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Table 5 Antimicrobial prescribing issues in rural and remote primary health care and actionable solutions

From: Antimicrobial stewardship in rural and remote primary health care: a narrative review

Factors influencing antimicrobial prescribing

Issues relevant to rural and remote settings

Potential strategies to address these issues

Upstream factors

Workforce

Shortage of physicians causes excess clinical workload, which may drive increased physician fatigue. This, together with time constraints for clinical assessment from busy schedules, could impede judicious prescribing [39, 41, 46, 48]

Incentivise medical workforce to work in rural and remote regions through increasing training and specialisation opportunities as well as offering financial benefits such as higher wages and tax benefits

Remoteness and access to healthcare

Remote communities and villages are geographically isolated. A substantial proportion of residents in these regions tend to be socioeconomically disadvantaged and have difficulty in traveling long distances to larger health care centres, especially for specialist care. These physical and economical barriers result in poor health care services delivered to underserved rural and remote populations [23, 57, 58]

Appointment of a clinical champion or team aiming to provide AMS specific service to a specified geographical region. With network connectivity and infrastructure expanding to rural regions in many countries, telemedicine is a viable option for those hindered by distance to access health care. If this is not possible, remote clinics or medical camps providing subsidised medical care and prescription drugs could be set up in villages and sparsely populated areas

Regular and scheduled visits from specialists could be arranged from the closest medical centres

Lack of AMR surveillance

Rural and remote populations are often underrepresented in standard surveillance systems, especially regarding antibiotic susceptibility of pathogens causing common infections [23]

Efforts to upgrade necessary technical infrastructure and establish a record-keeping culture in PHC would improve disease monitoring [23, 42]. Incentivise pathology services to compile annual antibiograms in geographic regions and to have a regional AMS team responsible for providing monitoring/surveillance activities as part of a systems approach to achieve particular targets

Financial incentives and pressures

In rural and remote health care settings, financial considerations of patient retention play a particularly important part during clinical interactions. Compounded by institutional pressures to generate revenue for health facilities and financial incentives from the sale of certain drugs, physicians may be compelled to prescribe unnecessary antimicrobials to patients who demand them [38, 52, 54]

Providing incentives for lower rates of prescribing has been proven to reduce antibiotic use

Equitable access to affordable medicine, potentially through subsidised medicines or insurance

Sources of guidance

Absence or limited depth of rural-specific clinical guidelines on which PHC providers can base prescribing practices [80]

Develop clear and concise clinical guidelines in consultation with relevant stakeholders including those with AMS expertise that take into account the unique cultural and socioeconomical aspects of specific remote communities of the region. If the problem lies in their implementation, CDSS may be beneficial in translating written guidelines to clinical practice

Health care facilities

Diagnostics

Rural and remote health centres lack diagnostic equipment such as X-ray, ECG and biochemistry facilities, which are often important to distinguish viral and bacterial infections and justify the correct antimicrobial prescription [38, 40]

Increase government funding and invite external sponsorship for rural and remote health care health infrastructure and equipment. Future options may include point-of-care testing for sample cultures, and antimicrobial susceptibility technologies

Physicians

Deficits in diagnostic knowledge

Rural physicians often prescribe antibiotics in the face of diagnostic uncertainty, which act as a surrogate for inadequate diagnostic knowledge [38]

Studies have shown that greater adherence to guidelines for the diagnostic process translates to reduced antibiotic prescriptions [38, 51]. CDSS could provide additional guidance to physicians in addressing diagnostic and treatment uncertainty

Inadequate provider knowledge on AMR

Evidence has shown that rural and remote PHC providers with lower qualifications possess misconceptions and insufficient knowledge on the proper use of antibiotics and local resistance patterns [40, 52, 53]

Increase physician knowledge through training programmes and education campaigns [52]. CDSS may also help in this regard. If widely implemented and accepted, indirect supervision of antimicrobial prescribing by qualified professionals such as pharmacists may provide a second line of defence against inappropriate prescriptions [76]

