Skip to content

Advertisement

  • Research note
  • Open Access

Rational prescribing of antibiotics in children under 5 years with upper respiratory tract infections in Kintampo Municipal Hospital in Brong Ahafo Region of Ghana

BMC Research Notes201811:443

https://doi.org/10.1186/s13104-018-3542-z

Received: 11 May 2018

Accepted: 26 June 2018

Published: 4 July 2018

Abstract

Objective

The aim of the study was to assess the rational use of antibiotics in children with URTIs in the Kintampo Municipal Hospital in Ghana.

Results

A total of 839 medicines were prescribed, 237 were antibiotics. The mean number of medicines prescribed per patient encounter was 3.1. The percentage of patient encounters with antibiotics was 28.2 and 0.4% for injections. The percentage of medicines prescribed by generic was 93.8% and from the essential medicines list was 94.9%. Ninety-two of patients received amoxicillin. Polypharmacy was common as prescriptions with five to six medicines per patient encounter was found. Some prescribers are not following the WHO/INRUD requirement of prescribing medicines in their generic and from the essential medicine list of the country.

Keywords

RationalMedicineAntibioticsChildrenUpper respiratory tract infectionGhana

Introduction

In the last decades, medicines have had an unprecedented positive effect on health, leading to decline in mortality, disease burden and overall quality of life [1]. The rational use of medicines is regarded as a measure of good clinical practice. The inappropriate use of medicines especially antibiotics have negative consequences on the quality of care and can lead to antibiotic- resistance strains of micro-organisms [25]. The conference of experts on the rational use of medicines (RUM), convened by the World Health Organization (WHO) in Nairobi in 1985 defined the RUM as giving patients medicines that are appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community. In view of this, the use of medicines that do not meet the needs of patients in terms of disease condition, dose, frequency and duration of therapy is described as inappropriate use of medicines [2]. This notwithstanding, studies have showed a high prevalence of antibiotic use among children under 5 with an estimate rate of 2.2 prescriptions per person per year [6, 7]. Though there are no age-specific disaggregated data, earlier studies have found that antibiotic use in Ghana to be between 11.9 and 60.7% [810].

Upper respiratory tract infections (URTIs) are infectious diseases of the upper respiratory tract and include condition such as common cold, influenza, pharyngitis, otitis media, tonsillitis and sinusitis [11]. However, common cold is reported as the most prevalent accounting for about 80% of URTIs [12]. URTIs are mostly managed symptomatically with basic analgesics to relief fever, increased fluid intake and with nasal decongestants [13] because they are mostly viral in origin and many (about 90%) resolve without any intervention [12].

URTIs are very common among paediatric population and therefore constitute a major target for inappropriate use of antibiotics. As a measure to help reduce the inappropriate use of antibiotics, the WHO has advocated for the use of essential medicine list and other policy guidelines for the use of medicines including antibiotics [1416]. The Ghana National Drug Programme has developed and distributed the essential medicines list (EML) and Standard Treatment Guidelines (STGs) to all public health institutions over the years [17]. The national drug treatment guideline requires that all prescription should be generic and should be listed in the essential medicine list of the country [17]. The STGs provides for age and disease-specific doses and duration of treatment. The aim of this study was to assess rational use of medicine among paediatric patients in the Kintampo Municipal hospital.

Main text

Materials and methods

Study design

We reviewed medical records of children under 5 years who attended the out-patient department of Kintampo Municipal Hospital with URTIs between the 1st of January, 2009 and 31st December, 2014 using a WHO checklist on rational use of medicine.

Study area

The Kintampo Municipality is one of the 28 districts in the Brong Ahafo region of Ghana. The municipality has a population of 111,263 [18]. The Kintampo Municipality has one District hospital of 125 bed capacity, two Health centres, two Rural clinics, one Community-based Health Planning Services (CHPS) compound and one Maternity home.

