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Rational prescription & use: A snapshot of the evidence from Pakistan and emerging concerns
Abstract
Introduction: Irrational drug use remains globally common and there is a lack of country level synthesis for strategizing policy actions in Pakistan. Methodology: We conducted a scoping review of available peer reviewed and grey literature on prescribing patterns and drug dispensing in Pakistan to identify emerging concerns. Results: There is excessive drug use in Pakistan compared to the average for LMICs with inappropriate prescribing, high use of injections and antibiotics, choice of more expensive drugs, inadequate dispensing and weak community pharmacy. Policy concerns include excessive drug registration, poor enforcement of essential drug lists and standard management protocols, open access of industry to health providers, and lack of private sector regulation. Conclusion and Policy Recommendations: Review of evidence demonstrates deviance from rational use in the areas of medicine prescription, dispensing and self-medication, and low impact of existing policy measures. Quality of research needs to be improved focusing on standardized national surveys, consumer related formative research, and interventional research. Rational drug use is a neglected area in Pakistan requiring policy measures at multiple levels of health system and continued and simultaneous investment in standardized research.
... More than two thirds of the drugs (67%) were prescribed from EML. Though this is below the WHO standard of 100% but the figures are encouraging as compared to national average of 50% and comparable to figures (72%) of low and middle-income countries 19 . Essential medicines are those that are safe, cost effective and selected by keeping in view the disease prevalence and public health relevance and hence fulfilling the health care requirements of majority of population. ...
... In the present study, 8% of the encounters had injection prescribed that is lower than the WHO standard (13.4-24.1 %) and way below the national average of 60% 19 . The lower predominance of injection might be due to outpatient setting in our study as well as social norms against this form of treatment intervention in the study area. ...
Objective: To evaluate prescribing practices in public health facilities of district Mirpur, Kashmir where no previous evidence regarding drug-prescribing behaviours was available.
Study Design: Cross-sectional study.
Place and Duration of Study: Department of Pharmacology and Therapeutics, Army Medical College, Rawalpindi and outpatient departments of public health facilities in district Mirpur, Kashmir, from Aug to Oct 2020.
Methodology: The prescribing pattern analysis was done by objective observations of prescriptions after patient-physician encounter. World health organization defined core and complementary prescribing indicators were evaluated for all the prescriptions.
Results: Among the core prescribing indicator, average number of medicines per prescription were 3.11 (World Health Organization’s standard, 1.6-1.8). Only 2% and 67% of medicines were generic and essential medicines respectively (standard, 100%). Almost half the prescriptions contained antibiotics (standard, 20-26.8%) whereas 8% had injections (standard, 13.4- 24.1%). Among the complementary indicators there was no prescription without medicines and average prescription cost was 479 Pakistani Rupees.
Conclusion: This is the first study to give a snapshot of prescribing behaviours in public health facilities in Kashmir. All the prescribing indicators except injectables were below the standards. A multi-disciplinary approach involving authorities, industry and professionals is required to promote rational prescribing.
... Results indicated that prescribed drug combinations have shown variation that may affect in vivo properties of the drug. Earlier studies suggested that regulation of policy investment to reduce un-necessary prescription of drugs is required (Zaidi and Nishtar 2012). Fixed dose combinations have also been included in the prescriptions which were evaluated in this study. ...
... Any inappropriate advertisement also reasons of irrational prescribing (Rohra et al, 2016). There is a need of regulation of policy investment to reduce not only the un-necessary prescription of drugs but the concept of community pharmacies and generic prescribing must be promoted (Zaidi and Nishtar 2012). Drug utilization practices also very significant. ...
Aim: This study evaluates effect of prescribed multiple tablets on their in-vitro disintegration time and pH and viscosity of disintegration medium when given individually and in prescribed combinations.
Material & Methods: Prescriptions having only tablet dosage forms were selected. Disintegration time of prescribed combinations was evaluated at three conditions. In Condition 1, prescribed tablets were taken individually in separate disintegration medium, In Condition 2, all tablet formulations prescribed on single prescription were placed at once in medium and in Condition 3, all prescribed tablet formulations on one prescription was placed one after another with 10 min interval. The disintegration time was noted for tablets in all the above conditions, while viscosity and pH of disintegration media were evaluated at Condition 1 and 2. The data of pH and viscosity of two tablet (C2) and that of three or more tablets (C≥ 3) were compared to data of all combinations (data of C2+ C≥ 3) and labeled as CT. Degree of unionized drug was computed for prescribe combination with significant change in pH in Condition 1 and 2. Data were statistically analyzed using SPSS.
