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
