Abstract

BackgroundIn many rural areas of Uganda, febrile patients presenting to health facilities are prescribed both antimalarials and antibiotics, contributing to the overuse of antibiotics. We identified the prevalence and correlates of inappropriate antibiotic management of patients with confirmed malaria.MethodsWe utilized individual outpatient data from 36 health centers from January to September 2011. We identified patients who were prescribed antibiotics without an appropriate clinical indication, as well as patients who were not prescribed antibiotics when treatment was clinically indicated. Multivariate logistic regression models were used to identify clinical and operational factors associated with inappropriate case management.FindingsOf the 45,591 patients with parasitological diagnosis of malaria, 40,870 (90%) did not have a clinical indication for antibiotic treatment. Within this group, 17,152 (42%) were inappropriately prescribed antibiotics. The odds of inappropriate prescribing were higher if the patient was less than five years old (aOR 1.96, 95% CI 1.75–2.19) and if the health provider had the fewest years of training (aOR 1.86, 95% CI 1.05–3.29). The odds of inappropriate prescribing were lower if patients had emergency triage status (aOR 0.75, 95% CI 0.59–0.96) or were HIV positive (aOR 0.31, 95% CI 0.20–0.45). Of the 4,721 (10%) patients with clinical indications for antibiotic treatment, 521 (11%) were inappropriately not prescribed antibiotics. Clinical officers were less likely than medical officers to inappropriately withhold antibiotics (aOR 0.54, 95% CI 0.29–0.98).ConclusionOver 40% of the antibiotic treatment in malaria positive patients is prescribed despite a lack of documented clinical indication. In addition, over 10% of patients with malaria and a clinical indication for antibiotics do not receive them. These findings should inform facility-level trainings and interventions to optimize patient care and slow trends of rising antibiotic resistance.

Highlights

  • In Uganda, malaria is the leading cause of morbidity and mortality, accounting for 25–40% of outpatient visits to health facilities and nearly half of inpatient pediatric deaths [1]

  • Over 40% of the antibiotic treatment in malaria positive patients is prescribed despite a lack of documented clinical indication

  • While clinical algorithms such as the WHO’s Integrated Management of Childhood Illness (IMCI) explicitly identify conditions appropriate for antibiotic treatment, the WHO estimates that in less developed countries only 40% of primary care patients in the public sector and 30% in the private sector are treated according to clinical guidelines [5,6]

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Summary

Introduction

In Uganda, malaria is the leading cause of morbidity and mortality, accounting for 25–40% of outpatient visits to health facilities and nearly half of inpatient pediatric deaths [1]. Febrile patients presenting to health facilities are prescribed both antimalarials and antibiotics, contributing to the overuse of antibiotics [2,3,4] While clinical algorithms such as the WHO’s Integrated Management of Childhood Illness (IMCI) explicitly identify conditions appropriate for antibiotic treatment, the WHO estimates that in less developed countries only 40% of primary care patients in the public sector and 30% in the private sector are treated according to clinical guidelines [5,6]. A review of factors that influence IMCI adherence found that supervision, in-service training, and job aids gave mixed results in improving the use of medicines and health worker performance [16] It is not well understood which clinical and operational factors are associated with health worker deviation from clinical guidelines and inappropriate drug treatment. We identified the prevalence and correlates of inappropriate antibiotic management of patients with confirmed malaria

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