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Assessment of prescribing practices at the primary healthcare facilities in Botswana with an emphasis on antibiotics: Findings and implications


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Background and aims: Inappropriate drug prescribing has increased especially in developing countries where systems for monitoring medicine use are not well developed. This increases the rate of antimicrobial resistance. The study aim was to assess the prescribing patterns among urban primary health facilities in Botswana to provide future guidance including developing future quality indicators. Methods: Retrospective data from patients' records between January and December 2013 in 19 clinics were collected in a cross-sectional study. The WHO/International Network for Rational Use of Drugs indicators were used to assess prescribing patterns in the study clinics. Results: Average number of drugs per prescription was 2.8; 78.6% of the prescribed antibiotics were by International Non-proprietary Name and 96.1% complied with the Botswana Essential Drugs List. Overall rate of antibiotic prescribing was high (42.7%) with 14.7%, 5.9% and 1.3% of prescriptions having two, three and four antibiotics, respectively. Systemic antibiotics (JO1C) accounted for 45.4% of prescribed antibiotics of which amoxicillin accounted for 28.4% and metronidazole 14.4% of all antibiotic prescriptions. There was low use of co-amoxiclav (0.3% of all antibiotic prescriptions). Third generation cephalosporins and macrolides accounted for 9.8% and 6.2% of antibiotic prescriptions respectively, with no prescribing of fluoroquinolones. The majority of indications (87%) for antibiotic prescriptions were according to ICD classification. Conclusions: While most indications for antibiotic prescriptions were based on signs and symptoms according to ICD, antibiotic prescribing rates were high with some conditions not requiring antibiotics because they are viral infections. There is a need to further improve prescribing practices through induction and training of in-service prescribers. An effective management tool for monitoring antibiotic prescribing practices at Primary Health Care facilities should be designed and implemented, including developing robust quality indicators.
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Int J Clin Pract. 2017;71:e13042.  
 1 of 10
© 2017 John Wiley & Sons Ltd
Assessment of prescribing practices at the primary healthcare
facilities in Botswana with an emphasis on antibiotics: Findings
and implications
Yohana Mashalla1| Vincent Setlhare2| Amos Massele1| Enoch Sepako1|
Celda Tiroyakgosi3| Joyce Kgatlwane4| Mpo Chuma5| Brian Godman6,7,8
1Department of Biomedical Sciences, Faculty
of Medicine, University of Botswana,
Gaborone, Botswana
2Department of Family Medicine and Public
Health, Faculty of Medicine, University of
Botswana, Gaborone, Botswana
3Ministry of Health, Gaborone, Botswana
University of Botswana, Gaborone, Botswana
5School of Public Health, Faculty of Health
Sciences, University of Botswana, Gaborone,
6Department of Clinical Pharmacology,
Biomedical Sciences, Strathclyde University,
Glasgow, UK
8Health Economics Centre, University of
Liverpool Management School, Liverpool, UK
Brian Godman, Division of Clinical
University Hospital, Stockholm, Sweden.
Funding information
and Development
Background and Aims: Inappropriatedrugprescribing hasincreasedespecially inde-
veloping countries where systems for monitoring medicine use are not well devel-
oped. This increases the rate of antimicrobial resistance. The study aim was to assess
the prescribing patterns among urban primary health facilities in Botswana to provide
future guidance including developing future quality indicators.
Methods: Retrospective data from patients’ records between January and December
Network for Rational Use of Drugs indicators were used to assess prescribing patterns
in the study clinics.
Results:Averagenumberofdrugs perprescriptionwas2.8;78.6%oftheprescribed
with14.7%,5.9%and1.3%of prescriptions having two, three and four antibiotics,
Third generation cephalosporins and macrolides accounted for 9.8% and 6.2% of
antibiotic prescriptions respectively, with no prescribing of fluoroquinolones. The
majority of indications (87%) for antibiotic prescriptions were according to ICD
Conclusions: While most indications for antibiotic prescriptions were based on signs
ditions not requiring antibiotics because they are viral infections. There is a need to
further improve prescribing practices through induction and training of in- service pre-
at Primary Health Care facilities should be designed and implemented, including devel-
oping robust quality indicators.
2 of 10 
cines as “patients receive medications appropriate to their clinical needs,
in doses that meet their own individual requirements for an adequate
period of time, at the lowest cost to them and their community”.1 To ad-
dress the irrational use of medicines, including inappropriate use of anti-
its associated impact on morbidity, mortality and costs,2-8the WHOin
collaborationwiththe InternationalNetworkforRationalUseofDrugs
care and facility- specific factors.2,9,10 These include the number of anti-
biotics per prescription without looking at issues of necessity or whether
prescribing adheres to current guidelines.11ThecurrentWHOreference
value for the average number of medicines per encounter is <2,10,12,13
with a comprehensive review between 1990 and 2009 reporting the
averagenumber among 104countries was 2.6for the Africaregion.14
Morerecentreports indicatea45.8%increasefrom2.4between 1995
and 2005 to 3.5 between 2006 and 2015.10 The percentage of medi-
cines prescribed by the generic (International Non-proprietary Name; 
INN)nameshould be 100% (acceptable >80%).2,9,13 However, studies
havereported lower ratesforthe Africanregionat between60%and
Currently, there is a scarcity of data regarding the quality of antibi-
for antibiotics to be prescribed for typically self- limiting conditions
suchas acuteupper respiratorytractinfections (URTIs)thatare pre-
dominantly viral in origin and for other infections which do not require
parativereportofantibioticprescribingratesin theAfricaregionbe-
tween 1995- 2005 and 2006- 2015 shows during the later period high
antibiotic prescribingrates (22%, 58% and 22%) in Ghana, Tanzania
and Nigeria, respectively,20-22 with most of the increase because of
prescribing in URTIs,which are typically viral in origin. Overall, ap-
proximately 50% of current antibiotic prescribing in outpatient de-
partments is seen as inappropriate.23 In Malaysia, as in Botswana,
antibiotics are commonly and inappropriately prescribed by primary
healthcare (PHC) providers at PHC facilities.24-27 Most of these re-
ports though are based on small- scale studies, which could be under-
estimation of the extent of antibiotic use in developing countries.
Following the Alma Ata Declaration in 1978,28 Botswana de-
veloped a successful and comprehensive PHC system with treat-
ment provided in accordance with the standards set out in the
Ministry of Health guidelines.29 However to date, few studies have
been undertaken to assess prescribing practices in PHC facilities
in Botswana.30-32 We have previously reported that 52 different
documents/guidelines existed at 18 PHC facilities in the Greater
Gaborone areaof Botswana, of which 50% focused on treatment
andmanagementofdiseases,the remaining50% weregeneral in-
formation and policy related.33 Except for the guidelines for treating
STIs found at 86% ofthe facilities, the majority of PHC facilities
(56%)didnot have currentguidelines available andtheBotswana
1.1 | Aims
The aim of this study was to assess current drug prescribing
practices in PHC facilities in Gaborone and surrounding areas
with a specific emphasis on antibiotic prescribing. The study
results would be used to guide future corrective interventions.
