An Evaluation of Antibiotic Prescribing Practices in a Rural Refugee Settlement District in Uganda

Scoping Review of Health Economics Research on Refugee Health in Sub-Saharan Africa

OBJECTIVES

Most refugees and internally displaced people (IDP) stay in low- and middle-income settings. A substantial proportion are hosted by countries in sub-Saharan African (SSA), which puts significant pressure on limited government healthcare budgets. As health economics may guide more optimal healthcare decision making, we scope the health economics literature on forcibly displaced populations in SSA to identify the nature and range of health economics evidence.

METHODS

We conducted a scoping review of peer-reviewed and gray literature in English published from 2000 to 2021. Our search terms comprised a combination of keywords related to refugees, SSA, and health economics. We followed a stepwise methodology consisting of the identification and selection of studies, extraction and charting of data.

RESULTS

We identified 29 health economics studies on refugees and IDPs in SSA covering different providers, interventions, and delivery platforms. Twenty-one articles studied the determinants of health, followed by 5 on the supply of healthcare and 2 concerned with economic evaluation and the demand for healthcare, respectively. We found an equal division of articles focusing on refugees and IDPs, as well as by settlement type. Mental health was the most frequently studied health area and Uganda was the most studied destination country.

CONCLUSIONS

The health economics literature on refugees in SSA remains limited. Our scoping review encourages future research to study a larger variety of healthcare systems and health economic topics such as economic evaluations, health financing and whole health systems to support resource allocation decisions and sustainable long-term solutions.

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

Objective

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

Methods

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

Results

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

Conclusion

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

An Evaluation of Antibiotic Prescription Rationality at Lower Primary Healthcare Facilities in Three Districts of South-Western Uganda

Purpose

Antimicrobial resistance is now one of the leading five causes of death globally. This study evaluated the rationality of antibiotic prescriptions at lower primary care levels in three districts of Southwestern Uganda.

Methods

This prospective cross-sectional study reviewed 9899 antibiotic prescriptions at 39 health centers following a drug delivery cycle by National Medical Stores in three phases (19 days each on average). Phase 1 started 3 days after delivery, mid-way (Phase 2) and towards the end (Phase 3). The proportion of rationally prescribed antibiotics was determined using a modified criterion by Badar and in reference to Uganda Clinical Guidelines (UCG). Using multivariate logistic regression, the factors associated with rational prescription were determined with 95% confidence intervals.

Results

Seven of every 10 antibiotic prescriptions were irrational. Half the prescriptions were made by unauthorized personnel (nurses) and many of the pediatric prescriptions (916, 46.5%) did not bear body weight measurements to guide appropriate dosing. Also, the proportion of rational prescriptions in reference to UCG, 2016 was very low (3387, 34.2%). However, a high proportion of antibiotic prescriptions were legibly written (9462, 95.7%), prescribed by generic names (9083, 91.8%) and had a diagnosis (9677, 97.8%) indicated. Multivariate logistic analysis showed that; availability of medicines (phase 1) (phase 2 AOR=1.14, 95% CI:1.02-1.28, phase 3, AOR=1.23, 95% CI:1.1-1.38), legibly written prescription (AOR=0.61, 95% CI: 0.47-0.78), indication of a date on the prescription (AOR=0.56, 95% CI0.38-0.81) and being a medical officer were factors associated with rational antibiotic prescription.

Conclusion

We observed a high rate of irrational prescription in the study sites and the majority of these were by unauthorized personnel. A review of antibiotic use policies and focused interventions is crucial in these settings.

Evaluation of Antibiotics Use and its Predictors at Pediatrics Ward of Jimma Medical Center: Hospital Based Prospective Cross-sectional Study

Background

One of the biggest emerging public health issues is the alarming increase in the prevelance of antibiotic resistance across the globe, which is linked to significant morbidity and mortality and demands special attention. The most significant risk factor for antimicrobial resistance (AMR), which is increasing considerably in Ethiopia and is responsible for increased adverse effects, treatment failure, and rising health-care costs, is inappropriate antibiotic usage. The purpose of this study was to assess the use of antibiotics in inpatient settings at an Ethiopian teaching hospital providing tertiary care.

