Cefazolin access and use in Ethiopia: A policy implication

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Abstract

Healthcare systems in resource-limited nations have been challenged by the shortage of essential medicines. This study explores cefazolin access and uses history in the Ethiopian healthcare delivery system, for possible policy implications. An exploratory qualitative study was conducted from July to August 2021. Semi-structured questions and observation guides were used to extract necessary data from people, documents, and field visits to hospitals, government supply agencies, and pharmaceutical business firms. The data were transcribed, coded, organized into themes, and presented. Cefazoline is the recommended first-line surgical antibiotic prophylaxis (SAP) in the Ethiopian Standard Treatment Guideline (STG) and is included in the national Essential Medicine List (EML). However, it was not available for use in the Ethiopian pharmaceutical markets for years. While the shortage might stem from supply-demand mismatches, multiple unknown issues exist in the background of the shortage. This is evidenced by the removal of cefazolin from the recent government procurement list regardless of the recommendation set in the national EML and STG. This study found a historic shortage of cefazolin in Ethiopian healthcare settings. This implies that the antibiotic availability in the pull market may not reflect required usage at facilities for several reasons including the misalignment of national guidelines and national procurement processes, and miscommunication between pharmacies and clinicians at sites on drug availability. Changing the essential medicines list and/or procurement requests without active review of the supply chain system and prescribing practices at facilities can lead to the elimination of necessary antimicrobial agents from the national public health sector supply.

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Point prevalence of hospital-acquired infections in two teaching hospitals of Amhara region in Ethiopia

Walelegn Yallew, Abera Kumie, Feleke Yehuala (2016)

Purpose Hospital-acquired infection (HAI) is a major safety issue affecting the quality of care of hundreds of millions of patients every year, in both developed and developing countries, including Ethiopia. In Ethiopia, there is no comprehensive research that presents the whole picture of HAIs in hospitals. The objective of this study was to examine the nature and extent of HAIs in Ethiopia. Methods A repeated cross-sectional study was conducted in two teaching hospitals. All eligible inpatients admitted for at least 48 hours on the day of the survey were included. The survey was conducted in dry and wet seasons of Ethiopia, that is, in March to April and July 2015. Physicians and nurses collected the data according to the Centers for Disease Control and Prevention definition of HAIs. Coded and cleaned data were transferred to SPSS 21 and STATA 13 for analysis. Univariate and multivariable logistic regression analyses were used to examine the prevalence of HAIs and relationship between explanatory and outcome variables. Results A total of 908 patients were included in this survey, the median age of the patients was 27 years (interquartile range: 16–40 years). A total of 650 (71.6%) patients received antimicrobials during the survey. There were 135 patients with HAI, with a mean prevalence of 14.9% (95% confidence interval 12.7–17.1). Culture results showed that Klebsiella spp. (22.44%) and Staphylococcus aureus (20.4%) were the most commonly isolated HAI-causing pathogens in these hospitals. The association of patient age and hospital type with the occurrence of HAI was statistically significant. Conclusion It was observed that the prevalence of HAI was high in the teaching hospitals. Surgical site infections and pneumonia were the most common types of HAIs. Hospital management should give more attention to promoting infection prevention practice for better control of HAIs in teaching hospitals.

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Multiple challenges of antibiotic use in a large hospital in Ethiopia – a ward-specific study showing high rates of hospital-acquired infections and ineffective prophylaxis

Girma Gutema, Helle Håkonsen, Ephrem Engidawork … (2018)

Background This project aims to study the use of antibiotics in three clinical wards in the largest tertiary teaching hospital in Ethiopia for a period of 1 year. The specific aims were to assess the prevalence of patients on antibiotics, quantify the antibiotic consumption and identify the main indications of use. Method The material was all the medical charts (n = 2231) retrieved from three clinical wards (internal medicine, gynecology/obstetrics and surgery) in Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa between September 2013 and September 2014. Data collection was performed manually by four pharmacists. Results Each medical chart represented one patient. About 60% of the patients were admitted to internal medicine, 20% to each of the other two wards. The number of bed days (BD) was on average 16.5. Antibiotics for systemic use were prescribed to 73.7% of the patients (on average: 2.1 antibiotics/patient) of whom 86.6% got a third or fourth generation cephalosporin (mainly ceftriaxone). The average consumption of antibiotics was 81.6 DDD/100BD, varying from 91.8 in internal medicine and 71.6 in surgery to 47.6 in gynecology/obstetrics. The five most frequently occurring infections were pneumonia (26.6%), surgical site infections (21.5%), neutropenic fever (6.9%), sepsis (6.4%) and urinary tract infections (4.7%). About one fourth of the prescriptions were for prophylactic purposes. Hospital acquired infections occurred in 23.5% of the patients (353 cases of surgical site infection). The prescribing was based on empirical treatment and sensitivity testing was reported in only 3.8% of the cases. Conclusions In the present study from three wards in the largest tertiary teaching hospital in Ethiopia, three out of four patients were prescribed antibiotics, primarily empirically. The mean antibiotic consumption was 81.6 DDD/100BD. Surgical site infections constituted a large burden of the infections treated in the hospital, despite extensive prescribing of prophylaxis. The findings show the need to implement antibiotic stewardship programs in Ethiopian hospitals with focus on rational prescribing, increased sensitivity testing and better procedures to prevent hospital acquired infections.

