1.

1 Background
A urinary tract infection (UTI) is a common bacterial infection affecting any part
of the urinary tract. The main causative agents are E.coli (75%), S.faecalis and
Klebseilla sp normally present in the gastrointestinal tract, and Proteus.vulgaris,
Pseudomonas sp and rarely Staphylococcus incase of congenital malformation of the
urinary tract. Obstruction in the urinary tract due to prostatic enlargement, pregnancy,
tumors, catheterization of bladder and diabetes mellitus are the predisposing factors
among others[1]. Common symptoms include pain during micturation, frequent urge to
urinate, blood and pus in urine, cloudy appearance of urine and low grade fever [2].
The standard treatment of lower urinary tract infections is composed of amoxicillin,
cotrimoxazole or nitrofurantoin as single dose or short course of 7-14 days and
amoxicillin or cotrimoxazole as short course of 7-14 days for upper UTIs. For relief
of pain and fever, paracetamol is administered. Incase of complicated upper UTIs
amoxicillin and gentamycin are to be administered intravenous [1].
In the developing world, particularly in tropical world, UTIs are a common cause
of childhood morbidity while in developed countries 1% boys and 3-8% of girls are
diagnosed with UTIs [3-4]. Approximately 7 million cases of UTI are reported in
developed countries per year [5], while two hundred and thirty-five pregnant women are
enrolled annually with complications of UTI in developing countries. [6].

1.2 Factors Affecting Rational Drug Use

1.2.1 Knowledge of prescribers about Standard Treatment Guidelines (STGs)

1

The lack of knowledge among prescribers regarding standard treatment guidelines

results in inappropriate prescriptions and hence affects rational drug use. Gaps are
reported between the actual practice and knowledge levels about rational drug use in
Nigeria[7].
In New Guinea, increased use of Standard Treatment Book is recommended for
pediatricians to have improved knowledge for giving appropriate advice to childrens
parents regarding their illness[8].

1.2.2

Availability of Standard Treatment Guidelines (STGs)

The government of a country is responsible to ensure the development and

development of STGs in all the sectors of the healthcare system, and implement a sound
program for evaluation of their implementation for promotion of rational drug use in the
country.

1.2.3

Adherence to Standard Treatment Guidelines (STGs)

The precribers may fail to adhere to STGs due to patient acceptance, clinical

requirements, availability of drugs, cost of treatment and other variable factors. But this
practice ultimately hinders the achievement of rational drug use. Adherence to STGs is
vital towards the achievement of rational prescribing practices and goal of therapy in UTI. The
duration of treatment of UTI is relatively short of about 7-14 days. Antibiotics like ciprofloxacin
and co-amoxiclav are usually prescribed and patient adherence is seen.
Obervations regarding treatment of neurogenic bladder among Dutch urologists are
contrary to the available guidelines and their recommendations[9].
2

A study conducted in Denmark concluded that improvement in performance of healthcare

workers can result from supervision on adherence to STGs[10]. Adherence to standard
treatment guidelines was found low in Sudan for prescribing of drugs in case of diarrhea
and malaria[11].

1.2.4

Prescribing Practices
The prescribing practices are the most important component of rational drug use.

Dose, drug and duration of treatment determine the appropriateness of a prescription

according to a rational drug use study conducted in Thailand[12].

1.2.5

Cost of Treatment
Economic status of the patient has great influence on his compliance to a

specific therapy. Reduced compliance prevents the achievement of therapeutic objectives

and affects the health of the patient. Non-adherence to anti-depressant therapy was
reported among low income groups in USA[13]. Moreover the complications or
worsening of a disease can result in increased cost of treatment. Asthmatic patients
without exacerbations have lower health costs than those with exacerbations[14].

