Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

5 July, 2020

Here are the citation, abstract and author summary of a new paper in PLoS Medicine, with a comment from me below.. The authors conclude with the need for 'urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines'.

CITATION: Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

Giorgia Sulis,Pierrick Adam,Vaidehi Nafade,Genevieve Gore,Benjamin Daniels,Amrita Daftary,Jishnu Das,Sumanth Gandra ,Madhukar Pai

Published: June 16, 2020


Background: The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.

Methods and findings: ... The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%–53%), with a prediction interval of 44%–60%. Individual studies’ estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.

Conclusions: Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.


Why was this study done?

Inappropriate use of antibiotics, both in terms of incorrect regimens and prescription without clinical indication, is a major driver of antibiotic resistance.

Global drug sales data indicate a substantial increase in antibiotic use in low- and middle-income countries (LMICs) over the past 2 decades.

An accurate quantification of antibiotic prescribing in primary care across LMICs is not available.

What did the researchers do and find?

We conducted a systematic review and meta-analysis to estimate the proportion of antibiotic prescribing across primary care settings in LMICs.

Our study showed that, on average, approximately half of patients attending primary care facilities in LMICs received at least 1 antibiotic.

Very few included studies made an attempt to assess the extent of inappropriate prescriptions and indicate potential misuse.

Among studies that provided information on the types of antibiotics used, we found that, in 12/16 studies, 60% of prescriptions were for antibiotics with low potential for resistance selection as defined by the World Health Organization (WHO).

What do these findings mean?

Our study highlights that antibiotics are highly prescribed in outpatient primary care settings.

Better quality data are necessary to dig deeper into the patterns of inappropriate use according to local epidemiologic scenarios.

Adapting WHO treatment recommendations and incorporating the WHO Access, Watch, and Reserve (AWaRe) classification of antibiotics into national guidelines will be a first key step to improve prescription practices.

COMMENT (NPW): As the authors point out, 'WHO recommends that the proportion of patients receiving antibiotics in an outpatient setting should be less than 30% [78]. However, this threshold was established somewhat arbitrarily more than 2 decades ago, due to a lack of evidence on prescription practices and actual needs according to patients’ clinical features.' and 'To promote the optimal use of antibiotics and assist antibiotic stewardship efforts, WHO introduced the AWaRe classification in 2017'

The authors appear to be recommending a further push for a strategy (getting WHO recommendations into policy and practice) that is clearly failing and, in my view, will continue to fail if not supplemented by a radical new approach. That radical new approach is simple: to ensure that prescribers and users of medicines have easy access to reliable information on how to select, prescribe and use medicines. As we have discussed on HIFA, such an approach would be very easy to achieve with a small investment, which would help prevent millions of deaths and loss of billions of dollars, but no funders are taking notice. Until then, we shall be left with the dismal status quo: ‘Globally, most prescribers receive most of their prescribing information from the pharmaceutical industry and in many countries this is the only information they receive.’ (World Medicines Report 2011, WHO)


Best wishes, Neil

Joint Coordinator HIFA Project on Information for Prescribers and Users of Medicines

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health campaign (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in collaboration with WHO. Twitter: @hifa_org FB: