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Rational use  –  Inspirational examples

Improving antibiotic use for urinary tract infections (UTIs) in Nepal

This small scale project aimed to optimize antibiotic prescriptions for Urinary Tract Infections (UTI) at Okhaldhunga Community Hospital in Nepal. A review of 18 months data from urine cultures taken in the hospital was completed in 2017. Presentations about antibiotic resistance, the local bacterial culture results and possible ways of changing prescription pattern were given for doctors, lab staff and community medical assistants (CMA). 16 months later the prescription rate of antibiotics frequently used for UTIs was followed up, with a 57% reduction of ciprofloxacin consumption!

Background and project initiation

Okhaldhunga Community Hospital in eastern Nepal is the only hospital in Okhaldhunga district and serves around 250 000 people. The practice of performing bacterial cultures in the hospital was started in January 2016. Culture results were reported to the clinician who ordered the test and the results were also recorded in a book in the microbiology laboratory. However, no review of the data was done.

Okhaldhunga Community Hospital

“When visiting the hospital in July 2017 I reviewed the data from all urine cultures, and made statistics and graphs. E. coli was the major pathogen in urine cultures and was therefore of special interest”, Dr. Altgärde says. He also found that the level of resistance in E. coli in urine cultures was high against several important groups of antibiotics, such as aminoglycosides, cephalosporins and quinolones. Ciprofloxacin resistance in E. coli from urine cultures was 45%, which is about the same, or slightly lower compared to other studies from NepalE. coli isolates were generally susceptible to nitrofurantoin. Continuous quality improvements of the antimicrobial susceptibility testing would help fine tune the data and further increase reliability of the resistance data in the hospital.

Dr Jakob Altgärde is a resident physician at the infectious diseases clinic at Ryhov Hospital in Jönköping, Sweden. During his training he had an opportunity to visit the Okhaldhunga Community Hospital, a visit that lead to a collaboration on rational use of antibiotics.

Educational tutorials with local data included

After the statistics were compiled, Dr Altgärde prepared and held educational tutorials about antibiotic resistance for all the doctors and CMAs, that is, all staff with the right to prescribe antibiotics. A separate tutorial was also given to the lab staff. The focus of the presentations was on the global increase of antibiotic resistance which disproportionally affects low-resource settings. A few fictional interactive case studies of patients with UTI (men, women, children and pregnant women) were discussed in order to understand how prescribing is done in the hospital. In the presentations local culture and resistance data was included. There was immediate interest and staff involvement.

The following treatment recommendations for UTI were given:

  1. Start to treat lower UTI/acute cystitis with nitrofurantoin. This treatment was recommended for both men, women and pregnant women (not around delivery).
  2. Stop treating asymptomatic bacteriuria (except in pregnant women).

More responsible and accurate prescription pattern

16 months later a follow-up was done. At this time, culture and antibiotic susceptibility data were expanded to also include Staphylococcus aureus in pus-cultures. The prescription of antibiotics frequently used for UTI was reviewed and very interesting results were observed.

Prescription of nitrofurantoin had increased from around 1500 to almost 3500 tablets per year (increase of 120%). Ciprofloxacin however had decreased from over 18 000 to less than 8000 tablets per year (decrease of 57%). According to the doctors and CMAs prescription of nitrofurantoin for acute cystitis had been effective, and no severe side effects had been reported using short course treatment.

Change in quinolone-consumption (number of tablets) over time during the study period (July 2014-June 2018). Times in the graph are according to Nepali calendar, corresponding to July 2014 – June 2015, July 2015 – June 2016, July 2016 – June 2017 and July 2017 – June 2018.

Work with surveillance of resistance levels in common pathogens in Okhaldhunga Community Hospital will continue, and hopefully expand in the years to come. Already we are glad to see a more responsible and accurate prescribing pattern. Hopefully Clostridioides difficile infections in the hospital will decrease and also the pressure of selection of bacteria producing extended-spectrum betalactamases (ESBLs). The well-known side effects of quinolones  is another reason to decrease the prescription of this group of antibiotics.

Dr. Altgärde describing change in Nitrofurantoin consumption during the study period.
European Medicines Agency - EMA. Fluoroquinolone and quinolone antibiotics: PRAC recommends restrictions on use. 2018 Oct 5;2.
Global Antibiotic Resistance Partnership - Nepal national working group. Situation Analysis and Recommendations: Antibiotic Use and Resistance in Nepal [Internet]. Washington, DC and New Delhi: Center for Disease Dynamics, Economics & Policy (CDDEP); 2015 [cited 2015 Aug 21]. Available from: