A Narrative Review of Recent Antibiotic Prescribing Practices in Ambulatory Care in Tanzania: Findings and Implications

Current access, availability and use of antibiotics in primary care among key low- and middle-income countries and the policy implications

INTRODUCTION

Antimicrobial resistance (AMR) poses a significant threat, particularly in low- and middle-income countries (LMICs), exacerbated by inappropriate antibiotic use, access to quality antibiotics and weak antimicrobial stewardship (AMS). There is a need to review current evidence on antibiotic use, access, and AMR, in primary care across key countries.

AREAS COVERED

This narrative review analyzes publications from 2018 to 2024 regarding access, availability, and use of appropriate antibiotics.

EXPERT OPINION

There were very few studies focussing on a lack of access to antibiotics in primary care. However, there was considerable evidence of high rates of inappropriate antibiotic use, including Watch antibiotics, typically for minor infections, across studied countries exacerbated by patient demand. The high costs of antibiotics in a number of LMICs impact on their use, resulting in short courses and sharing of antibiotics. This can contribute to AMR alongside the use of substandard and falsified antibiotics. Overall, limited implementation of national action plans, insufficient resources, and knowledge gaps affects sustainable development goals to provide routine access to safe, effective, and appropriate antibiotics.

CONCLUSIONS

There is a clear need to focus health policy on the optimal use of essential AWaRe antibiotics in primary care settings to reduce AMR in LMICs.

Navigating Antimicrobials and Combating Antimicrobial Resistance: Challenges, Impacts, and Strategies for Global Action

Antimicrobial resistance (AMR) is one of the biggest problems facing the scientific and medical communities. According to WHO, this growing issue might make once-effective antibiotics obsolete and pose a substantial risk to public health. Estimates indicate that multimillion deaths were either directly or indirectly caused by AMR, making it one of the most substantial risks to public health and development in the world. The issue of AMR is primarily caused by healthcare workers' excessive and inappropriate use of antimicrobial agents. Dentists are believed to prescribe a considerable portion of all antibiotics globally. The emergence of AMR, its causes, and its effects on human health are examined in this article, with special attention to dental offices and medical facilities. It draws attention to the rising issue of antibiotic overprescription and abuse, particularly in low- and middle-income countries, where improper antibiotic use is an everyday practice around the globe. The article discusses the role of antimicrobial stewardship programs and the importance of implementing precise, evidence-based practices in preventing AMR. Since antibiotic abuse in livestock greatly accelerates the spread of resistance, the role of antibiotics in animal agriculture is also investigated. To address AMR, the paper highlights the necessity of a global, coordinated response that bolsters surveillance systems, cuts back on needless antibiotic use, and expands access to alternative treatments. Recent research has called into question the efficacy of preventive antibiotic medication in these situations. According to other researchers, it might not help avoid surgical site infections. However, other experts say disrupting deeper tissues and local mucosal defenses during an intraoral surgical operation may raise the risk of infection even when antibiotics are used.

Status and implications of the knowledge, attitudes and practices towards AWaRe antibiotic use, resistance and stewardship among low- and middle-income countries

Background

There are concerns globally with rising rates of antimicrobial resistance (AMR), particularly in low- and middle-income countries (LMICs). AMR is driven by high rates of inappropriate prescribing and dispensing of antibiotics, particularly Watch antibiotics. To develop future interventions, it is important to document current knowledge, attitudes and practices (KAP) among key stakeholder groups in LMICs.

Methods

We undertook a narrative review of published papers among four WHO Regions including African and Asian countries. Relevant papers were sourced from 2018 to 2024 and synthesized by key stakeholder group, country, WHO Region, income level and year. The findings were summarized to identify pertinent future activities for all key stakeholder groups.

Results

We sourced 459 papers, with a large number coming from Africa (42.7%). An appreciable number dealt with patients' KAP (33.1%), reflecting their influence on the prescribing and dispensing of antibiotics. There was marked consistency of findings among key stakeholder groups across the four WHO Regions, all showing concerns with high rates of prescribing of antibiotics for viral infections despite professed knowledge of antibiotics and AMR. There were similar issues among dispensers. Patients' beliefs regarding the effectiveness of antibiotics for self-limiting infectious diseases were a major challenge, although educational programmes did improve knowledge. The development of the AWaRe (Access, Watch and Reserve) system, including practical prescribing guidance, provides a future opportunity for the standardization of educational inputs.

Conclusions

Similar KAP regarding the prescribing and dispensing of antibiotics across LMICs and stakeholder groups presents clear opportunities for standardization of educational input and practical training programmes based on the AWaRe system.

