.88; P = 0.005). Multi-drug resistance (MDR) and ABR were disproportionately higher among bloodstream infections than respiratory tract infections and urinary tract infections, often caused by Acinetobacter baumannii. Co-occurrence of ABR suggests that cephalosporins such as ceftriaxone are in high use all over Uganda.

Conclusions

ABR is indeed a silent pandemic, and our results suggest it is increasing at 0.5% per year, with a notable surge in 2021 likely due to coronavirus disease 2019 (COVID-19). Of concern, ABR and MDR are mainly associated with bloodstream and surgical wound infections, with a gender and age dimension. However, it is encouraging that carbapenem resistance remains relatively low. Such evidence is critical for contextualising the implementation and evaluation of national action plans.

Pharmaceutical Drug Promotion and Rational Drug Use: Assessment of Healthcare Workers Perspective

Background

Pharmaceutical drug promotion has the potential to improve rational drug use by creating awareness among healthcare workers and patients as well as increasing access to life-saving medicines. This study aimed to determine whether pharmaceutical drug promotion can improve rational drug use among healthcare workers.

Methods

Semi-structured questionnaires were filled by selected dispensers and prescribers in central Uganda. Forms of pharmaceutical drug promotion, sources of drug information, and views on the influence of drug promotion on rational drug use were investigated. Associations amongst selected variables were tested at bivariate and multivariate levels.

Results

Of the 383 participants enrolled in the study, 49.6% were dispensers. More dispensers (49.0%, 92/188) favored 1 on 1 discussion whereas prescribers (32.0%, 61/191) preferred continuous medical education. Most dispensers (85.6%, 161/188) and prescribers (68.6%, 131/191) reported that drug promotion influences their choice of drug use, with most (dispensers: 85.1%, 160/188 vs prescribers: 72.3%, 1/191) admittedly relying on drug promotion as their primary source of drug information.

Conclusion

Pharmaceutical drug promotion influences prescription and dispensing practices among health workers, and it should be strictly regulated to ensure accurate and essential information for health workers while prioritizing rational use of medicines.

Usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy in northern Tanzania

Introduction

Antimicrobial Resistance (AMR) is a growing concern globally, mostly being contributed by a limited understanding of antibiotic utilization as a result of inappropriate acquisition and prescription. Parental awareness is essential in optimizing their usage and preserving the effectiveness of these crucial medications. The current study investigates the usage and parental knowledge of antibiotics in children undergoing (adeno) tonsillectomy ((A)TE) in Northern Tanzania.

Methods

a cross-sectional survey was conducted among parents/caregivers of children who underwent (A)TE in Northern Tanzania. A modified and well-structured questionnaire, which was adapted from a World Health Organization (WHO) questionnaire and used to assess the parents´ knowledge of antibiotics and antibiotic use.

Results

the study included 157 participants. About 54% of the children under the age of 5 years. As of 88% of children had already received antibiotics prior to surgery, 92% of the used antibiotics were prescribed by a clinician, and 5% of parents to used leftovers antibiotics for their children. While 88% of the parents reported adhering to prescriptions, 8% of reported buying the same antibiotic (as prescribed before) without consulting a clinician again when their children are sick.

Conclusion

the use of antibiotics, including broad-spectrum antibiotics, was found to be high in our study group. Parents demonstrate a relatively good understanding of antibiotic usage. It is plausible to speculate that a higher prevalence of non-insured, unemployed, and less educated parents may lead to an increased incidence of misuse and misinterpretation of antibiotics.

Viral etiology of lower respiratory tract infections in adults in the pre-COVID-19 pandemic era: A cross-sectional study in a single center experience from Cameroon

Background and Aims

Respiratory viruses are responsible for the majority of lower respiratory tract infections (LRTIs) worldwide. However, there is a gap on the epidemiology of viral LRTIs in adults in sub-Saharan African countries. In Cameroon, like in other countries, the role of viral respiratory pathogens in the etiology of LRTIs in adults is helpful for clinical management. This study aimed to determine the viral aetiologies of LRTIs among hospitalized adults in a reference center for respiratory diseases in the town of Yaounde in Cameroon and its surroundings.

Methods

A cross-sectional study was conducted from January 2017 to January 2018 at Jamot Hospital in Yaounde (Cameroon). Clinical and demographic information; BAL and sputa were collected from hospitalized patients meeting LRTI case definitions. The clinical samples were investigated for respiratory pathogens with a commercial Reverse Transcriptase Real-Time Polymerase Chain Reaction (RT-PCR) targeting 21 viruses, cultures for bacterial and fungal infections.

Results

The 77 included adult patients with LRTIs had an appropriate clinical sample for microbial investigations. A viral agent was detected in 22.1% (17/77) samples. The main viruses detected included rhinovirus (10/77), coronavirus (hCoV-OC43 and hCoV-229E), and influenza A virus (3/77 each). A concomitant viral and bacterial co-infection occurred in 7.8% of patients (6/77) while viral co-infection occurred in one patient (1.3%). No Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) was detected in clinical samples. Most patients were under antimicrobials before getting diagnosed.

Conclusions

Respiratory viruses account for 22.1% of LRTIs in hospitalized patients in this study. Despite prior antimicrobial therapy and delay, rhinovirus, coronavirus and influenza A virus were the most detected in patients in the pre-COVID-19 pandemic era in a single center experience from Cameroon.

Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study

The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020−March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35−44 years (OR: 3.38; 95%CI: 1.15−9.88), >55 years (OR: 4.75; 95% CI 1.08−21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08−4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

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.