Prescribing Patterns of Antibiotics According to the WHO AWaRe Classification during the COVID-19 Pandemic at a Teaching Hospital in Lusaka, Zambia: Implications for Strengthening of Antimicrobial Stewardship Programmes
, Eustus Nsofu 1, Patience Chisha 1, Victor Daka 2, Billy Chabalenge 3, Webrod Mufwambi 1, Henson Kainga 4, Manal H.G. Kanaan 5, Ruth L. Mfune 2, Florence Mwaba 6, Mildred Zulu 6, Rabecca Tembo 6, Wizaso Mwasinga 7, Kennedy Chishimba 8, Grace Mwikuma 9, Ngula Monde 10, Mulemba Samutela 11, Harriet K. Chiyangi 12, Shafiq Mohamed 13 and Scott K. Matafwali 14Round 1
Reviewer 1 Report
Mudenda and colleagues sought to study the prescribing patterns of antibacterial agents at the University Teaching Hospital in Lusaka, Zambia during the COVID-19 pandemic to determine their appropriateness using the WHO AWaRe classification. Overall, the study is a useful addition to the available literature on antimicrobial prescribing in African countries and efforts at antimicrobial stewardship to help ward off the global problem of rising antimicrobial resistance.
A few points/issues to address:
1) The authors state that the study was conducted from August 2022 to September 2022. That appears to be incorrect since reviewed patient files were from January 2021 to December 2021 (lines 236-237).
2) The Introduction section is overly long and repetitive. Perhaps it can be made more concise.
3) In Table 1, the 95% confidence interval column is not helpful since the authors are only describing the demographic characteristics of the study population.
4) Section 2.3 and Table 3 results are to be expected since hospitalized patients are more ill and much less likely to need the “Access” type of drug. This also applies to Table 4 results.
5) Although the authors list the “Disease Condition” in Table 5, this does not give a clear picture of how sick patients were. For example, respiratory tract infection can mean empyema, a condition that would often require medications on the “Watch” list. Similarly, STDs, pelvic inflammatory disease, and septicemia are not conditions for which simpler “Access”-type of antibiotics would be suitable.
6) Despite repeatedly using the words “inappropriate” and “irrational”, Table 6 shows that 97%-99% of prescriptions at the University Teaching Hospital were appropriate in terms of dose, frequency, and duration, which is actually quite impressive.
7) Sulfamethoxazole-trimethoprim is a combination preparation of two antibiotics, and this was used in 3.4% of their patients. Thus, when counting “number of antibiotics” in Table 4, those who received this product should be shifted to those with “2” antibiotics. This would change the numbers and possible the P-value as well.
8) Since this study was done during a COVID-19 pandemic year, it may or may not reflect antibiotic prescribing patterns during a non-pandemic year. It would be helpful to know how many of the 384 patients had COVID-19 (suspected or confirmed).
Author Response
Please, see the attachment.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
I truly enjoyed reviewing this manuscript on appropriateness and prescribing patterns of inpatient and outpatient antibiotics in teaching hospital in Lusaka, Zambia according to the WHO AWaRe framework. As a steward practicing in the US, I'm less familiar with AWaRe and this study explained it very clearly. Other strong points of the study are the inclusion of both pediatric and adult patients and inpatient and outpatient antibiotics. Comparison to frequency of AWaRe categories in other countries is also helpful
I have a few minor suggestions
1. page 2 line 69, would change "impact" to "consequence"
2. please provide a brief explanation about the process of prescribing outpatient antibiotics inpatient and outpatient. Who is primarily responsible and what is their training? Do outpatient antibiotics require a prescription from a clinician? how is this enforced? For instance, in India, there is lots of dispensing from outpatient pharmacies without a prescription from a clinician
3. Results, table 2 - for oral antibiotic prescriptions, can you indicate frequency of inpatient or outpatient use?
4. Is there an OPAT program to manage IV antibiotics? if so, please briefly note this if relevant (i.e., if any outpatient antibiotics were IV)
5. Page 5, line 137 and table 4- does "prescriptions" refer to antibiotics prescribed at the same time/same infection episode?
6. Table 6 - why is appropriateness by "indication" not included? for instance, amox/clav would be appropriate/first line for ENT infection but ciprofloxacin may not be considered first line
Author Response
Please, see the attachment.
Author Response File: Author Response.pdf
Reviewer 3 Report
Very good work. Excellent detailed chart review.
A worrying trend of overuse of antibiotics has been observed in developing countries where regulations around pharmacies dispensing medications is extremely lax. This study throws light on this phenomenon in Zambia.
However since most charts indicated adherence and use of antibiotics could be considered appropriate in that individual it is reassuring to an extent but the use of "Access" antibiotics is concerning definitely.
Author Response
Please, see the attachment.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
The authors have addressed the points raised by my review. No additional comments or concerns.
