Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis

Autoři: Giorgia Sulis aff001;  Pierrick Adam aff001;  Vaidehi Nafade aff001;  Genevieve Gore aff003;  Benjamin Daniels aff004;  Amrita Daftary aff002;  Jishnu Das aff004;  Sumanth Gandra aff006;  Madhukar Pai aff001
Působiště autorů: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada aff001;  McGill International TB Centre, McGill University, Montreal, Quebec, Canada aff002;  Schulich Library of Physical Sciences, Life Sciences and Engineering, McGill University, Montreal, Quebec, Canada aff003;  McCourt School of Public Policy, Georgetown University, Washington, District of Columbia, United States of America aff004;  School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada aff005;  Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States of America aff006;  Manipal McGill Program for Infectious Diseases, Manipal Centre for Infectious Diseases, Manipal Academy of Higher Education, Manipal, Karnataka, India aff007
Vyšlo v časopise: Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis. PLoS Med 17(6): e32767. doi:10.1371/journal.pmed.1003139
Kategorie: Research Article
doi: 10.1371/journal.pmed.1003139



The widespread use of antibiotics plays a major role in the development and spread of antimicrobial resistance. However, important knowledge gaps still exist regarding the extent of their use in low- and middle-income countries (LMICs), particularly at the primary care level. We performed a systematic review and meta-analysis of studies conducted in primary care in LMICs to estimate the prevalence of antibiotic prescriptions as well as the proportion of such prescriptions that are inappropriate.

Methods and findings

We searched PubMed, Embase, Global Health, and CENTRAL for articles published between 1 January 2010 and 4 April 2019 without language restrictions. We subsequently updated our search on PubMed only to capture publications up to 11 March 2020. Studies conducted in LMICs (defined as per the World Bank criteria) reporting data on medicine use in primary care were included. Three reviewers independently screened citations by title and abstract, whereas the full-text evaluation of all selected records was performed by 2 reviewers, who also conducted data extraction and quality assessment. A modified version of a tool developed by Hoy and colleagues was utilized to evaluate the risk of bias of each included study. Meta-analyses using random-effects models were performed to identify the proportion of patients receiving antibiotics. The WHO Access, Watch, and Reserve (AWaRe) framework was used to classify prescribed antibiotics. We identified 48 studies from 27 LMICs, mostly conducted in the public sector and in urban areas, and predominantly based on medical records abstraction and/or drug prescription audits. The pooled prevalence proportion of antibiotic prescribing was 52% (95% CI: 51%–53%), with a prediction interval of 44%–60%. Individual studies’ estimates were consistent across settings. Only 9 studies assessed rationality, and the proportion of inappropriate prescription among patients with various conditions ranged from 8% to 100%. Among 16 studies in 15 countries that reported details on prescribed antibiotics, Access-group antibiotics accounted for more than 60% of the total in 12 countries. The interpretation of pooled estimates is limited by the considerable between-study heterogeneity. Also, most of the available studies suffer from methodological issues and report insufficient details to assess appropriateness of prescription.


Antibiotics are highly prescribed in primary care across LMICs. Although a subset of studies reported a high proportion of inappropriate use, the true extent could not be assessed due to methodological limitations. Yet, our findings highlight the need for urgent action to improve prescription practices, starting from the integration of WHO treatment recommendations and the AWaRe classification into national guidelines.

Trial registration

PROSPERO registration number: CRD42019123269.

Klíčová slova:

Antibiotic resistance – Antibiotics – China – Metaanalysis – Pediatrics – Primary care – Systematic reviews – Treatment guidelines


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