923 Effect of Interventions on Misuse of Antibiotics/Antibacterial Drugs in Developing Countries: a Systematic Review Bbosa, Godfrey Sande 1,2 ; Wong, Geoff 2 ; Kyegombe, David B 3 ; Ogwal-Okeng, Jasper 1 1: Makerere University College of Health Sciences, Uganda 2: University of London, United Kingdom 3: Kampala International University Medical School, Ishaka Campus, Uganda 1

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Introduction Misuse of antibiotics/antibacterial drugs is a global problem especially in developing countries with poor healthcare systems & corruption Occurs at all levels in both public & Private Healthcare facilities Reported up to 75 % of antibiotics are prescribed inappropriately in teaching hospitals in developing countries (Nambiar, 2003) Are used in conditons where not needed like flu etc. Resulted in failure of eradicating infectious bacteria, emergence of resistance, waste of resources, increased cost of treatment, ADR & death (Kardas et al., 2005) 3

Rational Drug Use Prescriber, Dispenser & their workplaces Drug Supply System Patient & community Many Factors Influence Use of Medicines Policy, Legal and Regulatory framework Interventions are directed at these components 4

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Objectives of the review Review determined effect of various intervention studies on AB misuse in developing countries Research question 1.What are the various interventions measures used in controlling irrational use of antibiotics/antibacterial agents in developing / poorer nations? 2.What is the impact of various intervention measures used in controlling the irrational use of antibiotics/antibacterial agents in developing / poorer nations? 6

Methods Study design: A systematic review Search strategy: was developed to retrieve relevant articles from various databases including: – Medline/PubMed – Embase – INRUD/Management Sciences for Health (MSH) – WHO – Cochrane – Google scholar search engine was used to retrieve more studies from Journal articles & abstracts – Gray literature by manual method 7

Criteria for inclusion and exclusion of studies in the review All the studies included in the review followed PICO-DTS where: – Patient, population, or problem (P) – Intervention, independent variable, or exposure (I) – Comparators (control) (C) – Dependent variables or outcomes of interest (O) – Study design (D) – Timing (T) – Study setting (S) (Moher & Tricco, 2008; Stone, 2002) All studies were included or excluded basing on each of the above 8

Data extraction & storage of primary data Data was extracted using the designed data extraction sheet basing on aims of review criteria: – Geographical location of where study was conducted based (World Bank Country Classification, 2010). – Categories & subcategories of intervention - Education- Managerial/education - Managerial - Economic/financial - Regulatory- Education/regulation - Diagnostic- Multifaceted (Combination of almost all) – Study settings -Hospitals - Out-patients Departments -Public Healthcare facilities- Private Pharmacies/ drug stores -Community – Outcome measure basing on effect & effect size on AB 9

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Quality of evidence Quality was judged by Appraisal of individual primary research studies for inclusion in reviews (Gough, 2007): A = Trustworthiness of results (Methodological quality) B = Appropriateness of use of that study design for review's research question (Methodological relevance) C = Appropriateness of focus of research for answering the review question (Topic relevance) D = Judgment of overall weight of evidence (WoE) based on assessments made for each of criteria A-C Each of the studies were assessed as follows: 1-Strongly Agree5- Agree10 –Disagree or using Yes (Y) or No (N) or Not applicable (NA) 11

Results Articles retrieved and screened 12

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Discussion A total of 722 articles were retrieved and 55 were reviewed – 10.9% were from Africa, 63.6% from Asia, 9.1% from Latin America & 16.4% from South-eastern Europe A total of 52.7% were hospital settings, 5.5% outpatient departments, 21.8 public health care facilities, 12.7% private pharmacies/drug stores, and 7.3% communities Education intervention was 27.3% – With group discussion having 19.2% mean reduction in AB use, 27.6% in AB prescription & 41% belief of no AB use – Community training had 30.5% reduction in AB use (highest), 23.8% mean reduction in AB prescription & 36% belief of no AB use 20

Managerial was 20% with 8% improvement in AB dose – 8–100% AB use adherence & 31.8% mean reduction of AB receipt – 29.1% change of AB in resistance cases and % reduction in prophylactic AB use. Managerial/education was 3.6% with 4.7% reduction in AB prescription Regulatory was 9.1% with 60.5% improvement in AB use in restriction unlike 16.4% in non-restriction Education/regulation were 9.1% – with 8% reduction in non-indicated AB, 24% improved AB use rate, 14% mean appropriate AB use improvement – 11.1% reduction of incidence of bacterial resistance – 75.1% reduction in AB use in diarrhea, 42.4% reduction in scabies, 13.8–33.6% reduction in AB use in ARI – Overall 60% reduction in AB use 21

Diagnostic was 3.6%, with 68% reduction in AB use after diagnostic test as compared to100% in control – Was 73% likelihood of AB use in +test vs 87% in –ve test Multifaceted interventions were 27.3% – 63% improvement in appropriate AB doses prescribed (best), 2.6 mean no. of AB encounter reduction, 23% AB prescription reduction – 18.3% generic AB prescribing improvement, 32.1% reduction in AB use, 89% reduction in AB use in ARI, 82% in surgery, 62.7% mean reduction in deliveries, 39% in STDs, 36.3% mean reduction in diarrhea, 14.6% mean reduction in malaria – 6–11% reduction cost of treating bacteria-resistant organisms – Some studies, was 6.3 reductions in mean AB encounters after 1 month of intervention, then increased to 7.7 after 3 months hence lack of sustainability of intervention programme as observed in some studies No study on economic/financial intervention found 22

Conclusion Misuse of antibacterial/antibacterial drugs is on increase especially in developing countries Variety of interventions are used for irrational use of AB drugs & had some impact Most of interventions were done in Asia Multifaceted interventions are effective in reducing misuse & inappropriate use of AB drugs & reduce emergence of resistance to commonest bacteria in developing countries Some studies showed a tendency of reverting once intervention programme stops 23

Acknowledgments & Source of funding Acknowledge staff of Common Wealth Scholarship programme & staffs of University of London, Department of Primary Care & Population Health (PCPH) for their support especially Prof. Petra Boyton, Prof. Ceri Butler, Prof. Trish Greenhalgh & others Funding Source: – Common Wealth Scholarship Programme and University College London, Department of Primary Care and Population Health (PCPH) 24

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