The interventions may include suggestions to develop new qual-
ity indicators, especially for antibiotic prescribing, in ambula-
This was a non- experimental cross- sectional descriptive study initially
usingtheWHO/INRUDindicators9 before looking more specifically at
antibiotic prescribing. The study was carried out between November
and December 2015, collecting retrospective data from patient re-
cords for the period between January and December 2013. The PHC
andMogoditshane(Kweneng District). The facilitiesarerepresenta-
tive of urban settings in Botswana where the majority of patients seek
their treatment from.
What’s known
• There is considerable overuse of common antibiotics
across countries particularly in primary healthcare cen-
tres, leading to increasing resistance rate.
There are ongoing developments to improve the use of
well as guidelines.
• However, there are concerns with the specificity of
tibiotic prescribing in ambulatory care as well as adher-
What’s new
• There were high rates of International Non-proprietary
Name prescribing in Botswana as well as high rates of
prescribing of medicines contained in the Botswana EDL.
However, there were high rates of antibiotic prescribing
as well as high rates of prescribing two or more antibiot-
ics on the first encounter. This may be because of a high
prevalence of gynaecological and sexually transmitted
infections in presenting patients in Botswana.
The majority of indications for antibiotic prescribing
(87%)werein accordance with ICD-10 codes;however
rates could be improved to enhance future quality of
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2.1 | Sample size and sampling procedures
TheWHO9 recommends that there should be a minimum of 600 pre-
scribing episodes included in a cross- sectional indicators survey, and
where there are fewer than 20 facilities in a geographical or admin-
istrative region to be studied, all facilities should be included in the
sample. The selected districts have a total of 20 PHC facilities; all were
included in the study.
Data were collected by trained research assistants under the
supervision of the principal researchers (YM and ES). Using pa-
tient’s records, we estimated to collect at least 30 prescriptions
from each PHC. To achieve this, patient prescription records were
listed according to the month in which they were prescribed and
assigned random numbers. Records were then randomly selected
to assess initial prescriptions only in this study. Consequently, all
records that showed re- attendances were excluded from the study.
The diagnoses on the patient’s records were used to determine
the indication for antibiotic prescription without contact with the
2.2 | Quality of antibiotic prescribing
The quality of antibiotic prescribing practices was assessed as fol-
lows:(i) prescribingagainstWHO/INRUD criteria9,10,13;(ii)antibiotic
prescribing against indicators developed and proposed by European
organisations and (iii) antibiotic prescribing against the Botswana
Essential Drug List.34
The following indicators have been proposed and used by
European organisations to assess the quality of systemic antibiotic
• Utilisationofpenicillin(J01C)asa%oftotalantibioticuse.
• Utilisation of combination penicillin (eg, co-amoxiclav)as a % of
total amoxicillin use.
• Utilisation of third- and fourth-generation cephalosporins vs first-
and second- generation cephalosporins.
• Utilisationoffluoroquinolones(J01MA)asa%oftotalantibioticuse.
Prescribing rates at PHC facilities in Botswana were assessed against
published rates among low and middle income European countries, in-
cluding former Soviet Union Republics, as no baseline data currently
exist for these facilities in Botswana.37,38
The utilisation metric used is a prescription rather than interna-
tionally recognised metrics such as defined daily doses (DDDs) or
DDDs per 1000 inhabitants perday (DIDs).37-39 This is because we
wanted to assess antibiotic prescribing for the first indication, and we
were evaluating antibiotic prescribing among providers at PHC facili-
ties rather than the population as a whole.
2.3 | Data processing and analysis
For the purpose of improving the quality of data and the rigour of
research results, data management procedures and processes were
in accordance with the methodology proposed by Vittinghoff et al40
This included data preparation, cleaning, editing and creation of vari-
ables and identification of missing data. Since we were not testing any
outcome variables against exposure interventions, and we were not
assessing associations between the prescribers and prescribed drugs,
only descriptive and inferential analysis frameworks were used to ana-
lyse prescribing information. Percentages, averages and frequencies
were also used to describe the data.
2.4 | Ethical considerations
The study received ethical clearance from the University of Botswana,
out the study in the PHC facilities was obtained from the Ministry
of Health and Wellness (Ref. PME.13/18/87). The District Health
Management Team Coordinator granted access to the facilities vide
letter Ref: GGDHMT/14/2/i dated 28 November 2014. The identity
of the clinics was protected by keeping them anonymous and assigned
coded numbers.
3.1 | General
Data from 19 PHC facilities only were analysed. Data from one clinic
were not collected because during data collection, the clinic staff were
on vacation. Out of an estimated 570 prescriptions that were col-
lected, 20 prescriptions were excluded from the final analysis because
seven patients had come to the clinics for routine Antenatal Clinic,
six were patients who had visited the clinics for counselling services
andanothersevenvisitedthe facilitiesforHIV testing.Thisreportis
therefore based on 550 prescriptions.
3.2 | Prescribing practices against
documented indicators
The total number of prescriptions analysed were 550 and the total
number of medicines prescribed for all conditions were 1551, giving
scribed,1219(78.6%)wereprescribedusingINN and235(42.7%)
encounters contained at least one antibiotic prescription. 1490
(96.1%)wereprescribedfrom the Botswana Essential Drug (EDL)
3.3 | Prescriptions with antibiotics
Table 2 shows that 306 antibiotics were prescribed during 235 patient
ointments, 3 Tetracycline ointments and one gentamicin ointment
prescription). Systemic antibiotics (J01) were the most commonly
prescribed.Thebeta-lactamantibiotics (J01C)accountedfor 45.4%
4 of 10 
phamethoxazole+tromethropim) accounted for 9.2% of all antibi-
otic prescriptions. Third generation cephalosporin (ceftriaxone) and
tively when only J01 systemic antibiotics were considered. No fluoro-
3.4 | Indications for antibiotic prescriptions
Table 3 shows 69 diagnoses for which antibiotic prescriptions were
written. Most diagnoses were based on signs and symptoms whilst
some were specific disease conditions including asthma, diabetes,
bronchitis, tonsillitis, conjunctivitis and chicken pox.
theInternationalClassification ofDiseases (2017ICD)while ninewere
not. The nine prescriptions were non- specific, unconventional and lacked
crucial information such as sputum information on the amount, colour,
odour and the presence of blood; “enlarged stomach” did not specify
whether the enlargement was because of gas, solid mass, shifting or fluc-
tuating; “local sepsis” did not contain information on location and nature
puss,odour)wasnot provided.Painfularmpitlackedinformationon the
Cough, vaginal discharge and sexually transmitted infections were
most commonly indicated for antibiotic prescriptions in that order. For
symptoms and signs involving the gastrointestinal system, diarrhoea
was the commonest indication for antibiotic.
3.5 | Indications for more than one antibiotic per
scription, respectively. Doxycycline was the most common antibi-
of antibiotics were mostly sexually transmitted conditions includ-
ing vaginal and urethral discharge and pelvic inflammatory diseases.
