Toward Improving Rational Use of Antibiotics in Peru. Kristiansson C 1 , Larsson M 1 , Thorson A 1 , Gotuzzo E 2 , Pacheco L 3 , Rodriguez Ferrucci H 4 , Reilly M 1 , Carvallo E 4 , Bartoloni A 5 , Bartalesi F 5 , Strohmeyer M 5 , Bechini A 6 , Paradisi F 5 , Falkenberg T 1.
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Kristiansson C1, Larsson M1, Thorson A1, Gotuzzo E2, Pacheco L3, Rodriguez Ferrucci H4, Reilly M1, Carvallo E4, Bartoloni A5, Bartalesi F5, Strohmeyer M5, Bechini A6, Paradisi F5, Falkenberg T1
1. IHCAR, Karolinska Institutet, Sweden
2. Inst. Med. Trop. A. von Humboldt, Universidad Peruana Cayetano Heredia, Peru.
3. Health Directorate of San Martin, Peru
4. Health Directorate of Loreto, Peru
5. UFDID, University of Florence, Italy.
6. UFDPH, University of Florence, Italy.
Antibiotics are among the most commonly used types of drugs and have had a significant impact to decrease morbidity and mortality in infectious diseases. However, irrational use of antibiotics leads to resistance, treatment failure, and waste of scarce resources. Irrational prescribing of antibiotics in Peru, partly related to fulfilmentof social expectations rather than doctors’ lack of knowledge, has been described (Paredes et al, 1996). With health care systems in constant change it is important to continuously monitor the rationality of antibiotic use, in order to evaluate policy changes and provide a knowledge basis for development of new interventions.
To investigate morbidity pattern, health seeking behaviour and antibiotic use among households with children aged 6 - 72 months in the urban community Yurimaguas, Alto Amazonas, Peru.
The caregivers of 800 children aged 6–72 months were interviewed using a pre-tested validated questionnaire. The questionnaire included questions regarding the children’s episodes of illness and health seeking behaviour the previous two weeks, including details on use of antibiotics.
Fifteen focus group discussions (FGDs), with 6–8 participants per group, were performed with health workers and caregivers, including mothers, fathers, and grandmothers. Issues of health seeking behaviour and concepts of health and illness were discussed.
No action takenGraph 1. Health seeking behaviour related to symptom clusters
1. Children’s symptoms previous two weeks, as reported by caregivers, was clustered into Diarrhoea- Dysentery and ARI-like clusters. Average number of symptoms per child: 3,6 (1-12).
Self treatment +
consult hc provider
Number of children
Mix diarrhoea upper ARI
Mix dysentery upper ARI
Mix diarrhoea-lower ARI
Mix dysentery lower ARI
Number of children
Number of children
No action taken
Self treatment +
Consult Health care provider
Consult Public doctor
Consult private pharmacy
Consult Public pharmacy
Consult Health technician
1. Health seeking behaviour and antibiotic consumption
No Antibiotics used
2. Type of health care provider combined with self treatment
Antimicrobial consumption for mixed health seeking behaviour (self medication + consultation)
Place of purchase of the antibiotic prescribed
Mix up.ARI + Dysentery
Mix up.ARI + Diarrhoea
Mix low.ARI + Dysentery
Mix low.ARI + Diarrhoea
Graph 3. Antibiotic treatment and antibiotic provider
relative to symptom clusters*
number of children
* Children’s symptoms previous two weeks, as reported by caregivers, was clustered into Diarrhoea- Dysenteryand ARI-like clusters. Average number of symptoms per child: 3,6 (1-12).
Focus Group Discussion (FGD) results consumption
The survey results shows that the majority of the antibiotics are obtained from the health sector. The self medication with antibiotics is relative low but considering the symptom clusters certain problem areas can be identified (e.g. diarrhoea).
The results show example of potential irrational use of antibiotics for children in Yurimaguas, e.g. short courses, over-prescribing, self medication etc.
The FGD results point out that the problem of irrational use can be even more widespread among the adults.
The public health insurance ”Seguro Integral de Salud - SIS”, which provides all children with health care free of charge, is likely to be an important reason for the high attendance of health care institutions in Yurimaguas. The treatment guidelines and systems of monitoring included in the SIS are likely to have influenced the antibiotic prescribing practices, illustrated for example by the low prescribing of antibiotics for diarrhoea by the health care sector.
Bad compliance and self medication with antibiotics seems to be a result of lack of communication between patient and health care providers as well as a result of economical constrains and traditional beliefs.
Interventions aiming at rationalise the antibiotic use are recommended to address the health care sector as well as the community.
As the majority of the antibiotics were obtained through the health sector, a high impact may be achieved through rational prescribing mediated by contextualized educational programs and peer-review strategiesaddressing the problems identified (Chuc et al 2002), including issues of patient/doctor communication.
The impact of the intervention might be higher if the community members, being the ultimate decision makers regarding health seeking behaviour and compliance with antibiotic treatments, are addressed by the intervention as well as they are invited to the planning and implementation of it.
SIS, the public health insurance, has likely had a high impact on health seeking behaviour and medication patterns. Changes of SIS, like those now being implemented as a result of economical constrains, may result in changes in health seeking behaviour, something that must be considered in intervention planning.
1. Paredes P, de la Pena M, Flores-Guerra E, Diaz J, Trostle J. Factors influencing physicians' prescribing behaviour in the treatment of childhood diarrhoea: knowledge may not be the clue. Soc Sci Med. 1996 Apr;42(8):1141-53.
2. Chuc NT, Larsson M, Do NT, Diwan VK, Tomson GB, Falkenberg T. Improving private pharmacy practice: a multi-intervention experiment in Hanoi, Vietnam. J Clin Epidemiol. 2002 Nov;55(11):1148-55.