Antibiotic use in a district hospital in Kabul, Afghanistan: are we overprescribing?

SETTING: A district hospital in Kabul, Afghanistan, supported by Médecins Sans Frontières (MSF). OBJECTIVES: To assess antibiotic prescribing practices in the out-patient department in summer (August 2013) and winter (January 2014). DESIGN: Cross-sectional study, using routinely collected hospital data and using World Health Organization (WHO) defined daily dose (DDD) methodology. RESULTS: An analysis of 4857 prescriptions (summer) and 4821 prescriptions (winter) showed that respectively 62% and 50% of all out-patients were prescribed at least one antibiotic. Prescriptions without a recorded diagnosis represented a sizeable proportion of all antibiotics prescribed. For upper respiratory tract infections (URTI), dental indications, urinary tract infections (UTI) and diarrhoea, good adherence to dosages recommended in the MSF standard treatment guidelines was observed when measured by DDD. However, certain drugs not indicated in the guidelines were prescribed, such as amoxicillin and metronidazole for UTI and azithromycin for URTI. CONCLUSION: Rates of antibiotic prescriptions for out-patients in a district hospital in Afghanistan were high, double the WHO recommendation of 30%. While systematic non-adherence to recommended dosages was not observed, inappropriate prescriptions for specific conditions may have occurred. This study suggests that knowledge about context-specific determinants of antibiotic prescribing is a first step towards promoting rational prescribing practices in such settings.

Contexte : Un hôpital de district à Kaboul, Afghanistan, soutenu par Médecins Sans Frontières (MSF).Objectifs : Evaluer les pratiques en matière de prescription d'antibiotiques en consultation externe en été (août 2013) et en hiver (janvier 2014).Schema : Etude transversale basée sur les données hospitalières recueillies en routine et la méthode de dose thérapeutique quotidienne (DDD) de l'Organisation Mondiale de la Santé (OMS).Resultats : L'analyse de 4857 prescriptions (été) et de 4821 prescriptions (hiver) a montré que respectivement 62% et 50% de tous les consultants externes se voyaient prescrire au moins un antibiotique. Les prescriptions non accompagnées d'un diagnostic établi représentaient une proportion importante de l'ensemble des antibiotiques prescrits. En ce qui concerne les infections respiratoires hautes (URTI), les problèmes dentaires, les infections urinaires (UTI) et la diarrhée, on notait une bonne adhésion aux doses recommandées dans les directives standard de traitement de MSF quand on les mesurait en fonction des DDD. Cependant, certains médicaments, ne figurant pas dans les directives, étaient néanmoins prescrits comme par exemple l'amoxicilline et la métronidazole dans les UTI et l'azithromycine dans les URTI.Conclusion : Les taux de prescriptions d'antibiotiques en consultation externe dans un hôpital de district d'Afghanistan étaient très élevés, atteignant le double des recommandations de l'OMS de 30%. Même s'il n'a pas été observé de non adhésion aux doses recommandées, il semble y avoir eu des prescriptions inappropriées pour certaines pathologies. Cette étude suggère que la connaissance des déterminants de la prescription d'antibiotiques en fonction du contexte est une première étape dans la rationalisation des pratiques de prescription dans ce type de situation.