Results: Disintegration times of studied tablets at all conditions did not differed (p≥0.05). However, combination of two tablets shown significant change in pH of respective disintegration media (p<0.05), while viscosity of disintegration media for C2, C≥ 3 and CT at Condition 1 and 2 and pH for C≥ 3 and CT at the above two conditions did not varied. Fraction unionized of drug in combination of C2 in Condition 1 and 2 also varied with changed pH of the disintegration media.
Conclusion: Prescribed drug combinations affect physicochemical parameters of in-vitro disintegration fluids, which may affect the bioavailability and therapeutic outcome.
... 10 Rational prescribing and quality use of medications remains a neglected domain within medical practice in Pakistan. 14 The International Network for the Rational Use of Drugs (INRUD) and WHO Action Program on Essential Drugs (WHO/DAP) collaborate and support many developing countries like Zimbabwe and Indonesia. They provide international indicators, methodologies and standard to deliver benchmark. ...
Pakistan is one of the countries with the highest number of medications filled per prescription due to overly prescribed antibiotics and injectable drugs. This is due to a lack of ethical practices in prescribing because doctors are significantly influenced by lucrative financial incentives of pharmaceutical companies rather than clinical findings. This immoral activity has become significantly amplified over the past few years and continues to be a challenge in Pakistan. Currently, there is no code of ethics for marketing and promotional activities of pharmaceutical companies. This year, authorities have step up and are in the process of creating policies to regulate companies and practitioners. Implementation of these new policies needs vigilance from health officials, strong professional commitment and institutional collaboration. If executed correctly, these polices should create an environment of professionalism within the healthcare sector.
Article Type: Letter
... This is similar to that reported by Deshmukh et al. 12 Similar type of finding were observed by two other studies which had shown average use of drug per patient in the range of 2.5 to 3.02. 13,14 Appropriate antibiotic prophylaxis can reduce the risk of wound infections after surgery, but additional antibiotic use also increases the selective pressure favouring the emergence of antimicrobial resistance. ...
Background: Surgical site infections are associated with prolonged hospital stays and increased cost of therapy. Prophylactic use of antimicrobials is to prevent the incidence of postoperative wound infection. To generate data on postoperative use of antimicrobials this study was planned.Methods: The information was collected in semi-structured questionnaire format from the patient’s case paper. Information regarding the antimicrobials prescribed by surgeon, including drug combinations, duration of therapy, frequency of drug administration, and diagnosis for the surgery was collected. Surgical wounds were classified based on National Research Council (NRC) criteria.Results: Mean duration of antibiotic use was 3.71 days for clean surgeries (70%) and ranging from 2.67 days to 6 days for clean contaminated, contaminated and dirty types of surgeries. average number of antimicrobials prescribed for surgical antimicrobial prophylaxis was 3 per patients. Ceftriaxone, cefixime, ofloxacin, levofloxacin, amikacin, amoxycillin + clavulanic acid, ampicillin, metronidazole were used for postoperative prophylaxis.Conclusions: As per guidelines, the usage of antibiotics was found to be inappropriate in some conditions. Third generation cephalosporin was the preferred or most prescribed choice of drug for postoperative prophylaxis. The average number of antimicrobials prescribed for postoperative prophylaxis was 3 per patients.
... Ideally, the use of antibiotic must be justifiable and appropriate tests must be done to confirm that the treatment is appropriate. Pakistan lists as one of top countries that utilize some of the costliest antibiotics in large quantity resulting in increased bacterial resistance, mostly due to their overuse [21]. ...
... Despite all quality measures at manufacturing and distribution level, it has also been found that the efficacy of the medicines is usually affected by storing the medicines at higher temperature ( > 25°C) than the required temperature (< 25°C) for most of the medicines (25,26). As the majority of the medicines are to be stored at less than 25 °C and the similar temperature is expected at the time of packing of medicines (27,28). ...
