ASSESSMENT OF ANTIBIOTIC USE AT TAMALE TEACHING HOSPITAL

ABSTRACT
Background and Objectives: Antimicrobial resistance is a major problem worldwide due to indiscriminate and widespread use of antimicrobials both in healthcare facilities and in communities. Tamale Teaching Hospital (TTH) is a major referral center for hospitals in and around the northern parts of the country. This study therefore seeks to investigate and evaluate the pattern of antibacterial medicines prescribed for infections management, and the quality of use of these agents at the hospital.
Methodology: This was a non-randomised observational study undertaken from June 2 to July 14, 2015. The design was cross-sectional and duration of data collection was six (6) weeks. Four hundred (400) in-patients from all the four directorates of the hospital were selected. The patients involved in the study were either diagnosed of having an infection or prescribed antibacterials and consented to participate in the study. The patients were then followed on daily basis for data on antimicrobial use until they were discharged, transferred out of the hospital or died. Appropriateness of antibacterial use was evaluated based on recommendations in the Standard Treatment Guidelines of Ghana (STG) 2010 and British National Formulary (BNF 69). The latter was recognized universally and adopted by clinicians at TTH.
Results: The most common infections diagnosed were respiratory tract infections (16.5%, n=66), gastrointestinal tract infections (16.5%, n=66), sepsis (10.2%, n=41) and infections associated with spontaneous vaginal delivery (8.8%, n=35). In all, 1120 out of 3572 in-patients encountered within the study period were prescribed antibacterial agents representing a prevalence of 31.35%. Almost all the prescriptions (99.8%, n=876) were from the Essential Medicines List (EML), 99.2% (n=871) was also based on the National Health Insurance Medicines List (NHIML). 45.3% (n=181) of the patients were prescribed 2 antibacterials, 24.0% (n=96) and 22.0% (n=88) were prescribed 3 and 1 antibacterial(s) respectively. The remaining (8.7%, n=35) were on 4 or more antibacterial agents. The most prescribed antimicrobial was metronidazole (26.3%, n=232), followed by Amoxicillin/Clavulanic acid (15.7%, n=139), then ceftriaxone (15%, n=132), cefuroxime (11.4%, n=101) and ciprofloxacin (11%, n=97). 79% (n=316) of the participants prescriptions were in line with recommendations in STG 2010 and BNF 69, and 21% (n=84) was not. Ninety one percent had their symptoms resolved after antibacterial therapy (n=364), and 9.0% (n=36) still had symptoms after antibacterial therapy. Of the 400 patients recruited, only 27 (6.8%) had samples taken for culture and sensitivity tests to guide antibacterial therapy. Common hospital flora including Escherichia coli and Staphylococcus Aureus were isolated and found to be resistant to CAGN (Co-trimoxazole, Ampicillin, Gentamycin, Nalidixic acid) and C2CFAG (Cefuroxime, Co-trimoxazole, Flucloxacillin, Ampicillin, Gentamycin) respectively. The average length of stay was 6.1days with 41.5% (n=166)) spending 1-3 days and 35% (n=140) spending 4-7 days at the hospital, and the remaining 23.5% spending more than 7 days at the hospital.

Conclusion: About a third of all in-patients within the study period were exposed to anti-bacterial therapy. Majority (close to four-fifths) of the treatments were in line with recommendations in the STG 2010 and BNF 69. Resistance to common hospital flora was identified in the few cases supported by culture and sensitivity test. As much as possible, culture and sensitivity data should be used to guide antimicrobial therapy at the hospital; this would improve the quality of infectious disease management and reduce risk of spread of antimicrobial resistance in hospitals.


CHAPTER ONE
1.1       INTRODUCTION
Infectious diseases remain among the commonest cause of deaths globally especially in Sub-Saharan Africa (World Health Organisation, 1995). In Africa, communicable diseases account for more than 70% of the burden of ill health, in contrast to about 10% in industrialised countries (World Bank, 1993).

