Initiatives to reduce non-prescription sales and dispensing of antibiotics in the Republic of Srpska : findings and implications

Objective: Irrational use of antimicrobials is a major driver of antimicrobial resistance, exacerbated by dispensing antibiotics without a prescription. Our previous study suggested this was a problem in the Republic of Srpska despite legislation. Since then, a number of activities have been initiated. Consequently, the study aimed to ascertain whether these multiple initiatives had reduced this. Methods: Patients visiting all community pharmacies in the Republic from October 2014 to July 2015 presenting with symptoms typical of an acute, viral and mostly uncomplicated upper respiratory tract infection, with results compared to the previous study. If an antibiotic was suggested, the maximum allowance was Euro 3/ pack. Findings: Self-medication with antibiotics significantly decreased from 58% to 18.5% of pharmacies. In both studies, most patients were offered over-the-counter medication. The most common reason for not dispensing an antibiotic was ‘antibiotics can be dispensed with a prescription only’. The penicillins were the most dispensed antibiotic. Fewer patients than the previous study were given instructions about antibiotic use and no discussion on their side-effects. Conclusion: Whilst encouraging that self-medication decreased significantly, 18.5% was disappointing given recent initiatives Fewer instructions about antibiotics if an antibiotic was dispensed was also disappointing. This suggests the need for even stronger enforcement of the laws as well as further training of pharmacy personnel to ensure future appropriate use of medicines

Standards of aminoglycoside therapeutic drug monitoring in a South African private hospital: perspectives and implications

Background: Therapeutic drug monitoring (TDM) is essential to ensure that aminoglycoside peak concentrations are high enough for effective antimicrobial treatment and trough levels are low enough to minimise toxicity. Inappropriate utilisation of TDM may lead to suboptimal therapy, toxicity and waste of resources. This study aimed to investigate the standard of aminoglycoside TDM performed in adult hospitalised patients.Design: An observational, descriptive, cross-sectional study.Setting: A 221-bed private hospital.Participants: All patients, older than 18 years, on intravenous aminoglycosides for more than 48 hours were included.Interventions: None, was observational. A computerised database and patient files were used to obtain the information required for this study. Descriptive statistical analysis was used.Main outcomes measures: Aminoglycoside blood levels and estimated glomerular filtration rate (eGFR) in the patients.Results: One hundred and three (103) patients were included: 65 on gentamicin and 38 on amikacin. Blood levels were performed in only 19 gentamicin (29.23%) and 22 amikacin (57.89%) patients. Trough levels were taken more than 2 hours before the next dose in 12 gentamicin (63.16%) and 12 amikacin (54.54%) patients. The majority of patients (96.92% on gentamicin and 84.21% on amikacin) received once daily doses. TDM was performed in all patients with an estimated glomerular filtration rate (eGFR) lower than 60 mL/min/1.73m2 and in 23.31% of gentamicin patients and 56.76% of amikacin patients with an eGFR higher than 60 mg/min/1.73m2.Conclusions: Incorrect sampling times and unnecessary levels taken in patients with normal renal function indicate a need for aminoglycoside treatment guidelines in the private hospital.Funding: NoneKeywords: Aminoglycosides, Dosing considerations, South Africa, Therapeutic DrugMonitoring, Sampling time

A cross-sectional analysis of the association between age and gender and prescribed minimum benefit chronic disease list conditions among South Africans with concomitant hypertension, diabetes and dyslipidaemia.

Background: Prescribed Minimum Benefit Chronic Disease List (PMB CDL) conditions are a regulated list of conditions most common to South Africa. Objectives: To investigate the prevalence and association between PMB CDL conditions and age and gender among patients with concomitant hypertension, diabetes and dyslipidaemia. Methods: The study population consisted of patients (n = 17 866) with a prescription containing at least one co-prescribed antilipemics, antihypertensive and antidiabetic (identified using the MIMS Desk Reference). ICD-10 codes on claims for PMB CDL conditions were counted. Results: 39.5% of patients had a PMB CDL condition. Women had higher odds for hypothyroidism (OR 6.30, 95% CI; 5.52, 7.19, p < 0.001) and lower odds for coronary artery disease (CAD) (OR 0.63, 95% CI; 0.55, 0.72, p < 0.001) than men. In combination with hypothyroidism the odds for CAD were reversed and strongly increased; 3.54 (95% CI; 2.38, 5.25, p < 0.001). The odds for females having cardiac failure (CF) was insignificant and low (OR 0.87, 95% CI; 0.75, 1.01, p = 0.063); however combined with hypothyroidism, the odds increased to 5.35 (95% CI; 3.52, 8.13, p < 0.001). Conclusion: Hypothyroidism was an important discriminating factor for co-morbidity in women with concomitant hypertension, diabetes and dyslipidaemia, in particular with cardiovascular disease