1.1 Country Profile

1.1.1

Country Demographics
Pakistan is South-east Asian muslim country comprising of four provinces of

Punjab, Sindh, Baluchistan and Khyber pakhtunkhwa, the territories of Gilgit, Baltistan,
3

Azad Jamu and Kahmir as well as the Federally-administered tribal areas (FATA) and the
capital territory of Islamabad[15]. The estimated population of the country is 180,808,000
and GNP is $ 2,950 [16].

1.1.2

Health Professionals
The total number of registered practicioners (RMPs) in the country registered up to may

2012 is 1,23,947 and 10,433 dental practitioners (RDPs) with basic degree while the specialists
are 25,197 RMPs and 711 RDPs. The current number of pharmacists in country is 8,124 [16].

1.1.3

Healthcare system of Pakistan

The healthcare system in the country comprises of three levels segregated among

the public, private and semi-government sectors. These levels of healthcare are
categorized according to available facilities and capacity. The primary healthcare level is
composed of Basic Health Units (BHUs) & Rural Health Centers. The common illness is
treated here e.g. Diarrhea, pain and fever. Only the basic equipment such as BP
apparatus, thermometer, etc. are available and the capacity is only of 5-10 patients. The
secondary healthcare level comprises of Tehsil and District Headquarter Hospitals where
the capacity is up to 100 patients and availability of equipment is improved. The tertiary
healthcare level hospitals have a capacity of up to 800 patients and it offers all
treatment and diagnostic facilities. Teaching hospitals are categorized as tertiary.

In the private sector, the GPs make up the primary level while at secondary and
tertiary levels hospitals are present. The semi-government sector is comprised by NGOs,
WHO-sponsored programs, Red Crescent programs and Armed Forces hospitals.
1.3.4 Prevalence of UTIs in the country
In Pakistan, the incidence of UTI is found to be more in chidren and women especially
during pregnancy. Females have been found to be susceptible more than males in the ratio of 3:1.
The prevelance of infection in middle aged patients is greatest and secondly in childrens [17].
UTI occurs in all age groups of women and incidence increases with age [18]. Increased
incidence of UTI in pregnancy follows with a history of past urological problems [19].
1.3.5 Current Scenario of UTIs in the country
Resisitent infections are mostly abserved in females. The patients from gynaecology
show the highest incidence than other wards. Imipenem has been shown to be most effective
among beta-lactams while resistance to aminoglycosides and cephalosporins is commonly
observed [17]. The prevelance in most cases isnt found to be reflected by symptoms although
they are important for diagnostic purposes [18].

1.4 Problem Statement

The lack of development and implementation of Standard Treatment Guidelines (STGs)
in the prescribing practices throughout the country have led to inappropriate therapy,
increased cost of treatment, opposition in prescribing and dispensing and hence the goal
5

of therapy is not achieved. Prescribers are not trained and they are not provided
opportunities to update their knowledge except for in a few institutions, hence the
adherence to STGs, if present, is not observed. Resistance to various antibiotics is seen which
ultimately results in poor patient compliance. All these factors are creating obstacles in
rational treatment of UTI in the country.

2.1

Literature Review
Fluoroquinolones are the preferred first line therapy for UTIs. The haphazard use

of antibiotics leads to development of resistant forms of pathogens. A study conducted

in Nigeria to investigate the antibiotics sensitivity among female students suffering from
UTI reported that most of the students urine specimen was positive and antibiotic
sensitivity was positive [20]. A multicenter research conducted in India on antibiotic
6

resistance in pathogen causing community-acquired UTI to check the pattern of resistance

in order to establish local guidelines on the treatment of UTI reported that extended
spectrum beta-lactamase producers among gram-negative CA- uropathogens were seen in
India and there was alarming rate of resistance to ciprofloxacin and amoxicillin [21].
Gram-negative isolates showed maximum resistance against antibiotics as compared
to gram-positive isolates while the risk factor of UTI in pregnant women was very less
and most of such cases were due to some other underlying problems in Pakistan [22-23].
Prospective studies are required to confirm the implications of association between UTIs
and common diseases in South Africa [24]. It was reported that sensitivity and specificity of
catalase test was more as compared to Sediment, Reactive Strip and Gram stains in USA
[25].

