Optimizing antibiotic prescribing in Nigerian hospitals

Background: Antimicrobial resistance (AMR) is a major concern facing global health today. It is severe in developing countries where the burdens of infectious diseases are much higher. Studies from developed countries suggest that antibiotic stewardship can improve antibiotic prescribing; however, these interventions are not directly applicable to developing countries. The aim of this study is to identify potentially feasible and effective strategies that will lead to improvements in antibiotic prescribing practices in hospitals in low and middle- income countries. Methods: A mixed methods approach was employed. First, a quantitative retrospective survey of antibiotic prescribing using patient’s case notes was conducted and then a qualitative prospective survey of prescribers and stakeholder’s perceptions of antibiotic prescribing. The qualitative survey employed semi-structured interviews to explore determinants of current antibiotic prescribing practices, suggestions to improve practice and the likely barriers. This study was carried out in four hospitals including two secondary and two tertiary care hospitals in Nigeria. Results: The results show that 72% of antibiotics were prescribed empirically. Only 28% of antibiotic prescriptions studied had complete compliance with the guidelines and relevant diagnostic tests were carried out in 15% of antibiotics prescriptions retrieved. Main determinants of current antibiotic prescribing practices include drug costs and availability, limited diagnostic resources and services, the excessive workload for healthcare providers, lack of policies/guidelines, and physicians’ attitudes. Recommendations prioritised by stakeholders for improvements to practice include provision of resources to support training and education, documentation and monitoring, improved diagnostic services and availability of antibiotics. Conclusion: This research extends our knowledge on antibiotic prescribing practices and strategies for implementing antibiotic stewardship programmes in resource poor settings. Establishing effective locally developed approaches can possibly improve antibiotic prescribing patterns. Achieving appropriate use and prescribing of antibiotics in Nigeria is a potentially achievable goal, provided the necessary resources are provided and funds allocated

Study of antimicrobial prescribing at a secondary health facility in a semi-urban community in Bayelsa State, south-south Nigeria

Background: Monitoring antimicrobial prescribing helps generate data to inform local policies on antimicrobial use and guides estimations for their stocking.Objectives: To assess utilization of antimicrobial agents, diagnosis and management of infections as well as associated drug therapy problems (DTPs) at a secondary health facility in Bayelsa State.Materials and Methods: In a retrospective study, case notes belonging to 1,278 patients who attended clinics at the study center from January 1st to December 31st, 2016 and who were prescribed at least an antimicrobial agent each for the treatment of infection were evaluated. Of these, 320 were retained for study having met completeness of prescription items. Data obtained were expressed in simple percentages while average values were presented in mean ± standard deviation (SD).Results: Two hundred and ninety-seven (92.8%) of the retained case notes were actually diagnosed with infections. In all, 24.8% of the 467 cases of infections treated were confirmed with requisite laboratory tests with 43.5, 19.9, and 13.1% of all being malaria, typhoid fever, and respiratory tract infections, respectively amongst others. Antibacterial (46.6%), antimalarial (35.5%), and anthelmintic (9.6%) agents were the most prescribed antimicrobial drugs. Respective average numbers of infections treated and antimicrobials prescribed per encounter were 1.47 ± 0.71 and 2.19 ± 0.97, and each prescription contained an average of 0.89 ± 0.86 DTP.Conclusion: Most of the antimicrobial prescribing were done without requisite diagnostic tests and each of the prescriptions contained at least a DTP necessitating a need for the education of the prescribers on rational use of antimicrobials.Keywords: Antimicrobial agents, communicable diseases, Niger Delta Are

Development of Antimicrobial Stewardship Programmes in Low and Middle-Income Countries: A Mixed-Methods Study in Nigerian Hospitals.

