TY - JOUR
T1 - Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India
T2 - a cross-sectional study
AU - Satyanarayana, Srinath
AU - Kwan, Ada
AU - Daniels, Benjamin
AU - Subbaraman, Ramnath
AU - McDowell, Andrew
AU - Bergkvist, Sofi
AU - Das, Ranendra K.
AU - Das, Veena
AU - Das, Jishnu
AU - Pai, Madhukar
N1 - Funding Information:
This study is funded by Grand Challenges Canada (grant ID: S5 0373-01 ), Bill & Melinda Gates Foundation (grant number: OPP1091843 ), Knowledge for Change Program , World Bank Development Research Group . SS is supported by a fellowship from the Canadian Thoracic Society and is also a senior operations research fellow at Center for Operational Research, The Union (Paris, France). RS is supported by a Fogarty Global Health Equity Scholars Fellowship ( NIAID R25 TW009338 ). JD and BD received funds from the Knowledge for Change Program (The World Bank) . MP is a recipient of Tier 1 Canada Research Chair from Canadian Institutes of Health Research. We thank Puneet Dewan, Sarang Deo, Nim Pathy, and Vaibhav Saria for useful input on analysis and interpretation; Rajan Singh, Purshottam, Chinar Singh, Geeta, Devender, Varun Kumar, Anand Kumar, Babloo, and Charu Nanda who supervised and implemented the ISERDD fieldwork; and all the standardised patients for their dedication and hard work. The findings, interpretations, and conclusions expressed here are those of the authors and do not necessarily represent the views of the World Bank, its Executive Directors, or the governments they represent.
Publisher Copyright:
© 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license
PY - 2016/11/1
Y1 - 2016/11/1
N2 - Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.
AB - Background India's total antibiotic use is the highest of any country. Patients often receive prescription-only drugs directly from pharmacies. Here we aimed to assess the medical advice and drug dispensing practices of pharmacies for standardised patients with presumed and confirmed tuberculosis in India. Methods In this cross-sectional study in the three Indian cities Delhi, Mumbai, and Patna, we developed two standardised patient cases: first, a patient presenting with 2–3 weeks of pulmonary tuberculosis symptoms (Case 1); and second, a patient with microbiologically confirmed pulmonary tuberculosis (Case 2). Standardised patients were scheduled to present each case once to sampled pharmacies. We defined ideal management for both cases a priori as referral to a health-care provider without dispensing antibiotics or steroids or both. Findings Between April 1, 2014, and Nov 29, 2015, we sampled 622 pharmacies in Delhi, Mumbai, and Patna. Standardised patients completed 1200 (96%) of 1244 interactions. We recorded ideal management (defined as referrals without the use of antibiotics or steroids) in 80 (13%) of 599 Case 1 interactions (95% CI 11–16) and 372 (62%) of 601 Case 2 interactions (95% CI 58–66). Antibiotic use was significantly lower in Case 2 interactions (98 [16%] of 601, 95% CI 13–19) than in Case 1 (221 [37%] of 599, 95% CI 33–41). First-line anti-tuberculosis drugs were not dispensed in any city. The differences in antibiotic or steroid use and number of medicines dispensed between Case 1 and Case 2 were almost entirely attributable to the difference in referral behaviour. Interpretation Only some urban Indian pharmacies correctly managed patients with presumed tuberculosis, but most correctly managed a case of confirmed tuberculosis. No pharmacy dispensed anti-tuberculosis drugs for either case. Absence of a confirmed diagnosis is a key driver of antibiotic misuse and could inform antimicrobial stewardship interventions. Funding Grand Challenges Canada, Bill & Melinda Gates Foundation, Knowledge for Change Program, and World Bank Development Research Group.
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U2 - 10.1016/S1473-3099(16)30215-8
DO - 10.1016/S1473-3099(16)30215-8
M3 - Article
C2 - 27568359
AN - SCOPUS:84994812849
SN - 1473-3099
VL - 16
SP - 1261
EP - 1268
JO - The Lancet Infectious Diseases
JF - The Lancet Infectious Diseases
IS - 11
ER -