Sumaila and Tabong BMC Res Notes (2018) 11:443 https://doi.org/10.1186/s13104-018-3542-z BMC Research Notes RESEARCH NOTE Open Access Rational prescribing of antibiotics in children under 5 years with upper respiratory tract infections in Kintampo Municipal Hospital in Brong Ahafo Region of Ghana Abdul‑Nasiru Sumaila1 and Philip Teg‑Nefaah Tabong2* Abstract Objective: The aim of the study was to assess the rational use of antibiotics in children with URTIs in the Kintampo Municipal Hospital in Ghana. Results: A total of 839 medicines were prescribed, 237 were antibiotics. The mean number of medicines prescribed per patient encounter was 3.1. The percentage of patient encounters with antibiotics was 28.2 and 0.4% for injec‑ tions. The percentage of medicines prescribed by generic was 93.8% and from the essential medicines list was 94.9%. Ninety‑two of patients received amoxicillin. Polypharmacy was common as prescriptions with five to six medicines per patient encounter was found. Some prescribers are not following the WHO/INRUD requirement of prescribing medicines in their generic and from the essential medicine list of the country. Keywords: Rational, Medicine, Antibiotics, Children, Upper respiratory tract infection, Ghana Introduction frequency and duration of therapy is described as inap- In the last decades, medicines have had an unprecedented propriate use of medicines [2]. This notwithstanding, positive effect on health, leading to decline in mortality, studies have showed a high prevalence of antibiotic use disease burden and overall quality of life [1]. The rational among children under 5 with an estimate rate of 2.2 pre- use of medicines is regarded as a measure of good clinical scriptions per person per year [6, 7]. Though there are practice. The inappropriate use of medicines especially no age-specific disaggregated data, earlier studies have antibiotics have negative consequences on the quality found that antibiotic use in Ghana to be between 11.9 of care and can lead to antibiotic- resistance strains of and 60.7% [8–10]. micro-organisms [2–5]. The conference of experts on the Upper respiratory tract infections (URTIs) are infec- rational use of medicines (RUM), convened by the World tious diseases of the upper respiratory tract and include Health Organization (WHO) in Nairobi in 1985 defined condition such as common cold, influenza, pharyngitis, the RUM as giving patients medicines that are appropri- otitis media, tonsillitis and sinusitis [11]. However, com- ate to their clinical needs, in doses that meet their own mon cold is reported as the most prevalent accounting individual requirements for an adequate period of time, for about 80% of URTIs [12]. URTIs are mostly man- and at the lowest cost to them and their community. In aged symptomatically with basic analgesics to relief fever, view of this, the use of medicines that do not meet the increased fluid intake and with nasal decongestants [13] needs of patients in terms of disease condition, dose, because they are mostly viral in origin and many (about 90%) resolve without any intervention [12]. URTIs are very common among paediatric population *Correspondence: philgh2001@yahoo.com 2 Department of Social and Behavioural Sciences, School of Public Health, and therefore constitute a major target for inappropri- University of Ghana, Legon, Accra, Ghana ate use of antibiotics. As a measure to help reduce the Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat ivecom mons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sumaila and Tabong B MC Res Notes (2018) 11:443 Page 2 of 5 inappropriate use of antibiotics, the WHO has advocated Study variables for the use of essential medicine list and other policy We extracted the following variables from patients pri- guidelines for the use of medicines including antibiot- mary medical records: diagnoses (primary and second- ics [14–16]. The Ghana National Drug Programme has ary) according to the International Classification of developed and distributed the essential medicines list Diseases (ICD-9), age, sex, and prescription of antibi- (EML) and Standard Treatment Guidelines (STGs) to all otic at that visit (whether prescribed or not, and if so, public health institutions over the years [17]. The national the type of antibiotic selected), dose, frequency and drug treatment guideline requires that all prescription duration. should be generic and should be listed in the essential medicine list of the country [17]. The STGs provides for age and disease-specific doses and duration of treatment. Data analysis The aim of this study was to assess rational use of medi- The data extracted were entered into STATA 13 and cine among paediatric patients in the Kintampo Munici- analysed. The results were than compared with WHO pal hospital. benchmark indicators. Appropriateness of treatment was determined by the extent of adherence to the Ghana STG and EML [20] using the criteria recommended by Kunin Main text et al. [21] and Deshmuch et al. [22]. Materials and methods Study design We reviewed medical records of children under 5  years Results who attended the out-patient department of Kintampo Type of URTIs and antibiotics used Municipal Hospital with URTIs between the 1st of Janu- The minimum age was 0.5  months (15  days), the ary, 2009 and 31st December, 2014 using a WHO check- maximum age was 57  months with an