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Abstract
Background Antibiotic use in primary care can drive antimicrobial resistance (AMR) in the community. However, our understanding of antibiotic prescribing in low- and middle-income countries (LMICs) stems mostly from hospital-based studies or prescription/sales records, with little information available on routine primary care practices. We used an innovative, paper-to-digital documentation approach to deliver routine data and understand antibiotic use for common infections in low-resource primary healthcare clinics (PHCs).
Methods Rubber stamps were introduced in nine private sector PHCs serving Nairobi’s informal settlements to ‘print-on-demand’ clinical documentation templates into paper charts. The intervention included one mobile phone per PHC to take and share images of filled templates, guideline compilation booklets and monthly continuing medical education (CME) sessions. Templates for upper respiratory tract (URTI), urinary tract (UTI), sexually transmitted (STI) and gastrointestinal infection (GI) management were used in eight PHCs. Information in templates from 889 patient encounters was digitised from smartphone images, analysed, and fed back to clinicians during monthly CME sessions. UTI charts (n=130 and 96, respectively) were audited preintervention and postintervention for quality of clinical documentation and management.
Results Antibiotics were prescribed in 94.3%±1.6% of all patient encounters (97.3% in URTI, 94.2% in UTI, 91.6% in STI and 91.3% in GI), with 1.4±0.4 antibiotics prescribed per encounter. Clinicians considered antibiotic use appropriate in only 58.6% of URTI and 47.2% of GI cases. While feedback did not affect the number of antibiotics prescribed for UTIs, the use of nitrofurantoin, an appropriate, narrow-spectrum antibiotic, increased (9.2% to 29.9%; p<0.0001) and use of broad spectrum quinolones decreased (30.0% to 16.1%; p<0.05).
Conclusion Antibiotic use for common infections is high in private sector PHCs in Kenya, with both knowledge and ‘know-do’ gaps contributing to inappropriate prescription. Paper-based templates in combination with smartphone technologies can sustainably deliver routine primary care case management data to support the battle against AMR.
- infections, diseases, disorders, injuries
- health systems
- public health
- health services research
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Footnotes
Handling editor Soumitra S Bhuyan
Twitter @@pratapatarp
BK and PK contributed equally.
Contributors BK was involved in the conception and design of the study, acquisition of data, analysis and interpretation of data, drafting the manuscript and revising it critically for important intellectual content. PK was involved in the conception and design of the study, analysis and interpretation of data, revising the manuscript for important intellectual content and providing final approval of the version to be submitted. MKN was involved in the conception and design of the study and revising the manuscript. AM was involved in the data collection and analysis. PW was involved in data collection and analysis. GR was involved in data collection. MM was involved in interpreting the data and revising the manuscript critically for important intellectual content.
Funding This work was supported by the Health Systems Research Initiative grant (MR/N005015/1) by the Department for International Development (DFID), the Economic and Social Research Council (ESRC), the Medical Research Council (MRC) and the Wellcome Trust (WT). Early work by Health-E-Net Limited was supported by following grants to the World Friends Onlus: The ‘In Buone Mani’ (In good hands) project (731/2014) was funded by the CEI (Italian Episcopal Conference); The F.A.R.E. (Facilities, Advancement and Referral Enhancement) project was funded by the Tuscany Region.
Competing interests PK is a director of Health-E-Net Limited, which has commercial interests in the technology described in the manuscript. BK, PW and GR were employed by Health-E-Net before the implementation of the study; BK was employed by Health-E-Net during a portion of the study period.
Patient consent for publication Not required.
Ethics approval Strathmore University Ethical Review Committee (SU-IRB 0015/15) and the ethics committee of Heidelberg University.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request.