Rapid assessment of country situation on antibiotics prescription, use and antimicrobial resistance and associated factors.

Research Report.

SUMMARY: Background and objectives: Antimicrobials are the most effective treatment for infectious diseases, they are generally safe, effective and to date, relatively inexpensive. Antimicrobial resistance (AMR) is a growing problem and threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. The impact results in prolonged illness and increased mortality.The objective of this study was to provide a baseline assessment on the antimicrobial resistance situation, knowledge and practice of clinicians, health workers, patients and farmers in Nepal. Methods:A quantitative cross-sectional survey was conducted in April-July 2017 in selected hospitals and places of Kathmandu valley, Morang, Sunsari, Chitwan, Kaski and Banke. Five groups of key actors of the antimicrobial resistance containment, clinicians and health workers (87), drug dispensers (33), patients (324) and food producing animal farmers (32) were interviewed to assess knowledge attitude and practices. Standardized and pre-tested questionnaires were used to each type of respondents for data collection. Information on morbidity and mortality related to AMR, through review of medical records data were examined.Data were entered into SPSS version 21. Data were analyzed using descriptive and inferential statistics. Results: According to doctors and health workers, multi drug resistant Pseudomonas aeruginosa, Acinetobacter spp., ESBL E. coli, ESBL Klebsiella pneumoniae, penicillin resistant Streptococcus pneumoniae, MRSA were the resistant bacteria prevalent in the hospitals. About 71% doctors and health workers mentioned that they prescribe antibiotics at least once a day. About 14% of them prescribed antibiotics at least once a week. Most of the doctors and health workers had perceived that antimicrobials are overused nationally. They perceived that health workers need more education on antimicrobial resistance and appropriate use of antimicrobials. Health workers also agreed that strong knowledge of antimicrobials is important in professional career. All drug sellers had the knowledge of antibiotics.According to drug sellers, average numbers of patients sold with antibiotics per day were 106 (minimum-3; maximum-700). All drug sellers mentioned that they explain the dose and schedule to the patients.Among 31 drug sellers, 87.1% had heard of antibiotic resistance. About 15% of the patients/care taker of patients mentioned that they had not received any advice from doctor and other health workers regarding the dose, duration of the antibiotics and other advice. Around 50% of the patients had taken all antibiotics as directed by health workers. About 46% of the patients stop taking antibiotics when they feel better. Only 22.2% of the respondents mentioned that antibiotics should be used only when prescribed by the clinicians/health workers. 14% of the respondents did not buy all the prescribed/advised drugs. The patients or their care takers bought medicine from particular outlet because of nearby to residence (43.2%), near to health centers (51.9%), availability of medicines (24.1%), pharmacies advised by doctors/prescribers (10.5%), and pharmacies with trained personnel (7.4%). Eighty four percent of the patients/care taker of the patients had not heard of any words that represents the antimicrobial resistance. Among 52 respondents who had heard of antibiotic resistance, 34.6% had heard from media (newspaper, TV, radio), 26.9% had heard from health workers (doctor, nurse, pharmacists), 23.1% had heard from family/friend. Only 3.8% had heard from antibiotic resistance related specific campaign. Laboratory related information was collected from 23 laboratories of the hospitals. Maximum of urine samples (Median-4083; Min.-50 and Max.-22000) were collected per hospital followed by blood (Median-1800; Min.-15 and Max.-19950). Urethral and cervical swabs were relatively less in the hospital. Only 10 laboratories among 23 assessed isolate Haemophilus influenzae, Neisseria gonorrhoeae, and Neisseria meningitidis. Fifteen laboratories isolate Streptococcus pneumoniae. Most of the laboratories followed CLSI guideline for AST. Two laboratories followed EUCAST guideline for AST. Only 9 laboratories have a clinical microbiologist. Only one laboratory communicated AST results with NPHL. Among 17 hospitals/health facilities, 7 had in-patients service and perform surgical interventions. But those hospitals did not have protocols or norms for surgical prophylaxis with antimicrobials. None of the hospitals had any record of AMR and record of mortality related to AMR in the last year (2015/2016). Regarding the knowledge of use of antibiotics for animals treatment 46.9 percent of the respondent had knowledge on the use of antibiotics in treatment of animals, 34.3% had little information on use of antibiotics for animals treatment where as 18.8% had not known about the use of antibiotics for animals treatments. Among the 21 interviewed farmers about consumption and selling of infected milk with mastitis 38.1% of the respondent consumed the infected milk with mastitis whereas 33.3% sold the milk of infected animals undergoing treatment with antibiotics. Among 17 respondents, 58.8% of the farmers use antibiotics in the day old chicks on arrival at farm. Conclusion:Use of low/narrow spectrum antibiotics should be encouraged than broad spectrum, when technically possible, to reduce drug pressure and reduce chances of exposure to resistance. Antibiotics prescription should be backed up by laboratory reports on culture and susceptibility pattern, guideline/SOP/training for treatment of infectious diseases should be regularly updated, implemented in each hospital and prescription audits should be practiced to improve it. Rational dispensing should be based on prescription, backed up by prescription recording and auditing. Treatment schedule should be explained by the treating doctors as they see what is being procured and used, rather than explaining by others. To improve rational use government should introduce mechanism of dispensing only based on SOP and advocacy programs for complete/full course use. Quality assurance, recording and reporting system need to be improved through electronic recording and monthly hospital wise reporting system should be in place. Directives/guidelines/SOPs for antibiotic use in animals, poultry farms should be in place and regulated.High level government mechanism should in place to effectively regulate antibiotic use in human and animals.