Dispensing of antimicrobials in Kenya : a cross sectional pilot study and its implications

Objectives: Irrational use of antibiotics is a major driver of antimicrobial resistance, enhanced by inappropriate prescribing and dispensing of antibiotics. Little is currently known about dispensing of antibiotics in Kenya including self-medication with antibiotics. Consequently, the objective was to evaluate the extent of self-medication of antibiotics and dispensing practices in Kenya. Methods: Cross sectional study among 3 randomly selected community pharmacies in Nairobi. Findings: There was a low level of dispensing of antibiotics without a prescription with over ninety percent (94.1%) of antibiotics dispensed with a valid prescription. The most common antibiotics dispensed were the penicillins at just over fifty percent of all antibiotics, the cephalosporins at over twelve percent (12.6%) and the fluoroquinolones at just under twelve percent (11.7%). There were concerns with high use of third and fourth generation cephalosporins versus first and second generation as well as co-amoxiclav versus other penicillins. Encouragingly, antibiotics were not dispensed for influenza or a common cold, and generally very good dispensing processes, with typically a good level of medication history and counselling. Conclusion: Low levels of self-medication of antibiotics and high adherence to quality standards for dispensing are encouraging and provide direction to other countries. Educational initiatives are needed though to address high levels of co-amoxiclav prescribing

Appropriateness of antibiotic prescribing and compliance to guidelines at a referral hospital in Kenya : a point prevalence survey

Background: A large proportion of antibiotics globally are prescribed, dispensed or administered irrationally. This is partly due to lack of local guidelines or non-adherence to available antibiotic use guidelines. The irrational use of antibiotics results in wastage of scarce health care resources, increases the risk of adverse drug reactions and increases the potential of development of resistance. This leads to poor health outcomes. Objectives: The aim of the study was to establish whether there was rational or irrational prescribing and adherence to guidelines in one of the referral hospitals in Kenya at a specific point in time. Methods: A point prevalence survey was conducted at a referral hospital in Kenya in April 2017. Stratified proportionate random sampling technique was used to select eligible patients who were on systemic antibiotics. Data was abstracted from the patient medical records into a predesigned patient form. Associations between predictor variables such as socio-demographic factors and outcome variables such as rational prescribing and guideline compliance were determined using Chi square. Stepwise backward binary logistic regression was done to determine the independent predictors of rational antibiotic prescribing and guideline compliance. Statistical significance was set at 95% confidence level and values with p≤0.05 were considered statistically significant. Approval to conduct the study was obtained from the Kenyatta National Hospital/University of Nairobi Research and Ethics Committee. Results: A total of 179 patients were recruited into the study. There was rational prescribing in 33.9% (n=121) of all the 357 antibiotic encounters. The neonatal medical ward had the highest prevalence of rational prescribing (80%, n=12) while the critical care unit had the highest prevalence of irrational prescribing (100%, n=4). The most powerful predictor variables of rational antibiotic prescribing were the department (AOR=0.778, 95% CI=0.640–0.945, p=0.011), a diagnosis of a neonatal infection (AOR=5.992, 95% CI=1.985–18.094, p=0.001), a diagnosis of skin, soft tissue, bone and joint infection (AOR=6.221, 95% CI=2.053–18.847, p=0.001) and a diagnosis of no defined site such as sepsis (AOR=5.540, 95% CI=1.486–20.648, p=0.011). There was guideline compliance in 45.8% (n=82) of the study population. The most powerful predictors of guideline compliance were a diagnosis of a respiratory infection (AOR=7.141, 95% CI=2.950–17.287, p<0.001), a diagnosis of a neonatal infection (AOR=10.603, 95% CI=1.671–67.280, p=0.012) and a diagnosis of a skin, soft tissue, one and joint infections (AOR=5.606, 95% CI=1.730–18.162, p=0.004). Conclusions: Rational prescribing was documented in only a third of all antibiotics prescribed. There was poor compliance to guidelines. Local guidelines were not available for a significant proportion of conditions. International guidelines were used in such scenarios

Antibiotic prescribing patterns at a referral hospital in Kenya : a point prevalence survey

