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Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey

Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey Original Article Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey 1 2 2 3 4,5 4,6,7 Lydia Momanyi , Sylvia Opanga , David Nyamu , Margaret Oluka , Amanj Kurdi , Brian Godman Department of Pharmacy, Objective: Antibiotics are essential with inappropriate use leading to antimicrobial Rift Valley Provincial General resistance (AMR). Currently, little is known about antibiotic use among hospitals Hospital, Nakuru, Kenya in Kenya, which is essential to tackle as part of the recent national action plan Department of addressing rising AMR rates. Consequently, the objective was to overcome this Pharmaceutics and Pharmacy gap in a leading referral hospital in Kenya. The findings will subsequently be used Practice, University of to develop quality improvement programs for this and other hospitals in Kenya. Nairobi, Nairobi, Kenya Methods: This was a point prevalence survey. Data on antibiotic use were abstracted from patient medical records by a pharmacy team. Findings: The prevalence of Department of Pharmacology and Pharmacognosy, antibiotic prescribing was 54.7%, highest in the intensive care unit and isolation University of Nairobi, wards. Most antibiotics were for treatment (75.4%) rather than prophylaxis Nairobi, Kenya (29.0%). The majority of patients on surgical prophylaxis were on prolonged duration (>1 day), with only 9.6% on a single dose as per current guidelines. Department of Pharmacoepidemiology, Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed Strathclyde Institute of antibiotic classes. The indication for antibiotic use was documented in only 37.3% Pharmacy and Biomedical of encounters. Generic prescribing was 62.5% and empiric prescribing was seen Sciences, University of in 82.6% of encounters. Guideline compliance was 45.8%. Conclusion: Several Strathclyde, Glasgow, UK areas for improvement were identified including addressing prolonged duration Department of Pharmacology, for prophylaxis, extensive prescribing of broad-spectrum antibiotics, high rates Hawler Medical University, of empiric prescribing, and lack of documenting the indication for antimicrobials. Erbil, Iraq Initiatives are ongoing to address this with pharmacists playing a key role. Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden Division of Public Health Pharmacy and Management, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa Received: 28-08-2018. Accepted: 27-01-2019. Keywords: Antibiotics, Kenya, point prevalence survey, prescribing, utilization Published: 16-10-2019. Introduction Address for correspondence: Prof. Brian Godman, E-mail: brian.godman@strath.ac.uk ntibiotics are widely prescribed globally with Aantibiotic use increasing by 36% during the past This is an open access journal, and articles are distributed under the terms of the [1] decade. However, their overuse has increased rates of Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical Access this article online terms. Quick Response Code: For reprints contact: reprints@medknow.com Website: www.jrpp.net How to cite this article: Momanyi L, Opanga S, Nyamu D, Oluka M, Kurdi A, Godman B. Antibiotic prescribing patterns at a leading DOI: 10.4103/jrpp.JRPP_18_68 referral hospital in Kenya: A point prevalence survey. J Res Pharm Pract 2019;8:149-54.  2019 Journal of Research in Pharmacy Practice | Published by Wolters Kluwer - Medknow 149 Abstract Momanyi, et al.: Prescribing patterns of antibiotics in Kenya antimicrobial resistance (AMR), increasing morbidity, CAIs were documented if symptoms started <48 h from [2] mortality, and costs. This has resulted in international admission to hospital (or present on admission) and [3,4] [10,13] and national programs to address rising AMR rates. HAIs if symptoms started 48 h after admission. We This is particularly important in countries such as Kenya also assessed whether there was an association between with high rates of HIV and tuberculosis (TB) and antibiotic classes and departments for possible future [5-7] growing AMR rates, resulting in the recent launch of interventions. [5] the Kenyan National Action Plan. This includes a need Prescribing patterns were assessed against the findings for greater understanding of antibiotic use including of the Global PPS study, especially among African hospitals to inform future policies. [10] countries. The quality of antibiotic prescribing We have previously reported on concerns with antibiotic was also assessed by evaluating whether the reason use in a referral hospital in Western Kenya as well as for the prescription was documented, current generic antibiotic prophylaxis to prevent surgical site infections prescribing rates and the extent of empiric versus [8,9] (SSIs) in patients with neurotrauma. However, we targeted prescribing. Guideline compliance was also have not previously reported antibiotic utilization patterns assessed. While there is currently no hospital formulary, within a level 5 facility in Kenya. This is important as this prescriptions are guided by the Kenyan Essential [14,15] is a leading teaching hospital in Kenya providing direction Medicine List and relevant international guidelines. to others. In addition, the recent Global Point Prevalence This formed the basis of whether treatment was guideline Survey (PPS) only contained data from five African compliant or not. Sampling of patients’ notes was [10] countries excluding Kenya and children. Consequently, undertaken as part of ethical approval. The sample size the study was undertaken to address this knowledge gap was calculated using the Fisher formula adjusted for with Kenya one of the most populous African countries. [16] average hospital bed occupancy. However, there was The findings will be applicable across Kenya. no sampling for antibiotic use. On the day of the survey, the total number of patients Methods admitted by 8 AM was recorded followed by the total [8,10] A PPS study was undertaken in April 2017 to number of patients on systemic antibiotics at 8 AM. The ascertain the prevalence and patterns of antibiotic medical records of all inpatients on systemic antibiotics prescribing at a specific point in time at the Rift Valley were obtained, with their file numbers entered onto Provincial General Hospital, a level 5 teaching hospital. Microsoft Excel, with the computer providing a random It is the fourth largest government referral hospital in sample of files to be studied in full. There was no Kenya with 532 beds. direct engagement of patients. The patients' files were All the neonatal, pediatric, adult, and mixed departments subsequently reviewed by the data collectors including were included. All patients who were receiving systemic medical students led by a pharmacist, and the data antibiotic therapy at 8 AM on the day of the survey were were entered onto the PPS form. Data were recorded eligible, with the antibiotics including antibacterials for as anonymous by employing a study number