Medicines are the crucial tools to control and prevent various diseases. Ineffective medicines can cause wastage of resources. The efficacy of medicines gets affected due to improper storage conditions particularly the improper temperature. The objective of this review was to synthesize the findings regarding the storage of medicines on required temperature in Pharmacies and role of community pharmacies, particularly in rural areas. An extensive literature review was carried by retrieving articles from various databases like Pub med, Google scholar and Science Direct and by using terms like 'temperature', 'pharmacy ', 'medicines' and 'storage'. Types of studies were descriptive studies, systematic reviews, and various WHO reports. Normal storage conditions mean storage in dry, well-ventilated places at temperatures of 15–25 °C or, depending on climatic conditions and properties of the drug; it might go up to 30◦C. Furthermore, uninterrupted cold chain maintenance is required from the manfacturer till the dispensing of the medicines. Temperature monitoring devices must be used, in order to ensure the appropriate temperature of the medicines during transportation from one to another place. Medicinal products require appropriate storage conditions in order to ensure the quality and efficacy of medicines. Improper storage can increase the unnecessary burden on the economy of general population due to their poor efficacy. Strong monitoring of storage conditions is required to ensure storage practices in community pharmacies. Furthermore, ongoing training should be arranged for pharmacy owners to teach them about standard storage practices, particularly in rural areas. Keywords: Temperature, Community Pharmacy, Medicines.
... The injudicious use of anti-microbials attribute towards antimicrobial resistance and emergence of new mutant strain. [5][6][7][8] In Pakistan, there is need to conduct drug utilization to identify appropriate usage of drugs in terms of medical, social and economic aspects. To overcome the problem, strategies to decrease unnecessary anti-biotic prescription like "Antibiotic Stewardship Prog-rams" must be implemented. ...
p>The practice of medicine has been transformed by antimicrobials. However, overuse and misuse of anti-microbials is one of the major global health problems. Longer and expensive hospital stays are expected for those patients who are suffering from multi-drug resistant organisms.<sup>1</sup>
Antibiotic stewardship is an emerging concept and may be defined as coordinated interventions to imp-rove and measure the appropriate use of antimicrobials with selection of the optimal antimicrobial drug regimen, duration, dose, and route of administration.” Antibiotic stewardship program (ASP) is aimed to tar-get the antibiotic related optimal clinical outcomes, minimal toxicity and adverse events, cost reduction for infections, and curtail the selection for antimicrobial resistant strains.Centre for disease control and prevention (CDC) has described core elements of hospital ASP, the essentials of these are leadership commitment, accountability, drug expertise, action, tracking, reporting, and education.<sup>2</sup> This program has larger impact on infection rates, resistance patterns, costs and clinical outcomes in many studies.<sup>3, 4</sup>
Pakistan, being the developing country, is facing the problem of antimicrobial resistance at large due to irrational use of antimicrobials. Review of data on drug use in Pakistan shows the excessive and irrational drug use in Pakistan with higher use of antimicrobials and injections and choice of more expensive drugs with inadequate dispensing, compared to the lower middle income countries<sup>. </sup>The injudicious use of anti-microbials attribute towards antimicrobial resistance and emergence of new mutant strain.<sup>5-8</sup>
In Pakistan, there is need to conduct drug utilization to identify appropriate usage of drugs in terms of medical, social and economic aspects. To overcome the problem, strategies to decrease unnecessary anti-biotic prescription like “Antibiotic Stewardship Programs” must be implemented.<sup>9</sup> In Pakistan, Medical microbiology and Infectious diseases society of Pakis-tan (MMIDSP) has taken initiative to develop indigenous ASP and training program. The ASP should be the part of undergraduate curriculum to sensitize our future doctors. The regulatory authorities should also be active in monitoring the judicious use of antimicrobials. The masses should have easy access to the quality health care services, so as to minimize the irrational antimicrobial use.</p
... In a study involving, the analysis of treatment records for 150 in patients at a primary health complex in Bangladesh in 2009, the highest prescribed College, Bengaluru in 2012, and drug utilization study of antimicrobials in post-operative showed that the average number of drugs prescribed was 2.5±3.02 which is similar to our study [13]. Another study conducted in Department of Community Health Sciences and Women and Child Health Division, Aga Khan University, Stadium Road, Karachi, Pakistan in 2013, and rational prescription and use showed that the average number of drugs prescribed was 3 or more which is similar to our study [14]. ...
