Investigation of antimicrobial use at a tertiary care hospital in Southern Punjab, Pakistan using WHO methodology

Antimicrobial Use Among Outpatients at Benjamin Mkapa Hospital in Dodoma Central Zone of Tanzania: A Prospective Descriptive Study

Objective

Irrational antimicrobial use (AMU) has led to an exponential increase in antimicrobial resistance (AMR) in hospitals and communities, which creates challenges in treating infectious diseases caused by bacteria. This study aimed to evaluate antimicrobial prescriptions and usage patterns for treating bacterial infections among outpatients at Benjamin Mkapa Hospital (BMH).

Materials and Methods

A prospective descriptive study design was used to evaluate the AMU trend. The data were collected from August 2022 to October 2022 from outpatient pharmacies at BMH using the World Health Organization/International Network of Rational Use of Drugs (WHO/INRUD) indicators. The simple random sampling method was employed to select the prescriptions. The WHO AWaRe (Access, Watch, and Reserve) classification was used to classify common antimicrobials. We analyzed the prevalence of outpatient AMU, including the types of antimicrobials, indications, and compliance with treatment guidelines. We also examined the number of antimicrobials per prescription and the adherence to drug use.

Results

We examined 1557 prescriptions, 406 (26.1%) (WHO recommendation 20.0-26.8%) of which included antimicrobials. All prescriptions with antimicrobials were written in generic names, drug utilization-90% (DU90%) was 100% (WHO recommendation 100%). The number of parenteral antimicrobials prescribed was 79 (19.5%) (WHO recommendation 13.4-24.1%). Furthermore, prescriptions with antimicrobials that complied with the current Standard Treatment Guidelines and National Essential Medicine List in Tanzania (STG/NEMLIT) were 369 (90.9%) (WHO recommendation 100%). Most antimicrobials were prescribed as monotherapy, accounting for 265 (65.3%). There were 1.4 (WHO recommendation 1.6-1.8) antimicrobials per prescription. Our study identified 21 commonly prescribed antimicrobials, whereby 9 (42.9%) (WHO recommendation >60%) antimicrobials were Access, 10 (47.6%) (WHO recommendation <20%) Watch, and 2 (9.5%) (WHO recommendation <1%) Reserved classes.

Conclusion

Our study showed that BMH has optimal practices for prescribing and using antimicrobials for outpatients. It further underlined the need to expand and strengthen antimicrobial stewardship efforts to reinforce prescribing antimicrobials.

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

Background

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

Methods

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

Results

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

Conclusion

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

Assessment of antibiotic prescribing pattern and cost for hospitalized patients: A study from Palestine

BACKGROUND

One of the largest problems facing the world today is the morbidity and mortality caused by antibiotic resistance in bacterial infections. A major factor in antimicrobial resistance (AMR) is the irrational use of antibiotics. The objective of this study was to assess the prescribing pattern and cost of antibiotics in two major governmental hospitals in the West Bank of Palestine.

METHODS

A retrospective cohort study was conducted on 428 inpatient prescriptions containing antibiotics from two major governmental hospitals, they were evaluated by some drug use indicators. The cost of antibiotics in these prescriptions was calculated based on the local cost. Descriptive statistics were performed using IBM-SPSS version 21.

RESULTS

The mean ± SD number of drugs per prescription (NDPP) was 6.72 ± 4.37. Of these medicines, 38.9% were antibiotics. The mean ± SD number of antibiotics per prescription (NAPP) was 2.61 ± 1.54. The average ± SD cost per prescription (CPP) was 392 ± 744 USD. The average ± SD antibiotic cost per prescription (ACPP) was 276 ± 553 USD. The most commonly prescribed antibiotics were ceftriaxone (52.8%), metronidazole (24.8%), and vancomycin (21.0%). About 19% of the antibiotics were prescribed for intra-abdominal infections; followed by 16% used as prophylactics to prevent infections. Almost all antibiotics prescribed were administered intravenously (IV) 94.63%. In general, the average duration of antibiotic therapy was 7.33 ± 8.19 days. The study indicated that the number of antibiotics per prescription was statistically different between the hospitals (p = 0.022), and it was also affected by other variables like the diagnosis (p = 0.006), the duration of hospitalization (p < 0.001), and the NDPP (p < 0.001). The most commonly prescribed antibiotics and the cost of antibiotics per prescription were significantly different between the two hospitals (p < 0.001); The cost was much higher in the Palestinian Medical Complex.

CONCLUSION

The practice of prescribing antibiotics in Palestine's public hospitals may be unnecessary and expensive. This has to be improved through education, adherence to recommendations, yearly immunization, and stewardship programs; intra-abdominal infections were the most commonly seen infection in inpatients and ceftriaxone was the most frequently administered antibiotic.

Regional and National Trends in Consumption of Antimicrobials in Pakistan; Pre and Post-COVID (2019-2021)

BACKGROUND

Efforts to combat antimicrobial resistance, a growing public health problem in Pakistan, have been hampered by the lack of high-quality national and provincial-level antimicrobial consumption data. The singular objective of this retrospective study was to measure antimicrobial consumption over 3 years between 2019 and 2021.

METHODS

The study was designed to estimate antimicrobial consumption at National and Regional levels. Antimicrobial consumption data was collected by IQVIA covering 110 districts of Pakistan in which 88% of sales are census (accurate sales collected directly from distributors), whereas 12% of sales (sales of 300 pharmacies) are projected on the national level. To determine the usage for 3 consecutive years, the consumption of antibiotics was calculated as defined daily doses (DDD) of antibiotics per 1000 inhabitants per day (DID).

RESULTS

The results of our study demonstrated a steep increase in the consumption of antimicrobials from 2019 to 2021. An increase in consumption of most classes of antibiotics was observed both nationally and Regionally. Quinolones, penicillins (co-amoxiclav), macrolides, and third-generation cephalosporins remained the most frequently used antibiotics nationally. A 40% increase in intravenous use of antimicrobials was observed between 2019 and 2021 at the national level. Moxifloxacin, Levofloxacin, Ciprofloxacin, and linezolid were the most commonly used intravenous antibiotics. Region 7 (Peshawar) demonstrated the highest consumption, followed by Region 1 (Karachi) and Region 6 (Faisalabad). Among the most commonly used antibiotics, the use of third-generation cephalosporin (cefixime), quinolones, penicillins (amoxicillin + clavulanic acid), and macrolides (azithromycin) was most noticeable in all regions, particularly in those with the higher consumption of antibiotics.

CONCLUSIONS

Although the increase in consumption of all antibiotics is concerning, the steep increase in the use of watch and reserve category antibiotics during the study period calls for immediate actions to limit and regulate their usage.

Evaluation of healthcare professionals' understanding of fluoroquinolones' safety profile, usage, and boxed warnings in Pakistan

INTRODUCTION

Fluoroquinolones (FQs) is a distinct class of antibiotics which are prescribed and used quite frequently worldwide, despite the box warnings (BW) issued by Food and Drug Administration (FDA). Literature has shown in spite of BWs related to FQs there is minimal impact on health care professionals (HCPs) prescribing habits, potentially attributing towards limited and insufficient awareness. In Pakistan, FQs are mostly prescribed antibiotics for microbial treatments, therefore the purpose of this study was to determine the level of knowledge about the safety profile, use, and BW of FQs among HCPs working in Pakistan.