for each systemic use (J01), TB (J04A), intestinal anti-infectives patient. The data were subsequently validated for [11] (A07AA) and antiprotozoals (P01AB). Outpatients completeness and correctness by two other pharmacists. and daytime admissions for ambulatory patients for To calculate the prevalence of antibiotic use, the procedures such as endoscopy or renal dialysis were denominator was the total number of admitted patients excluded as well as antibiotics for topical use. while the numerator was the total number of patients on Antibiotic use was recorded by prescription, with usage systemic antibiotics at 8 AM of the day the ward was broken down into either prophylaxis or treatment. surveyed. Prophylaxis was further divided into medical or surgical The prevalence of antibiotic use in the various prophylaxis. Medical prophylaxis was documented when departments including whether for prophylaxis or antibiotics were prescribed to prevent infections in treatment was also calculated. Descriptive statistics were patients with medical conditions. Surgical prophylaxis [9] used to summarize and describe the study variables included the use of antibiotics to prevent SSIs. The as appropriate using means and standard deviations extent of comorbidities were also recorded including for continuous variables while using frequency and HIV, which is particularly prevalent in sub-Sarah Africa [12] for patients admitted to hospitals. Infections were percentages for categorical variables. The Chi-square further divided into community-acquired infection (CAI) test was used to test the association between the use of various antibiotic classes among the different hospital and hospital-acquired infection (HAI), especially given [13] the extent of HAIs in sub-Sahara Africa. departments, whereas the Fisher exact test was used 150 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya instead of the Chi-square test when the Chi-square test The penicillins (46.9%) (J01C) were the most prescribed assumptions (≥80% of the expected values in various class followed by the cephalosporins (44.7%) (J01D) cells were ≥5 or no expected values were <1) were and aminoglycosides (26.3%) (J01G). There was limited violated, consequently invalid. prescribing of the nitrofurans (0.6%) (J01XE) [Figure 1]. Ethical approval was obtained from the KNH-UON Individually, ceftriaxone was the most prescribed Ethics Committee reference number P36/01/2017. Further antibiotic (39.7%) followed by benzylpenicillin (29.0%) approval was obtained from the hospital administration and metronidazole (25.1%) [Table 1]. of the Rift Valley Provincial General Hospital before There was a statistically significant association between commencement of the study. Confidentiality of the data antibiotic prescribing and departments. Aminoglycosides was stringently maintained throughout. were commonly prescribed in the pediatric medical wards (P < 0.001). Macrolides (P = 0.002), nitroimidazole Results derivatives (P = 0.002), and anti-TB antimicrobials The study was conducted on 179 patients whose median (P < 0.001) were the most frequently prescribed in the adult age was 25.3 years (interquartile range = 4–38). Adults medical wards. Penicillins (P = 0.002) were commonly (20–59 years) formed the largest proportion (93, 52%) prescribed in the adult surgical wards. Tetracyclines were followed by neonates (23, 12.9%). There were more prescribed mostly in the OBGYN departments (P = 0.004). females (99, 55.3%) than males (44.6%). The adult Carbapenems were commonly prescribed in the ICU and surgical ward (53, 29.6%) and the adult medical ward pediatric medical wards (P = 0.002) [Table 2]. (41, 22.9%) had the largest proportion of patients with The pattern of antibiotic prescribing varied by indication least in the intensive care unit (ICU) (4, 2.2%). [Figure 2]. The overall prevalence of antibiotic prescribing was The most commonly prescribed antibiotic classes for 54.7%, with the highest level of prescribing for treatment (75.4%). respiratory infections were aminoglycosides (19.5%) and penicillins (18.6%). For SSTBJ infections, The ICU (100.0%) and the isolation ward (100.0%), cephalosporins (37.8%) and penicillins (27.0%) classified under a mixed department, had the highest were commonly prescribed. For neonatal infections, prevalence of antibiotic prescribing (100.0%), followed aminoglycosides (41.2%) and penicillins (41.2%) were by the newborn unit (93.7%), the pediatric medical ward commonly prescribed. (84.2%), the adult medical ward (61.5%), and the adult surgical ward (57.3%). The obstetric or gynecological Less than half of the patients were on a single antibiotic (OBGYN) department had the least prevalence of (41.3%), with the majority (58.7%) on combination antibiotic prescribing (20.8%). therapy, and 17.9% having 3 or more antibiotics. The most prevalent antibiotic combinations were The majority of patients had no comorbidities aminoglycosides and penicillins (20.7%), followed by (96, 53.6%). Among those with comorbidities, the cephalosporins and nitroimidazole derivatives (13.4%), most prevalent was HIV (8.4%) followed by diabetes penicillins and nitroimidazole derivatives (9.5%), and mellitus (6.7%), low birth weight (6.7%), anemia cephalosporins and penicillins (6.7%). There were also (5.6%), respiratory distress (5.0%), and hypertension some unusual combinations. (3.9%). The most frequent indication for antibiotic use was for CAIs (54.2%) followed by prolonged surgical The reason for the antibiotic prescription was prophylaxis at >1 day (22.4%), medical prophylaxis documented in 37.3% (n = 133) of occasions. (15.1%), 1-day surgical prophylaxis (3.9%), single-dose surgical prophylaxis (2.8%), and HAIs (2.8%). The respiratory system was the anatomical site with the greatest proportion of antibiotics prescribed for treatment (24.6%) followed by the skin, soft tissue, bone, and joint infections (SSTBJ) at 12.3%. Eyes (0.6%), the cardiovascular system (0.6%), and ENT (0%) had the least antibiotics prescribed. For prophylactic use, OBGYN surgery was highest (10.1%) followed by SSTBJ anatomical sites (8.9%), with the least for urinary tract infections (0%) and the cardiovascular system (0%). Figure 1: Prevalence of antibiotic prescribing by class Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 151 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Discussion Table 1: Prevalence of specific antibiotics prescribed Specific antibiotics n (%) The prevalence of antibiotic prescribing was 54.7%, [17] Cephalosporins Ceftriaxone 71 (39.7) comparable to Nigerian hospitals at 55.9%, Egyptian Ceftazidime 7 (3.9) [18] [8] hospitals at 59%. Western Kenya at 67.7%, Uganda Penicillins Benzyl penicillin 52 (29.0) [19] [20] (79%), and Ghana (51.4%), as well as the African Flucloxacillin 20 (11.2) [10] countries in the Global PPS (50.0%). However, Ampicillin/cloxacillin 14 (7.8) this was higher than the overall rate for antimicrobial Amoxicillin/clavulanic 10 (5.6) [10] prescribing in the Global PPS study (34.1%). This acid may reflect the higher burden of