Recent Initiatives in the Republic of Srpska to Enhance Appropriate Use of Antibiotics in Ambulatory Care; Their Influence and Implications

Abstract

Introduction: There are increasing concerns world-wide with growing rates of antibiotic resistance necessitating urgent action. There have been a number of initiatives in the Republic of Srpska in recent years to address this and improve rational antibiotic prescribing and dispensing despite limited resources to fund multiple initiatives.Objective: Analyse antibiotic utilization patterns in the Republic of Srpska following these multiple initiatives as a basis for developing future programmes in the Republic if needed.Methods: Observational retrospective study of total outpatient antibiotic utilization from 2010 to 2015, based on data obtained from the Public Health Institute, alongside documentation of ongoing initiatives to influence utilization. The quality of antibiotic utilization principally assessed according to ESAC, ECDC, and WHO quality indicators and DU 90% (the drug utilization 90%) profile as well as vs. neighboring countries.Results: Following multiple initiatives, antibiotic utilization remained relatively stable in the Republic at 15.6 to 18.4 DIDs, with a decreasing trend in recent years, with rates comparable or lower than neighboring countries. Amoxicillin and the penicillins accounted for 29–40 and 50% of total utilization, respectively. Overall, limited utilization of co-amoxiclav (7–11%), cephalosporins, macrolides, and quinolones, as well as low use of third and fourth generation cephalosporins vs. first and second cephalosporins. However, increasing utilization of co-amoxiclav and azithromycin, as well as higher rates of quinolone utilization compared to some countries, was seen.Conclusions: Multiple interventions in the Republic of Srpska in recent years have resulted in one of the lowest utilization of antibiotics when compared with similar countries, acting as an exemplar to others. However, there are some concerns with current utilization of co-amoxiclav and azithromycin which are being addressed. This will be the subject of future research activities.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…Regular monitoring of prescribing activities for patients with URTIs in ambulatory care using both quantitative and qualitative research methods -helped by IT systems and mobile technologies. This can include accountability systems for prescribers where they have to justify the need for an antibiotic for patients with URTIs as well as the antibiotic selected (building on restrictions for certain antibiotics in a number of countries as well as the WHO Access, Watch, Reserve -AwaRe -antibiotic groupings 40,71,387,388 ).…”

“…Multiple strategies are typically needed to reduce unnecessary prescribing and dispensing of antibiotics in ambulatory care among all key stakeholder groups including patients, parents, community pharmacists and physicians 29,40,52,60,70,71,74,97,154,243 . This reflects the complexity of the situation, the different beliefs of key stakeholder groups and often multiple organizations and personnel within a country involved with improving antibiotic utilization and reducing AMR rates 244 .…”

“…A number of approaches to improve the use of antibiotics in ambulatory care in high-as well as high-middle income countries have been described and reviewed by Dyar et al 85 These are of relevance to LMICs as the care of patients with URTIs increasingly moves to physicians. The approaches can Activities included diagnostic and prescribing advice for physicians, a limited list of reimbursed antibiotics, continual education of pharmacists and pharmacist technicians as well as published guidelines for pharmacy personnel to successfully treat URTIs patients with over-the-counter medicines or refer them to a GP 71 .…”

“…In addition, continual inspections by Republic of Srpska Inspectorate personnel since by law antibiotics are restricted to prescription only medicines in the Republic. These combined activities resulted in the Republic having one of the lowest utilisations of antibiotics in recent years compared with similar countries as well as an appreciable reduction in the self-purchasing of antibiotics in recent years 71,306 .…”

“…Unfortunately, antibiotics can achieve good health outcomes even in patients with viral infections, which runs counter to changing public perceptions of their efficacy [56][57][58][59] . Concerns with rising rates of AMR, coupled with the continued irrational use of antibiotics to treat self-limiting infections such as upper respiratory tract infections (URTIs), have resulted in multiple initiatives internationally, regionally, and nationally aimed at reversing current trends 6,8,21,36,40,[60][61][62][63][64][65][66][67][68][69][70][71][72][73][74] .…”