The use of non-prescribed antibiotics; prevalence estimates in low-and-middle-income countries. A systematic review and meta-analysis.

BACKGROUND: The global increase in the utilization of non - prescribed antibiotics (NPA), is concerning, with high persistence within the low and middle-income countries (LMICs). With a negative impact on the health of individuals and communities the use of NPA paves the way to the  propagation of superbugs that potentially predisposes to changes in bacterial resistance patterns, antibiotic resistance (AR) and antimicrobial resistance (AMR). This study aimed at estimating through a systematic review and meta-analysis, the prevalence of NPA utilisation and describe its primary sources in LMICs. METHODS: The study is a systematic review and meta-analysis which study protocol was registered in PROSPERO (CRD42017072954). The review used The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines.  The studies searched in databases were deemed eligible if reported evidence of practices of self-medication with antibiotics (SMA) and the prevalence of NPA utilisation within adult participants from LMICs, published between 2007 to 2017. The pooled analyses were carried out using Meta XL statistical software. The pooled prevalence was calculated with a 95% confidence interval (CI). The risk of bias of the included studies was assessed using the Quality in Prognosis Studies (QUIPS) tool. RESULTS: The review included a total of 11 cross-sectional studies, involving 5080 participants and conducted in LMICs from Asia (India, Laos, Nepal, Pakistan, Sri Lanka and Yemen), Latin America (Guatemala), Africa (Nigeria). All studies reported existing  practices of SMA, with reported prevalence ranging from 50% to 93,8%. The pooled prevalence of SMA was 78% (95% CI: 65-89%). The main sources of NPA were; pharmacies, family and friends, old prescriptions, home cabinet and leftover antibiotics. CONCLUSION: This study revealed a high prevalence of utilisation of NPA in the studied LMICs, these were found to be twice as high in women than men and those participants aged between 18 and 40 years old. The review suggests f considering broader qualitative and comprehensive contextuallized research to better understand the nuances of NPA use. These would be benefitial to uncover uncover gray areas, inform decisions, support the (re) design and implementation of multifaceted interventions towards antibiotic stewardship and conservancy in LMICs.

Identifying the commonly used antibiotics for self-medication in urban Mozambique: a qualitative study.

OBJECTIVES: The study aimed at identifying the commonly used non-prescribed antibiotics (NPAs) and the main health conditions leading to the practices of self-medication with antibiotics (SMAs) in Maputo city, Mozambique. DESIGN: Cross-sectional qualitative study based on individual and group interviews. SETTING: The study was conducted in nine pharmacies of three socioeconomic areas of Maputo city, from October 2018 to March 2019. PARTICIPANTS: The study included 32 pharmacy clients and 17 pharmacists. The pharmacy clients included men 10 (31%) and women 22 (69%) ranging from 19 to 67 years while the pharmacists included men 6 (35,3%) and women 11 (64,7%) with ages ranging from 24 to 47 years. FINDINGS: The majority of the pharmacy clients 30 (93.75%) admitted frequent use of NPAs, 15 (88.2%) out of the 17 pharmacists admitted dispensing NPAs. While the majority of the participants (16) mentioned the use of amoxicillin, also known as 'two colours medicine', 14 mentioned the use of cotrimoxazole and seven mentioned amoxicillin with clavulanic acid. Two to five participants also used tetracycline, ciprofloxacin, azithromycin, doxycycline, erythromycin, metronidazole and phenoxymethylpenicillin. The above mentioned NPAs were used to treat self-perceived sore throat, fever, pain, cough, vaginal discharge, eye problems, the common influenza, urinary infections, respiratory tract infections, wounds and toothaches. CONCLUSIONS: Antibiotics are perceived as essential medical resources to manage health and illnesses. While taking an active role in their health-disease process, participants commonly used amoxicillin, 'two colours', cotrimoxazole and amoxicillin with clavulanic acid to manage their health and that of their families. In this sense, the practices of SMAs were perceived as part of the self-care process and not necessarily as misuse of antibiotics. A wideunderstanding of health-seeking beliefs and behaviours regarding the utilisation of antibiotics is needed to inform public health experts, health policymakers and other stake-holders in designing and implementing public health education and health promotion programsat all levels in Mozambique.

