Rational prescribing of antibiotics in children under 5 years with upper respiratory tract infections in Kintampo Municipal Hospital in Brong Ahafo Region of Ghana

Appropriateness of Antibiotic Prescription Among Children Under 5 Years: A Cross-Sectional Study in a Ghanaian Regional Hospital

Background and Aim

Misuse of medications, particularly antibiotics, severely impacts the standard of care and can result in antibiotic resistance. Antibiotic resistance is a growing problem in Ghana, compromising patient outcomes. This study aims to assess antibiotic prescription pattern and level of inappropriateness based on Standard Treatment Guideline (STG) recommendations in children under 5 years.

Methods

An analytical cross-sectional study design was used to assess antibiotic prescription in children under 5 years attending the Wa Regional Hospital in Ghana. Medical records of pediatric outpatients from January to December 2022 were reviewed. Patients' sociodemographic characteristics, prescribed antibiotics, principal diagnosis, dose, and duration were extracted using a semi-structured form. Prescriptions with clinical indication, dose, and duration which did not meet the requirements of the STG were coded as inappropriate. Data were analyzed and factors associated with inappropriate antibiotic prescription were determined using logistic regression.

Results

Children's mean age was 2.95 ± 1.20 years, with males comprising 54.5%. Most patients had NHIS coverage (90.6%). This study reports 62.7% (266/424) inappropriate antibiotic prescriptions in children under 5 years with infections. The most common classes of antibiotics wrongly prescribed were cephalosporin 54.3% (230/424), penicillin 21.7% (92/424), and aminoglycoside 12.5% (53/424). The class of principal diagnoses likely to have inappropriate antibiotic prescriptions included respiratory tract infections (aOR = 3.82; 95% CI = 2.13, 6.85; p < 0.0001) and urinary tract infections (aOR = 0.21; 95% CI = 0.11, 0.41; p < 0.0001).

Conclusion

Prevalence of inappropriate prescription of antibiotics was high among the study population, and this was strongly associated with respiratory and urinary tract infections. This study highlights the need to monitor antibiotic prescriptions in hospitals to ensure treatment effectiveness and combat antimicrobial resistance.

Knowledge and practices of healthcare professionals regarding antibiotic use in a district hospital, Southern Mozambique: a cross-sectional study

Tackling the worldwide problem of antibiotic resistance requires addressing the lack of knowledge about antibiotics and understanding the impact of resistance. This study aimed to assess healthcare professionals' (HCP) knowledge about antibiotics and antibiotic resistance and the antibiotic prescription practices for outpatients at the Manhiça District Hospital in Mozambique. This cross-sectional study assessed the knowledge and practices of 20 HCPs about antibiotic use and resistance and evaluated quality indicators of antibiotic use of 200 prescriptions. We observed that 20% of the participants incorrectly placed amoxicillin in the cephalosporin group, and 10% considered antibiotic resistance a rejection reaction by the patient's body. However, the HCPs showed Knowledge level A. Antibiotics featured in 88% of prescriptions, with an average of one antibiotic per prescription. Cotrimoxazole (30.77%) and amoxicillin (26.15%) were the most frequently prescribed antibiotics. Cotrimoxazole was more prescribed for adults (21.54%) and amoxicillin for children (17.95%). Seasonal variation was observed with an increased winter consumption of cotrimoxazole and phenoxymethylpenicillin in summer. The results revealed a high level of knowledge of HCPs about how to use and identify antibiotics. A higher frequency of broad-spectrum antibiotic prescriptions was observed with cotrimoxazole and amoxicillin being the most prescribed.

A retrospective clinical evaluation of the quality of antibiotic use in treating ear, nose and throat infections in ambulatory care setting of a teaching hospital in Ghana: findings and implications

BACKGROUND

Ear, nose and throat (ENT) infections are often associated with high levels of morbidity and mortality. Antibiotic overuse and misuse for most ENT infections have been reported, caused by a lack of expertise or uncertainties to distinguish between infection types. This study sought to determine the level of appropriateness of antibiotics for ENT infections and its associated factors in ambulatory care in a teaching hospital in Ghana to guide future policies given rising resistance rates.