2.2

Current Scenario of UTI in Developed Countries

A study conducted in Australia to check the diversity of group b streptococcus serotypes

causing UTI showed that the sample of most of the outpatient and obstestrics care was positive
[26]. Whereas a research conducted in New York for prevention and treatment of Lower UTI
naturally showed that Vitamins , D-mannose and probiotica provides effective prophylaxis in the
case of recurrent infection [27].
In England diagnostic accuracy was seen to be improved considerably when
combined with dipstick test particularly tests for nitrates [28]. In Mexico surveillance of UTIs
for the first three months was the reasonable option for improving graft function free of kidney
infections and assuring the quality of life for the kidney transplant population and the loss of
7

graft function, especially for female patients [29]. A study conducted in Nigeria for screening of
febrile children on hospital Admission for UTI showed that very few children showed symptoms
of UTI, women were more prone to UTI as compared to men and It was recommended that
nitrofurantoin should be used in children who developed antibiotics restance against UTI [3031].
A study conducted in Cincinatti children hospital USA to determine association of
UTI with sexually transmitted infections showed that neither urinary symptoms nor UTI was
significantly associated With STI [32]. A multicenter qualitative study on preventing hospitalacquired urinary tract infection in US hospitals showed that new policies are required to
promote the removal of unnecessary urinary catheters or exploit external forces, such public
reporting, to enhance patient safety [33] . Whereas in Canada Trimethoprim-sulfamethaxozole
and nitrofurantoin is used as first line of therapy against UTI [34].

2.3

Current Scenario of UTI in Developing Countries

A study conducted in Antananarivo to check antimicrobial resistance among

uropathogens that cause community-acquired urinary tract infections shoed that there is need of
designing of new drugs in order to reduce the risk of antimicrobial resistance in near future [35].
Whereas UTI was part of other common disease like gastroenteritis, acute chronic respiratory
infection in Durban. [36] Antibiotic sensitivities of common bacterial pathogens in UTI patients
was very high in Ethiopia [37]. In Libiya episodic UTI was diagnosed in Kidney transplant
patients during first three month after transplantation [38].
In sweden Floroquinolones were found to be the most effective against urethra, bladder,
ureter and kidney infections caused by E-coli and fungi, majority of children populations were at
8

greater risk of UTI during their first year after birth, a statistical data showed the protective role
of breast feeding against UTI and it is recommended that treatment for febrile UTI in young
children should at least for 7-14 days [39-40].
A study conducted in Norway to determine bacterial etiology and susceptibility in UTI
concluded that Bacteria causing urinary tract infections in Norway are less resistant to
antibacterial medication than in other western countries and most urine culture of most the
patients showed the presence enterococci specie [41-42].

2.4

Current Scenario of UTI in Pakistan

A study conducted in Ayub teaching Hospital, Pakistan to check UTI in childerens

showed that majority of patients belonged to age group 13-60 months [43] .whereas in tertiary
hospital in Islamabad bacterial Uropathogens showed resistance against cefexime, levofloxacin,
ciprofloxacin, ceftriaxone and Amikacin and uti is found to be the common problem in
pregnancy due to increase in sex harmone, the anatomical and physiological changes during
pregnancy and in Hyderabad it was concluded that the most common urinary symptoms in
pregnant women were abnormal voiding pattern followed by irritative symptoms. [44-45].
A research conducted in Muhammad medical college Mirpurkhas To determine the
frequency of the various organisms causing urinary tract infection, as well as finding their
sensitivity to various antibiotics in patients attending Urological OPD showed that The
distribution of bacteria causing urinary tract infection and their sensitivity to various antibiotics
are different from those reported in most standard textbooks and guidelines [46].
9