Pharmacists' practices for non-prescribed antibiotic dispensing in Mozambique.

BACKGROUND: Antibiotics are the most frequently used medicines worldwide with most of the countries defining these as prescription-only medicines. Though, dispensing non-prescribed antibiotics represent one of the chief causal factors to the irrational use of antibiotics that paves the way to the development of antimicrobial resistance. OBJECTIVE: We aimed at describing the practices and the enablers for non-prescribed antibiotic dispensing in Maputo city, Mozambique. METHODS: A qualitative study was conducted, between October 2018 and March 2019, in nine private pharmacies randomly selected across Maputo city. Eighteen pharmacists were contacted and seventeen enrolled through snowball sampling. In-depth interviews were conducted, audiotaped, and transcribed verbatim. Transcripts were coded and analysed though thematic analysis with guidelines from Braun and Clark. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist by (Tong, 2007) was performed. RESULTS: Out of seventeen, fifteen pharmacists admitted non-prescribed dispensing of antibiotics. Common antibiotic dispensing practices included; dispensing without prescription, without asking for a brief clinical history of patients, without clear explanation of the appropriate way of administering, without advising on the side effects. Reasons for non-prescribed antibiotic dispensing are linked to patients' behaviour of demanding for non-prescribed antibiotics, to the patients expectations and beliefs on the healing power of antibiotics, to the physicians' prescribing practices. Other reasons included the pressure for profits from the pharmacy owners, the fragile law enforcement, and absence of accountability mechanisms. CONCLUSIONS: The practices of non-prescribed antibiotic dispensing characterize the 'daily life' of the pharmacists. On the one hand, the patient's demand for antibiotics without valid prescriptions, and pharmacist's wish to assist based on their role in the pharmacy, the pressure for profits and on the understanding of the larger forces driving the practices of self-medication with antibiotics - rock. On the other hand, pharmacists are aware of the legal status of antibiotics and the public health consequences of their inappropriate dispensing practices and their professional and ethical responsibility for upholding the law - hard place. Highlighting the role of pharmacists and their skills as health promotion professionals is needed to optimizing antibiotic dispensing and better conservancy in Mozambique.

Pharmacists' practices for non-prescribed antibiotic dispensing in Mozambique

BACKGROUND: Antibiotics are the most frequently used medicines worldwide with most of the countries defining these as prescription-only medicines. Though, dispensing non-prescribed antibiotics represent one of the chief causal factors to the irrational use of antibiotics that paves the way to the development of antimicrobial resistance. OBJECTIVE: We aimed at describing the practices and the enablers for non-prescribed antibiotic dispensing in Maputo city, Mozambique. METHODS: A qualitative study was conducted, between October 2018 and March 2019, in nine private pharmacies randomly selected across Maputo city. Eighteen pharmacists were contacted and seventeen enrolled through snowball sampling. In-depth interviews were conducted, audiotaped, and transcribed verbatim. Transcripts were coded and analysed though thematic analysis with guidelines from Braun and Clark. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist by (Tong, 2007) was performed. RESULTS: Out of seventeen, fifteen pharmacists admitted non-prescribed dispensing of antibiotics. Common antibiotic dispensing practices included; dispensing without prescription, without asking for a brief clinical history of patients, without clear explanation of the appropriate way of administering, without advising on the side effects. Reasons for non-prescribed antibiotic dispensing are linked to patients' behaviour of demanding for non-prescribed antibiotics, to the patients expectations and beliefs on the healing power of antibiotics, to the physicians' prescribing practices. Other reasons included the pressure for profits from the pharmacy owners, the fragile law enforcement, and absence of accountability mechanisms. CONCLUSIONS: The practices of non-prescribed antibiotic dispensing characterize the 'daily life' of the pharmacists. On the one hand, the patient's demand for antibiotics without valid prescriptions, and pharmacist's wish to assist based on their role in the pharmacy, the pressure for profits and on the understanding of the larger forces driving the practices of self-medication with antibiotics - rock. On the other hand, pharmacists are aware of the legal status of antibiotics and the public health consequences of their inappropriate dispensing practices and their professional and ethical responsibility for upholding the law - hard place. Highlighting the role of pharmacists and their skills as health promotion professionals is needed to optimizing antibiotic dispensing and better conservancy in Mozambique

