Professional Documents
Culture Documents
Malang, Indonesia
c National Institute of Health Research and Development, Ministry of Health,
Received 19 May 2015 ; received in revised form 23 January 2016; accepted 31 January 2016
Corresponding author at: Pharmacology Department, Faculty of Pharmacy, Universitas Indonesia, Kampus UI, Depok 16424,
http://dx.doi.org/10.1016/j.jiph.2016.01.012
1876-0341/ 2016 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier Limited. All rights reserved.
42 R. Andrajati et al.
training. Physicians with a short working period (i.e., <7 years) were 3.95 times more
rational in prescribing antibiotics than physicians who had been working for longer
periods (i.e., >7 years). Most antibiotics were prescribed irrationally. Training for
rational drug use and length of practice were factors related to the rationality of
antibiotic prescriptions. Suitable interventions are urgently required to encourage
the rational prescription of antibiotics in the PHCs.
2016 King Saud Bin Abdulaziz University for Health Sciences. Published by Elsevier
Limited. All rights reserved.
Am Ce Ci Ch Co Er Me Te Th
Abscess, furuncle, and 2 0 0 0 1 0 0 0 0 3 (0.4)
carbuncle
Acute otitis media 8 0 0 0 1 0 0 0 0 9 (1.1)
Acute pharyngitis 270 0 12 0 34 1 0 0 0 317 (40.2)
Acute tonsillitis 35 0 0 0 6 1 0 0 0 42 (5.3)
Amebiasis 0 0 0 0 10 0 0 0 0 10 (1.3)
Bacterial conjunctivitis 12 0 0 0 0 0 0 0 0 12 (1.5)
Burn wound 1 0 0 0 0 0 0 0 0 1 (0.1)
Bronchitis 4 1 1 0 0 0 0 0 0 6 (0.8)
Bronchopneumonia 0 1 0 0 0 1 0 0 0 2 (0.3)
Chronic suppurative otitis 2 0 0 0 0 0 0 0 0 2 (0.3)
Common cold 24 0 1 0 4 0 0 0 0 29 (3.7)
Coughs 5 0 0 0 1 0 0 0 0 6 (0.8)
Cystitis 5 0 4 0 3 0 0 0 0 12 (1.5)
Dengue fever 3 1 0 0 0 0 0 0 3 7 (0.9)
Diarrhea 0 1 0 0 23 0 0 5 0 29 (3.7)
Dysentery 0 0 0 0 0 0 3 0 0 3 (0.4)
Dyspepsia 2 0 0 0 1 0 0 0 0 3 (0.4)
Eczema 10 0 0 0 0 0 0 1 0 11 (1.4)
Febris observation 5 0 1 0 6 0 0 0 0 12 (1.5)
Impetigo 11 0 0 0 1 0 0 0 0 12 (1.5)
Mumps 1 0 0 0 0 0 0 0 0 1 (0.1)
Non-specic gastro intestinal 1 0 0 0 0 0 0 0 0 1 (0.1)
infection
Non-specic acute 156 0 2 0 42 0 0 0 0 200 (25.4)
respiratory infection
Non-specic skin disorders 13 0 1 0 1 0 2 1 0 18 (2.3)
Other signs and symptoms 6 0 0 0 0 0 0 0 0 6 (0.8)
Pneumonia 0 0 1 0 3 0 0 0 0 4 (0.5)
Sinusitis 1 0 0 0 0 0 0 0 0 1 (0.1)
R. Andrajati et al.
Stomatitis 2 0 0 0 0 0 0 0 0 2 (0.3)
Tuberculosis suspect 0 1 0 0 0 0 0 0 0 1 (0.1)
Typhoid 0 0 2 1 0 0 0 0 23 26 (3.3)
Total (%) 579 (73.5) 5 (0.6) 25 (3.2) 1 (0.1) 137 (17.4) 3 (0.4) 5 (0.6) 7 (0.9) 26 (3.3) 788 (100)
Am amoxicillin, Ce cephadroxil, Ci ciprooxacin, Ch chloramphenicol, Co cotrimoxazole, Er erythromycin, Me metronidazole, Te tetracycline, Th thiamphenicol.
Factor related to rational antibiotic prescriptions in Indonesia community health centers 45
Table 3 The distribution of the irrationality of antibiotic prescriptions based on the type of disease.
Type of disease Type of irrationality
largest group of patients was women (54.4%) aged administration (1.8%). Irrational administration and
between 19 and 60 years (46.0%) (Table 1). duration of antibiotic treatment occurred most
Of the 70 infectious diseases diagnosed (Table 2), often for pharyngitis, which was the most common
the most common were pharyngitis (40.2%), non- infectious problem (Table 3).
specic acute respiratory infection (25.4%), acute Physicians who had attended training on rational
tonsillitis (5.3%), the common cold (3.7%), diar- drug use were 2.01 times more likely to be rational
rhea (3.7%) and typhoid (3.3%). Nine antibiotics in the prescription of antibiotics than those who
were prescribed according to availability. The most had not completed such training. Physicians with
frequently prescribed were amoxicillin (73.5%), less experience (i.e., <7 years) were 3.95 times
co-trimoxazole (17.4%), and thiamphenicol (3.3%). more likely to be rational when prescribing antibi-
Amoxicillin and co-trimoxazole were mostly pre- otics than those who had worked for longer (i.e.,
scribed for acute pharyngitis, nonspecic acute 7 years) (Table 4).
respiratory infections and the common cold. Co-
trimoxazole was also prescribed for diarrhea.