METHODS

A retrospective cross-sectional study design was undertaken to audit the quality of antibiotic use in Ho Teaching Hospital, a leading teaching hospital in Ghana, between January 2022 to December 2022. A checklist was designed to extract patient socio-demographic and clinical information from electronic medical records. The main study outcome was the appropriate choice of antibiotics principally in accordance to the Ghana standard treatment guidelines. Descriptive, bivariate and multivariate analyses were performed on the data collected using STATA version 14.

RESULTS

The electronic medical records of a total of 3,279 patients were extracted. The majority (57.88%, n = 1898) of patients were females, median (inter-quartile range) age was 25 [7-42] years. Ear infections were the commonest (66.24%, n = 2172) diagnosed ENT infection, followed by throat infections (15.74%, n = 516). The most prescribed antibiotic was oral amoxicillin-clavulanic acid together with a topical neomycin-steroid combination (28.00%, n = 918), followed by amoxicillin-clavulanic acid alone (18.69%, n = 613). The appropriate choice of antibiotic for all ENT infections in accordance with treatment guidelines was 60.11%. Inappropriate use of antibiotics was high when more than one antibiotic and World Health Organisation (WHO) 'Watch' group antibiotics were prescribed and ear infections compared to the nose and throat infections were treated.

CONCLUSION

The appropriateness of antibiotic use for ENT infections in this hospital was suboptimal. It was predicted by the type of infection, the number of antibiotics prescribed and the WHO AWaRe group. Antimicrobial stewardship interventions such as clinical audit with feedback and clinician education must be enhanced to among other things identify antibiotic use gaps to help reduce unnecessary use of antibiotics for ENT infections.

Antibiotic Usage for Treatment of Acute Upper Respiratory Tract Infections in Children in Lithuania from 2018 to 2022

Background/Objectives: Acute upper respiratory tract infections (URIs) are defined as inflammatory diseases of the nose, sinuses, pharynx, larynx, or trachea. They are common in children. The prescription of antibiotics for the treatment of URIs became a relevant theme in the scientific literature in recent decades. One of the most important ways to deal with increasing antimicrobial resistance is rational antibiotic therapy. This study aimed to evaluate the tendencies of antibiotic prescribing practices for Lithuanian children with URIs from 2018 to 2022. We describe how many children with URIs were prescribed antibiotics, which antibiotics were used, and whether prescribing practices meet national guidelines. Methods: Secondary data, which were used in this observational study, were collected from the Lithuanian Compulsory Health Insurance Fund (CHIF) electronic records. The study population consisted of children aged between 0 and 18 years who visited their primary care doctors (pediatricians or family doctors) between January 2018 and December 2022 and were prescribed antibiotics for the treatment of URIs. Results: Between 2018 and 2022, there were 445,328 visits reported when antibiotics, which belong to the J01 group according to the Anatomical Therapeutic Chemical Classification (ATC), were prescribed to children aged 0-18. In more than half of the visits (51.70%), children aged 0-5 were consulted. Penicillins were mostly prescribed for the treatment of acute nasopharyngitis. Macrolides were mostly used to treat acute laryngitis and tracheitis. Of all penicillin-class antibiotics, the most popular choice was amoxycillin. The primary choice of cephalosporin was cefadroxil, and the primary choice of macrolide was clarithromycin. Conclusions: During the period of 2018-2022, the number of prescriptions for antibiotics for URTIs decreased, but prescriptions for penicillin-class antibiotics increased in a relative manner. The most common diagnoses during these visits were acute tonsillitis and acute pharyngitis, and most antibiotic prescriptions were for children in the 0-5 age group. If Lithuania's National Recommendations on the Rational Use of Antibiotics were implemented during the analyzed period, the prescribing tendencies would not meet them.

