Antibiotic Prescribing Patterns at Rift Valley Provincial General Hospital

113 Pages·2017·1.68 MB·English

by  Momanyi Lydia

ANTIBIOTIC PRESCRIBING PATTERNS AT RIFT VALLEY PROVINCIAL
GENERAL HOSPITAL: A POINT PREVALENCE SURVEY

MOMANYI LYDIA BOSIBORI (BPHARM)
U56/80860/2015

A DISSERTATION SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF
PHARMACY IN CLINICAL PHARMACY OF THE UNIVERSITY OF NAIROBI

DECEMBER, 2017
APPROVAL BY SUPERVISORS
This research dissertation has been submitted for evaluation with our approval as
University supervisors.
1. Dr. David Nyamu
Department of Pharmaceutics & Pharmacy Practice
School of Pharmacy
University of Nairobi
Signature_______________ Date _____________

2. Dr. Margaret Oluka
Department of Pharmacology & Pharmacognosy
School of Pharmacy
University of Nairobi
Signature_______________ Date _____________

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DECLARATION OF ORIGINALITY

Name of Student: Lydia Bosibori Momanyi
Name of Student: Lydia Bosibori Momanyi
Registration Number: U56/80860/2015
Registration Number: U56/80860/2015
College: Health Sciences
College: Health Sciences
School: Pharmacy
School: Pharmacy
Department: Pharmaceutics and Pharmacy Practice
Department: Pharmaceutics and Pharmacy Practice
Course Name: Clinical Pharmacy
Course Name: Clinical Pharmacy
Title: Antibiotic Prescribing Patterns at Rift Valley Provincial General Hospital: A Point
Title: Antibiotic Prescribing Patterns at Rift Valley Provincial General Hospital: A
Prevalence Survey
Point Prevalence Survey

1. I understand what plagiarism is and I am aware of the University‟s policy in this
regard.
2. I declare that this dissertation is my original work and has not been submitted
elsewhere for examination, the award of a degree or publication. Where other people‟s
work or my own work has been used, this has properly been acknowledged and
referenced in accordance with the University of Nairobi‟s requirements.
3. I have not sought or used the services of any professional agencies to produce this
work.
4. I have not allowed, and shall not allow anyone to copy my work with the intention of
passing it off as his/her own work.
5. I understand that any false claim in respect of this work shall result in disciplinary
action, in accordance with University Plagiarism Policy.

Name: Lydia Bosibori Momanyi - U56/80860/2015

Signature: _______________Date:_______________

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DEDICATION
To the Almighty God who gave me the strength to do all things and was faithful to
complete the good work He had begun.
To my loving and supportive parents, Mr. & Mrs. Momanyi, I am because you are.

iv
ACKNOWLEDGEMENT
First and foremost, I thank the Almighty God for providing this opportunity and for
guiding me throughout this journey. I would like to sincerely thank my supervisors
Dr.David Nyamu and Dr. Margaret Oluka for their guidance and support during the
process. My heartfelt gratitude goes to Dr. Peter Karimi and Dr. Faith Okalebo for their
guidance during the data management and analysis. Many thanks to my research
assistants – Doris, Mugo, Joy, Gideon, Kibet, Sharon and Simiyu who made the process
of data collection and entry smooth and enjoyable. I also appreciate my classmates who
provided positive criticism and valuable input that enabled the refinement of this
document. My heartfelt gratitude goes to the University of Nairobi for the postgraduate
scholarship. I cannot forget to thank my wonderful family for their immense support and
understanding. May the Lord bless you abundantly.

