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Impact of Medicine Management and Rational Use Workshop on Antimicrobial Drug Use in five
Hospitals – Eastern Province, Zambia
Kandeke C, Chibuta C, Banda D
Churches Health Association of Zambia, www.chaz.org.zm , P.O. Box 34511, Lusaka, Zambia
1. Abstract ID: 192
2. Background and setting
Author Name: Kandeke C
Email: [email protected];
Presenter Name: Kandeke C
Authors: Kandeke C, Chibuta C, Banda D
The Churches Health Association of Zambia (CHAZ) is
an interdenominational non-governmental umbrella
Institution: Churches Health Association of Zambia
Title: Impact of Medicine Management and Rational Use Workshop on Use of
Antimicrobial Drugs in Five Hospitals in the Eastern Province, Zambia
Abstract:
Problem Statement: Antimicrobial drugs (AMDs) are the most frequently
prescribed therapeutic agents in Zambia. Antimicrobial agents account for
50% to 80% of drug prescriptions. Stock outs may jeopardize lives as they are
necessary for the treatment of most bacterial infections; inappropriate use can
lead to the development of resistance, adverse drug reactions, and waste of
scarce resources.
Objectives: To describe antimicrobial drug prescribing practices in five
hospitals (four church affiliated and one government in the eastern provine of
Zambia; to compare antimicrobial use among the five hospitals; and to assess
changes resulting from a training workshop on the use of antimicrobial drugs in
the five hospitals.
Design: Before and after study with no control group was carried out in a
sample of four mission and one government hospitals using some of the MSH
in-patient drug use indicators.
Setting and Population: Four church and one government hospital in the
Eastern Province using in-patient drug charts and case notes. One hundred inpatient records were randomly (simple random sampling) selected from each
hospital during baseline and post training phases.
Intervention: A baseline study on antimicrobial use was conducted using
selected Management Sciences for Health (MSH) indicators in February 2003,
followed by a training workshop on antimicrobial therapy (with experiential
practical exercises at a hospital and a health center) in March 2003.
Participants included medical doctors, clinical officers, pharmacy technologists
and nurses. A post training study was then conducted six months after the
workshop.
Outcome Measures: Availability of a key set of antimicrobial drugs; average
number of days out of stock; % of hospitalizations with one or more AMDs
prescribed; average number of AMDs prescribed per hospitalization; % AMDs
prescribed consistent with the hospital formulary list; average duration of
prescribed antimicrobial treatment; % antimicrobials prescribed by generic
name; % of doses of prescribed AMDs actually administered; average duration
of hospital stay of patients on antimicrobial drugs; number of AMD sensitivity
tests reported per hospital admission including AMD treatment.
Results: Availability of key AMDs on day of study decreased from 95% to
88.6%. Average number of days out of stock increased from 88 to 139; %
hospitalisations with or more AMDs decreased from 65.7% to 62.5%; average
number of AMDs prescribed per hospitalisation decreased from 1.6 to 1.5; %
prescribed consistent with formulary list remained same (100%); percentage
of generic AMDs prescribed increased from 55.7 to 65; percentage of doses of
AMDs actually administered increased from 54% to 56%; average duration of
hospital stay was reduced; only one hospital admission sensitivity test was
conducted.
Conclusions: Training workshop with experiential practical exercises
improved use of AMDs in most hospitals. However, there were some outcomes
that improved only slightly (% of doses of prescribed AMD actually
administered) some were worse than the baseline in some hospitals.
Study Funding: Catholic Organization for Relief and Development
(CORDAID) in conjunction with Churches Health Association of Zambia
(CHAZ)
3. Study Objectives
5. Intervention
1.
The training was designed to address problems identified in
the pre-training indicator study.
The target group was health providers involved in prescribing,
dispensing and administering antimicrobial drugs. These
included medical doctors, clinical officers, pharmacy
technologists and nurses.
The training workshop lasted five days. Training methodology
included lectures, group discussions, case studies and
experiential field visits to nearby health facilities.
Facilitators were from CHAZ secretariat and member
institutions and was comprised of a pharmacist, medical
doctor, nurse and a pharmacy technologist.
To describe antimicrobial drug prescribing
organisation of the 116 church health administered
practices in five hospitals (four church affiliated
health institutions in Zambia. It is responsible for 30% of
and one government in the eastern province of
national and 50% of rural health care in Zambia.