METHODS

A cross-sectional study was undertaken among the HCPs of Khyber Pakhtunkhwa province of Pakistan from October 2022 to December 2022. A validated questionnaire was used to assess the knowledge of HCPs regarding FQs, its safety profile and BW. A random convenient sample technique was used while recruiting HCPs in this study. As the HCPs comprised physicians, dentists, pharmacist and nurses, all were approached in person and the study objective was fully elaborated and explained to them. The statistic test like: one-way ANOVA, independent-t test, multivariate logistic regression were used keeping the p-value < 0.05 as statistically significant.

RESULTS

A total of n = 250 HCPs were approached, of which n = 186 HCPs completed the questionnaire with a response rate of 74.4%. FQs prescribing pattern was only assessed among the prescribers, i.e., physicians and dentists (39/186). The mean knowledge score for indications was 5.29 ± 3.05, while for the adverse effects was 7.70 ± 2.61. The highest score for knowledge for indications and adverse effect score was achieved by physicians followed by dentist. The mean knowledge score for the BW was 3.46 ± 2.93 and among the HCPs for the BW of FQs, 20.4% of the HCPs had appropriate knowledge score (score ≥ 50%). The knowledge score was significantly higher in males (p = 0.039), dentists (p = 0.001), HCPs having master/specialization level of education (p = 0.003), HCPs working in government sector hospitals (p = 0.010) and secondary care hospitals (p = 0.001) while the multivariate logistic regression analysis showed that HCPs working in primary care hospital (OR: 6.2) and secondary care hospital (OR: 20.3) were associated with the tendency to achieve 50% or above knowledge score.

CONCLUSION

 Findings of this study reveals the unsatisfactory knowledge of HCPs regarding the safety profile, use, and BW of FQs putting patients at heightened risks of FQs associated AEs. Therefore, it is crucial to implement a national antimicrobial stewardship program, seminars and lectures aimed at continuously updating the knowledge of HCPs, regardless of their specialties, and effectively restrict the misuse of antimicrobial and disseminate FDA BWs in clinical practice.

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 .

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia

Introduction

Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes.

Methods

An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics.

Results

During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively).

Conclusion

Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.

Prevalence of antibiotics prescription amongst patients with and without COVID-19 in low- and middle-income countries: a systematic review and meta-analysis

Antimicrobial resistance (AMR) poses a substantial risk to public health. In low-income and middle-income (LMICs) nations, the impact of AMR is significantly more severe. The absence of data from low-income countries (LMICs) causes this topic to be frequently overlooked. Additionally, the COVID-19 pandemic could make the AMR issue even worse. Earlier guidelines recommended antibiotic use in patients with COVID-19, even in those without bacterial coinfection. This study aims to investigate the proportion of antibiotic prescriptions in LMICs among patients with and without coronavirus disease-2019 (COVID-19), the proportion of inappropriate antibiotics, and multi-antibiotic prescribing. We followed the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA). We retrieved data through online databases, including PubMed, Scopus, and ScienceDirect. Amongst COVID-19 patients, the meta-analytic estimate of antibiotic prescription was 0.80 (95% CI: 0.72-0.88), whereas antibiotic use among patients with non-COVID-19 infections was 0.54 (95% CI: 0.49-0.58). Half of those prescribed antibiotics (0.52, 95% CI: 0.32-0.72) are inappropriate prescriptions. In addition, we found that one-third of antibiotics prescriptions consisted of more than one antibiotic (0.32, 95% CI: 0.21-0.43). In conclusion, antibiotics are highly prescribed across LMICs, and their use is increased in patients with COVID-19. Amongst those prescriptions, inappropriate and multiple use was not uncommon. This study has several limitations, as it included two studies in an ambulatory setting, and some of the studies included in the analysis were conducted on a small scale. Nevertheless, our findings suggest that urgent action to improve prescribing practices is essential.

Antibiotic Susceptibility Surveillance in the Punjab Province of Pakistan: Findings and Implications

Background and Objectives: The increase in antimicrobial resistance (AMR) across countries has seriously impacted the effective management of infectious diseases, with subsequent impact on morbidity, mortality and costs. This includes Pakistan. Antimicrobial surveillance activities should be mandatory to continually assess the extent of multidrug-resistant bacteria and the implications for future empiric prescribing. The objective of this retrospective observational study was to monitor the susceptibility pattern of microbes in Pakistan. Materials and Methods: Clinical samples from seven laboratories in Punjab, Pakistan were collected between January 2018 and April 2019, with Punjab being the most populous province in Pakistan. The isolates were identified and their antimicrobial susceptibility was tested using the Kirby-Bauer disc diffusion assay and micro broth dilution methods. The antibiotics assessed were those typically prescribed in Pakistan. Results: In total, 2523 bacterial cultural reports were studied. The most frequently isolated pathogens were Staphylococcus aureus (866, 34.3%), followed by Escherichia coli (814, 32.2%), Pseudomonas aeruginosa (454, 18.0%) and Klebsiella pneumoniae (269, 10.7%). Most pathogens were isolated from pus (1464, 58.0%), followed by urine (718, 28.5%), blood (164, 6.5%) and sputum (81, 3.2%). Conclusions: The findings suggest that current antimicrobial options are severally restricted in Pakistan due to the emergence of multidrug-resistant pathogens. This calls for urgent actions including initiating antimicrobial stewardship programs to enhance prudent prescribing of antibiotics. This includes agreeing on appropriate empiric therapy as part of agreed guidelines, in line with the WHO EML and AWaRe book, whilst awaiting culture reports. This is alongside other measures to reduce inappropriate antimicrobial prescribing and reverse the threat of rising AMR.

Antibiotic utilization pattern in treatment of acute diarrheal diseases: the case of Hiwot Fana Specialized University Hospital, Harar, Ethiopia

BACKGROUND

The vast majority of acute diarrheal diseases are self-limiting and do not require treatment on a regular basis. Empirical antibiotics should only be used to treat dysenteric and invasive bacterial diarrhea. Antibiotic misuse in the treatment of acute diarrhea is widespread in clinical practice worldwide. Hence, the purpose of this study was to examine the pattern of antibiotic use for the acute diarrheal diseases at Hiwot Fana Specialized University Hospital, Harar, Ethiopia.

METHODS

A retrospective, institution-based cross-sectional study was conducted to investigate the antibiotic utilization pattern for the treatment of acute diarrheal diseases from September 1 to September 30, 2022. Data were obtained retrospectively from patient cards treated for diarrheal disorders from August 1, 2021 to August 31, 2022, using standardized questionnaires, and the analysis was performed using IBM SPSS Statistics version 27.