Outcome of the first Medicines Utilisation Research in Africa Group meeting to promote sustainable and rational medicine use in Africa

The first MURIA (Medicines Utilisation Research in Africa) group workshop and symposium brought researchers together from across Africa to improve their knowledge on drug utilisation (DU) methodologies as well as exchange ideas. As a result, progress DU research to formulate future strategies to enhance the rational use of medicines. Anti-infectives was the principal theme for the one day symposium following the workshops. This included presentations on the inappropriate use of antibiotics as well as ways to address this. Concerns with adverse drug reactions and adherence to anti-retroviral medicines was also discussed, with poor adherence remaining a challenge. There were also concerns with the underutilisation of generics. These discussions resulted in a number of agreed activities before the next conference in 2016

Medicines dispensers' knowledge on the implementation of an artemisinin-based combination therapy policy for the treatment of uncomplicated malaria in Tanzania

Objectives In 2005, Tanzania changed its policy for uncomplicated malaria treatment from sulphadoxine–pyrimethamine (SP) to artemisinin-based combination therapy (ACT), specifically artemether–lumefantrine (ALU). SP remains the medicine of choice for intermittent preventive treatment in pregnancy (IPTp). There is a need to assess dispensers' knowledge regarding the treatment of uncomplicated malaria and IPTp in Tanzania given appreciable self-purchasing to improve future care. Methods Descriptive cross-sectional design with structured questionnaires to capture quantitative data, with qualitative data captured using focus groups. The study was performed at 32 private pharmacies and 33 Accredited Drug Dispensing Outlets in the Nyamagana and Sengerema Districts in Tanzania, with 20 dispensers included in the qualitative discussions. Key findings The knowledge level of dispensers in the private medicine outlets was variable. Most dispensers knew ALU was first-line treatment in uncomplicated malaria, however variable knowledge about taking ALU with fatty meals. Generally, dispensers had poor knowledge about dosing intervals for SP in IPTp and variable knowledge regarding treatments in the first trimester. Overall, 49% had good knowledge and 48% had moderate knowledge of ACT in uncomplicated malaria. There was a significant relationship between dispenser type and knowledge of ACT but no statistical relationship between the level of knowledge on IPTp and the dispenser. Conclusions The majority of dispensers in private medicines outlets have good knowledge on ACT policy in the treatment of uncomplicated malaria; however, few dispensers had good knowledge on IPTp, which may contribute to irrational dispensing of SP. This needs addressing given the extent of self-purchasing in Tanzania

Patient-related beliefs and adherence toward their medications among the adult hypertensive outpatients in Tanzania

The following article has been retracted from Journal of Comparative Effectiveness Research as it did not meet the ethical standards of the Journal and the Universities, owing to the use of an invalidated MMAS-8 scale: Jande M, Katabalo DM, Sravanam P, Marwa C, Madlan B, Burger J, Godman B, Oluka M, Massele A, Mwita S. Patient-related beliefs and adherence toward their medications among the adult hypertensive outpatients in Tanzania. J. Comp. Eff. Res. 6(3), 185–193 (2017). The authors and editors of the Journal of Comparative Effectiveness Research regret any negative consequences this publication might have caused in the scientific and medical communities.</jats:p