average age list on rational use of medicine. of 18.3 ± 13  months. Children aged 1–5  years (12– 59  months) accounted for majority of patients (62.6%). Only 3 patients were less than 1  month (1.1%). Out of Study area the 270 patients, 140 (52.0%) were males. Among the The Kintampo Municipality is one of the 28 districts in 270 patients, the most common URTI was common cold the Brong Ahafo region of Ghana. The municipality has (52.6%). However, 17 patients had conditions which did a population of 111,263 [18]. The Kintampo Municipality not fit into the classification criteria for any URTIs and has one District hospital of 125 bed capacity, two Health were therefore described as non-specific. centres, two Rural clinics, one Community-based Health A total of 839 medicines were prescribed for the 270 Planning Services (CHPS) compound and one Maternity patients with no patient reporting multiple attendance home. for URTI. Two hundred and seven (237) antibiotics were prescribed per patient encounter; penicillin (58%), Sample size determination cephalosporins (19%) and macrolides (10%). Amoxicillin We used Yamane’s formula (1967) for population propor- (38.8%), cefuroxime (18.6%) and amoxicillin + clavulanic tion to compute the sample size for this study; acid (17.3%) were the commonly prescribed antibiotics (Table 1). N Sixty-two (43.7%) of patients with common cold n = (1) 1+ N (e2) received amoxicillin, 5 (3.5%) received amoxicillin with clavulanic acid and 6 (4.2%) received azithromycin and where n = minimum sample size, N = population size of cefuroxime whilst 32 (22.6%) did not receive any anti- 648, e = level of precision which was set at 5%. Substitut- biotic. Among patients with otitis media, majority, 23 ing the above into Eq. 1 resulted in a sample size of 248. (33.3%) were given amoxicillin + clavulanic acid whilst However, it was increased by 10% to 270. 21 (30.4%) received amoxicillin. Patients with pharyngitis received amoxicillin with clavulanic acid (47.8%). Data collection A systematic random sampling procedure was used. The Assessment of rational prescribing sampling interval of two was obtained by dividing the The mean number of medicines per patient encounter study population (N) by the sample size (n) [19]. We used was 3.1 which was higher than the WHO standard of ≤ 2 this sampling interval to sample patients and retrieved medicines per patient encounter. The prevalence of anti- their medical records for the review. biotic use for URTIs was 28.6%. Prescription by generic Sumaila and Tabong B MC Res Notes (2018) 11:443 Page 3 of 5 Table 1 Antibiotics prescribed for  the  management total prescriptions. This findings as agrees with literature of URTIs that showed that children tend to develop 3–8 bouts of Antibiotic (n = 237) Frequency (F) Percentage common cold in a year and this even tends to increase (F × 100/n) for children who attend daycare or preschool [23, 24]. Out of the 142 URTIs diagnosed with common cold, 110 Penicillins (77.4%) were given antibiotics. In Northern Tanzania, it Amoxicillin suspension 92 38.8 was found that about 68.9% of children under 5 received Amoxicillin + clavulanic acid 41 17.3 suspension antibiotic [25] despite the fact this condition in mainly Flucloxacillin suspension 4 1.7 viral and therefore the use of antibiotic is inappropriate. Cephalosporins Generally, it is recommended that children with com- Cefuroxime suspension 44 18.6 mon cold should managed with nasal decongestant [26], Ceftriaxone injection 1 0.4 antihistamine [27] and zinc [28] as these help to relief Macrolides symptom leading to spontaneous recovery. The use of Azithromycin suspension 17 7.2 intranasal ipratropium bromide has also be found to be Erythromycin suspension 7 3.0 very useful in relieving symptoms of common cold [29]. Sulphonamides The findings of study underscore the need to sensitize Cotrimoxazole suspension 21 8.9 prescribers on rational use of medicines especially for Others 10 4.2 common cold. No antibiotic 33 12.2 The study revealed three main classes of antibiotics which were commonly used to manage URTIs in children in the hospital. These classes were the penicillins, cepha- losporins and the macrolides and similar findings have and from the essential medicines list were 93.8 and been reported in a study in South Western Nigeria [30]. 94.9%, respectively (Table 2). The most prescribed class was the penicillins specifically About 93.0% of prescriptions had appropriate doses, amoxicillin and amoxicillin + clavulanic acid. Amoxicil- 95.6% were appropriate in frequency and 96.7% had lin is the first line antibiotic in the management of URTIs appropriate duration of treatment (Table 3). according to the Standard Treatment Guideline of Ghana [31]. Discussion Furthermore, the study revealed a 3.1 average number This study revealed that common cold was the most diag- of medicines prescribed per patient encounter, implying nosed URTI, followed by otitis media. Common cold that, patients were likely to receive three medicines per accounted for more than half of the diagnoses of the visit. The WHO indicator tools for rational prescribing Table 2 Comparison between the uses of medicine for URTIs in the study are against the WHO standard Prescribing indicator Value WHO standard Total number of patients prescriptions analysed 270 ≥ 100 Total number of medicines prescribed 839 – Average number of