Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India

Abstract

Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

Keywords: Healthcare providers; India; antibiotics; infectious diseases; prescription; rural population.

Figure 1

Relative distribution of proportion of prescribed antibiotics out of the total prescriptions in the respective seasons and percentage ofprescribed antibiotics for the individual complaint out of the total antibiotic prescriptions in the respective seasons in rural Ujjain, India. X axis represents the seasons (April–May 2015 Pre-monsoon 1, June–September 2015 Monsoon 1, October–December 2015 Post-monsoon, January–February 2016 Winter, March–May 2016 Pre-monsoon 2, June–September 2016 Monsoon 2); Primary Y axis on left represents the percentage of prescribed antibiotics out of total prescriptions in the respective season and secondary Y axis on right represents the percentage of prescribed antibiotics for the individual complaints (Fever, URTI—Upper respiratory tract infection, Gastro-intestinal disorders, Oral and dental problems, Skin infections, and Unspecified pain) out of the total antibiotic prescriptions in the respective seasons.

Figure 2

Relative distribution of defined daily doses/1000 prescriptions/presenting complaints (DDD/TPP) in rural Ujjain, India. X axis represents the defined daily doses/1000 prescriptions/presenting complaints (DDD/TPP); Y axis represents the complaints (URTI—Upper respiratory tract infection, Pain—Unspecified pain).

Figure 3

Geographical location of the selected informal healthcare providers. The maps show India, Madhya Pradesh, Ujjain district, and the location of participating informal healthcare providers within the sampling frame.