The Legalization of Antibiotic Prescription Essay

This project was developed by the Antimicrobial Resistance Centre at the London School of
Hygiene and Tropical Medicine (LSHTM) in 2017 and was funded by the World Health
Organisation’s Antimicrobial Resistance Secretariat. Additional funds for some student
travel expenses were provided by LSHTM and the Royal Veterinary College (RVC).
Authors: Maddy Pearson, Anne Doble, Rachel Glogowski, Stella Ibezim, Tom Lazenby, Ayda
Haile-Redai, Nabila Shaikh, Ashley Treharne, Selin Yardakul, Rahel Yemanaberhan, Lucy
Reynolds and Clare Chandler*The Legalization of Antibiotic Prescription Essay

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The authors, consisting of three LSHTM staff and nine students, are grateful to the following
advisors and supporters of the project: the AMR Secretariat team in Geneva, particularly Liz
Tayler, Karen Mah, Penelope Andrea and Marc Sprenger; project supervisors and
administrative support based in London: Elizabeth Jackson, Jackie Cardwell and Nicola Lord;
field based supervisors and local collaborators: Behzad Nadjm (Vietnam), Nasir Umar
(Nigeria), Dr. Abhijit Chowdhury, Dr. Dipesh Das, Meenakshi Gautham, Sayak Manna, Dr.
Partha Sarathi Mukherjee, Dr. Indranil Samanta (West Bengal), Nishi Ananth, Alakananda
Bagchi, Dr. George, Ketevan Kandelaki, Subha Sundarmoorthy (Chennai), Ms. Barcelona, Ms.
Sabijon, Ketevan Kandelaki, EMT team at WPRO (Philippines), Adamu Addissie, Tenaw
Tadege, Gebremedhin Gebretekle (Ethiopia), Michael Callaghan, Dr. Imogen Clarke, Dr.
Danny McLeron-Billows, Dr. Raj Rajarman, Kings Sierra Leone Partnership (Sierra Leone). We
acknowledge with thanks all respondents in the studies for their time and engagement and
for permitting their insights to be shared.
Citation: Maddy Pearson, Anne Doble, Rachel Glogowski, Stella Ibezim, Tom Lazenby, Ayda
Haile-Redai, Nabila Shaikh, Ashley Treharne, Selin Yardakul, Rahel Yemanaberhan, Lucy
Reynolds and Clare Chandler C.I.R. (2018) Antibiotic Prescribing and Resistance: Views from
LMIC Prescribing and Dispensing Professionals. Report to World Health Organisation AMR
Secretariat, available online at http://www.who.int/antimicrobial-resistance/LSHTMAntibiotic-Prescribing-LMIC-Prescribing-and-Dispensing-2017.pdf The Legalization of Antibiotic Prescription Essay

Antimicrobial resistance poses a threat to the future of human and animal health,
compromising the treatment of basic infections and the capacity for routine medical
procedures. Addressing prescribing and dispensing practice has been a focal point of
strategies to decrease antimicrobial usage for many years, but implementers lack data on
the current status of health care professionals’ understanding and experience of
antimicrobial resistance that could guide interventions.
This report draws together data from nine studies undertaken in April to August 2017 by
Masters students at the London School of Hygiene & Tropical Medicine and the Royal
Veterinary College. The students worked with 246 qualified health care professionals in six
low and middle income country (LMIC) settings within India (3), Philippines (1), Vietnam (1),
Sierra Leone (1), Nigeria (1), Ethiopia (2). The studies aimed to ascertain and situate
awareness of AMR and knowledge of antibiotics within the lived experience of prescribing
and dispensing across a range of LMIC settings. Qualitative methods were used including
semi-structured interview and rapid ethnographic observation. Data analysis involved
primary analysis by students who identified site-specific themes from the transcripts and
their observations of the operational context, and secondary analysis of the 246 interview
transcripts by researchers at the LSHTM to identify key themes emerging across field sites.The Legalization of Antibiotic Prescription Essay
The following cross-site themes emerged:
 Health professionals had a higher level of knowledge surrounding antibiotics than
expected.