Methods

The hospital-based prospective cross-sectional study was undertaken at JMC in southwest Ethiopia. Data were collected by using structured checklist which contains patient's sociodemographic characteristics and pattern of antimicrobial use. All cards of patients which fulfill the inclusion criteria were selected by using a systematic random sampling technique. Bivariate analysis was done to know the association between independent variable and the outcome variable.

Results

The medical records of 402 pediatric patients who had taken at least one systemic antibiotic were examined. The most frequently prescribed combination antibiotics were ampicillin+gentamycin (43.33%) followed by ceftriaxone+gentamycin (15.23%). Gentamycin 116 (24.11%) was the most frequently used antimicrobial. Overall 19.29% of antibiotic use was improper. A higher percentage of participants 149 (22.41%) experienced inappropriate antibiotic usage as a result of inappropriate frequency. Pediatric patients stay in hospital ≥7 days (AOR; 2.45, 95%CI: 2.32-5.34), prescribed antibiotics ≥2 3.12 (AOR: 3.12, 95%CI: 6.32-13.37) and prescribed empirical treatment types (AOR; 2.65, 95%CI: 4.23-8.87) were independent predictors of inappropriate antibiotics use.

Conclusion

Antibiotics were generally used inappropriately at high rates. Gentamycin and crystalline penicillin were the most prescribed antibiotics. Longer hospital stay, antibiotics prescription ≥2, and empirical treatments were the independent predictors of inappropriate antibiotic use.

Scoping Review of National Antimicrobial Stewardship Activities in Eight African Countries and Adaptable Recommendations

Antimicrobial resistance (AMR) is a global health problem threatening safe, effective healthcare delivery in all countries and settings. The ability of microorganisms to become resistant to the effects of antimicrobials is an inevitable evolutionary process. The misuse and overuse of antimicrobial agents have increased the importance of a global focus on antimicrobial stewardship (AMS). This review provides insight into the current AMS landscape and identifies contemporary actors and initiatives related to AMS projects in eight African countries (Ghana, Kenya, Malawi, Nigeria, Sierra Leone, Tanzania, Uganda, and Zambia), which form a network of countries participating in the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme. We focus on common themes across the eight countries, including the current status of AMR, infection prevention and control, AMR implementation strategies, AMS, antimicrobial surveillance, antimicrobial use, antimicrobial consumption surveillance, a one health approach, digital health, pre-service and in-service AMR and AMS training, access to and supply of medicines, and the impact of COVID-19. Recommendations suitable for adaptation are presented, including the development of a national AMS strategy and incorporation of AMS in pharmacists’ and other healthcare professionals’ curricula for pre-service and in-service training.

Point Prevalence Survey of Antibiotic Use across 13 Hospitals in Uganda

Standardized monitoring of antibiotic use underpins the effective implementation of antimicrobial stewardship interventions in combatting antimicrobial resistance (AMR). To date, few studies have assessed antibiotic use in hospitals in Uganda to identify gaps that require intervention. This study applied the World Health Organization’s standardized point prevalence survey methodology to assess antibiotic use in 13 public and private not-for-profit hospitals across the country. Data for 1077 patients and 1387 prescriptions were collected between December 2020 and April 2021 and analyzed to understand the characteristics of antibiotic use and the prevalence of the types of antibiotics to assess compliance with Uganda Clinical Guidelines; and classify antibiotics according to the WHO Access, Watch, and Reserve classification. This study found that 74% of patients were on one or more antibiotics. Compliance with Uganda Clinical Guidelines was low (30%); Watch-classified antibiotics were used to a high degree (44% of prescriptions), mainly driven by the wide use of ceftriaxone, which was the most frequently used antibiotic (37% of prescriptions). The results of this study identify key areas for the improvement of antimicrobial stewardship in Uganda and are important benchmarks for future evaluations.

An opportunity for global antimicrobial stewardship research: Refugee populations

Antimicrobial resistance is a well-known global health threat that has higher prevalence in the refugee population. Although guidance has been provided by the World Health Organization and Centers for Disease Control and Prevention on implementing antimicrobial stewardship in lower- and middle-income countries, as well as by the United Nations Refugee Agency on other infection prevention and control efforts, no specific guidance exists for implementation of stewardship in this population. We highlight challenges specific to this population, review recent studies of interest within this space, and propose a research agenda to help move stewardship forward in the refugee population. We advocate for the importance of this issue, particularly given recent current events of geopolitical volatility that render this population more vulnerable, in the setting of its already well-known numerous health challenges.