Feedback to prescribers on local resistance patterns and inappropriate prescribing may assist reflection on practice

Willingness to adjust practice for AMS

Modern measures against excessive antibiotic use such as delayed prescription is less commonly adopted by general practitioners in rural and remote areas than those in urban practices [49]

Implement policies mandating the adherence of antimicrobial prescribing practices to updated evidence-based medicine. Encourage rural physicians to attend seminars and conferences to gain exposure of the latest developments in AMS

Incentivise KPI targets for appropriate prescribing for remote physicians

Concerns for patient safety

Although patients show symptoms indicative of a viral infection during the initial consultation, rural physicians tend to prescribe antibiotics due to the fear of complications arising from secondary bacterial infections, which may occur at a time when the patient is unable to access medical care [52, 54]

For clinical cases involving ambiguity in aetiology, encourage physicians to employ a watch-and-wait strategy with appropriate follow up and management [73]. Schedule regular home visits for patients at risk of being lost to follow-up

Pressure to maintain good patient relations

Physicians often need to maintain a good reputation among members of the closely-knit rural community and are highly dependent on patient relations to maintain personal livelihoods. Due to their relatively low position in health care networks, rural physicians are especially vulnerable to medico-legal disputes, hence they would often fulfil their patients’ wishes regarding antimicrobial prescriptions [54]

Establish formal councils and committees to advocate and protect the interests of rural doctors. Perform clinician education on the importance of appropriate prescribing and engaging with patients in discussions on judicious use of antimicrobial agents, especially antibiotics

Pharmacists and informal health care providers

Over-the-counter antimicrobial agents

Particularly in developing countries, unlicensed practitioners and pharmacists are often the primary source of health care. In rural and remote areas with a shortage of primary health physicians, these providers provide consultations and supply antibiotics to rural communities, often without a prescription [40, 55, 58]

Enforce stricter rules and regulations on the provision of antibiotics to the general public, restricting their availability to those with a prescription by a qualified health professional. Provide education to health care professionals on the dangers of AMR and implications of excessive use of antimicrobials

Patients

Carriage of potentially pathogenic microorganisms

Nasopharyngeal carriage of respiratory pathogens is found to be significantly higher in rural and remote populations than those in urban areas, which portends a higher risk of transmitting organisms resistant to antibiotics [30, 30]

Monitor populations at risk of bacterial infestation

Consider decolonisation therapy using topical agents in high risk patients

Perform community-wide surveillance on carriage of drug-resistant organisms in areas where AMR is suspected to be problematic

Suboptimal adherence

Rural and remote populations, especially those in lower socio-economic status groups, generally have a poorer adherence to prescribed treatment [58]

Physicians and allied health professionals need to adopt a patient-centred approach that addresses factors leading to non-adherence and provide clear instructions for patients to follow regarding prescribed medications

Self-medication

Given the distance to PHC centres and costly consultation fees, patients tend to develop the habit of self-medication which includes using over-the-counter medications or those leftover from past illnesses or obtained from friends and family members [59]

Implement community-based programmes and campaigns to promote help-seeking behaviour and educate the public on the hazards and risks of self-medication

Restrict inappropriate access to antibiotics

Expectation of an antimicrobial prescription

Some population groups have higher expectations of obtaining antibiotics after each consultation and may prefer to visit doctors who prescribe antibiotics [47, 52]

Provide education to patients during consultations through easy-to-understand explanations and distribution of printed materials on proper antibiotic use—preferably using the patient’s own language and tailored to local cultures and preferences [57]

Implement community-based programmes and campaigns to promote proper antibiotic use

Patient knowledge

Populations in rural and remote areas are relatively disadvantaged in accessing health information. Evidence have shown that antimicrobial prescriptions are more likely to be given to patients who have lower antimicrobial-related knowledge [47, 59]

Conduct community-level stewardship programmes focused on community health literacy [60, 61]

  1. AMR antimicrobial resistance, AMS antimicrobial stewardship, CDSS clinical decision support system, PHC primary health care