 Health professionals had a greater awareness of AMR than expected, most often
indicated through treatment failure rather than diagnostics.
 Health professionals’ prescribing and dispensing practices responded to continued
challenges of access to information on resistance patterns, access to next line
antibiotics, access to diagnostics and access to patient medical records.
 Health professionals’ prescribing and dispensing practices responded to concerns
over the burden of infectious disease, attributed to poor infection control,
sanitation, hygiene, nutrition and biosecurity.
 Health professionals reported prescribing in terms of the empirical weighing up of
risks, on the one hand of not giving antibiotics, and on the other of which antibiotic
to prescribe. Awareness of resistance, fake drugs and side effects of some types of
drugs led to empirical tailoring of treatments.
 Health professionals’ prescribing and dispensing practices responded in many cases
to shortages of human resources coupled with high patient load.
 Health professionals across settings reported that medical or pharmaceutical
representatives visited frequently and influenced their prescribing of antibiotics.The Legalization of Antibiotic Prescription Essay
 Health professionals in the veterinary sector additionally reported problems with
adhering to withdrawal periods in livestock.
4
Health professionals proposed their own solutions for addressing AMR, with a strong
demand for more antibiotic medicines in order to respond to resistant infections; at the
same time they asked for tighter regulations on the quality of those medicines and on the
visits of representatives; there was a strong desire for a platform showing local patterns of
resistance; and better infrastructure – in terms of medical records, human resources and
basic hygiene inside and outside of health facilities.
These findings are limited to nine settings in six countries, most respondents were well
qualified prescribers, dispensers and educators, and most study settings were urban or periurban. The period of time spent in each site was sufficient for a snap-shot assessment of the
situation, but more in-depth understanding could be gleaned from longer term
ethnographic work. A wider assessment of views and responses to AMR could be achieved
through a questionnaire that builds on the findings in these studies, eliciting responses from
across a larger number of health professionals and expanded range of settings. However, as
a means through which to capture key aspects of the AMR awareness situation, this project
demonstrates the value of rapid qualitative methods which could be implemented
elsewhere.The Legalization of Antibiotic Prescription Essay
The findings across these studies echo the calls from multilateral agencies for a holistic
approach to addressing AMR. Contrary to the expectation of the need for more education to
improve knowledge of AMR, this report finds that awareness of resistance amongst these
health professionals – who were qualified prescribers and dispensers – was high. An
important distinction can be made between knowledge of AMR and of prudent use of
antibiotics, and information about, or needed to address AMR, which was lacking in terms of
local patterns. Health professionals believed they could be more targeted about antibiotic
treatment if they had access to this information. However, from our respondents’
perspectives, the concerns over risks of non-treatment will remain while infrastructure to
allow follow-up, to provide confidence in hygiene standards, and to ensure adequate time
and investigation of each patient remains poor.The Legalization of Antibiotic Prescription Essay

Antimicrobial resistance has been identified as one of the greatest threats to future human
health (1), (2), with an increasing number of resistant microbial strains reported each year
across both human and animal populations in developed and developing countries(3) (4).
Policy makers, health organisations and research institutes have called for tighter control
over their distribution and use in society (5) (6), with an emphasis on front-line antibiotic
prescribers and dispensers(7). While efforts have been sustained over many years to
promote the ‘rational use of drugs’, for example through the WHO’s International Network
on the Rational Use of Drugs programme (INRUD), the scale of antibiotic use appears to be
escalating.
