Experiences and views of healthcare professionals on the prescription of antibiotics in Eastern Uganda: A qualitative study

Knowledge, attitude, and practices regarding antibiotic use and antimicrobial resistance among urban slum dwellers in Uganda

BACKGROUND

Antimicrobial resistance (AMR) remains a public health threat especially in low-and-middle-income countries (LMICs). Urban slum dwellers are at higher risk of developing AMR than the general population. The aim of this study was to assess the knowledge, attitude and practices (KAP) regarding antibiotic use and AMR and the associated socio-demographic determinants among urban slum dwellers in Uganda.

METHODS

A cross sectional study was conducted among 371 adults of Bwaise slum in Uganda selected through multi-stage cluster sampling techniques. An interviewer administered questionnaire was used to collect data on participants' socio-demographics, KAP regarding antibiotic use and AMR. The responses to the KAP were aggregated into scores for each participant which were later dichotomized by the mean to form the predictors variables. Analysis was done in STATA 17.0. A modified Poisson regression model was used to determine predictors of each of KAP, while considering a 5% significance level.

RESULTS

The study enrolled 371 participants of which 238(64.2%) were females. The median (IQR) age of the participants was 31 [24, 40] years. Over half of the respondents, 205(55.3%) were married and 157(42.3%) had primary level education. Of all participants, 177 (47.7%), 184 (49.6%) and 205 (55.3%) had good knowledge, a positive attitude and good practices regarding antibiotic use and AMR respectively. Being single (aPR = 0.75, p-value = 0.040) was negatively associated with good knowledge of antibiotic use and resistance, while having acquired tertiary education level (aPR = 1.88, p-value < 0.001) and self-employed (aPR = 1.36, p = 0.017) were associated with good knowledge of antibiotic use and resistance. Male gender (aPR = 1.25, p-value = 0.036) and monthly income < 300,000 UGX (aPR = 1.42, p-value = 0.003) were associated with a positive attitude towards antibiotic use and resistance. Likewise tertiary level of education (aPR = 0.64, p-value = 0.033) was negatively associated with good practices of antibiotic use and resistance.

CONCLUSION AND RECOMMENDATIONS

Residents of urban slums have limited knowledge of antibiotic use and AMR with minimal understanding of AMR concepts. Education level, gender, occupational status are key players in people's understanding and practices of antibiotic use and AMR. There's need for context specific health education programs. Health promotion messaging should emphasize AMR concepts and dangers of drug misuse. Antimicrobial stewardship initiatives should trickle down to the local citizen.

Antibiotic consumption and utilization at a large tertiary care level hospital in Uganda: A point prevalence survey

INTRODUCTION

Effective antimicrobial stewardship programs require data on antimicrobial consumption (AMC) and utilization (AMU) to guide interventions. However, such data is often scarce in low-resource settings. We describe the consumption and utilization of antibiotics at a large tertiary-level hospital in Uganda.

METHODS

In this cross-sectional study at Kiruddu National Referral Hospital, we analyzed medicine delivery records for the period July 2021 to June 2022, accessed on 12/08/2022, to extract AMC data expressed as defined daily doses (DDDs) per 1000 inhabitants per day (DID). We used the WHO point prevalence survey (PPS) to analyze AMU data with a systematic sampling of outpatient department (OPD) for a period between June and August 2022 and selected all inpatient department (IPD) patients admitted before 8:00 AM on 27/11/2022. AMU data was analyzed as the proportion of individual antibiotic prescriptions, indications for prescriptions, and compliance with the national treatment guidelines. Both AMC and AMU data were categorized by the WHO AWaRe (access, watch, and reserve) criteria.

RESULTS

In the year 2021-2022, a total of 6.05 DID of antibiotics were consumed comprising 3.61 DID (59.6%) access, 2.44 DID (40.3%) watch, and 0.003 (0.1%) reserve antibiotics. The most consumed antibiotics comprised penicillin (1.61 DID, 26.7%), cephalosporins (1.51, 25%), and imidazole (1.10 DID, 18.1%). A total of 119/211 (56%) patients in the OPD and 99/172 (57.5%) patients in the IPD were prescribed antibiotics. Of the 158 OPD antibiotic prescriptions, 73 (46.2%) were access, 72 (45.6%) were watch, 0 (0%) were reserve, and 13 (8.2%) were unclassified antibiotics. Of the 162 IPD antibiotic prescriptions, 62 (38.3%) were access, 88 (54.3%) were watch, 01 (0.6%) was reserve, and 11 (6.8%) were unclassified antibiotics. Indications for antibiotic prescriptions in the OPD comprised respiratory tract infections (53, 38.1%), urinary tract infections (34, 26.6%), gastrointestinal infections (20, 14.4%), sepsis (17, 12.2%), and medical prophylaxis (12, 8.7%). The indications for antibiotic prescriptions in the IPD comprised sepsis (28.2%), respiratory tract infections (18.3%), burn wounds (14.1%), and gastrointestinal infections (14.1%).

