Antibacterial prescription and the associated factors among outpatients diagnosed with respiratory tract infections in Mbarara Municipality, Uganda

Antibacterial misuse is a major contributor to antimicrobial resistance - an emerging global threat to the achievements of modern medicine [1]. Globally, around 50% of antibiotic prescriptions are incorrect [2] and inappropriate use of antibacterials in upper respiratory tract infections (URTI) have been reported [3]. In Uganda the Annual health sector report of 2018/2019 showed that Upper respiratory tract infections are the second most common causes of Hospital attendance at 10.6% just after Malaria at 12.5% [4].

In majority of these cases the Uganda clinical guidelines recommend supportive treatment due to their viral etiology. However a study in Mubende Regional Referral Hospital reported that over 81% of outpatients with upper respiratory infection received an antibiotic [5]. Furthermore, high rate of antibacterial use among children with acute respiratory tract infection was reported in northern Uganda at 60.2% in a house hold survey study [6]. Another household study in Kampala region among children reported 53.5% of the acute respiratory as inappropriately managed [7]. These findings point at possible misuse of antibacterial in Uganda but no study has been done to find out the burden in southwestern part of the country. Studies on antibacterial use amongst acute respiratory tract infection have reported high prevalence of misuse of antibiotics in Uganda at over 50% [6, 7].

Misuse of antibacterials is associated with increased morbidity, mortality, wastage of health resources and bacterial resistance. It is estimated that antimicrobial resistant infections cause about 50,000 deaths a year in Europe and the United states of America (USA) alone, perhaps aggregating to several hundred thousand when other countries are added [8]. Apart from the mortality associated with it, undue use of antibiotics increases medical cost in healthcare facilities [9]. The growing burdens associated with misuse of antibiotics are extremely worrying and the World Health Organization (WHO) assembly adopted a global action plan to fight antimicrobial resistance, in which antibiotic surveillance was emphasized. Examining prescriptions for rational drug use is a widely accepted strategy by WHO through which set indicators can assist in achieving the above goal [10].

Several studies on prescribing pattern have been carried out in other parts of Africa. In Nigeria the study noted poly pharmacy and non-adherence to essential medicine list [11]. Further still in eastern Ghana’s public health facilities antibiotic use was observed to be high compared to levels of developing countries throughout the world [12]. In Cameroun antibiotics were wrongly used in management of indications such as Uncomplicated Malaria that do not require antibiotic intervention in their standard management guides [13]

In Uganda the Annual health sector report of 2018/2019 showed that Upper respiratory tract infections (URTI) are the second most common causes of Hospital attendance at 10.6% just after Malaria at 12.5% [4]. In majority of these cases the Uganda clinical guidelines recommends supportive treatment due to their viral aetiology. However a study in Mubende Regional Referral Hospital reported that over 81% of outpatients with upper respiratory infection received an antibiotic [5]. Furthermore, high rate of antibacterial use among children affected by acute respiratory tract infection was reported in northern Uganda at 60.2% [6]. A similar study in Kampala region reported 53.5% of the acute respiratory cases as inappropriately managed [7]. These findings point at possible misuse of antibacterials in Uganda.

Respiratory tract infections are among the most prevalent cases in outpatient department and thus contribute highest to prescriptions that lead to misuse of antibiotics [7]. Unfortunately, there is a limited insight into the antibacterial use and prescribing pattern among outpatients diagnosed with respiratory tract infections in the Mbarara municipality, and as such this study aims to assess the antibacterial prescribing rate, RTI prescription pattern and the factors associated to antibiotic exposure.

Results show that the antibacterial prescribing rate among outpatients with RTI Mbarara municipality is 77.6%. They further show that 68.7% of all URTI encounters received antibacterials and beta lactams as the most prescribed antibacterials.

The prescribing rate means that approximately eight out of ten patients with a RTI were prescribed an antibacterial drug. This is inappropriately high given that only 217 (27.7%) of the patients were diagnosed with LRTI which mainly require antibacterials [5]. This Prescribing rate (77.6%) is higher than 60.2% reported by a cross sectional survey conducted in children under five years in Gulu, Northern Uganda [6] but lower compared to 92.7% from a previous study in Mubende regional referral Hospital of Uganda [5]. The latter study in Mubende had similar methodology as this study but difference in results could be due to the prescribing pattern of the prescribers in these two different regions.

