Project on UTI

7/23/2019 Project on UTI

1/34

1.1 Background

A urinary tract infection (UTI) is a common bacterial infection affecting any part

of the urinary tract. The main causative agents are E.coli (75%) !.faecalis an"

#lebseilla sp normally present in the gastrointestinal tract an" $roteus.vulgaris

$seu"omonas sp an" rarely !taphylococcus incase of congenital malformation of the

urinary tract. bstruction in the urinary tract "ue to prostatic enlargement pregnancy

tumors catheteri&ation of bla""er an" "iabetes mellitus are the pre"isposing factors

among others'. *ommon symptoms inclu"e pain "uring micturation fre+uent urge to

urinate bloo" an" pus in urine clou"y appearance of urine an" lo, gra"e fever '-.

The stan"ar" treatment of lo,er urinary tract infections is compose" of amoicillin

cotrimoa&ole or nitrofurantoin as single "ose or short course of 7/0 "ays an"

amoicillin or cotrimoa&ole as short course of 7/0 "ays for upper UTIs. 1or relief

of pain an" fever paracetamol is a"ministere". Incase of complicate" upper UTIs

amoicillin an" gentamycin are to be a"ministere" intravenous '.

In the "eveloping ,orl" particularly in tropical ,orl" UTIs are a common cause

of chil"hoo" morbi"ity ,hile in "evelope" countries % boys an" 2/3% of girls are

"iagnose" ,ith UTIs '2/0. Approimately 7 million cases of UTI are reporte" in

"evelope" countries per year '5 ,hile t,o hun"re" an" thirty/five pregnant ,omen are

enrolle" annually ,ith complications of UTI in "eveloping countries. '4.

1.2 Factors Affecting Rational Drug Use

1.2.1 Knowledge of prescribers about Standard Treatent !uidelines "ST!s#

1


2/34

The lac of no,le"ge among prescribers regar"ing stan"ar" treatment gui"elines

results in inappropriate prescriptions an" hence affects rational "rug use. 6aps are

reporte" bet,een the actual practice an" no,le"ge levels about rational "rug use in

igeria'7.

In e, 6uinea increase" use of !tan"ar" Treatment 8oo is recommen"e" for

pe"iatricians to have improve" no,le"ge for giving appropriate a"vice to chil"ren9s

parents regar"ing their illness'3.

1.2.2 A$ailabilit% of Standard Treatent !uidelines "ST!s#

The government of a country is responsible to ensure the "evelopment an"

"evelopment of !T6s in all the sectors of the healthcare system an" implement a soun"

program for evaluation of their implementation for promotion of rational "rug use in the

country.

1.2.& Ad'erence to Standard Treatent !uidelines "ST!s#

The precribers may fail to a"here to !T6s "ue to patient acceptance clinical

re+uirements availability of "rugs cost of treatment an" other variable factors. 8ut this

practice ultimately hin"ers the achievement of rational "rug use. A"herence to !T69s is

vital to,ar"s the achievement of rational prescribing practices an" goal of therapy in UTI. The

"uration of treatment of UTI is relatively short of about 7/0 "ays. Antibiotics lie ciprofloacin

an" co/amoiclav are usually prescribe" an" patient a"herence is seen.

bervations regar"ing treatment of neurogenic bla""er among :utch urologists are

contrary to the available gui"elines an" their recommen"ations';.

2


3/34

A stu"y con"ucte" in :enmar conclu"e" that improvement in performance of healthcare

,orers can result from supervision on a"herence to !T6s'ab !in"h 8aluchistan an" #hyber pahtunh,a the territories of 6ilgit 8altistan

3


4/34

A&a" @amu an" #ahmir as ,ell as the 1e"erally/a"ministere" tribal areas (1ATA) an" the

capital territory of Islamaba"'5. The estimate" population of the country is 3


5/34

In the private sector the 6$s mae up the primary level ,hile at secon"ary an"

tertiary levels hospitals are present. The semi/government sector is comprise" by 6s

DB/sponsore" programs =e" *rescent programs an" Arme" 1orces hospitals.

1.&.( )re$alence of UT-s in t'e countr%

In $aistan the inci"ence of UTI is foun" to be more in chi"ren an" ,omen especially

"uring pregnancy. 1emales have been foun" to be susceptible more than males in the ratio of 2.

The prevelance of infection in mi""le age" patients is greatest an" secon"ly in chil"rens '7.

