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Non-compliance with antibiotics regimen at high rates: Local study

19 Jul 2021

  • Adverse health and economic consequences result
BY Ruwan Laknath Jayakody A local study on compliance with antibiotics regimens prescribed and dispensed in the setting of a tertiary care government hospital by its outdoor pharmacy revealed alarmingly high rates of both non-compliance and partial compliance which resulted in both adverse health and economic consequences. This finding was made by T.D. Gamage (attached to the University of Ruhuna Faculty of Medicine pharmacy degree programme), P.L.G.C. Liyanage (attached to the same faculty’s Department of Pharmacology), and M. Kommalage (attached to the same faculty’s Department of Physiology) in an original research paper titled “Poor compliance to antibiotics dispensed in a tertiary care hospital: A follow-up study from Sri Lanka”, which was published in the Sri Lanka Journal of Medicine’s 30th Volume’s First Issue on 1 July 2021. Non-compliance involves a range of behaviours such as a patient missing a dose, stopping the drug earlier than expected, taking the drug at the wrong time, initiating treatment later than expected, taking multiple doses together, and stopping taking the drug for a certain period. In this regard, P. Kardas noted in “Patient compliance with antibiotic treatment for respiratory tract infections” that the most frequent forms involved the alteration of the dose frequency, omitting doses, and the premature halting of antibiotics. In the specific case of poor compliance with regard to antibiotics, it was found in several studies (Kardas, a survey in Japan, a cohort in Malawi and “Relationship between the prescriber’s instructions and compliance with antibiotherapy in outpatients treated for an acute infectious disease” by O. Favre, E. Delacretaz, M. Badan, M. Glauser, and B. Waeber) that the adverse effects of antibiotics, the low income of patients, the high prices of antibiotics, poor understanding about the use of antibiotics, early symptomatic relief, factors associated with the form or preparation of the antibiotics such as unpleasant flavour, difficulties in adjusting the dosing regimen to the patient’s lifestyle, and poor instructions by the prescriber were the commonly identified reasons. As Kardas explains, such poor compliance in turn leads to therapeutic failure and re-infection, thus precipitating additional treatment and thereby an increase in the direct and indirect costs related to the treatment. Moreover, Gamage et al. point to the development of antibiotic resistance, a phenomenon which has been observed to a large degree in developing countries by J.A. Ayukekbong, M. Ntemgwa, and A.N. Atabe in “The threat of antimicrobial resistance in developing countries: Causes and control strategies”. The misuse of antibiotics is also a problem as has been noted by Gamage et al. Furthermore, poor compliance with regard to antibiotics is seen in low-income countries as per J.C. Pechere’s “Patients interviews and misuse of antibiotics”. Additionally, both the Antimicrobial Resistance Surveillance Project (ARSP) Working Group, The Sri Lanka College of Microbiologists (TSLCoM) and the World Health Organisation (WHO) have noted the presence of many irrational practices in Sri Lanka with regard to compliance with antibiotic use. Therefore, a convenient sample of patients who received antibiotics (indicated with a mark on the packet of drugs) from an outlet of the outdoor pharmacy in the Karapitiya Teaching Hospital were enrolled by Gamage et al., with those already on antibiotics excluded. A total of 318 patients (62.4%) out of 509 participated in the follow-up telephone conversations, whereas the rest only took part in the initial data collection stage. The age of the patients ranged from six months to 79 years with the mean age being 43 years. This included 278 (87%) adults and 40 (13%) children below the age of 16 years. The education level varied from 17 (5.3%) having no schooling, 49 (15.4%) having primary school, 146 (46.9%) having the GCE Ordinary Level, 90 (28.3%) having the GCE Advanced Level, and 12 (3.8%) having higher education. The data including about the duration and frequency of use and the instructions on the dosages of the prescribed antibiotics were collected in March 2018. An interviewer-administered questionnaire was used. Patients were considered as fully compliant to the drug regimen if they were compliant with the dose, the frequency of the dose, and the duration of the use of the antibiotic. When a single dose was missed or eight hourly doses were taken with little adjustment, such patients were deemed to be marginally compliant. These two groups were collectively named as the group with good compliance. Those who were deemed non-compliant were those who had missed more than one dose, were not adhering to the expected frequency of the dose, and/or were not continuing the antibiotics regimen till the third day. The results revealed that in terms of compliance, 169 (53.1%) exhibited good compliance, 143 (45%) full compliance, 26 (8.1%) marginal compliance, and 149 (46.9%) non-compliance. Interpreting the findings, Gamage et al. observed that approximately 55% of patients did not show complete adherence to the prescribed antibiotic regimen. Further, from the 318 respondents, 28 (8.8%) did not strictly adhere to the instructions on “dosing” (some of them had also altered the dose) while 171 (53.8%) did not strictly adhere to the instructions related to the “frequency” (included missing one or more doses, taking less or more than has been prescribed, and alterations of the frequency). These figures included those described as showing marginal compliance. On the other hand, in the case of four (1.2%) patients, both the dose and frequency were incorrect while all those who used the correct doses and correct frequency, in short, the compliant group, had continued taking the drug regimen up to the third day. Reasons for non-compliance that were considered in the study were forgetfulness, intentionally not taking the medicine, side effects, school, employment or other work, family-related commitments, poor understanding of the instructions, feeling cured, and starting treatment from another place or other places. The results of 174 respondents revealed that being forgetful was the commonest reason. This, Gamage et al. opined, could be due in part to less interest in antibiotics and with regard to their use. Intentional avoidance was found to be the second main reason which Gamage et al. also attributed to be likely due to the lack of interest in the use of such. A Malawi-based study had described this lack of interest as poor effort or laziness. Further, a considerable number of patients had mentioned family commitment and other commitments such as occupation, school, and other work as reasons for the same, which means that certain social and economic factors (also noted in a Chinese study) would have contributed to this situation. The sense of feeling better after taking a few doses was also given as a reason for stopping the treatment regimen. With regard to starting treatment from other places which too was given as a reason, Gamage et al. explained that in Sri Lanka, it is a common practice for patients who start treatment from one medical practitioner to afterwards go to another for a second opinion, sometimes within the course of the same day. It was also found that there was no relationship between the prescribed antibiotic and compliance. In terms of the frequency, the antibiotics had been prescribed three times a day, two times a day, four times per day, eight hourly and six hourly. In this regard, it was found that there was a significant association between the prescribed dose frequency and compliance, where higher compliance was observed in patients who were on twice a day and eight hourly regimens than compared to the others. More frequent dosing, Gamage et al. observed, reduces compliance. The study also analysed a few common disease conditions, namely respiratory conditions, skin conditions, post-operative treatment, ear infections, and urinary tract infections, and compliance on the part of the patients for each such identified disease indication category. It was found in this regard that there was a significant relationship between the indication and compliance, with indications such as post-surgical treatment and urinary tract infection having higher compliance than in the case of respiratory tract infections and skin conditions which had low adherence. “A patient’s interest in using antibiotics depends on the patient’s perception of the requirement. Kardas points out that if a patient feels that a disease is a severe one, they tend to adhere to the regimen more. Since a patient is relatively ill after undergoing a surgery or when having a urinary tract infection, they can easily understand the need for antibiotics compared to when they have conditions like respiratory tract infections. Also, patients may be in a dilemma about the actual requirement of antibiotics in the case of respiratory tract conditions.” Also, no association or relationship was found between compliance and the patient’s age or the level of education of the patient or the patient’s guardian. Gamage et al. opined that the influence of education could be undermined by factors such as the disease condition and the frequency of the dosage. “General population’s knowledge and attitudes about antibiotics: A systematic review and meta-analysis” by M.R. Gualano, R. Gili, G. Scaioli, F. Bert, and R. Siliquini noted that regardless of the patient’s level of education, in general, there is poor understanding about antibiotics. Poor compliance also needs to be considered when interpreting the clinical response of antibiotics as poor compliance is not only a major cause of treatment failure (per Kardas) but may also lead to antibiotics being left over at home and the resultant increase in the likelihood of self-medication due to their use during the next infection or illness (per Pechere who found that a considerable number of patients, in the setting of developing countries, had deliberately reserved and retained antibiotics for future use).


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