Assessment of Guideline Concordant Antibiotic Prescribing for Patients With Community Acquired Pneumonia at the Kenyatta National Hospital Medical Wards.

Abstract

Background: Pneumonia is a major cause of morbidity and mortality globally. Despite the proven benefits of guideline concordant antibiotic prescribing, research has shown that adherence to clinical guideline recommendations is dismal. Objectives: The study aims to determine utilization of Kenyatta National Hospital antibiotic guideline titled ‗The KNH guide to empiric antimicrobial therapy 2018‘ in the management of community acquired pneumonia in the Kenyatta National Hospital medical wards and the perceived barriers towards the utilization of this guideline. Study site: Kenyatta National Hospital general medical wards. Study design: Cross- sectional study. Study participants: Medical records of patients 18 years and above admitted with community acquired pneumonia at the Kenyatta National Hospital medical wards and the doctors who prescribe antibiotics at admission for these patients (Internal medicine registrars and medical officers in the Outpatient department). Materials and methods: A check list derived from the Kenyatta National Hospital guide to empiric antimicrobial therapy 2018 was used to assess guideline concordance based on seven quality indicators: empiric antibiotic, dose and route of administration, switch to oral antibiotics, duration of antibiotics (at least 5 days), collection of microbiological samples before initiating antibiotics, review of antibiotics at 48 hours and once the culture results are out. Online self-administered questionnaires were used to determine attitude and perceived barriers towards utilization of the KNH guideline among the Internal Medicine registrars and medical officers. Analysis: Descriptive statistics were applied in the representation of each of the seven quality indicators. These were then compared with the guideline recommendations and adherence to the guideline for each parameter was expressed as a percentage of the total number of patients admitted with community acquired pneumonia. These were then graded into the following categories based on the level of concordance: Good >90%, Intermediate 60- 90%, poor <60%. xii Questions on the attitude and the perceived barriers towards KNH guideline utilization were answered using a 5 point Likert scale. Perceived barrier statements that were positively formulated were then recorded so that a lower score meant a lower level of the perceived barriers and vice versa. Percentages were then calculated for the total number of doctors that agreed or strongly agreed that the barrier was applicable. An open ended question on the top 3 barriers to the KNH guideline utilization was also included in the questionnaire. Significance of the research project: Enforcement of good antibiotic stewardship with the aim of reducing antibiotic resistance and improving patient outcomes. Results: For each of the other quality indicators, adherence to the KNH guideline for patients with community acquired pneumonia was as follows: empiric antibiotic choice 48%, collection of samples for culture prior to antibiotic administration 0%, review of antibiotics at 48hours 26.4%, review of antibiotics with culture results 45.8%, total duration of antibiotics 28.8% and time to switch to oral antibiotics 3.6%. The top 3 barriers towards guideline utilization among the doctors were: unavailability of drugs (52.7%), inaccessibility of the KNH guideline (45.1%) and lack of or delay of investigations (34.1%). Conclusion: This study has demonstrated that the level of adherence to the 7 quality indicators from the KNH guide is poor with the overall adherence being 35.5%. The recommendation least adhered to was collection of microbiological samples before initiation of empiric antibiotics. The most commonly identified barriers to utilization of the guideline were external and guideline related barriers.