Knowledge, Attitudes, Motivations, Expectations, and Systemic Factors Regarding Antimicrobial Use Amongst Community Members Seeking Care at the Primary Healthcare Level: A Scoping Review

BACKGROUND/OBJECTIVES

Antimicrobial resistance (AMR) is a major global health challenge, particularly in low- and middle-income countries (LMICs). Understanding the knowledge, attitudes, motivations, and expectations of community members regarding antimicrobial use is essential for effective stewardship interventions. This scoping review aimed to identify key themes relating to the critical areas regarding antimicrobial use among community members in primary healthcare (PHC), with a particular focus on LMICs.

METHODS

OVID Medline, PubMed, and CINAHL databases were searched using Boolean operators and Medical Subject Headings (MeSH) terms relevant to antimicrobial use and community behaviors. The Population, Intervention, Comparison, Outcome, and Study Design (PICOS) framework guided study selection, which focused on community members seeking care in PHC in LMICs. Data management and extraction were facilitated using the Covidence platform, with the Critical Appraisal Skills Programme (CASP) qualitative checklist applied for qualitative studies. A narrative synthesis identified and grouped key themes and sub-themes.

RESULTS

The search identified 497 sources, of which 59 met the inclusion criteria, with 75% of the studies conducted in outpatient primary care settings. Four key themes were identified: (1) the 'patient' theme, highlighting beliefs, knowledge, and expectations, which was the most prominent (40.5%); (2) the 'provider' theme, emphasizing challenges related to clinical decision-making, knowledge gaps, and adherence to guidelines; (3) the 'healthcare systems' theme, highlighting resource limitations, lack of infrastructure, and policy constraints; and (4) the 'intervention/uptake' theme, emphasizing strategies to improve future antibiotic use and enhance access to and quality of healthcare.

CONCLUSIONS

Stewardship programs in PHC settings in LMICs should be designed to be context-specific, community-engaged, and accessible to individuals with varying levels of understanding, involving the use of information and health literacy to effectively reduce AMR.

The Comparative Efficacy of Burs Versus Piezoelectric Techniques in Third Molar Surgery: A Systematic Review Following the PRISMA Guidelines

Background and Objectives: Third molar (wisdom tooth) extraction is one of the most common surgical procedures in oral and maxillofacial surgery. Traditional rotary instruments and burs have long been the standard tools for this procedure. However, recent advancements in surgical techniques, such as piezoelectric surgery, have gained popularity due to their purported advantages in terms of precision, safety, and postoperative outcomes. This systematic review aims to evaluate the efficacy, safety, and clinical outcomes of third molar surgery performed using burs versus piezoelectric surgery. Materials and Methods: This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive literature search was performed using the PubMed, Scopus, Web of Science, and Cochrane databases to identify relevant studies published up until October 2024. Randomized controlled trials (RCTs), clinical trials, and comparative studies assessing third molar surgery using either burs or piezoelectric instruments were included. The primary outcomes evaluated were surgical time, postoperative pain, swelling, nerve damage, and healing time. The data extraction and quality assessment were performed independently by two reviewers using standardized tools, and any discrepancies were resolved by a third reviewer. Results: A total of five studies met the inclusion criteria, and the meta-analysis revealed that piezoelectric surgery resulted in significantly lower postoperative pain and swelling compared to traditional bur techniques (p < 0.05). Additionally, the incidence of nerve injury was lower in the piezoelectric group, though the difference was not statistically significant. Surgical time was found to be longer with piezoelectric devices, but this was offset by improved healing outcomes and patient comfort. Conclusions: Piezoelectric surgery offers a less traumatic alternative to traditional burs for third molar extraction, with reduced postoperative morbidity and enhanced patient outcomes. Although the longer surgical duration may be a drawback, the overall benefits, particularly in terms of pain management and tissue preservation, support the adoption of piezoelectric techniques in clinical practice. Further high-quality randomized trials are recommended to strengthen the evidence base for these findings.

Antibiotic Prescribing Behavior of Physicians in Outpatient Departments in Hospitals in Northwest Ethiopia: Structural Equation Modeling Approach

BACKGROUND

Antibiotic resistance, fueled by irrational prescribing, is a global threat associated with health, social, and economic consequences. Understanding antibiotic prescribing behavior and associated factors is important to promote good prescribing practice.

OBJECTIVE

This study aimed to determine the factors affecting antibiotic prescribing behaviors of physicians based on the theory of planned behavior in hospitals in northwest Ethiopia in 2022.

METHODS

A cross-sectional study was conducted from September 2022 to October 2022. A total of 185 health professionals were included, and a self-administered questionnaire was used to collect data. A structural equation model based on the modified theory of planned behavior was used to determine factors affecting antibiotic prescribing behavior. The percentages of physicians' estimated prescriptions for patients with upper respiratory tract infections (URTIs) and during weekly outpatient visits were used to predict antibiotic prescribing behavior and finally linked with behavioral constructs. A P value <.05 was considered significant.