infectious diseases Amoxicillin 4 (2.2) [6,7,12] among African countries including Kenya. Nitroimidazole derivatives Metronidazole 45 (25.1) Aminoglycosides Gentamicin 40 (22.3) The ICU and the isolation departments had the Amikacin 7 (3.9) highest rate of antibiotic prescribing (100%), similar Rifamycins Rifampicin 11 (6.1) [18] to Egypt and the African countries in the Global Macrolides Erythromycin 10 (5.6) [10] PPS, probably due to the critical nature of the Clarithromycin 1 (0.6) patients’ illness and increased risk of infections, Lincosamides Clindamycin 7 (3.9) [21] especially if patients are on a ventilator. The Sulfonamides Cotrimoxazole 5 (2.8) OBGYN department (20.8%) had the least prevalence Chloramphenicol Chloramphenicol 3 (1.7) [20] of antibiotic prescribing, similar to Ghana but Quinolones Ciprofloxacin 3 (1.7) [8] Levofloxacin 1 (0.6) different to a previous Kenyan study. Tetracyclines Doxycycline 2 (1.1) 75.4% of antibiotic prescribing was for treatment, Carbapenems Meropenem 2 (1.1) [10] similar to the Global PPS. The respiratory system Glycopeptides Vancomycin 2 (1.1) had the largest proportion of antibiotics prescribed Furadantin Nitrofurantoin 1 (0.6) (24.6%) followed by SSTBJ infections (12.3%), Ethambutol 12 (6.7) Others [18] [8] similar to Egypt and a previous study in Kenya. Pyrazinamide 12 (6.7) The gynecological system had the highest proportion Isoniazid 11 (6.1) of prophylactic antibiotic use (10.1%), again similar to Capreomycin 2 (1.1) [18] [8] Cycloserine 1 (0.6) Egypt and a previous Kenyan study. This could be Prothionamide 1 (0.6) due to the frequent use of prophylactic antibiotics for cesarean sections. The most common indication for antibiotic use was CAIs (54.2%), followed by surgical prophylaxis (29.1%) which was similar to the African countries in the Global PPS (57.4%, 23.2%) and Ghana (40.1%, 33.6%), [10,20] respectively. HAIs accounted for 2.8% of antibiotic [18] prescribing, comparable to Egypt but considerably lower than the African countries in the Global PPS [10,13,20] (9.5%) and generally across Africa, which may be due to poor documentation in our study. The use of penicillins was prevalent across indications [Table Figure 2: Antibiotic prescribing by indication 2 and Figure 2]. Cephalosporins were the most prescribed class for CAIs (24.1%) with ceftriaxone the most prescribed Clarithromycin, levofloxacin, and the anti-TB (91.3%). Ceftriaxone was also the most prescribed agent antimicrobials had the reason for their use documented all the time. Ampicillin-cloxacillin, doxycycline, for single-dose surgical prophylaxis (100%), similar to a [9] previous Kenyan study for patients with neurotrauma, nitrofurantoin, and vancomycin did not have their African countries in the Global PPS, and other African reason documented at all. The generic prescribing rate [10,19,22,23] was 62.5%, while the empiric prescribing rate was countries. This is a concern as ceftriaxone is a broad-spectrum antibiotic used first line in many bacterial 82.6%. Four antimicrobials which were always used for targeted therapy including clarithromycin, cycloserine, infections, and overuse will increase AMR rates, with prothionamide, and levofloxacin. Overall, antimicrobial guidelines advocating against broad-spectrum antibiotics [24] prescribing was guideline compliant on 45.8% of in this situation. In addition, the majority (76.9%) of occasions. patients on surgical prophylaxis were on prolonged duration 152 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Table 2: Variation of antibiotic prescribing by classes across the various departments Antibiotic class PMW, n (%) NMW, n (%) AMW, n (%) ASW, n (%) ICU, n (%) OBGY, n (%) MIXED, n (%) P Aminoglycosides 17 (9.5) 13 (7.3) 6 (3.3) 8 (4.5) 2 (1.1) 1 (0.6) 0 (0.0) <0.001 Cephalosporins 16 (8.9) 2 (1.1) 19 (10.6) 29 (16.2) 2 (1.1) 7 (3.9) 5 (2.8) 0.114 Penicillins 16 (8.9) 13 (7.3) 13 (7.3) 27 (15.1) 0 (0.0) 5 (2.79) 10 (5.6) 0.002 Macrolides 0 (0.0) 0 (0.0) 4 (2.2) 0 (0.0) 0 (0.0) 3 (1.7) 4 (2.2) 0.002 Quinolones 0 (0.0) 0 (0.0) 2 (1.1) 2 (1.1) 0 (0.0) 0 (0.0) 1 (0.6) 0.758 Nitroimidazole 2 (1.1) 1 (0.6) 10 (5.6) 2 (1.1) 0 (0.0) 7 (3.9) 2 (1.1) 0.002 Carbapenems 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0.002 Sulfonamides 1 (0.6) 0 (0.0) 3 (1.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0.287 Glycopeptides 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0.409 Chloramphenicol 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0.480 Lincosamide 1 (0.6) 0 (0.0) 0 (0.0) 6 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 0.071 Tetracycline 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (1.1) 0 (0.0) 0.004 Furadantin 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) <0.001 Rifamycins 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Isoniazid 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Pyrazinamide 2 (1.1) 0 (0.0) 10 (5.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Ethambutol 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Others 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0.759 PMW=Pediatric medical ward, NMW=Neonatal medical ward, AMW=Adult medical ward, ASW=Adult surgical ward, OBGYN=Obstetrics and gynecology, ICU=Intensive care unit, Mixed=all those departments that have both adults and pediatrics in the same ward (>1 day) with only 9.6% on a single dose as per current The prevalence of antibiotic prescribing at RVPGH was [24] [18] [22] guidelines, similar to Egypt and Botswana. This high although similar to other African countries. There was also extensive use of broad-spectrum antibiotics prolonged use may be due to misconceptions that this [17,22] and prolonged duration of antibiotic prophylaxis. This reduces SSIs and a key area for improvement. In Thika is being addressed along with encouraging increased hospital in Kenya, another level 5 hospital, there was a 98% documentation of antibiotic indications in patients' adherence to the policy to improve surgical prophylaxis charts and reducing empiric use of antibiotics. Other within 6 weeks of implementation of a program, leading [25] interventions to improve future antibiotic use include to a significant reduction in the risk of SSIs, providing establishing AMS programs with the help of pharmacists. guidance to other hospitals. Other concerns include clinically unjustified antibiotic Authors’ Contribution combinations, the reason for which antimicrobials David Nyamu and Margaret Oluka are supervisors were prescribed was recorded in only 37.3% of all while Lydia Momanyi is the principal investigator. encounters, and only 45.8% of prescriptions were Lydia Momanyi, David Nyamu, and Margaret Oluka guideline compliant. In addition, empiric prescribing participated in the study design. Lydia Momanyi was accounted for 82.6% of total antibiotic encounters. involved in the data collection and data analysis under This needs addressing. Another concern is that generic the supervision of David Nyamu and Margaret Oluka. (International Nonproprietary Name) prescribing Lydia Momanyi prepared the first draft of the manuscript was documented in only 62.5% of cases, although while David Nyamu and Margaret Oluka provided [26] an improvement compared to 31.8% in 2008. critical review to the manuscript. All authors read and Antimicrobial stewardship (AMS) programs can help approved the final manuscript. with quality improvement programs, with pharmacists Acknowledgments playing a key role in their implementation and the We gratefully acknowledge Dr. Peter Karimi and Dr. [27] monitoring of subsequent antibiotic use. Faith Okalebo for their statistical support during data The study had several limitations. There were challenges analysis and interpretation of results. in obtaining all relevant medical records and limitations Financial support and sponsorship with the PPS study design including not documenting Nil. AMR rates and not contacting physicians to clarify Conflicts of interest their actions. Notwithstanding this, we identified several potential areas for improvement. There are no conflicts of interest. Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 153 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Available from: http://www.publications.universalhealth2030. References org/uploads/KEML-2016Final-1.pdf. [Last accessed on 2018 1. Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Aug 20]. Klugman K, et al. Access to effective antimicrobials: A worldwide 15. IDSA Practice Guidelines. Available from: https://www.idsociety. challenge. Lancet 2016;387:168-75. org/practice-guidelines/#/score/DESC/0/+/. [Last accessed on 2. O’Neill J. Securing New Drugs for Future Generations: The 2018 Aug 20]. Pipeline of Antibiotics. The Review of Antimicrobial Resistance. 16. Arya R, Antonisamy B, Kumar S. Sample size estimation in Available from: https://www.amr-review.org/sites/default/files/ prevalence studies. Indian J Pediatr 2012;79:1482-8. SECURING%20NEW%20DRUGS%20FOR%20FUTURE%20 17. Nsofor CA, Amadi E, Ukwandu N, Obijuru CE, Ohalete CV, GENERATIONS%20FINAL%20WEB_0.pdf. [Last accessed on et al. Prevalence of antimicrobial use in major hospitals in 2018 Jul 25]. Owerri, Nigeria. EC Microbiol 2016;3:522-7. 3. Jinks T, Lee N, Sharland M, Rex J, Gertler N, Diver M, et al. A 18. Talaat M, Saied T, Kandeel A, El-Ata GA, El-Kholy A, Hafez S, time for action: Antimicrobial resistance needs global response. et al. A point prevalence survey of antibiotic use in 18 hospitals Bull World Health Organ 2016;94:558-558A. in Egypt. Antibiotics 2014;3:450-60. 4. World Health Organization. Global Action Plan on 19. Kiguba R, Karamagi C, Bird SM. Extensive antibiotic Antimicrobial Resistance. Available from: http://www.who.int/ prescription rate among hospitalized patients in Uganda: But antimicrobial-resistance/publications/global-action-plan/en/. [Last with frequent missed-dose days. J Antimicrob Chemother accessed on 2018 Jul 18]. 2016;71:1697-706. 5. Avert. HIV and AIDS in Kenya 2017. Available from: 20. Labi AK, Obeng-Nkrumah N, Owusu E, Bjerrum S, https://www.avert.or g/professionals/hiv - around - world/ Bediako-Bowan A, Sunkwa-Mills G, et al. Multi-centre sub-saharan-africa/kenya. [Last accessed on 2018 August 20]. point-prevalence survey of hospital-acquired infections in Ghana. 6. Ombuor R. Kenya Releases Results of National TB Prevalence J Hosp Infect 2019;101:60-8. Survey 2017. Available from : https://www.voanews.com/a/ 21. Fourie T, Schellack N, Bronkhorst E, Coetzee J, Godman kenya-releases-results-national-tb-prevalence-survey/3780722. B. Antibiotic prescribing practices in the presence of html. [Last accessed on 2018 Aug 20]. extended-spectrum β-lactamase (ESBL) positive organisms 7. Republic of Kenya. National Policy for the Prevention and in an adult intensive care unit in South Africa – A pilot study. Containment of Antimicrobial Resistance, Nairobi, Kenya; Alexandria J Med 2018;54:541-47. April, 2017. Available from: http://www.health.go.ke/wp-content/ 22. Mwita JC, Souda S, Magafu MG, Massele A, Godman B, uploads/2017/04/Kenya-AMR-Containment-Policy-_Final_April. Mwandri M, et al. Prophylactic antibiotics to prevent surgical pdf. [Last accessed on 2018 Aug 21]. site infections in Botswana: Findings and implications. Hosp 8. Okoth C, Opanga S, Okalebo F, Oluka M, Baker Kurdi A, Pract 2018;46:97-102. Godman B, et al. Point prevalence survey of antibiotic use 23. van der Sandt N, Schellack N, Mabope LA, Mawela MP, and resistance at a referral hospital in Kenya: Findings and Kruger D, Godman B, et al. Surgical antimicrobial prophylaxis implications. Hosp Pract 2018;46:128-36. among pediatric patients in South Africa comparing two 9. Opanga SA, Mwang’ombe NJ, Okalebo FA, Godman B, healthcare settings. Pediatr Infect Dis J 2019;38:122-6. Oluka M, Kurai KAM, et al. Determinants of the effectiveness 24. Bratzler DW, Houck PM; Surgical Infection Prevention of antimicrobial prophylaxis among neurotrauma patients at a Guidelines Writers Workgroup, American Academy of referral hospital in Kenya: Findings and implications. Infect Dis Orthopaedic Surgeons, American Association of Critical Preve Med 2017;5:3. Care Nurses, American Association of Nurse Anesthetists. 10. Versporten A, Zarb P, Caniaux I, Gros MF, Drapier N, Miller M, Antimicrobial prophylaxis for surgery: An advisory statement et al. Antimicrobial consumption and resistance in adult hospital from the national surgical infection prevention project. Clin inpatients in 53 countries: Results of an internet-based global Infect Dis 2004;38:1706-15. point prevalence survey. Lancet Glob Health 2018;6:e619-e629. 25. Aiken AM, Wanyoro AK, Mwangi J, Juma F, Mugoya IK, 11. WHO Collaborating Centre for Drug Statistics Methodology. Scott JA, et al. Changing use of surgical antibiotic prophylaxis ATC/DDD Index. Available from: https://www.whocc.no/. in Thika hospital, Kenya: A quality improvement intervention [Accessed 2018 Aug 20]. with an interrupted time series design. PLoS One 2013;8:e78942. 12. Tiroyakgosi C, Matome M, Summers E, Mashalla Y, 26. Ministry of Health. Access to Essential Medicines in Kenya: A Paramadhas BA, Souda S, et al. Ongoing initiatives to improve Health Facility Survey. Available from: http://www.apps.who.int/ the use of antibiotics in Botswana: University of Botswana medicinedocs/documents/s18695en/s18695en.pdf. [Last accessed symposium meeting report. Expert Rev Anti Infect Ther on 2018 Jul 20]. 2018;16:381-4. 27. Schellack N, Bronkhorst E, Coetzee R, Godman B, Gous AGS, 13. Rothe C, Schlaich C, Thompson S. Healthcare-associated Kolman S, et al. SASOCP position statement on the pharmacist’s infections in sub-Saharan Africa. J Hosp Infect 2013;85:257-67. role in antibiotic stewardship 2018. South Afr J Infec Dis 14. Republic of Kenya. Kenya Essential Medicines List; 2016. 2018;33:28-35. 154 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Research in Pharmacy Practice Pubmed Central

Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey

Journal of Research in Pharmacy Practice , Volume 8 (3) – Oct 16, 2019

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Copyright: © 2019 Journal of Research in Pharmacy Practice