Sample size determination

We used Yamane’s formula (1967) for population proportion to compute the sample size for this study;
$${\text{n}} = \frac{N}{{1 + N(e^{2} )}}$$
(1)
where n = minimum sample size, N = population size of 648, e = level of precision which was set at 5%. Substituting the above into Eq. 1 resulted in a sample size of 248. However, it was increased by 10% to 270.

Data collection

A systematic random sampling procedure was used. The sampling interval of two was obtained by dividing the study population (N) by the sample size (n) [19]. We used this sampling interval to sample patients and retrieved their medical records for the review.

Study variables

We extracted the following variables from patients primary medical records: diagnoses (primary and secondary) according to the International Classification of Diseases (ICD-9), age, sex, and prescription of antibiotic at that visit (whether prescribed or not, and if so, the type of antibiotic selected), dose, frequency and duration.

Data analysis

The data extracted were entered into STATA 13 and analysed. The results were than compared with WHO benchmark indicators. Appropriateness of treatment was determined by the extent of adherence to the Ghana STG and EML [20] using the criteria recommended by Kunin et al. [21] and Deshmuch et al. [22].

Results

Type of URTIs and antibiotics used

The minimum age was 0.5 months (15 days), the maximum age was 57 months with an average age of 18.3 ± 13 months. Children aged 1–5 years (12–59 months) accounted for majority of patients (62.6%). Only 3 patients were less than 1 month (1.1%). Out of the 270 patients, 140 (52.0%) were males. Among the 270 patients, the most common URTI was common cold (52.6%). However, 17 patients had conditions which did not fit into the classification criteria for any URTIs and were therefore described as non-specific.

A total of 839 medicines were prescribed for the 270 patients with no patient reporting multiple attendance for URTI. Two hundred and seven (237) antibiotics were prescribed per patient encounter; penicillin (58%), cephalosporins (19%) and macrolides (10%). Amoxicillin (38.8%), cefuroxime (18.6%) and amoxicillin + clavulanic acid (17.3%) were the commonly prescribed antibiotics (Table 1).
Table 1

Antibiotics prescribed for the management of URTIs

Antibiotic (n = 237)

Frequency (F)

Percentage (F × 100/n)

Penicillins

 Amoxicillin suspension

92

38.8

 Amoxicillin + clavulanic acid suspension

41

17.3

 Flucloxacillin suspension

4

1.7

Cephalosporins

 Cefuroxime suspension

44

18.6

 Ceftriaxone injection

1

0.4

Macrolides

 Azithromycin suspension

17

7.2

 Erythromycin suspension

7

3.0

Sulphonamides

 Cotrimoxazole suspension

21

8.9

 Others

10

4.2

 No antibiotic

33

12.2

Sixty-two (43.7%) of patients with common cold received amoxicillin, 5 (3.5%) received amoxicillin with clavulanic acid and 6 (4.2%) received azithromycin and cefuroxime whilst 32 (22.6%) did not receive any antibiotic. Among patients with otitis media, majority, 23 (33.3%) were given amoxicillin + clavulanic acid whilst 21 (30.4%) received amoxicillin. Patients with pharyngitis received amoxicillin with clavulanic acid (47.8%).

Assessment of rational prescribing

The mean number of medicines per patient encounter was 3.1 which was higher than the WHO standard of ≤ 2 medicines per patient encounter. The prevalence of antibiotic use for URTIs was 28.6%. Prescription by generic and from the essential medicines list were 93.8 and 94.9%, respectively (Table 2).
Table 2

Comparison between the uses of medicine for URTIs in the study are against the WHO standard

Prescribing indicator

Value

WHO standard

Total number of patients prescriptions analysed

270

≥ 100

Total number of medicines prescribed

839

Average number of medicines prescribed per encounter

3.1

≤ 2

% Medicines prescribed by generic

93.8

100

% Patient encounters with antibiotics prescribed

28.2

≤ 30

% of patient encounters with injections prescribed

0.4

≤ 10

% of medicines prescribed from essential medicines list or formulary

94.9

100

About 93.0% of prescriptions had appropriate doses, 95.6% were appropriate in frequency and 96.7% had appropriate duration of treatment (Table 3).
Table 3