The joint effort of the WHO, OIE and FAO to define a Global Action Plan (GAP) led to five
central objectives: the first was a priority on raising awareness about AMR, and the fourth
was to optimise antimicrobial use in humans and animals. The WHO commissioned a survey
of awareness amongst members of the public in 12 countries (8). Similar surveys amongst
health care professionals in different countries are desired in order to provide a baseline
assessment of awareness and to inform interventions that will address the GAP objectives
of raising awareness and optimising use in different settings. The design of survey tools is
challenging, especially if the key concepts to capture are difficult to define, and if the tools
are to be adopted across different settings. Typically, survey design is improved through
initial qualitative formative research. While there have been many qualitative studies that
have explicated the rationales for antimicrobial use across different settings(9), (10), (11), a
focus on resistance and how understanding of resistance might be worked into prescribing
decisions has not been at the fore of previous studies. Qualitative research that attempts to
capture understandings of AMR and the context of prescribing is therefore relevant at this
time, both to inform current discussions around awareness raising and optimal antibiotic
use as well as to support the design of domains and questions for a survey tool.
Project Design
This report draws together data from nine student studies that aimed to ascertain and
situate awareness of AMR and knowledge of antibiotics within the lived experience of
prescribing and dispensing across different settings.
The project, developed by the Antimicrobial Resistance Centre at the London School of
Hygiene and Tropical Medicine (LSHTM) with financial support from the World Health
Organisation’s AMR Secretariat, included nine qualitative research studies across six LMICs
covering India (3), Philippines (1), Vietnam (1), Sierra Leone (1), Nigeria (1), Ethiopia (2). The Legalization of Antibiotic Prescription Essay
8
Objectives
While studies were individually tailored to accommodate variations in institutional setting
and roles regarding antibiotic prescribing and dispensing, all studies shared the same overall
objectives:
 To develop a qualitative understanding of how antibiotic resistance is understood in
LMIC settings
 To explore the variety of roles antibiotics play for medical and veterinary prescribing
and dispensing professionals
Participants
Informed by a one-health approach, the studies included interviews with a wide spectrum of
antibiotic prescribers, dispensers and educators in human medicine, and in two settings also
in veterinary medicine.
Purposive sampling was used to identify medical professionals for interview, with local
contacts made prior to each study providing assistance in recruiting initial study subjects.
Further interviewees were identified by students themselves through chain-referral or
snowball sampling. Students aimed to interview a diverse cohort of participants regarding
professional profile, work-setting, age and gender. Strict sample size was not set prior to
data collection due to the iterative grounded theory approach taken. Sample size was thus
determined when saturation point was reached.
Table 1. Samples across study sites
Country Region Focus of Antibiotic use Number of
participants
Vietnam Hanoi Human 24
Nigeria Abuja Human and animal 24
India West Bengal Animal 8
West Bengal Human 19
Chennai Human 30
Philippines Manila Human 61
Ethiopia Addis Ababa Human 33
Addis Ababa Human 36
Sierra Leone Freetown Human 11
Ethics
The LSHTM and relevant institutional ethics boards in each country study granted ethical
approval and consent was obtained from all 246 informants represented in the report. With
permission, interviews were recorded and transcribed and where interviewees declined to
be recorded, with agreement the interviewer took written notes.
9
Methods
The primary method of data collection was interviews, with some students also carrying out
observations. The West Bengal veterinary focused study made considerable use of
observational methods, following vets in practice over several days. Interviews largely
followed a pre-determined set of topics, as shown in Table 2. Students used pre-prepared
questions guided by these topics (see Appendix 1) and follow-up probes to allow for a
flexible participant-led approach to data collection. For this reason, not all informants were
asked the same questions or gave indications of their knowledge on all topics. The included
statistics are representative of those who contributed information in a way deemed to
sufficiently fit the answer criteria. Across the sample the inclusion rate for each question
ranges from 65% to 98% thus while results cannot be considered wholly representative,
they give a strong initial indication of knowledge patterns and are sufficient for the purposes
of this first project and report which uses these statistics as a springboard to stimulate
discussion, rather than as conclusive statements.
