Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis
Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis
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DOI：
10.1371/journal.pmed.1003139
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发表时间：
2020-06-01
期刊：
影响因子：
15.8
通讯作者：
Pai, Madhukar
中科院分区：
文献类型：
--
作者：
Sulis, Giorgia;Adam, Pierrick;Pai, Madhukar
背景抗生素的广泛使用在抗生素耐药性的发展和传播中起着重要作用。然而，在低收入和中等收入国家，特别是在初级保健一级，关于其使用程度，仍然存在重大的知识差距。我们对中低收入国家初级保健中进行的研究进行了系统回顾和荟萃分析，以估计抗生素处方的流行率以及此类处方中不适当的比例。方法和发现我们搜索了PubMed、Embase、Global Health和CENTRAL，以查找2010年1月1日至2019年4月4日期间发表的文章，没有语言限制。随后，我们更新了PubMed上的检索，仅获取截至2020年3月11日的出版物。纳入了在报告初级保健药物使用数据的中低收入国家（根据世界银行标准定义）进行的研究。3名评审员通过标题和摘要独立筛选引文，而所有选定记录的全文评价由2名评审员进行，他们还进行数据提取和质量评估。利用Hoy及其同事开发的工具的修改版本来评估每个纳入研究的偏倚风险。采用随机效应模型进行荟萃分析，以确定接受抗生素治疗的患者比例。世卫组织获取、观察和储备（AWaRe）框架用于对处方抗生素进行分类。我们从27个低收入国家中确定了48项研究，主要在公共部门和城市地区进行，主要基于医疗记录摘要和/或药物处方审计。抗生素处方的合并患病率比例为52%（95%CI：51%-53%），预测区间为44%-60%。各个研究的估计值在不同环境下是一致的。仅有9项研究评估了合理性，各种疾病患者中不适当处方的比例从8%到100%不等。在15个国家的16项研究中，报告了处方抗生素的详细信息，其中12个国家的抗生素占总数的60%以上。合并估计值的解释受到相当大的研究间异质性的限制。此外，大多数现有的研究方法问题和报告不足的细节，以评估适当的prescript.ConclusionsAntibiotics是高度规定在初级保健中的LMIC。虽然一部分研究报告了很高比例的不适当使用，但由于方法学的限制，无法评估真实程度。然而，我们的研究结果突出表明，需要采取紧急行动改善处方做法，首先将世卫组织的治疗建议和AWaRe分类纳入国家指南。
BackgroundThe widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.Methods and findingsWe searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%-53%), with a prediction interval of 44%-60%. Individual studies' estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.ConclusionsAntibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.