Antibiotic ATC classification Frequency (N) Per cent
Beta-lactams (J01C)
Amoxicillin J01CA04 87 28.4
Ampicillin J01CA01 3 1.0
Benzathinepenicillin(Retarpen) J01CE08 13 4.2
Cloxacillin J01CF02 21 6.9
Co- amoxiclav J01CR02 1 0.3
Crystalline penicillin J01CE01 1 0.3
Penicillin V J01CE02 13 4.2
Total Beta- lactams 139 45.4
Cotrimoxazole J01EE01 28 9.2
Ceftriaxone J01DD54 30 9.8
Chloramphenicol capsules S01A01 3 1.0
Chloramphenicol ointment S01AA01 13 4.2
Doxycycline J01AA02 23 7.5
Erythromycin J01FA01 19 6.2
Gentamicin J01GB03 2 0.7
Metronidazole J01XD01 44 14.4
J01XE 1 0.3
Tetracycline ointment S01AA 3 1.0
Gentamicin ointment SO1AA 1 0.3
Total 306 100
TABLE2 Commonly prescribed
antibiotics at PHC facilities in Botswana
TABLE1 Prescribing practices against documented indicators
Prescription practices N %
Total number of prescriptions analysed 550
Total number of drugs prescribed 1551
Averagedrugs/prescription 2.8
Totalprescriptionswithgeneric(INN)names 1219 78.6
Total antibiotic encounters 235 42.7
Medicines from EDL 1490 96.1
 5 of 10
TABLE3 Classification of the diseases, symptoms and signs
indicated for antibiotics prescription at PHC facilities in Botswana by
Condition ICD- 10- CM/code Frequency
General symptoms and signs
Fever R50 10
Headache R51 8
Dehydration E86.0 1
Symptoms and signs involving the circulatory and respiratory systems
Cough R05 37
Acutetonsillitis J03 18
J00 7
Pharyngitis J02 4
Sputum(unspecified) R09.3 3
J04 2
Asthma J45.909 2
Pleural thickening L85.9 2
Upper respiratory
J06 2
Aspirationpneumonia J69.0 1
Bronchitis J20.0 1
Symptoms and signs involving the digestive system and abdomen
Diarrhoea R19 15
Abdominalandpelvicpain R10 11
Loss of appetite R63 6
Nausea and vomiting R11 4
Constipation K59.0 1
Enteritis K52.9 1
Heartburn(epigastricpain) R12 1
Symptoms and signs involving the skin and subcutaneous tissues
Wound/sores T81.30 12
Rash CM/21 9
Boils and abscesses CM/22 8
Skin condition unspecified R23 7
Herpeszoster B02 2
Chickenpox B01 2
Burn T30.0 2
L23.89 2
Acne CM/706 1
Fibrobullar M72 1
Viralwarts(genital) B07 1
V25.5 1
Skin fungal infection
L08.9 1
Condition ICD- 10- CM/code Frequency
Endocrine, nutritional and metabolic disease
Diabetes mellitus E08 1
Symptoms and signs involving genitourinary system
Vaginal discharge
N89.8 34
Sexually transmitted
A64 25
Dysuria(unspecified) R30.0 6
Penile discharge
R36.9 5
Pelvic inflammatory
N73.9 4
Vagina itching
N89.4 3
Menstrual disorder
N92.6 3
Ovariancyst N83.2 3
Pregnancy masses CM/09A 3
Orchitis N45.2 2
Postsafe male circumcision
Z41.2 2
Painful urinary bladder
N32.9 1
Diseases of the ear and mastoid process
Otitismedia H60 7
Painful jaw 2
Disorders of soft tissues and chest
Chestpain(unspecified) R07.9 10
Backache M54.9 2
Joint pain M79.609 1
Diseases of the eye and adnexa
Conjunctivitis H10.0 5
H04.309 1
Symptoms and signs involving breast
Swollenbreast(engorged) N64.59 1
Dental and oral diseases
Dentalcaries(unspecified) K02.9 3
Chronic periodontitis K05.3 2
Toothache(Unspecified) K08.8 1
Traumatic disorders
Injury(unspecified) CM/929.9 14
Fractured index finger
S62.600A 1
Other unspecified symptoms and signs
Altereddiscomfort 1
Swollen foreskin 1
TABLE3 (Continued)
6 of 10 
there was evidence of good prescribing practices in Botswana. This is
The high rate of prescribing in accordance with the Botswana EDL34 com-
paresfavourablywithWHOrecommendationsof100%10,12,13,41 as well
EastAsiaregions.2,10,42 The high prescribing rate from the EDL could be
attributed to easy accessibility of the Botswana Treatment Guidelines at
PHC facilities,33 the routine availability of medicines incorporated into the
Botswana EDL in PHCs, and the limited influence of pharmaceutical com-
panies unlike other countries.2,21,43-46
reportedin theEasternMediterraneanandSoutheastAsianregions41
aswell as 68%forAfricaas awhole.10 Possible explanations for high
INN prescribing in this studycould be a result of frequent in-service
training workshops for health workers in Botswana sponsored by the
government, benchmarking with colleagues in the region, the establish-
ment of a medical school whose trainees are exposed to patient care
to digital information. This mirrors successful campaigns in other coun-
attainWHO recommendation,9,10we believeINNprescribing training
should be intensified through regular training of in- service practitioners.
In this study, 42.7% of the encounters contained an antibiotic
prescription,higherthan<30%recommendedbyWHO.10,12,13 This is
marginallyhigherthan 39%and 34%fortheAmericasandEuropean
regions,but lowerthan 53%for theEastern Mediterraneanregion41
and Africaas a whole (47%).10 This rate is also higher than 27% in
a previous study in Botswana,31 and higher than 30% for Acute
Respiratory Infections in children under 5 years old previously re-
ported in Botswana.32 The high use of antibiotics could be because
of a high burden of gynaecological and sexually transmitted infec-
tions (Table3). There is also high prevalence (pandemic) of HIV in
Botswana.49 However, these patients are normally treated in spe-
cialist clinics, although in some cases, opportunistic infections may
be treated in PHCs. The extent of multiple antibiotic prescribing is a
concern, but again may reflect the high prevalence of gynaecological
and sexually transmitted infections in our study with up to three an-
tibiotics recommended in the Botswana guidelines for these patients
Regarding the quality of antibiotic prescribing, it is generally ac-
cepted as good clinical practice that antibiotics should be prescribed for
specific diagnosis. We found that most of the indications for antibiotic
prescriptions were based on signs and symptoms, rather than specific
tients to express themselves during history taking, poor history taking or
diagnoses would go a long way towards creating a common language
for classifying undifferentiated conditions that are seen in PHC settings.
There are concerns that some diagnoses such as a common cold,
diarrhoea, painful legs, constipation and unclassified muscular pains,
containing antibiotics had no established diagnosis. The situation in this
patient’s folders reviewed had no established diagnosis.50 The factors
that contribute to over prescribing of antibiotics include inadequate
in- service training, socio- cultural factors and patient demand.16,18,27,51
Most health facilities in Botswana and elsewhere are characterised
by inadequate skilled human resources. These lower level healthcare
workers are overwhelmed by the large number of patients seeking care
and some pressurising on prescribers to prescribe injections and anti-
biotics.52-54 The establishment of the Medical School in 2009 is a ded-
icated effort by the Government of Botswana to improve the number
andqualityofhealthcareprovidersinthe country.Assessmentoffac-
tors influencing antibiotic prescribing practices was outside the scope
of this study but will be explored further in future research.