While interviews worked to ascertain ‘what’ individuals knew in relation to antibiotics and
AMR, they remained conversational and fluid, allowing narratives of knowledge to remain
embedded within wider realms of social practice (5). Interviewers paid close attention to
practitioner’s reflections, exploring the social and environmental factors that present
challenges when grappling with responsibility for AMR in LMIC settings(10).The Legalization of Antibiotic Prescription Essay
Table 2. Summary of a priori interview topics
1. Professional profile  Position, institution, role in
prescribing/dispensing
2. Teaching on antibiotics/AMR  Involvement in teaching
 Curriculum for covering antibiotics/AMR
3. Knowledge on antibiotics  Purpose of antibiotics
 Biological mechanisms
 Sources of knowledge/guidance
4. Awareness of AMR  Understandings of AMR
 Role of diagnostics/empirical evidence
 Information on local resistance patterns
 Causes/drivers of AMR
5. Prescribing/dispensing
practice
 Position of antibiotics in diagnostic process
 Differences between training and everyday
practice
6. Source, influences and
regulation
 Sourcing of antibiotics
 Influences including medical representatives
 Regulation including government bodies,
awareness/efficacy of current laws
7. Current initiatives, future
suggestions
 Awareness of current campaigns, antimicrobial
stewardship programmes
 Suggestions for future interventions,
dissemination of information and resources
10
Data management and analysis
Where necessary a translator aided both at interview and transcription stage. Interviews
were transcribed verbatim, by the students themselves where in their own language, or
with support from transcribers and translators. Data were kept securely on password
protected computers and transcripts were anonymised.
Data analysis for this report involved primary analysis by students who organised and coded
transcripts to identify emerging themes, drawing on their insights from field observations.The Legalization of Antibiotic Prescription Essay
Secondary analysis of all 246 transcripts was later undertaken by staff at LSHTM to identify
themes emerging across the field sites. After the data was qualitatively analysed and coded
it was imported into Microsoft Excel to produce retrospectively-coded percentages of
respondents who had reported a particular view.
A central contribution of the report for future interventions is the importance of keeping
quantitative findings embedded in their qualitative contexts when devising, constructing
and implementing workable AMR strategies.
Limitations
In terms of potential limitations, all sites were urban or peri-urban thus findings are not
representative of rural settings. A number of informants were practising in city based
teaching hospitals therefore knowledge regarding antibiotics and AMR as well as access to
diagnostics and resistance profiles may not be reflective of prescribers and dispensers in
more peripheral areas or in less established institutions. The project does not explore the
role of gender demographics in antibiotic prescribing and dispensing, something future
projects may wish to consider. Informants have not been demarcated as public or private
practitioners; during interview these categories showed themselves to be inherently porous
(9) with most individuals straddling this divide in highly informal, contextually specific ways.The Legalization of Antibiotic Prescription Essay

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Antibiotics have played a major role in our society thanks to Sir
Alexander Fleming’s careful observations in 1928. Without it, many lives would be in danger due to infectious diseases.

Antibiotics are chemical substances produced by various species of microorganisms and other living systems that are capable in small concentrations of inhibiting the growth of or killing bacteria and other microorganisms. These organisms can be bacteria, viruses, fungi, or animals called protozoa. A particular group of these agents is made up of drugs called antibiotics, from the Greek word anti (“against”) and bios
(“life”). Some antibiotics are produced from living organisms such as bacteria, fungi, and molds. Others are…show more content…
This assures that the bacteria are either killed or reduced enough in numbers so that the body can repel them. When too little antibiotic is taken, bacteria can often develop methods to protect themselves against it . The next time the antibiotic is needed against these bacteria, it will not be effective. Taking in Antibiotics. To work against infecting organisms, an antibiotic can be applied externally, such as to a cut on the skin’s surface, or internally, reaching the bloodstream within the body. Antibiotics are made in several forms and given in different ways. Topical. Topical application means “to a local area” such as on the skin, in the eyes, or on the mucous membrane. Antibiotics for topical use are available in the form of powders, ointments, or creams. Oral. Tablets, liquids, and capsules are swallowed. The antibiotic is released in the small intestine to be absorbed into the bloodstream. Troches, or lozenges, are allowed to dissolve in the mouth, where the antibiotic is absorbed through the mucous membrane. Parenteral. Applications outside the intestine are called parenteral. The Legalization of Antibiotic Prescription Essay