[e-drug] Use of ceftriaxone in poor countries

E-DRUG: Use of ceftriaxone in poor countries
--------------------------------------------

Hi All,

I am a Guyanese Pharmacist who works at a regional hospital.

Ceftriaxone is considered a reserved antibiotic in my hospital but for the past year or so I noticed that it is being used for any infection.
Other antibiotics are available which include, ampicillin, cloxacillin, benzylpenicillin, benzathine penicillin, procaine penicillin, gentamicin, cefuroxime, azithromycin but the first choice seems to be ceftriaxone.

I would like to know what are the uses of ceftriaxone in poor countries and how to deal with this problem because I personally believe that we would be creating resistance to this drug in the near future.
I also recieved some very negative comments like "I am the doctor and so you need to do what I say."

I spoke to the doctors on several occasions about the availability of other antibiotics but the problem keeps recurring.

Regards

Sunil, R Pharm, GUYANA.
sunil4ya@yahoo.com

E-DRUG: Use of ceftriaxone in poor countries (2)
---------------------------------------------

Hi,

In Fiji, it also regarded as one of the Restricted Antimicrobial.
As per our Antibiotic guideline it is recommended for empirical treatment of bacterial Meningitis for those hypersensitive to Penicillin.
Also indicated for brain abscess.
It has also been indicated for empirical therapy in sexual assault cases for children and some gonococcal infections (both indications ceftriaxone is rarely used since we have other antibiotics).

We do come across certain times when doctors do commence treatment for other indications provided with proper sensitivity results. Otherwise some doctors treat when patients are clinically responding.
Yet as pharmacists we do intervene whenever we feel there is irrational prescribing of Ceftriaxone injection.

Thank you.

Asaeli Raikabakaba
Actg. Principal Pharmacist
Lautoka Hospital
Fiji Island
asaeli.raikabakaba@health.gov.fj

E-DRUG: Use of ceftriaxone in poor countries (3)
-------------------------------------------

Hi Sunil,

I am very grateful that you've raised this crucial point. I am the chief pharmacist at Port Moresby General Hospital,Papua New Guinea.

The crux of the matter is that ceftriaxone is a third line cephalasporin and the issues you've encountered are no different to my hospital despite our advise and drug information leaflets to prescibers.

Currently, we are documenting all ceftriaxones requests and hopeful we shall deduce a study analysis on that.

However, could someone out there help with strageties to correct the prescibing pattern.

Thank you
Allan Kango
POM GEN Hospital,PNG
agkango2004@yahoo.com

E-DRUG: Use of ceftriaxone in poor countries (5)
---------------------------------------------

Dear All,

I agree with Sunil we are having this problem in our institution which is a
Health Unit in a University. We have been writing notices to our clinicians
asking them to us cheaper alternatives. We also us CMEs (continous medical
education) to let them appreciate the need to preserve the third generation
antibiotics for more serious conditions and this seems to bear some fruits
as well as restricting the supply of Ceftriazone.

The rational use of antibiotics like all other improvements of drug use
interventions need are best with concerted efforts i.e. a combination of
administrative or managerial, regulatory and education measures. An active
pharmacy and therapeutics committee in the hospital gives you a forum where
you address the prescribing habit, problems and attitude of clinicians.

Regards,

Dr. Bilha Kiama- Murage
Pharmacist in charge
Kenyatta University
Health Unit
Secretary- INRUD-Kenya Chapter
Email: bmurage2001@gmail.com

E-DRUG: Use of ceftriaxone in poor countries (4)
-----------------------------------------------

well i am facing the same problem here in ghana. i work in a district hospital as a pharmacist and patients who are coughing are even put first on inj ceftiaxone. its really amazing. it is really a countrywide in ghana and some prescribers argue that there is already resistance and so they are helpless.

one problem i have also realised is that the ceftriaxone in our system are usually the generics and there have been some few trials showing that patients responded more to the original brand than the generic brands. This is quite worrying and worsening the incidence of resistance.

[Can you (or another E-drugger) please list references to studies showing differences in response to originator and generic copies of ceftriaxone? Undocumented claims are no good. Moderator].

Christian Ayin
Pharmacist
Ghana
teye82@hotmail.com

E-DRUG: Use of ceftriaxone in poor countries (11)
--------------------------------------------

Could someone explain why this is happening? Are the drug companies pressurizing doctors to prescribe expensive, newish, drugs?

[Injections have always been popular in poor countries and I would guess one injection a day sounds appealing to some. Introducing generics can also have the adverse effect of increasing consumption. And in itself and as part of competition, also heavy marketing contributes. Guidelines and enforcing them is clearly necessary, but how do we change the 'injection culture'? Moderator]

Valeria

------------------------------------------
Dr Valeria Frighi
University Dept. of Psychiatry
Neurosciences Building
Warneford Hospital
Oxford
OX3 7JX
UK
Tel. -44 -1865 -223779
Fax -44 -1865 251076
Mobile phone 07974920013
Valeria.Frighi@psych.ox.ac.uk

E-DRUG: Use of ceftriaxone in poor countries (8)
--------------------------------------------

Hi All,

Use of antimicrobials is always a problematic issue. You will always get
resistance from clinicians everywhere you may be practicing. My advice is
to establish an "Antibiotic Guideline" for your rspective area/hospital.
This can be developed through collective work with the head of pharmacy
chairing the committee. Alternatively an infectious disease consultant or a
senior microbiologist. Invite senior clinicians, one from each clinical
dept, nursing service and a microbiologist. Obtain a working/recent
antibiotic guideline from the nearest hospital/country as a starting point.
If you fail to get one let me know I will send you a copy from our hospital.

Let each clinical dept to develop its own preferential list of antibiotics
for empirical use and when to switch to reported antibiotic from the
microbiology dept. The committee will evaluate the lists developed by the
respective clinical dept whether the selection complies with evidence based
practice. Once the guidelines are ready to be launched carry out a one day
antibiotic prescribing from all units. Repeat a similar study at regular
intervals and publicise you results within your practicing site. You may
also conduct antimicrobial usage/prescribing pattern with the help of the
DDD/100bed days. Ensure that your antibiotic guidelines are developed using the WHO recommended ATC classification. The pharmacy dept must take the initiative and do not give up. This is a problem of attitude amongst
clinicians and the fact that during the undergraduate schooling most syllabi do not teach misuse of antimicrobials seriously. This comment applies to all health related programs. All the best and if you need any practical tips of how to handle this do not hesitate to ask.

[the moderator agrees measuring consumption and use that to develop guidelines and then regularly to monitor is a good way to start.]

Qasim Ahmed Al Riyami
Assistant Dean of Training
College of Pharmacy & Nursing
University of Nizwa
P.O.Box 33 PC 616
Birket Al Mouz, Nizwa
Oman
email: karafuu@gmail.com & qassim@unizwa.edu.om

E-DRUG: Use of ceftriaxone in poor countries (9)
-------------------------------------------

I agree that this is a very important problem especially in developing countries where there are no treatment guidelines. I work as a physician/clinical pharmacologist in Nigeria and the irrational use of ceftriaxone is common in both the secondary and tertiary health facilities. A study conducted by my team at a teaching hospital in Kano, Nigeria and presented at the 34th West African Society of Pharmacology Annual Conference in 2007 clearly shows that Ceftriaxone was second only to Co-Amoxiclav in prescriptions from the medical wards of the hospital. Another finding was that treatment with ceftriaxone was started empirically without regards for culture results and for conditions where less expensive antibiotics would have been effective. My explanation for this frequent use especially in tertiary health facilities is that patients are already far advanced in their disease process before they are brought to the hospital and the doctors think that the most aggressive antibiotic treatment would bring the required results. This fact is also supported by the fact that most patients have already self-medicated with one or two different antibiotics before coming to the hospital.

As a clinical pharmacologist, I strive to educate colleagues on the need for rational use of medicines and especially antibiotics. I guess there is an urgent need for the development and implementation of treatment guidelines and also adherence to the use of essential drug list in our health facilities. And of course there is the need of continuing medical education at all levels and the need for the regulatory authorities to check the bioequivalence of generics of ceftriaxone in use.

Joseph Fadare MD
Physician/Clinical Pharmacologist
Nigeria
dokita007@yahoo.com

E-DRUG: Use of ceftriaxone in poor countries (12)
-------------------------------------------

Dear All

It is true that ceftriaxone, alongside other antibiotics are used
irrationally in developing countries. Having heard experience of practicing as a pharmacist in both a public hospital and a private pediatric hospital, i noticed that the pattern of use of ceftriaxone differs depending on the facility. public hospitals are often resource poor and hence limit the use of expensive medicines, for which ceftriaxone happens to be one, while private hospitals have a clientelle that demands expensive medicines under the wrong assumption that the more expensive a drug is, the more effective. the predictors for irrational use of antibiotics in public and private health facilities therefore often differ and customized approaches shoud be adopted to tackle the problem.

