Prevalence of antibiotic prescription
Approximately 61 out of 100 outpatients at Mulago Hospital during the study period were prescribed at least one antibiotic medicine. From this study, 57 out of 100 patients were diagnosed with bacterial infections; hence the high prescription of antibiotic medicines. However, 8.3% of the patients were prescribed antibiotic medicines yet they did not have any bacterial infection, which led to wastage. This wastage of antibiotic medicines can lead to other patients who require these medicines missing treatment because of faster antibiotic stockouts. On the other hand, 4.9% of the patients who were not prescribed antibiotic medicines were diagnosed with bacterial infections. This can lead to increased morbidity and mortality among the patients. However, a global point prevalence survey of 17 hospitals across Ghana, Uganda, Zambia, and Tanzania; about antimicrobial use reported an overall prevalence of antibiotic prescription of 50%, with Uganda’s rate standing at 45% [10]. The difference might be due to the changes in prescribing patterns over the years, and improved availability of antibiotics in Mulago Hospital.
According to the WHO AWaRe antibiotic classification, Access antibiotics were prescribed to 40% of the patients versus the WHO-recommended country target of at least 60% [7]. This low prescription of Access antibiotics implies that the Watch category is prescribed mostly to patients. This could have been due to either, Access antibiotics becoming more resistant to bacterial infections, or the hospital availed more of the Watch compared to Access antibiotics. This can increase the cost of treatment to the hospital, and have more financial implications for the patients in case the prescribed medicines are out of stock. This may cause medicine non-adherence, hence the development of antibacterial resistance. This is consistent with a point prevalence survey to assess antibiotic use in 13 hospitals in Uganda which reported that the “Watch” antibiotics were used for 44% of prescriptions [4].
Only 11.2% of the patients who were prescribed antibiotic medicine had laboratory investigations requested before diagnosis. This led to the prescription of antibiotics in the absence of bacterial infections, which might lead to toxicity, and increase unnecessary costs to the patient in case of medicine stockouts. There is a possibility that sometimes laboratory reagents are stocked out, and when patients are sent for investigations, they are bounced back which reduces laboratory investigation requests. This coupled with the high patient load at the laboratory which increases patient waiting time, deters requests for laboratory investigations; hence the prescription of antibiotics based on the clinical presentation of the patient. This increases the prescription of antibiotics in the absence of confirmed bacterial infections, hence leading to antibiotics stockouts in the hospital. This can result in patients who genuinely require antibiotics not accessing them from the hospital. The majority of the patients cannot afford to buy these antibiotics from pharmacies outside the hospital, so they either buy half a dose or none at all. This can increase antibiotic resistance, morbidity, and mortality.
Results are consistent with studies [3], and ([11] which reported that the prescription of Access antibiotics was below the WHO recommended level.
Compliance with the Uganda Clinical Guidelines
Results of the study show that 58 out of 100 outpatient antibiotic prescriptions were written as per the UCG 2023. These patient prescriptions had the right antibiotic prescribed for the diagnosis, in the right dose, and with the right duration of treatment.
The majority of the outpatients (87.5%) were prescribed the right antibiotic for the diagnosis, with the WHO Watch category prescribed up to a level of 60%. However; 39 out of 100 were not prescribed the right dose, especially in paediatrics. This is possibly due to the weight-dose calculation for paediatric patients. Mulago Hospital is a teaching health facility with many medical students, spanning from years three to five, from intern doctors to senior house officers. There is a possibility that some of these prescriptions originated from these students who are still being perfected in prescription writing; hence this high level of incorrect dose among the prescriptions. Out of all the patients prescribed antibiotics, 20% of the prescriptions did not have the right treatment duration. This is possibly due to a lack of reference UCG for the prescribers. The UCG has just been reviewed, new copies have not yet been disseminated to the public hospitals, and even the old ones are limited; so, they cannot easily be accessed by the prescribers for reference. Therefore, doctors will have to rely on their knowledge, and experience to prescribe treatment for the patients. This can increase antibiotic resistance, and transmission of resistant bacterial strains; hence increasing the burden of bacterial infections.
Most patients had shorter than the recommended duration for treatment, especially those diagnosed with peptic ulcer disease, and cystitis. Some respiratory tract infections had treatment for only three days. This breeds antibacterial resistance, increased morbidity, and less human productivity, reducing the country’s gross domestic product.