RESULTS

Among 332 patients in present study, 271 (81.63%) of them received nine different types of antibiotics, with the most commonly prescribed drugs were Cotrimoxazole (30.26%), Ciprofloxacin (19.19%), and Azithromycin (17.71%). Based on the presence of blood in the stools, 14.76% of the cases were invasive bacterial in nature. Antibiotics were prescribed about 2.55 times more frequently to patients under the age of 12 than to subjects 65 and older (AOR 2.55, 95% CI 1.45-3.87). Patients who received three or more medications were 2.77 times more likely to be prescribed antibiotics (AOR 2.77, 95% CI 1.84-7.56). For every unit increase in the number of drugs prescribed, the odds of prescribing antibiotics increased by 2.44 units (COR 2.44; 95% CI 2.06-4.32).

CONCLUSIONS

The current study found that antibiotics were overused in both adults and children with acute diarrheal diseases at Hiwot Fana Specialized University Hospital. The number of antibiotics prescribed was significantly associated with the patient's age and the number of medications prescribed. To reduce antibiotic overuse, health professionals have to follow the national standard treatment guidelines.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Point Prevalence Survey of Antimicrobial Use during the COVID-19 Pandemic among Different Hospitals in Pakistan: Findings and Implications

The COVID-19 pandemic has significantly influenced antimicrobial use in hospitals, raising concerns regarding increased antimicrobial resistance (AMR) through their overuse. The objective of this study was to assess patterns of antimicrobial prescribing during the current COVID-19 pandemic among hospitals in Pakistan, including the prevalence of COVID-19. A point prevalence survey (PPS) was performed among 11 different hospitals from November 2020 to January 2021. The study included all hospitalized patients receiving an antibiotic on the day of the PPS. The Global-PPS web-based application was used for data entry and analysis. Out of 1024 hospitalized patients, 662 (64.64%) received antimicrobials. The top three most common indications for antimicrobial use were pneumonia (13.3%), central nervous system infections (10.4%) and gastrointestinal indications (10.4%). Ceftriaxone (26.6%), metronidazole (9.7%) and vancomycin (7.9%) were the top three most commonly prescribed antimicrobials among surveyed patients, with the majority of antibiotics administered empirically (97.9%). Most antimicrobials for surgical prophylaxis were given for more than one day, which is a concern. Overall, a high percentage of antimicrobial use, including broad-spectrums, was seen among the different hospitals in Pakistan during the current COVID-19 pandemic. Multifaceted interventions are needed to enhance rational antimicrobial prescribing including limiting their prescribing post-operatively for surgical prophylaxis.

Perceptions of healthcare professionals and patients on the role of the pharmacist in TB management in Pakistan: A qualitative study

Background: Globally, tuberculosis (TB) is the second major cause of death from infectious diseases, particularly in developing countries. A multidisciplinary approach to the management of TB may help to curb the disease burden. Objective: The objective of this study was to outline the perceptions of healthcare professionals and patients regarding the potential role of pharmacists in TB management in Pakistan. Method: This was a large-scale qualitative study conducted at the Chest Disease Unit (CDU) of the Bahawal Victoria Hospital (BVH), Punjab, Pakistan. Data were collected through semi-structured interviews with physicians, pharmacists, and patients recruited using a mix of convenient and snowball sampling. The sample size was decided through standard saturation point criteria. All interviews were audio recorded and transcribed verbatim. The data were analyzed to draw conclusions using a thematic analysis approach. Results: Analysis of the data yielded 19 categories and seven themes. Physicians considered pharmacists qualified healthcare professionals, whereas patients considered them merely dispensers. Inventory management and dispensing of medicines were considered as major responsibilities of pharmacists. Physicians were extremely overburdened and wanted to delegate certain duties to pharmacists, subject to their prior extensive trainings. However, most of the physicians were unaware of the legal scope of pharmacy practice in Pakistan. With regard to the potential duties of pharmacists, physicians, pharmacists, and patients (patients-upon explaining the potential roles during the interview) endorsed monitoring, counseling, medicine brand selection, dose adjustment, inventory management, dispensing, and polypharmacy assessment as their potential roles. In view of all stakeholders, the rationale for integrating pharmacists in TB management included overburdened physicians, sub-standard patient care, medication safety issues, and patient dissatisfaction. The healthcare professionals highlighted that the major barriers to integrating pharmacists within the TB management system were limited interest of regulatory authorities and policy makers, followed by inadequate training and experience-driven questionable competency of pharmacists. Conclusion: The study participants acknowledged the potential role of pharmacists in TB management. However, it was emphasized that healthcare policy makers should devise strategies to overcome the underlying barriers before assigning medicine-related clinical roles to pharmacists.

Antimicrobial Stewardship in Tropical Infectious Diseases: Focusing on Dengue and Malaria

Acute undifferentiated febrile illness (AUFI) is the presenting symptom of various tropical and infectious diseases. Viral infection is generally the most common cause of AUFI, accounting for 8–11.8% of cases; thus, antibiotics might be unnecessary. Dengue and malaria are common tropical infectious diseases requiring effective supportive treatment and antimalarial agents, respectively. The uncertainty of early diagnosis results in widespread empirical antimicrobial treatment in high -income as well as in low-and middle-income countries. Although rapid diagnostic tests (RDTs) have been shown to limit antibiotic prescriptions in dengue and malaria, we observed a wide range of antibiotic prescriptions for 13–92.7% of cases in previous literature, particularly in RDT-negative malaria cases. Given several RDT limitations, antimicrobial stewardship (AMS) appears to be an effective strategy for controlling unnecessary antibiotic use and antimicrobial resistance (AMR) prevention. This program should be endorsed by a multidisciplinary team in tropical diseases to control collateral damage of inappropriate antimicrobial use. Empirical antibiotic treatment should be administered based on clinical judgement, microbiological evidence, and local epidemiological data. Rapid termination of antibiotic therapy, including disease control or elimination, is the mainstay of AMS in tropical diseases. Local and international sectors should implement an AMS programme to reduce AMR in the Tropics.

Evaluation of antibiotic prescribing patterns among inpatients using World Health Organization indicators: A cross-sectional study

Objective:

Even though antibiotic resistance is one of the most serious threats to global public health, it is becoming more common due to inappropriate antibiotic prescribing patterns. Thus, the purpose of this study is to assess antibiotic prescribing patterns among inpatients at an Ethiopian comprehensive specialized hospital.

Methods:

An institutional-based cross-sectional study was used. During the study period, data were collected from the charts of admitted patients in selected wards of Debre Tabor comprehensive specialized hospital. The World Health Organization’s developed questionnaire and conventional antibiotic prescribing indicators were used to assess rational drug usage, with an emphasis on antibiotic prescribing trends. The data were analyzed using SPSS 25.0 statistical software.

Results:

For 861 patients admitted to medical and pediatric wards, a total of 1444 antibiotics were prescribed. Overall, 60.6% of inpatients were prescribed at least one antibiotic, with an average (mean ± SD) number of antibiotics prescribed per patient of 1.7 ± 1.6. During their hospital stay, patients were given antibiotics for an average (mean ± SD) of 6.4 ± 2.7 days. Furthermore, 83.3% of antibiotics were prescribed for therapeutic purposes, whereas 100% were provided for empiric purposes. Ceftriaxone was the most commonly administered antibiotic in the study settings (49.2%). During the study period, Debre Tabor comprehensive specialized hospital had access to 67.5% of key antibiotics.

