2.1. Study Setting
2.2. Study Design
2.3. Data Collection
3.1. Survey of Antibiotic Use in Hospitals in Bayelsa State, Nigeria
3.2. Interviews with Prescribers
4.1. Feasibility and Priorities for Implementation
4.2. Set up and Operation of the AMS Plan
Conflicts of Interest
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|Characteristics||Number of Participants n = 17 (%)|
|Years of practice||≤5||7 (40)|
|Rank||Medical officer||7 (40)|
|Senior medical officer||3(18)|
|Principal medical officer||4 (24)|
|Specialty||Internal Medicine||6 (35)|
|Obstetrics & Gynaecology||2 (12)|
|Level of care||Tertiary||11(65)|
|Steps to improve the availability of drugs:
|Policy Category||Intervention Functions||Suggestions and Recommendations from Stages 1 and 2||Implementation|
|Increase awareness of problems and rational prescribing|
Use of fliers and posters as well as on-line and face-to-face methods.
Education and training via short courses, workshops, use of local data to educate prescribers, highlight best practice and address problems
|Provision of up-to-date guidelines and treatment protocols|
Enablement, and models, of best practice
Strict protocols to restrict access to reserved products, including restricted pharmacy dispensing
|Improvements to lab facilities to provide enabling environment for rational prescribing.|
Wider coverage of health insurance,
Stocking of low-cost generics to promote affordability for patients
Invest in quality assurance units to safeguard product quality, so quality is not a barrier to optimal prescribing
|Implementation of prescribing guidelines|
Regular auditing of practice to regulate and inform improvements to practice
Collection and use of local data to provide directly relevant feedback to practitioners and teams
|Support at Government/health policy levels for prioritization of structural changes, and wider enforcement.||LT|
|Environmental/social planning||Environmental restructuring|
|At Government/health policy and institutional levels: interventions as above to ensure enabling environment||M/LT|
|Implementation of guidelines|
Availability and use of laboratory facilities
Regular auditing of practice to identify and address problems; and ensure continued enabling environment
|Increasing awareness and education about antibiotic resistance|
It was recommended that initiatives to increase awareness should target patients, other health professionals as well as prescribers.
Stakeholders perceived that there was a general awareness, and one hospital reported to have already held a presentation. Thus, there were some opportunities to build on existing initiatives. Stakeholders saw important challenges in addressing attitudes and behaviours. Securing engagement and attendance and promoting a desire among practitioners to change was highlighted.
Recommendations for AMS action plan and implementation:
|Provision of policies and guidelines|
Stakeholders reported that in the past prescribing guidelines had been developed, but these were commonly seen as not up-to-date or not readily accessible.
A potential challenge in the development of guidelines was having sufficient expertise for their development. However, it was acknowledged that a wide range of stakeholders e.g. DTC, infectious disease clinicians and scientists, pharmacists would bring together their professional expertise.
Ensuring engagement, ownership and acceptance by all stakeholders was seen as important for co-operation, compliance and enforcement. In one setting, restricted dispensing had already been accepted by the DTC, which included a procedure for review and approval of restricted products. Acceptance and implementation may be facilitated by a collaborative approach (scientists and health professionals) to their development.
|Monitoring and surveillance of antibiotic use|
On-going monitoring of the use of antibiotics and local research on infections and resistance could inform more rational use and was also of value in the development of policies and guidelines.
A monitoring or surveillance programme was also seen as a way of engaging professional groups and bringing them together in a shared AMS programme. In one site discussions had already begun. The principal barrier identified was having sufficient personnel with expertise to lead for an on-going surveillance and research programme. Possible action points were:
|Improved laboratory and diagnostic services|
Improvement of laboratory services and training of scientists to reduce empirical prescribing was identified as a requirement to guide judicious antibiotic prescribing. The key challenge highlighted was the recruitment of scientists with sufficient expertise. It was suggested that pharmaceutical companies may be able to assist, e.g. with the provision of sensitivity discs for their products. Thus, as part of an action plan:
|Procurement and quality assurance|
Steps to ensure continuity in availability, affordability and trust in the quality of products (especially low-cost generics) was seen as essential for the successful operation of an AMS programme in short, medium, and longer term. Barriers to access to quality medicines was seen as encompassing manufacturing and regulation, affordability for patients and prescribing practices.
In terms of quality assurance, facilities, personnel, and expertise was highlighted as a challenge. Possible collaboration between manufacturing and regulatory bodies was also mentioned. Despite the challenges, it was viewed that the AMS team should:
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