2.5

Rationale of Study
The prescribing practices in Pakistan are not found satisfactory and irrational

prescribing is common. In other words, the main components of rational drug use i.e.
right diagnosis, right drug, right strength, right dose, right frequency and right patient are
not being practiced.
Lack of knowledge among prescribers regarding STGs may lead to irrational drug
use, similarly high cost of prescribed drugs leads to poor compliance. On the other hand
limited data is available in Pakistan thus this study is designed to assess prescribing
practices, cost, adherence and knowledge with respect to standard treatment guidelines for
treatment of urinary tract infections, and this will provide a quantitative data which will
provide a baselines for the future researchers for qualitative research.

2.5

Significance of Study
The result of this study will provide baseline data to prescribers, policy-makers

and stake holders to improve the prescribing pattern and address the issues and factors
affecting cost, adherence and knowledge that will ultimately improve the conditions and
will provide quantitative data.

2.7

Study Objectives
Objective of our study is the Assessment of prescribing practices, adherence to

standard treatment guidelines, knowledge of prescribers regarding urinary tract infections and
cost of treatment in secondary and tertiary healthcare facilities in different cities of
Pakistan.
10

2.8

General Objectives
The main objective of the study is to assess the prescribing practices, adherence to

standard treatment guidelines, knowledge of prescribers regarding urinary tract infections and
cost of treatment in secondary and tertiary healthcare facilities in different cities of
Pakistan.

2.9 Specific Objectives

To assess and compare prescribing practices for treatment of UTIs at different levels
of healthcare.
To assess and compare cost of treatment for UTIs at different healthcare levels.
To assess compare adherence to STGs for treatment of UTIs at different healthcare
levels.
To assess and compare knowledge of prescribers regarding urinary tract infections.
To assess and compare prescribing practices for treatment of UTIs at public and
private healthcares of different cities.
To assess and compare cost of treatment for UTIs at public and private healthcares of
different cities.
To assess compare adherence to STGs for treatment of UTIs at public and private
healthcares of different cities.
To assess and compare knowledge of prescribers regarding urinary tract infections at
public and private healthcares of different cities.
11

3.1 Study design

12

A comparative cross-sectional study was design to assess and compare the knowledge,
cost, adherence and perception of prescribers in treatment of UTIs among public and private
health care facilities in different cities.

3.2 Ethical Requirement:

Since no ethical committee exists in Pakistan for approval of research permission from
the respective MS of healthcare facility was obtained for data collection. Written consent was
taken from the prescriber before the filling of questionnaire and confidentiality of their responses
was ensured.

3.3 Data Type:

Prescriptions were collected retro prospectively from the past medical record of one year
while questionnaires were directly delivered to the prescriber. Quantitative as well as qualitative
methods were used to generate quantitative data.

3.4 Study Population and Respondents:

Four public and private hospitals in different cities were selected to collect UTIs
prescriptions. All the semi-Government and homeopathic clinics were excluded.

3.5 Sampling Technique:

A list of healthcare facility was obtained from the respective district health office.
Random sampling technique was used to select the healthcare facility and prescription from the
respective selective healthcare facility. Convenient sampling technique was used for the filling of
questionnaires.
13

3.6 Sample Size:

A total of 120 prescriptions were collected among which 60 were collected from public as
well as from private healthcare facility. 30 prescriptions were collected from each healthcare
facility. A total of 360 questionnaires were filled from practitioners.

3.7 Data Collection Tools:

WHO prescribing indicator form were used to evaluate the prescribing practices in
selected healthcare facility. The tool was modified according to the study objective. The form
consisted of three sections. First section was comprised of demographic data, section two
consisted of 14 questions including prescribing indicator, section three included cost assessment
form which was used to asses cost of treatment of different drug in UTI. This form included
name of drug, local or multi-national brand, cost calculated per day and total cost of treatment of
UTI. A structured questionnaire was used to asses knowledge and perception of prescriber in
treatment of UTI. The questionnaire was divided in two sections, section 1 demographic and
section two of management. Section 1 of demographic data comprised of five question including
occupation, place of graduation, unit of work, experience in medicine and practicing in
management of UTI patient. Section 2 of management included guideline adherence, current
medication, factors affecting guideline adherence, effectiveness of different drugs and need for
educational programme. While section 3 was comprised of questions regarding knowledge for
standard treatment regime of children and adults.