Objective: The present study aims to determine the pattern of antibiotic utilization at the surgery department of a tertiary care hospital.Method: A prospective observational study was conducted over a period of 6 months period in surgical ward at Bharti Hospital and Research Centre, Pune, a 1000 bedded teaching hospital. Patients above 18 years and receiving antibiotic therapy pre and post-surgery were included in the study.Results:160 patients with surgical operations were included in the study.The disease spectrum was classified into respective system-wise surgical procedures of which 49.37% cases are skin & soft tissue infections, 25.62% cases of general surgical procedure, 12.5% cases of gastrointestinal surgical procedure, 11.25% cases of urinary system and 1.25% case of head neck system. 20.62% of the study patients had hernia, 18.12% patients had cellulitis, 16.87% patients had diabetic foot ulcer, 16.25% patients had abscess, and 10.62% patients had appendicitis and cholelithiasis. In this study, it was found that 471 antibiotics were used in total of 160 patients, among which highest group of antibiotics prescribed were third generation Cephalosporin (28.23%) followed by Penicillins (23.56%). The most frequently prescribed antibiotics were Metronidazole − 19.74% among the Nitroimidazoles followed by Ceftriaxone − 19.53% of the class Cephalosporins.Conclusion: The rate of prescribing of broad-spectrum antibiotics has increased demonstrably which may result in development of bacterial resistance; however development of guidelines for antibiotic prescription and use of appropriate drugs for the diseases can minimize the unfavourable use of antibiotics and cost of healthcare.
... Evidence suggests that self-medication with antibiotics is commonly practices by 6-11% of the population. [13] Rational drug use is well recognized as an important part of health policy. The underlying principles or criteria include safety, accessibility and efficacy/effectiveness. ...
Background: This article provides a review of different studies about rational use of drugs in Pakistan and different interventions to improve drug use in the country. The analysis of these studies focused on the quality of services offered by these pharmacies, knowledge of drug sellers and dispensing practices. Material and methods : The summary of rational drug use and their possible health consequences is based on reviews of drug use in Pakistan. A systematic inventory of published research work since 1990 to 2015 was undertaken to identify studies which focused on different aspects of rational drug use. Annals and computerized databases of International Network for Rational Use of Drugs (INRUD), WHO, PubMed, Science Direct were screened for relevant journal articles, research reports and newsletters. To expand and fortify the search process, the general search engine Google was utilize. Results: Initially, a total of 60 articles were retrieved for electronic databases by the authors. These articles were then again matched with the objectives of this study and those articles which did not qualify, were excluded. After further screening, 20 articles were selected and 15 appropriate studies were finally included in the review. Conclusion: In this study, we find out that large number of drugs is being used in wrong way. The current paper highlighted that quality of services provided at community pharmacies in Pakistan is not satisfactory. The situation of rational drug use indicators in the hospitals where the study was conducted is alarming. There is an urgent need for intervention to improve the situation. Key words: Rational drug use, Irrational drug use, Pakistan.
Background: Overuse of antibiotics is a significant problem in low- and middle-income countries where recommended treatment guidelines are not routinely practiced, resulting in antimicrobial resistance. Acute respiratory tract infections, mostly viral in origin, remain the clinical category for most commonly prescribed antibiotics. Due to the lack of local evidence about antibiotic prescribing trends in such infections, this study was conducted to evaluate the prescribing patterns in general and antibiotic prescribing trends specifically in prescriptions with the diagnosis of acute respiratory infections in district Mirpur of Azad Kashmir. Patients and methods: A prospective cross-sectional study carried out in the Department of Pharmacology and Therapeutics, Army Medical College, Rawalpindi, and outpatient departments of public health facilities in district Mirpur, Kashmir, from Aug to Oct 2020. Data were collected from 10 different public health facilities in District Mirpur, Kashmir including, three rural health centers (RHC) and five basic health units (BHU). Prescribing pattern analysis by objective observations of the prescriptions after patient-physician encounter against the World Health Organization defined core prescribing indicators. The appropriateness of antibiotic use was analyzed against clinical practice guidelines. IBM SPSS Statistics for Windows, Version 26 was used for data analysis. Descriptive analysis was done to find frequencies and percentages for categorical data and means and standard deviation for continuous data. Results: Total number of prescriptions evaluated was 144. Number of prescriptions containing antibiotics was 118 (82%) (standard, 20 - 26.8%). Inappropriate use of antibiotics was seen in 78% of cases where no antibiotics were indicated. The average number of medicines per prescription was 3.11 (standard, 2.1), whereas 79% of medicines prescribed were from the national essential medicine list (standard, 100%). Only 2.5% (standard, 100%) of the medications were prescribed with generic names. Conclusion: This study shows an inappropriate and overuse of antibiotics for acute respiratory tract infections, indicating a lack of adherence to core prescribing indicators and clinical guidelines by the physicians in outpatient clinics of Mirpur.
