Background to the Study
Disease prevention, management and treatment require use of different classes of medications. One of the commonest classes of medications used for such purposes is antibiotics. Antibiotics are chemical substances produced by microorganisms which have the capacity, in dilute solutions, to inhibit the growth of or to kill other microorganisms. Antibiotics are also produced in the laboratory. Those that inhibit growth of microorganisms are said to be bacteriostatic and those that kill microorganisms are said to be bacteriocidal (Abu-Saeed, Joseph & Folake, 2013).
Since the discovery of antibiotics, many substances have become available for the treatment of infections. The advent of antibiotics, which are one of the most successful drug groups used in medicine, dramatically improved the prognoses of patients with bacterial infections. Their power in both therapy and prophylaxis was so convincing that many older antibiotics have never undergone controlled clinical trials. Unfortunately, following several decades of optimism, the excessive and indiscriminate use of these antibiotics in both human and veterinary practices has led to the emergence and dissemination of resistant organisms that endanger their efficacy, accompanied by unwanted side effects and high cost (Osama & Maha, 2012). Antibiotics use has been practiced with the aim of reducing/eradicating infections and it is estimated that prophylactic antibiotics would reduce the overall incidence of wound infection by 17 percent if administered appropriately (Ronald, Woods & Patchen, 2015).
The goal of antibiotics use is to reduce the incidence of postoperative wound infection or surgical site infections (SSIs), control of infection, prophylaxis and assumes use where contamination might occur, but has not yet happened. Effective use of antibiotics in the hospital environment is therefore essential (Horan, Culver, Gaynes, Jarvis, Edwards & Reid, 2010). The role of antibiotics in preventing and treating infection has been recognized from the 1950s. Since that time, there has been an enormous amount of research, comment and opinion published that have advanced our understanding surrounding the use of antibiotics.
Globally, misuse of antibiotics, including failure to complete therapy, skipping of doses, reuse of leftover antibiotics, inappropriate choice of antibiotics, inappropriate combination, inappropriate dose regimen and too long duration of drug usage can potentially expose patients to suboptimal effectiveness of antibiotic therapy (Osama & Maha, 2012). Such antibiotic-taking behaviours can result in difficulty eradicating infectious bacteria and potentially create an environment that promotes antibiotic resistance (Osama & Maha, 2012). Antibiotic misuse or over-use may increase the emergence of resistant bacteria and as a result increase the selection pressure on physicians who tend to prescribe newer broad spectrum agents for excessive periods of time (Hulscher, & Grol van der Meer, 2010).
In Sub-Saharan Africa, irregular antibiotics administration has led to resistance which has become a large growing problem among patients and as a result, the effectiveness of currently available antibiotics is also decreasing and the problem of infection continues to rise due to the inability of the available antibiotics to eradicate the causative organisms of such infection. This has caused high cost of care, prolonged hospitalization, readmission and death among patients as well as the ever-increasing pressure on clinicians and providers to reduce the incidence and the burden of infections (Okonko, Soleye, Amusan, Ogun, Ogunnusi & Ejembi, 2009).
The administration of antibiotics (pre, intra and post operatively) is a common practice in Nigeria both in clean and contaminated/dirty surgical procedures due to fear of surgical site infections (SSIs), and in nonsurgical cases that require antibiotics (John & Obi, 2014). This has greatly achieved prevention of SSIs, eradication of pathogenic microorganisms and has encouraged speedy wound healing. Antibiotics is clearly recommended for certain orthopedic procedures such as; insertion of a prosthetic joint, ankle fusion, revision of a prosthetic joint, reduction of hip fractures, reduction of high-energy closed fractures and reduction of open fractures; non orthopaedic procedures such as gastrointestinal tract surgeries, plastic surgeries, eye surgeries etc and nonsurgical cases. Surgical procedures are associated with a risk of infection of 5 to 15 percent, reduced to less than three percent by regular and appropriate use of antibiotics (Culver, Horan, Gaynes, Martone, Jarvis & Emori, 2009).
Inappropriate antibiotics administration has led to resistance which is identified as a common problem in the world (Thuong, Shortgen, Zazempa, Girou, Soussy & Brun-Buisson, 2010). Resistance occurs when sub therapeutic dosage of the antibiotic is administered to cure or prevent infection thereby causing the microorganisms to develop adaptations in order to survive and resist future doses of antibiotics. Thus, subsequent administration of even therapeutic doses of the antibiotics will lead to non efficacy of the drugs towards inhibiting the growth or killing the microorganisms. Resistant isolates have been found in healthy persons and those with community acquired infection in developing countries (Abu-Saeed et al., 2013). Antibiotic resistance has become a serious problem in both developed and developing nations. In certain settings, such as hospitals and some child-care locations, the rate of antibiotic resistance is so high that the normal, low cost antibiotics are virtually useless. This leads to a never-ending ever-spiraling race to discover new and different antibiotics just to keep the healthcare providers from losing ground in the battle against infection (Kardas, Devine, Golembesky & Roberts, 2011).
The problem of antibiotics misuse and abuse on the part of healthcare providers and patients due to poor knowledge of the disease condition and treatment pattern, higher rates of infection transmission due to increased travel, and use of antibiotics in agriculture have also contributed to antibiotics resistance. This can result from inappropriate self medication by patients; issue of poor compliance to prescribed medication by not using the antibiotic appropriately as prescribed (both by the patients and the healthcare providers who are involved in antibiotics administration); problem of manufacturing and sales of substandard, adulterated or fake antibiotics; wrong prescription of the antibiotics for treatment of ailments by the physicians or prescribers (Abu-Saeed et al., 2013). Once resistance is established, it cannot be reversed, but proper use of antibiotics minimizes the flourishing of resistant strains. Drastic measures should be taken to promote appropriate antibiotic prescribing and minimization of development and spread of resistant bacteria (Osama & Maha, 2012).