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Abstract

Original Article Antibiotic Prescribing Patterns at a Leading Referral Hospital in Kenya: A Point Prevalence Survey 1 2 2 3 4,5 4,6,7 Lydia Momanyi , Sylvia Opanga , David Nyamu , Margaret Oluka , Amanj Kurdi , Brian Godman Department of Pharmacy, Objective: Antibiotics are essential with inappropriate use leading to antimicrobial Rift Valley Provincial General resistance (AMR). Currently, little is known about antibiotic use among hospitals Hospital, Nakuru, Kenya in Kenya, which is essential to tackle as part of the recent national action plan Department of addressing rising AMR rates. Consequently, the objective was to overcome this Pharmaceutics and Pharmacy gap in a leading referral hospital in Kenya. The findings will subsequently be used Practice, University of to develop quality improvement programs for this and other hospitals in Kenya. Nairobi, Nairobi, Kenya Methods: This was a point prevalence survey. Data on antibiotic use were abstracted from patient medical records by a pharmacy team. Findings: The prevalence of Department of Pharmacology and Pharmacognosy, antibiotic prescribing was 54.7%, highest in the intensive care unit and isolation University of Nairobi, wards. Most antibiotics were for treatment (75.4%) rather than prophylaxis Nairobi, Kenya (29.0%). The majority of patients on surgical prophylaxis were on prolonged duration (>1 day), with only 9.6% on a single dose as per current guidelines. Department of Pharmacoepidemiology, Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed Strathclyde Institute of antibiotic classes. The indication for antibiotic use was documented in only 37.3% Pharmacy and Biomedical of encounters. Generic prescribing was 62.5% and empiric prescribing was seen Sciences, University of in 82.6% of encounters. Guideline compliance was 45.8%. Conclusion: Several Strathclyde, Glasgow, UK areas for improvement were identified including addressing prolonged duration Department of Pharmacology, for prophylaxis, extensive prescribing of broad-spectrum antibiotics, high rates Hawler Medical University, of empiric prescribing, and lack of documenting the indication for antimicrobials. Erbil, Iraq Initiatives are ongoing to address this with pharmacists playing a key role. Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden Division of Public Health Pharmacy and Management, Faculty of Health Sciences, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa Received: 28-08-2018. Accepted: 27-01-2019. Keywords: Antibiotics, Kenya, point prevalence survey, prescribing, utilization Published: 16-10-2019. Introduction Address for correspondence: Prof. Brian Godman, E-mail: brian.godman@strath.ac.uk ntibiotics are widely prescribed globally with Aantibiotic use increasing by 36% during the past This is an open access journal, and articles are distributed under the terms of the [1] decade. However, their overuse has increased rates of Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as appropriate credit is given and the new creations are licensed under the identical Access this article online terms. Quick Response Code: For reprints contact: reprints@medknow.com Website: www.jrpp.net How to cite this article: Momanyi L, Opanga S, Nyamu D, Oluka M, Kurdi A, Godman B. Antibiotic prescribing patterns at a leading DOI: 10.4103/jrpp.JRPP_18_68 referral hospital in Kenya: A point prevalence survey. J Res Pharm Pract 2019;8:149-54.  2019 Journal of Research in Pharmacy Practice | Published by Wolters Kluwer - Medknow 149 Abstract Momanyi, et al.: Prescribing patterns of antibiotics in Kenya antimicrobial resistance (AMR), increasing morbidity, CAIs were documented if symptoms started <48 h from [2] mortality, and costs. This has resulted in international admission to hospital (or present on admission) and [3,4] [10,13] and national programs to address rising AMR rates. HAIs if symptoms started 48 h after admission. We This is particularly important in countries such as Kenya also assessed whether there was an association between with high rates of HIV and tuberculosis (TB) and antibiotic classes and departments for possible future [5-7] growing AMR rates, resulting in the recent launch of interventions. [5] the Kenyan National Action Plan. This includes a need Prescribing patterns were assessed against the findings for greater understanding of antibiotic use including of the Global PPS study, especially among African hospitals to inform future policies. [10] countries. The quality of antibiotic prescribing We have previously reported on concerns with antibiotic was also assessed by evaluating whether the reason use in a referral hospital in Western Kenya as well as for the prescription was documented, current generic antibiotic prophylaxis to prevent surgical site infections prescribing rates and the extent of empiric versus [8,9] (SSIs) in patients with neurotrauma. However, we targeted prescribing. Guideline compliance was also have not previously reported antibiotic utilization patterns assessed. While there is currently no hospital formulary, within a level 5 facility in Kenya. This is important as this prescriptions are guided by the Kenyan Essential [14,15] is a leading teaching hospital in Kenya providing direction Medicine List and relevant international guidelines. to others. In addition, the recent Global Point Prevalence This formed the basis of whether treatment was guideline Survey (PPS) only contained data from five African compliant or not. Sampling of patients’ notes was [10] countries excluding Kenya and children. Consequently, undertaken as part of ethical approval. The sample size the study was undertaken to address this knowledge gap was calculated using the Fisher formula adjusted for with Kenya one of the most populous African countries. [16] average hospital bed occupancy. However, there was The findings will be applicable across Kenya. no sampling for antibiotic use. On the day of the survey, the total number of patients Methods admitted by 8 AM was recorded followed by the total [8,10] A PPS study was undertaken in April 2017 to number of patients on systemic antibiotics at 8 AM. The ascertain the prevalence and patterns of antibiotic medical records of all inpatients on systemic antibiotics prescribing at a specific point in time at the Rift Valley were obtained, with their file numbers entered onto Provincial General Hospital, a level 5 teaching hospital. Microsoft Excel, with the computer providing a random It is the fourth largest government referral hospital in sample of files to be studied in full. There was no Kenya with 532 beds. direct engagement of patients. The patients' files were All the neonatal, pediatric, adult, and mixed departments subsequently reviewed by the data collectors including were included. All patients who were receiving systemic medical students led by a pharmacist, and the data antibiotic therapy at 8 AM on the day of the survey were were entered onto the PPS form. Data were recorded eligible, with the antibiotics including antibacterials