Improving antibiotic utilization in West Africa: enhancing interventions through systematic review and evidence synthesis

BACKGROUND

Bacterial infection has been estimated to become the leading cause of death by 2050, causing 10 million deaths across the globe due to the surge in antibiotic resistance. Despite western sub-Saharan Africa being identified as one of the major hotspots of antimicrobial resistance (AMR) with the highest mortality, a comprehensive regional analysis of the magnitude and key drivers of AMR due to human antibiotic use has not been conducted.

METHOD

We carried out a systematic review by conducting a comprehensive search in various databases including PubMed and Scopus for eligible articles published in the English Language between 1 January 2000 and 14 February 2024. Five key domains of antibiotic use were focused on: (1) antibiotic consumption; (2) appropriate antibiotic prescription; (3) indicators or key drivers of antibiotic use; (4) antimicrobial stewardship (AMS) interventions; (5) knowledge, attitudes and perceptions of antibiotic consumers and providers. Data were extracted from eligible papers for all the five domains under consideration and random-effects model meta-analysis was carried out for antibiotic consumption.

RESULTS

Out of the 2613 records obtained, 64 articles which were unevenly distributed in the region were eligible for inclusion in our study. These articles reported on antibiotic consumption (5), appropriate antibiotic prescription (10), indicators or key drivers of antibiotic use (10), AMS interventions (10), and 31 studies reported on knowledge, attitudes and perceptions. Antibiotic consumption for inpatients has a pooled estimate of 620.03 defined daily dose (DDD) per 100 bed-days (confidence interval [CI] 0.00-1286.67; I2 = 100%) after accounting for outliers while prescribing appropriateness ranged from 2.5% to 93.0% with a pooled estimate of 50.09 ([CI: 22.21-77.92%], I2 = 99.4%). Amoxicillin, gentamicin, amoxicillin-clavulanate, metronidazole, and ceftriaxone were the commonly consumed antibiotics. Community-acquired infection, hospital-acquired infection, and prophylaxis were the major indicators of antibiotic use. AMS was effective to varying degrees with bundled interventions and gamified antimicrobial stewardship decision support application being the most effective. Healthcare workers demonstrated acceptable antibiotic knowledge but individuals from formal and informal settings self-medicate with antibiotics and had moderate to low knowledge of antibiotic use and resistance.

CONCLUSION

This review identified gaps in knowledge and highlighted areas where prompt actions are required, it further guides future research endeavors and policy development. The findings underscore the need for further implementation of AMS programs across the West African region to enhance understanding of antibiotic use patterns, prescribing practices, and the factors influencing them in the region.

Healthcare provider cost of antimicrobial resistance in two teaching hospitals in Ghana

Understanding the healthcare provider costs of antimicrobial resistance (AMR) in lower-middle-income countries would motivate healthcare facilities to prioritize reducing the AMR burden. This study evaluates the extra length of stay and the associated healthcare provider costs due to AMR to estimate the potential economic benefits of AMR prevention strategies. We combined data from a parallel cohort study with administrative data from the participating hospitals. The parallel cohort study prospectively matched a cohort of patients with bloodstream infections caused by third-generation cephalosporin-resistant enterobacteria and methicillin-resistant Staphylococcus aureus (AMR cohort) with two control arms: patients infected with similar susceptible bacteria and a cohort of uninfected controls. Data collection took place from June to December 2021. We calculated the cost using aggregated micro-costing and step-down costing approaches and converted costs into purchasing power parity in international US dollars, adjusting for surviving patients, bacterial species and cost centres. We found that the AMR cohort spent a mean of 4.2 extra days (95% CI: 3.7-4.7) at Hospital 1 and 5.5 extra days (95% CI: 5.1-5.9) at Hospital 2 compared with the susceptible cohort. This corresponds to an estimated mean extra cost of $823 (95% CI: 812-863) and $946 (95% CI: US$929-US$964) per admission, respectively. For both hospitals, the estimated mean annual extra cost attributable to AMR was approximately US$650 000. The cost varies by organism and type of resistance expressed. The result calls for prioritization of interventions to mitigate the spread of AMR in Ghana.