Antimicrobial resistance (AMR) is a major concern facing global health today, with the greatest impact in developing countries where the burden of infectious diseases is much higher. The inappropriate prescribing and use of antibiotics are contributory factors to increasing antibiotic resistance. Antimicrobial stewardship programmes (AMS) are implemented to optimise use and promote behavioural change in the use of antimicrobials. AMS programmes have been widely employed and proven to improve antibiotic use in many high-income settings. However, strategies to contain antimicrobial resistance have yet to be successfully implemented in low-resource settings. A recent toolkit for AMS in low- and middle-income countries by the World Health Organisation (WHO) recognizes the importance of local context in the development of AMS programmes. This study employed a bottom-up approach to identify important local determinants of antimicrobial prescribing practices in a low-middle income setting, to inform the development of a local AMS programme. Analysis of prescribing practices and interviews with prescribers highlighted priorities for AMS, which include increasing awareness of antibiotic resistance, development and maintenance of guidelines for antibiotic use, monitoring and surveillance of antibiotic use, ensuring the quality of low-cost generic medicines, and improved laboratory services. The application of an established theoretical model for behaviour change guided the development of specific proposals for AMS. Finally, in a consultation with stakeholders, the feasibility of the plan was explored along with strategies for its implementation. This project provides an example of the design, and proposal for implementation of an AMS plan to improve antibiotic use in hospitals in low-middle income settings

An analysis of pharmacy workforce capacity in Nigeria.

BACKGROUND: Pharmacists are critical for attaining the goal of universal health coverage and equitable access to essential health services, particularly in relation to access to medicines and medicines expertise. We describe an analysis of the pharmacy workforce in Nigeria from 2011 to 2016 in order to gain insight on capacity and to inform pharmacy workforce planning and policy development in the country. METHOD: The study was conducted using census data obtained from the Pharmacists Council of Nigeria (PCN) via a validated data collection tool. The statistical methods used for analysis were descriptive (frequencies, percentages, mean) and linear regression. Secondary data on population distribution per state was obtained from the Federal Bureau of Statistics and the National Population Commission (NPC) of Nigeria. RESULT: The data showed 21,892 registered pharmacists with only 59% (n = 12,807) in active professional practice. There are also more male (62%) compared to female pharmacists while 42% of the licensed workforce with known area of practice are in community practice followed by hospital pharmacy (11%). A rise in number of pharmacists (0.53-0.66) and new pharmacy graduates per year (0.062-0.083) per 10,000 population was observed over the five years analysed; however the overall density remains significantly low. Pharmacists' density also varied considerably between states (Median = 0.39; Min - Max: 0.05-4.3). Regionally, more than a third (~ 40%) of the licensed workforce and community pharmacies are situated in the South West region with fewer than 10% of the total in the North East and North West regions combined. A steady decline in number of pharmacists requesting a "letter of good standing" from PCN, a proxy measure of intent to migrate was also observed. CONCLUSION: The data indicate ongoing deficits in availability and supply of pharmacists in the country with widespread variance in distribution observed across the 36 states and the Federal Capital Territory (FCT). The findings suggest that observed deficits are not solely related to out-migration and highlights the need for policies that will promote increased within-country availability, equitable distribution and retention, especially in the underserved regions of North East and North West of Nigeria

Quality of life of healthy subjects and patients with arthritis and diabetes mellitus in Bayelsa State, Niger Delta region

PURPOSE: There is paucity of information about quality of life (QOL) studies among patients with arthritis and diabetes mellitus in developing countries. The objective of this study was to evaluate quality of life of patients with arthritis (AR) and diabetes mellitus (DM). METHODS: A total of 507 subjects comprising 364 healthy adult volunteers and 143 hospitals patients with arthritis and diabetes mellitus were enrolled into the study. Data were collected using Ferrans and Powers QOL index (QLI). The generic version and disease specific versions were administered to healthy subjects and hospital patients respectively and the data analyzed. RESULTS: The highest mean overall QOL scores of the healthy subjects (364; 71.79%) which ranged from 24.43(SD=4.08) to 26.62 (SD=2.15) (95% CI 24.94-27.27) is the second most desirable category of QOL rating relative to the reference standard score of zero to 30 for the worst and best case scenarios respectively. This was distantly followed by patients with diabetes mellitus alone (slightly satisfied) with mean OQOL score of 18.92 (SD=2.59; 95% CI 16.03-19.24). Subjects with AR had lower OQOL than diabetic subjects with mean OQOL scores of 15.98 (SD=2.75; 95% CI 13.15-16.77). The least mean OQOL score (moderately dissatisfied) was recorded for patients with AR co-existing with other chronic illnesses with a mean OQOL scores of 8.92 (SD=3.97; 95%CI 7.36 - 13.4). There was statistically significant difference between the OQOL of healthy subjects and patients with arthritis and diabetes mellitus (p<0.0001). A strong association also exists between OQOL and age, marital status, employment and gender (p<0.05). CONCLUSIONS: Arthritis and diabetes mellitus severely impaired patient QOL. Arthritis has more pronounced effects on QOL either alone or as co-morbid chronic illness. Concerted efforts at stemming the prevalence of these conditions, supportive roles for the elderly and married women as well as cost effective management of these conditions among others must be put in place