for as anonymous by employing a study number for each systemic use (J01), TB (J04A), intestinal anti-infectives patient. The data were subsequently validated for [11] (A07AA) and antiprotozoals (P01AB). Outpatients completeness and correctness by two other pharmacists. and daytime admissions for ambulatory patients for To calculate the prevalence of antibiotic use, the procedures such as endoscopy or renal dialysis were denominator was the total number of admitted patients excluded as well as antibiotics for topical use. while the numerator was the total number of patients on Antibiotic use was recorded by prescription, with usage systemic antibiotics at 8 AM of the day the ward was broken down into either prophylaxis or treatment. surveyed. Prophylaxis was further divided into medical or surgical The prevalence of antibiotic use in the various prophylaxis. Medical prophylaxis was documented when departments including whether for prophylaxis or antibiotics were prescribed to prevent infections in treatment was also calculated. Descriptive statistics were patients with medical conditions. Surgical prophylaxis [9] used to summarize and describe the study variables included the use of antibiotics to prevent SSIs. The as appropriate using means and standard deviations extent of comorbidities were also recorded including for continuous variables while using frequency and HIV, which is particularly prevalent in sub-Sarah Africa [12] for patients admitted to hospitals. Infections were percentages for categorical variables. The Chi-square further divided into community-acquired infection (CAI) test was used to test the association between the use of various antibiotic classes among the different hospital and hospital-acquired infection (HAI), especially given [13] the extent of HAIs in sub-Sahara Africa. departments, whereas the Fisher exact test was used 150 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya instead of the Chi-square test when the Chi-square test The penicillins (46.9%) (J01C) were the most prescribed assumptions (≥80% of the expected values in various class followed by the cephalosporins (44.7%) (J01D) cells were ≥5 or no expected values were <1) were and aminoglycosides (26.3%) (J01G). There was limited violated, consequently invalid. prescribing of the nitrofurans (0.6%) (J01XE) [Figure 1]. Ethical approval was obtained from the KNH-UON Individually, ceftriaxone was the most prescribed Ethics Committee reference number P36/01/2017. Further antibiotic (39.7%) followed by benzylpenicillin (29.0%) approval was obtained from the hospital administration and metronidazole (25.1%) [Table 1]. of the Rift Valley Provincial General Hospital before There was a statistically significant association between commencement of the study. Confidentiality of the data antibiotic prescribing and departments. Aminoglycosides was stringently maintained throughout. were commonly prescribed in the pediatric medical wards (P < 0.001). Macrolides (P = 0.002), nitroimidazole Results derivatives (P = 0.002), and anti-TB antimicrobials The study was conducted on 179 patients whose median (P < 0.001) were the most frequently prescribed in the adult age was 25.3 years (interquartile range = 4–38). Adults medical wards. Penicillins (P = 0.002) were commonly (20–59 years) formed the largest proportion (93, 52%) prescribed in the adult surgical wards. Tetracyclines were followed by neonates (23, 12.9%). There were more prescribed mostly in the OBGYN departments (P = 0.004). females (99, 55.3%) than males (44.6%). The adult Carbapenems were commonly prescribed in the ICU and surgical ward (53, 29.6%) and the adult medical ward pediatric medical wards (P = 0.002) [Table 2]. (41, 22.9%) had the largest proportion of patients with The pattern of antibiotic prescribing varied by indication least in the intensive care unit (ICU) (4, 2.2%). [Figure 2]. The overall prevalence of antibiotic prescribing was The most commonly prescribed antibiotic classes for 54.7%, with the highest level of prescribing for treatment (75.4%). respiratory infections were aminoglycosides (19.5%) and penicillins (18.6%). For SSTBJ infections, The ICU (100.0%) and the isolation ward (100.0%), cephalosporins (37.8%) and penicillins (27.0%) classified under a mixed department, had the highest were commonly prescribed. For neonatal infections, prevalence of antibiotic prescribing (100.0%), followed aminoglycosides (41.2%) and penicillins (41.2%) were by the newborn unit (93.7%), the pediatric medical ward commonly prescribed. (84.2%), the adult medical ward (61.5%), and the adult surgical ward (57.3%). The obstetric or gynecological Less than half of the patients were on a single antibiotic (OBGYN) department had the least prevalence of (41.3%), with the majority (58.7%) on combination antibiotic prescribing (20.8%). therapy, and 17.9% having 3 or more antibiotics. The most prevalent antibiotic combinations were The majority of patients had no comorbidities aminoglycosides and penicillins (20.7%), followed by (96, 53.6%). Among those with comorbidities, the cephalosporins and nitroimidazole derivatives (13.4%), most prevalent was HIV (8.4%) followed by diabetes penicillins and nitroimidazole derivatives (9.5%), and mellitus (6.7%), low birth weight (6.7%), anemia cephalosporins and penicillins (6.7%). There were also (5.6%), respiratory distress (5.0%), and hypertension some unusual combinations. (3.9%). The most frequent indication for antibiotic use was for CAIs (54.2%) followed by prolonged surgical The reason for the antibiotic prescription was prophylaxis at >1 day (22.4%), medical prophylaxis documented in 37.3% (n = 133) of occasions. (15.1%), 1-day surgical prophylaxis (3.9%), single-dose surgical prophylaxis (2.8%), and HAIs (2.8%). The respiratory system was the anatomical site with the greatest proportion of antibiotics prescribed for treatment (24.6%) followed by the skin, soft tissue, bone, and joint infections (SSTBJ) at 12.3%. Eyes (0.6%), the cardiovascular system (0.6%), and ENT (0%) had the least antibiotics prescribed. For prophylactic use, OBGYN surgery was highest (10.1%) followed by SSTBJ anatomical sites (8.9%), with the least for urinary tract infections (0%) and the cardiovascular system (0%). Figure 1: Prevalence of antibiotic prescribing by class Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 151 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Discussion Table 1: Prevalence of specific antibiotics prescribed Specific antibiotics n (%) The prevalence of antibiotic prescribing was 54.7%, [17] Cephalosporins Ceftriaxone 71 (39.7) comparable to Nigerian hospitals at 55.9%, Egyptian Ceftazidime 7 (3.9) [18] [8] hospitals at 59%. Western Kenya at 67.7%, Uganda Penicillins Benzyl penicillin 52 (29.0) [19] [20] (79%), and Ghana (51.4%), as well as the African Flucloxacillin 20 (11.2) [10] countries in the Global PPS (50.0%). However, Ampicillin/cloxacillin 14 (7.8) this was higher than the overall rate for antimicrobial Amoxicillin/clavulanic 10 (5.6) [10] prescribing in the Global PPS study (34.1%). This acid may reflect the higher burden of infectious diseases Amoxicillin 4 (2.2) [6,7,12] among African countries including Kenya. Nitroimidazole derivatives Metronidazole 45 (25.1) Aminoglycosides Gentamicin 40 (22.3) The ICU and the isolation departments had the Amikacin 7 (3.9) highest rate of antibiotic prescribing (100%), similar Rifamycins Rifampicin 11 (6.1) [18] to Egypt and the African countries in the Global Macrolides Erythromycin 10 (5.6) [10] PPS, probably due to the critical nature of the Clarithromycin 1 (0.6) patients’ illness and increased risk of infections, Lincosamides Clindamycin 7 (3.9) [21] especially if patients are on a ventilator. The Sulfonamides Cotrimoxazole 5 (2.8) OBGYN department (20.8%) had the least prevalence Chloramphenicol Chloramphenicol 3 (1.7) [20] of antibiotic prescribing, similar to Ghana but Quinolones Ciprofloxacin 3 (1.7) [8] Levofloxacin 1 (0.6) different to a previous Kenyan study. Tetracyclines Doxycycline 2 (1.1) 75.4% of antibiotic prescribing was for treatment, Carbapenems Meropenem 2 (1.1) [10] similar to the Global PPS. The respiratory system Glycopeptides Vancomycin 2 (1.1) had the largest proportion of antibiotics prescribed Furadantin Nitrofurantoin 1 (0.6) (24.6%) followed by SSTBJ infections (12.3%), Ethambutol 12 (6.7) Others [18] [8] similar to Egypt and a previous study in Kenya. Pyrazinamide 12 (6.7) The gynecological system had the highest proportion Isoniazid 11 (6.1) of prophylactic antibiotic use (10.1%), again similar to Capreomycin 2 (1.1) [18] [8] Cycloserine 1 (0.6) Egypt and a previous Kenyan study. This could be Prothionamide 1 (0.6) due to the frequent use of prophylactic antibiotics for cesarean sections. The most common indication for antibiotic use was CAIs (54.2%), followed by surgical prophylaxis (29.1%) which was similar to the African countries in the Global PPS (57.4%, 23.2%) and Ghana (40.1%, 33.6%), [10,20] respectively. HAIs accounted for 2.8% of antibiotic [18] prescribing, comparable to Egypt but considerably lower than the African countries in the Global PPS [10,13,20] (9.5%) and generally across Africa, which may be due to poor documentation in our study. The use of penicillins was prevalent across indications [Table Figure 2: Antibiotic prescribing by indication 2 and Figure 2]. Cephalosporins were the most prescribed class for CAIs (24.1%) with ceftriaxone the most prescribed Clarithromycin, levofloxacin, and the anti-TB (91.3%). Ceftriaxone was also the most prescribed agent antimicrobials had the reason for their use documented all the time. Ampicillin-cloxacillin, doxycycline, for single-dose surgical prophylaxis (100%), similar to a [9] previous Kenyan study for patients with neurotrauma, nitrofurantoin, and vancomycin did not have their African countries in the Global PPS, and other African reason documented at all. The generic prescribing rate [10,19,22,23] was 62.5%, while the empiric prescribing rate was countries. This is a concern as ceftriaxone is a broad-spectrum antibiotic used first line in many bacterial 82.6%. Four antimicrobials which were always used for targeted therapy including clarithromycin, cycloserine, infections, and overuse will increase AMR rates, with prothionamide, and levofloxacin. Overall, antimicrobial guidelines advocating against broad-spectrum antibiotics [24] prescribing was guideline compliant on 45.8% of in this situation. In addition, the majority (76.9%) of occasions. patients on surgical prophylaxis were on prolonged duration 152 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Table 2: Variation of antibiotic prescribing by classes across the various departments Antibiotic class PMW, n (%) NMW, n (%) AMW, n (%) ASW, n (%) ICU, n (%) OBGY, n (%) MIXED, n (%) P Aminoglycosides 17 (9.5) 13 (7.3) 6 (3.3) 8 (4.5) 2 (1.1) 1 (0.6) 0 (0.0) <0.001 Cephalosporins 16 (8.9) 2 (1.1) 19 (10.6) 29 (16.2) 2 (1.1) 7 (3.9) 5 (2.8) 0.114 Penicillins 16 (8.9) 13 (7.3) 13 (7.3) 27 (15.1) 0 (0.0) 5 (2.79) 10 (5.6) 0.002 Macrolides 0 (0.0) 0 (0.0) 4 (2.2) 0 (0.0) 0 (0.0) 3 (1.7) 4 (2.2) 0.002 Quinolones 0 (0.0) 0 (0.0) 2 (1.1) 2 (1.1) 0 (0.0) 0 (0.0) 1 (0.6) 0.758 Nitroimidazole 2 (1.1) 1 (0.6) 10 (5.6) 2 (1.1) 0 (0.0) 7 (3.9) 2 (1.1) 0.002 Carbapenems 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0.002 Sulfonamides 1 (0.6) 0 (0.0) 3 (1.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0.287 Glycopeptides 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0.409 Chloramphenicol 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0.480 Lincosamide 1 (0.6) 0 (0.0) 0 (0.0) 6 (3.3) 0 (0.0) 0 (0.0) 0 (0.0) 0.071 Tetracycline 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (1.1) 0 (0.0) 0.004 Furadantin 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) <0.001 Rifamycins 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Isoniazid 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Pyrazinamide 2 (1.1) 0 (0.0) 10 (5.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Ethambutol 2 (1.1) 0 (0.0) 9 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) <0.001 Others 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0.759 PMW=Pediatric medical ward, NMW=Neonatal medical ward, AMW=Adult medical ward, ASW=Adult surgical ward, OBGYN=Obstetrics and gynecology, ICU=Intensive care unit, Mixed=all those departments that have both adults and pediatrics in the same ward (>1 day) with only 9.6% on a single dose as per current The prevalence of antibiotic prescribing at RVPGH was [24] [18] [22] guidelines, similar to Egypt and Botswana. This high although similar to other African countries. There was also extensive use of broad-spectrum antibiotics prolonged use may be due to misconceptions that this [17,22] and prolonged duration of antibiotic prophylaxis. This reduces SSIs and a key area for improvement. In Thika is being addressed along with encouraging increased hospital in Kenya, another level 5 hospital, there was a 98% documentation of antibiotic indications in patients' adherence to the policy to improve surgical prophylaxis charts and reducing empiric use of antibiotics. Other within 6 weeks of implementation of a program, leading [25] interventions to improve future antibiotic use include to a significant reduction in the risk of SSIs, providing establishing AMS programs with the help of pharmacists. guidance to other hospitals. Other concerns include clinically unjustified antibiotic Authors’ Contribution combinations, the reason for which antimicrobials David Nyamu and Margaret Oluka are supervisors were prescribed was recorded in only 37.3% of all while Lydia Momanyi is the principal investigator. encounters, and only 45.8% of prescriptions were Lydia Momanyi, David Nyamu, and Margaret Oluka guideline compliant. In addition, empiric prescribing participated in the study design. Lydia Momanyi was accounted for 82.6% of total antibiotic encounters. involved in the data collection and data analysis under This needs addressing. Another concern is that generic the supervision of David Nyamu and Margaret Oluka. (International Nonproprietary Name) prescribing Lydia Momanyi prepared the first draft of the manuscript was documented in only 62.5% of cases, although while David Nyamu and Margaret Oluka provided [26] an improvement compared to 31.8% in 2008. critical review to the manuscript. All authors read and Antimicrobial stewardship (AMS) programs can help approved the final manuscript. with quality improvement programs, with pharmacists Acknowledgments playing a key role in their implementation and the We gratefully acknowledge Dr. Peter Karimi and Dr. [27] monitoring of subsequent antibiotic use. Faith Okalebo for their statistical support during data The study had several limitations. There were challenges analysis and interpretation of results. in obtaining all relevant medical records and limitations Financial support and sponsorship with the PPS study design including not documenting Nil. AMR rates and not contacting physicians to clarify Conflicts of interest their actions. Notwithstanding this, we identified several potential areas for improvement. There are no conflicts of interest. Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019 153 Momanyi, et al.: Prescribing patterns of antibiotics in Kenya Available from: http://www.publications.universalhealth2030. References org/uploads/KEML-2016Final-1.pdf. [Last accessed on 2018 1. Laxminarayan R, Matsoso P, Pant S, Brower C, Røttingen JA, Aug 20]. Klugman K, et al. Access to effective antimicrobials: A worldwide 15. IDSA Practice Guidelines. Available from: https://www.idsociety. challenge. Lancet 2016;387:168-75. org/practice-guidelines/#/score/DESC/0/+/. [Last accessed on 2. O’Neill J. Securing New Drugs for Future Generations: The 2018 Aug 20]. Pipeline of Antibiotics. The Review of Antimicrobial Resistance. 16. Arya R, Antonisamy B, Kumar S. Sample size estimation in Available from: https://www.amr-review.org/sites/default/files/ prevalence studies. Indian J Pediatr 2012;79:1482-8. SECURING%20NEW%20DRUGS%20FOR%20FUTURE%20 17. Nsofor CA, Amadi E, Ukwandu N, Obijuru CE, Ohalete CV, GENERATIONS%20FINAL%20WEB_0.pdf. [Last accessed on et al. Prevalence of antimicrobial use in major hospitals in 2018 Jul 25]. Owerri, Nigeria. EC Microbiol 2016;3:522-7. 3. Jinks T, Lee N, Sharland M, Rex J, Gertler N, Diver M, et al. A 18. Talaat M, Saied T, Kandeel A, El-Ata GA, El-Kholy A, Hafez S, time for action: Antimicrobial resistance needs global response. et al. A point prevalence survey of antibiotic use in 18 hospitals Bull World Health Organ 2016;94:558-558A. in Egypt. Antibiotics 2014;3:450-60. 4. World Health Organization. Global Action Plan on 19. Kiguba R, Karamagi C, Bird SM. Extensive antibiotic Antimicrobial Resistance. Available from: http://www.who.int/ prescription rate among hospitalized patients in Uganda: But antimicrobial-resistance/publications/global-action-plan/en/. [Last with frequent missed-dose days. J Antimicrob Chemother accessed on 2018 Jul 18]. 2016;71:1697-706. 5. Avert. HIV and AIDS in Kenya 2017. Available from: 20. Labi AK, Obeng-Nkrumah N, Owusu E, Bjerrum S, https://www.avert.or g/professionals/hiv - around - world/ Bediako-Bowan A, Sunkwa-Mills G, et al. Multi-centre sub-saharan-africa/kenya. [Last accessed on 2018 August 20]. point-prevalence survey of hospital-acquired infections in Ghana. 6. Ombuor R. Kenya Releases Results of National TB Prevalence J Hosp Infect 2019;101:60-8. Survey 2017. Available from : https://www.voanews.com/a/ 21. Fourie T, Schellack N, Bronkhorst E, Coetzee J, Godman kenya-releases-results-national-tb-prevalence-survey/3780722. B. Antibiotic prescribing practices in the presence of html. [Last accessed on 2018 Aug 20]. extended-spectrum β-lactamase (ESBL) positive organisms 7. Republic of Kenya. National Policy for the Prevention and in an adult intensive care unit in South Africa – A pilot study. Containment of Antimicrobial Resistance, Nairobi, Kenya; Alexandria J Med 2018;54:541-47. April, 2017. Available from: http://www.health.go.ke/wp-content/ 22. Mwita JC, Souda S, Magafu MG, Massele A, Godman B, uploads/2017/04/Kenya-AMR-Containment-Policy-_Final_April. Mwandri M, et al. Prophylactic antibiotics to prevent surgical pdf. [Last accessed on 2018 Aug 21]. site infections in Botswana: Findings and implications. Hosp 8. Okoth C, Opanga S, Okalebo F, Oluka M, Baker Kurdi A, Pract 2018;46:97-102. Godman B, et al. Point prevalence survey of antibiotic use 23. van der Sandt N, Schellack N, Mabope LA, Mawela MP, and resistance at a referral hospital in Kenya: Findings and Kruger D, Godman B, et al. Surgical antimicrobial prophylaxis implications. Hosp Pract 2018;46:128-36. among pediatric patients in South Africa comparing two 9. Opanga SA, Mwang’ombe NJ, Okalebo FA, Godman B, healthcare settings. Pediatr Infect Dis J 2019;38:122-6. Oluka M, Kurai KAM, et al. Determinants of the effectiveness 24. Bratzler DW, Houck PM; Surgical Infection Prevention of antimicrobial prophylaxis among neurotrauma patients at a Guidelines Writers Workgroup, American Academy of referral hospital in Kenya: Findings and implications. Infect Dis Orthopaedic Surgeons, American Association of Critical Preve Med 2017;5:3. Care Nurses, American Association of Nurse Anesthetists. 10. Versporten A, Zarb P, Caniaux I, Gros MF, Drapier N, Miller M, Antimicrobial prophylaxis for surgery: An advisory statement et al. Antimicrobial consumption and resistance in adult hospital from the national surgical infection prevention project. Clin inpatients in 53 countries: Results of an internet-based global Infect Dis 2004;38:1706-15. point prevalence survey. Lancet Glob Health 2018;6:e619-e629. 25. Aiken AM, Wanyoro AK, Mwangi J, Juma F, Mugoya IK, 11. WHO Collaborating Centre for Drug Statistics Methodology. Scott JA, et al. Changing use of surgical antibiotic prophylaxis ATC/DDD Index. Available from: https://www.whocc.no/. in Thika hospital, Kenya: A quality improvement intervention [Accessed 2018 Aug 20]. with an interrupted time series design. PLoS One 2013;8:e78942. 12. Tiroyakgosi C, Matome M, Summers E, Mashalla Y, 26. Ministry of Health. Access to Essential Medicines in Kenya: A Paramadhas BA, Souda S, et al. Ongoing initiatives to improve Health Facility Survey. Available from: http://www.apps.who.int/ the use of antibiotics in Botswana: University of Botswana medicinedocs/documents/s18695en/s18695en.pdf. [Last accessed symposium meeting report. Expert Rev Anti Infect Ther on 2018 Jul 20]. 2018;16:381-4. 27. Schellack N, Bronkhorst E, Coetzee R, Godman B, Gous AGS, 13. Rothe C, Schlaich C, Thompson S. Healthcare-associated Kolman S, et al. SASOCP position statement on the pharmacist’s infections in sub-Saharan Africa. J Hosp Infect 2013;85:257-67. role in antibiotic stewardship 2018. South Afr J Infec Dis 14. Republic of Kenya. Kenya Essential Medicines List; 2016. 2018;33:28-35. 154 Journal of Research in Pharmacy Practice ¦ Volume 8 ¦ Issue 3 ¦ July-September 2019

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Journal of Research in Pharmacy PracticePubmed Central

Published: Oct 16, 2019

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