CONCLUSION

Prescription of watch antibiotics in both OPD and IPD hospital settings was high. Establishment of robust antimicrobial stewardship measures could help improve the rational prescription of antibiotics.

'Some patients demand for a prescription of an antibiotic': an assessment of barriers and facilitators to rational antimicrobial use in a private health facility in Uganda

Background

Antimicrobial misuse and overuse propagate antimicrobial resistance, yet data on factors influencing antibiotic prescription decisions in low-resource settings are limited. We describe factors influencing antimicrobial prescription at a large tertiary care private not-for-profit hospital in Uganda.

Methods

We conducted a descriptive phenomenology qualitative study involving face-to-face in-depth interviews of 12 purposively selected prescribers (four intern doctors, six medical officers and two Internal Medicine physicians) in a private not-for-profit hospital in Kampala, Uganda. Audio recordings and filed notes were transcribed verbatim and analysed manually by content analysis. Emerging themes and sub-themes were recorded and reported.

Results

Three broad themes emerged: experience with antimicrobial use in Uganda, barriers and facilitators to rational antimicrobial prescription and measures to address irrational antimicrobial use. Participants recognized that antibiotics are often used irrationally, prescribed even when there is uncertainty regarding clinical evidence for infection, and influenced by drug promoters, and noted high levels of antibiotic resistance. Patients' symptoms and clinical signs, previous experience using antibiotics, fear of bad outcomes, patient demand and expectations, influence from senior colleagues, the turnaround time of clinical investigations and drug marketers were the barriers and facilitators to antimicrobial prescription. Prescribers also acknowledged the need to update clinical guidelines, set up hospital antibiograms, and provide continuous medical education on rational antimicrobial use.

Conclusions

A complex interplay of intrinsic and extrinsic factors influences antibiotic prescribing decisions in this hospital. Targeted interventions through continuous education and training for prescribers, providing local prescription guidelines and antibiograms and implementing regulations on over-the-counter antibiotic sales are needed to implement robust antimicrobial stewardship programmes to curb antimicrobial resistance successfully.

Behavioral Nudges to Encourage Appropriate Antimicrobial Use Among Health Professionals in Uganda

Background/Objectives: Antimicrobial resistance (AMR) is a global public health concern exacerbated by inappropriate antimicrobial prescribing practices, particularly in low-resource settings such as Uganda. The research aimed to develop a culturally sensitive behavioral intervention, leveraging a "nudge" strategy, to improve healthcare provider adherence to the 2016 Uganda Clinical Guidelines (UCG 2016) in five Ugandan hospitals. This intervention formed part of broader antimicrobial stewardship initiatives led by the United States Agency for International Development Medicines, Technologies, and Pharmaceutical Services Program. Methods: This study employed a mixed-methods approach, combining formative research and behavioral intervention. Guided by the Deloitte Behavioral Insights Framework, the research team conducted key informant interviews to identify prescribing barriers and motivators and developed three suitable behavioral interventions: perceived monitoring, ward leaderboards, and educational workshops. The study evaluated the interventions' impact through point prevalence surveys (PPS), using the World Health Organization PPS methodology at three stages: pre-intervention, immediate post-intervention, and one-month post-intervention. Results: Key behavioral themes across individual, social, environmental, and organizational elements informed the intervention design and implementation. The behavioral intervention package increased antimicrobial prescription compliance with the UCG 2016 from 27% at baseline to 50% immediately post-intervention, though these effects diminished at one-month post-intervention. Conclusions: Our study addresses an existing gap in behavioral nudges-based operational research on antimicrobial prescribing in low- and middle-income countries. These results showed an immediate improvement in adherence to the UCG 2016 among healthcare providers in Ugandan hospitals, though the effect was attenuated at one-month follow-up. Despite the attenuation, behavior change presents a feasible, cost-effective, and sustainable approach to improving antimicrobial prescribing practices and addressing AMR.

Drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia: a qualitative study

OBJECTIVE

Antibiotic misuse includes using them to treat colds and influenza, obtaining them without a prescription, not finishing the prescribed course and sharing them with others. Although drug providers are well positioned to advise clients on proper stewardship practices, antibiotic misuse continues to rise in Ethiopia. It necessitates an understanding of why drug providers failed to limit such risky behaviours. This study aimed to explore drug providers' perspectives on antibiotic misuse practices in eastern Ethiopia.

SETTING

The study was conducted in rural Haramaya district and Harar town, eastern Ethiopia.

DESIGN AND PARTICIPANTS

An exploratory qualitative study was undertaken between March and June 2023, among the 15 drug providers. In-depth interviews were conducted using pilot-tested, semistructured questions. The interviews were transcribed verbatim, translated into English and analysed thematically. The analyses considered the entire dataset and field notes.

RESULTS

The study identified self-medication pressures, non-prescribed dispensing motives, insufficient regulatory functions and a lack of specific antibiotic use policy as the key contributors to antibiotic misuse. We found previous usage experience, a desire to avoid extra costs and a lack of essential diagnostics and antibiotics in public institutions as the key drivers of non-prescribed antibiotic access from private drug suppliers. Non-prescribed antibiotic dispensing in pharmacies was driven by client satisfaction, financial gain, business survival and market competition from informal sellers. Antibiotic misuse in the setting has also been linked to traditional and ineffective dispensing audits, inadequate regulatory oversights and policy gaps.

CONCLUSION

This study highlights profits and oversimplified access to antibiotics as the main motivations for their misuse. It also identifies the traditional antibiotic dispensing audit as an inefficient regulatory operation. Hence, enforcing specific antibiotic usage policy guidance that entails an automated practice audit, a responsible office and insurance coverage for persons with financial limitations can help optimise antibiotic use while reducing resistance consequences.

Antibiotic resistance in Sudan: assessing the knowledge and practices of healthcare workers in Khartoum

Background

Antibiotic resistance (ABR) is a major public health issue, associated with increased patient morbidity and mortality globally, with significantly higher rates in low- and middle-income countries (LMICs). Assessment of contextual factors, such as information, education, infrastructure and regulations are important for developing local solutions against ABR.

Objectives

To determine the knowledge and practices of healthcare workers (HCWs) towards ABR in hospitals in Sudan.

Materials and methods

A survey was conducted in three different hospitals in Khartoum, Sudan from February to December 2020. HCWs of different specialties and expertise were invited to participate. Data were descriptively analysed using Statistical Package for Social Sciences (SPSS).

Results

ABR was identified as a big challenge by 89% of 345 HCWs who participated. The results show that 79% of doctors don't rely on the clinical microbiology laboratory (CML) results for antibiotic prescription or clinical decision-making. Sixty percent of HCWs agreed there are infection prevention and control (IPC) guidelines in their hospital, but 74% of them don't have access to them, and infrequently receive relevant IPC training. Furthermore, HCWs obtain ABR information from other colleagues informally, not through local data or reports.

Conclusions

Despite adequate knowledge of ABR locally, there are significant contextual technical challenges facing HCWs in Sudan, such as availability of policies and accurate data from CMLs. The results indicate a poor link between HCWs and the CMLs for infection management and it is essential to improve communication between the different hospital departments with regard to ABR transmission, and ensure the effectiveness of local IPC policies based on locally available data.

Antimicrobial stewardship in private pharmacies in Wakiso district, Uganda: a qualitative study

BACKGROUND

Private pharmacies are the first point of contact for the public regarding acquisition of medicines and other pharmaceuticals in many low- and middle-income countries including Uganda. Most antimicrobial stewardship (AMS) programmes in Uganda have targeted pharmacies in public health facilities, with little known about private pharmacies. This study explored knowledge and practices related to AMS in private pharmacies in Wakiso district, central Uganda.

METHODS

This was a qualitative study that involved 31 in-depth interviews to explore AMS among retail private pharmacy staff including pharmacists, pharmacy technicians/dispensers, and nurses. Participants were asked about antimicrobial resistance (AMR) and AMS practices at their pharmacy. The audio-recorded interviews were transcribed verbatim and imported to NVivo 2020 (QSR International) for thematic analysis.