Distribution of prescriptions according to appropriateness

Parameter

No. appropriate

Prescriptions (N = 270)

% inappropriate

% appropriate

No. inappropriate

Dose

251

93.0

19

7.0

Frequency

258

95.6

12

4.4

Duration

261

96.7

9

3.3

Discussion

This study revealed that common cold was the most diagnosed URTI, followed by otitis media. Common cold accounted for more than half of the diagnoses of the total prescriptions. This findings as agrees with literature that showed that children tend to develop 3–8 bouts of common cold in a year and this even tends to increase for children who attend daycare or preschool [23, 24]. Out of the 142 URTIs diagnosed with common cold, 110 (77.4%) were given antibiotics. In Northern Tanzania, it was found that about 68.9% of children under 5 received antibiotic [25] despite the fact this condition in mainly viral and therefore the use of antibiotic is inappropriate. Generally, it is recommended that children with common cold should managed with nasal decongestant [26], antihistamine [27] and zinc [28] as these help to relief symptom leading to spontaneous recovery. The use of intranasal ipratropium bromide has also be found to be very useful in relieving symptoms of common cold [29]. The findings of study underscore the need to sensitize prescribers on rational use of medicines especially for common cold.

The study revealed three main classes of antibiotics which were commonly used to manage URTIs in children in the hospital. These classes were the penicillins, cephalosporins and the macrolides and similar findings have been reported in a study in South Western Nigeria [30]. The most prescribed class was the penicillins specifically amoxicillin and amoxicillin + clavulanic acid. Amoxicillin is the first line antibiotic in the management of URTIs according to the Standard Treatment Guideline of Ghana [31].

Furthermore, the study revealed a 3.1 average number of medicines prescribed per patient encounter, implying that, patients were likely to receive three medicines per visit. The WHO indicator tools for rational prescribing however requires that only one or two medicines are prescribed per patient encounter [32]. This finding suggests the presence of poly pharmacy. A study carried out at the Ghana Police Hospital revealed a similar finding of 3.7 [33]. Similar findings have been reported in studies in Uganda (2.6) [34] and Jordan (2.4) [35].

The findings of this study further showed that the percentage of medicines prescribed by generic wad 93.8% which is less than the requirement that all medicines should be prescribed in generic. This further call for refresher training for prescribers to conform to the standards in prescribing medicines for patients as rational use of medicines has become an indicator for measuring quality of health care [3638].

The percentage of patient encounters with antibiotics prescribed was 28.6%. This is within the range of ≤ 30% optimal, WHO standards and therefore tends to suggest a prudent use of antibiotics in Kintampo Municipal Hospital. Such a judicious use of antibiotics will go a long way to minimize antibiotic resistance and serious adverse effects [39, 40]. A percentage of 0.4% obtained for patient encounters with injections is also within WHO/INRUD Standard of ≤ 10%. This is however higher than the findings of a study conducted in Ethiopia that reported a lower percentage of 0.04% [41]. Globally, the use injections should be kept to the minimum because of the increasing risk of transmission of HIV, hepatitis and other blood related diseases through injection [4244]. The low rate of injection use is also likely to reduce the risk of anaphylactic shock, tissue necrosis and sepsis in patients [4547].

The findings showed that 94.9% for medicines prescribed from the essential medicines list falls short of the optimal WHO/INRUD standard of 100%. This is however higher than a study conducted in Ghana in 2014 which found a 53.6% adherence to WHO/INRUD requirement [33]. This finding also indicate the need for training and development of quality assurance programmes. In Europe, quality assurance programmes and public campaigns have been developed and launched to improve the use of antibiotics in primary care [4850]. This strategy could be harnessed for Ghana to improve rational use of antibiotics and adherence to standards in the use of medicines.