Conclusion:

The antibiotic prescribing pattern in our study diverged from the World Health Organization-recommended guidelines. Furthermore, all antibiotics were given without a culture or sensitivity test in every case. Setting up an antibiotic stewardship program, introducing antibiotic use based on culture and sensitivity tests, and adopting institutional guidelines could all help to address this issue.

Frequency and Factors Associated With Adverse Events Among Multi-Drug Resistant Tuberculosis Patients in Pakistan: A Retrospective Study

Background

Treatment of multi-drug resistant tuberculosis (MDR-TB) for a prolonged period with comparatively less effective and more toxic second-line anti-TB drugs is associated with greater incidence of adverse events.

Study aim

This study aimed to evaluate the frequency and factors associated with occurrence of adverse events among patients with MDR-TB attending the Bahawal Victoria Hospital, Bahawalpur, Pakistan.

Study design

This retrospective study included all patients with MDR-TB who were registered and treated at the study site between June 2014 and December 2016 and had their treatment outcomes available at the time of data collection (i.e., November 2018).

Measures and outcomes

The Electronic Nominal Record System (ERNS) records, medical charts of patients, and laboratory reports were reviewed to obtain the data. Adverse events were reported as per the standard criteria recommended by the WHO. Multivariate binary logistic regression was used to find the independent factors associated with the occurrence of adverse events.

Results

A total of 179 patients with MDR-TB were included in the final analysis. Out of these, 114 (63.7%) patients experienced at least one adverse event during the course of their treatment. Depression was the most common adverse events (33%), followed by nausea and vomiting (27.4%) and arthralgia (27.4%). The factors associated with the occurrence of adverse events included presence of comorbidity (adjusted odds ratio [AOR] 2.951; 95% CI 1.423, 6.118) and being employed (AOR 3.445; 95% CI 1.188, 9.993).

Conclusion

Adverse events were prevalent in this cohort, however, resolved with the effective management approaches. Patients with identified factors for occurrence of adverse events need special attention and enhanced clinical management.

Knowledge, perceptions and practices on antibiotic use among Sri Lankan doctors

INTRODUCTION

Prescribers have a major role in preventing antimicrobial resistance (AMR) through appropriate prescribing. However, in countries like Sri Lanka, where continuous professional development is not mandatory for license renewal and antimicrobial stewardship is not implemented, prescribing practices go largely unchecked.

OBJECTIVES

To identify the knowledge on antibiotic use and practices related to antibiotic prescribing among Sri Lankan doctors.

METHODS

This cross-sectional study was conducted in 2020. We used a validated, pretested Google-form based questionnaire with multiple choices, single best answer questions, polar questions (Yes/No) and five-point Likert scale questions. The Google-sheet generated was used for data analysis. Knowledge and practice scores were calculated.

RESULTS

Of the 262 respondents, 40.1% were males. Majority (61.8%) were aged 25-35-years and in medical practice for 0-5 years (48.9%) while 46.2% had or were engaged in post graduate studies. Knowledge scores ranged from 98.31% to 46.55% [mean:71.27% (SD±10.83); median:71.18% (IQR 64.4-79.7)]. Most (98.09%) obtained ≥50 marks while 45.8% scored more than the mean. The practice scores ranged from 100% to 0% [mean:65.33% (SD±18.16), median:66.67% (IQR53.3-80)]. The majority (81.3%) scored ≥50 in the practice score while 52.3% achieved more than the mean practice score. The knowledge score and the practice score differed significantly (p<0.001, related sample Wilcoxon Signed Rank Test) but the knowledge and practice scores were significantly correlated [Spearman correlation, p<0.001, r = 0.343 (Bias corrected 95% CI 0.237-0.448)]. Knowledge scores and the practice scores were significantly higher in those with or undergoing postgraduate training.

CONCLUSIONS

While the knowledge and practice scores were high, and knowledge and practice scores were correlated, the practices score was lower than that of knowledge indicating the need to encourage correct practices through means other than solely promoting knowledge.

Seasonality and Annual Utilization Patterns of Antibacterials at Muhimbili National Hospital, Dar es Salaam, Tanzania: A 2015 Monthly Survey

Introduction

Antibacterial utilization studies can help identify areas of intervention of antimicrobial stewardship programs (ASP) to facilitate rational use and prevent the emergence of antimicrobial resistance (AMR). Assessment and comparison of antibacterial utilization depend on the Anatomical Therapeutic Chemical (ATC) classification system and Defined Daily Dose (DDD) recommended by the World Health Organization (WHO) collaborative center for international drug monitoring. This study aimed to determine the DDD of each prescribed antibacterial group and the proportions of wide-spectrum antibacterials used at Muhimbili National Hospital (MNH) in Tanzania to allow baseline data for hospital ASPs.

Methods

A retrospective analytical study using data collected from 1st January 2015 to 31st December 2015 was undertaken at MNH. Data on antibacterials prescribed and dispensed were obtained from the MNH database. The ATC/DDD system was used to classify and quantify the antibacterial utilization patterns.

Results

A total of 10,643.1 DDDs were used in thirteen ward units at the Kibasila, Mwaisela and Sewahaji blocks of the MNH. Eighteen different antibacterials were prescribed and dispensed to 1496 patients. Capsules were the most dispensed dosage form. The drug ciprofloxacin was the leading antibacterial prescribed, with a DDD of about 3780 (35.5%) per year. This was followed by metronidazole and amoxicillin. The proportion of wide-spectrum antibacterials was as high as 66%. Utilization peaks were noted in April, July and September. There was a significant monthly increase in antibacterials utilization between January and December 2015 (p-value = 0.002, R-square = 0.64). The trends forecasted increased through June 2016.

Conclusions

Utilization trends indicated a significant monthly increase in 2015 at MNH wards in Tanzania. The use of wide-spectrum antibacterials was widespread. This calls for continued antibacterial utilization surveillance and implementation of hospital-based ASP to mitigate the rapidly rising global threat of AMR.

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.

Prescribing Patterns for Upper Respiratory Tract Infections: A Prescription-Review of Primary Care Practice in Quetta, Pakistan and the Implications

Background: To identify and address the potential overuse of antibiotics, it is important to ascertain the prescribing practices of physicians. We, therefore, conducted this prescription analysis to document URTI-specific antibiotic prescription frequency in a public primary healthcare setting of Quetta city, Pakistan.

Methods: A retrospective record review was conducted of all prescriptions for URTIs in Combined Military Hospital, Quetta from 1 March to 31st May 2021. The Mann-Whitney U and Jonckheere–Terpstra test was used to evaluate the association between the tendencies of a different group of prescribers. p-value of <0.05 was of statistical significance.

Results: Over the 3 months, 50,705 prescriptions were screened and analyzed according to the established inclusion and exclusion criteria. A total of 4,126 (8.13%) URTI prescriptions met the inclusion criteria, of which 2,880 (69.80%) prescriptions contained antibiotics. Among all antibiotics, penicillins (Amoxicillin + Clavulanate) were the most prescribed antibiotic, constituting 1,323 (45.9%) of total antibiotics prescribed for all cases, followed by the Macrolide group 527 (18.2%). The Jonckheere–Terpstra test revealed a statistically significant association between the status of the prescriber and the diagnosis (p = 0.002). Furthermore, a moderate positive trend was reported with specialists being more competent in antibiotic prescribing based on their diagnosis, followed by postgraduates and house officers (τ = 0.322).