Rationality of Prescriptions by Rational Use of Medicine Consensus Approach in Common Respiratory and Gastrointestinal Infections: An Outpatient Department Based Cross-Sectional Study from India

BACKGROUND

Drug utilisation studies are relevant for the analysis of prescription rationality and are pertinent in today's context of the increasing burden of antimicrobial resistance. Prescriptions for patients with diarrhoea or Acute Respiratory Infection (ARI) have been analysed in this study to understand the prescription pattern among various categories of prescribers in two tertiary care centers.

METHODS

This cross-sectional study was conducted from August 2019 to December 2020 in the medicine and pediatrics outpatient departments of two government teaching hospitals in West Bengal, India. A total of 630 prescriptions were evaluated against WHO standards. Prescriptions were assessed by a 'Rational Use of Medicine Consensus committee' approach.

RESULTS

The Fixed Dose Combination (FDC) was used in half of the patients (51%). Both the generic prescription (23.3%) and adherence to hospital formulary rates (36.5%) were low. The antibiotics prescription rate was high (57%), and it was higher for diarrhoea than ARI. Deviations from the standard treatment guidelines were found in 98.9% of prescriptions. Deviations were commonly found with prescriptions written by the junior doctors (99.6%).

CONCLUSION

Irrational prescribing patterns prevail in tertiary care centers and indicate the necessity of awareness generation and capacity building among prescribers regarding AMR and its unseen consequences.

Antibiotic prescription for febrile outpatients: a health facility-based secondary data analysis for the Greater Accra region of Ghana

Background

Misguided prescription of antibiotics is an important contributor towards the emergence and spread of antibiotic resistance. The absence of effective interventions to control antibiotic use leads to increased consumption beyond the needed requirements. Antibiotic stewardship interventions must be appropriately targeted and assessed to enhance the controlled use of antibiotics. The objective of this study was to determine the factors associated with antibiotic prescription to febrile outpatients who seek care in health facilities within the Greater Accra region of Ghana.

Methods

Secondary data obtained from the medical records of 2519 febrile outpatients, consecutively sampled at the outpatient department of 6 health facilities in 3 municipalities during the baseline survey of a quasi-experiment in 2015 was used. The primary outcome was prescription of any antibiotic. Independent variables included patients’ demographics, symptoms, laboratory investigations (blood film microscopy, malaria rapid diagnostic test, full blood count, urine and stool routine examinations), diagnoses, and prescribers’ demographics. Crude and adjusted logistic regression analyses were used to determine the factors associated with antibiotic prescription.

Results

The prevalence of antibiotic prescription was 70.1% (95% CI: 67.7–72.4). Prescribers with more years of practice (> 5 years) were more likely to prescribe antibiotics compared to those with less than 3 years of practice (p <  0.001). Integrated Management of Neonatal and Childhood Illnesses (IMNCI) training was associated with a 2.3 (95% CI: 1.54, 3.53, p <  0.001) fold odds of antibiotic prescribing. Patients aged 5 years or more were 60% less likely to receive antibiotics compared with those under 5 years (AOR = 0.40, 95% CI: 0.32, 0.51; p <  0.001). Patients referred for laboratory investigations were 29% less likely to be prescribed antibiotics than those not referred. The presence of cough as a presenting symptom was associated with a 3.5 (95% CI: 2.54, 4.92) fold odds of antibiotic prescription.

Conclusion

Prescription of antibiotics to febrile outpatients was high. Promoting laboratory testing can potentially reduce irrational antibiotic prescription. Prescribing antibiotics for children under five and the prescribing practices of prescribers with longer years of practice should be targeted with interventions to reduce high use of antibiotics.

Determinants of Inappropriate Antibiotics Use in Rural Central Ghana Using a Mixed Methods Approach

Background: The consequences of antibiotic resistance are projected to be most severe in low and middle income countries with high infectious disease burden. This study examined determinants of inappropriate antibiotic use at the community level in rural Ghana.