Background: Antibiotics are important in prevention and treatment of infections and the reduction in associated morbidity and mortality. Inappropriate use can lead to antimicrobial resistance, rendering them ineffective. Studies have shown variations in antibiotic prescribing patterns across different patient populations within the same hospital. Objectives: Our study aimed at establishing the prevalence and patterns of antibiotic use in a referral hospital in Kenya, with the aim of using the data for quality improvement. Methods: A point prevalence survey was conducted at a referral hospital in Kenya in April 2017. All patients who received antibiotics were recruited from all departments. Descriptive and inferential data analysis was done to establish the patterns of antibiotic use and the associations between variables. Ethical approval was obtained from the Kenyatta National Hospital/ University of Nairobi Research and Ethics Committee. Results: A hundred and seventy nine patients were enrolled in the study. The prevalence of antibiotic prescribing was 54.7%. The highest prevalence of antibiotic prescribing was found in critical care unit and isolation ward, both at 100%. Obstetrics and gynecology department had the least prevalence at 20.8%. Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes. A larger proportion of antibiotic prescribing was for treatment (75.4%) as compared to prophylaxis (29.0%). Majority (76.9%, n=52) of the patients on surgical prophylaxis were on prolonged duration (>1 day). Empiric prescribing accounted for 82.6% of the total antibiotic encounters while targeted treatment was recorded in 17.4%. Conclusions: The study identified several areas for potential improvement in antibiotic prescribing such as the high prevalence of inpatient antibiotic use, prolonged duration of antibiotic use in surgical prophylaxis, extensive prescribing of broad spectrum agents such as ceftriaxone and the low prevalence of targeted antibiotic prescribing

Socio-demographic and treatment-related variables associated with CD4 cell counts in Kenyan HIV patients on second-line regimens

Background: CD4 cell response in patients on second-line therapy has not been evaluated in Kenya. Patients failing second-line are changed to third-line, however, the drugs used for third-line are expensive and unavailable. Therefore, early identification of potential poor responders to treatment would lead to early intervention and thus improve therapy of patients on second-line. Objectives: To identify socio-demographic and treatment related variables that affect CD4 response of HIV-positive patients on second-line regimens in Kenyatta National Hospital (KNH). Methods: A historical cohort study carried out at KNH between January and April 2016 and entailed collection of patient data from the files. The main outcome variable was CD4 cell count.  The predictor variables of interest were sex, age, education level, and ART regimens. Results: All the study participants were on a lopinavir-based regimen. The study involved 84 study participants, 59.5% female study participants and 40.5% male. Male patients had significantly lower baseline CD4 cell counts and lower CD4 cell counts at ART (antiretroviral therapy) switch to second line compared to female patients. Efavirenz-based regimens were significantly associated with low CD4 cell count at ART switch to second-line. Conclusion: Patients should be started on nevirapine-based regimens unless contraindicated. Keywords: CD4 cell count, ART switch, second-lin

Clinical and Financial Implications of Medicine Consumption Patterns at a Leading Referral Hospital in Kenya to Guide Future Planning of Care

Background: Medicines can constitute up to 70% of total health care budgets in developing countries as well as considerable expenditure in hospitals. Inventory management techniques can assist with managing resources efficiently. In Kenyatta National Hospital (KNH), a leading hospital in Kenya, over 30% of medical expenses are currently allocated to medicines, and this needs to be optimally managed. Objective: To investigate drug consumption patterns, their costs and morbidity patterns at KNH in recent year. Methodology: Cross-sectional retrospective record review. Inventory control techniques, ABC (Always, Better, Control), VEN (Vital, Essential and Non-essential) and ABC-VEN matrix analysis used to study drug expenditure patterns. Morbidity data extracted from the Medical Records. Results: Out of an average of 811 medicine types procured annually (ATC 5), 80% were formulary drugs and 20% were non-formulary. Class A medicines constituted 13.2% to 14.2% of different medicines procured each year but accounted for an average of 80% of total annual drug expenditure. Class B medicines constituted 15.9%-17% of all the drugs procured yearly but accounted for 15% of the annual expenditure, whilst Class C medicines constituted 70% of total medicines procured but only 5% of the total expenditure. Vital and Essential medicines consumed the highest percentage of drug expenditure. ABC-VEN categorization showed that an average of 31% medicine types consumed an average of 85% of total drug expenditure. Therapeutic category and Morbidity patterns analysis showed a mismatch between drug expenditure and morbidity patterns in over 85% of the categories. Conclusion: Class A medicines are few but consume the largest proportion of hospital drug expenditure. Vital and essential items consume the highest drug expenditure, and need to be carefully managed. ABC-VEN categorization identified medicines were major savings could potentially be made helped by Therapeutic category and Morbidity pattern analysis. There was a high percentage of non-formulary items, which needs to be addressed. Inventory control techniques should be applied routinely to optimize medicine use within available budgets especially in low and middle income countries. This is now being implemented