RESULTS

Five major themes emerged from the study: commonly sold antimicrobials; knowledge on AMR and AMS; potential contributors to AMR; practices related to AMS; and challenges to AMS. The commonly sold antimicrobials in the pharmacies with or without prescriptions were oral azithromycin, Ampiclox® (ampicillin and cloxacillin), amoxicillin, ciprofloxacin, Septrin® (co-trimoxazole), metronidazole, Flucamox® (amoxicillin and flucloxacillin), Augmentin® (amoxicillin and clavulanic acid), cephalexin, doxycycline, and chloramphenicol. Participants had heard about AMR but not AMS, although only a few correctly defined AMR. Lack of knowledge among health workers and local communities; the overuse, misuse, and abuse of antimicrobials such as non-adherence to dosage; self-medication; and purchase of drugs without prescription were identified as potential accelerators to the emergence of AMR. Current practices related to AMS in private pharmacies were limited to meetings, antimicrobial dispensing, providing client advice, record keeping, and monitoring of drugs. Cost of healthcare, client satisfaction and retention, outdated guidelines, and the business orientation of pharmacies were the main challenges related to AMS.

CONCLUSION

There was poor knowledge of AMR and AMS, and limited AMS practices in private pharmacies. Private pharmacies have the potential to contribute to Uganda's fight against AMR if motivated and equipped with adequate knowledge to enhance their practices related to AMS.

A case for routine microbial diagnostics: Results from antimicrobial susceptibility testing in post-traumatic wound infections at a Ugandan tertiary care hospital

The global spread of antimicrobial resistance (AMR) poses an increasing challenge for clinicians in Uganda, where microbiological diagnostics are not routinely available or accessible. The aim of this study was to determine pathogen prevalence and antibiotic resistance patterns in patients with wound infections following trauma at a national referral hospital in Kampala, Uganda. In addition, the suitability of currently used empirical treatment options in this setting was evaluated. This prospective, observational study analysed antimicrobial prescriptions, culture results and antimicrobial sensitivity testing (AST) of wound swabs and blood samples from patients with clinical signs of wound infections on the trauma ward. A total of 124 patients (n = 99, 79.8% male) with a median age of 30 years (IQR 23-39) were enrolled between October 2021 and January 2022. Wound infections were classified as nosocomial in 69% of the cases. Pathogens were isolated from 122 wound swabs, yielding 238 bacterial isolates. The most prevalent pathogens were gram-negative bacteria including Escherichia coli (n = 48, 20.2%) and Acinetobacter spp. (n = 43, 18.1%). Empiric treatment consisted of ceftriaxone and gentamicin which was administered to 67.2% (n = 78) and 62.1% (n = 72) of patients, respectively. High rates of antimicrobial resistance could be demonstrated across gram-negative and gram-positive species towards the most common empiric antibiotics. Following the AST results, over 95% (n = 111) of patients required a change of treatment. Our findings demonstrate that current empiric treatment for wound infections is missing its target in hospitalized patients in Kampala. To address the growing problem of AMR in Uganda, there is a pressing need to enhance diagnostic capacity and implement structured antimicrobial stewardship programs.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Exploring Barriers to One Health Antimicrobial Stewardship in Sri Lanka: A Qualitative Study among Healthcare Professionals

Antimicrobial resistance (AMR) is a global health threat, but little is known about the perceptions regarding antimicrobials and AMR among healthcare professionals in Sri Lanka. This research aimed to take a One Health approach to explore the knowledge, attitudes and perceptions of antibiotic stewardship and AMR among healthcare professionals in Sri Lanka. A qualitative study, using telephone interviews, allowing for an in-depth exploration of attitudes, beliefs and perspectives was conducted. Healthcare professionals from both the medical and veterinary sectors were included (n = 29). Interviews were conducted by an independent interviewer and were audio-recorded and transcribed. Conventional qualitative content analysis was undertaken. Four main categories were identified: (1) understanding of AMR and observing AMR, (2) barriers to antimicrobial stewardship, (3) personal factors in, and as a result of, inappropriate antibiotic usage and (4) how to tackle AMR. Healthcare professionals showed poor awareness regarding the spread of AMR and identified inappropriate prescribing behaviours by their inter- and intra-professional colleagues. Patient demands and the influence of pharmaceutical companies were factors contributing to poor prescribing behaviour. Suggestions for the future are stricter regulation of AMR control policy, effective government involvement, and awareness campaigns for healthcare professionals and the public.