The high use of beta- lactamase antibiotics compares favourably
withformerSovietUnionRepublics andTurkeywith ratesof37.5%-
65.6%oftotalJ01 antibiotics.37 The low use of co- amoxiclav is also
encouraging as there are concerns that high utilisation increases side
effects and resistance as well as costs.55-57 With rising concerns on
the development of Clostridium difficile resistance,58,59 the low utilisa-
tionof cephalosporinsin thisstudy (Table2)is alsoencouragingand
comparesfavourablywithrates of0.5%-12.2%among formerSoviet
Union Republics and Turkey.37 Similarly, the lack of fluoroquinolone
prescribing is encouraging attributed to the non-inclusion of these
medicines in the Botswana EDL.34
ment guidelines alongside establishing quality indicators for antibiotic
prescribing among providers in both urban and rural PHC facilities in
Botswana, which will assist prescribers with improving their quality
of care.60Adherenceisacomplexphenomenonandtypicallyfarfrom
optimal across countries.19,61-63For instance,46% of antibioticpre-
scriptions in a recent study were not indicated by the guidelines.64
However, higher adherence rates were recently seen in Namibia
(62%),althoughbelow nationaltarget ratesof95%.11 Guideline ad-
herence is influenced by several factors including the level of training
Condition ICD- 10- CM/code Frequency
Enlarged stomach 1
Swellings(unspecified) 4
Local sepsis 2
Bacterial exudate 1
Itchyeyes 8
Painful armpit 1
Musclepain(unspecified) 1
TABLE3 (Continued)
 7 of 10
of PHC personnel, available resources at healthcare facilities, work-
load, staff motivation, staff experience and the availability of mana-
gerial tools for monitoring prescribing patterns. Physicians may also
misinterpret patient expectations, influencing adherence rates.65
Effective monitoring can enhance adherence rates.66 Care though
must be taken in communicating appropriate guidelines, especially
if there are differences between different policies and guidelines as
recently seen in Namibia.67
TABLE4 The pattern of antibiotic combinations and the indications at PHC facilities in Gaborone, South East and Kweneng districts,
Antibiotics Diagnoses
Amoxicillin Metronidazole Cough Chest pain
Amoxicillin Gentamicin ear drops Ear sores
Amoxicillin Metronidazole Agsoris Headache
Amoxicillin Metronidazole Retarpen Pharyngitis Swollen jaw
Amoxicillin Cotrimoxazole Post SMC
Amoxicillin Cotrimoxazole Cough Eye watering
Amoxicillin Metronidazole Abscess
Amoxicillin Ceftriaxone PV discharge
Amoxicillin Metronidazole Dental caries
Augmentin Doxycycline Pelvic pain Pleural thickening
BenzathinePenicillin Doxycycline Metronidazone Ceftriaxone PV discharge
BenzathinePenicillin Ceftriaxone Gonococcal infection
BenzathinePenicillin Penicillin V Tonsillitis
BenzathinePenicillin Amoxicillin Sputum
BenzathinePenicillin Amoxicillin NIL
BenzathinePenicillin Amoxicillin Bacterial exudate
Ceftriaxone Metronidazole Doxycycline PV discharge
Ceftriaxone Doxycycline Metronidazole PV discharge
Ceftriaxone Doxycycline Metronidazole PV discharge
Ceftriaxone Doxycycline Metronidazole Penile rash
Ceftriaxone Metronidazole Abdominalpain
Ceftriaxone Doxycycline Urethral discharge
Ceftriaxone Doxycycline Metronidazole Pelvic pain PV discharge
Ceftriaxone Doxycycline Metronidazole PV discharge
Ceftriaxone Doxycycline Metronidazole STIdischarge
Ceftriaxone Erythromycin PV discharge Gynaecological pelvis
Ceftriaxone Doxycycline Metronidazole PV discharge VRT
Ceftriaxone Cotrimoxazole Metronidazole Doxycycline PV discharge
Ceftriaxone Metronidazole Erythromycin Pregnant masses
Ceftriaxone Erythromycin Metronidazole Cotrimoxazole PV discharge Dysuria
Ceftriaxone Doxycycline Urethral discharge
Cloxacillin Bactrim Abscess
Cotrimoxazole Ceftriaxone Doxycycline Metronidazole PID
Doxycycline Ceftriaxone Orchitis
Doxycycline Metronidazole STIcontact
Doxycycline Metronidazole STIcontact
Doxycycline Ceftriaxone Metronidazole PV discharge
Gentamicin Chloramphenicol Dacryocystitis Chest pain
Metronidazole Ceftriaxone Erythromycin PV discharge
Metronidazole Ceftriaxone Doxycycline PV discharge
8 of 10 
Based on our findings, we recommended that in order to improve
prescribing at PHC facilities in Botswana, it is essential that prescrib-
ers be provided with in- service training on the use of current national
treatment guidelines, classification of diseases, INN prescribing, as
wellas properhistorytaking andrecordingofdiagnoses.Inaddition,
ier classification of undifferentiated conditions that present in PHC
facilities. Pharmacists should also play a key role in promoting rational
prescribing practices by conducting drug utilisation reviews and using
the findings to stimulate dialogue among practitioners to enhance the
future rational use of medicines at PHC facilities.
The Ministry of Health and Wellness, as the major stakeholder re-
sponsible for policy formulation and guidance, should seek to design a
harmonised managerial tool that will contain pertinent quality indica-
tors for monitoring antibiotic prescribing practices at all PHC facilities.
This includes targets for adherence to National Treatment Guidelines
as well as classes of antibiotics prescribed, building on European and
conditions in ambulatory care as seen by the high prevalence of gy-
naecological and sexually transmitted infections in Botswana, which
is not universal especially among European populations. This will help
sector antimicrobial initiatives and programmes should be developed
and implemented across all locations to improve future antibiotic
prescribing through monitoring antimicrobial usage as well as devel-
oping and implementing strategic interventions aimed at optimising
antimicrobialuse andreducingAMR.This mayhelp toimprove anti-
biotic prescribing in the futurein Botswana and reduce AMR rates.
Hopefully any quality indicators developed will also be of interest to
The study was carried out in an urban area of Botswana and did
not include rural areas. However, as mentioned, this is where the
majority of patients are currently treated in Botswana, although we
recognise there could be differences in the characteristics of the re-
rospective collection of data, and information on the characteristics
of practitioners was not collected. However, we believe our findings
will already give guidance to key stakeholders on ways to improve
antibiotic prescribing in Botswana. We also believe our ongoing re-
search to develop pertinent quality indicators across all locations,
including both urban and rural PHCs, will be of interest to other
This study was funded by the University of Botswana Office of
Research and Development and the authors wish to acknowledge the
Ministry of Health, Botswana for granting permission to carry out the
study and to the staff and patients in the PHC facilities. We would also
potential statistical analyses.