Conclusion: The prescribing patterns for the management of URTIs in the hospital were inconsistent with current guidelines. Strict adherence to guidelines must be ensured and antibiotic prescribing for URTIs should be discouraged.

Antimicrobial use among hospitalized patients: A multi-center, point prevalence survey across public healthcare facilities, Osun State, Nigeria

INTRODUCTION

In order to inform sub-national action plan for control of antimicrobial resistance (AMR) and benchmark interventions to improve antibiotic use, it is essential to define situations on antibiotic use using standardized tools. We sought to assess quality of antimicrobial prescription across all government healthcare facilities with capacities for in-patient care in the first of the 36 states in Nigeria as part of ongoing state-wide situation analysis on AMR.

METHODS

A survey was conducted between 10-27 June 2019 using the WHO methodology for point prevalence survey on antibiotic use in hospitals. Data was collected from hospital administrators and records of hospitalized patients. Data analysis was done using Microsoft Excel 2010 (Redmond Washington).

RESULTS

Prevalence of antibiotic use amongst all 321 included patients was 76.6% (246/321). Of all indications recorded, the highest was surgical prophylaxis (96/260, 36.9%) for which there were multiple doses beyond 24 hours in almost all cases (91/96, 94.8%). The largest volume of prescribing took place in the surgical wards, and the most common prescriptions were metronidazole (142/564, 25.2%), cefuroxime (104/564, 18.4%), and ceftriaxone (77/564, 13.7%). Overall, 46.3% of the antibiotics used belong to Access group, 53.5% to watch and only 0.2% to Reserve. Treatment in almost all instances 544/563 (96.6%) was empiric.

CONCLUSIONS

The majority of patients received multiple antibiotics mostly without compliance to guidelines. There was low prescribing of Access antibiotics and excessive use of antibiotics in the Watch group. Antibiotics were used most commonly for surgical prophylaxis but inappropriately. Inappropriate use of antibiotics in this study underscores the crucial need for an action plan incorporating antimicrobial stewardship.

Genetic Diversity of Staphylococcus aureus Strains from a Tertiary Care Hospital in Rawalpindi, Pakistan

Staphylococcus aureus is an important healthcare-associated bacterium that causes a multitude of infections in humans such as superficial skin and soft tissue infections, necrotizing pneumonia, foodborne illnesses and postsurgical infections. Treatment of S. aureus infections has become more complicated due to the emergence of Methicillin-Resistant Staphylococcus aureus (MRSA), some of which are multidrug resistant. The present study aimed to characterize S. aureus isolates from a tertiary care hospital in the Rawalpindi district of Pakistan. Staphylococci were isolated from 300 clinical samples collected from January 2018 to January 2019 and S. aureus isolates were tested for antimicrobial susceptibility and analyzed using Pulsed-Field Gel Electrophoresis (PFGE), Multi-Locus Sequence Typing (MLST), staphylococcal cassette chromosome mec (SCCmec) and spa typing. Approximately 25.3% (76/300) of the clinical samples were positive for S. aureus; of those, 88.2% (67/76) were mecA+ (MRSA). In addition to the β-lactam antibiotics, high levels of resistance were also found to the fluoroquinolones (ciprofloxacin, gatifloxacin and levofloxacin (73.7% each)). Of the 23 different spa types identified, the majority of isolates belonged to spa type t632 and t657 (9/66; 13.6% each spa type). ST772-t657 (Bengal Bay clone) was the most commonly identified clone in this study although other clones circulating around different regions of the world were also found indicating the diversity in MRSA isolates from this area of Pakistan. This study emphasizes the need to monitor MRSA in the clinical setting for improved infection control and treatment options.

Progress on the national action plan of Pakistan on antimicrobial resistance (AMR): a narrative review and the implications

Introduction: The emergence of antimicrobial resistance (AMR) is a threat to public health. In 2015, the World Health Organization (WHO) introduced a global action plan to tackle AMR in the World Health Assembly. Pakistan's national action plan (NAP) for AMR was released in May 2017 by the Ministry of National Health Services. Based on the NAP, strategies have been initiated on a national and provincial scale in Pakistan.Areas covered: This narrative review of the five components of the Pakistan NAP has been undertaken to discuss some of the challenges in implementation of the NAP for AMR in Pakistan including different opinions and views of key stakeholders, combined with suggestions on potential ways to reduce the burden of the AMR.Expert opinion: Going forward, healthcare authorities should focus on screening and monitoring of all the objectives of the NAP by establishing proper policies as well as promoting antimicrobial stewardship interventions and Infection prevention and control (IPC) practices. Overall, the comprehensive strengthening of the healthcare system is required to adequately implement the NAP, tackle continued inappropriate antimicrobial use and high AMR rates in Pakistan.

Evaluation of Prescribing Patterns of Antibiotics Using Selected Indicators for Antimicrobial Use in Hospitals and the Access, Watch, Reserve (AWaRe) Classification by the World Health Organization

Objectives

Antibiotic resistance poses a significant threat to the world, and irrational use of antibiotics is a major contributing factor. Evaluation of antimicrobial use is underway with the help of indicators and the World Health Organization (WHO) classification of antibiotics into Access, Watch, and Reserve (AWaRe) categories. We aimed to evaluate the prescribing pattern of antibiotics using the AWaRe classification by the WHO and selected indicators for antimicrobial use in hospitals.

Materials and Methods

A total of 1.000 prescriptions were analyzed during the study for antibiotic prescribing patterns. Antibiotic consumption was calculated using defined daily dose (DDD) methodology. The prescribing pattern was evaluated using the WHO classification of antibiotics into the categories AWaRe and using selected indicators (hospital and prescribing) for antimicrobial use in hospitals.

Results

A total of 1.128 antibiotics were prescribed during the study. The 19-44 age group was prescribed a high number of antibiotics (n=510). Females were prescribed a high number of antibiotics compared with males (n=602). Azithromycin was the most commonly consumed antibiotic (14.97 DDD/1000/day). Four antibiotics from the Access category and five from the Watch category were prescribed in the study. The Watch category of antibiotics were consumed in a high number. There were no standard treatment guidelines in the hospital. In all, 98.0% of antibiotics were consistent with the hospital formulary and prescribed under generic names. The average number of antibiotics prescribed per patient was 1.12. The average duration of antimicrobial treatment was 5.24 days. The percentage of patients prescribed antimicrobials for pneumonia in accordance with treatment guidelines was 13.28%.

Conclusion

Irrational use of antibiotics exists in hospitals. There is a need to maintain standard treatment guidelines in the hospital because it prevents irrational use of antibiotics.

A prospective study to evaluate antimicrobial prescribing pattern among admitted patients in hilly Himalayan region of northern India

Background and Aim

Global scenario of antimicrobial (AM) utilization depicts 20-50% inappropriateness. Majority of the hospital admissions are due to unwanted effects because of non-judicial usage of these drugs. The present study focuses on utilization pattern of antimicrobials (AMs) in a tertiary care hospital in northern India.

