Antibiotic Prescribing Practices in Primary Care Settings Using 2019 WHO AWaRe Framework

Background: Bacteria have ability to rapidly evolve, develop strategies to resist antibiotics, and reduce the effectiveness of antibiotics. The emergence and spread of antimicrobial resistance is an important global public health challenge to tackle. Studying antibiotic prescribing practices would allow rational use and preserve effectiveness of antibiotics.

Objective: To study prescribing practices of antibiotics in out-patients in primary care settings using the WHO AWaRe framework.

Methodology: A prospective cross-sectional study was conducted to evaluate prescribing practices of antibiotics in the primary care facility of three private hospitals using the WHO ‘core prescribing indicators’ and Access, Watch, and Reserve (AWaRe) classification. A systematic sampling technique was employed to collect the prescriptions at each hospital for three months. Descriptive statistics were applied to the collected data.

Results: A total of 2685 prescriptions were systematically evaluated. 1280 encounters had at least one antibiotic (47.7%), of which 1041 consist of only one antibiotic (81.5%). Among 1280 antibiotic encounters, the average number of antibiotics per encounter was 1.2 and 14.6% were prescribed with a parenteral antibiotic. 26.6% and 78.6% antibiotics were prescribed using generic names and from the WHO Essential Medicines List, respectively. Amoxicillin/clavulanic acid, ceftriaxone, azithromycin, cefoperazone, and amoxicillin were the five most commonly prescribed antibiotics. According to the WHO AWaRe classification, a total of 27 specific antibiotics (Access 11, Watch 14, and Reserve 2) were prescribed. 38.4%, 53.7%, 0.3%, and 10.5% of antibiotics prescribed were from the ‘Access’, ‘Watch’, ‘Reserve’, and ‘Not Recommended’ categories, respectively. Third generation cephalosporins (24.0%) were prescribed in high rate among ‘Watch’ category. The most commonly prescribed ‘Access’ and ‘Watch’ antibiotics were amoxicillin/clavulanic acid (12.5%) and ceftriaxone (10.6%), respectively. Amoxicillin index was 19.5% and ‘Access-to-Watch’ index was 0.76, which were below the priority values.

Conclusion: Except few indicators, still better prescribing practices of antibiotics are needed to fully meet the WHO recommendations. Antibiotic prescribing guidelines as per the WHO AWaRe framework, changes in prescription patterns and preference of “Access” over ‘Watch’ antibiotics are crucial to preserve effectiveness and promote rational use of antibiotics.