The authors declare no competing interests with this study.
YM, VS, AM, ES and MC designed the study and were involved in
manuscript.Allauthorscritiquedsuccessive draftsofthemanuscript
before submission and re- submission.
Brian Godman
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How to cite this article:MashallaY,SetlhareV,MasseleA,
healthcare facilities in Botswana with an emphasis on
antibiotics: Findings and implications. Int J Clin Pract.
... In ambulatory care, especially among low-and middle-income countries (LMICs), oral antimicrobials are consistently in the top therapeutic classes of medicines by frequency of use [1,2]. Alongside this, there are concerns with high inappropriate prescribing among ambulatory care healthcare professionals (HCPs), enhanced by the time pressures on them combined with pressures from patients [1,3,4]. ...
... Since URTIs were the most frequent diagnosis (22.8%), this may explain why the penicillins were the most prescribed antimicrobials ( Table 2). Other studies have also shown that the penicillins (β-lactams) are among the most prescribed and dispensed class of antibiotics in ambulatory care given the high prevalence rates of URTIs [2,65,[74][75][76][77]. β-lactams have continued to be the mainstay of antimicrobial therapy due to their wide spectrum of activity against both gram positive and negative organisms. ...
... This is because high rates of TB are typically not seen in a number of other LMICs, or high-income countries, making comparisons regarding antimicrobial prescribing difficult without such knowledge. This suggestion is further endorsed by a study conducted among PHCs in Botswana where high rates of prescribing of metronidazole were documented, which was due to a high burden of sexually transmitted and gynecological infections [2]. This is different to ambulatory care prescribing seen in many other countries where high rates of URTIs are seen [10,75]. ...
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Objective Up to 90% of antimicrobials globally are prescribed and dispensed in ambulatory care. However, there are considerable gaps regarding the extent and rationale for their use especially in low- and middle-income countries such as South Africa. Point prevalent surveys (PPS) are useful to determine current prescribing patterns, identify targets for quality improvement and evaluate the effectiveness of antimicrobial stewardship programmes (ASPs) within institutions. Consequently, the objective of this study was to undertake a PPS within community health centres (CHCs) in South Africa given their importance to the public healthcare system. The findings will be used to provide guidance on future interventions to improve antimicrobial use in South Africa and wider. Methods A PPS of antimicrobial consumption was undertaken among patients attending 18 CHCs in South Africa. A web-based application was used to record the utilisation data, with utilisation assessed against World Health Organization (WHO) and South African guidelines. Results overall prevalence of antimicrobial use amongst patients attending the CHCs was 21.5% (420 of 1958 patients). This included one or more antimicrobials per patient. The most frequently prescribed antimicrobials were amoxicillin (32.9%), isoniazide (11.3%) and a combination of rifampicin, isoniazid, pyrazinamide and ethambutol (Rifafour®) (10.5%), with the majority from the WHO Access list of antibiotics. There was high adherence to guidelines (93.4%). The most common indication for antibiotics were ear, nose and throat infections (22.8%), with no culture results recorded in patients’ files. Conclusions It’s encouraging to see high adherence to South African guidelines when antimicrobials were prescribed, with the majority taken from the WHO Access list. However, there were concerns with appreciable prescribing of antimicrobials for upper respiratory tract infections that are essentially viral in origin, and a lack of microbiological testing. The establishment of ASPs can help address identified concerns through designing and implementing appropriate interventions.
... For instance in Scotland, the healthcare system currently only collects data on medicines dispensed in ambulatory care and not the indication; this has to be inferred from hospital data aided by patients having the same healthcare number unless other data sets are available [47][48][49]. This compares with Botswana and Sweden where diagnostic data is available in ambulatory care in their healthcare systems to audit the prescribing performance of GPs [50][51][52]. Table 1. Indicators used across countries to improve the prescribing of antibiotics in ambulatory care. ...
... GPs between the ages of 35-44 years, >55 years and in practice <15 years were also significantly more likely to prescribe antibiotics empirically in our study. The reason why GPs with less experience and younger GPs prescribe more antibiotics maybe because they find it more difficult to differentiate between viral or bacterial infections without pragmatic guidance, which could potentially include electronic decision support systems [52,108,113]. Alternatively, they are less confident dealing with demanding patients who expect an antibiotic. ...
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The overuse of antibiotics is the main driver of antimicrobial resistance (AMR). However, there has been limited surveillance data on AMR and antibiotic prescribing at a primary healthcare level in South Africa. An observational, analytic, cross-sectional study was undertaken to assess key factors associated with empiric antibiotic prescribing among private sector general practitioners (GPs) in the eThekwini district in South Africa, particularly for patients with acute respiratory infections (ARIs). A semi-structured web-based questionnaire was used between November 2020–March 2021. One hundred and sixteen (55.5%) responding GPs prescribed antibiotics empirically for patients with ARIs more than 70% of the time, primarily for symptom relief and the prevention of complications. GPs between the ages of 35–44 years (OR: 3.38; 95%CI: 1.15–9.88), >55 years (OR: 4.75; 95% CI 1.08–21) and in practice < 15 years (OR: 2.20; 95%CI: 1.08–4.51) were significantly more likely to prescribe antibiotics empirically. Three factors—workload/time pressures; diagnostic uncertainty, and the use of a formulary, were significantly associated with empiric prescribing. GPs with more experience and working alone were slightly less likely to prescribe antibiotics empirically. These findings indicate that a combination of environmental factors are important underlying contributors to the development of AMR. As a result, guide appropriate interventions using a health system approach, which includes pertinent prescribing indicators and targets.
... Consequently, rates of antibiotic prescription have been reported to be high at primary health facilities in Africa, ranging from 36.7% in Cameroon [16] to 59.9% in Ghana [17]. According to various surveys, penicillin (46%), cotrimoxazole (40%), third-generation cephalosporins (34%) and metronidazole (31%) are the most prescribed antibiotics [16,18,19]. ...
... In contrast, third generation cephalosporins, quinolones and antibiotics belonging to the WHO Watch group were more frequently administered (often in combination) at the hospital. Our results are concurrent with studies from Malawi, Cameroon and Botswana assessing clinical management and prescription practices among febrile patients at primary care level [13,16,18]. At the health center level, penicillin and cotrimoxazole are easily accessible in Guinea [38], maybe explaining the general antibiotic overuse for the major clinical scenarios (gastrointestinal and respiratory infections). ...