3.8 Validity of Tools:

14

Revalidated tools were used. Focused group discussion was also conducted to finalize
and modify the tools; pilot testing was generated on 10% of total sample size to confirm the
reliability of tools.

3.9 Data Collection:

A group of five final year students were trained by the supervisor for data collection. Data
collectors visited the respective healthcare facilities and collected the data.

3.10 Data Analysis:

After data collection it was coded and statically analyzed by using Spss 16.0. Man
Whittney and Kruskel Wallis test were applied to determine the differences among various
variables.

15

SECTION I
4.1 Demographics:
A total of 120 prescriptions were collected from tertiary care hospitals, out of which 50%
(n=60) were collected from public sector while other 50% (n=60) from private sector of both
Gujjar Khan and Attock. Out of 120 prescriptions 75% (n=90) were of female while 25% (n=30)
were of males.

4.2 Prescribing practices in case of UTI in tertiary health care facilities in

Attock and Gujjar Khan:
Out of 120 prescriptions antibiotics were prescribed in 90% (n=108) of the cases,
injections were given to almost 1% (n=1) of the patient treated in private sector hospital and to
none of the patients in public sector hospital. Drugs were prescribed by their generic names in
15% (n=9) and 1% (n=6) of the cases in public and private sector respectively. Out of 120
prescriptions, all drugs were prescribed in accordance with EDL, in both public and private
healthcare facilities. A detailed description is given in (Table 4.1).

Table 4.1: Prescribing practices in case of UTI in tertiary health care facilities in Attock and Gujjar
Khan

16

Cities

Attock

Composite

Gujjar Khan
n= 60

n= 60
Public

Private

Public

Private

(F%)

(F%)

(F%)

(F%)

Antibiotics given

29(96.7)

22(73.3)

26(86.7 )

28(93.3)

55(91.66) 50(83.33)

Injection given

0(0)

0(0)

0(0)

1(3.33)

0(0)

1(1.66)

Drugs prescribed by

9(30.3)

0(0)

0(0)

1(3.33)

9(15)

1(1.66)

30(100)

30(100)

30(100)

30(100)

60(100)

60(100)

Variables

Public

Private

(F%)

(F%)

generic

Drugs on EDL

4.3 Commonly prescribed drugs in Treatment of UTI in Tertiary Healthcare

Facilities in Attock and Gujjar Khan:
Antibiotics were prescribed in 90% (n=108) of the cases. Ciprofloxacin, amoxicillin and
levofloxacin were the most commonly prescribed antibiotics given in 50% (n=60), 25% (n=30)
and 25% (n=30) of the prescriptions in public and private sectors respectively. A detailed
description of drugs prescribed in treatment of UTI is given in (Table 4.2).
17

Table 4.2: Drugs Prescribed in Treatment of UTI in Tertiary Health Facility in Attock and Gujjar
Khan:

Cities

Composite

Attock

Gujjar Khan

N= 60

N= 60
Public

Private

(F%)
Antibiotics given
(F%)

Public

Private

Public

Private

N=30

N=30

N=30

N=30

(F%)

(F%)

(F%)

(F%)

Amoxicillin

4(13.3) 2(6.66)

5(16.66) 3(10)

9(15)

5(8.23)

Ciprofloxacin

5(16.6) 3(10)

9(30)

11(36.6)

14(23.3)

14(23.3)

Levofloxacin

2(6.6)

1(3.33)

3(10)

2(6.66)

5(8.33)

3(5)