The rational drug prescribing practice is an important health concern around the globe that not only interferes patient's life but also the socioeconomic issues.
The aim of current study was to evaluate the rational use of drug, prescribing behaviour of consultant physicians, role of medical team members in irrational therapy and form the basis for providing necessary information to the policy makers.
This cross-sectional study was conducted involving a set of 340 medication orders containing about 1,755 medications prescribed to patients in DHQ Teaching Hospital DI Khan, Pakistan from March to July 2009. The WHO operational package for monitoring and assessing country pharmaceutical situations indicators were used for data collection.
Among drugs prescribed per average encounter, 75% were dispensed from hospital pharmacy. Generally about 22.3% encounters of overdosing, 16.16% drug duplication, 24.25% drug-drug interactions, 3.5% adverse drug effects and 3.8% cases of contraindications were recorded. The proportion of consultations with antibiotics and injectables prescribed was 80% and 57% respectively. Likewise not less than 70% patients were prescribed NSAIDS, 67% steroids, 55% vitamin supplements, and 34% oral re-hydration solutions. Minimum 5 drugs per prescription were recorded and 70% of prescriptions were reported with high cost of therapy.
The drug practice among hospitalised patients was clearly irrational accompanied by high levels of medication error. An accurate prescribing decision, appropriate treatment, and rational use of drugs are major needs of the day to ensure safe medication practice.
To determine the prevalence, attitude and knowledge of self-medication amongst university students of Karachi, Pakistan.
This cross-sectional, study was conducted from Jan-Feb 2007. A convenience sample was taken from 2 medical and 2 non-medical universities of the city of Karachi, Pakistan. Data was analyzed using SPSS v 14 and associations were tested using the Chi square test.
Of the 572 participants (mean age=21 +/- 1.8 years, Male: Female ratio=1:1.5), 295 were medical and 277 were non-medical students. The prevalence of self-medication was 76%. Forty three percent students stated that they alter the regimen of prescribed medicines while 61.9% stated that they stop taking a prescribed medicine without consulting a doctor. The most common reason for self-medication was previous experience (50.1%) and the most common symptoms were headache (72.4%), flu (65.5%), and fever (55.2%). Commonly used medicines were analgesics (88.3%), antipyretics (65.1%) and antibiotics (35.2%). Eighty seven percent of students thought self-medication could be harmful and 82.5% students thought that it was necessary to consult a doctor before taking a new medicine. There was no significant difference between the self medication practices of medical and non medical students (p=0.8)
Prevalence of self-medication is high in the educated youth, despite majority being aware of its harmful effects. There is a need to educate the youth to ensure safe practices. Strict policies need to be implemented on the advertising and selling of medications to prevent this problem from escalating.
Antibiotics are used to eradicate the pre- and postoperative infections in surgical procedures and in all others medical cases. However, inappropriate and indiscriminate use of antimicrobial agents can potentially have a number of problems. The emergence of antimicrobial resistant bacteria, an increased number of patients experiencing adverse drug events, and increased drug-related cost have been documented. The objective of the study was to determine the trend of use of antibiotics and hospitalisation of patients in various units of a tertiary care hospital, to investigate practice variation of antimicrobial agents within the hospital, and to identify and document any opportunity for its improvement.