UTI occurs in all age groups of ,omen an" inci"ence increases ,ith age '3. Increase"

inci"ence of UTI in pregnancy follo,s ,ith a history of past urological problems ';.

1.&.* +urrent Scenario of UT-s in t'e countr%

=esisitent infections are mostly abserve" in females. The patients from gynaecology

sho, the highest inci"ence than other ,ar"s. Imipenem has been sho,n to be most effective

among beta/lactams ,hile resistance to aminoglycosi"es an" cephalosporins is commonly

observe" '7. The prevelance in most cases isn9t foun" to be reflecte" by symptoms although

they are important for "iagnostic purposes '3.

1.( )roble Stateent

The lac of "evelopment an" implementation of !tan"ar" Treatment 6ui"elines (!T6s)

in the prescribing practices throughout the country have le" to inappropriate therapy

increase" cost of treatment opposition in prescribing an" "ispensing an" hence the goal

5


6/34

of therapy is not achieve". $rescribers are not traine" an" they are not provi"e"

opportunities to up"ate their no,le"ge ecept for in a fe, institutions hence the

a"herence to !T6s if present is not observe". =esistance to various antibiotics is seen ,hich

ultimately results in poor patient compliance. All these factors are creating obstacles in

rational treatment of UTI in the country.

2.1 /iterature Re$iew

1luoro+uinolones are the preferre" first line therapy for UTIs. The hapha&ar" use

of antibiotics lea"s to "evelopment of resistant forms of pathogens. A stu"y con"ucte"

in igeria to investigate the antibiotics sensitivity among female stu"ents suffering from

UTI reporte" that most of the stu"ents urine specimen ,as positive an" antibiotic

sensitivity ,as positive '-


7/34

resistance in pathogen causing community/ac+uire" UTI to chec the pattern of resistance

in or"er to establish local gui"elines on the treatment of UTI reporte" that eten"e"

spectrum beta/lactamase pro"ucers among gram/negative *A/ uropathogens ,ere seen in

In"ia an" there ,as alarming rate of resistance to ciprofloacin an" amoicillin '-.

6ram/negative isolates sho,e" maimum resistance against antibiotics as compare"

to gram/positive isolates ,hile the ris factor of UTI in pregnant ,omen ,as very less

an" most of such cases ,ere "ue to some other un"erlying problems in $aistan '--/-2.

$rospective stu"ies are re+uire" to confirm the implications of association bet,een UTI9s

an" common "iseases in !outh Africa '-0. It ,as reporte" that sensitivity an" specificity of

catalase test ,as more as compare" to !e"iment =eactive !trip an" 6ram stains in U!A

'-5.

2.2 +urrent Scenario of UT- in De$eloped +ountries

A stu"y con"ucte" in Australia to chec the "iversity of group b streptococcus serotypes

causing UTI sho,e" that the sample of most of the outpatient an" obstestrics care ,as positive

'-4. Dhereas a research con"ucte" in e, For for prevention an" treatment of Go,er UTI

naturally sho,e" that Hitamins :/mannose an" probiotica provi"es effective prophylais in the

case of recurrent infection '-7.

In Englan" "iagnostic accuracy ,as seen to be improve" consi"erably ,hen

combine" ,ith "ipstic test particularly tests for nitrates '-3. In ?eico surveillance of UTIs

for the first three months ,as the reasonable option for improving graft function free of i"ney

infections an" assuring the +uality of life for the i"ney transplant population an" the loss of

7


8/34

graft function especially for female patients '-;. A stu"y con"ucte" in igeria for screening of

febrile chil"ren on hospital A"mission for UTI sho,e" that very fe, chil"ren sho,e" symptoms

of UTI ,omen ,ere more prone to UTI as compare" to men an" It ,as recommen"e" that

nitrofurantoin shoul" be use" in chil"ren ,ho "evelope" antibiotics restance against UTI '2


9/34

greater ris of UTI "uring their first year after birth a statistical "ata sho,e" the protective role

of breast fee"ing against UTI an" it is recommen"e" that treatment for febrile UTI in young

chil"ren shoul" at least for 7/0 "ays '2;/0


10/34

2.* Rationale of Stud%

The prescribing practices in $aistan are not foun" satisfactory an" irrational

prescribing is common. In other ,or"s the main components of rational "rug use i.e.

right "iagnosis right "rug right strength right "ose right fre+uency an" right patient are

not being practice".