Conclusions

This study conclude that the overuse of antibiotics for URTIs was common in Ghana. The penicillins and cephalosporins are the most preferred antibiotics prescribed for the management of upper respiratory tract infections in children under 5 years. Some prescribers are not following the WHO/INRUD requirement of prescribing medicines in their generic and from the essential medicine list of the country.

Limitation

The study was carried out in only one health facility within the municipality and region, hence the conclusions should be interpreted in the context of the limited scope of the research.

Abbreviations

INRUD: 

International Network for Rational Use of Drugs

RUM: 

rational use of medicine

STG: 

Standard Treatment Guideline

URTI: 

upper respiratory tract infection

WHO: 

World Health Organisation

Declarations

Authors’ contributions

Conceived and designed the experiments: ANS, PT-NT. Performed the experiments: ANS Analyzed the data: ANS, PT-NT. Contributed reagents/materials/analysis tools: ANS, PT-NT. Wrote the paper: ANS, PT-NT. All authors read and approved the final manuscript.

Acknowledgements

We wish to thank the Medical Superintendent of the Kintampo Municipal Hospital and medical records staff for the assistance.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

The data sets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Consent to publish

Not applicable.

Ethics approval and consent to participate

The proposal for this study was reviewed and approved by the Ethics and Review Committee of the Ghana Health Service (GHS-ERC 104/02/15). We also received administrative permission from the health facility to review patient records and use the data for this study.

Funding

This study was conducted as part of the requirements for the award of a Master of Public Health Degree by ANS. He did not receive any funding from any institution.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Pharmacy Department, Jema District Hospital, Ghana Health Services, Accra, Ghana
(2)
Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, Ghana