A questionnaire containing relevant information about the study was prepared. Patients' age, sex, diagnosis, duration of hospital stay and type of antibiotic used were recorded and analysed, with particular reference to antibiotic group and disease pattern, in 3 different treatment areas of Hayatabad Medical Complex (HMC), Peshawar, Pakistan, from July 2006 to June 2007.
During the period under report, a total of 519 patients were studied for their disease and the type of antibiotics used. The leading type of antibiotics reported were 3rd generation antibiotic used on 147 (28.33%) patients in the 3 units collectively, 1st generation 127 (24.47%), and penicillin 99 (19.08%), while macrolides were the least used.
The available resources are needed to be effectively utilised, to minimise the hospital stay due to rational use of antibiotics, and to minimise burden of antibiotics on poor patients.
A total of 856 diabetic patients were evaluated for pharmacotherapy-based problems like for possible drug interactions, adverse drug reactions, and other mismatches, if any. Poor correlation between the advised insulin therapy and patients' fasting blood glucose levels (12%, n=103) was observed. To most of the patients (41.66%, n= 357), insulin therapy was advised in combination with glucocorticoides, thiazides diuretics, and propranolol. Prescribing beta blocker (propranolol) with insulin is contraindicated. The higher incidence of diabetic foot patients was in the mean age of 57±3.4 years that was controlled with combination therapy of insulin and oral antidiabetics (63.0%, n=516). 11.1% of the treated patients could not take the prescribed therapy due to poor acceptance of insulin therapy due to its syringe needle prick. 41.66% risks of potential drug interactions, 7.93% adverse drug reactions, and 6.6% mismatches were recorded, as per the international approved algorithm, for managing a diabetes mellitus that reflects poor health care system. All these events necessitate for coordinating with other health professionals to make the therapy safer in the better interest of the patients. It is concluded that in practice prescribing pattern carries more risks for patients. It is imperative to improve the practice of pharmacotherapeutics rather than to practice in routine.
Pneumonia is an infection of the pulmonary parenchyma. The current recommendations for treating pneumonia on an outpatient basis are to use a respiratory fluoroquinolone or a macrolide or a β- lactam. The study was conducted in the Rural Health Training Centre in Thane District to assess the efficacy of the recommended drugs for pneumonia in comparison to each other. All patients with a presumptive diagnosis of pneumonia were asked to undergo a chest X-ray, sputum microscopy and leukocyte count, to make a definitive diagnosis of pneumonia. The patients who fit into the inclusion criteria were randomized and either given a macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO once, then 250 mg od)] OR a respiratory fluoroquinolone [levofloxacin (750 mg PO od)] OR a β- lactam [high-dose amoxicillin (1 g tid) ]. A total of 31 patients were studied. No significant difference was detected regarding clinical success or mortality, regardless of atypical coverage or between antibacterial classes with similar atypical coverage. It was not possible to demonstrate any advantage of specific anti-bacterial for mild community-acquired pneumonia in relatively healthy outpatients. In mild-to-moderate cases of outpatient-treated community-acquired pneumonia, it might be most appropriate to select antibacterial according to side-effects, patient preferences, availability and cost.
Pediatric population constitutes about 40% of total population in India. Infections remain most common cause of illness and hospitalization in children in spite of the medical advances in infection control and emergence of more potent antibiotics. Rational antibiotic therapy for infectious diseases is very much essential to avoid high level resistance. A prospective study was carried out with the objective of analyzing the spectrum of infectious diseases in children and to study the antibiotic usage and selection of the dosage forms in pediatric population. 863 pediatric patients (54.9% males and 45.1% females; age range of 1 month to 16 years) attending outpatient department (excluding those coming for vaccination, new borne (below 1month) and hospitalized patients) were included in the study and the data including patient demographics (name, age, sex, body weight), past medical history, past medication history, allergy details, diagnosis, drug details which included name of the drug, generic/brand name, dosage form, dose frequency and duration were obtained and analyzed for the prevalence of diseases, the drugs prescribing patterns and the dosage forms preferred. Majority of the patients were in the age range >1 - ≤ 4 years (30.1%) and average of 2.07 (Mean ± SD 2.07±0.9) drugs were prescribed per prescription. Incidence of infections was found to be 61% (525 patients), of which respiratory tract infections (48%) were common among 414 patients and penicillins were the commonest antibiotics prescribed (39%), among which amoxicillin was most frequent, followed by a macrolide antibiotic azithromycin in 69 patients (30%). Syrups were the common dosage forms prescribed for all patients in the pediatric age group followed by tablets where as capsules were least preferred.