Improper use of antimicrobial agents also have been identified as one of the worldwide health concerns due to the growing rate of resistance of common pathogenic organisms to otherwise effective agents, and poor treatment outcomes from antimicrobial therapy (Carlet et al., 2012). The problem of antimicrobial resistance is much worse in low and middle income countries (Okeke et al., 2005;) (levy, 1998). More so due to the high burden of infectious diseases in Africa, antibiotics are amongst the most frequently prescribed and extensively used medicines in hospitals and in community-based medicine outlets (Syed et al., 2014; Shankar et al., 2003). Of individuals who receive antibiotics, over 30% have been found not to have a prescription from a registered clinician before accessing the antibiotics, and more than one in five obtain the antibiotics from an informal dispenser (Vialle-Valentin et al., 2012).

In emergency settings in hospitals, considering the urgent requirements of most patients’ conditions, the interaction between prescribers and patients may be irregular in nature. This results in a greater number of antibacterial prescriptions being empirical and/or for prophylactic purposes. From a study in an emergency department of a tertiary hospital in Taiwan, empirical antibacterial therapy has been shown to correlate with high mortality rates (Chen et al., 2013). A study by Kang and associates (2005) also showed evidence of increased mortality among bacteraemic patients with inappropriate first antimicrobial therapy (Kang et al., 2005). Also findings from rational use of medicines survey 2008, in Ghana, showed that in public health facilities the percentage of patients that were prescribed antibiotics was 43.3%, a figure which is high compared to WHO recommended standards (Arhinful, 2009).

Two leading factors that have been shown to contribute to antimicrobial resistance include unnecessary use of antimicrobials (AMs), adding to an augmented selection pressure, and insufficient infection control practices in the health system, favouring the spread of resistant microorganisms (Okeke, 2010). Of the two stated factors, antibiotic use has largely been identified as the main selective pressure fueling antimicrobial resistance (Malhotra-Kumar et al., 2007) (Goossens et al., 2005). As antibiotics are important to treat infections, their use usually requires more resources, and inappropriate use further exposes patients to the added risk of side effects, whilst under-prescribing may be related with poor health outcomes and greater risk of complications from untreated infections (Peterson et al., 2007). Therefore patients who receive AMs may have an increased risk of acquiring infection from resistant microorganisms (Costelleo et al., 2010) and such infections may be associated with increased mortality and morbidity (Shanthi and Sekar, 2009) (Woodford and Livermore, 2009).

Several studies in Africa have stated the occurrence of resistant strains of bacteria, including reports from Nigeria, (Dada-Adegobola and Muili, 2010) Uganda, (Andabati and Byamugisha, 2010) Tanzania, (Moyo et al., 2010) Zimbabwe, (Mbanga, Dube and Munyanduki, 2010) and Ghana, (Edoh and Alomatu, 2008) all presenting high levels of resistance to antimicrobial agents. A study in the Tamale Teaching Hospital on susceptibility of bacterial agents to frequently used antimicrobial drugs in children with sepsis identified coagulase negative, coagulase positive Staphylococci, Salmonella and Klebsiella as major causative microorganisms of bloodstream infection among children at the hospital. Even though both gram-negative and gram-positive bacteria showed very low susceptibility to ampicillin, tetracycline and co-trimoxazole, the gram negative rods were fairly susceptible to gentamicin and third-generation cephalosporins (Acquah et al., 2013).

In Ghana, antimicrobial prescribing is mostly empirical because of relative absence of suitable laboratory facilities required for carrying out culture and sensitivity testing in numerous healthcare facilities. Even in situations where appropriate laboratories exist, microbiological investigations may not be carried out to guide therapy (Newman et al., 2011). Understandably, lack of surveillance data of susceptibility of antimicrobial agents, will result in empirical management that may not be effective yet costly. The effect of antibacterial mistreatment in hospital and the social damage may be high to individual patients and the entire health system. In a study in Chicago involving a sample of 1391, 13.5% had resistant bacteria with social cost approximated to be 13.35 million dollars in 2008 (Roberts et al., 2009).

Another challenge is the drop in investment and development of new antibacterial agents by pharmaceutical groups (Spellberg et al., 2004). Antimicrobial agents are products of low return on their economic interest and failure of discovery of new agents are established on conventional models of discovery amid other reasons (Livemore, 2011; Davies, 2006). Only a handful of new agents, few of which are novel, being introduced into clinical practice each year (Chambers, 2006). This places much responsibility on all key players to safeguard the antimicrobial agents currently in use.