References

  1. WHO. The pursuit of responsible use of medicines: sharing and learning from country experiences. Vet Rec. 2012;169:78.Google Scholar
  2. Bbosa GS, Wong G, Kyegombe DB, Ogwal-Okeng J. Effects of intervention measures on irrational antibiotics/antibacterial drug use in developing countries: a systematic review. Health. 2014;6:171–87.View ArticleGoogle Scholar
  3. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579–87.View ArticlePubMedGoogle Scholar
  4. Friedman BC, Schwabe-Warf D, Goldman R. Reducing inappropriate antibiotic use among children with influenza infection. Can Fam Physician. 2011;57:42–4.PubMedPubMed CentralGoogle Scholar
  5. Gebeyehu E, Bantie L, Azage M. Inappropriate use of antibiotics and its associated factors among urban and rural communities of Bahir Dar city administration, northwest Ethiopia. PLoS ONE. 2015;10:e0138179.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Marc C, Vrignaud B, Levieux K, Robine A, Guen CG-L, Launay E. Inappropriate prescription of antibiotics in pediatric practice. J Child Health Care. 2016;20:530–6.View ArticleGoogle Scholar
  7. Rossignoli A, Clavenna A, Bonati M. Antibiotic prescription and prevalence rate in the outpatient paediatric population: analysis of surveys published during 2000–2005. Eur J Clin Pharmacol. 2007;63:1099–106.View ArticlePubMedGoogle Scholar
  8. Apenteng JA, Addy BS, Onwukwe EO, Brookman-amissah G. Antibiotics prescribing patterns and incidence of respiratory tract infection in children under five years: a study in two hospitals in Accra, Ghana. Int J Med Med Sci. 2018;10:47–58.View ArticleGoogle Scholar
  9. Prah J, Kizzie-Hayford J, Walker E, Ampofo-Asiama A. Antibiotic prescription pattern in a Ghanaian primary health care facility. Pan Afr Med J. 2017;28:1–10.View ArticleGoogle Scholar
  10. Ahiabu MA, Tersbøl BP, Biritwum R, Bygbjerg IC, Magnussen P. A retrospective audit of antibiotic prescriptions in primary health-care facilities in Eastern Region, Ghana. Health Policy Plan. 2016;31:250–8.View ArticlePubMedGoogle Scholar
  11. NHS. Respiratory tract infections—antibiotic prescribing. NICE Clin Guidel. 2008;69:1–240.Google Scholar
  12. Cotton M, Innes S, Jaspan H, Madide A, Rabie H. Management of upper respiratory tract infections in children. South Afr Fam Pract. 2014;50:6–12.View ArticleGoogle Scholar
  13. Thi D, Nguyen K, Leung KK, Mcintyre L, Ghali WA, Sauve R. Does integrated management of childhood illness (IMCI) training improve the skills of health workers ? A systematic review and meta-analysis. Plos ONE. 2013;8:e66030.View ArticleGoogle Scholar
  14. Braine T. WHO to launch first essential medicines list for children. Bull World Health Organ. 2007;85:249–50.PubMedPubMed CentralGoogle Scholar
  15. WHO. WHO model list of essential medicines. Children. 2010;19:1–43.Google Scholar
  16. WHO. WHO model list of essential medicines. 18th ed. Geneva: WHO; 2013.Google Scholar
  17. GHS. Ghana essential medicines list. Accra: Ghana Health Service; 2004.Google Scholar
  18. Ghana Statistical Service. Population and housing census. Ghana Stat Serv. 2010;2012:1–117.Google Scholar
  19. Bowling A. Research methods in health: investigating health and health service. 4th ed. England: Open University Press; 2014.Google Scholar
  20. MOH(GNDP). Standard treatment guidelines. 6th ed. Accra: MOH(GNDP); 2010.Google Scholar
  21. Kunin C, Tupasi T, Craig W. Use of antibiotics. A brief exposition of the problem and some tentative solutions. Ann Intern Med. 1973;79:555–60.View ArticlePubMedGoogle Scholar
  22. Deshmukh A, Ghadlinge M, Tamboli S, Deshmukh J, Chhabra R. Study of rationality and utilization pattern of antimicrobials in ear, nose, throat outpatient department of Tertiary Care Hospital, Nanded. Int J Basic Clin Pharmacol. 2015;4:734–8.View ArticleGoogle Scholar
  23. Amra B, Sohrab-Pour H, Shirani S, Golshan M. Prevalence of the common cold symptoms and associated risk factors in a large population study. Tanaffos. 2006;5:13–7.Google Scholar
  24. Rerksuppaphol S, Rerksuppaphol L. A randomized controlled trial of chelated zinc for prevention of the common cold in Thai school children. Paediatr Int Child Health. 2013;33:145–50.View ArticlePubMedGoogle Scholar
  25. Gwimile JJ, Shekalaghe SA, Kapanda GN, Kisanga ER. Antibiotic prescribing practice in management of cough and/or diarrhoea in Moshi Municipality, Northern Tanzania: cross-sectional descriptive study. Pan Afr Med J. 2012;12:103.PubMedPubMed CentralGoogle Scholar