Materials and Methods

A prospective observational study was conducted over a period of one year in seven departments of a tertiary care hospital in hilly Himalayan region. Aim of the study was to analyze the AM utilization pattern using World Health Organization (WHO) indicators and instruments.

Results

A total 700 prescriptions were analyzed in the present study. Injectable antibiotics (71%) followed by oral (29%) were most commonly prescribed. Beta lactams (79%) were the most frequently used antibiotic class. Most commonly prescribed AM was Ceftriaxone (30%). Majority of the time AMs were given empirically (44.8%), where most common indication was respiratory infections (42%). Culture and sensitivity tests were done for guiding curative therapy in 34.71% cases. The average duration of patient hospital stay was 8.81 days in the study population. The mean duration of prescribed antimicrobial treatment was 5.12 days. On an average 1.93 AMs were prescribed per patient. AMs were prescribed by International nonproprietary name (INN) in 62.19% of the admissions. The most common AM related adverse drug reaction was gastritis (96%) and skin rash (4%) with Amoxicillin + clavulanic acid being the most common causative agent. Total antimicrobial consumption was 148.24 DDD/100 bed days with Medicine department showing the highest consumption (36.25/100 bed days).

Conclusion

The present study is the first and largest antimicrobial utilization study in the hilly Himalayan region of northern India. Our study found an urgent need for improvement of prescribing patterns, patient care indicators and strict adherence to standard guidelines.

Antibiotic stewardship program in Pakistan: a multicenter qualitative study exploring medical doctors' knowledge, perception and practices

BACKGROUND

The emerging threat of antibiotic resistance is growing exponentially and antibiotic stewardship programs are cornerstone to fight against this global threat. The study aimed to explore the knowledge, perspectives and practices of physicians regarding various aspects of antibiotic stewardship program including antibiotic stewardship activities, rational use of antibiotics, antibiotic resistance, prescribing practices and factors associated with these practices.

METHODS

In this qualitative study, a total of 17 semi-structured, in-depth interviews with doctors of three tertiary care public sector hospitals in Bahawalpur and Rahim Yar Khan were conducted. The convenient sampling method was adopted to collect the data and the saturation point criterion was applied to determine the sample size. Thematic analysis approach was used to draw conclusions from the data.

RESULTS

The analysis of data yielded five themes, 12 subthemes and 26 categories. The themes included, (i) perception about antibiotic use and antibiotic stewardship, (ii) antibiotic prescription practices, (iii) antibiotic resistance, (iv) limited strategies adopted by hospital administration to ensure quality and safe distribution of antibiotics, (v) implementation of antibiotic stewardship program: barriers, suggestion and future benefits. Doctors had misconceptions about the rational use of antibiotics. The perception regarding antibiotic stewardship programs was poor. Moreover, very few activities related to ASP existed. The participants gave many suggestions for successful implementation of ASP in order to reduce the burden of antibiotic resistance, including development of guidelines for the use of antibiotics, strict legislation regarding use of antibiotics, active participation of healthcare professionals and awareness program among general public about the use of antibiotics.

CONCLUSION

This study concluded that poor knowledge of doctors regarding ASP, non-existence of antibiogram of hospital and lack of rules for the safe use of antibiotics were the main driving factors associated with irrational antibiotic prescription practices and development of AR.

An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes

Background

Antibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC.

Method

We conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September–December 2017) and post-ASP data (April–July 2018). January–March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness.

Result

123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly.

Conclusion

ASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.

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

Background

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

Methods

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

Results

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

Conclusion

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

Antibiotic prescription patterns for treating dental infections in children among general and pediatric dentists in teaching institutions of Karachi, Pakistan

BACKGROUND

Antibiotics are regularly prescribed by dental professionals in their practice, for the purpose of dental treatment as well as for the prevention of infection. The inappropriate use of antibiotics is a significant factor in the rise of antibiotic resistance. There is an immediate need for the advancement of prescribing guidelines and instructive polices to encourage the rational and appropriate utilization of medications especially antibiotics in dentistry.

OBJECTIVE

The aim of this study was to identify the frequency of antibiotic prescription for treating dental infections in children among dentists in teaching institutions of Karachi, Pakistan and whether they are adhering to the prescribed international guidelines.

METHODS

A cross-sectional study was conducted in three private and two public colleges of Karachi. After taking written informed consent and checking the inclusion criteria, a total of 380 participants were interviewed using a pre-designed validated questionnaire which included demographic profile and clinical case scenarios. Data were entered and analyzed on SPSS version 20. Inferential analysis was performed using chi-square test. The significance level was set at 0.05.

RESULTS

Of the 380 subjects, a majority (71.3%) treated 15 or less children per month (n = 271) while 28.7% of dentists (n = 109) treated more than 15 children per month. Overall adherence to American Academy of Pediatric Dentistry guidelines was low from 26.1% to 44.2%. The difference between adherence of dentists with low and high volume of pediatric patients was significantly different for case scenarios 1, 3, 4 and 5 (p<0.001 for all) where dentists who treated 15 or less children per month were more likely to be adherent to standard antibiotic prescription guidelines than those who treated more than 15 children per month.

CONCLUSIONS

This study shows that majority of dentists, particularly dentists with high volume of pediatric patients lacked adherence to professional guidelines for prescribing antibiotics for treating dental infection in children. There seem to be a lack of harmony between the recommended professional guidelines and the antibiotic prescribing pattern of dentists. Regular updates and continuing medical education for the health professionals regarding comprehensible and specific professional guidelines may lead to improved adherence of antibiotics prescription amongst dentists.

Pattern of inappropriate antibiotic use among hospitalized patients in Pakistan: a longitudinal surveillance and implications

Background

The inappropriate use of antibiotics in hospitals increases resistance, morbidity, and mortality. Little is currently known about appropriate antibiotic use among hospitals in Lahore, the capital city of Pakistan.

Methods

Longitudinal surveillance was conducted over a period of 2 months among hospitals in Lahore, Pakistan. Antibiotic treatment was considered inappropriate on the basis of a wrong dosage regimen, wrong indication, or both based on the British National Formulary.

Results

A total of 2022 antibiotics were given to 1185 patients. Out of the total prescribed, approximately two-thirds of the study population (70.3%) had at least one inappropriate antimicrobial. Overall, 27.2% of patients had respiratory tract infections, and out of these, 62.8% were considered as having inappropriate therapy. Cephalosporins were extensively prescribed among patients, and in many cases, this was inappropriate (67.2%). Penicillins were given to 283 patients, out of which 201 (71.0%) were prescribed for either the wrong indication or dosage or both. Significant variations were also observed regarding inappropriate prescribing for several antimicrobials including the carbapenems (70.9%), aminoglycosides (35.8%), fluoroquinolones (64.2%), macrolides (74.6%) and other antibacterials (73.1%).

Conclusion

Educational interventions, institutional guidelines, and antimicrobial stewardship programs need to be developed to enhance future appropriate antimicrobial use in hospitals in Pakistan. Policies by healthcare and Government officials are also needed to minimize inappropriate antibiotic use.