One of the best strategies to approach this problem is to promote evidence based medicine. We often tell clinicians that their practice is irrational without providing evidence, this cannot work. The development of standard treatment guidelines for the management of common conditions and antibiotic use guidelines is important in promoting rational use. The clinical guidelines, especially those on infectious diseases, should reflect local resistance patterns, and offer clear guidelines on antibiotic choice. Once the guidelines are backed by evidence, then a prescribing restriction policy would be easy to implement. Regular updates to ALL clinicians on local antibiotic resistance patterns will help in fostering confidence in clinicians that other antbiotics are as effective.

Operational research to quantify rational use issues, and device and
implement Interventions in collaboration with all stakeholders, clinicians,
pharmacists and laboratory staff will also help.

Dr Barasa W. Edwine BPharm MPSK
Child and Newborn Health Group
Centre for Geographic Medicine
KEMRI-University of Oxford-Wellcome Trust Collaborative Research Programme
Kenyatta National Hospital Grounds (Behind NASCOP)
P.O. Box 43640 – 00100
Nairobi, Kenya
Tel: +254 20 2715160 or 2720163 or 2719936
Fax: +254 20 2711673
Cell: +254 722 129 757
edwine.halton@gmail.com

E-DRUG: Use of ceftriaxone in poor countries (13)
-----------------------------------------------

I am practising in rural Australia, not exactly a poor country, though
isolated rural places here share some infrastructure problems with
poor countries.

From a doctor's perspective, Ceftriaxone offers several advantages:

1) no drug level monitoring (eg. compared to Aminoglycosides)
2) no dose adjustment necessary in renal failure
3) once daily im dosing allows home treatment, no hospitalization
required for parenteral antibiotics
4) fairly broad spectrum with so far very little resistance
5) serious adverse effects are rare
6) allergies to it are rare

While the concern regarding resistance is of course there,
economically it often makes sense to use the relatively expensive
Ceftriaxone:
1) sending a blood test to the lab (eg drug levels, Creatinine) a long
distance outside normal courier traffic for blood levels can cost an
order of magnitude more than the drug - can be avoided with
Ceftriaxone
2) having to admit the patient can cost a public health system or the
patient far, far more than the drug - can be avoided with Ceftriaxone

Thus, if Ceftriaxone is likely to cover the pathogen spectrum of a
patient, we often deploy it if
- a patient's renal function is impaired or unknown and it is Friday
(no routine blood tests before Monday)
- a patient is suitable for home treatment but requires parenteral
antibiotics (many of our daiy farmer resume working while on treatment
as soon as they can walk again)
- we run out of other suitable drugs, which is a sad reality even in
"highly developed" Australia with its sometimes very poor
infrastructure in rural and remote areas.

For some colleagues medicolegal aspects play a role too - in these
days where "litigation fear driven medicine" beats "evidence driven
medicine" hands down, the treatment with the highest likelihood of
success and least likelihood of harm for the individual is often
chosen regardless of the consequences for the population as a whole.

I have never met a pharma rep trying to push us to use Ceftriaxone -
not once in practising rural and remote medicine for almost 15 years.

Horst
Horst Herb
subscriptions@gnumed.net

E-DRUG: Use of ceftriaxone in poor countries (14)
----------------------------------------------

Hi all,

I do not see a problem using ceftriaxone in poor countries or developing world. Reasons being that

-most patients have tried some form of self medication with antibiotics when they present to you.

In most developing countries, patients are able to buy these oral antibiotics (amoxicillin, tetracycline, cotrimoxazole, ampicillin etc) over the counter without prescription. And in most cases, they do not buy a complete course enough for 5 to 10 days of therapy.

We must also bear in mind that there are some WHO notifiable diseases that you must start on emperic therapy as you wait for your lab results eg bacterial menengitis.

-Use of ceftriaxone improves compliance. It can be given as a once a day dosing or twice daily.

-Daily or twice a day dosing ensures that patients can take parenteral therapy from the comfort of their homes.

-Use of ceftriaxone also reduces sick days; patients are able to return to work ASAP, hence keeps our economy running in such hard times

-We should worry less about resistance, especially if we use this drug appropriately as recommended.

-I also do believe that if a patient can afford it, then give it to him/her. Why subject them to suffering while you are trying out the "cheaper" oral antibiotics! It ends up being expensive to the patient and employers anyway, since they will miss so many days of work due to sickness!!

-The goal should be quick recovery, and return to work soon

-Like someone already mentioned, with ceftriaxone, you do not have to worry about renal dose adjustments; you do not have to worry about drug levels as is with gentamicin, amikacin, vancomycin etc; steady-state levels achieved around the 3rd dose.

[The moderator finds that some discussants are not differentiating between substituting oral narrov-spectrum antibiotics for minor infections with ceftriaxone and serious infections needing admittance to hospital.]

Dr. Otieno A.A
otienoaduma@hotmail.com