Thiamphenicol was mostly prescribed for typhoid.
Discussion
Rational analysis
Because the most common infectious diseases in
Out of 788 prescriptions with antibiotics, 392 pre- Indonesia are acute respiratory infections [14], it
scriptions were randomly chosen and evaluated. was not surprising that the most common infec-
Approximately 220 of the 392 prescriptions did tions in this study were pharyngitis, non-specic
not meet the criteria for rational antibiotic pre- acute respiratory infection, and acute tonsillitis.
scriptions in antibiotic selection (22.7%), duration The results of this study are similar to Munafs
of administration (72.3%), frequency of admin- ndings in six PHCs in South Sumatra, Indonesia
istration (3.2%), or duration and frequency of [27], although in the latter study, ampicillin was
46 R. Andrajati et al.
Table 4 Multivariate association of characteristic of physicians and the rationality of antibiotic prescriptions in
11 primary health center.
Characteristic of physicians Rationality of antibiotic OR 95% CI p value
prescribing (n = 172)
Education
Master of medicine 13 (92.4%) 6.264 0.0201.273 0.083
General medicine 159 (42.1%)
Years of service
Short (<7 years) 91 (65.0%) 3.952 0.1580.405 0.000
Long (7 years) 81 (32.1%)
Training on rational drug use
Had attended 142 (46.1%) 2.014 0.2860.860 0.013
Had never attended 30 (35.7%)
the most frequently prescribed antibiotic (31% of norms and local medical cultures, timely labora-
1776 prescriptions). This difference may relate to tory results and an unstable antibiotic supply [19].
the availability of antibiotics at the centers. In A qualitative study in Spain [30] revealed that
the present study, ampicillin was not available the identication of physician attitudes and knowl-
in the health centers, and amoxicillin was not edge related to inappropriate antibiotic prescribing
available at the PHCs in Munafs study. An inap- enables the development of specic interventions.
propriate supply of medicine is one of several A recent systematic review concluded that inade-
determinants of irrational antibiotic use [12], and quate knowledge of prescribing is prevalent among
the lack of availability of the indicated antibi- physicians, however many physicians were inter-
otics may limit the ability of prescribers to provide ested in improving their antibiotic prescribing [31].
appropriate antimicrobial therapy [19]. That chlor- A major nding of this study was that the dura-
amphenicol and thiamphenicol, which have similar tion of antibiotic administration was frequently
indications, were available while ampicillin was too short. This observation is in agreement with
not reects the poor supply in the area of our the published data indicating that medical doctors
study. are most likely to prescribe antibiotics for insuf-
This study revealed evidence of irrational antibi- cient periods of time in developing and transitional
otic prescribing for diarrhea and the common countries [12]. In Depok City, this behavior may
cold. For both conditions, it is clearly mandated have been inuenced by the pooled procurement
that antibiotics should not be used because most system for all PHCs, which might have resulted in
episodes are caused by a virus [16]. In our study, the an insufcient supply of antibiotics. A study in Korea
most frequently prescribed antibiotic for diarrhea concluded that prescription patterns were more
was co-trimoxazole (Table 3). A study conducted affected by supply factors than by demand fac-
in India showed that the main antibiotic class that tors [32] and that antibiotic choices were guided by
was prescribed for diarrhea was uoroquinolones the availability of drugs. Lack of prescriber knowl-
[28]. Similar to our ndings, a study in Hong Kong edge could be a cause of an inappropriate antibiotic
reported upper respiratory tract infections to be therapy duration [12]. Future studies should be con-
the most common diagnoses and amino-penicillin to ducted to further determine the possible causes
be the most commonly prescribed antibiotic [29]. for the irrationally short durations of antibiotic
The ndings of the present study highlight the therapy.
irrational use of antibiotics in Depok Citys health Rational drug use training leads to an increased
centers. As in previous studies, the principles understanding of the considerations associated with
of rational antibiotic prescription were not fully prescribing antibiotics. By following these gen-
applied by physicians in daily medical practice eral principles, all physicians are expected to
[3,57]. These ndings also support the claim prescribe antimicrobial agents in a responsible
that most antibiotic prescriptions in primary health manner that benets both the individual patients
care are irrational [2,4,12,18,28,29]. The deter- and the community [9,12,15]. On average, edu-
minants of antibiotic prescribing include a lack cational interventions targeting health providers
of knowledge, perceived patient demand, eco- have the largest effect [12]. Moreover, many physi-
nomic incentives, pressure from pharmaceutical cians are interested in improving their antibiotic
promotions, fear of bad clinical outcomes, peer prescribing [31].
Factor related to rational antibiotic prescriptions in Indonesia community health centers 47
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