In National Orthapaedic Hospital Enugu, antibiotics are prescribed and administered both to surgical and nonsurgical inpatients with cases that require antibiotics; pre, intra and postoperatively. Cases managed in the hospital range from clean wounds to dirty/infected wounds which according to McCahill (2007) need appropriate and judicious antibiotics administration to prevent infection and to eradicate existing infections. Judicious administration of prescribed antibiotics will prevent SSI and antibiotics resistance. The problem of antibiotics misuse has become an increasing health care problem in hospitals (Osama & Maha, 2012). Considering the state of the problem, the researcher therefore intends to find out from the nurses and doctors in National Orthopaedic Hospital, Enugu who are directly involved in the administration, the barriers to effective administration of prescribed antibiotics.
Statement of the Problem
Effective antibiotics administration is an evidence based intervention that has been shown to eradicate infections, prevent resistance, prevent prolonged hospital stay and reduce surgical site infections, and to achieve these, healthcare professionals, health facility and patients are encouraged to use antibiotics more effectively to improve the safety of the patients and quality of care that patients receive (APIC, 2010). Antimicrobial agents are beneficial in contaminated wounds, infected cases, prophylaxis and surgical procedures associated with high rates of infection such as clean-contaminated or contaminated procedures. They may also be beneficial in clean surgery where prosthetic devices are implanted, because although the infection rate is low, the consequence of infection is severe, and for antibiotics to achieve the purpose for which they are produced, proper administration is needed (Bratzler, Dellinger & Olsen, 2013).
The problem of inappropriate administration of antibiotics has increased the prevalence of antibiotic-resistant bacteria infection (Institute for Healthcare Improvement, 2012). In human surgery over the last 10 years, an increasing number of resistant pathogens, such as meticillin-resistant Staphylococcus aureus (MRSA) and Candida species, and infection with organisms such as Clostridium difficile (a cause of antibiotic-associated colitis), have been commonly implicated in surgical wound infections. Such developments have forced a tougher evaluation of antibiotic usage, and a strict adherence to national guidelines (Institute for Healthcare Improvement, 2012).
However, as a clinical nurse in National Orthopaedic Hospital Enugu the researcher has observed that there have been cases of delayed wound healing, antibiotics resistance, wound breakdown and surgical site infections (SSIs) among patients which according to Osama and Maha (2012) are as a result of inappropriate use of antibiotics. It is on this background that the researcher deemed it necessary to assess those barriers to effective administration of prescribed antibiotics to inpatients in National Orthopaedic Hospital, Enugu.
Purpose of the Study
The study investigated healthcare providers’ perceived barriers to effective administration of prescribed antibiotics to inpatients in National Orthopaedic Hospital Enugu.
Objectives of the study
Objectives of the study were to:
- Determine patient-related barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
- Identify healthcare providers’ related barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
- Identify perceived health-system related barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
The research questions addressed were:
- What are the patient-related barriers to effective administration of prescribed antibiotics to inpatients in NOHE?
- What are the healthcare providers’ related barriers to effective administration of prescribed antibiotics to inpatients in NOHE?
- What are the health-system related barriers to effective administration of prescribed antibiotics to inpatients in NOHE?
The following null hypotheses were tested:
- There is no significant relationship between the professional status of the healthcare providers and their perceived barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
- There is no significant relationship between the gender of the healthcare providers and their perceived barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
- There is significant relationship between the years of experience healthcare providers and their perceived barriers to effective administration of prescribed antibiotics to inpatients in NOHE.
Significance of the Study
Findings from this study revealed some of the problems of antibiotics use and barriers to regular administration of prescribed antibiotics among inpatients in National Orthopaedic Hospital Enugu; and will also be a guide on how to tackle the problems for a better health service outcome.
Surgical site infections pose a lot of problems to the patients and the hospital. If the identified barriers are addressed properly, it will reduce SSI, poor wound healing and cost of healthcare services. Prolonged hospitalization, readmission, deformity and death from wound infection can be reduced if the identified barriers are addressed and eliminated.
Findings from this study will also help NOHE in making policies that will eliminate barriers to effective administration of prescribed antibiotics and ensure effective use of antibiotics so as to improve the quality of care given to the patients.
Further research can emanate from this study such as barriers to administration of antibiotics as prescribed to inpatients in National Orthoapedic hospital Dala, Kano state and National Orthopaedic hospital Igbobi, Lagos state.
Scope of the Study
This study was limited to identifying the barriers to effective administration prescribed antibiotics to only inpatients in NOHE as perceived by the healthcare providers (doctors and nurses) who are directly involved in the administration of antibiotics.
Operational definition of terms
Effective administration of prescribed antibiotics in this context is the administration of prescribed antibiotics as and when due; to the right patient; the right dose; at the right time and for the stipulated duration.
Barriers to effective antibiotics administration are those problems or hindrances encountered by healthcare providers (doctors and nurses) in the administration of prescribed antibiotics in NOHE as and when due.
Healthcare providers in this context are limited to nurses and doctors who are directly involved in the administration of prescribed antibiotics to inpatients NOHE. Registrars, senior registrars, medical officers and consultants are the only categories of doctors in NOHE to be used for the study, while nurses are only those in the wards and theatres directly involved in the administration of antibiotics to inpatients.
Prescribed antibiotics are those antibiotics that are strictly indicated or written down by the doctors for the treatment of infections or prevention of infections in patients as indicated by their health conditions.