Table 3 Risk factors associated with spread of antimicrobial resistance
From: Antimicrobial stewardship in rural and remote primary health care: a narrative review
Reference # | First author | Year | Study type | JBI checklist used (score/total) | Country | Setting/population | Main findings |
|---|---|---|---|---|---|---|---|
Rural and remote | |||||||
[59] | Chai | 2019 | Cross-sectional quantitative study | Cross Sectional Study (8/8) | China | Residents of 12 rural villages | Use of antimicrobials bought from medicine shops without prescriptions ranged from 8.8 to 17.2% whereas use of antimicrobials leftover from previous illnesses or given by a relative ranged from 7.6 to 13.4%. Antimicrobial prescriptions were less likely to be given to respondents having greater antimicrobial-related knowledge |
[45] | Cuningham | 2020 | Retrospective data analysis | Prevalence Study (9/9) | Northern Australia | 15 remote primary health care clinics | The adapted GP NAPS tool demonstrated potential as an audit tool of antimicrobial use for the remote primary health care setting in Australia. Compared with other Australian settings, narrow spectrum antimicrobials were more commonly prescribed with high appropriateness of use (WA: 91%; NT: 82%; QLD: 65%). The dominant treatment indications were skin and soft tissue infections (WA: 35%; NT: 29%; QLD: 40%) |
[54] | Chen | 2020 | Cross-sectional qualitative study | Cross Sectional Study (5/8) | China | Village doctors and township level physicians | The dissonance between physicians' knowledge and their prescribing behaviour were due to various official regulations, institutional pressures to generate revenues, their desire to maintain good patient relationships and concerns for patient safety. Physicians often leave the responsibility for antimicrobial stewardship to the government or higher bodies in the health care system |
[38] | Xue | 2019 | Quasi-experimental | Quasi-experimental Study (9/9) | China | Rural village clinics and township health centres | Primary care providers in rural China frequently prescribed antibiotics inappropriately, predominantly due to deficits in diagnostic knowledge but also to financial incentives linked to drug sales and perceived patient demand |
[52] | Zhang | 2016 | Cross-sectional qualitative study | Cross Sectional Study (7/8) | China | Village doctors, primary caregivers, directors from the local county-level CDC, Health Bureaus or CFDA offices, and township hospital staff | Unnecessary prescribing for children with upper respiratory tract infections was common in village clinics in rural China, where doctors often had inadequate knowledge and misconceptions of antibiotic use. Prescribing behaviour was influenced by doctors' fear of complications, primary caregivers' pressure for antibiotic treatment, and financial considerations of patient retention |
Urban | |||||||
[60] | Collins | 2020 | Qualitative survey | Prevalence Study (6/10) | United States | Community | Self-prescription of antibiotics should be taken into account in a community-based stewardship programme, in which prescriber education and patient communication should be prioritised. The highest risk of self-prescription was among military personnel, students, immigrants, isolated and rural populations, and uninsured patients |
Mixed urban and rural | |||||||
[50] | Al-Homaidan | 2018 | Cross-sectional qualitative study | Cross Sectional Study (6/8) | Saudi Arabia | 20 rural and 12 urban primary health cares | Many physicians believed that antibiotic use lessens symptoms in viral disease, and attributed bacterial resistance to inadequate prescription, use without prescription, and patient non-compliance. The pharmacist was often blamed for contributing to antibiotic resistance. High fever was regarded as the symptom prompting antibiotic prescription when laboratory confirmation was unavailable |
[58] | Barker | 2017 | Cross-sectional qualitative study | Cross Sectional Study (6/8) | India | Community members in 3 rural and 2 urban villages | Community members' understanding of antibiotics and consequences of misuse were low |
[51] | Dallas | 2014 | Qualitative survey | Prevalence Study (8/10) | Australia | Rural and urban general practice registrars | General practice registrars recognised that evidence-based antibiotic prescribing is important and overprescribing leads to potentially increased resistance. However, discrepancy between their knowledge and behaviours exist because of patient and system factors, diagnostic uncertainty, transitioning from hospital medicine, and the habits of, and relationship with, their supervisor. Some registrars opined that some specific antibiotic would not contribute to resistance patterns |
[53] | Duane | 2015 | Qualitative study | Qualitative Research (8/10) | Ireland | General practice and community setting | Formal feedback on prescribing was seldom given to general practitioners and most were unfamiliar with local resistance patterns. Instead, antibiotic prescribing practices were formed through habit, anecdotal evidence from patient observation, and the individual laboratory results |
[57] | Fletcher-Lartey | 2016 | Cross-sectional qualitative study | Cross Sectional Study (5/8) | Australia | Primary care general practitioners (37.5% rural) | General practitioners cited patient expectations, which includes limited time, poor doctor–patient communication and diagnostic uncertainty, as the primary reason for prescribing inappropriately. Many did not attribute their prescribing in primary care to the development of antibiotic resistance, unlike use in hospitals or for veterinary purposes |
[40] | Kumar | 2008 | Cross-sectional quantitative study | Cross Sectional Study (8/8) | India | Primary and secondary health care settings in rural and urban areas | Higher antibiotic use was correlated with rural settings, lower patient age and higher socioeconomic status. Lower antibiotic prescribing was correlated with government health facilities which have larger allied health support and better infrastructure and specialist practices with more qualified staff |
[40] | Kumari Indira | 2008 | Cross-sectional quantitative study | Cross Sectional Study (7/8) | India | Primary and secondary health care settings in rural and urban areas | Antimicrobials were more commonly prescribed by physicians practising in rural and public/government settings, and to patients presenting with fever and high-income patients |
[55] | Nair | 2019 | Cross-sectional qualitative study | Cross Sectional Study (4/8) | India | Allopathic doctors, informal health providers, nurses, and pharmacy shopkeepers | Doctors did not translate knowledge into practice as many prescribed antibiotics inappropriately, citing inconsistent follow up, lack of testing facilities, risk of secondary infections, and unhygienic living conditions as their reasons to prescribe. Prescription behaviour was influenced by patients demanding antibiotics and seeking the fastest cure possible. Allopathic doctors and informal health providers frequently impart blame on the other party for contributing to antibiotic resistance, and yet both referred patients to one another |
[61] | Salm | 2018 | Cross-sectional quantitative survey | Cross Sectional Study (8/8) | Germany | Rural, suburban and urban populations | Recent antibiotic use likely confers patients with more knowledge, highlighting health literacy as a tool against inappropriate antibiotic use |
[39] | Singer | 2018 | Retrospective cohort study | Cohort Study (8/11) | Canada | 32 urban and rural primary care clinics | A potentially inappropriate antimicrobial prescription was given in 18% of primary care visits. For viral infections, older patients, patients with more comorbidities, more office visits and larger or rural practices were more likely to be prescribed antimicrobials inappropriately. For bacterial infections, female patients, younger age and less office visits were more likely |
[47] | Wang | 2020 | Cross-sectional quantitative study | Cross Sectional Study (8/8) | China | 67 primary care facilities (19 urban, 48 rural) | Prescribers' insufficient knowledge, indifference to changes, complacency with satisfied patients, low household income and rural location coincided with higher antibiotic use |