AN INVESTIGATION OF ANTIBIOTIC PRESCRIBING IN PATIENTS WITH UPPER RESPIRATORY ...

150 Pages·2014·2.61 MB·English

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AN INVESTIGATION OF ANTIBIOTIC PRESCRIBING IN
PATIENTS WITH UPPER RESPIRATORY TRACT
INFECTIONS (URTIs) AT KATUTURA HEALTH CENTRE
A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE
REQUIREMENTS FOR THE DEGREE OF MASTER IN PUBLIC
HEALTH

OF

THE UNIVERSITY OF NAMIBIA

BY

MWAPE KUNDA
APRIL 2014

Main Supervisor: Dr Lischen Haoses-Gorases (UNAM)
Co- Supervisor: Dr Solomon Yigeremu (I-Tech, University of Washington)
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DECLARATION

I, Mwape Kunda, hereby declare that this study is a true reflection of my own
research and that this work has not been submitted for a degree at any other
educational institution.

This thesis, partly or as a whole may not be reproduced in any form be it by means of
(e.g. electronic, mechanical, photocopying or recording or by any other means)
without prior permission from the author, or the University of Namibia.

I, Mwape Kunda, grant The University of Namibia the right to produce this thesis in
whole or in part, in any manner or format, which the University of Namibia may
deem fit, for any person or institution requiring it for study and research; provided
the University of Namibia shall waive this right if the whole thesis has been or being
published in a manner satisfactory to the University

________________________ _______________
Mwape Kunda Date
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DEDICATION

To my late mother, Alice Chilufya, thank you for encouraging me to exhale high in
my education. I have made it this far because of your encouragement and spiritual
guidance during the time you were here on earth. Rest in peace.

To my father, Mr Kenneth Kunda, you taught me to work hard and always gave me
support in every way. I believe you will be proud of this work.
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ACKNOWLEDGEMENTS
I would like to thank Jehovah God, my Father, for his everlasting love and grace
that enabled me to do this study. (Not to me, Lord, not to me, but to your name be the
glory, because of your love and faithfulness: Psalms 115 verse 1)

To my supervisors Dr L. Haoses-Gorases and Dr D. Solomon, thank you so much
for your guidance, advice and support which made my study a success. God bless
you abundantly always in everything.

My dearest husband Mespa Manyepa, your encouragement, understanding and
support helped me to achieve this great success. I love you!

My sisters, Ngosa, Kunda and Chisanga thank you for your support during my
study.

My research assistant, Mr George Santos (MoHSS, Katutura Health Center), thank
you for being an enthusiastic in helping me to collect data for this study. May God
bless you richly!

Many thanks to the statistician, Mr I. Maposa (Polytechnic of Namibia) and Mr M.
Gawanab(MoHSS) for your help in data analysis.

Many thanks to Mr E. Sagwa (MSH), for taking time reviewing my thesis.
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ABSTRACT