RESULTS

Physicians estimated that they prescribed antibiotics for 54.8% (9896/18,049) of weekly outpatient encounters, and 178 (96.2%) of the 185 physicians estimated they prescribed antibiotics for patients who presented with symptoms of a URTI. Physicians aged ≤30 years were less likely to prescribe antibiotics (48/100, 48%) for patients who presented with a URTI than physicians older than 30 years (51/100, 51%; P=.004), and general practitioners were less likely to prescribe antibiotics (47/100, 47%) for patients who presented with a URTI than residents (51/100, 51%; P=.03). Similarly, during outpatient visits, physicians ≤30 years old were less likely to prescribe antibiotics (54/100, 54%) than physicians older than 30 years (57/100, 57%; P<.001), male physicians were less likely to prescribe antibiotics (53/100, 53%) than female physicians (64/100, 64%; P=.03), and general practitioners were less likely to prescribe antibiotics (53/100, 53%) than residents (57/100, 57%; P=.02). Physicians with good knowledge were less affected by perceived social pressure (mean 4.4, SD 0.6) than those with poor knowledge (mean 4.0, SD 0.9; P<.001) and felt it was easy to make rational decisions (mean 4.1, SD 1.1) compared with those with poor knowledge (mean 3.8, SD 1; P<.001). However, intentions to reduce and prescribe antibiotics were not affected by attitudes, subjective norms, or perceived behavioral control, and perceived antibiotic prescribing behavior was not related to intentions to reduce or prescribe antibiotics.

CONCLUSIONS

Antibiotic prescribing behavior was not under the volitional control of physicians. This calls for a systematic approach to change antibiotic prescribing practices in hospital.

Community antibiotic consumption and associated factors in Lusaka district of Zambia: findings and implications for antimicrobial resistance and stewardship

Introduction

Antimicrobial resistance (AMR) is a global public health crisis. This study assessed the general public's consumption of antibiotics and associated factors in the Lusaka district of Zambia.

Methods

This cross-sectional study was conducted among 2038 participants between December 2022 and January 2023. Data were analysed using Stata 13.0. Multivariable regression techniques were used to determine the factors that influenced antibiotic consumption.

Results

Of the 2038 participants, 53.4% were female, and 51.5% had attended at least secondary school. Antibiotic use was 99.2%, of which 40.9% were appropriately used. Overall, 79.1% of antibiotics were prescribed in hospitals, while 20.9% were used from leftovers and accessed without prescriptions. This study found that the appropriate use of antibiotics was associated with being female, being aged 35 years and above, attaining secondary school or tertiary education, having a monthly expenditure of 195 USD and above, being aware that antibiotics were not the same as painkillers, and being confident that when someone was hospitalized, they would get well.

Conclusions

This study found that the appropriate use of antibiotics was low, and this is an urgent public health issue requiring community engagement in tackling AMR and adherence to treatment guidelines in healthcare facilities. Additionally, there is a need to implement and strengthen antimicrobial stewardship programmes in healthcare facilities to promote the rational use of antibiotics in Zambia. There is also a need to heighten community awareness campaigns and educational activities on the appropriate use of antibiotics.

Hospital prescribing patterns of antibiotics in Zambia using the WHO prescribing indicators post-COVID-19 pandemic: findings and implications

Background

Antimicrobial resistance (AMR) is a global public health problem that is fuelled by the inappropriate prescribing of antibiotics, especially those from the 'watch' and 'reserve' antibiotic lists. The irrational prescribing of antibiotics is particularly prevalent in developing countries, including Zambia. Consequently, there is a need to better understand prescribing patterns across sectors in Zambia as a basis for future interventions. This study evaluated the prescribing patterns of antibiotics using the WHO prescribing indicators alongside the 'access, watch and reserve' (AWaRe) classification system post-COVID pandemic at a faith-based hospital in Zambia.

Methods

A cross-sectional study was conducted from August 2023 to October 2023 involving the review of medical records at St. Francis' Mission Hospital in Zambia. A WHO-validated tool was used to evaluate antibiotic prescribing patterns alongside the AWaRe classification tool.

Results

Out of 800 medical records reviewed, 2003 medicines were prescribed. Each patient received an average of 2.5 medicines per prescription. Antibiotics were prescribed in 72.3% of encounters, of which 28.4% were injectable. The most frequently prescribed antibiotics were amoxicillin (23.4%-access), metronidazole (17.1%-access), ciprofloxacin (8%-watch) and ceftriaxone (7.4%-watch), with 77.1% overall from the 'access' list. Encouragingly, 96.5% of the medicines were prescribed by their generic names and 98% were from the Zambia Essential Medicines List.

Conclusions

There were high rates of antibiotic prescribing, including injectable antibiotics, which needs addressing going forward. It is crucial to implement targeted measures, including antimicrobial stewardship programmes, to improve future antibiotic prescribing in Zambia and reduce the risk of AMR.