Data-driven Community-based Antibiotic Footprint Detection

We harness the power of PPS application to get a snapshot of prescribing practices and dispensing of OTC antibiotics in the community. We use analytics of captured data to design SMART educational interventions for behaviour change and policy making related to Access antibiotics. 

Dr Sanjeev Singh

Medical Director

Amrita Institute of Medical Sciences

Faridabad, Delhi NCR

Globally, antibiotic consumption increased by 65% between 2000 - 2015, driven largely by LMICs. A major concern in LMICs is availability of over the counter (OTC) antibiotics in Asia and Africa, leading to inappropriate and excessive antibiotic use in the community, which is a driver for the spread of resistant bacteria with consequent threat to the treatment of community and healthcare associated infections.

AMS strategies are mostly absent in LMICs. In the absence of reliable data regarding the magnitude of OTC consumption of antibiotics, detection of important community related foci that drives irresponsible antibiotic use remains unaddressed. Policymakers globally expressed concerns, leading to national regulations to ban OTC antibiotics in LMIC. Yet enforcement and implementation of prescription-only antibiotics in LMIC is often non-existent. Many causes of OTC antibiotics have been described using qualitative studies. A systematic review showed that it is possible to improve antibiotic dispensing practices at the community level in LMIC whereby stakeholders' involvement is key in the design and implementation of interventions. We aim to adopt the WHO Consultation Report ‘Global campaign to phase out OTC antibiotic sales’ recommendation of stepwise approach rooted in consultations and actions at national levels rather than at global level.

The target population includes the whole chain of stakeholders from patients/clients at household level, dispensers at pharmacies/drugstores, prescribers at primary care facilities and hospital outpatient clinics, microbiologists, doctors, students. As such, we obtain the antibiotic pathway in the community. To obtain meaningful conclusions; we need the involvement of specific skills and knowledge from a range of health professional organizations, such as pharmacist associations, nurse associations, pediatric associations, associations involved in clinical microbiology so that they can transfer AMS in the community and support AMS activities.

Individual local healthcare professionals appointed for this project, aided by continuous technical support from the Global-PPS team, will gain the necessary skills to collect antimicrobial surveillance data, interpret these, take the lead to customize local stewardship actions at different levels in the outpatient setting and inform and educate other healthcare professionals on appropriate antimicrobial prescribing, dispensing and usage in healthcare centers. Evidence-based actionable data will on its turn help regulatory policy making.

The sample population will be chosen from one district in Asia (Delhi, India) and one in Africa (Lagos, Nigeria).

The public good available are:

• A free-to-use dedicated application to enter and validate surveillance data on the quantity and quality of antimicrobial prescribing and dispensing. Raw data are extractable at any time in excel format, allowing verification and analysis of own data.
• Availability of free real-time feedback reporting to all participants: The solution offers besides own results also benchmarking results (country, region). Feedback report is developed using the R statistical software package on one side and the interactive website through the application (longitudinal results).
• Free access to all documents such as protocols, training materials, FAQ, peer-reviewed open access publications, promotional materials to aid communication at local level.
• Possibility to translate and make freely available all documents in different languages
• Possibility to have access to data of multiple institutions/pharmacies collecting outpatient data (attribution local administrator and  extra users). As such, MoH can become owner of all data for a certain region (already existing for the Global-PPS).
• Possibility of data-sharing between individual participating centres/pharmacies/drug stores or any public organisation if agreed upon by all partners using the tool.
• Continuous knowledge transfer using data-driven AMS through the identification of local champions

We aim to create data driven communication strategies to intervene at two levels:

1. Inadequate/Incorrect prescriptions as per national recommendations or WHO handbook: communication strategies will aim to improve prescription quality by providing educational material to the concerned prescribers (e.g. in the form of paper leaflets, educative video messages).
2. Absent prescriptions and OTC antibiotic seeking behavior: Educational interventions for the dispensers and at the patient level.

As shown in multiple studies from LMICs, targeted interventions have an effect on prescribing behavior in hospitals. The same approach, we believe will also work for the outpatient setting. However, different stakeholders will be involved. Multiplex strategies to influence behavior tend to have a higher success rate in changing behavior than a single strategy-based intervention.

The developed AMS work manual will guide AMS implementation step by step. Feedback from multiple PPS of the sites will help in determining change in prescription and dispensing behavior. The work manual and all other tools will be freely available to all partners/professionals involved in AMS. The work manual also serves as teaching material for university students (doctors, pharmacists, nurses) and will be made available locally/regionally by pharmacy associations or other stakeholders involved in AMS. 