Exploring the Antimicrobial Stewardship Educational Needs of Healthcare Students and the Potential of an Antimicrobial Prescribing App as an Educational Tool in Selected African Countries

Antimicrobial resistance (AMR) is a global health threat and one of the top 10 global public health threats facing humanity. AMR contributes to 700,000 deaths annually and more deaths, as many as 10 million are projected to happen by 2050. Antimicrobial stewardship (AMS) activities have been important in combating the ripple effects of AMR and several concerted efforts have been taken to address the issues of antimicrobial resistance. The Commonwealth Pharmacists Association through the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) programme has been enhancing the capacity of health institutions in Low-Middle-Income Countries (LMIC) to combat AMR. Through such efforts, an antimicrobial prescribing app (CwPAMS app) was launched and delivered to support antimicrobial prescribing and improve AMS practice in four African countries; Ghana, Uganda, Zambia, and Tanzania. The app provides easy access to infection management resources to improve appropriate use of antimicrobials in line with national and international guidelines. This study aimed to identify and explore the potential for the usability of the CwPAMS app among healthcare students across selected African countries that are part of the Commonwealth. The study equally evaluated the healthcare students’ understanding and attitudes towards antimicrobial resistance and stewardship. Despite 70% of the respondents indicating that they had been taught about prudent use of antibiotics, diagnosis of infections and their management using antibiotics in their universities, notable knowledge gaps were discovered: 52.2% of the respondents had no prior information on the term AMS, 50.6% of them reported a lack of resources for accessing up-to-date information on drugs, for instance only 36% had had an opportunity to access an app as a learning resource even when 70% of the respondents thought that a mobile app would support in increasing their knowledge. Those challenges reveal an opportunity for the CwPAMS App as a potential option to address AMR and AMS gaps among healthcare students.

Hospital-Based Antimicrobial Stewardship Programs Used in Low- and Middle-Income Countries: A Scoping Review

The burden of antimicrobial resistance (AMR) is considerable in many low- and middle-income countries (LMICs), and it is important to describe the antimicrobial stewardship program (ASP) activities found in these countries and report their impact. Importantly, as these programs target prescribing behavior, the factors influencing prescription of antimicrobials must also be taken into account. This scoping review aimed to (1) describe hospital-based ASP activities, (2) report methods used to measure the impact of ASPs, and (3) explore factors influencing antimicrobial prescribing behavior in LMICs. PubMed was searched from database inception until April 2021. Factors influencing antimicrobial prescribing behavior were canvassed using the Capability-Opportunity-Motivation and Behavior framework. Most of ASP studies in LMICs were predominantly conducted in tertiary care and university-based hospitals. Audit of antimicrobial prescriptions with feedback and restrictive-based strategies was the main reported activity. Total antimicrobial consumption was the main method used to measure the impact of ASPs. Positive outcomes were observed for both clinical and microbiological outcomes; however, these were measured from nonrandomized controlled trials. Dominant factors identified through the behavioral framework were a limited awareness of AMR as a local problem, a perception that overprescription of antimicrobials had limited consequences and was mainly driven by a motivation to help improve patient outcomes. In addition, antimicrobial prescribing practices were largely influenced by existing hierarchy among prescribers. Our scoping review suggests that LMICs need to evaluate antimicrobial appropriateness as an added measure to assess impact. Furthermore, improvements in the access of microbiology and diagnostic facilities and ensuring ASP champions are recruited from senior prescribers will positively influence antimicrobial prescribing behavior, helping improve stewardship of antimicrobials in these countries.

Indonesian healthcare providers' perceptions and attitude on antimicrobial resistance, prescription and stewardship programs

Background: A successful antimicrobial stewardship program (ASP) is sustained through improving antimicrobial prescribing by changing prescribing behavior. This requires a better understanding of hospital stakeholders' views regarding antimicrobial resistance (AMR), antimicrobial use and participation in ASP activities. Objectives: Identify perceptions and attitudes among physicians and pharmacists in a public hospital toward AMR, prescription and ASP. Methods: A questionnaire consisting of 45 items was distributed to physicians and pharmacists in a 320-bed public hospital. All responses were formatted into the Likert scale. Results: A total of 78 respondents (73% response rate) completed the questionnaire. The majority of the respondents perceived AMR within hospital as less of a severe problem, and factors outside hospital were considered to be greater contributors to AMR. In addition, interprofessional conflict was identified as a serious concern in relation to implementing ASP. Conclusion: This finding indicates the need to address existing perceptions and attitudes toward ASP activities that may hamper its successful implementation in Indonesia.

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.