Gac of no,le"ge among prescribers regar"ing !T6s may lea" to irrational "rug

use similarly high cost of prescribe" "rugs lea"s to poor compliance. n the other han"

limite" "ata is available in $aistan thus this stu"y is "esigne" to assess prescribing

practices cost a"herence an" no,le"ge ,ith respect to stan"ar" treatment gui"elines for

treatment of urinary tract infections an" this ,ill provi"e a +uantitative "ata ,hich ,ill

provi"e a baselines for the future researchers for +ualitative research.

2.* Significance of Stud%

The result of this stu"y ,ill provi"e baseline "ata to prescribers policy/maers

an" stae hol"ers to improve the prescribing pattern an" a""ress the issues an" factors

affecting cost a"herence an" no,le"ge that ,ill ultimately improve the con"itions an"

,ill provi"e +uantitative "ata.

2.0 Stud% becti$es

b>ective of our stu"y is the Assessment of prescribing practices a"herence to

stan"ar" treatment gui"elines no,le"ge of prescribers regar"ing urinary tract infections an"

cost of treatment in secon"ary an" tertiary healthcare facilities in "ifferent cities of

$aistan.

10


11/34

2.3 !eneral becti$es

The main ob>ective of the stu"y is to assess the prescribing practices a"herence to

stan"ar" treatment gui"elines no,le"ge of prescribers regar"ing urinary tract infections an"

cost of treatment in secon"ary an" tertiary healthcare facilities in "ifferent cities of

$aistan.

2.4 Specific becti$es

To assess an" compare prescribing practices for treatment of UTIs at "ifferent levels

of healthcare.

To assess an" compare cost of treatment for UTIs at "ifferent healthcare levels.

To assess compare a"herence to !T6s for treatment of UTIs at "ifferent healthcare

levels.

To assess an" compare no,le"ge of prescribers regar"ing urinary tract infections.

To assess an" compare prescribing practices for treatment of UTIs at public an"

private healthcares of "ifferent cities.

To assess an" compare cost of treatment for UTIs at public an" private healthcares of

"ifferent cities.

To assess compare a"herence to !T6s for treatment of UTIs at public an" private

healthcares of "ifferent cities.

To assess an" compare no,le"ge of prescribers regar"ing urinary tract infections at

public an" private healthcares of "ifferent cities.

11


12/34

&.1 Stud% design

12


13/34

A comparative cross/sectional stu"y ,as "esign to assess an" compare the no,le"ge

cost a"herence an" perception of prescribers in treatment of UTI9s among public an" private

health care facilities in "ifferent cities.

&.2 5t'ical Re6uireent7

!ince no ethical committee eists in $aistan for approval of research permission from

the respective ?! of healthcare facility ,as obtaine" for "ata collection. Dritten consent ,as

taen from the prescriber before the filling of +uestionnaire an" confi"entiality of their responses

,as ensure".

&.& Data T%pe7

$rescriptions ,ere collecte" retro prospectively from the past me"ical recor" of one year

,hile +uestionnaires ,ere "irectly "elivere" to the prescriber. uantitative as ,ell as +ualitative

metho"s ,ere use" to generate +uantitative "ata.

&.( Stud% )opulation and Respondents7

1our public an" private hospitals in "ifferent cities ,ere selecte" to collect UTI9s

prescriptions. All the semi/6overnment an" homeopathic clinics ,ere eclu"e".

&.* Sapling Tec'ni6ue7

A list of healthcare facility ,as obtaine" from the respective "istrict health office.

=an"om sampling techni+ue ,as use" to select the healthcare facility an" prescription from the

respective selective healthcare facility. *onvenient sampling techni+ue ,as use" for the filling of

+uestionnaires.

13


14/34

&.8 Saple Si9e7

A total of -< prescriptions ,ere collecte" among ,hich 4< ,ere collecte" from public as

,ell as from private healthcare facility. 2< prescriptions ,ere collecte" from each healthcare

facility. A total of 24< +uestionnaires ,ere fille" from practitioners.