We will create a first HUB from a selection of pharmacies/drug stores (minimum 10) and PHC and outpatient clinics (minimum 5) and implement the WHO multimodal improvement strategy addressing the five areas: Build it, Teach it, Check it, Sell it, Live it;not forgetting the patient community. We want to scale up to other geographical areas within the same region/province (Delhi NCR and Lagos) after at least two years of implementation. Active communication and dissemination of the project results will contribute to essential leadership alignment at different levels and will encourage local policymakers and governments to prioritize and support efforts to reduce inappropriate antibiotic use in the outpatient setting. 

Quantitative measure of effectiveness of the solution can be assessed by conducting a pre & post PPS evaluation of antibiotic use in the community.

• Number of community pharmacies and prescribers from PHC and outpatient clinics, collecting “repeated” Global-PPS data
• Surveillance results conducted at the local level will provide prevalence of antimicrobial prescribing and dispensing (OTC use) by diagnosis, symptoms recorded, use of medical microbiology laboratory, POCT/RDT, (data collection templates attached).
• Comparison of antibiotic choice before and after data driven communication
• Comparison of dose, duration and formulation before and after data driven communication
• Impact on OTC antibiotic prescriptions before and after data driven communication.
• Local champions can interpret results, identify the problem, choose the behavior to target, can assess determinants influencing behavior and can identify what needs to be addressed by the institution/pharmacy/drugstore/patients/clients to ensure the right treatment for the right patient.
• Local champions develop, present and discuss to the core-team, and implement a tailor-made step-by-step AMS plan, based on the AMS work manual.
• Sustainability: Local pharmacy associations take over the educative role
• Socio-economic impact 

Cultural and market barriers: Perception of threat by community pharmacies as many may view this exercise as a threat to their business. We plan to enroll pharmacies by offering training and all necessary educational documents which they can display in their pharmacy or drug store in support of their communications with patients/clients. The work plan as described above needs to be followed whereby targets will be set and repeated PPS should be implemented to measure if targets are obtained. If targets are met, certificates will be delivered which they can on their turn use in their business. If the work manual as described above can be adopted by official organizations (e.g. African CDC), this certificate could obtain the power as to acknowledge a certified pharmacy for a specific defined period (e.g. 1 year) with possibility to extend for a defined period. This plan to overcome barriers will be tested locally and improved during the project. Pharmacies/drug stores will at the beginning may need to receive an incentive. Whenever a pharmacy or drug store get the reputation of delivering good quality of care, they will not loose clients and the incentive may not be necessary.

We believe we have a powerful tool that already exists and can be easily extended for other purposes. The tool is specifically designed to explore data on antimicrobial use, it includes all the necessary metrics for exporting and feeding back results to participating institutions. The team provides ongoing content and technical support to the network so that participants can collect valid data.

The university has years of experience in data management of outpatient and inpatient antimicrobial use data and is well positioned to provide support to countries seeking to improve their data-driven AMS programmes. The university is also currently involved in the drive-AMS project (see above) and we see a huge opportunity to extend this experience and apply it to outpatient and community settings in LMICs.

The Global-PPS team has a longstanding successful collaboration with India and Nigeria; and our complementary roles will lead the success for this project.

-The Change Exchange will help develop behavioural change solutions based on the interventions identified  from the data on antibiotic prescribing, dispensing from the outpatient clinics, community pharmacies and drug stores.  They can help design a survey to assess behaviour change following interventions and help with planning healthcare worker training/capacity building assessments.

- IQVIA (market research for pharmaceuticals) to harness antibiotic consumption data

- National Centre of Disease Control (NCDC), India will help in up-scaling the solution in wider geographical area

- Indian Council of Medical Research (ICMR) India will help in up-scaling the solution in wider geographical area

- African CDC and regional WHO experts will help in up-scaling the solution in wider geographical area in Africa

- Nigerian Society for Paediatric Infectious Diseases (NISPID)

- Pharmacist associations working in India and Nigeria. They will be able to help with the implementation of our plan and ensure sustainability of the project. The global-PPS has worked before with colleagues from the Commonwealth Pharmacists Association and we would love to have them on board again.  

- We are open to any collaboration to enhance appropriate prescribing and dispensing in the community setting in LMIC.