Bbosa , Godfrey Sande 1,2 ; Wong, Geoff 2 ; Kyegombe , David B 3 ; Ogwal-Okeng , Jasper 1

1. 923 Effect of Interventions on Misuse of Antibiotics/Antibacterial Drugs in Developing Countries: a Systematic Review Bbosa, Godfrey Sande1,2; Wong, Geoff2; Kyegombe, David B3; Ogwal-Okeng, Jasper1 1: Makerere University College of Health Sciences, Uganda 2: University of London, United Kingdom 3: Kampala International University Medical School, Ishaka Campus, Uganda

3. 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)

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

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

7. 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

8. 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

9. 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

11. 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 Agree 5- Agree 10 –Disagree or using Yes (Y) or No (N) or Not applicable (NA)

12. Results Articles retrieved and screened

20. 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

21. 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 9.8-100% 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

22. 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

23. 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

24. 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)

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