Toward improving rational use of antibiotics in peru
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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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Toward improving rational use of antibiotics in peru l.jpg
Toward Improving Rational Use of Antibiotics in Peru

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.

Problem statement l.jpg
Problem statement

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.

Objective of study l.jpg
Objective of study

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.

Methods l.jpg

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.

Graph 1 health seeking behav iour related to symptom clusters l.jpg

Consult health care provider

Self treatment

No action taken

Graph 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






Upper ARI


Lower ARI

Mix diarrhoea upper ARI

Mix dysentery upper ARI

Mix diarrhoea-lower ARI

Mix dysentery lower ARI

Slide6 l.jpg

Graph 2. Health seeking behaviour related to antimicrobial consumption




Number of children









Number of children


Consult Other

No action taken

Self treatment +

Consult Health care provider

Consult Nurse/Obst.


Consult Public doctor

Exclusive Self-treatment

Consult private pharmacy

Consult Public pharmacy

Consult Health technician


1. Health seeking behaviour and antibiotic consumption

No Antibiotics used

Antibiotics used

2. Type of health care provider combined with self treatment

Antimicrobial consumption for mixed health seeking behaviour (self medication + consultation)


Public doctor


Private doctor

Health technician

Public pharmacy

Private pharmacy

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Table 1. Prescriber and place of purchase of antibiotics consumption

Place of purchase of the antibiotic prescribed

Slide8 l.jpg

250 consumption

No antibiotics


Self treatment






Health technician






Upper ARI

Lower ARI

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).

Results from survey l.jpg
Results from survey consumption

  • The symptoms that each child had shown the last two weeks, as reported by the caregivers, were grouped into ARI- Diarrhoea- and Dysentery-like symptom clusters. Upper ARI-like symptom cluster were the most prevalent, followed by a mix of upper ARI and diarrhoeal symptoms, (graph 1).

  • The majority of the caregivers (44%) of the 504 children with symptoms were exclusively treating the children at home, without advice from health professionals. For health problems resembling lower ARI and for mixes of symptoms caregivers were more prone to consult health providers, (graph 1).

  • The majority of antibiotics were obtained through the health care sector. Of 177 children medicated with antibiotics 71% had their antibiotics prescribed by a health care professional, 8% had consulted a pharmacist and 19% had self-medicatedwithout consulting a health care supplier, (table 1).

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Results from survey consumption

  • Children whose caregivers have consulted a health care provider are more likely to be treated with antibiotics than children that have been exclusively self medicated by their caregivers, (graph 2).

  • Of the children with upper ARI-like symptoms, 28% was treated with antibiotics. A higher percentage of the children with ARI-diarrhoea mixes (38% resp 46%), lower ARI (50%) and diarrhoea (44%) received antibiotics, (graph 3).

  • For most symptom clusters, the majority of the antibiotics were prescribed by the health care system, (graph 3) Diarrhoea being the exception, 26% of the children were self medicated with antibiotics while 16% obtained the antibiotic from the health care sector.

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Focus Group Discussion (FGD) results consumption

  • Healthseeking behaviour

  • Most caregivers attempt to cure their children at home and the use of traditional medicine is widespread. If the child does not improve within some days they turn to the health center.

  • Some caregivers seeks help at Pharmacies or buy medicine at markets before they turn to the health center, or after, if they are not satisfied with the advice of the health providers.

  • The traditional healer is consulted for chronic diseases or diseases like ”susto”, (”fear”), incurable by a medical doctor.

  • Time, economical resources and traditional beliefs effects the health seeking behaviour. Caregivers have elaborated theories on diseases and their origins and appropriate treatment.

Slide12 l.jpg

  • Healthseeking behaviour consumption

  • Many caregivers frequently seek help for their children at the health care centers as the public health insurance ” Seguro Integral de Salud - SIS”, which includes all children, makes it accessible. For the adults self-medication seems to be more widespread.

  • However, caregivers also express doubts about the insurance, they say that not all medicines are available and the doctors prescribe the same medicines for different diseases; what they have, not what you need. The generic antibiotics of the public health sector are said to be of lower quality.

  • Antibiotics

  • Antibiotics are perceived as strong medicines. They affects the red blood cells, and should be used with caution. Caregivers express doubts about taking the full course.

  • Traditional medicine is sometimes mixed with antibiotics, for example to cure some types of Diarrhoea.

Conclusions l.jpg
Conclusions 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.

Discussion l.jpg
Discussion consumption

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.

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Recommendations consumption

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.

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Recommendations, continuing consumption

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.

Reference list l.jpg
Reference consumptionlist

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.