Retrospective Assessment of Antibiotics Prescribing at Public Primary Healthcare Facilities in Addis Ababa, Ethiopia

Background. Antibiotic overprescribing is the major driving force for the emergence of antibiotics resistance. The aim of this study was to assess antibiotics prescribing at primary healthcare facilities in Addis Ababa, Ethiopia. Methods. The study was conducted in six public health centers found in Addis Ababa City. Data was collected retrospectively from a total of 900 prescriptions and selected medical charts of patients in the health centers in 2016. Data was entered and analyzed using EPI Info 7 and SPSS 20, respectively. Descriptive statistics and logistic regression analysis were used to analyze the data. Results. One or more antibiotics were prescribed in 56.0% of the prescriptions. Antibiotics accounted for 46.0% of the total cost of medicines prescribed. Amoxicillin was the most frequently (44.8%) prescribed antibiotic and upper respiratory tract infection was the most common (24.5%) diagnosis for prescribing antibiotics. Laboratory investigation was done for only about 27% of the cases for which antibiotics were prescribed. Conclusion. There was a high rate of antibiotics prescribing in the health centers often empirically which might exacerbate the antimicrobial resistance situation in the country. Large-scale study should be conducted to fully understand the prescribing pattern and identify the associated factors thereby design and implement appropriate interventions

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

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.Health StudiesD.Phil. (Public Health

EVALUATION OF PROPHYLACTIC USE OF COTRIMOXAZOLE FOR PEOPLE LIVING WITH HIV/AIDS IN JIMMA UNIVERSITY SPECIALIZED HOSPITAL, SOUTHWEST ETHIOPIA

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Prevalence and predictors of undernutrition among infants aged six and twelve months in Butajira, Ethiopia: The P-MaMiE Birth Cohort

<p>Abstract</p> <p>Background</p> <p>Child undernutrition is a major public health problem in low income countries. Prospective studies of predictors of infant growth in rural low-income country settings are relatively scarce but vital to guide intervention efforts.</p> <p>Methods</p> <p>A population-based sample of 1065 women in the third trimester of pregnancy was recruited from the demographic surveillance site (DSS) in Butajira, south-central Ethiopia, and followed up until the infants were one year of age. After standardising infant weight and length using the 2006 WHO child growth standard, a cut-off of two standard deviations below the mean defined the prevalence of stunting (length-for-age <-2), underweight (weight-for-age <-2) and wasting (weight-for-length <-2).</p> <p>Results</p> <p>The prevalence of infant undernutrition was high at 6 months (21.7% underweight, 26.7% stunted and 16.7% wasted) and at 12 months of age (21.2% underweight, 48.1% stunted, and 8.4% wasted). Significant and consistent predictors of infant undernutrition in both logistic and linear multiple regression models were male gender, low birth weight, poor maternal nutritional status, poor household sanitary facilities and living in a rural residence. Compared to girls, boys had twice the odds of being underweight (OR = 2.00; 95%CI: 1.39, 2.86) at 6 months, and being stunted at 6 months (OR = 2.38, 95%CI: 1.69, 3.33) and at 12 months of age (OR = 2.08, 95%CI: 1.59, 2.89). Infant undernutrition at 6 and 12 months of age was not associated with infant feeding practices in the first two months of life.</p> <p>Conclusion</p> <p>There was a high prevalence of undernutrition in the first year of infancy in this rural Ethiopia population, with significant gender imbalance. Our prospective study highlighted the importance of prenatal maternal nutritional status and household sanitary facilities as potential targets for intervention.</p