Zambia;
CHAZ has been involved in supporting member
2.
institutions in drug supply management and promoting
To compare antimicrobial use among the five
hospitals
appropriate use for over ten years. In all these CHAZ has
3.
been involved in training activities, concerns have
To assess changes resulting from a training
always been raised on the use of antimicrobial agents
workshop on the use of antimicrobial drugs in the
for in patients. Out patient drug use indicator studies by
five hospitals.
various groups estimate that 80% of outpatient
4. Design
prescriptions have at least one antimicrobial agent
prescribed (Chileshe et al 1998, O.Hazemba 1999).
Before and after study with no control group was carried out in
a sample of four mission and one government hospitals using
some of the MSH in-patient drug use indicators.
However, no studies have been conducted in Zambia to
look at antimicrobial use for in patients.
A post training study was then conducted six months after
the workshop.
The Churches Health Association of Zambia (CHAZ)
decided to conduct a study on in patient antimicrobial
use in five hospitals in the Eastern Province of Zambia.
This was done following reports of high drug
3 6
1
consumptions and increased drug expenditures in
mission hospitals due to inappropriate use . To compare
how mission hospitals were using AMDs one
2 2
8 3
3 6
1
government district hospital was included in the study.
The hospitals are located in rural and semi-urban areas
of the province.
6
4
5
3
8. Results
6. Data collection
Average days out of stock of key Antim icrobial Drugs
Availability of key Antimicrobial Drugs
Percentage admissions with at least one AMD
Data was collected retrospectively. In both baseline and post
40
20
Post
M
3. Percentage of hospitalizations with one or more AMDs
Post
40
20
0
0
Av
er
ag
e
M
ini
m
um
um
ax
im
E
D
C
B
A
2. Average number of days out of stock;
10
5
0
1. Availability of a key set of antimicrobial drugs;
Pre
A
B
C
D
E
Maximum
Mean
Minimum
Mi
nim
um
7. Outcome measures
Post
15
Me
an
60
Pre
Ma
x im
um
Pre
80
60
E
80
study.
20
D
100
100
C
randomly selected and examined for outcome measures of the
25
B
120
A
training studies 100 in patient drug charts for 2002 were
prescribed;
4. Average number of AMDs prescribed per
hospitalization;
5. Percentage AMDs prescribed consistent with the hospital
formulary list;
Percentage AMD prescribed by generic
6. Average duration of prescribed antimicrobial treatment;
Pre
2
Post
1.5
Pre
80
1
Post
60
100
Av
era
ge
Mi
nim
um
admission including AMD treatment.
0
0
A
B
C
D
E
Maximum
Average
Minimum
4755.6
Antimicrobial drugs in most hospitals after training
workshop. However, there were instances where some
indicators actually deteriorated. For example availability of
Pre
Post
100
63 53 5361.8 5462 5963 54.256.4
61.7
59
52
52
Pre
33.4
33.4
50
Ma
x im
um
Av e
rag
e
Mi n
imu
m
Post
E
D
C
B
100
80 55.167.9 59.1 54.555.6 55.2
47
60
40
20
0
Generally results show some improvement in the use of
Percentage of doses of prescribed AMDs actually
administered
Percentage AMD prescribed by generic
83
66.659.1 66.6
55.764.9
Post
20
9. Summary
83
Pre
40
A
1. Number of AMD sensitivity tests reported per hospital
120
0.5
Ma
x im
um
Antimicrobial drugs;
A
.
E
9. Average duration of hospital stay of patients on
D
administered;
Percentage consistent with EML
2.5
C
8. Percentage of doses of prescribed AMDs actually
100
80
60
40
20
0
B
7. Percentage antimicrobials prescribed by generic name;
Average number of AMDs per hospitalisation
key antimicrobials decreased from baseline (there were
logistical problems at the Medical Stores) and others
where there was a very small improvement.
The use of laboratory for sensitivity testing was only done
in two cases at one hospital. Prescriptions for Antimicrobial
0
A
B
C
D
drugs were therefore written empirically.
E Maxi Mean Mini
Generally use of AMDs was better in smaller hospitals than
bigger ones.
5
1
3
7
Acknowledgements
The authors acknowledge the Catholic Organisation for Relief and
Development (CORDAID) and the Churches Health Association of Zambia
(CHAZ) for funding this study. Special thanks to Mr. Oliver
Hazemba for help with this work.
A
B
C
D
E
Maximum
Average
Minimum
10. Discussion
Although results show some improvement in the use of
antimicrobials after training, there could have been
other external factors other than the training that could
have affected the results. For example reduced
availability of key antimicrobials could have influenced
prescribing habits.
However, other indicators such as administration of
doses prescribed and generic prescribing could not
have been influenced by availability.
It is recommended that future studies be designed in
such a way that there are control groups.