A qualitative study exploring basis for antibiotics prescription without microbiological investigations, Dar es Salaam Tanzania CURRENT

Background Prescription of antibiotics based on microbiological investigations is a commendable rational use of antibiotics and help in fighting the spread of resistance. Although shortage of microbiology laboratory is indicated to impair this practice but prescription without microbiological investigation has been reported even in settings with laboratory facilities. Methods Semi structured key informant interviews with 31 prescribing medical doctors in Dar es Salaam, Tanzania were conducted from January to June 2019. The purpose of the interviews was to obtain the insight into the prescriptions of antibiotics without microbiological investigations especially in hospitals with laboratory facilities. Results Majority of participants (26/31) were ready to prescribe antibiotics without microbiological investigations. In addition, a total of four major themes were identified as the basis for this practice; i) clinical condition of the patient ii) past experience with the clinical condition and/or patient iii) an intention to prevent the spread of infection and iv) patient’s history and physical examination were adequate to establish the management plan. Conclusion In use this study Stewardship


Abstract
Background Prescription of antibiotics based on microbiological investigations is a commendable rational use of antibiotics and help in fighting the spread of resistance. Although shortage of microbiology laboratory is indicated to impair this practice but prescription without microbiological investigation has been reported even in settings with laboratory facilities.
Methods Semi structured key informant interviews with 31 prescribing medical doctors in Dar es Salaam, Tanzania were conducted from January to June 2019. The purpose of the interviews was to obtain the insight into the prescriptions of antibiotics without microbiological investigations especially in hospitals with laboratory facilities.
Results Majority of participants (26/31) were ready to prescribe antibiotics without microbiological investigations. In addition, a total of four major themes were identified as the basis for this practice; i) clinical condition of the patient ii) past experience with the clinical condition and/or patient iii) an intention to prevent the spread of infection and iv) patient's history and physical examination were adequate to establish the management plan.
Conclusion In recognition of the urgent need to improve antibiotic use in hospitals, this study highlights the need to implement hospital Antibiotic Stewardship Programs in Dar es Salaam, Tanzania. Background Antimicrobial resistance i.e. antibiotics poses a serious global threat and raising concern to human, animal, and environment health. [1].Most of the frequent isolated pathogens are becoming resistant to conventional antimicrobial medicines hence putting the world at an increased risk of morbidity and mortality due resistant bacteria strains [2].
If uncontrolled, antibiotics resistance may not only threaten health of individuals but also results to an increased economic burden through use of expensive medicine and increased number of hospital stay [3]. In this regard, low and middleincome countries (LMICs) including Tanzania which are struggling with severe underfunding and improving their weak health systems are particularly at more risks of antibiotic resistance and its associated problems [4].
At present, there are no doubts on the existence of relationship between the irrational use of antibiotics such as prescription without microbiological investigation and the spread of antibiotic resistance [5]. In combating the problem, World Health Organization (WHO) has continued to recommend the rational use of antibiotics such as prescription based on culture and sensitivity [6]. Furthermore, the national standard treatment guidelines (STGs), Tanzania in particular advocate on evidence based prescription [7].
For the purpose of exploring the basis of this practice especially in setting with facilities, a qualitative study involving prescribing medical doctors was conducted methods Study design, period and area The study was conducted using semi-structured key informant interviews where thirty-one prescribing Medical Doctors (MDs) from tertiary hospitals in Dar es Salaam, Tanzania were interviewed in person between January and June 2019. Dar es Salaam region is the business city in Tanzania with approximated population of five million people (almost 10% of the country population) according to the National Census of 2012 [17]. Prescribing MDs included general practitioner, specialist and consultants. The study sites included eight hospitals (four private and public hospitals). Microbiology laboratory for culture and sensitivity and laboratory personnel were available in all study sites.

Participants and selection
This study involved employed MDs with at least bachelor degree in medicine and one year of working experience as a prescriber. Participant was required to be an employee who works at tertiary hospital. Additionally, this study excluded intern doctors and medical students who were under supervision. Participants for the key informant interviews were purposively selected based on the reason that his/her hospital should have a good microbiology laboratory.

Data collection
Semi-structured, individual interviews lasting 15 min each, were conducted in the hospital surroundings after office hours by two members of the study team (FFM and GMB). The question aimed at exploring the reasons, which prompt the prescription of antibiotics with microbiological investigations i.e. culture and sensitivity, especially in resources available settings (hospitals). The guiding question(s) were developed after comprehensive literature review of the studies that were conducted to access this practice in LMICs [4,8,9,11,15]. Specifically, the questions included: work experience and position; hospital category (private/ public hospital), patient category (in/out-patients); and number the number of patients he/she attends per day. The main question was: "Can you prescribe antibiotics to a patient without culture and sensitivity results?" (Additional file 1)

Data analysis
All interviews were tape recorded and fully transcribed. The process of analysisinvolved familiarization with the data, development of initial codes based on the research questions and issues emerging from the data, refinement of codes, and their allocation to broad themes. Furthermore, all analysis of interviews was done by hand coding, and emerging themes were identified based on frequency of appearance. In addition, analysis was done by two members of the study team who did not conduct the actual interviews (DM and KDM) [21]. In the event of discrepancies, discussion between the researchers and verification with interviewers took place until consensus was reached.

Ethical consideration
Ethical approval to conduct this study was sought from Muhimbili University of to inform the ongoing antimicrobial resistance stewardship program [18]. Therefore, a qualitative study using MDs was conducted to explore the basis of prescribing antibiotics without culture and sensitivity evidence.
This study found that, factors such as patient's clinical condition, time taken for culture and sensitivity and doctor's experience on the disease condition influence prescription and dispensing of antibiotics without microbiological investigations in in Dar es Salaam hospital with laboratory capacity to preform culture and sensitivity. These findings were similar from the studies conducted elsewhere [12][13][14][15][16].
Evidence from the study conducted to assess medical seeking behaviors found that that, medical seeking behavior in most cases are influenced by symptoms, patients who are on treatment believe to have the correct diagnosis due to lack of follow-up [19]and recurrence of a disease is mistakenly assumed as the new infection due to lack of prognostic testing. These result concurred with the finding of the current study where Doctors reported that, patient do not come back for their results when they are asked to do so.
The high replication of an infectious disease make difficult for a clinician to wait for culture and sensitivity results [19]. This has been supported by the current findings where the patient's medical condition influenced the prescription without waiting for culture and sensitivity. For the life saving purpose, broad spectrums are mostly prescribed [20].
Lastly, this study found physical examination, which is a result of patient's history, leads to an establishment of diagnosis in most cases accompanied with empirical treatment. But again due to health seeking behaviors outpatients who are given empirical antibiotics rarely return to hospital for their results [19].
The conclusion of these findings was limited to health practitioners working in Dar es Salaam hospitals, which had laboratory capacity to perform culture and sensitivity. In addition, the current study did not assess the practice to differentiate between prescription only medicine and over the counter medicines. Availability of data and materials All data used to draw conclusion of the study is provided in the manuscript.

Competing interests
Authors declare that they have no competing interest.

Funding
Authors received no fund to conduct this study.