Evaluation of the clinical practice of aminoglycosides use in paediatric patients in Kenya : findings and implications to Low-middle Income Countries

Objectives To evaluate the practice of aminoglycoside use/monitoring in Kenya and explore healthcare worker (HCW) perceptions of aminoglycoside monitoring to identify gaps and opportunities for future improvements, given the low therapeutic index of aminoglycosides. Methods This was a two-phase study whereby we reviewed patients' medical records at Kenyatta National Hospital (October-December 2016) in Phase 1 and interviewed HCWs face to face in Phase 2. Outcome measures included describing and evaluating the practice of aminoglycoside use and monitoring and compliance to guidelines. Data were analysed using descriptive and inferential analysis. Results Overall, out of the 2318 patients admitted, 192 patients (8.3%) were prescribed an aminoglycoside, of which 102 (53.1%) had aminoglycoside doses that did not conform to national guidelines. Aminoglycoside-related adverse effects were suspected in 65 (33.9%) patients. Monitoring of aminoglycoside therapy was performed in only 17 (8.9%) patients, with no therapeutic drug monitoring (TDM), attributed mainly to knowledge and skill gaps and lack of resources. Out of the 28 recruited HCWs, 18 (64.3%) needed training in how to perform and interpret TDM results. Conclusions The practice of using and monitoring aminoglycosides was suboptimal, raising concerns around potential avoidable harm to patients. The identified gaps could form the basis for developing strategies to improve the future use of aminoglycosides, not only in Kenya but also in other countries with similar settings and resources

Assessing utilisation and expenditure on long-acting insulin analogues in Kenya; findings and implications for the future

Prevalence rates for patients with diabetes mellitus are rising across countries including sub-Saharan African countries, which will continue. As a result, there are an increasing number of patients with insulin-dependent diabetes across sub-Saharan Africa including Kenya. Growing prevalence rates are increasing the costs of treating patients with diabetes enhanced by associated complications. These include both microvascular and macrovascular complications, with hypoglycaemia and generally poor control of diabetes contributing to the burden. Long-acting insulin analogues were developed to reduce rates of hypoglycaemia associated with insulin usage, including nocturnal hypoglycaemia, and improve adherence through improving patient convenience. As a result, they are now included in the Kenyan Essential Medicines List. However, long-acting insulin analogues are typically considerably more expensive than standard insulins limiting their use in practice, especially in countries such as Kenya with concerns with affordability even for standard insulins such as Mixtard®. Consequently, a need to ascertain current utilisation and expenditure patterns for the different insulins including long-acting insulin analogues across Kenya starting with leading referral hospitals. Research in Kenyatta National Hospital (KNH) showed growing use of insulin glargine reaching up to 3.4 to 3.6% of total insulin utilisation in 2019 and 2020. However, prescribing was limited by considerably higher prices (3.4 fold higher) than standard insulins on a defined daily dose basis. Considerably higher prices resulted in no utilisation of long-acting insulin analogues in another leading referral hospital in Kenya. Overall, appreciably lowering the prices of long-acting insulin analogues through instigating local production and other activities should increase their use benefiting patients and the healthcare system in Kenya and wider. These are considerations for the future

Point prevalence survey of antibiotic use and resistance at the biggest national referral hospital in Kenya : findings and implications