The results are consistent with [12] who reported a UCG compliance of 30%.
Factors associated with antibiotic prescription
Directorate
The prevalence of antibiotic prescription was 3.8% lower in the directorate of paediatric patients; and 4.5% lower in the directorate of surgery patients than in those in the directorate of internal medicine.
Most of the prescriptions in internal medicine (849/918) are written based on clinical presentation without laboratory investigations. This leads to a high antibiotic prescription. The prescribers in the directorate of internal medicine have different qualifications including clinical officers, and intern doctors, especially Mac adult. These clinical officers have worked in this department for more than 20 years without any further knowledge improvement, and no continuous medical education about rational prescription writing. They end up prescribing antibiotics even when there is no need, hence the high antibiotic prescription.
Type of diagnosis
The odds of antibiotic prescription were 8 times higher in patients with bacterial diagnosis than in patients without bacterial diagnosis.
Bacterial diagnoses should be prescribed antibiotics following the WHO AWaRe classification with reference to the UCG. In this study, most of the antibiotic prescriptions were from the Watch category which did not follow the WHO guidelines [7]. Some of the patients without bacterial diagnoses were prescribed antibiotics which can breed resistance. However, none of the patients were prescribed Reserve antibiotics.
The prescription of antibiotic medicines in non-bacterial diagnoses shows how blindly prescriptions are written, specifically with no laboratory investigations. This implies that; either some prescriptions presented to the pharmacies do not originate from the hospital health care workers, or there is a knowledge gap amongst the prescribers which leads to antibiotic wastage, and faster stockouts.
Number of drugs prescribed
The prevalence of antibiotic prescription was 13.3% higher in patients who were prescribed four or more drugs than in those prescribed one to three drugs. Most of the patients prescribed more than three drugs had more than one diagnosis, and most probably one was bacterial, hence the higher antibiotic prescription than their counterparts. Sometimes antibiotics were indicated for diagnoses that were not bacterial; like malaria, hypertension, and diabetes mellitus which increased the antibiotic prescription. This irrational antibiotic use leads to wastage; and faster stockout of medicines which can lead to increased morbidity and mortality.
This is consistent with studies [3, 4, 9].
Patient age
The prevalence of antibiotic prescription was 3.4% higher among patients aged 0 to 5 years; 5.25% higher among patients who were aged 6 to 17 years; 4.2% higher in patients who were aged 18 to 35 years; and 3.1% higher in patients who were aged 36 to 49 years than in those aged 50 years and above.
Most paediatric patients presented with respiratory tract infections, hence the high prescription of antibiotics compared to adults. Bacterial infections especially respiratory tract infections spread easily in paediatrics because of their low immunity, interactions at school, and social behavior, hence high antibiotic prescriptions. Urinary tract infections can also be high because of using the same toilets at school, hence the high prevalence of antibiotic prescriptions. The spread of bacterial infections is also rampant in 18 to 35 years because of workplace interactions, and the social lifestyles of the youth, hence high antibiotic prescription. Some youths don’t care so much about their health and thus, do not engage so much in disease prevention measures. They too, present mostly with bacterial infections which warrant an antibiotic prescription. At the ages of 36 years and above, people begin to be keener about their lifestyle, engage in more disease preventive measures, and hence can avoid some diseases like respiratory tract infections, and urinary tract infections. This leads to fewer antibiotic prescriptions. Our findings are consistent with studies done in the USA which showed that children below 18 years of age had more antibiotic prescriptions than older people [13, 14]. However, the results are contrary to a study done in Uganda which reported that the age group of 18–59 years was associated with antibiotic prescription [9]. This might be due to the different facilities used in the two studies.
Gender
The prevalence of antibiotic prescription was 1.2% higher in male patients compared to their female counterparts. In Uganda, most male patients visit private facilities, and if they visit public facilities; they present late when they are too sick [15, 16]. They also have poor health-seeking behavior compared to females. They therefore; miss several health education talks done routinely in health facilities about disease-preventive practices. Despite the introduction of sensitization programs to the public by the Ministry of Health through the media, males tend not to engage in them especially hand washing, and wearing masks, and hence end up getting more bacterial infections. This explains the higher antibiotic prescriptions in males compared to females.
This is consistent with a study carried out at Mbarara Hospital [9]. However, our findings are contrary to a study done in the USA which showed that female patients had a higher overall rate of antibiotic visits than male patients [14].