Abstract
Background:
Assessing whether antibiotic prescriptions are inappropriate requires knowledge of patients’ underlying conditions, which is often challenging in low and middle-income countries (LMICs), where misdiagnoses are frequent. Using predefined cases, standardized patient (SP) studies offer unique opportunities to generate more unbiased estimates of antibiotic overuse compared to conventional methods.
Methods:
We conducted secondary analyses of data from nine SP studies to estimate the proportion of SP-provider interactions resulting in antibiotic overprescribing across primary care settings in China, India, and Kenya. The WHO Access-Watch-Reserve (AWaRe) framework was used to categorize antibiotics based on their potential for selecting resistance. We estimated the overall prevalence of antibiotic prescribing and examined the associated factors, focusing on India as richer data were available from that country.
Results:
Across health facilities, antibiotics were given in 2392/4798 (49.9%; 95% CI: 40.8-54.5) interactions in India, 83/166 (50.0%; 95% CI: 42.2-57.8) in Kenya, and 259/899 (28.8%; 95% CI: 17.8-50.8) in China. Prevalence ratios of antibiotic overuse in India were significantly lower in urban versus rural areas (aPR 0.70; 95% CI: 0.52-0.96), and higher for qualified versus non-qualified providers (aPR 1.55; 95% CI: 1.42-1.70), and for presumptive tuberculosis cases versus other conditions (aPR 1.19; 95% CI: 1.07-1.33). Access-antibiotics were predominantly used in Kenya (85%), but Watch-antibiotics (quinolones, cephalosporins) were highly prescribed in India (47.6%) and China (32.9%).
Conclusion:
Solid SP data indicate alarmingly high levels of antibiotic over-prescription for key conditions across primary care settings in India, China and Kenya, with broad-spectrum agents being excessively used in India and China.