Outcomes of antibacterial therapy can be determined using various means: This includes clinical assessment of cure (where resolutions of signs and symptoms including temperature is used) (Buabeng, 1999; Leekha, Terrell and Edson, 2011), microbiological cure (which embroils negative growth for culture after antimicrobial therapy), economic (which embroils prolonged hospital stay days and high cost of care) and ecological (where resistance rates of regularly isolated organisms are determined) (Davey et al., 2005). However, studies on antibacterial effectiveness mostly use two main frameworks; clinical improvement/cure and microbiological cure (Havey, Fowler and Daneman, 2011).

In 2001, the World Health Organisation (WHO) released a global strategy engaging all stakeholders to deal with the occurrence and spread of antimicrobial resistance (WHO, 2001). To handle the problem of antimicrobial resistance, the WHO suggested the adoption of some intervention strategies. These consist of developing pointers to monitor and assess the effect of resistance to antimicrobial agents, creating a national task force and designing reference microbiological laboratory facilities that would bring together effective surveillance of antimicrobial resistance among common pathogens (WHO, 2001). However, lack of effective use of resources often constrains execution in several developing countries where therapeutic alternatives also turn out to be relatively narrow. Owing to the fact that antibiotics are among the most frequently prescribed drugs in hospitals in Ghana and their use/misuse are among the important factors for the development and spread of microbial resistance, an assessment of their use in a hospital setting is therefore important. Evidence from such a project would provide the necessary guidance for the review and implementation of antimicrobial stewardship programs in health care facilities.

1.2       Problem statement
Although antibiotics are useful for the management of infectious diseases, which are prevalent especially in Sub-Saharan Africa (World Bank, 1993), their quality of use have been recognised as the main selective pressure leading antimicrobial resistance (Malhotra-Kumar et al., 2007; Goossens et al., 2005). Also, the use of antibiotics motivates patients to reconsult and thus exposed to the added risk of side effects, whilst under-prescribing may be related with poor outcomes to therapy and increased risk of complications from unmanaged microbial infections (Peterson et al., 2007).

It has been observed that close to half of the patients that visit public health facilities in Ghana are prescribed antibiotics, this is quite high, and also significant proportion of such patients may not require antibiotics to meet their health care needs. There is therefore the need to step up or actively promote rational use of activities to improve the quality of prescribing and use of antibiotics for best outcomes (Arhinful, 2009). More so there is paucity of documented findings on the pattern and quality of use of antibiotics in TTH in particular. This study therefore seeks to determine the pattern and quality of use of antibiotics in TTH. The findings of which will be used to guide the formulation of policies to improve antibiotic use at the hospital.

1.3       Research questions to be considered in this study
What types of infections are seen at the hospital?

What is the prevalence of antibiotic use in the hospital?

How many antibiotics are prescribed per patient?

What is the pattern of antibiotics prescribing?

Are antimicrobial prescriptions guided by culture and sensitivity?

What is the appropriateness of the treatment regimens prescribed?

What is the cost of antibiotics prescribed per patient?

Are treatment regimens based on definitive diagnosis?

What is the treatment outcome of patients with bacterial infections managed in the hospital? 

1.4       Main Aim
The aim of this study was to assess the prescribing of antimicrobials in the management of bacterial infections and its utilization among hospitalized patients at Tamale Teaching hospital.

1.4.1    Specific Objectives
* To identify the types of infectious diseases presented at the hospital within the study period.

* To determine the prevalence of use of antibacterial agents within the study period.

* To determine the pattern and types of antibacterial agents prescribed for patients at the hospital.

* To assess if the selection of antimicrobials for prescribing is in conformity to recommendations in Standard Guidelines like the National Treatment Guidelines and the British National Formulary.

* To assess patients response to antibacterial treatment (using outcome measures like symptoms resolution, length of hospital stay and overall wellbeing of the patients after therapy).

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Item Type: Ghanaian Project Material  |  Attribute: 83 pages  |  Chapters: 1-5
Format: MS Word  |  Price: GH50  |  Delivery: Within 30Mins.
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