&.0 Data +ollection Tools7

DB prescribing in"icator form ,ere use" to evaluate the prescribing practices in

selecte" healthcare facility. The tool ,as mo"ifie" accor"ing to the stu"y ob>ective. The form

consiste" of three sections. 1irst section ,as comprise" of "emographic "ata section t,o

consiste" of 0 +uestions inclu"ing prescribing in"icator section three inclu"e" cost assessment

form ,hich ,as use" to asses cost of treatment of "ifferent "rug in UTI. This form inclu"e"

name of "rug local or multi/national bran" cost calculate" per "ay an" total cost of treatment of

UTI. A structure" +uestionnaire ,as use" to asses no,le"ge an" perception of prescriber in

treatment of UTI. The +uestionnaire ,as "ivi"e" in t,o sections section "emographic an"

section t,o of management. !ection of "emographic "ata comprise" of five +uestion inclu"ing

occupation place of gra"uation unit of ,or eperience in me"icine an" practicing in

management of UTI patient. !ection - of management inclu"e" gui"eline a"herence current

me"ication factors affecting gui"eline a"herence effectiveness of "ifferent "rugs an" nee" for

e"ucational programme. Dhile section 2 ,as comprise" of +uestions regar"ing no,le"ge for

stan"ar" treatment regime of chil"ren an" a"ults.

&.3 :alidit% of Tools7

14


15/34

=evali"ate" tools ,ere use". 1ocuse" group "iscussion ,as also con"ucte" to finali&e

an" mo"ify the toolsJ pilot testing ,as generate" on


16/34

S5+T-< -

(.1 Deograp'ics7

A total of -< prescriptions ,ere collecte" from tertiary care hospitals out of ,hich 5


17/34

:ariables

+ities +oposite

Attock

n= 8;

!uar K'an

n= 8;

)ublic

"F>#

)ri$ate

"F>#

)ublic

"F>#

)ri$ate

"F>#

)ublic

"F>#

)ri$ate

"F>#

Antibiotics gi$en -;(;4.7) --(72.2) -4(34.7 ) -3(;2.2) 55(;.44) 5


18/34

Table (.27 Drugs )rescribed in Treatent of UT- in Tertiar% ,ealt' Facilit% in Attock and !uar

K'an7

Antibiotics gi$en

+ities +oposite

Attock


19/34

so"ium

*iprofloacineL"iclofenic

so"ium

(2.22) 0(2.22)


20/34

(.( Ad'erence of )rescribers wit' ST! in Treatent of UT-7

ut of -< prescription right "ose right fre+uency right "uration right strength ,as

gives as


21/34

Ao?icillin *; gkgda% in &@( di$ided doses +otrio?a9ole (3 gkgda% in 2

di$ided doses#

)ublic

F ">#

)ri$ate

F>

)ublic

F>

)ri$ate

F>

Rig't Dose 2< (


22/34

Attock74.27M2-.57

544.27M23.52 520.57M--3.#

Acute and +'ronic UTI in patients are

,ell controlle" ,ith current me"ication.

Dhat is your opinion on this statementO

3 (0) < (


25/34

In your opinion empiric therapy for

acute uncoplicatedupper UTI before

results of culture test ,ith broa"

spectrum antibiotics is a rational

practiceO

00 (--) ;(5;.5) < (


26/34

(.4 T'e Cost +oon +ause of UT- in Attock and !uar K'anG n=2;;7

?ost of the prescribers ,ere of the vie, that E/coli is the most common cause of

pylonephritis an" lo,er UTI in 3


27/34

5 coli -;(40.5)


28/34

Table (.37 Factors affect guideline ad'erence in t'e anageent of UT-

Factors

Strongl%

Disagree

1(%)

Disagree

1(%)


29/34

Table (.47 5ffecti$eness of different agents for t'e treatent of acute uncoplicated lower

urinar% tract infections "p%elonep'ritis#

5ffecti$eness Rating 5ffecti$e

F">#

#

Drugs

Ao?icillin 75(37.5) -() 4(2)

+o@ao?icla$e 7;(3;.5) 2(.5) (


30/34

5ffecti$eness

Rating

5ffecti$e

F">#

#

Drugs

+efuro?in 7- (34.


31/34

Table (.117 Knowledge of )rescribers regarding ST! in treatent of UT- and e?perience

in UT- anageent

Knowledge of )rescribers Regarding ST!s

:ariable < , Cean Rank )@:alue

Designation Bouse officer ;;

.;-


32/34

The results of the present stu"y highlighte" that in case of urinary tract infections "isease

management in the country is not satisfactory in both public an" private healthcare facilities.