Prescribing practices using WHO prescribing indicators and factors associated with antibiotic prescribing in six community pharmacies in Asmara, Eritrea: a cross-sectional study

Background

Antibiotics require more prudent prescribing, dispensing and administration than other medicines because these medicines are at a greater risk of antimicrobial resistance (AMR). Studying the current medicine use practices and factors affecting the prescribing of an antibiotic would help decision makers to draft policies that would enable a more rational use of medicines.

Methods

A prospective, descriptive, and cross-sectional study was conducted to assess the current prescribing practices including antibiotics use in six community pharmacies in Asmara. A total of 600 encounters were reviewed using the WHO core prescribing indicators between May 5 and May 12, 2019 using stratified random sampling technique. Descriptive statistics and logistic regression were employed using IBM SPSS® (version 22).

Results

The average number of medicines per prescription was 1.76 and 83.14% of the medicines were prescribed using generic names while 98.39% of the medicines were from the National Essential Medicines List (NEML). The percentage of prescriptions containing antibiotics was 53%. The number of encounters containing injections was 7.8%. Patient age, gender and number of medicines prescribed were significantly associated with antibiotic prescribing at bivariate and multivariable models. Subjects under the age of 15 were approximately three times more likely to be prescribed antibiotic compared to subjects whose age is 65 and above (Adjusted Odds Ratio (AOR): 2.93, 95%CI: 1.71–5). Similarly, males were more likely to be prescribed antibiotic than females (AOR: 1.57, 95%CI: 1.10–2.24). Subjects to whom three to four medicines prescribed were two times more likely to be prescribed an antibiotic compared to those who were to be prescribed one to two medicines per encounter (AOR: 2.17, 95%CI: 1.35–3.5). A one-unit increase in the number of medicines increased the odds of antibiotic prescribing increased by 2.02 units (COR: 2.02; 95%CI: 1.62–2.52).

Conclusions

This study found that the percentage of antibiotics being prescribed at the community pharmacies in Asmara was 53% which deviated significantly from the WHO recommended values (20–26.8%). Furthermore, the percentage of encounters with an injection was 7.8% lower than the WHO value of 13.4–24.0%. Patients’ age, gender and number of medicines were significantly associated with antibiotic prescribing.

Prescribing patterns of antimicrobials in the Internal Medicine Department of Ibrahim Malik Teaching Hospital in Khartoum, 2016

Introduction

Antimicrobials are among the most commonly prescribed therapeutic agents in hospitals. Irrational use of antimicrobials results in the development of antimicrobial resistance which could lead to life-threatening illnesses. Therefore, the assessment of antimicrobial prescribing and use is of utmost importance. This study aimed to examine the prescribing patterns of antimicrobials in the Internal Medicine Department of Ibrahim Malik Teaching Hospital in Khartoum, Sudan.

Methods

A descriptive, cross-sectional study was conducted using World Health Organization (WHO) indicators for antimicrobial use in hospitals. Systematic random sampling was used to select 245 medical records from the 2613 medical records of patients admitted to the internal medicine department in 2016. Data were collected using a data collection form and a structured interview with the chief pharmacist in the hospital.

Results

Of the 245 medical records examined, 201 (82%) patients were prescribed one or more antimicrobial drug. The average number of antimicrobials per patient was (2.1±1.1). The average duration of antimicrobial treatment was (4.9±3.8) days. The generic name was used in (35.6%) of antimicrobials, while (95.5%) of all antimicrobials were prescribed from the national essential medicines list. Overall, there were 421 courses of antimicrobials prescribed. The most frequently prescribed antimicrobials were ceftriaxone (131 courses) and metronidazole (89 courses). Among the documented infectious diseases, the most frequently encountered was pneumonia, followed by malaria. There was no drug and therapeutic committee, hospital formulary or essential medicines list, and standard treatment guidelines for infectious diseases in the hospital.

Conclusion

The results of the study revealed a high percentage of antimicrobial use in the Internal Medicine Department. Multifaceted interventions are urgently needed to promote rational prescribing of antimicrobials.

Community pharmacists as antibiotic stewards: A qualitative study exploring the current status of Antibiotic Stewardship Program in Bahawalpur, Pakistan

BACKGROUND

The World Health Organization released a Global Action Plan to overcome the threatening concerns of antibacterial resistance. One of the cornerstones of this plan is the Antibiotic Stewardship Program (ASP). The study aimed to assess the community pharmacists' knowledge, perceptions and current practices regarding ASP.

METHODS

A qualitative study was conducted in Bahawalpur, Pakistan, in which data were collected from the community pharmacists through in-depth, semi-structured interviews. The convenience sampling technique was used to recruit the study participants. Interview protocol was pilot tested and the sample size was limited by applying the saturation point criteria. All interviews were audio recorded and transcribed verbatim. The thematic analysis approach was used to analyze the data and draw conclusions based on study objectives.

RESULTS

A total of fifteen community pharmacists were interviewed. Analysis of the data yielded five themes and 16 subthemes. All of the respondents had sound knowledge about the irrational use of antibiotics; however, they were oblivious about the ASP. After explaining the term, the respondents were of the opinion that these strategies could not be implemented in the current healthcare system of the country. According to the findings of the study, prescribing and dispensing practices were not followed. Only a few patients were educated about the antibiotics they were purchasing.

CONCLUSION

Most of the study participants were unaware of any ASP being offered in the community pharmacy settings. The study participants agreed to be the antibiotic stewards, but a number of obstacles were reported. The training of pharmacists, medication reconciliation, the implementation of the good pharmacy practice guidelines and assurance of pharmacist availability at drug retail outlets were few suggestions given by the study participants to incorporate the ASP in the community settings.

Point prevalence study of antimicrobial use among hospitals across Botswana; findings and implications

Objective: There is an urgent need to undertake Point Prevalence Surveys (PPS) across Africa to document antimicrobial utilisation rates given high rates of infectious diseases and growing resistance rates. This is the case in Botswana along with high empiric use and extended prophylaxis to prevent surgical site infections (SSIs) Method: PPS was conducted among all hospital sectors in Botswana using forms based on Global and European PPS studies adapted for Botswana, including rates of HIV, TB, malaria, and malnutrition. Quantitative study to assess the capacity to promote appropriate antibiotic prescribing. Results: 711 patients were enrolled with high antimicrobial use (70.6%) reflecting an appreciable number transferred from other hospitals (42.9%), high HIV rates (40.04% among those with known HIV) and TB (25.4%), and high use of catheters. Most infections were community acquired (61.7%). Cefotaxime and metronidazole were the most prescribed in public hospitals with ceftriaxone the most prescribed antimicrobial in private hospitals. Concerns with missed antibiotic doses (1.96 per patient), high empiric use, extended use to prevent SSIs, high use of IV antibiotics, and variable infrastructures in hospitals to improve future antibiotic use. Conclusion: High antibiotic use reflects high rates of infectious diseases observed in Botswana. A number of concerns have been identified, which are being addressed.

Antimicrobial susceptibility against metronidazole and carbapenem in clinical anaerobic isolates from Pakistan

Background

Globally metronidazole and carbapenem resistance in anaerobic organisms is increasing necessitating continuous surveillance to guide selection of empirical treatment. In this study we have determined metronidazole resistance in anaerobes using MIC Evaluator strips (M.I.C.E strips). Carbapenem resistance was evaluated only in metronidazole resistant isolates.