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Antibiotic usage in surgical prophylaxis: A prospective observational study in the surgical ward of Nekemte referral hospital

Getachew Alemkere (2018)

Background Surgical antimicrobial prophylaxis guidelines are considered as important interventional tools for antimicrobial resistance. Guideline compliance was poor across different countries and thus results in an inappropriate and overuse of antibiotics. Objective To evaluate the selection, timing and duration of prophylactic antibiotic administration among surgical patients in Nekmte referral hospital. Method Prospective, facility based cross-sectional study was conducted from 1st April to 30th June 2017. Data were collected using data abstraction format among surgical inpatients prescribed with surgical antibiotic prophylaxis. Surgical antimicrobial prophylaxis guidelines were used as data assessment protocols. SPSS version 21.0 was used for data entry and analysis. Descriptive statistics and binary logistic regression were used for analysis. Results The median age of the study participants was 35.0 (IQR: 25–50) years with the preponderance (58.8%) of male patients. The median hospitalization period was 8.0 (IQR: 5–11) days. Majority of the participants were from the general surgical ward (60.1%). About 43% of the procedures were clean. Most of the surgical cases were gastrointestinal (39.2%). Only 10.6% of the drug selections comply with American Society of Health-System Pharmacists guideline. Surprisingly, none of the selections were compliant to the national Standard Treatment Guideline of the country. About 84% of the study participants received ceftriaxone. Majority of the prophylactic antibiotics (75.8%) were administered for greater than 24 hours and above half (52.3%) of the antibiotics were administered preoperatively. Emergent surgery procedures (AOR = 2.89, 95% CI: (1.09–9.10) and being a male patient (AOR = 3.10, 95% CI: 1.07–8.98) were associated with inappropriate preoperative antibiotic administration. Patients admitted to the gynecology and obstetrics ward was less likely to receive surgical prophylaxis for greater than 24 hours (AOR = 0.07, 95% CI: 0.01–0.81). Conclusion Surgical antibiotic compliance was far below the guideline recommendation. Patients admitted in the gynecology and obstetrics ward were more likely to comply with the surgical antimicrobial prophylaxis duration recommendation. The timing was most likely to be inappropriate among male patients and patients on emergent surgery. Availability and awareness creation on the antibiotic drugs and the guidelines were important interventions recommended for appropriate surgical antimicrobial use.

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Contributors

Getachew Alemkere:

ORCID: https://orcid.org/0000-0002-8728-7600

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Asres Teshome: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – review & editing

Gobezie Temesgen: Role: Data curationRole: MethodologyRole: Project administrationRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Getnet Abebe: Role: ConceptualizationRole: Data curationRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing

Yidnekachew Degefaw:

ORCID: https://orcid.org/0000-0002-0224-1890

Role: ConceptualizationRole: MethodologyRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing

Hiwot Tilahun: Role: Project administrationRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing

Workineh Getahun: Role: ConceptualizationRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – review & editing

Eshetu Girma: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Wondwossen Amogne: Role: Data curationRole: MethodologyRole: ResourcesRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Thomas P. Van Boeckel: Role: Editor

Journal

Journal ID (nlm-ta): PLOS Glob Public Health

Journal ID (iso-abbrev): PLOS Glob Public Health

Journal ID (publisher-id): plos

Title: PLOS Global Public Health

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 2767-3375

Publication date (Electronic): 17 January 2023

Publication date Collection: 2023

Volume: 3

Issue: 1

Electronic Location Identifier: e0001421

Affiliations

[1 ] Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

[2 ] Department of Surgery, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

[3 ] Antimicrobial Resistance Prevention and Control Case Team, Pharmaceuticals and Medical Equipment Directorate, Ministry of Health, Addis Ababa, Ethiopia

[4 ] Department of Surgery, Gimjabet Primary Hospital, Gimjabet, Amhara, Ethiopia

[5 ] Antimicrobial Resistance and Global Partnership, USAID Medicines, Technologies, and Pharmaceutical Services Program, Management Sciences for Health, Addis Ababa, Ethiopia

[6 ] Department of Preventive Medicine, School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

[7 ] Department of Infectious Diseases, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Swiss Federal Institute of Technology Zurich: Eidgenossische Technische Hochschule Zurich, SWITZERLAND

Author notes

The authors have declared that no competing interests exist.

* E-mail: getachewalemkere@ 123456gmail.com

Author information

Getachew Alemkere https://orcid.org/0000-0002-8728-7600

Yidnekachew Degefaw https://orcid.org/0000-0002-0224-1890

Article

Publisher ID: PGPH-D-22-00804

DOI: 10.1371/journal.pgph.0001421

PMC ID: 10021613

PubMed ID: 36962932

SO-VID: ad89e584-8b2f-42f6-a295-f19ab27e7cd4

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 12 May 2022

Date accepted : 17 December 2022

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Figures: 1, Tables: 2, Pages: 11

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The authors received no specific funding for this work

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Cefazolin access and use in Ethiopia: A policy implication

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Abstract

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PLOS Global Public Health

Most cited references 31

Point prevalence of hospital-acquired infections in two teaching hospitals of Amhara region in Ethiopia

Multiple challenges of antibiotic use in a large hospital in Ethiopia – a ward-specific study showing high rates of hospital-acquired infections and ineffective prophylaxis

Antibiotic usage in surgical prophylaxis: A prospective observational study in the surgical ward of Nekemte referral hospital

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