Methods: An observational study involving qualitative and quantitative methods was conducted between July, 2016 and September, 2018 in Ghana. Two household surveys were conducted at two time points (2017 and 2018) among 1,100 randomly selected households over 1 year. The surveys focused on antibiotic use episodes in the past month. Four in-depth interviews and two focus group discussions were performed to further explain the survey results. Determinants of inappropriate antibiotic use were assessed using a mixed effect logistic regression analysis (multilevel analysis) to account for the clustered nature of data. We defined inappropriate antibiotic use as either use without prescription, not completing treatment course or non-adherence to instruction for use. Qualitative data were thematically analyzed.

Results: A total of 1,100 households was enrolled in which antibiotics were used in 585 (53.2%) households in the month prior to the surveys. A total of 676 (21.2%) participants out of 3,193 members from the 585 reportedly used antibiotics for 761 episodes of illness. Out of the 761 antibiotic use episodes, 659 (86.6%) were used inappropriately. Paying for healthcare without health insurance (Odds Ratio (OR): 2.10, 95% CI: 1.1–7.4, p-value: 0.026), not seeking healthcare from health centers (OR: 2.4, 95% CI: 1.2–5.0, p-value: 0.018), or pharmacies (OR: 4.6, 95% CI: 1.7–13.0, p-value: 0.003) were significantly associated with inappropriate antibiotic use. Socio-demographic characteristics were not significantly associated with inappropriate antibiotic use. However, the qualitative study described the influence of cost of medicines on inappropriate antibiotic use. It also revealed that antibiotic users with low socioeconomic status purchased antibiotics in installments which, could facilitate inappropriate use.

Conclusion: Inappropriate antibiotic use was high and influenced by out-of-pocket payment for healthcare, seeking healthcare outside health centers, pharmacies, and buying antibiotics in installments due to cost. To improve appropriate antibiotic use, there is the need for ministry of health and healthcare agencies in Ghana to enhance healthcare access and healthcare insurance, and to provide affordable antibiotics.

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.

Prevalence and determinants of Acute Lower Respiratory Infections among children under-five years in sub-Saharan Africa: Evidence from demographic and health surveys

Acute Lower Respiratory Infections (ALRIs) account for 5.8 million deaths globally and 50% of these deaths occur in sub-Saharan Africa. In this paper, we examined the prevalence and determinants of ALRIs among children under-five years in 28 sub–Saharan African countries. We used data from the most recent (2011–2016) Demographic and Health Surveys of the 28 countries. Women aged 15–49 (N = 13,495) with children under-five years participated in the study. Data were extracted and analysed using STATA version 14.2. Bivariate and multivariate analyses were done to establish associations between the outcome and explanatory variables. The prevalence of ALRI for all the countries was 25.3%. Congo (39.8%), Gabon (38.1%), Lesotho (35.2%), and Tanzania (35.2%) were the countries with the highest prevalence of ALRIs. The results from the multivariate analyses showed that children aged 24–59 months (AOR = 1.15; 95% CI = 1.04–1.28), and children who received intestinal parasite in the 6 months preceding the survey (AOR = 1.11; 95% CI = 1.02–1.22) had higher odds of developing ALRIs. However, children whose mothers were employed (AOR = 0.77; 95% CI = 0.64–0.94) and those whose households used improved toilet facilities (AOR = 0.72; 95% CI = 0.64–0.97) had lower odds of contracting ALRIs. Our findings underscore the need for stakeholders in health in the various sub-Saharan African countries, especially those worst affected by ALRIs to implement programmes and develop policies at different levels aimed at reducing infections among children under-five years. Such strategies should specifically focus on improving the administration of medications for intestinal worms, health education to mothers with children under five on ALRIs and improving the sanitation situations of households through the provision of improved toilet facilities.

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We examined the prevalence and determinants of Acute Lower Respiratory Infections (ALRIs) among children under-five years in sub–Sahara Africa.

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ALRIs account for 5.8 million deaths globally.

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The prevalence of ALRI is 25.3% in sub-Sahara Africa.

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Children aged 24–59 months had higher odds of developing ALRIs.

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Employed mothers and improved toilet facility are protective factors against ALRIs.