  26. Taverner D, Latte J. Nasal decongestants for the common cold. Rev: Cochrane Database Syst; 2007.View ArticleGoogle Scholar
  27. De Sutter AIM, Saraswat A, van Driel ML. Antihistamines for the common cold. Cochrane Database Syst Rev. 2015;11:CD009345.Google Scholar
  28. Singh M, Das RR. Zinc for the common cold. Evid Based Child Health. 2012;314:1235–308.View ArticleGoogle Scholar
  29. AlBalawi ZH, Othman SS, AlFaleh K. Intranasal ipratropium bromide for the common cold. Cochrane Database Syst. Rev. 2013;7:1–36.Google Scholar
  30. Joseph F, Oladele O, Oludare O, Olatunde O. Drug prescribing pattern for under-fives in a paediatric clinic in south-western Nigeria. Ethiop J Health Sci. 2015;25:73.View ArticleGoogle Scholar
  31. Ghana National Drugs Programme (GNDP), Ministry of Health. STG. Standard Treatment Guidelines (Ministry of Health-Ghana). 6th ed. Accra: Ghana National Drugs Programme (GNDP), Ministry of Health; 2010.Google Scholar
  32. WHO (World Health Organization). Guide to good prescribing. Can Med Assoc J. 1993;2:383–90.Google Scholar
  33. Afriyie DK. A description of the pattern of rational drug use in Ghana Police Hospital. Int J Pharm Pharmacol. 2014;3:143–8.Google Scholar
  34. Mcgaughey N. Prescribing practices and polypharmacy in Kitovu Hospital, Uganda. East Cent Afr J Pharm Sci. 2010;13:66–71.Google Scholar
  35. Al-Niemat SI, Aljbouri TM, Goussous LS, Efaishat RA, Salah RK. Antibiotic prescribing patterns in outpatient emergency clinics at Queen Rania Al Abdullah II Children’s Hospital, Jordan. Oman Med J. 2013;2014:250–4.Google Scholar
  36. Ferreira MBC, Heineck I, Flores LM, Camargo AL, Dal Pizzol TDS, Torres ILDS, et al. Rational use of medicines: prescribing indicators at different levels of health care. Braz J Pharm Sci. 2013;49:329–40.View ArticleGoogle Scholar
  37. Wagner AK, Quick JD, Ross-Degnan D. Quality use of medicines within universal health coverage: challenges and opportunities. BMC Health Serv Res. 2014;14:357.View ArticlePubMedPubMed CentralGoogle Scholar
  38. Laing R, Waning B, Gray A, Ford N, Hoen ET. 25 Years of the WHO essential medicines lists: progress and challenges. Lancet. 2003;361:1723–9.View ArticlePubMedGoogle Scholar
  39. Ventola CL. The antibiotic resistance crisis. Pharm Ther. 2015;40:277–83.Google Scholar
  40. French GL. The continuing crisis in antibiotic resistance. Int J Antimicrob Agents. 2010;36:S3–7.View ArticlePubMedGoogle Scholar
  41. Sebsibie G, Gultie T. Retrospective assessment of irrational use of antibiotics to children attending in Mekelle general hospital. Sci J Clin Med. 2014;3:46–51.Google Scholar
  42. Altaf A, Ali Shah S, Khamassi S. Preventing transmission of hepatitis C due to unsafe injections should be a priority for Pakistan. J Pak Med Assoc. 2014;64:239–41.PubMedGoogle Scholar
  43. Gisselquist DP. Estimating HIV-1 transmission efficiency through unsafe medical injections. Int J STD AIDS. 2002;13:152–9.View ArticlePubMedGoogle Scholar
  44. White RG, Ben SC, Kedhar A, Orroth KK, Biraro S, Baggaley RF, et al. Quantifying HIV-1 transmission due to contaminated injections. Proc Natl Acad Sci. 2007;104:9794–9.View ArticlePubMedGoogle Scholar
  45. Limsuwan T, Demoly P. Acute symptoms of drug hypersensitivity (urticaria, angioedema, anaphylaxis, anaphylactic shock). Med Clin. 2010;94:691–710.Google Scholar
  46. Canabal J, Caballero T, Caminoa M, Fiandor A, Quirce S, Cabañas R. Anaphylactic shock caused by a hidden allergen in blood sausage. J. Invest Allergol Clin Immunol. 2016;26:200–1.View ArticleGoogle Scholar
  47. Prusakowski MK, Chen AP. Pediatric sepsis. Emerg Med Clin N Am. 2017;35:123–38.View ArticleGoogle Scholar
  48. Welschen I, Kuyvenhoven M, Hoes A, Verheij T. Antibiotics for acute respiratory tract symptoms: patients’ expectations, GPs’ management and patient satisfaction. Fam Pract. 2004;21:234–7.View ArticlePubMedGoogle Scholar
  49. Goossens H, Guillemot D, Ferech M, Schlemmer B, Costers M, Van Breda M, et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol. 2006;62:373–9.View ArticlePubMedGoogle Scholar
  50. Huttner B, Harbarth S. ‘Antibiotics are not automatic anymore’—The French national campaign to cut antibiotic overuse. PLoS Med. 2009;6:e1000080.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© The Author(s) 2018

Advertisement