Marco de referencia: Un hospital distrital de Kabul en Afganistán, que cuenta con el respaldo de Médecins Sans Frontières.Objetivos: Evaluar las prácticas en materia de formulación de antibióticos en el servicio ambulatorio durante el verano (agosto del 2013) y el invierno (enero del 2014).Método: Fue este un estudio transversal a partir de la información hospitalaria recogida de manera sistemática, mediante la aplicación del sistema de clasificación anatómica terapéutica química y dosis diaria definida (ATC/DDD) de la Organización Mundial de la Salud (OMS).Resultados: Al analizar las 4857 recetas del verano y las 4821 recetas del invierno, se puso en evidencia que 62% de los pacientes ambulatorios durante el verano y 50% de los pacientes durante el invierno recibían una receta como mínimo con un antibiótico. En una proporción considerable de todas las recetas con antibióticos, no existía un diagnóstico asociado registrado. Se observó un cumplimiento adecuado de las dosis recomendadas en las infecciones de las vías respiratorias superiores, las indicaciones odontológicas, las infecciones del tracto urinario y la diarrea, al comparar las directrices de tratamiento de Médecins Sans Frontières con las medidas DDD. Sin embargo, se recetaron algunos medicamentos que no estaban indicados en las directrices, como la amoxicilina y el metronidazol en casos de infección de las vías urinarias y la azitromicina en casos de infección de las vías respiratorias superiores.Conclusión: Se encontró que los pacientes ambulatorios recibían un alto índice de recetas con antibióticos en un hospital distrital de Afganistán, el cual correspondió al doble del 30% que recomienda la OMS. No se observó un incumplimiento sistemático de las dosis recomendadas, pero es posible que se hayan prescrito recetas inapropiadas para determinados cuadros clínicos. Los resultados del presente estudio ponen de manifiesto que el conocimiento de los factores determinantes de la receta de antibióticos en un contexto específico representa la primera etapa en el fomento de las prácticas idóneas prescripción en estos entornos.

Non-adherence to standard treatment guidelines in a rural paediatric hospital in Sierra Leone.

SETTING: A rural paediatric hospital in Bo, Sierra Leone. OBJECTIVES: To assess the level of adherence to standard treatment guidelines among clinicians prescribing treatment for children admitted with a diagnosis of malaria and/or lower respiratory tract infection (LRTI), and determine the association between (non) adherence and hospital outcomes, given that non-rational use of medicines is a serious global problem. DESIGN: Secondary analysis of routine programme data. RESULTS: Data were collected for 865 children admitted with an entry diagnosis of malaria and 690 children with LRTI during the period January to April 2011; some patients were classified in both categories. Non-adherence to guidelines comprised use of non-standard drug regimens, dosage variations, non-standard frequency of administration and treatment duration. Cumulative non-adherence to guidelines for LRTI cases was 86%. For malaria, this involved 12% of patients. Potentially harmful non-adherence was significantly associated with an unfavourable hospital outcome, both for malaria and for LRTI cases. CONCLUSIONS: Overall non-adherence to standard treatment guidelines by clinicians in a routine hospital setting is very high and influences hospital outcomes. This study advocates for the implementation of routine measures to monitor and improve rational drug use and the quality of clinical care in such hospitals.

The 1980 earthquake in Southern Italy--morbidity and mortality.

The effects on health of the 1980 earthquake in southern Italy were surveyed retrospectively. The sample population includes 3619 people living in seven villages situated near the epicentre. Deaths were one hundred times and injury rates more than five times higher in trapped than in non-trapped victims. The possibility for escape was crucial for survival and depended on the type of building. Most of the rescue and relief work was carried out within a few days by unprepared local people who concentrated assistance on people sharing the same dwelling. The results suggest that the emergency phase for medical care was limited to the three to four days after impact. During the 18 months following the quake, mortality rates in injured (13.7%) and non-injured victims (15.8%) were similar. These results point to the need to establish, in each disaster prone area, a health evaluation system on which effective disaster relief and especially the preparedness of the community can be based.

The 1980 earthquake in southern Italy: rescue of trapped victims and mortality.

A retrospective survey was undertaken on the health effects of the 1980 earthquake in southern Italy. The study population included 3619 people living in 7 villages situated near the epicentre of the disaster. The overall casualty rate (dead and injured) was 19.7%. Nearly all the deaths (192/202) occurred among trapped people who died before they could be rescued. Eighty per cent of all the trapped people were extricated within 2 days, mostly without the use of sophisticated means. The probability of survival decreased sharply, the longer the time before extrication. The crude mortality during the 18 months following the earthquake was 19.0 per thousand among the injured people who received treatment, and 14.1 per thousand among non-injured people. After age standardization, there was no significant difference between these two figures and the expected mortality figures for the Italian population in normal times (14.4 per thousand). These results stress the importance of providing rescue activities in the first 48 hours after the impact. Strengthening the self-reliance of the community in disaster preparedness is suggested as the best way to improve the effectiveness of relief operations. In disaster-prone areas, training and education in methods of rescue should be an integral part of any primary health care programme.