The URTI category which included common cold, laryngitis, rhinitis, pharyngitis, rhinitis had close to 68.7% of these encounters receiving antibacterial drugs, which in most cases is inappropriate. This misuse of antibacterials as noted in numerous studies [18, 19] is contrary to Uganda clinical guidelines recommendations of supportive treatment. A similar study in Kenya by Momanyi in Rift valley Hospital [20], we reported beta-lactam as the most frequently prescribed antibacterials class at 88.2%. Amoxicillin was the most prescribed individual antibacterial drug at 72.8% and this is because it is the recommended drug of choice in empiric treatment of LRTI but its usage in 91% of encounters with URTI diagnosis without a secondary diagnosis points towards inappropriate use

The measure of the degree of polypharmacy (the practice of the administration/ of multiple medications at the same time) showed that the average number of drugs per encounter (2.5 drugs) was closely similar at all the different health facility levels but is slightly above the recommended WHO standard of below two drugs [16]. Higher degree of polypharmacy was also noted in a study in Ghana and Nigeria [11, 12] reported at an average of 4 drugs for the general outpatients which was higher than the results in this study. A different study by Yimenu in Nigeria reported lower average number of drugs per prescription of 1.6 drugs [21]. These differences are probably due to variations in the prescribers’ prescribing habits. Despite polypharmacy presenting several challenges some scholars are against the use of numerical thresholds like average number of drugs per script in measuring polypharmacy because they do not put into consideration the clinical context such as multimorbid individuals [22, 23].

Encounters with injection rates were within the recommended range of <10% [16]. The use of injections among RTI outpatients seemed to increase as we go up the level of health facility with health Centre II having no injection whereas HC IV and regional referral had percentages of 2.4% and 2% respectively. This was likely because the lower health facilities do not stock these injection products and also the referral system allows more complicated/severe cases which may need parenteral route to be handled by higher level health facilities. Findings at our lower healthcare centers were similar to a study carried out in India [24].

The average percentage of drugs prescribed by generic was 80.8% which was below the 100% recommendation by WHO [16]. Moreover, there was observed a high difference among the lower health facilities and Regional referral hospital on the tendency to prescribe by generic name, with percentages of 94%, 97% and 92% for HCII, HCIII and HCIV respectively as compared to 55% for the Regional referral hospital. The difference could be attributed to medical marketing which emphasizes brand prescribing focusing on high level hospitals based in bigger towns [25]. This generic name prescription rate of 55% by the regional referral hospital is comparable to 62.5% prevalence in a referral hospital in Kenya at 62.5% [20]. This finding by the current study is against the recommendations that prescribing in generic show that it lowers costs because cheaper generics can be used, reduces confusion among health workers and minimizes influence of marketing on prescribing [25].

The results further showed that the percentage of drugs prescribed from essential drug list was 84%, lower-level health facilities, HCII, HCIII and HCIV showed 96%, 97%, 93% adherence to the essential medicine list respectively whereas MRRH showed 62%, though WHO recommendation is 100%. This showed a small non adherence to the essential medicine list at lower health facilities and a major difference by prescribers in the referral hospital which may be explained by drug marketing that which influences the choice of drug a prescriber chooses [25], and possibly lack of supervision of the prescribers on drug policies. Several studies have reported results short of the essential medicine prescribing target in Africa [12], in China [26] while some show compliance in Cameroun [13].

The study identified female gender, adult age (18–59) and prescribing 3 or more drugs as independent associated factors to the antibacterial prescribing. Accordingly, female patients were about 1.5 times more likely to be prescribed antibiotic compared to males and adults were about 1.66 times more likely to be prescribed an antibacterial. Likewise, those who were prescribed 3 or more drugs were about 2.7 times more likely to be prescribed an antibacterial compared to those who were prescribed 2 or less drugs.

Similarly, several other previous studies also showed that being female was independently associated with antibacterial prescribing [13, 27, 28]. This can be explained by the fact that females have higher health care seeking behavior compared to males,thus interact more with prescribers and as such possibly demand for the antibacterials [29].However, this gender association was contrary to findings by a study in Ethiopia [30] and a study in Bangladesh [31] where males were more likely to receive antibiotics. Several reasons linked to this gender disharmony in antibacterial prescribing include the difference in social and behavioral factors among males and females.

On the other hand, the higher propensity for the adult age group (18-59 years to be prescribed antibacterials compared to the young (below 5 years) may be attributed to several factors which include demand for antibiotics by the patients or pressure by the prescriber not to disappoint and as such prescribe antibacterials several studies have elucidated this association with the antibacterial prescribing [32‐34].

The current finding that the higher the number of drugs prescribed, the higher the chances of getting an antibacterial prescribed, is also comparable with findings of previous studies [35]. This can be explained by the fact that if a prescriber is prone to overprescribing then it is more likely that antibacterials shall be prescribed when they are not necessary

The antibacterial prescribing rate in Mbarara municipality was high at 77%, yet LRTI encounters formed 27.78% of all encounters, this discrepancy indicates unnecessary antibiotic exposure hence antibiotic irrational use. RTI Outpatients were averagely prescribed 2.47 drugs per prescription which is slightly above the WHO recommended standard. There is non-conformity to the national drugs policy as evidenced by the percentage of drugs prescribed from the national essential medicine list at 84% and the tendency to prescribe by generic name at 80.8%. This non adherence was more reported at the regional referral Hospital compared to the other health facilities. The study also showed that being female, age group (18–59 years) and total drugs prescribed (at least three) were associated with antibacterial prescribing.