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Introduction Febrile illnesses constitute a major clinical challenge in tropical settings. We aimed to assess the frequency, presentation and management of febrile illness at two health facilities in Forecariah, Guinea, with a focus on appropriateness of antibiotic prescription. Materials and methods This was a retrospective study conducted in patient files in a health center and a district hospital. Proportions of antibiotic prescription were determined by age group and syndromes as well as appropriateness of antibiotic prescription using the WHO model list (2019). Results From 2014 to 2020, 23,583 of 62,185 (38.0%) visits were related to febrile illness. Most patients with fever were female (56.1%) and evaluated at the health center (81.0%). Gastrointestinal (40.6%) and respiratory syndromes (36.8%), and undifferentiated fever (30.0%) were the most common presentations. Malaria was confirmed in 61.3% of the cohort. Overall, the rate of antibiotic prescription was high (14,834/23,583, 62.9%), mostly among patients aged <5 years (5,285/7,566, 69.9%), those with respiratory (7,577/8,684, 87.3%) and gastrointestinal (6,324/9,585, 66.0%) syndromes. Moreover, 7,432/14,465 (51.4%) patients with malaria were also prescribed an antibiotic. Penicillin (42.0%), cotrimoxazole (26.3%) and quinolones (18.7%) were the most frequently prescribed antibiotics. Overall, appropriateness of antibiotic prescription was low (38.3%), and even more so in patients with respiratory (29.1%) and gastrointestinal (25.8%) syndromes. Conclusions Febrile illness is a major cause of consultation in rural Guinea. Rate of antibiotic prescription was high, even in confirmed malaria and was often considered inappropriate. There is a pressing need to investigate the etiological spectrum and improve the diagnostic approach of febrile illness in Guinea.
... Nowadays, the misuse of antibiotics has led to a gradual increase in bacterial resistance, especially in developing countries [1], increasing the incidence of globalized infectious diseases and potentially leading to a global situation of no drug availability [2,3], threatening public health and increasing healthcare costs [4]. Therefore, countries around the world have begun to focus on the restriction of antibiotic drugs, and antimicrobial susceptibility testing (AST) of bacteria is an effective way to prevent antibiotic abuse. ...
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Currently, the world is facing the problem of bacterial resistance, which threatens public health, and bacterial antimicrobial susceptibility testing (AST) plays an important role in biomedicine, dietary safety and aquaculture. Traditional AST methods take a long time, usually 16–24 h, and cannot meet the demand for rapid diagnosis in the clinic, so rapid AST methods are needed to shorten the detection time. In this study, by using an in-house built centrifuge to centrifuge bacteria in a liquid medium onto the inner wall of the bottom surface of a counting plate, and using a phase contrast microscope to track bacterial growth under the effect of different antibiotic concentrations, the results of the minimum inhibitory concentration (MIC) of bacteria under the effect of antibiotics can be obtained in as early as 4 h. We used a combination of E. coli and tigecycline and obtained MIC results that were consistent with those obtained using the gold standard broth micro-dilution method, demonstrating the validity of our method; due to the time advantage, the complete set can be used in the future for point of care and clinical applications, helping physicians to quickly obtain the MIC used to inhibit bacterial growth.
... Provisional diagnoses included fever with and without thrombocytopenia, tropical fever, pyrexia of unknown cause, fever with sepsis, fever with discomfort in the abdomen, and dengue fever. Furthermore, establishing or excluding bacterial aetiology as a cause of continuing illness may be more difficult [17,18] . Importantly, this research was not undertaken at a time when viral diseases, such as dengue or swine flu, were prevalent. ...
In siloed discussions of antimicrobial resistance, antibiotic use on farms in the Global South has emerged as a key site for intervention. The antibiotic consumption targeted is not all consumption, but “irrational” consumption. This concept of irrationality is neither new, nor true, but rather is a long‐standing form of maintenance work within global health systems. Via an attention to chickens and the antibiotics farmers use to raise them in the suburbs of Kampala, we suggest that claims of irrationality are a central part of constituting what Tania Li has called the ‘deficient subject’. In other words, irrationality, like the chicken and the antibiotic, is itself a humanitarian device that maintains a certain condition of governance where ‘Africans’ are imagined as being in deficit of rationality and good behavior. Claims of irrationality justify (and mask the political nature of) intervention.
Background: Antibiotic prescribing should be guided by national essential medicines lists (NEMLs) and treatment guidelines; however, there are inadequate data on antibiotic utilization patterns in tertiary hospitals in Tanzania. This study aimed to determine antibiotic prescribing patterns in tertiary hospitals in Dar es Salaam, Tanzania. Methods: A retrospective cross-sectional study was conducted in three regional referral hospitals. About 200 prescription records from 2020 to 2022 were analysed at each hospital for prescribing patterns using WHO/ International Network of Rational Use of Drugs (INRUD) indicators (1993) and the AWaRe 2021 classification. Factors associated with receiving an antibiotic prescription were assessed using a logistic regression model. Facilities were ranked on prescribing practices using the index of rational drug prescribing (IRDP). Results: A total of 2239 drugs were prescribed, of which 920 (41.1%) were antibiotics. An average of 3.7 ± 1.5 (optimal: 1.6-1.8) total medicines and 1.53 ± 0.78 antibiotics were prescribed per patient. About 88.0% (528) of the prescriptions contained antibiotics (optimal: 20.0%-26.8%), while 78.2% (413) of all antibiotic prescriptions contained injections (optimal: 13.4%-24.1%). Furthermore, 87.5% (462) of the antibiotics were prescribed in generic names (optimal: 100%), while 98.7% (521) conformed to the NEML (optimal: 100%). Metronidazole was the most frequently prescribed antibiotic (39.2%; n = 134), followed by ceftriaxone (37.1%, n = 127) and amoxicillin/clavulanic acid (8.5%, n = 29). Conclusions: We found substantial empirical prescribing and overuse of antibiotics exceeding WHO recommendations. Antibiotic overuse varied across the hospitals. Being male, having underlying conditions such as diabetes mellitus, and/or being treated at Temeke hospital were associated with receiving an antibiotic prescription. We recommend strengthening antibiotic stewardship programmes in the studied facilities.
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.
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Objectives Over the past decade, concerning trends in antimicrobial resistance have emerged in Southern Africa. Given a paucity of pediatric data, our objectives were to (1) describe antibiotic utilization trends at a national referral center in Southern Africa and (2) assess the proportion of patients receiving antibiotics appropriately. In addition, risk factors for inappropriate use were explored. Methods We performed a prospective cohort study on medical and surgical pediatric patients aged below 13 years admitted to the country’s tertiary care referral hospital in Gaborone, Botswana. We collected demographics, clinical, laboratory, and microbiology details, in addition to information on antibiotic use. We separately categorized antibiotic prescriptions using the World Health Organization AWaRe Classification of Access, Watch, and Restrict. Results Our final cohort of 299 patients was 44% female and 27% HIV-exposed; most (68%) were admitted to the General Pediatrics ward. Infections were a common cause of hospitalization in 29% of the cohort. Almost half of our cohort were prescribed at least one antibiotic during their stay, including 40% on admission; almost half (47%) of these prescriptions were deemed appropriate. At the time of discharge, 52 (21%) patients were prescribed an antibiotic, of which 37% were appropriate. Of all antibiotics prescribed, 42% were from the World Health Organization Access antibiotic list, 58% were from the Watch antibiotic list, and 0% were prescribed antibiotics from the Restrict antibiotic list. Univariate analyses revealed that surgical patients were significantly more likely to have inappropriate antibiotics prescribed on admission. Patients who were treated for diseases for which there was a clinical pathway, or who had blood cultures sent at the time of admission were less likely to have inappropriate antibiotics prescribed. On multivariate analysis, apart from admission to the surgical unit, there were no independent predictors for inappropriate antibiotic use, although there was a trend for critically ill patients to receive inappropriate antibiotics. Conclusion Our study reveals high rates of antibiotic consumption, much of which was inappropriate. Promising areas for antimicrobial stewardship interventions include (1) standardization of management approaches in the pediatric surgical population and (2) the implementation of feasible and generalizable clinical pathways in this tertiary care facility.