African countries are working together to enhance medicine use

Growing burden of infectious and NCDs across Africa, e.g. 70% of world’s HIV patients live in sub-Sahara Africa and 30 to 45% of adults have hypertension. This requires groups to collaborate. This is happening, e.g. SAHTAS, PharfA and MURIA. MURIA is researching antibiotic use, adherence to medicines and strengthening DTCs. This should continue to optimise medicine use and scarce resources. The socioeconomic burden of diseases is increasing in Africa. For instance in 2011, 70% of the world’s HIV population resided in sub-Sahara Africa. There are also growing rates of AMR, which necessitates newer more expensive antibiotics adding to costs. There is also a growing burden of NCDs, 3 out of 4 patients with hypertension currently live in LMICs, with prevalence rates up to 30% to 45% among adults in Africa. Alongside this, up to 70% of total healthcare expenditure is spent on medicines in LMICs; much of this out-of-pocket. Consequently, an urgent need to strengthen collaborative research to improve medicine use. Summary of groups working together in Africa including the Medicines Utilisation Research in Africa (MURIA) group. African Strategies for Health identifies and advocates best practices, as well as works with others to develop sustainable solutions. Pharmacology for Africa (PharfA) organises and promotes pharmacology on the African continent, including research in clinical pharmacology, alongside the IUPHAR sub-division. ISPOR Africa co-ordinates activities from the different African country chapters. SAHTAS is a scientific and professional society for all those who produce, use, or encounter HTA in Southern Africa, and WHO International and Regional groups are improving antibiotic drug utilisation capabilities in Africa. The MURIA group was established in 2015 [1]. Ongoing collaborative research includes (i) initiatives to optimise antibiotic use; (ii) methods to enhance adherence to anti-infective prescribing guidance, (iii) approaches to improve adherence to HIV and NCDs; (iv) researching current anti-hypertensive and anti-diabetes medicines utilisation patterns and knowledge; (v) approaches to enhance DTC activities, and (vi) strengthening medicine utilisation capabilities [2,3]. These activities have already strengthened research ties across Africa. A number of groups are already working across Africa to enhance appropriate medicine use, and should continue. Ongoing MURIA activities include antibiotic point-prevalence studies, ongoing research into infectious diseases, NCDs and DTCs including adherence as well as the third workshop and symposium in Namibia in 2017

Challenges and issues in drug utilization research identified from the Latin American and African regions

Background: Despite advancements in drug utilization research (DUR), these have not been universal. Some regions such as the Latin America (LatAm) and African regions are facing challenges that are impeding the development of DUR. Objectives: To identify the main challenges and issues for DUR in the LatAm and African regions Methods: A collaborative initiative by the International Society of Pharmacoepidemiology Global Development Committee in partnership with the Latin America Drug Utilization Group and the Medicines Utilization Research in Africa Group was undertaken. A comprehensive literature review was conducted to identify local and international DUR publications. A core group of investigators and experts in DUR reviewed the publications and identified the main methodological challenges and issues. Subsequently, the group exchanged materials, participated in WebEx discussions, and reviewed the draft document. Results: Main issues: 1) Socioeconomic: high unemployment rate with poor standard of living, socioeconomic inequalities, low literacy levels, urban segregation, high migration rates, high rates of violent crime including drug trafficking and possession. 2) Healthcare-related: Disparities of social determinants of health, differences in the quality of public and private health sectors; and epidemiologic transition from communicable diseases to non-communicable diseases. Most health care systems are fragmented with variable access to medical care and medicines, and substandard record keeping. 3) Drug utilization-related: Inappropriate use of medicines including the elderly; limited infrastructure to reliably collect DU data; over-prescription of antimicrobials; polypharmacy; high rates of self-medication; and poor patient adherence (e.g. HIV/AIDS, diabetes mellitus and hypertension). Planning for DUR is affected by the multiplicity of drug distribution channels; trading in sub-standard, counterfeit medicines and insufficient quality control centers. Some publications are generated by local investigators, often suffering of methodological issues such as lack of representativeness of the population, limited data validity, and small sample sizes. Conclusions: There are common challenges for DUR when working within the LatAm and African regions. Based on our findings, the group is developing Guidance on Good Practices of Drug Utilization Research in those regions to assist researchers with issues pertaining to the planning, conduct, and evaluation of DUR

A cross-sectional analysis of the association between age and gender and prescribed minimum benefit chronic disease list conditions among South Africans with concomitant hypertension, diabetes and dyslipidaemia