Community pharmacists' contribution to public health: assessing the global evidence base

In the UK, community pharmacies are more accessible to the general population than general practices. Therefore, government white papers and briefing documents from pharmacy professional bodies have advocated the expansion of the role of community pharmacists, particularly in relation to the provision of services that contribute to disease prevention and health improvement. It is unknown whether the same evidence exists globally for the expansion of these roles. This article attempts to appraise and summarise the global evidence for the public health roles that community pharmacists play. Barriers, as well as strategies that can enhance these roles, are also discussed. Electronic databases were searched to retrieve relevant literature published since 1 January 2000. The selected literature included 2 meta-analyses, 7 literature reviews, 23 interventional studies and 41 descriptive studies. These were assessed according to health topics (i.e. smoking cessation, weight management, health promotion, disease screening and preventive activities, vaccination and immunisation, alcohol dependence advice and drug misuse, emergency hormonal contraception, and sexual health services). The effectiveness of community pharmacy-based public health interventions was shown in smoking cessation, health promotion, disease screening and preventive activities, provision of emergency hormonal contraceptive, and vaccination services. Although there was mixed evidence with respect to weight management and alcohol dependence advice interventions, the available data suggest feasibility and acceptability of these services due to the perceived ease of access and convenience

Development of a research mentorship guide and consensus statement for low- and middle-income countries: Results of a modified Delphi process

Background Institutional research mentorship is a form of mentorship whereby institutions foster mentor-mentee relationships. Research mentorship improves research effectiveness and supports relationships. However, resources are needed in order to institutionalize research mentorship tailored to low- and middle- income countries (LMICs). The aim of this study was to develop a consensus document on institutionalizing research mentorship through a modified Delphi process as part of the practical guide development process. Methods This study used a two-round modified Delphi process, which is an iterative, structured approach of consensus decision making. Each participant was asked about a series of items related to research mentorship using Likert scale questions. Agreement for each item was pre-defined as ≥80% of participants rating the item as “agree” or “strongly agree.” The items that reached agreement, were then discussed during round two at an in-person conference in Ethiopia. A separate group of individuals only participated virtually. For the final consensus survey, response rates and commenting rates (participants who wrote two or more comments) were compared among conference and non-conference participants. Results The Delphi process led to the inception of three main themes in terms of developing research mentorship: leveraging existing resources, measuring and evaluating institutional mentorship, and encouraging a research mentorship life cycle. During the virtual first round, 59% (36/61) participants who were emailed completed the survey. In the second round, conference participants had a response rate of 79% (11/14) compared to non-conference participants with a response rate of 45% (21/47). Conference participants had a 100% (11/11) commenting rate whereas non-conference participants had a 38% (8/21) commenting rate. This study achieved consensus in both survey rounds for all 35 items on the consensus document. Conclusions The data suggest that an in-person conference may increase participant engagement. The consensus developed through a modified Delphi method directly informed a practical guide on institutionalizing research mentorship in LMICs

Crowdsourcing to develop open-access learning resources on antimicrobial resistance