The Global Project on Anti-Tuberculosis Drug Resistance has been gathering data since 1994. This study provides the latest data on the extent of drug resistance worldwide.
Data for drug susceptibility were gathered from 90 726 patients in 83 countries and territories between 2002 and 2007. Standardised collection of results enabled comparison both between and within countries. Where possible, data for HIV status and resistance to second-line drugs were also obtained. Laboratory data were quality assured by the Supranational Tuberculosis Reference Laboratory Network.
The median prevalence of resistance to any drug in new cases of tuberculosis was 11.1% (IQR 7.0-22.3). The prevalence of multidrug resistance in new tuberculosis cases ranged from 0% in eight countries to 7% in two provinces in China, 11.1% in Northern Mariana Islands (although reporting only two cases), and between 6.8% and 22.3% in nine countries of the former Soviet Union, including 19.4% in Moldova and 22.3% in Baku, Azerbaijan (median for countries surveyed 1.6%, IQR 0.6-3.9). Trend analysis showed that between 1994 and 2007, the prevalence of multidrug-resistant (MDR) tuberculosis in new cases increased substantially in South Korea and in Tomsk Oblast and Orel Oblast, Russia, but was stable in Estonia and Latvia. The prevalence of MDR tuberculosis in all tuberculosis cases decreased in Hong Kong and the USA. 37 countries and territories reported representative data on extensively drug-resistant (XDR) tuberculosis. Five countries, all from the former Soviet Union, reported 25 cases or more of XDR tuberculosis each, with prevalence among MDR-tuberculosis cases ranging between 6.6% and 23.7%.
MDR tuberculosis remains a threat to tuberculosis control in provinces in China and countries of the former Soviet Union. Data on drug resistance are unavailable in many countries, especially in Africa, emphasising the need to develop easier methods for surveillance of resistance in tuberculosis.
Global Project: United States Agency for International Development and Eli Lilly and Company. Drug resistance surveys: national tuberculosis programmes, the Government of the Netherlands, the Global Fund to Fight AIDS, Tuberculosis and Malaria, Japan International Cooperation Agency, and Kreditanstalt für Wiederaufbau.
Irrational prescribing is a global problem. Rational prescribing cannot be defined without a method of measurement and a reference standard. The former is now available but the latter needs further development. Proven effective interventions to promote rational prescribing in developed countries are treatment protocols based on wide consultation and consensus, properly introduced and with a possibility of feedback; face-to-face education focussed on a particular prescribing problem in selected individuals; structured order forms; and focussed educational campaigns. Essential drugs lists are probably effective when based on consensus and used within a comprehensive educational programme. Printed materials alone are not effective. In most cases the usefulness of such strategies in developing countries has not been proven and should be studied. Medical education in clinical pharmacology and pharmacotherapy should be based on the practical needs of future prescribes, should include the principles of rational therapeutics and problem solving, and should immunize the students against the influences they are likely to encounter in their professional life, such as patient pressure, drug promotion and irrational prescribing by peers. Within the scope of a national formulary, specialist departments in teaching hospitals should define prescribing policies as the basis for prescribing, teaching, examinations and medical audit.
In 1990 paediatric formulations of antimotility drugs were deregistered in Pakistan. Although preliminary research data suggests the incidence of paralytic ileus in children suffering from acute diarrhoea has fallen, cases continue to be recorded. A small-scale survey conducted in 1993 to assess the effectiveness of the regulatory intervention conclusively proved that while the deregistered products had been successfully withdrawn from the overwhelming majority of retail outlets, blackmarketing of a paediatric antimotility drug was taking place in one city. The results also indicated that throughout the country the deregistered formulations were being substituted by other irrational therapies, including the misuse of adult formulations. As a regulatory intervention, therefore, deregistration needs to be accompanied by efforts to change patient attitudes and physician prescribing habits.