Background: A substantial amount of antibiotic use in hospitals may be inappropriate, leading to an increase in antibiotic resistance, adverse effects, mortality and increased costs. This can be reduced by documenting and understanding current utilisation patterns to instigate appropriate measures. Objective: To assess antibiotic use patterns and prevalence of antibiotic resistance in the biggest national referral hospital in Kenya; subsequently identify opportunities for quality improvement. Methodology: A point prevalence survey (PPS) was carried out with data abstracted principally from patient medical records supplemented by interviews from physicians, using the global PPS data collection tool and methodology. Patients were selected using universal sampling. Descriptive analysis was used to describe the pattern of antibiotic use. Differences in antibiotic use and indications between the selected wards were compared using the Chi-square test or Fisher’s exact tests. Results: Among the patients surveyed (n=269), 67.7% (n=182) were on antibiotics. The most common classes of antibiotics prescribed were third generation cephalosporins (55%), imidazole derivatives, e.g. metronidazole (41.8%), and broad spectrum penicillins (41.8%). Most common indication for antibiotic use was medical prophylaxis (29%). Dosing of antibiotics was seen as typically optimal when assessed against current recommendations. Among gram positive organisms, Staphylococcus aureus isolates were resistant to cotrimoxazole (90%), amoxicillin (69%), co-amoxyclav (67%) and cefaclor (67%). Among gram negative bacteria, Escherichia coli isolates were resistant to piperacillin (90%). Pseudomonas aeruginosa isolates were resistant to imipenem (100%). Conclusion: Whilst the dosing of antibiotics seemed adequate, there was high use of antibiotics, exacerbated by the high proportion being prescribed without reference to current guidelines. Antibiotic resistance also seems to be very high especially against the broadest spectrum antibiotics, which is a real concern and imposes sever negative clinical implications. Programmes are currently being instigated to address these concerns

Accessibility of medicines used in the management of substance use disorders in selected hospitals in Nairobi

Background: Substance use disorder is a complex chronic disease that requires a multidisciplinary approach in treatment. Pharmacotherapy is one of the components in the treatment of this condition. This study sought to assess the accessibility of medicines used in the treatment of substance use disorders in both a public and a private health facility in Nairobi. Methodology: This descriptive cross-sectional study with both qualitative and quantitative components was carried out in April and May 2015 at two hospitals in Nairobi, Mathare Mental Hospital (public) and Chiromo Lane Medical Centre (private).  Data on availability and affordability was collected from the two sites and the WHO performance indicators for health facilities used to assess availability. Affordability was determined using the daily wage of the lowest paid government worker. Interviews with the key informants were conducted to determine factors that influence the accessibility of the medicines. Results: About 50% of medicines on the Kenya Essential Medicines List for management of substance use disorders were available in Mathare while Chiromo Lane had all of them. The mean stock out duration was 8 months and 0.5 months in Mathare and Chiromo Lane, respectively.  More than 67 % of the medicines required less than a single day’s wage to buy a month’s supply in Mathare while in Chiromo Lane all the medicines required more than a single day’s wage to purchase.  The cheapest medicine required 0.3 days wage to purchase while the most expensive drug required 50 days wage to purchase. Conclusion: Medicines for the treatment of substance use disorders had limited availability but were relatively affordable in Mathare while their availability was better in Chiromo Lane but with limited affordability.  The Kenya Essential Medicines List for substance use disorders requires updating to include newer and more efficacious medicines. National guidelines for the treatment of substance use disorders should be developed and disseminated. Key words: Substance use disorders, pharmacotherapy, accessibility and affordabilit

One-day out-patient prescribing patterns at a national referral hospital in Kenya

Background: Poor prescribing habits lead to ineffective and unsafe treatment for patients, exacerbating or prolonging of illness as well as causing distress and harm to them. Drug utilization studies can help identifying gaps in prescribing and feed the results back to prescribers to enhance future rational use of medicines. Objective: Evaluate outpatient prescribing practices and patterns in a leading national Hospital in Kenya. Methods: A sample of 60 prescriptions was selected by quasi-random sampling. Data was abstracted using a pre-designed data collection form, entered into and analyzed using Excel software. Results: The average number of drugs prescribed per prescription was three with a polypharmacy rate (&gt;4 drugs) of 20%. Only two-thirds (65%) of the prescribed drugs were actually dispensed at the hospital pharmacy due to shortages, principally shortages of originators. Slightly more than half (52%) of the drugs were prescribed by generic name. Prescribing by brand names was highest among medical interns (61%). Almost all drugs prescribed (95%) were consistent with the hospital tender list. Conclusions: There is a need to increase the rate of prescribing of generics to save costs as well as reduce stock-out levels. This can be helped by instigating a comprehensive generics policy. There is also a need to strengthen and empower drugs and therapeutic committees (DTCs) to improve selection and availability of quality generics to win the confidence of prescribers. Keywords: Drug utilisation studies, generics, prescribing patterns, prescribing indicators, polypharmacy, WHO indicators, Keny