Prescriber and dispenser perceptions about antibiotic use in acute uncomplicated childhood diarrhea and upper respiratory tract infection in New Delhi: Qualitative study

Abstract

OBJECTIVE:The objective of the study was to explore the prescribing practices, knowledge, and attitudes of primary care doctors and community pharmacists, regarding antibiotic use in acute upper respiratory tract infections (URTI) and diarrhea in children to better understand causes of misuse and identify provider suggestions to change such behavior.MATERIALS AND METHODS:Two focus group discussions (FGDs) each were conducted with primary care government doctors (GDs), private general practitioners (GPs), pediatricians, and community pharmacists in Delhi. Each FGD had 8–12 participants and lasted 2 h. Furthermore, 22 individual face-to-face semi-structured interviews were conducted with providers of varying type and experience at their workplaces. Thematic and summative qualitative content analysis was done.RESULTS:All groups admitted to overusing antibiotics, GPs appearing to use more antibiotics than GDs and pediatricians for URTI and diarrhea in children. Pharmacists copy the prescribing of neighborhood doctors. Antimicrobial resistance (AMR) knowledge was poor for all stakeholders except pediatricians. Causes for prescribing antibiotics were patient pressure, profit motive, lack of follow-up and in addition for GDs, workload, no diagnostic facility, and pressure to use near-expiry medicines. Knowledge was gained through self-experience, copying others, information from pharmaceutical companies, and for some, training, continuous medical education/conferences. All groups blamed other professional groups/quacks for antibiotic overuse. Interventions suggested were sensitizing and empowering prescribers through training of providers and the public about the appropriate antibiotic use and AMR and implementing stricter regulations.CONCLUSIONS:A package of interventions targeting providers and consumers is urgently needed for awareness and change in behavior to reduce inappropriate community antibiotic use.

Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India

“…To the best of our knowledge, this is the first study to describe and quantify the antibiotic prescription practices of IHCPs in rural India, contrasting with other studies in India conducted in a hospital setting with formal healthcare providers [19,20,21,22,23,24,25]. The results of our study reveal that the IHCPs prescribed antibiotics at a high proportion (74%) for common illnesses compared to other non-antibiotic medications.…”

“…The prescription patterns of the IHCPs, particularly for loose motions, indicated that they probably duplicated treatments prescribed by qualified medical practitioners from the same area [24]. Similar findings were reported in a qualitative study on IHCP treatment practices [25].…”

A qualitative literature review exploring the drivers influencing antibiotic over-prescribing by GPs in primary care and recommendations to reduce unnecessary prescribing

“…25 I think AMR (anti-microbial resistance) is more related to hospital acquired resistance and not due to dispensaries. 27 But general practice is just ... it's not necessarily a question of being able to stick to some paragraphs or rules. 32…”

Need to improve availability of “access” group antibiotics and reduce the use of “watch” group antibiotics in India for optimum use of antibiotics to contain antimicrobial resistance

“…Penicillins are recommended as the first line antibiotics for treatment of respiratory tract infections [12]. However, recent trends indicate that penicillins are increasingly substituted by second and third generation cephalosporins for treatment of respiratory tract infections in both outpatient [13, 14] and inpatient settings [15, 16]. In a study between December 2007 and November 2008 which conducted exit interviews of patients with upper respiratory tract infections showed that in private clinics, cephalosporins were prescribed to 39% of patients followed by fluoroquinolone (24%), penicillins (19%) and macrolides (11%) [13].…”

“…However, in public clinics, the main class of antibiotics prescribed were penicillins (31%), followed by macrolides (25%), fluoroquinolones (20%) and cephalosporins (10%). In a 2014 qualitative study involving focus-group discussions and face-to-face interviews with doctors and pharmacists to study the behavior and perception about antibiotic use for acute upper respiratory tract infections (URTIs) and diarrhea in children in New Delhi indicated that some General Practitioners use cefixime and cefpodoxime for URTIs [14]. In a retrospective five-year study between 2007 and 2012 among hospitalized patients with community acquired pneumonia showed that cephalosporin prescriptions significantly increased whereas penicillin prescriptions significantly decreased over the study period [15].…”