# Contextual analysis of antibiotic prescribing practices for upper respiratory infections and diarrhoea in rural Punjab, Pakistan

## TL;DR

This study examines antibiotic prescribing in rural Punjab, Pakistan, to address inappropriate use for common infections and inform strategies to reduce misuse.

## Contribution

The study applies a care-cascade framework to identify systemic issues in antibiotic stewardship in rural healthcare settings.

## Key findings

- Antibiotic prescriptions in rural Punjab are largely empirical and driven by patient demands and clinical acumen.
- Health facilities lack standard guidelines, diagnostic protocols, and adequate lab facilities.
- Stakeholders recommend clinical protocols, training, and digital tools to improve antibiotic stewardship.

## Abstract

Antimicrobial resistance (AMR) poses a major global public health threat, with deaths projected to reach 10 million annually by 2050, disproportionately affecting LMICs. Almost 80% of prescriptions at primary healthcare facilities contain at least one antibiotic. This study explores the existing care context at rural health centres (RHC) in Punjab to inform the development of an intervention package aimed at reducing inappropriate antibiotic prescriptions for two most common infections in the outpatient department of RHCs i.e., upper respiratory tract infections (URTI) and diarrhoea.

This study employed a care-cascade framework, selected for its suitability in resource-constrained settings and its applicability in contexts with limited evidence on AMR and stewardship practices. The mixed-methods design included: literature review; facility review (n = 3); key informant interviews with healthcare providers (n = 6) and patients (n = 6); and focus group discussions with health managers (n = 1), healthcare providers (n = 2), patients (n = 2), patients with experience of using mobile healthcare applications (n = 2) and community significants (n = 1). The data analysed at each step informed the next step and was populated in the pre-defined care tasks considered as themes.

Using the care-cascade framework, four major care tasks were identified in URTI and diarrhoea management at RHCs: (1) patient consultation and laboratory testing, (2) drug prescription, (3) drug dispensing, and (4) patient education and counselling. At the RHCs there were no standard guidelines or diagnostic protocols being followed, inadequate lab facilities, and very brief patient consultations. Antibiotic prescription was largely empirical, driven by doctor’s clinical acumen and patient demands. Drug dispensing practices were inconsistent, involving dispensing partial courses without counselling. Patients were insufficiently counselled on disease management and antibiotic use. Stakeholders made context specific recommendations for developing clinical protocols, patient counselling, and training both doctors and dispensers. They also informed the design and content of the digital tools for patient engagement.

This study underscores the complexity of antibiotic stewardship in rural health systems. A care-cascade framework allowed us to unpack these multi-layered challenges and identify leverage points for improvement. Future implementation strategies must embed these insights into program design, ensuring that stewardship is not merely a clinical responsibility but a health system imperative.