Material and methods

The study was conducted at the Aga Khan University (AKU) Hospital laboratory, Karachi, Pakistan (2014–2017). Metronidazole and imipenem resistance was evaluated using M.I.C.E strips and minimum inhibitory concentrations (MICs) were interpreted using Clinical Laboratory Standards Institute (CLSI) criteria. Clinical details including demographics, prolonged hospital stay, malignancy, transplant, dialysis, diabetes, site of infection and outcome were analyzed for association with metronidazole resistance.

Results

Of the 223 clinically significant isolates, 39 (17.5%) were metronidazole resistant (excluding the inherently resistant organisms; for example Cutibacterium species). Imipenem resistance was determined in 29 metronidazole resistant isolates and of these 7 (24.1%) were found to be resistant. Proportion of metronidazole resistant strains was highest amongst Bacteroides species. A significant increase in metronidazole resistance from 12.3% in 2010–2011 to 17.5% in the current study was found. Carbapenem resistance also emerged in the period 2014–2017.

Isolates from malignancy and transplant patients showed lower odds of developing metronidazole resistance (0.003(95% CI: 1.7–17.9)). Prolonged hospital stay was not associated with metronidazole resistance (1.1((95% CI: 0.5–2.5)).

Conclusion

The rising trend of metronidazole resistance and emergence of carbapenem resistance in anaerobic bacteria is alarming. Continued surveillance with strengthening of laboratory capacity regarding anaerobic susceptibility testing is urgently needed in Pakistan.

What drives inappropriate use of antibiotics? A mixed methods study from Bahawalpur, Pakistan

Purpose

This study investigates the knowledge, attitudes and practices of the general public regarding the use of antibiotics in community pharmacy, in Pakistan.

Methods

This is a mixed method study where data were collected through a validated questionnaire and semi-structured interviews. Convenience sampling techniques were used to recruit participants from the general public of Bahawalpur, Pakistan who visited pharmacies to purchase antibiotics between 1 June 2018 and 31 July 2018. Descriptive statistics and regression analyses were used to tabulate the results of quantitative data while inductive thematic analysis was used to identify themes and draw conclusions from the qualitative data.

Results

Over 60% of the 400 survey participants (n=246; 61.5%) had a moderate level of antibiotic knowledge; however, attitudes regarding antibiotics use were poor in half the sample (n=201; 50.3%). More than half (n=226; 56.6%) of the respondents stated that antibiotics could cure all types of infections. Just under one third (n=129; 32.3%) of respondents obtained the appropriate dosage regimen while the majority did not complete the course (n=369; 92.3%); stopping when they felt better. Inductive thematic analysis yielded four themes, 10 subthemes and 27 categories. Two subthemes were related to knowledge, one to attitude, three to practices and four subthemes were related to suggestions to improve the healthcare system. Inappropriate antibiotic practices included: lack of consultation with healthcare professionals, purchase of antibiotics without prescription or refilling of previous prescription, use of home supply of antibiotics, sharing of antibiotics with others, improper dosage regimens and early cessation of antibiotic therapy.

Conclusion

Level of education, low health literacy, high consultation fees of private practitioners, inadequate health facilities in government hospitals and patient overload, busy schedules of people, poor healthcare infrastructure in rural areas and unrestricted supply of antibiotics were key factors associated with inappropriate use of antibiotics in Pakistan.

A multicenter point prevalence survey of antibiotic use in Punjab, Pakistan: findings and implications

OBJECTIVES

In line with the recent global action plan for antimicrobial resistance, this is the first time such a comprehensive antimicrobial point prevalence survey has been undertaken in Pakistan, the sixth most populous country.

METHODS

This point prevalence survey (PPS) was conducted in 13 hospitals among 7 different cities of Pakistan. The survey included all inpatients receiving an antibiotic on the day of PPS. A web-based application was used for data entry, validation, and reporting as designed by the University of Antwerp (www.global-pps.com).

RESULTS

Out of 1954 patients, 1516 (77.6%) were treated with antibiotics. The top three most reported indications for antibiotic use were prophylaxis for obstetrics or gynaecological indications (16.5%), gastrointestinal indications (12.6%) and lower respiratory tract infections (12.0%). The top three most commonly prescribed antibiotics were ceftriaxone (35.0%), metronidazole (16.0%) and ciprofloxacin (6.0%). Out of the total indications, 34.2% of antibiotics were prescribed for community-acquired infections (CAI), 5.9% for healthcare-associated infections (HAI), and 57.4% for either surgical or medical prophylaxis. Of the total use for surgical prophylaxis, 97.4% of antibiotics were given for more than one day.

CONCLUSIONS

Unnecessary prophylactic antibiotic use is extremely high, and broad-spectrum prescribing is common among hospitals in Pakistan. There is an urgent need to work on the  national action plan of Pakistan on antibiotic resistance to address this.

Antimicrobial use by WHO methodology at primary health care centers: a cross sectional study in Punjab, Pakistan

BACKGROUND

To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan.

METHODS

A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS.

RESULTS

Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1-19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1-39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1-1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9-89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3-6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6-4.3). The PHCCs prescribed a median of 5 (range = 3-9) types of AMs, including 10 (range = 5-15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs.

CONCLUSIONS

In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Knowledge of community pharmacists about antibiotics, and their perceptions and practices regarding antimicrobial stewardship: a cross-sectional study in Punjab, Pakistan

Objective

To evaluate the knowledge of community pharmacists about antibiotics, and their perceptions and practices toward antimicrobial stewardship (AMS) in Punjab, Pakistan.

Materials and methods

A descriptive cross-sectional study was conducted among community pharmacists in Punjab, Pakistan from April 1, 2017 to May 31, 2017. A self-administered and pretested questionnaire was used for data collection. A simple random-sampling method was used to select community pharmacies. Independent-sample Mann-Whitney U tests, independent sample Kruskal-Wallis tests, and logistic regression analysis were performed with SPSS version 21.0.

Results

Of the 414 pharmacists, 400 responded to the survey (response rate 96.6%). The participants had good knowledge about antibiotics. They showed positive perceptions, but poor practices regarding AMS. All of the participants were of the view that AMS program could be beneficial for health care professionals for improvement of patient care, and 78% (n=312) of participants gave their opinion about incorporation of AMS programs in community pharmacies. Collaboration was never/rarely undertaken by pharmacists with other health care professionals over the use of antibiotics (n=311, 77.8%), and a significant proportion of participants (n=351, 87.8%) never/rarely participated in AMS-awareness campaigns. Logistic regression analysis revealed that male sex (OR 0.204, 95% CI 0.104-0.4; P<0.001), age 20-29 years (OR 0.172, 95% CI 0.05-0.595; P=0.005), and <1 year of experience (OR 0.197, 95% CI 0.083-0.468; P<0.001) were the factors associated with poor practices regarding AMS.

Conclusion

Pharmacists had good knowledge about antibiotics. There were some gaps in perceptions and practices of community pharmacists regarding AMS. In the current scenario, it will be critical to fill these gaps and improve perceptions and practices of community pharmacists regarding AMS by developing customized interventions.