Interventions to Reduce Antibiotic Prescribing in LMICs: A Scoping Review of Evidence from Human and Animal Health Systems

Abstract

This review identifies evidence on supply-side interventions to change the practices of antibiotic prescribers and gatekeepers in low- and middle-income countries (LMICs). A total of 102 studies met the inclusion criteria, of which 70 studies evaluated interventions and 32 provided insight into prescribing contexts. All intervention studies were from human healthcare settings, none were from animal health. Only one context study examined antibiotic use in animal health. The evidence base is uneven, with the strongest evidence on knowledge and stewardship interventions. The review found that multiplex interventions that combine different strategies to influence behaviour tend to have a higher success rate than interventions based on single strategies. Evidence on prescribing contexts highlights interacting influences including health system quality, education, perceptions of patient demand, bureaucratic processes, profit, competition, and cultures of care. Most interventions took place within one health setting. Very few studies targeted interventions across different kinds of providers and settings. Interventions in hospitals were the most commonly evaluated. There is much less evidence on private and informal private providers who play a major role in drug distribution in LMICs. There were no interventions involving drug detailers or the pharmaceutical companies despite their prominent role in the contextual studies.

Ongoing strategies to improve the management of upper respiratory tract infections and reduce inappropriate antibiotic use particularly among lower and middle-income countries: findings and implications for the future

“…A systematic review was not performed as there has already been an appreciable number of recent publications, including systematic reviews, discussing ongoing research in this area, which includes current self-purchasing rates as well as public awareness campaigns 29 Consequently, our findings and suggested activities for key stakeholder groups are based on relevant publications known to the authors, coupled with their considerable knowledge of ongoing activities in their own countries (and more broadly) to improve the prescribing and dispensing of antibiotics for patients with URTIs. This approach has been used successfully to stimulate debate in other priority healthcare areas to provide future guidance [161][162][163][164][165][166][167][168][169][170][171] .…”

“…Multiple strategies are typically needed to reduce unnecessary prescribing and dispensing of antibiotics in ambulatory care among all key stakeholder groups including patients, parents, community pharmacists and physicians 29,40,52,60,70,71,74,97,154,243 . This reflects the complexity of the situation, the different beliefs of key stakeholder groups and often multiple organizations and personnel within a country involved with improving antibiotic utilization and reducing AMR rates 244 .…”

“…Sub-optimal management of URTIs in LMICs including the overuse of antibiotics is promoted by misconceptions, social-cultural issues, diagnostic uncertainty, and clinical competency as well as commercial, patient and time pressures 21,29,50,52,57,92,[96][97][98][99][100][101][102][103][104][105][106][107][108][109] . Inappropriate management is also a concern in countries with high rates of infectious diseases such as HIV, malaria and tuberculosis (TB), which is the case in sub-Saharan Africa, as this may complicate treatment [110][111][112] .…”

“…Neither do we consider antibiotic availability, which can also be a concern in LMICs 149 . The key issue discussed in this paper is the identification of potential ways to reduce rising AMR rates given the high global priority via the appropriate management of URTIs in LMICs 29,88,125,150 .…”

“…We are aware that an appreciable number of publications and ongoing research already exist discussing potential ways to improve antibiotic utilization especially in LMICs, which includes improved surveillance 29,45,61,66,85,100,119,120,151,152 . A number of systematic reviews regarding the management of URTIs and ways to improve both the prescribing and dispensing of antibiotics for patients with URTIs have also been published 21,43,45,57,61,74,85,108,153,154 .…”