Objectives Antimicrobial resistance (AMR) is a significant threat to global public health. Many medical curricula have limited clinical cases and materials focused on AMR, yet enhanced AMR education and training are needed to support antimicrobial stewardship programmes. We used crowdsourcing methods to develop open-access, learner-centred AMR resources. Crowdsourcing is the process of having a large group, including experts and non-experts, solve a problem and then share solutions with the public. Methods We organised a global crowdsourcing contest soliciting AMR-related multiple-choice questions, infographics, and images. First, we convened a diverse steering committee group to finalise a call for entries. Second, we launched the contest and disseminated the call for entries using social media, blog posts, email, and an in-person event. Partner institutions included two digital healthcare platforms: Figure 1® and Ding Xiang Yuan. Both organizations serve as online communities for healthcare specialists and professionals to report and comment on clinical information. At the end of the call, solicited entries were screened for eligibility and judged on merit and relevance to AMR learning and education. Exceptional entries were recognised, awarded prizes, and further reviewed for sharing with the public via open-access platforms. Results We received 59 entries from nine countries. These included 54 multiple-choice questions, four infographics, and one image. Eligible entries (n = 56) were reviewed and assigned a score on a 1-10 scale. Eight entries received mean scores greater than 6.0 and were selected as finalists. The eight finalist entries consisted of three infographics and five multiple-choice questions. They were disseminated through open-access publications and online medical communities. Although we launched a global call, we relied heavily on medical student groups and the entries received were not entirely globally representative. Conclusions We demonstrate that crowdsourcing challenge contests can be used to identify infectious disease teaching materials. Medical educators and curriculum developers can adapt this method to solicit additional teaching content for medical students

Diagnostic Infectious Diseases Testing Outside Clinics: A Global Systematic Review and Meta-analysis.

BACKGROUND: Most people around the world do not have access to facility-based diagnostic testing, and the gap in availability of diagnostic tests is a major public health challenge. Self-testing, self-sampling, and institutional testing outside conventional clinical settings are transforming infectious disease diagnostic testing in a wide range of low- and middle-income countries (LMICs). We examined the delivery models of infectious disease diagnostic testing outside clinics to assess the impact on test uptake and linkage to care. METHODS: We conducted a systematic review and meta-analysis, searching 6 databases and including original research manuscripts comparing testing outside clinics with conventional testing. The main outcomes were test uptake and linkage to care, delivery models, and adverse outcomes. Data from studies with similar interventions and outcomes within thematic areas of interest were pooled, and the quality of evidence was assessed using GRADE. This study was registered in PROSPERO (CRD42019140828).We identified 10 386 de-duplicated citations, and 76 studies were included. Data from 18 studies were pooled in meta-analyses. Studies focused on HIV (48 studies), chlamydia (8 studies), and multiple diseases (20 studies). HIV self-testing increased test uptake compared with facility-based testing (9 studies: pooled odds ratio [OR], 2.59; 95% CI, 1.06-6.29; moderate quality). Self-sampling for sexually transmitted infections increased test uptake compared with facility-based testing (7 studies: pooled OR, 1.74; 95% CI, 0.97-3.12; moderate quality). Conclusions.  Testing outside of clinics increased test uptake without significant adverse outcomes. These testing approaches provide an opportunity to expand access and empower patients. Further implementation research, scale-up of effective service delivery models, and policies in LMIC settings are needed

Innovative strategies to fight antimicrobial resistance: crowdsourcing to expand medical training

Background: Antimicrobial resistance is a serious public health concern across the world, but public awareness is low, few educational resources on diagnostics exist and professional interest in infectious diseases is waning. To spur interest in infectious disease, emphasize the role of diagnostics in management of resistant infections and develop educational resources to support antimicrobial stewardship. Methods: We employed crowdsourcing methods, using an open challenge contest to solicit clinical cases on antimicrobial resistance and clinical diagnostics. Results: We received 25 clinical cases from nine countries. After screening, 23 cases were eligible for judging. Three cases emerged as the top finalists and were further developed into an open access learning module on diagnostics and antimicrobial resistance. Conclusions: Crowdsourcing methods are beneficial for generating interest in infectious disease and developing educational resources to support antibiotic stewardship.</ns4:p