Background: Prescribed Minimum Benefit Chronic Disease List (PMB CDL) conditions are a regulated list of conditions most common to South Africa. Objectives: To investigate the prevalence and association between PMB CDL conditions and age and gender among patients with concomitant hypertension, diabetes and dyslipidaemia. Methods: The study population consisted of patients (n = 17 866) with a prescription containing at least one co-prescribed antilipemics, antihypertensive and antidiabetic (identified using the MIMS Desk Reference). ICD-10 codes on claims for PMB CDL conditions were counted. Results: 39.5% of patients had a PMB CDL condition. Women had higher odds for hypothyroidism (OR 6.30, 95% CI; 5.52, 7.19, p < 0.001) and lower odds for coronary artery disease (CAD) (OR 0.63, 95% CI; 0.55, 0.72, p < 0.001) than men. In combination with hypothyroidism the odds for CAD were reversed and strongly increased; 3.54 (95% CI; 2.38, 5.25, p < 0.001). The odds for females having cardiac failure (CF) was insignificant and low (OR 0.87, 95% CI; 0.75, 1.01, p = 0.063); however combined with hypothyroidism, the odds increased to 5.35 (95% CI; 3.52, 8.13, p < 0.001). Conclusion: Hypothyroidism was an important discriminating factor for co-morbidity in women with concomitant hypertension, diabetes and dyslipidaemia, in particular with cardiovascular disease. Keywords: Concomitant hypertension, diabetes and dyslipidaemia, South Africa, prescribed minimum benefit chronic disease list (PMB CDL) condition

Antibiotic prescribing to inpatients in Limpopo, South Africa: a multicentre point-prevalence survey

Abstract Background Electronic continuous surveillance databases are ideal for monitoring antibiotic use (ABU) in hospitalised patients for antibiotic stewardship programmes (ASP). However, such databases are scarce in low-resource settings. Point prevalence surveys (PPS) are viable alternatives. This report describes ABU and identifies ASP implementation improvement areas in Limpopo Province, South Africa. Methods This cross-sectional descriptive study extracted patient-level ABU data from patients’ files using a modified global PPS tool. Data were collected between September and November 2021 at five regional hospitals in Limpopo Province, South Africa. All patients in the wards before 8 a.m. on study days with an antibiotic prescription were included. Antibiotic use was stratified by Anatomic Therapeutic Chemical and Access, Watch, Reserve classifications and presented as frequencies and proportions with 95% confidence intervals (CI). Associations between categorical variables were assessed using the chi-square test. Cramér’s V was used to assess the strength of these associations. Results Of 804 inpatients surveyed, 261 (32.5%) (95% CI 29.2–35.7) were prescribed 416 antibiotics, 137 were female (52.5%) and 198 adults (75.9%). One hundred and twenty-two (46.7%) patients received one antibiotic, 47.5% (124/261) received two, and 5.7% (15/261) received three or more antibiotics. The intensive care units had a higher ABU (68.6%, 35/51) compared to medical (31.3%, 120/384) and surgical (28.5%, 105/369) wards (p = 0.005, Cramér’s V = 0.2). Lower respiratory tract infection (27.4%, 104/379), skin and soft tissue infections (SST) (23.5%, 89/379), and obstetrics and gynaecology prophylaxis (14.0%, 53/379) were the common diagnoses for antibiotic prescriptions. The three most prescribed antibiotic classes were imidazoles (21.9%, 91/416), third-generation cephalosporins (20.7%, 86/416) and combination penicillin (18.5%, 79/416). Access antibiotics accounted for 70.2% (292/416) of prescriptions and Watch antibiotics for 29.6% (123/416) (p = 0.110, Cramér’s V = 0.1). Reasons for prescribing and treatment plans were documented in 64.9% (270/416) (95% CI 60.3–69.5) and 21.4% (89/416) (95% CI 17.3–25.3) of prescriptions, respectively. Conclusions The study serves as a baseline for ABU surveillance at the five regional hospitals in Limpopo Province. Lack of documentation indicates poor prescribing practices; ASP should address gaps by deploying evidence-based, multifaceted and stepwise interventions