$rescribing practices are reflective of the treatment strategies employe" for the

management of a specific "isease. The result of the present stu"y sho,e" that the in>ections ,ere

prescribe" in very fe, cases of UTI an" most of the "rugs ,ere prescribe" by bran" names.

*iprofloacin ,as the most commonly prescribe" antibiotic in the treatment of UTIs. All the

"rugs prescribe" ,ere accor"ing to essential "rug list. $rescribing practices in "ifferent health

care facilities ,ere not satisfactory. The main reasons for irrational prescribing practices ,ere

lac of no,le"ge of prescribers regar"ing stan"ar" treatment gui"elines lac of generic

prescribing unavailability of stan"ar" treatment gui"elines an" non/a"herence. !imilar results

,ere reporte" in etherlan"s ';.

A"herence to stan"ar" treatment gui"elines (!T6s) is vital to,ar"s the achievement of

rational prescribing practices an" goal of therapy. The results of the present stu"y in"icate" that

strength fre+uency an" "uration of treatment for antibiotics lie ciprofloacin an" co/amoiclav

,ere accor"ing to stan"ar" treatment gui"elines in most of the cases ,hile "ose fre+uency an"

"uration of antibiotic treatment ,ere not mentione" in cases of *efiime floacin an"

Gevofloacin. The prescribers at private sector ,ere a"hering relatively more to !T6s as

compare" to prescribers in public sector ,hile there ,as no significant "ifference regar"ing

a"herence ,ith !T69s bet,een prescribers in "ifferent cities of $aistan. This is reflective of

lac of a"herence of prescribers ,ith the stan"ar" treatment gui"elines that can be attribute" to

unavailability of !T69s an" lac of supervision on a"herence to !T69s. A"herence to !T69s ,as

foun" lo, in !u"an ,hile a stu"y con"ucte" in :enmar conclu"e" that improvement in

32


33/34

performance of healthcare ,orers can result from supervision on a"herence to !T69s

'arhan. This might be "ue to prescribing by bran" names

prescribing of multinational bran"s an" combination of "rugs in the prescription. on/

compliance is sho,n if therapy is not affor"able as reporte" in U!A '2.

#no,le"ge of prescribers regar"ing !T69s sho,s the "evelopment of healthcare system

as it is "epen"ent on the training an" upgra"ing the no,le"ge of healthcare professionals. The

results of present stu"y sho,e" that most of the prescribers agree" that acute an" chronic UTI9s

in patients are ,ell/controlle" ,ith current me"ications an" e"ucational program for

management an" prevention of UTI among public can be fruitful. ?ost of the prescribers ,ere of

the vie, that the empiric therapy for upper an" lo,er UTI shoul" not be practice". $rescribers

agree" that lac of a,areness regar"ing !T69s an" their availability an" accessibility

prescriber9s eperience an" resistance to various antibiotics are the ma>or factors affecting

a"herence to !T69s in management of UTIs. *iprofloacin ,as recommen"e" as the most

effective antibiotic for UTIs. The implementation of an" training regar"ing !T69s ,oul" be

effective in improving prescribers9 no,le"ge an" promoting rational "rug use. Irrational

prescribing may result from "ifference bet,een no,le"ge levels an" actual prescribing

practices similar results ,ere reporte" in a stu"y con"ucte" in igeria '7.

33


34/34

*.2 /iitations of t'e Stud%

Time an" financial constrains ,ere fe, of the limitations face" "uring the con"uction of

the stu"y. !econ"ly of reluctance of the prescribers to share "ata an" lac of accessibility to

hospital recor"s ,ere also fe, hur"les face" "uring "ata collection.

*.& +onclusions and Recoendations

The results of the present stu"y conclu"e" that unavailability of stan"ar" treatment

gui"elines relatively less no,le"ge of prescribers lac of a"herence ,ith !T69s an" non/

generic prescribing ,ere fe, of the contributing factors to,ar"s irrational prescribing practices

for UTIs in $aistan. Bigher cost of treatment in public an" private sectors re"uce" patient

compliance. 8y ensuring availability of !T69s an" E:G in healthcare facilities strict

implementation of stan"ar" treatment gui"elines an" regular training of prescribers rational "rug

use can be promote" in the country patient compliance can be enhance" an" goal of therapy ,ill

be achievable. This ,ill be a step for,ar" to,ar"s effective "isease management an" "ecreasing

rates of morbi"ity an" mortality.

Project on UTI

Documents

Transcript of Project on UTI