Levels and determinants of overprescribing of antibiotics in the public and private primary care sectors in South Africa

Abstract

Although overprovision of antibiotics in primary care is a key driver of antibiotic resistance, little is known about its determinants in low-income and middle-income countries. Patient demand and financial incentives for providers are often held responsible for overprovision. Yet, inadequate provision exists in their absence and could be fuelled by quality of care issues and incorrect beliefs of providers regarding patients’ expectations. We explored these issues in the private and public sector in South Africa, by conducting a cross-sectional study using standardised patients (SPs)—healthy individuals trained to portray a scripted clinical case to providers—presenting with symptoms of a viral respiratory infection in a sample of public and private sector clinics. We linked data from SP visits to rich survey data to compare the practices and their predictors in the two sectors. Unnecessary rates of antibiotics were similarly high in the public (78%) and private sector (67%), but private providers prescribed more antibiotics at higher risk of resistance development. In the private sector, overprescription of antibiotics diminished when consultations were more thorough, but increased for consultations scheduled later in the day, suggesting contrasting effects for provider effort and decision fatigue. We observed differences in beliefs that could be responsible for overprescription: in the public sector, a majority of providers (nurses) wrongly believed that antibiotics would help the patient recover more quickly. In the private sector, a majority of doctors thought patients would not come back if they did not receive antibiotics. Overall, this evidence suggests that different factors may be responsible for the high overprescribing rates of antibiotics in the public and private sectors. Tailored stewardship interventions are urgently needed that tackle providers’ engrained habits and incorrect beliefs.

Pattern of inappropriate antibiotic use among patients in the medical wards of a tertiary hospital in southwest Nigeria

“…Clearly, inappropriate antibiotic prescribing is a complex process which is driven by several factors including lack of antibiotic prescribing guidelines, absence of antimicrobial stewardship programmes and inadequate knowledge of appropriate antibiotic prescribing (19,20). In addition, a major factor driving inappropriate antibiotic prescribing, is an effort by the physicians to use antibiotics to prevent infections i. e. prophylaxis (21).…”

The Risk of Death among Patients with Healthcare-associated Infections and Cardiovascular Diseases Admitted to the Intensive Care Unit in Romania

“…30 Studies have shown that inadequate antimicrobial treatment is an important risk factor for death in critical patients, suggesting that the aim should be to reduce the occurrence of this important problem by using efficient prophylactic methods. 31 Important studies have revealed the association of dysbiosis with the development of various pathologies including cardiovascular diseases, as the microbiota affects the host's immunity. 32 Because of the steadily increasing incidence of nosocomial infections related to cardiac surgery in the last decades, prophylaxis should mainly target the prevention and appropriate treatment of bacteremia associated with invasive hospital-based procedures performed in high-risk patients.…”

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“…Healthcare professionals (HCPs) contribution in addressing antibiotic resistance plays a vital role. In order to to achieve this, focus must be on several key actions like: reducing inappropriate antibiotic prescription and distribution, reducing the sell of antibiotics at the over the counter (OTC) drugs without prescriptions, capacity building on AMR, monitoring the current usage and resistance patterns, and initiating antimicrobial stewardship (ASP) initiatives (Alam et al, 2023;Karimi et al, 2023;Lagarde & Blaauw, 2023). Along with three states that have already implemented the AMR Action Plan, India should urge other states to implement State Action Plan with newer initiatives that are appropriate to track and regulate the use of antibiotics, adhere to national action plan, and also focus on community and hospital-based research on public health aspects of AMR are all critically needed (Ahmed et al, 2019;Gelband & Delahoy, 2014;Sahni et al, 2020); (Ruckert et al, 2020).…”