Perinatal mental distress and infant morbidity in Ethiopia: a cohort study

OBJECTIVES: (1) To investigate the impact of perinatal common mental disorders (CMD) in Ethiopia on the risk of key illnesses of early infancy: diarrhoea, fever and acute respiratory illnesses (ARI) and (2) to explore the potential mediating role of maternal health behaviours. DESIGN: Population-based cohort study. SETTING: Demographic surveillance site in a predominantly rural area of Ethiopia. PARTICIPANTS: 1065 women (86.3% of eligible) in the third trimester of pregnancy were recruited and 954 (98.6%) of surviving, singleton mother-infant pairs were followed up until 2 months after birth. MAIN EXPOSURE MEASURE: High levels of CMD symptoms, as measured by the locally validated Self-Reporting Questionnaire (SRQ-20 ≥6), in pregnancy only, postnatally only and at both time-points ('persistent'). MAIN OUTCOME MEASURES: Maternal report of infant illness episodes in first 2 months of life. RESULTS: The percentages of infants reported to have experienced diarrhoea, ARI and fever were 26.0%, 25.0% and 35.1%, respectively. Persistent perinatal CMD symptoms were associated with 2.15 times (95% CI 1.39 to 3.34) increased risk of infant diarrhoea in a fully adjusted model. The strength of association was not affected by including potential mediators: breast feeding practices, hygiene, the infant's vaccination status or impaired maternal functioning. Persistent perinatal CMD was not associated with infant ARI or fever after adjusting for confounders. CONCLUSIONS: Persistent perinatal CMD was associated with infant diarrhoea in this low-income country setting. The observed relationship was independent of maternal health-promoting practices. Future research should further explore the mechanisms underlying the observed association to inform intervention strategies

The effect of maternal common mental disorders on infant undernutrition in Butajira, Ethiopia: The P-MaMiE study

BACKGROUND: Although maternal common mental disorder (CMD) appears to be a risk factor for infant undernutrition in South Asian countries, the position in sub-Saharan Africa (SSA) is unclear METHODS: A population-based cohort of 1065 women, in the third trimester of pregnancy, was identified from the demographic surveillance site (DSS) in Butajira, to investigate the effect of maternal CMD on infant undernutrition in a predominantly rural Ethiopian population. Participants were interviewed at recruitment and at two months post-partum. Maternal CMD was measured using the locally validated Self-Reported Questionnaire (score of > or = six indicating high levels of CMD). Infant anthropometry was recorded at six and twelve months of age. RESULT: The prevalence of CMD was 12% during pregnancy and 5% at the two month postnatal time-point. In bivariate analysis antenatal CMD which had resolved after delivery predicted underweight at twelve months (OR = 1.71; 95% CI: 1.05, 2.50). There were no other statistically significant differences in the prevalence of underweight or stunted infants in mothers with high levels of CMD compared to those with low levels. The associations between CMD and infant nutritional status were not significant after adjusting for pre-specified potential confounders. CONCLUSION: Our negative finding adds to the inconsistent picture emerging from SSA. The association between CMD and infant undernutrition might be modified by study methodology as well as degree of shared parenting among family members, making it difficult to extrapolate across low- and middle-income countries

Immunological and clinical progress of HIV/AIDS patients on antiretroviral therapy at a health center in Addis Ababa, Ethiopia

Objective: The objective of the following study was to assess the immunological and clinical progress of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) patients on antiretroviral therapy (ART) at a health center in Addis Ababa, Ethiopia. Materials and Methods: A retrospective follow-up study was carried out using the medical records of HIV/AIDS patients who initiated ART between August 2005 and 2007. A total of 83 patients were included in the study. The records were used to get a 1 year progress since ART initiation. Results: At ART initiation the median CD4 + cell count was 127 cells/mm 3 and the median weight 50 kg. Out of the total patients 47% were ambulatory and 16% were bedridden in their functional status. The regimen initiated by most patients, 59 (71%), was "Stavudine/Lamivudine/Nevirapine (D4T/3TC/NVP)". After 12 months on ART, 63 (76%) of the patients were still actively following the treatment. After the same period, 12% of them were deceased. The functional status of 69 (83.1%) of the patients on ART improved to "working" status after 6 months. At the end of the 1 year on ART all the 63 patients, who were actively following the treatment, improved to "working" status. Weight of the patients improved to 54 and 56 kg after 6 and 12 months respectively. The increase in the CD4 + cell count was 92 and 118 cells/mm 3 after 6 and 12 months respectively. Conclusion: This study showed that immunological and clinical status of the patients had improved within the 1 year of therapy as evidenced by increase and improvement in the functional status, median weight and CD4 + cell count