923
Effect of Interventions on Misuse of
Antibiotics/Antibacterial Drugs in Developing
Countries: a Systematic Review
Bbosa, Godfrey Sande1,2; Wong, Geoff2; Kyegombe,
David B3; Ogwal-Okeng, Jasper1
1: Makerere University College of Health Sciences, Uganda
2: University of London, United Kingdom
3: Kampala International University Medical School, Ishaka Campus,
Uganda
1
2
Introduction
• Misuse of antibiotics/antibacterial drugs is a global
problem especially in developing countries with poor
healthcare systems & corruption
• Occurs at all levels in both public & Private Healthcare
facilities
• Reported up to 75 % of antibiotics are prescribed
inappropriately in teaching hospitals in developing
countries (Nambiar, 2003)
• Are used in conditons where not needed like flu etc.
• Resulted in failure of eradicating infectious bacteria,
emergence of resistance, waste of resources, increased
cost of treatment, ADR & death (Kardas et al., 2005)
3
Many Factors Influence Use of Medicines
Policy, Legal and Regulatory
framework
Prescriber,
Dispenser &
their
workplaces
Rational
Drug Use
Patient &
community
Drug Supply System
Interventions are directed at these components
4
5
Objectives of the review
• Review determined effect of various intervention
studies on AB misuse in developing countries
Research question
1. What are the various interventions measures used in
controlling irrational use of antibiotics/antibacterial
agents in developing / poorer nations?
2. What is the impact of various intervention measures
used in controlling the irrational use of
antibiotics/antibacterial agents in developing / poorer
nations?
6
Methods
• Study design: A systematic review
• Search strategy: was developed to retrieve relevant
articles from various databases including:
– Medline/PubMed
– Embase
– INRUD/Management Sciences for Health (MSH)
– WHO
– Cochrane
– Google scholar search engine was used to retrieve
more studies from Journal articles & abstracts
– Gray literature by manual method
7
Criteria for inclusion and exclusion of
studies in the review
• All the studies included in the review followed PICO-DTS
where:
– Patient, population, or problem (P)
– Intervention, independent variable, or exposure (I)
– Comparators (control) (C)
– Dependent variables or outcomes of interest (O)
– Study design (D)
– Timing (T)
– Study setting (S)
(Moher & Tricco, 2008; Stone, 2002)
• All studies were included or excluded basing on
each of the above
8
Data extraction & storage of primary data
• Data was extracted using the designed data extraction sheet
basing on aims of review criteria:
– Geographical location of where study was conducted based
(World Bank Country Classification, 2010).
– Categories & subcategories of intervention
- Education
- Managerial
- Regulatory
- Diagnostic
- Managerial/education
- Economic/financial
- Education/regulation
- Multifaceted (Combination of almost all)
– Study settings
- Hospitals
- Public Healthcare facilities
- Community
- Out-patients Departments
- Private Pharmacies/ drug stores
– Outcome measure basing on effect & effect size on AB
9
10
Quality of evidence
• Quality was judged by Appraisal of individual primary research
studies for inclusion in reviews (Gough, 2007):
A = Trustworthiness of results (Methodological quality)
B = Appropriateness of use of that study design for review's
research question (Methodological relevance)
C = Appropriateness of focus of research for answering the review
question (Topic relevance)
D = Judgment of overall weight of evidence (WoE) based on
assessments made for each of criteria A-C
• Each of the studies were assessed as follows:
1-Strongly Agree 5- Agree
10 –Disagree or using Yes (Y) or
No (N) or Not applicable (NA)
11
Results
Articles retrieved and screened
12
13
14
15
16
17
18
19
Discussion
• A total of 722 articles were retrieved and 55 were reviewed
– 10.9% were from Africa, 63.6% from Asia, 9.1% from Latin America & 16.4%
from South-eastern Europe
• A total of 52.7% were hospital settings, 5.5% outpatient
departments, 21.8 public health care facilities, 12.7% private
pharmacies/drug stores, and 7.3% communities
• Education intervention was 27.3%
– With group discussion having 19.2% mean reduction in AB use, 27.6% in AB
prescription & 41% belief of no AB use
– Community training had 30.5% reduction in AB use (highest), 23.8% mean
reduction in AB prescription & 36% belief of no AB use
20
• Managerial was 20% with 8% improvement in AB dose
– 8–100% AB use adherence & 31.8% mean reduction of AB receipt
– 29.1% change of AB in resistance cases and 9.8-100% reduction in
prophylactic AB use.
• Managerial/education was 3.6% with 4.7% reduction in AB
prescription
• Regulatory was 9.1% with 60.5% improvement in AB use in
restriction unlike 16.4% in non-restriction
• Education/regulation were 9.1%
– with 8% reduction in non-indicated AB, 24% improved AB use rate,
14% mean appropriate AB use improvement
– 11.1% reduction of incidence of bacterial resistance
– 75.1% reduction in AB use in diarrhea, 42.4% reduction in scabies,
13.8–33.6% reduction in AB use in ARI
– Overall 60% reduction in AB use
21
• Diagnostic was 3.6%, with 68% reduction in AB use after
diagnostic test as compared to100% in control
– Was 73% likelihood of AB use in +test vs 87% in –ve test
• Multifaceted interventions were 27.3%
– 63% improvement in appropriate AB doses prescribed (best), 2.6 mean
no. of AB encounter reduction, 23% AB prescription reduction
– 18.3% generic AB prescribing improvement, 32.1% reduction in AB use,
89% reduction in AB use in ARI, 82% in surgery, 62.7% mean reduction in
deliveries, 39% in STDs, 36.3% mean reduction in diarrhea, 14.6% mean
reduction in malaria
– 6–11% reduction cost of treating bacteria-resistant organisms
– Some studies, was 6.3 reductions in mean AB encounters after 1 month
of intervention, then increased to 7.7 after 3 months hence lack of
sustainability of intervention programme as observed in some studies
• No study on economic/financial intervention found
22
Conclusion
• Misuse of antibacterial/antibacterial drugs is on
increase especially in developing countries
• Variety of interventions are used for irrational use of AB
drugs & had some impact
• Most of interventions were done in Asia
• Multifaceted interventions are effective in reducing
misuse & inappropriate use of AB drugs & reduce
emergence of resistance to commonest bacteria in
developing countries
• Some studies showed a tendency of reverting once
intervention programme stops
23
Acknowledgments & Source of funding
• Acknowledge staff of Common Wealth Scholarship programme &
staffs of University of London, Department of Primary Care &
Population Health (PCPH) for their support especially Prof. Petra
Boyton, Prof. Ceri Butler, Prof. Trish Greenhalgh & others
• Funding Source:
– Common Wealth Scholarship Programme and University
College London, Department of Primary Care and Population
Health (PCPH)
24
End