Knowledge and practices of healthcare professionals regarding antibiotic use in a district hospital, Southern Mozambique: a cross-sectional study
The HCPs interviewed showed a high level of knowledge about identifying, differentiating from other drugs, and using antibiotics. However, a tenth of the HCPs showed limited knowledge of antibiotic resistance, and classification of the main pharmacological groups of antibiotics was observed. Some HCPs could not explain the meaning of “antibiotic” and “antibiotic resistance”. With specific training of HCPs, this situation can be improved, therefore contributing to the control of antibiotic resistance. Behavior change interventions based on education strategies, either as stand-alone interventions or as part of multifaceted interventions, positively impact antibiotic use5. The high level of knowledge observed in this study may be partially explained by the fact that the HCPs interviewed were from a district hospital (i.e., a secondary reference level health facility). A high prescriber’s knowledge, associated with compliance in the use of antibiotics, is a good starting point for appropriate antibiotic prescription and indeed contributes to the fight against antibiotic resistance2.
Some studies elsewhere reported that respiratory tract infections (RTIs) are the most common indications for prescribing antibiotics19. Prognostic uncertainty and the complexity of diagnosing RTIs have been reported as factors that influence antibiotic prescribing decisions. In this study, it was observed that almost one-third of the respondents (35%) stated that the last prescribed antibiotics were indicated for RTIs. This finding is concerning, as there is evidence of inappropriate use of antibiotics to treat RTIs, especially upper respiratory tract infections, such as the common cold20. Most upper RTIs are of viral etiology, and therefore the use of antibiotics is not indicated21. It is restricted to patients with a confirmed diagnosis of a bacterial infection or when prophylaxis is strongly recommended because of a higher risk for a bacterial infection.
In addition to RTIs, gastrointestinal tract infections are also common and more susceptible to the empirical use of antibiotics, especially in LICs such as Mozambique, where access to diagnostic tests is scarce14. Xavier et al.10 and Monteiro et al.13 showed that antibiotics were mostly prescribed for pediatric patients with gastroenteritis, thus agreeing with the results of the present study. In this study, 30% of the respondents reported having been prescribed the last antibiotics for gastroenteritis.
The study found considerable use of antibiotics, in the order of 88% of all prescriptions, with at least one antibiotic per prescription. This frequency is high compared to the WHO reference of 20−26.8% 18. Compared with studies carried out in Mozambique, this frequency (88%) is lower than the 97.6% reported by Monteiro et al. and 97.5% by Xavier et al. in pediatric patients and higher than the 65.9% reported by Faiela & Sevene in HIV-infected patients10,13,14. The frequency is also higher compared to 37.7% reported in South Africa and 46.7% in Kenya22,23. Other regional studies also reported high frequencies, such as 84.9% in Tanzania, 80.6% in Nigeria, and 70.6% in Botswana24,25,26. These differences may reflect the use of antibiotics in different contexts such as urban or rural, as well as a different pattern of behavior among prescribers. In addition, considering that the study was conducted in a secondary-level hospital, it is likely that some of the patients might have been referred from a primary healthcare facility with more severe infections that would require an antibiotic. The high frequency of antibiotic prescriptions observed in this study may indicate excessive use.
Most drugs were prescribed by generic name (96%), showing the trend of compliance with Mozambican medicines legislation that requires prescription by generic name. This frequency is lower than the 100% recommended by the WHO for prescriptions by generic name18. Our results are similar to 98.4% reported in Cameroon and 97% in Ethiopia27,28. Prescribing by generic name reduces the chances of drug duplication, as patients unknowingly buy and use the same drug from different prescribers when a prescriber uses a brand name and another generic name or when both use different brand names27. However, the prescription by generic name observed in this study may also show a high availability of drugs as generics. In Mozambique, generic drugs are more available in the public sector, while branded drugs are mainly found in the private sector.
All prescriptions had medicines listed in the National Medicines Formulary showing good compliance with the WHO reference rate of 100%. In contrast, the rate of prescriptions with an injectable antibiotic was relatively higher compared to the WHO reference range. The relatively higher rate may be linked to the healthcare being the local reference hospital, and it might have received patients referred to it for severe bacterial infections requiring an injectable antibiotic. Additionally, all injectable antibiotics were observed in children, and probably some could not take oral antibiotics.