Upper Respiratory Tract Infections (URTIs) are viral in 80% of the cases (Mazur,
2010) but antibiotic prescribing in these illnesses still remains a problem in many
places, where about 60% of patients with URTIs receive antibiotics inappropriately
(WHO, 2010).This makes URTIs important targets for strategies aimed at reducing
irrational antibiotic use because irrational use of antibiotics leads to the emergence
and spread of bacterial resistance, which is a growing global public health concern.
Other consequences of irrational use of antibiotics are wastage of resources and
adverse effects. The purpose of this study was to explore antibiotic prescribing in
patients with URTIs at Katutura Health Centre (KHC).
A descriptive, cross sectional, quantitative design based on patients‟ prescriptions
was used. Data was analysed using Epi info version 7.1.1.14 and SPSS version 22.0
statistical packages. Microsoft office excel 2010 was also used for graphical
presentation of the results.
The rate of antibiotic prescribing for patients with URTIs at KHC was 78% (95% CI,
74% - 82%). Further analysis with the chi-square test of antibiotic prescribing
(response variable) and illness, age, gender and profession (exposure variables)
showed that age and illness were significantly associated with antibiotic prescribing
(p< 0.05) while gender and profession rank were not. Compliance to treatment
guidelines was 47% (CI, 40%-54%). The total cost of antibiotic prescribing in this
study was N$ 2406.98, of which non-specific URTIs accounted for 48% (N$
1150.45). Irrationally prescribed antibiotics accounted for 44 % (N$ 1052.07) and
those that were rationally prescribed, 8% (N$ 204.46). The total cost of antibiotic
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treatment of illnesses assessed for rationally was N$ 1256.5 of which N$ 1052.07
(84%) was the cost of irrationally prescribed antibiotics and N$ 204.46 (16%) for
rationally prescribed antibiotics. This showed that the cost of irrational prescribing
was costing five times more than that of rational prescribing.
Antibiotic over prescribing is a problem in patients with URTIs. The Ministry of
Health and Social Services need to develop or adopt international strategies that
deliver proven efficacy in reducing antibiotic prescribing in URTIs. These include
developing or adopting antibiotic policies that are specific to URTIs, patient
education through literature and media campaigns, and implementing and enforcing
continued education for health workers on the judicial use of antimicrobials. Further
research is also needed to determine the factors that contribute to antibiotic over
prescribing in URTIs.
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TABLE OF CONTENTS