medicines prescribed per encounter 3.1 ≤ 2 % Medicines prescribed by generic 93.8 100 % Patient encounters with antibiotics prescribed 28.2 ≤ 30 % of patient encounters with injections prescribed 0.4 ≤ 10 % of medicines prescribed from essential medicines list or formulary 94.9 100 Table 3 Distribution of prescriptions according to appropriateness Parameter No. appropriate Prescriptions (N = 270) % inappropriate % appropriate No. inappropriate Dose 251 93.0 19 7.0 Frequency 258 95.6 12 4.4 Duration 261 96.7 9 3.3 Sumaila and Tabong BMC Res Notes (2018) 11:443 Page 4 of 5 however requires that only one or two medicines are Limitation prescribed per patient encounter [32]. This finding sug- The study was carried out in only one health facility gests the presence of poly pharmacy. A study carried out within the municipality and region, hence the conclu- at the Ghana Police Hospital revealed a similar finding of sions should be interpreted in the context of the limited 3.7 [33]. Similar findings have been reported in studies in scope of the research. Uganda (2.6) [34] and Jordan (2.4) [35]. The findings of this study further showed that the per- centage of medicines prescribed by generic wad 93.8% AbbreviationsINRUD: International Network for Rational Use of Drugs; RUM: rational use of which is less than the requirement that all medicines medicine; STG: Standard Treatment Guideline; URTI: upper respiratory tract should be prescribed in generic. This further call for infection; WHO: World Health Organisation. refresher training for prescribers to conform to the stand- Authors’ contributions ards in prescribing medicines for patients as rational use of Conceived and designed the experiments: ANS, PT‑NT. Performed the experi‑ medicines has become an indicator for measuring quality ments: ANS Analyzed the data: ANS, PT‑NT. Contributed reagents/materials/ of health care [36–38]. analysis tools: ANS, PT‑NT. Wrote the paper: ANS, PT‑NT. All authors read and approved the final manuscript. The percentage of patient encounters with antibiotics prescribed was 28.6%. This is within the range of ≤ 30% Author details 1 optimal, WHO standards and therefore tends to sug- Pharmacy Department, Jema District Hospital, Ghana Health Services, Accra, Brong Ahafo Region, Ghana. 2 Department of Social and Behavioural Sciences, gest a prudent use of antibiotics in Kintampo Municipal School of Public Health, University of Ghana, Legon, Accra, Ghana. Hospital. Such a judicious use of antibiotics will go a long way to minimize antibiotic resistance and serious adverse AcknowledgementsWe wish to thank the Medical Superintendent of the Kintampo Municipal effects [39, 40]. A percentage of 0.4% obtained for patient Hospital and medical records staff for the assistance. encounters with injections is also within WHO/INRUD Standard of ≤ 10%. This is however higher than the findings Competing interestsThe authors declare that they have no competing interests. of a study conducted in Ethiopia that reported a lower per- centage of 0.04% [41]. Globally, the use injections should Availability of data and materials be kept to the minimum because of the increasing risk of The data sets during and/or analyzed during the current study are available from the corresponding author on reasonable request. transmission of HIV, hepatitis and other blood related dis- eases through injection [42–44]. The low rate of injection Consent to publish use is also likely to reduce the risk of anaphylactic shock, Not applicable. tissue necrosis and sepsis in patients [45–47]. Ethics approval and consent to participate The findings showed that 94.9% for medicines prescribed The proposal for this study was reviewed and approved by the Ethics and from the essential medicines list falls short of the optimal Review Committee of the Ghana Health Service (GHS‑ERC 104/02/15). We also received administrative permission from the health facility to review patient WHO/INRUD standard of 100%. This is however higher records and use the data for this study. than a study conducted in Ghana in 2014 which found a 53.6% adherence to WHO/INRUD requirement [33]. This FundingThis study was conducted as part of the requirements for the award of a finding also indicate the need for training and development Master of Public Health Degree by ANS. He did not receive any funding from of quality assurance programmes. In Europe, quality assur- any institution. ance programmes and public campaigns have been devel- oped and launched to improve the use of antibiotics in Publisher’s Note primary care [48–50]. This strategy could be harnessed for Springer Nature remains neutral with regard to jurisdictional claims in pub‑lished maps and institutional affiliations. Ghana to improve rational use of antibiotics and adherence to standards in the use of medicines. Received: 11 May 2018 Accepted: 26 June 2018 Conclusions This study conclude that the overuse of antibiotics for URTIs was common in Ghana. The penicillins and cepha- References 1. WHO. The pursuit of responsible use of medicines: sharing and learning losporins are the most preferred antibiotics prescribed for from country experiences. Vet Rec. 2012;169:78. the management of upper respiratory tract infections in 2. Bbosa GS, Wong G, Kyegombe DB, Ogwal‑Okeng J. Effects of intervention children under 5 years. 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