Correlates of Inappropriate Prescription of Antibiotics to Patients with Malaria in Uganda

Abstract

<bold>Background<bold> In many areas, febrile patients presenting to health facilities are prescribed both antimalarials and antibiotics. It is not well understood which patient and facility-level factors are associated with health worker deviation from clinical guidelines and inappropriate drug treatment. The objective of this study was to identify the prevalence and correlates of inappropriately prescribing antibiotics when not required as well as of inappropriately withholding antibiotics following a clinical indication, in a population of malaria-positive patients in Uganda. <bold>Methods<bold> We utilized outpatient data from an evaluation of an integrated infectious disease training intervention including facilities from all health administrative regions. We identified patients who were prescribed an antibiotic without an appropriate clinical indication, as well as patients who were not prescribed an antibiotic when antibiotic treatment was clinically indicated. Separate multivariate logistic regression models were used to identify clinical and operational factors associated with inappropriately prescribing antibiotics and with inappropriately withholding antibiotics. <bold>Findings<bold> Of the 45,591 patients with malaria, 40,870 (90%) did not have a clinical indication for antibiotic treatment. Within this group, 17,152 (42%) were inappropriately prescribed antibiotics. Inappropriate prescription of antibiotics was more likely if the patient was less than five years old (aOR 1.96, 95% CI 1.75-2.19) and if the health provider was in the lowest training cadre (aOR 1.86, 95% CI 1.05-3.29). In contrast, patients were less likely to be inappropriately prescribed antibiotics if they were categorized as emergency triage status (aOR 0.75, 95% CI 0.59-0.96) or were HIV positive (aOR 0.31, 95% CI 0.20-0.45). Of the 4,721 (10%) patients with indications for antibiotic treatment, 521 (11%) were inappropriately not prescribed antibiotics despite having a clinical indication. Correlates of inappropriately withholding antibiotics included being treated by a medical officer (compared to clinical officers: aOR 0.54, 95% CI 0.29-0.98) and visiting a facility in a high entomologic inoculation rate area (compared to very high: aOR 2.11, 95% CI 1.52-2.94). <bold>Interpretation<bold> Much of the antibiotic treatment in malaria positive patients is prescribed despite a lack of documented clinical indication. These findings provide important data for decision making regarding the refinement of clinical guideline trainings.