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Patterns of self-medication with antibiotics in Maputo City: a qualitative study.

Background: Mozambique classifies but does not yet enforce antibiotics as prescription-only-medicine (POM) allowing the public access to a variety of antibiotics that otherwise are provided on prescription. This contributes to the growing practice of self-medication with antibiotics (SMA) which systematically exposes individuals to the risk of developing antibiotic resistance, antibiotic side effects and increases the health service costs and morbidity. This study aimed at describing the patterns of SMA among Maputo city pharmacy customers. Methods: A qualitative study conducted between October 2018 and March 2019 was developed with thirty-two pharmacy customers and seventeen pharmacists. Using convenience sampling, customers were recruited after buying antibiotics without prescription from nine private pharmacies. Of the thirty-two participants, twenty participated in in-depth interviews and twelve in two focus groups discussions (FGD) with six participants each. Purposive sampling and a snowball technique were used to recruit pharmacists. The transcripts were coded and analyzed using latent content analysis. Nvivo 11 was used to store and retrieve the data. The COREQ (Tong, 2007) checklist for interviews and FGD was performed. Results: Customers admitted practices of SMA, pharmacists admitted dispensing a variety of antibiotics without prescription. Non-prescribed antibiotics (NPA) were obtained through five different patterns including; using the generic name, describing the physical appearance and using empty package, describing symptoms or health problem to pharmacists, using old prescriptions and sharing antibiotics with family, friends, and neighbors. Conclusion: Different patterns of SMA are contributing to the indiscriminate use of antibiotics among customers. The NPA utilization is perceived as an expression of self-care where participants experience self-perceived symptoms and indulge in self-treatment as a method of caring for themselves. Moreover, antibiotics are mostly used to treat diseases that do not necessarily need antibiotics. Strong and effective public health education and promotion initiatives should be implemented to discourage inappropriate utilization of antibiotics and SMA practices.

The examination of nurses' adherence to the 'five rights' of antibiotic administration and factors influencing their practices: a mixed methods case study at a tertiary hospital, Malawi.

Background: Adherence to 'Five Rights' of medication administration guidelines namely the right drug, the right patient, the right dose, the right time and the right route is the basic nursing standard and a crucial component in medication safety. Specifically for antibiotics, this helps to minimize resistance and reduce hospital costs. There is a dearth in literature on how nurses apply this standard when administering antibiotics to inpatients. This study explored nurses' adherence to the 'Five Rights' of antibiotic administration and factors influencing their practices. Methods: This was a cross sectional case study using prospective observation of 23 nurses and 49 patients with pneumonia and follow up interviews with 13 nurses. Participants were selected between November 2015 and February 2016. The study setting was two medical wards of a tertiary hospital. Observations were guided using a checklist to collect quantitative data. This was followed by semi-structured in-depth interviews with nurses. Results: From the quantitative data, untimely administration of antibiotics was common, with only 10.1% of patients given antibiotics at the right time. Nurses gave the right (prescribed) antibiotics in 67.3% of the patients and 59.2% of the patients received the required doses. 69.4% of the patients received the antibiotics using the right route. The right documentation of dose initiation and continuation occurred in 38.5% and 24.5% respectively. From follow up interview data, two main themes were identified: Competency gap with subthemes namely inconsistent undestanding of three/four times a day dosing schedules and knowledge translation gap; Conflict between medication administration times and ward routines. Conclusions: We found poor compliance with the 'Five Rights' of antibiotic administration. This has been attributed to both a competency gap and challenges within the hospital system.