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TABLE OF CONTENTS
DECLARATION OF ORIGINALITY .......................................................................... iii
DEDICATION.................................................................................................................. iv
ACKNOWLEDGEMENT ................................................................................................ v
LIST OF TABLES ............................................................................................................ x
LIST OF FIGURES ......................................................................................................... xi
ABSTRACT ..................................................................................................................... xii
ABBREVIATIONS & ACRONYMS ........................................................................... xiv
OPERATIONAL DEFINITION OF TERMS .............................................................. xv
CHAPTER ONE: INTRODUCTION ............................................................................. 1
1.1 Background ............................................................................................................... 1
1.1.1 Prevalence of Antibiotic use ............................................................................... 1
1.1.2 Rational and Irrational use of antibiotics ............................................................ 1
1.1.3 Guidelines on use of antibiotics.......................................................................... 2
1.1.4 Targets for potential improvement in the use of antibiotics ............................... 2
1.2 Problem Statement .................................................................................................... 3
1.3 Research Questions ................................................................................................... 4
1.4 Study Objectives ....................................................................................................... 4
1.4.1 General Objective ............................................................................................... 4
1.4.2 Specific Objectives ............................................................................................. 4
1.5 Study Significance..................................................................................................... 4
1.6. Conceptual Framework ............................................................................................ 6
CHAPTER TWO: LITERATURE REVIEW ................................................................ 7
2.1 Global, Regional and Local Antibiotic Consumption ............................................... 7
2.2 Rational and irrational use of antibiotics................................................................... 9
2.3 Antibiotic prescribing guidelines ............................................................................ 13
2.4 Challenges in the use of Antibiotics ........................................................................ 16
2.5 Antibiotic resistance and its consequences ............................................................. 17
2.6 Factors affecting antibiotic prescribing pattern ....................................................... 19
2.6.1 Patient factors ................................................................................................... 19
2.6.2 Provider related factors that influence antibiotic prescribing ........................... 20
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2.6.3 Institutional factors that affect antibiotic prescribing ....................................... 23
2.6.4 Health system factors that affect antibiotic prescribing ................................... 23
2.7 Identified targets for potential improvement in the use of antibiotics .................... 24
2.8 Knowledge gaps identified ...................................................................................... 26
CHAPTER THREE: METHODOLOGY .................................................................... 27
3.1 Research Design ...................................................................................................... 27
3.2 Location of the Study .............................................................................................. 27
3.3 Target population .................................................................................................... 28
3.4 Inclusion and Exclusion Criteria ............................................................................. 28
3.4.1 Inclusion Criteria .............................................................................................. 28
3.4.2 Exclusion Criteria ............................................................................................. 28
3.5 Sampling.................................................................................................................. 29
3.5.1 Sample Size Estimation .................................................................................... 29
3.5.2 Sampling Technique ......................................................................................... 30
3.6 Participants Recruitment ......................................................................................... 31
3.7 Research Instruments .............................................................................................. 31
3.8 Pilot Study ............................................................................................................... 31
3.9 Study Validity ......................................................................................................... 32
3.10 Study Reliability .................................................................................................... 32
3.11 Data collection technique ...................................................................................... 32
3.12 Data Management ................................................................................................. 33
3.13 Study Variables ..................................................................................................... 33
3.14 Data Analysis ........................................................................................................ 34
3.15 Logistical and Ethical Considerations ................................................................... 34
CHAPTER FOUR : RESULTS ..................................................................................... 35
4.1 Sociodemographic characteristics of the study population ..................................... 35
4.2 Clinical Characteristics of the Study Population .................................................... 35
4.2.1 Use of Antibiotics in Hospital .......................................................................... 35
4.2.2 Co-morbidities .................................................................................................. 36
4.2.3. Indications ....................................................................................................... 37
4.3 Prevalence of Antibiotic Prescribing....................................................................... 38
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4.3.1 Overall prevalence of antibiotic prescribing .................................................... 38
4.3.2 Prevalence of antibiotic classes ........................................................................ 38
4.3.3 Prevalence of specific antibiotics prescribed .................................................... 39
4.3.4 Association between age and antibiotic class ................................................... 39
4.3.5 Association between age and specific antibiotics ............................................. 41
4.3.6 Association between Department and Antibiotic Class ................................... 42
4.3.7 Antibiotic prescribing by Indication ................................................................. 44
4.4 Quality Indicators of antibiotic prescribing ............................................................ 49
4.5 Rational antibiotic prescribing ................................................................................ 52
4.6 Guideline Compliance ............................................................................................. 64
4.6.1 Guidelines used for assessment of compliance and availability of local
guidelines ................................................................................................................... 64
4.6.2 Association between availability of local guidelines and patient diagnoses .... 66
4.6.3 Overall Guideline compliance .......................................................................... 67
4.6.4 Association between guideline compliance and patient sociodemographic
characteristics ............................................................................................................ 68
4.6.5 Association between guideline compliance and patient clinical factors .......... 69
4.6.6. Guideline compliance across the various antibiotic classes ............................ 70
4.6.7 Logistic regression analysis for the predictors of guideline compliance .......... 71
CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS 74
5.1 Discussion ............................................................................................................... 74
5.1.1 Prevalence of Antibiotic Prescribing ................................................................ 74
5.1.2 Patterns of Antibiotic Prescribing..................................................................... 75
5.1.3 Rational use of antibiotics ................................................................................ 78
5.1.4 Compliance to the Guidelines in Antibiotic Prescribing .................................. 80
5.1.5 Quality indicators for antibiotic prescribing ..................................................... 81
5.2 Study limitations ..................................................................................................... 82
5.3 Conclusion ............................................................................................................... 83
5.4 Recommendations ................................................................................................... 83
APPENDICES ................................................................................................................. 85
Appendix 1: Ward Form ............................................................................................... 85
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Appendix 2: Global-PPS Patient Form ......................................................................... 86
Appendix 3A - Diagnostic codes (what the clinician aims at treating) ......................... 88
Appendix 3B - Type of Indication ................................................................................. 90
REFERENCES ................................................................................................................ 91

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LIST OF TABLES
Table 1: Proportionate sampling of the RVPGH according to bed capacity ................................. 30
Table 2: Classification of the hospital departments ....................................................................... 33
Table 3: Sociodemographic characteristics .................................................................................... 35
Table 4: Use of Antibiotics in the Hospital.................................................................................... 36
Table 5: Overall prevalence of Antibiotic Prescribing .................................................................. 38
Table 6: Prevalence of specific antibiotics prescribed ................................................................... 39
Table 7: Relationship between prescribed classes of antibiotics and participants‟ age category .. 40
Table 8: Relationship between the specific antibiotics prescribed and the participants‟ age ........ 42
Table 9: Variation of antibiotic prescribing by classes across the various departments ................ 43
Table 10: Prevalence of documentation of Indication in notes ...................................................... 50
Table 11: Prevalence of Generic Prescribing ................................................................................. 51
Table 12: Prevalence of empiric versus targeted prescribing ........................................................ 52
Table 13: Evaluation of choice of specific antibiotics ................................................................... 53
Table 14: Evaluation of Dose of specific antibiotics ..................................................................... 54
Table 15: Evaluation of frequency of specific antibiotics ............................................................. 55
Table 16: Evaluation of route of specific antibiotics ..................................................................... 56
Table 17: Duration of antibiotic use .............................................................................................. 57
Table 18: Rational prescribing of specific antibiotics.................................................................... 58
Table 19: Relationship between rational prescribing of antibiotics and sociodemographic .......... 59
Table 20: Relationship between rational prescribing of antibiotics and patient clinical factors .... 60
Table 21: Relationship between rational prescribing and antibiotic class ..................................... 61
Table 22: Univariate binary logistic regression analysis for predictors of rational antibiotic ....... 63
Table 23: Parsimonius model of the most powerful predictors of rational prescribing ................. 64
Table 24: Availability of local guidelines across the various Indication and Diagnosis ............... 67
Table 25: Relationship between guideline compliance and availability of local guidelines ......... 68
Table 26: Guideline Compliance across patient sociodemographic characteristics ...................... 69
Table 27: Guideline compliance across patient diagnosis and indications .................................... 70
Table 28: Guideline compliance across the various antibiotic classes .......................................... 71
Table 29: Univariate binary logistic regression analysis for predictors of Guideline compliance 72
Table 30: Parsimonius model of the most powerful predictors of guideline compliance .............. 73

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