Guidelines to improve antibiotic prescribing practice at primary healthcare facilities in Ethiopia

Abstract

Background Antibiotics are the most frequently used medicines in healthcare facilities. Since their discovery, they have played a pivotal role in combating infectious diseases and maintaining health, especially in developing countries where such diseases still remain as a big challenge. In recent years, however, the benefits derived from antibiotic use are facing great challenges due to the emergence of resistance where many bacteria have become resistant to the most commonly used first-line antibiotics. The major driver of antimicrobial resistance is known to be the huge increase in antibiotic prescribing, especially in low- and middle-income countries. Studies conducted on the rate of antibiotic resistance in Ethiopia have shown that the majority of bacteria that cause infections have developed a considerable degree of resistance to commonly used first-line antibiotics. In this country, antibiotics are prescribed at a far higher rate than the optimal value recommended by the World Health Organization. This exposes the available antibiotics to the risk of resistance. Purpose The purpose of this study was to describe the rate and patterns of antibiotic prescribing, explore the factors that affect the decisions to prescribe antibiotics, and identify interventions that should be implemented with a view to developing evidence- based and theory-informed intervention guidelines to improve antibiotic prescribing at primary healthcare facilities in Ethiopia. Methods Guided by the PRECEDE-PROCEED Model, the study was conducted using an explanatory sequential mixed method approach. In the first phase of the study (quantitative), data was collected from 2 000 prescriptions and patient medical charts sampled from ten randomly selected, public health centres situated in five of the sub cities in Addis Ababa City Administration. The second phase of the study (qualitative) was undertaken through in-depth interview of 20 prescribers from five of the health centres, as well as with 22 key informants from the five health centres, five sub-city health offices and the Health Bureau. The quantitative data was analysed using SPSS version 28. Thematic content analysis supported by ATLAS.ti 9 was used to analyse the qualitative data. Intervention guidelines to improve antibiotic prescribing were then developed by integrating findings of the qualitative and quantitative studies. Results The average number of medicines per prescription was 1.87 ranging from 1.71 to 2.11 among the health centres. The percentage of prescriptions containing one or more antibiotic was 52.5%, with wide variation (41.5% to 61.5%) among the health centres included in the study. The rate of antibiotic prescribing was shown to have a statistically significant correlation with the patient’s age, the qualification of the prescriber and the season of prescribing. Amoxicillin, ciprofloxacin, cloxacillin, doxycycline and cotrimoxazole accounted for nearly 80% of the antibiotics prescribed, with amoxicillin (41.2%), ciprofloxacin (14.1%) and cloxacillin (9.6) being the top three most commonly prescribed. About 56% of the prescribed antibiotics belong to the Penicillins category and majority (92.7%) of the antibiotics were prescribed for oral administration. Nearly 77% belong to the Access category and the remaining 23% to the Watch category of the World Health Organization’s Access, Watch and Reserve Classification of antibiotics. Upper respiratory tract infection (21.7%), urinary tract infections (13.1%) and topical infections – skin, eye and ear (9.7%) were the most common diagnoses for prescribing the antibiotics. About 37.3% of the cases for prescribing of antibiotics were respiratory tract infections, the majority (90.7%) being for upper respiratory tract infections. Of those prescribed for respiratory tract cases, 51.6% were found appropriate and 34.9% inappropriate. The types of inappropriate antibiotic therapy included unnecessary antibiotic use (53%); high dose (16%); need for additional antibiotic (14%); not choosing the right antibiotic (11%); and low dose (6%). Cost wise, antibiotics accounted for 36.2% of the total cost of medicines prescribed, with the majority of that being for amoxicillin (39.8%), cloxacillin (15.7%) and ciprofloxacin (10.3%). Five of them (amoxicillin, cloxacillin, ciprofloxacin, amoxicillin/clavulanic acid and cotrimoxazole) accounted for about 81% of the total cost of antibiotics prescribed. Antibiotics prescribed for all kinds of upper respiratory tract cases accounted for over one-third of the total cost of antibiotics prescribed. There were various kinds of problems with the prescription of antibiotics and their use at health centres, including the repeated use of antibiotics for the same diagnosis; use of antibiotics for minor problems; using high level antibiotics; discontinuing medication; and self-medication with antibiotics. The decision of healthcare providers to prescribe antibiotics is influenced by various predisposing, enabling and reinforcing factors. The factors are related with prescribers, patients and the health system, including gaps in the knowledge of health professionals on the use of antibiotics and resistance, low awareness of patients and the public on antimicrobial resistance, shortage of antibiotics and laboratory reagents, lack of updated information on the national and local antibiotic resistance pattern, patient pressure, patient load, excessive antibiotic prescribing at private health facilities, and the dispensing of antibiotics without prescription at private pharmacies. Though not as such heavily focused on antibiotics and resistance, various initiatives have been implemented at health centres that could contribute to improving the prescription of antibiotics and their use. Various interventions have been identified based on which intervention guidelines are developed to improve antibiotic prescribing at primary healthcare facilities. Challenges that might be faced when implementing these proposed interventions include shortage of personnel; financial constraints; resistance to change from professionals; shortage of medicines and laboratory reagents; inadequate government commitment; and resistance from the private sector because of the profit-motive. Conclusion There is high rate of antibiotic prescribing at health centres that far exceeds the recommended rate for primary healthcare facilities. The majority of antibiotics were prescribed for upper respiratory tract infections which are known to be mostly viral origin. Most of the antibiotics prescribed belong to the Access group of the World Health Organization’s Access, Watch and Reserve Classification. Antibiotics accounted for over one-third of the cost of medicines prescribed. Despite prescribers and key informants being aware of antibiotic resistance, its causes and consequences, there are still various types of antibiotic prescribing problems at health centres. The prescribing decisions of healthcare providers are influenced by several factors that are categorised as predisposing, enabling or reinforcing factors. Intervention guidelines that will be used to improve the prescribing of antibiotics at health centres were developed based on the interventions suggested by the study participants. urther studies on medicine use are required to appropriately understand the rate and patterns of antibiotic prescribing, and prescribers’ adherence to the new Primary Healthcare Clinical guidelines in managing commonly encountered cases such as upper respiratory tract infections at primary healthcare facilities. Research should be undertaken to evaluate the effectiveness of the intervention guidelines developed following PRECEED component (implementation, and monitoring and evaluation phases) of the PRECEDE-PROCEED Model that guided this study. The piloting and implementation of the guidelines requires the active involvement of all stakeholders under the leadership of Ministry of Health and the Health Bureau. The anticipated challenges need to be taken into consideration in implementing the interventions.