Knowledge, attitudes and practices related to self-medication with antimicrobials in Lilongwe, Malawi.

Background: The use of antimicrobials is associated with the emergence of antimicrobial resistance (AMR), and self-medication increases the risk of the inappropriate use of antimicrobials. This study aims to describe the knowledge, attitudes, and practices (KAP) regarding self-medication with antimicrobials among residents in Lilongwe, Malawi. Methodology: This study has a cross-sectional, mixed-methods design. We conducted two focus group discussions (n=15) to describe community attitudes towards self-medication with antimicrobials and used a structured questionnaire to collect data on individual KAP regarding self-medication from 105 respondents. Results: Self-medication was common, and the sources of these medicines were market vendors, pharmacies, drugs shared with friends and family and those leftover from previous treatments. The lack of medical supplies, long distances to health facilities, poor attitudes of medical professionals towards patients, and past experience with the disease and treatment are the main factors that influence self-medication. KAP respondents had little knowledge of antimicrobials, their use, or any awareness of AMR. Seventy-four per cent (n=78) were unable to differentiate antimicrobials from other categories of medicines, and 92.4% wrongly responded that antimicrobials could be used to stop a fever. Concerning attitudes towards self-medication, over 54% wrongly believe that antimicrobials are effective in treating common colds. In regard to practice, 53% reported that they would use antimicrobials to treat upper respiratory infections, and 41% agreed that they must complete antibiotic therapy even if they are improving. Logistic regression analysis found that stocking antimicrobials at home for future use significantly promotes self-medication whereas an awareness of AMR would reduce self-medication. Conclusion: Self-medication is a public health risk that needs to be addressed urgently. Findings from this study point to the need for multifaceted interventions.

Evidence of factors influencing self-medication with antibiotics in LMICs: a systematic scoping review protocol.

BACKGROUND: The Sustainable Development Goals (SDGs) emphasize the need for strengthening the capacity of all developing countries in the early warning, risk reduction and management of national as well as global health risks. Despite there being a considerable amount of effort in controlling and promoting the rational use of antibiotics, studies show that the practice of self-medication with antibiotics (SMA) systematically exposes individuals to the risk of antibiotic resistance and other antibiotic side effects. The proposed scoping review aims to map literature on the factors influencing self-medication with antibiotics in low- and middle-income countries (LMICs). METHODS AND ANALYSIS: The adopted search strategy for this scoping review study will involve electronic databases including PubMed, Web of Knowledge, Science Direct, EBSCOhost (PubMed, CINAHL, MEDLINE), Google Scholar, BioMed Central and World Health Organization library. A two-stage mapping strategy will be conducted. Stage 1 will screen studies through examining their titles and screening abstracts descriptively by focus and method as stipulated by the inclusion and exclusion criteria. In stage 2, the researchers will extract data from the included studies. A parallel screening and data extraction will be undertaken by two reviewers. In accessing the quality of the included studies, the researchers will utilize the mixed methods appraisal tool (MMAT, version 11). The NVivo computer software (version 11) shall be used to classify, sort, arrange and examine relationships in the data, and to extract the relevant outcomes and for the thematic analysis of the studies. DISCUSSION: The study anticipates finding relevant studies reporting evidence on the factors influencing self-medication with antibiotics in LMICs. The evidence obtained from the included studies will help guide future research. The study findings will be disseminated electronically and in print with presentations being done at relevant platforms, i.e. conferences related to antibiotic use, antimicrobial resistance, health seeking behaviour and the use of medicines. SYSTEMATIC REVIEW REGISTRATION: Prospero Registration Number: CRD42017072954.