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Getting the most out of the pharmaceutical budget is critical across all countries as the financial pressures on healthcare systems intensify. In this paper, we review global practice on encouraging the use of low costs generics versus branded pharmaceuticals, including patented products in the same class where care is not compromised. Our review ranges widely among European countries as well as other high income countries, including Abu Dhabi, Japan and the USA, and other low and middle income Countries. There is a particular focus on Scotland, building on previous publications. We conclude based on multiple publications, including several case studies, that achieving efficiency in pharmaceutical spending is possible in virtually all environments, although there are examples of technologies where generic or therapeutic substitution should not be encouraged. However, there is no magic bullet to achieving full and appropriate use of generics. Countries have to be prepared to use a number of different education, economic, engineering and enforcement methods to achieve success. Similarly, different approaches to achieve low prices for good quality generics. The combination of low prices and increased use of generics will help achieve or attain universal healthcare, benefiting all key stakeholder groups. We conclude with a call for greater cross-country learning in pursuit of what should be a common goal for all health systems.
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Background It has been proven that the interaction between pharmaceutical representatives and physicians can directly influence the latter’s prescribing behaviour. This meta-synthesis aims to explore the available studies regarding the nature of the interaction that takes place between pharmaceutical representatives and physicians. It highlights the different aspects of that interaction by investigating the reasons why these meetings happen in the first place, their benefits and drawbacks and their impact on patients’ health and, ultimately, the health of the public. MethodsA search for published articles was conducted in April 2015. Three databases (PubMed, Ovid Medline, and ProQuest) were searched for articles published between January 2000 and April 2015. Authors worked autonomously and in pairs to select eligible articles. In this case, the meta-synthesis approach was used to develop a fuller understanding and to facilitate new knowledge by bringing together qualitative findings on physician-PR interaction. ‘Meta-synthesis’ is the process of amalgamation of a group of similar studies with the aim of developing an explanation for their findings (Walsh and Downe, J Advanc Nurs 50: 204–211, 2005). A thematic content analysis was conducted on the 15 included full text articles (qualitative and quantitative studies) whereby the original authors’ understanding of key concepts in each study was identified and listed in a summary form in the data extraction sheet under “key findings” column. These findings were then juxtaposed to identify homogeneity and dissonance (Walsh and Downe, J Advanc Nurs 50: 204–211, 2005). Homogenous findings were then coded together on a different data extraction table to form a theme. ResultsA total of 15 articles met the inclusion criteria and were included in this meta-synthesis;six from the United States, two from Libya, and one each from Turkey, Peru, India, Germany, the United Kingdom, Yemen, and Japan. Six main themes were derived from the included articles: 1-the frequency of pharmaceutical representatives’ visits, 2-the perceived ethical acceptability of the interactions between pharmaceutical representatives and physicians, 3-the attitudes held by physicians towards visits by pharmaceutical representatives, 4-their perception of the effect of such visits on prescription patterns, 5-reasons to accept or reject pharmaceutical representatives, and lastly, 6-guidelines. Conclusions The physicians referred to pharmaceutical representatives as efficient and convenient information resources and were willing to meet them and accept their gifts. It was also evident that most physicians believed that their prescribing would not be influenced by pharmaceutical representatives.
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Medicines play an integral part of healthcare delivery. However, they are expensive commodities and account for a significant proportion of overall health expenditure in most countries. Irrational use of medicines is a major challenge facing many health systems across the world. Such practices are likely to lead to poor health delivery that may put patients at risk and result in wastage of scarce resources that could have been used to tackle other pressing health needs. The concept of " rational use of medicine " can at times be confusing and not easily appreciated by patients, healthcare providers, policy makers, or the public, all of whom need to collaborate effectively to address this challenge. In this article, we summarize basic concepts such as rational medicine use, good prescribing and dispensing, and explore some of the factors that contribute to irrational use of medicines as well as potential impacts of such practices. This article has been written with the intention of offering a clear, concise, and easy to understand explanation of basic medicine use concepts for health professionals, patients, policy makers, and the public.
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Background Rational medicine use is essential to optimize quality of healthcare delivery and resource utilization. We aim to conduct a systematic review of changes in prescribing patterns in the WHO African region and comparison with WHO indicators in two time periods 1995–2005 and 2006–2015. Methods Systematic searches were conducted in PubMed, Scopus, Web of science, Africa-Wide Nipad, Africa Journals Online (AJOL), Google scholar and International Network for Rational Use of Drugs (INRUD) Bibliography databases to identify primary studies reporting prescribing indicators at primary healthcare centres (PHCs) in Africa. This was supplemented by a manual search of retrieved references. We assessed the quality of studies using a 14-point scoring system modified from the Downs and Black checklist with inclusions of recommendations in the WHO guidelines. Results Forty-three studies conducted in 11 African countries were included in the overall analysis. These studies presented prescribing indicators based on a total 141,323 patient encounters across 572 primary care facilities. The results of prescribing indicators were determined as follows; average number of medicines prescribed per patient encounter = 3.1 (IQR 2.3–4.8), percentage of medicines prescribed by generic name =68.0 % (IQR 55.4–80.3), Percentage of encounters with antibiotic prescribed =46.8 % (IQR 33.7–62.8), percentage of encounters with injection prescribed =25.0 % (IQR 18.7–39.5) and the percentage of medicines prescribed from essential medicines list =88.0 % (IQR 76.3–94.1). Prescribing indicators were generally worse in private compared with public facilities. Analysis of prescribing across two time points 1995–2005 and 2006–2015 showed no consistent trends. Conclusions Prescribing indicators for the African region deviate significantly from the WHO reference targets. Increased collaborative efforts are urgently needed to improve medicine prescribing practices in Africa with the aim of enhancing the optimal utilization of scarce resources and averting negative health consequences.
