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Clinical Infection & Immunity

Original Article

Volume 2, Number 2-3, September 2017, pages 19-26

Pattern of Antibiotic Usage in Rural and Sub-Urban Settings in Bangladesh: Experience From a Primary Health Care Facility

Antibiotic resistance, its use and misuse have been a very much discussed and debated topic all over the world. In recent days, the discourse has gained even more importance. Bangladesh is not exempted from the grave dangers of antibiotic resistance and the other problems arising from its misuse. In fact, the opposite is true, as witnessed by the physicians in Bangladesh, who are facing a great number of patients misusing antibiotics, every day in their clinical practice. The problem is not new in this country [1-3], but today’s picture must be the gravest one. The causes and antibiotic resistance are often postulated to its misuse and abuse [1, 4, 5]. The prevalent aberrations in the practice of using antibiotics in Bangladesh include self-medication, prescription by quacks and non-physicians, non-registered “village doctors”, irrational prescription, etc. [2, 6, 7]. The resultant rises in resistant strains of several bacteria are also seen [4, 8-10] and probably much is yet unseen and unnoticed. There is lack of available literature in this respect, and especially the picture of a primary health care center is not available. Hence this study attempts to describe the actual scenario.

The objectives were: 1) to describe the pattern and practice of using antibiotic in rural and sub-urban peripheral level in Bangladesh; 2) to find out the common indications of antibiotic use; 3) to find out the common prescribers of antibiotics; 4) to find out the awareness of antibiotic use; and 5) to determine if the antibiotics are being used correctly or being misused.

This was an observational, descriptive study.

The study was done in the Outpatient Department of Upazilla Health Complex, Dhamrai, Dhaka, a Government run primary health care facility providing primary medical care to the rural and sub-urban people, and acting as a referral center. The hospital provides service to a very dense community, and has to deal with a very high patient load, so it is a suitable place for conducting such study.

Consecutive, purposive sampling technique was employed. A total of 155 patients were included in this study.

Inclusion criteria included: 1) patients of all ages presenting to the outpatient department with common cold symptoms (with/without fever), or gastrointestinal (GI) upset (constipation/diarrhea/abdominal pain) with/without fever, or urinary symptoms (dysuria/frequency) with or without fever, or only fever with or without body ache but without above mentioned features, or some other clinical problems; and 2) presenting with or without history of taking antibiotic for current problem; or 3) presenting with or without history of taking antibiotic for any such problem in the past 1 year.

Exclusion criteria included: 1) unwilling to participate; and 2) patients without history of taking within the past 1 year.

Data were collected by a structured closed end questionnaire with predefined set of questions. Data collection was done meticulously with detailed interviewing of the respondents.

Written informed consents were taken from all of the participants or in case of minors, consents were taken from the accompanying legal guardians/parents. In all steps of the study, all ethical aspects were strictly observed and the privacy of the data of the patients was strictly maintained.

Ethical approval was taken from the ethical committee of Dhaka Medical College, Dhaka.

Data analysis was done in Statistical Package for Social Sciences (SPSS, IBM Corporation, USA) version 23.0. Mostly descriptive analysis was conducted and presented with figures and tables, suitable with the purpose of this article.

Some words and terms are used in this article which denotes a specific meaning. They are described and explained below: 1) doctors/physicians/registered doctors, who have passed MBBS examination and possess certification from Government Universities, and registered with Bangladesh Medical and Dental Council, BMDC (http://bmdc.org.bd/); 2) village doctors/quacks: persons who practice medicine unlawfully and do not have the quality of a doctor mentioned above, and according to law of the Government of the People’s Republic of Bangladesh, Bangladesh Medical and Dental Council Act, 2010; 3) drug sellers/pharmacists: not a true pharmacist, and who have neither medical nor pharmaceutical university degree. They are unlicensed to practice medicine, often with very short schooling (illiterate/below SSC); and 4) SACMO (Sub Assistant Community Medical Officer): previously known as medical assistants, trained in Medical Assistant Training Schools (MATS).

Educational level and occupation of each respondent has been recorded, but in case of minors (< 18 years of age), those of the accompanying parent were recorded for the purpose of this study.

Data were collected from 155 patients. Age and sex distribution are shown in Figures 1 and 2, along with other demographic information in Table 1.

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Figure 1. Distribution of age of the respondents.

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Figure 2. Box plot showing distribution of age in different sex groups of the respondents.

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Table 1. Demographic Information of the Respondents

Table 1 shows that most of the respondents were physical workers or housewives, and most of them had an educational level below secondary school graduation, followed by illiteracy being the second most common educational level.

Common presentations of the patients are shown in Table 2, which shows that most common problems for which the patients took antibiotics were common cold symptoms (with/without fever), only fever with or without body ache but without any other specific features and GI upset (constipation/diarrhea/abdominal pain) with/without fever.

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Table 2. Presentation of the Patients (Current Symptoms/Signs)

Various questions were presented to the respondent to bring out different aspects of antibiotic use, and these are presented in Table 3. It is found that most (67.9%) of the patients also had taken some antibiotics in the past year for similar reasons, most common of which is “mixed reasons”, followed by common cold. Most of the time, the antibiotic was prescribed by drug seller at medicine store (89, 57.4%) followed by quack/village doctor (29, 18.7%). Only in mere 14.2% of cases, the antibiotic was prescribed by registered MBBS doctors (22, 14.2%). Most of the patients have no clear idea about the definition of a doctor, and most of the respondents (137, 89%) consider non-medical persons (other than registered MBBS physicians/surgeons) as doctors and think them to be qualified enough to prescribe antibiotic. Most of the respondents (about 80% in all cases), the respondents had no idea or flawed idea about importance of regularity in taking antibiotics, or completion of the course or the concept and threat of antibiotic resistance. Most commonly taken antibiotic was ciprofloxacin (38, 24.7%), followed by cefixime (30, 19.5%) and azithromycin (26, 16.9%).

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Table 3. Common Scenario of Antibiotic Use Gathered From the Patients Presented

Only a limited number of patients (33, 29%) could provide information of already spent money and doses already taken, but the available information are shown in Table 4, which gives some idea about the economic impact of antibiotic use.

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Table 4. How Many Doses Have Already Been Taken and the Amount of Money Already Spent Before Presenting to Registered Doctors

The results compiled from the respondents show a very grave picture. The result found in this study clearly shows that most of the respondents have been taking antibiotics for very trivial reasons, like common cold and non-specific fever. Most of them have an incomplete formal education, and most of them cannot distinguish between a registered physician and quacks pretending to be registered doctors. Thus, drug sellers and pharmacists prescribe most of the antibiotics, and even the very advanced powerful ones like fluoroquinolones (e.g. ciprofloxacin), or third generation cephalosporins (e.g. cefixime). The patients often have poor idea or absolutely no idea about the urgency of completing the course or regularly taking the medicine. They often do not have faintest idea about antibiotic resistance and there is a big gap in awareness concerning proper use of antibiotic.

Similar grave pictures have been found by other researchers in Bangladesh. In a population survey in Rajshahi City in Northern area of Bangladesh, it was found that 347 (26.69%) out of 1,300 participants self-prescribed antibiotics [6]. The highest percentage of self-prescribed antibiotics was metronidazole (50.43%) followed by azithromycin (20.75%), ciprofloxacin (11.53%), amoxicillin (10.37%) and tetracycline (7.49%), respectively [6].

Fahad et al also found similar findings to us, in a primary health care-based study [7]. They reported that the highest prescribed antibiotic was ceftriaxone (30.19%) followed by cefixime (18.87%) and amoxicillin (16.98%). We in our study also found cefixime to be the second most common antibiotic prescribed, although, ciprofloxacin topped our list. Fahad et al reported that antibiotics were most frequently prescribed for physical assault, general weakness, acute watery diarrhea, acute trauma, GI symptoms and respiratory diseases. More or less similar indications are also found in our study. Fahad et al reported that the average cost of each prescription was Bangladeshi Taka (BDT) 238.50 and the antibiotics accounted for BDT 136.30. The group who received antibiotics paid on average BDT 105.90 more than the group not receiving an antibiotic. In our study, we also found similar findings, as we showed that the patients had already spent from a minimum of 12 BDT to a maximum of 675 BDT, average being 166.61 BDT and a median of 117 BDT, before coming for consultation. So the economic impact is also not negligible.

Sutradhar et al, in another population-based survey conducted in rural areas of Dhaka and Rajshahi in Bangladesh [1], found that significantly more doctors prescribe antibiotics in suspected infections (P < 0.0001). Around 44.1% doctors prescribe antibiotics in cold and fever before diagnosis. We in our study also found that common cold is the most common indication for prescribing antibiotic followed by non-specific fever. Sutradhar et al also found that although 48.6% patients think that it is important to strictly follow the doctor’s prescription, a significant percentage believe that it is not always necessary (26.7%, P < 0.0001) and more than 50% patient stop taking the antibiotic as soon as the symptoms disappear, while only 25.2% patients complete their full course. When a drug does not work, the patients usually consider the doctor is incompetent (25.6%) and many (24.5%) believe that the quality of the drug is not up to the mark [1].

We concur with other researchers [1, 6, 7] that gross misuse of antibiotics is being done in Bangladesh. Most of the responsibilities of gross misuse belong to two parties, non-physicians, illegal medical practitioners, quacks, and lack of awareness among the patients. We thus recommend the following.

1. All illegal practicing by anyone other than registered MBBS physicians or surgeons must be banned, and use of the title “doctor” should only be reserved for them by the law.

2. To protect antibiotics from being misused, only authorized prescriptions from MBBS qualified and registered physicians or surgeons (doctors, collectively) must be used for selling of antibiotics.

3. MBBS qualified registered physicians and surgeons (doctors), especially those in could be employed, empowered with magistracy power, to fight the illegal practices and prevent the imminent catastrophe of antibiotic resistance.

Funding

None.

Competing Interests

None.

Author Contributions

PH contributed in conception of the research idea, planning, organization, questionnaire preparation, data analysis and presentation and manuscript preparation, communication, etc. KTM contributed in conception of the research idea, planning, organization, questionnaire preparation and acquisition of data greatly. MZH contributed in organizing the research activities. RR contributed in acquisition of data. In addition, all the authors contributed intellectually in the complete process of conduction of this study up to the very step of final publication, in accordance to the serial by which they are named here.

Abbreviations

BDT: Bangladeshi Taka (currency); HSC: Higher Secondary School Certificate; MATS: Medical Assistant Training Schools; MBBS: Bachelor of Medicine and Bachelor of Surgery, University degree provided to respected, registered physicians and surgeons, equivalent to Master’s degree; SACMO: Sub Assistant Community Medical Officer, trained in Medical Assistant Training Schools; SPSS: Statistical Package for Social Sciences; SSC: Secondary School Certificate

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Clinical Infection and Immunity is published by Elmer Press Inc.