DECLARATION .............................................................................................................. i
DEDICATION ................................................................................................................. ii
ABSTRACT .................................................................................................................... iv
TABLE OF CONTENTS ............................................................................................... vi
LIST OF TABLES ............................................................................................................ x
LIST OF FIGURES ........................................................................................................ xi
LIST OF ABBREVIATIONS ....................................................................................... xii
CHAPTER 1 ...................................................................................................................... 1
INTRODUCTION ............................................................................................................ 1
1.1 Background ................................................................................................................. 1
1.2 Problem statement ...................................................................................................... 4
1.2 Purpose of the study ................................................................................................... 5
1.3 Objectives .................................................................................................................... 5
1.5 Significance of the study............................................................................................. 5
1.6 Definitions of Key Concepts ....................................................................................... 6
1.7 Ethical considerations ................................................................................................ 8
1.8 Summary ..................................................................................................................... 9
CHAPTER 2 .................................................................................................................... 10
LITERATURE REVIEW AND CONCEPTUALISATION....................................... 10
2.1 INTRODUCTION .................................................................................................... 10
2.2 CONCEPTUALIZATION OF THE STUDY ........................................................ 10
2.2 UPPER RESPIRATORY TRACT INFECTIONS ................................................ 12
2.2.1 The common cold.................................................................................................. 13
2.2.2 Acute pharyngitis and tonsillitis ........................................................................... 16
2.2.3 Acute Otitis Media (AOM) ................................................................................... 18
2.3 TREATMENT OF UPPER RESPIRATORY TRACT INFECTIONS............... 20
2.3.1 Treatment of the common cold ............................................................................. 24
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2.3.2 Treatment of acute pharyngitis and / tonsillitis (sore throat) ................................ 25
2.3.3 Treatment of Acute Otitis Media .............................................................. ………….27
2.4 ANTIBIOTIC PRESCRIBING IN URTIS ........................................................... 31
2.5 CONSEQUENCES OF IRRATIONAL ANTIBIOTIC
PRESCRIBING ........................................................................................................ 34
2.5.1 Antimicrobial resistance ....................................................................................... 34
2.5.2 Wastage of resources ............................................................................................ 37
2.5.3 Side effects ............................................................................................................ 39
2.5.4 Eroded patient Confidence .................................................................................... 39
2.6 SUMMARY ............................................................................................................... 40
CHAPTER 3 .................................................................................................................... 41
RESEARCH METHODOLOGY .................................................................................. 41
3.1 INTRODUCTION .................................................................................................... 41
3.2 RESEARCH DESIGN .............................................................................................. 41
3.3 RESEARCH METHODS......................................................................................... 42
3.3.1 Study setting .......................................................................................................... 42
3.3.2 Study population ................................................................................................... 44
3.3.3 Sample size ........................................................................................................... 44
3.3.4 Sampling ............................................................................................................... 46
3.5 DATA COLLECTION TOOL ................................................................................ 47
3.6 PILOT OF THE DATA EXTRACTION FORM .................................................. 50
3.7 DATA COLLECTION ............................................................................................. 51
3.8 STRATEGIES TO ENSURE VALIDITY AND RELIABILITY OF
THE DATA EXTRACTION FORM. ..................................................................... 53
3.8.1 Validity ................................................................................................................. 53
3.8.2 Reliability .............................................................................................................. 54
3.9 DATA ANALYSIS .................................................................................................. 54
3.10 SUMMARY ............................................................................................................ 58
CHAPTER 4 .................................................................................................................... 59
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PRESENTATION OF THE RESEARCH FINDINGS AND DISCUSSION ............ 59
4.1 INTRODUCTION .................................................................................................... 59
4.2 COVERAGE RATE ................................................................................................. 60
4.3 PATIENTS’ DEMOGRAPHICS ............................................................................ 60
4.3.1 Gender ................................................................................................................... 60
4.3.2 Age 61
4.3.3 Sex and Age Group ............................................................................................... 62
4.4 ANTIBIOTIC PRESCRIBING IN URTIs ............................................................. 63
4.4.1 Proportion of patients with URTIs ........................................................................ 63
4.4. 2 The rate of antibiotic prescribing in URTIs ......................................................... 64
4.4.3 Antibiotic prescribing by age group ...................................................................... 66
4.4.4 Antibiotic prescribing by patient gender ............................................................... 67
4.4.5 Antibiotic prescribing in the different types of URTIs ......................................... 68
4.4.6 The rate of antibiotic prescribing according to profession or rank ...................... 76
4.4.7 Number of antibiotics per prescription ................................................................ 77
4.4.8 Names of Antibiotics prescribed ........................................................................... 78
4.4.9 Other medicines prescribed .................................................................................. 80
4.4.10 Number of medicines per prescription ................................................................ 82
4.5 Rational prescribing in URTIs ................................................................................ 84
4.6 The cost of rational and irrational antibiotic prescribing .................................... 90
4.7 SUMMARY ............................................................................................................... 93
CHAPTER 5 .................................................................................................................... 95
CONCLUSIONS, RECOMMENDATIONS AND LIMITATIONS OF THE
STUDY ....................................................................................................................... 95
5.1 INTRODUCTION .................................................................................................... 95
5.2 CONCLUSIONS FROM THE STUDY .................................................................. 95
5.2.1 Objective 1: To determine the rate of antibiotic prescribing in patients with URTIs
....................................................................................................................................... 95
5.2.2 Objective 2: To assess the rationality of antibiotic treatment of URTIs .............. 96
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5.2.3 Objective 3: To compare the cost of rational and irrational antibiotic use in URTIs
....................................................................................................................................... 97
5.2 RECOMMENDATIONS ......................................................................................... 97
5.2.1 Introduction ........................................................................................................... 97
5.2.2 Recommendations to promote rational use of antibiotics at health facility and
community level. ............................................................................................................ 97
5.2.3 Recommendations for future research ................................................................ 100
5.3 STUDY LIMITATIONS ........................................................................................ 100
5.4 SUMMARY ............................................................................................................. 101
5.5 CONCLUSION OF THE STUDY......................................................................... 101
REFERENCES ............................................................................................................. 102
ANNEXURES ............................................................................................................... 126
ANNEXURE A: UNIVERSITY Of NAMIBIA POST GRADUATE
COMMITTEE APPROVAL LETTER ............................................................... 126
ANNEXURE B: MINISTRY OF HEALTH AND SOCIAL SERVICES
APPROVAL LETTER .......................................................................................... 127
ANNEXURE C: DATA COLLECTION TOOL ....................................................... 128
ANNEXURE D: AN EXTRACT OF THE NAMIBIA STANDARD
TREATMENT GUIDELINES…...............................................................129