Documentation of the antibiotic plan (or detailed antibiotic treatment) is a basic requirement for further antibiotic stewardship efforts. Although we have found good performance in the documenting of the prescriptions, some areas need improvement. We assume that the documentation of the prescribers’ names, clinical indications, dosage, and duration of the treatment, with a frequency of less than 90%, needs to be improved.
However, greater attention is needed regarding the key aspect of documenting the clinical indication (specifically in adults), the prescriber’s name, and the duration of the treatment. The prescriber’s name was not indicated in one-third of the prescriptions. The lack of the prescriber’s name may hinder the communication between the prescriber and pharmacist in the case of unclear prescriptions. The lack of duration of the treatment may contribute to the inappropriate use of antibiotics by favoring patients to take medicines for a period that is not recommended.
A total of nine different types of antibiotics, seven broad-spectrum and two narrow-spectrum were prescribed at the study site. Increased prescription of broad-spectrum antibiotics is a common phenomenon reported in other studies conducted in different contexts27. When the use of broad-spectrum antibiotics is indicated, there is a greater risk of resistance due to the selection of resistant strains, making them ineffective in controlling infections. Unfortunately, prescribers tend to use broad-spectrum antibiotics to treat suspected cases of gram-positive and gram-negative bacterial infections27. They are sometimes, prescribed for conditions that do not require antibiotic treatment, such as the common cold and flu, which are viral infections14.
Five different classes of antibiotics were prescribed in this study, with penicillins and sulfonamides being the most prescribed groups. Penicillins were more prescribed for children, while sulfonamides were for adults. This finding aligns with a study carried out in HIV-infected patients in southern Mozambique, which reported a higher frequency of prescription of antibiotics from the penicillin and sulfonamide groups14. The literature also shows that the antibiotics penicillin families are consumed more in hospitals and primary healthcare facilities27,29.
Cotrimoxazole was the most commonly prescribed antibiotic in adults and amoxicillin in children (Table 4). This finding may substantiate the knowledge of health professionals who are familiar with cotrimoxazole and amoxicillin12. The prevalence of HIV in Mozambique and the risk of opportunistic infections that require antibiotics for treatment or prevention could probably be responsible for the high frequency of cotrimoxazole prescription in this study. In addition, RTIs are more frequent in children and are mainly treated with amoxicillin, which probably justifies being the most prescribed antibiotic in children in this study30. The higher frequency of amoxicillin prescription in pediatric patients observed in this study is consistent with the literature. Studies in different contexts found amoxicillin to be the most prescribed antibiotic for pediatric patients in hospitals in Ghana and India20,31. In addition, we assume that prescribers tend to prescribe cotrimoxazole and amoxicillin more frequently because they are more accessible and belong to the group of antibiotics with a good safety profile regarding side effects, according to WHO AWaRe classification32.
The seasonal pattern of infections characterizes the demand for antibiotics. Most antibiotics are prescribed in winter, when an increase in bacterial and viral infections, such as rhinosinusitis and the common cold, is expected33. However, in this study, we observed a different trend of increased cotrimoxazole prescriptions in winter and phenoxymethylpenicillin in summer. In contrast, using a different approach, Caucci et al. found no seasonal trend for the prescription of cotrimoxazole and penicillin in a European context33.
Strengths and limitations
Our study was able to identify targets for improvement and stewardship efforts. The high frequency of antibiotic prescribing reveals a need to develop strategies to de-implement unnecessary and wasteful antibiotic prescriptions. We have addressed several points that reinforce our results, including the knowledge chain, antibiotic access through inventory, and prescription rates by age group and seasonality. We have identified some areas for improvement. These targets for improvement should inform and guide future training and development of guidelines to enhance the performance of the HCPs. With these findings, community and hospital-based awareness was performed.
Multiple-choice questions may not measure respondents’ accurate knowledge level because they could choose any alternative when they do not know the correct answer. However, tendencies were clear and unlikely of random responses. We assume that this limitation did not significantly impact our results, and it was a way to gather clear, concise quantitative data that could be easily parsed and shared. The relatively small sample size of healthcare professionals does not allow us to generalize the findings. Prescription data were collected retrospectively from copies kept at the pharmacy, so there may have been information bias. To minimize information bias, we have compared prescriptions kept at the pharmacy with other medical records. We did not measure antibiotic use or audit prescriptions to determine whether or not antibiotics were used appropriately, but we have identified areas for improvement. Despite these limitations, the study provides a good insight into the knowledge and antibiotic prescribing practices of HCPs from the MDH.
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