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Objective To examine the association between payments made by the manufacturers of pharmaceuticals to physicians and prescribing by physicians within hospital referral regions. Design Cross sectional analysis of 2013 and 2014 Open Payments and Medicare Part D prescribing data for two classes of commonly prescribed, commonly marketed drugs: oral anticoagulants and non-insulin diabetes drugs, overall and stratified by physician and payment type. Setting 306 hospital referral regions, United States. Participants 45 949 454 Medicare Part D prescriptions written by 623 886 physicians to 10 513 173 patients for two drug classes: oral anticoagulants and non-insulin diabetes drugs. Main outcome measures Proportion, or market share, of marketed oral anticoagulants and non-insulin diabetes drugs prescribed by physicians among all drugs in each class and within hospital referral regions. Results Among 306 hospital referral regions, there were 977 407 payments to physicians totaling $61 026 140 (£46 174 600; €54 632 500) related to oral anticoagulants, and 1 787 884 payments totaling $108 417 616 related to non-insulin diabetes drugs. The median market share of the hospital referral regions was 21.6% for marketed oral anticoagulants and 12.6% for marketed non-insulin diabetes drugs. Among hospital referral regions, one additional payment (median value $13, interquartile range, $10-$18) was associated with 94 (95% confidence interval 76 to 112) additional days filled of marketed oral anticoagulants and 107 (89 to 125) additional days filled of marketed non-insulin diabetes drugs (P<0.001). Payments to specialists were associated with greater prescribing of marketed drugs than payments to non-specialists (212 v 100 additional days filled per payment of marketed oral anticoagulants, 331 v 114 for marketed non-insulin diabetes drugs, P<0.001). Payments for speaker and consulting fees for non-insulin diabetes drugs were associated with greater prescribing of marketed drugs than payments for food and beverages or educational materials (484 v 110, P<0.001). Conclusions and study limitations Payments by the manufacturers of pharmaceuticals to physicians were associated with greater regional prescribing of marketed drugs among Medicare Part D beneficiaries. Payments to specialists and payments for speaker and consulting fees were predominantly associated with greater regional prescribing of marketed drugs than payments to non-specialists or payments for food and beverages, gifts, or educational materials. As a cross sectional, ecological study, we cannot prove causation between payments to physicians and increased prescribing. Furthermore, our findings should be interpreted only at the regional level. Our study is limited to prescribing by physicians and the two drug classes studied.
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Objectives: Antibiotic use is unnecessarily high for paediatric respiratory tract infections (RTIs) in primary care, and implementation of treatment guidelines is difficult in practice. This study aims to assess guideline adherence to antibiotic prescribing for RTIs in children and examine potential variations across Dutch general practices. Methods: We conducted a retrospective observational study, deriving data on diagnoses and prescriptions from the electronic health records-based NIVEL Primary Care Database. Patients <18 years of age with a diagnosis of fever, ear and respiratory infections (International Classification of Primary Care codes A03, H71, R72, R75, R76, R78 and R81) during 2010-12 were included. Antibiotics were linked to episodes of illness. Two types of disease-specific outcomes were used to assess adherence to national guidelines regarding antibiotic prescribing choices. Inter-practice variability in adherence was assessed with multilevel analysis. Results: Half of the episodes with RTIs with restrictive prescribing policy and 65% of episodes with pneumonia were treated with antibiotics. General practitioners prescribed antibiotics for 40% of episodes with bronchitis, even though guidelines discourage antibiotic prescribing. First-choice antibiotics were prescribed in 50%-85% of episodes with selected diseases, with lowest values for narrow-spectrum penicillins. Levels of adherence to guidelines varied widely between diagnoses and between practices. Conclusions: Most paediatric RTIs in the Netherlands continue to be treated with antibiotics conservatively. Potential aspects of concern are the inappropriate antibiotic prescribing for acute bronchitis and the underuse of some first-choice antibiotics. Continuing progress may be achieved by targeting practices with lower adherence rates to guidelines.
Background: Sub-optimal antibiotic prescribing remains a public health concern in Namibia. The objective is to determine the level and predictors of compliance to guidelines in the prescribing of antibiotics in acute infections at a national referral hospital in Namibia to improve future prescribing. Methods: Descriptive observational cross-sectional study. The clinical records of patients receiving care were reviewed. Prescribing practices were assessed using a self- administered questionnaire with reference to Namibia Standard Treatment Guidelines (NSTG). Results: The majority of prescriptions (62%) complied with the NSTGs; however, lower than national targets (95%). Most prescriptions were empiric and prescribers typically made reference to the NSTG (58%). Diagnosed infections were principally respiratory infections (58%) and penicillins were the most used antibiotics. Good concurrence between signs and symptoms with the diagnosis; diagnosis of upper respiratory tract, oral-dental and urogenital infections with prescribing of penicillins. Combination antibiotics and amphenicols were independent predictors of compliance to the NSTGs. The main behaviours associated with antibiotic prescribing were patient influences, clinical state, and access to guidelines. Conclusions: Compliance to NSTGs is suboptimal. Prescribing of combination antibiotics, penicillins and diagnosis of oral dental, genitourinary and ear, nose and throat infections were important predictors for NSTG compliance. There is a need to implement antibiotic indicators and stewardship programmes, and ensure access to NSTGs, to improve future antibiotic prescribing in Namibia.
Background: Despite Namibia's robust medicine use systems and policies, antibiotic use indicators remain suboptimal. Recent medicine use surveys rank cotrimoxazole, amoxicillin and azithromycin (CAA) among the most used medicines. However, there is rising resistance to CAA (55.9%-96.7%). Unfortunately, to date, there have been limited studies evaluating policies to improve antibiotic use in Namibia. Aim: To evaluate public sector pharmaceutical policies and guidelines influencing the therapeutic use of CAA antibiotics in Namibia. Methods: Evaluate Namibia's pharmaceutical policies and guidelines for CAA use through quantitative text analysis. The main outcome variables were the existence of antibiotic policies, therapeutic indications per antibiotic and the type/level of healthcare facility allowed to use the antibiotic. Results: Policies for antibiotic use were limited, with only the draft Namibia Medicines Policy having a statement on antibiotic use. Several essential antibiotics had no therapeutic indications mentioned in the guidelines. Twenty-nine antibiotics were listed for 69 therapeutic indications; CAA (49.3%) antibiotics and ATC J01C/J01D (48%) having the highest indications per antibiotic. For CAA antibiotics, this suggested use was mainly for acute respiratory infections (n=22, 37.2%). Published policies (58.6%-17/29) recommended antibiotics for use at the primary healthcare (PHC) level, with CAA antibiotics recommended mostly for respiratory tract infections and genitourinary infections. Conclusions: Policy and guidelines for antibiotic use in Namibia are not comprehensive and are skewed towards PHCs. Existing policies promote the wide use of CAA antibiotics, which may inadvertently result in their inappropriate use enhancing resistance rates. This calls for the development of more comprehensive antibiotic guidelines and essential medicine lists in tandem with local antimicrobial resistance patterns. In addition, educational initiatives among all key stakeholder groups.
Objectives: Self-medication with antibiotics among households is common in Uganda. However, there are limited studies evaluating self-purchasing of antibiotics for acute respiratory infections (ARI) in the under-fives. Consequently, the objective was to evaluate patterns of household self-medication with antibiotics in ARI among under-fives in Kampala. Methods: Descriptive cross-sectional observational design. Care takers at households were selected from five divisions of Kampala using the WHO 30-cluster method and interviewed using a standardized questionnaire in June - July 2011. Results: Out of the 200 households, most ARI cases 107 (53.5%; p = 0.322) were inappropriately managed. The prevalence of antibiotic use in ARI was 43% (p < 0.001). Amoxicillin 31.4% and cotrimoxazole (30%) were the most self-medicated antibiotics. Antibiotics use was associated with pneumonia symptoms and access to antibiotics. Conclusions: Household use of antibiotics in ARIs among under-fives is suboptimal. There is an urgent need for guidelines on awareness to reduce self-medication of ARIs in Uganda.