Cefixime

1(3.33) 1(3.33)

3(10)

4(13.33)

4(6.66)

5(8.33)

Amikacin

1(3.33) 0(0)

0(0%)

1(3.3%)

1(1.66%) 1(1.66)

Ofloxacin+cefixime

1(3.33) 0(0)

2(6.6)

2(6.66)

3(5)

2(3.33)

Amoxicillin+sodium acid

2(6.66) 0(0)

2(6.6)

2(6.66)

4(6.66)

2(3.33)

Levofloxacin+cefixime

2(6.66) 0(0)

2(6.6)

2(6.66)

4(6.66)

2(3.33)

Levofloxacin+diclofenic

2(6.6)

2(6.6)

0(0)

4(6.6)

0(0)

citrate

0(0)

18

sodium
Ciprofloxacine+diclofenic

1(3.33) 4(13.33)

0(0)

0(0)

1(1.66)

4(6.66)

3(10)

0(0)

1(3.33)

3(5)

1(1.66)

Amoxicillin+diclofenic sodium 1(3.33) 1(3.33)

1(1.33)

0(0)

2(3.33)

1(1.66)

Ofloxacin+sodium acid citrate 3(10)

0(0)

2(6.66)

3(5)

2(3.33)

1(3.33) 3(10)

0(0)

0(0)

1(1.66)

3(5)

Ciprofloxacin+ranitidine

0(0)

1(3.33)

0(0)

0(0)

0(0)

1(1.66)

Lecofloxacine+diclofenic

0(0)

1(3.33)

0(0)

0(0)

0(0)

1(1.66)

Cefixime+ibuprofen

1(3.3)

2(6.66)

0(0)

0(0)

1(1.66)

2(3.33)

Ciprofloxacin + iboprfen

0(0)

1(3.33)

0(0)

0(0)

0(0)

1(1.66)

Diclofenic

0(0)

1(3.33)

0(0)

0(0)

0(0)

1(1.66)

0(0)

1(3.33)

0(0)

0(0)

0(0)

1(1.66)

0(0)

2(6.66)

0(0)

0(0)

0(0)

2(3.33)

Calcium Carbonate+diclofenic 0(0)

2(6.66)

0(0)

0(0)

0(0)

2(3.33)

0(0%)

0(0)

1(1.66)

1(1.66)

sodium
Gentamycin+sodium acid

0(0)

citrate

Pipemedic acid+diclofenic

0(0)

sodium

sodium+ cefime

sodium+phenezopyridine
Ciprofloxacine
+ibuprofen+calcium carbonate
Levofloxacin+ibuprofen

sodium+cefime
Diclofenic

1(3.33) 1(3.33)

sodium+ciprofloxacin+cefime

19

4.4 Adherence of Prescribers with STG in Treatment of UTI:

Out of 120 prescription, right dose, right frequency, right duration, right strength was
gives as 100% (n=120), 50% (n=60), 30% (n=36) and 50% (n=60) in public healthcare facilities
while in private healthcare facilities right dose, right frequency, right duration, right strength
was stated as 96% (n=115), 50% (n=60), 38% (n=45) 70% (n=84) respectively. A detailed
descriptions are given in (Table 4.3)
Table 4.3: Adherence of Prescribing with STG in Treatment of UTI

Standard Treatment Regimen

For acute uncomplicated lower UTI for adults
Amoxicillin 500 mg TDS for 7-10 days/Co-amoxiclav 500 mg TDS for 7-10
days/Cefalaxin 500 mg TDS for 7-10 days /Trimethoprim 200 mg BD for 3
days/Nitrofurantoin 50 mg QID for 5 days /Ciprofloxacin 500 mg BD for 3 days
For Children
Amoxicillin 50 mg/kg/day in 3-4 divided doses/Cotrimoxazole 48 mg/kg/day in 2 divided
doses/Nitrofurantoin 5-7 mg/kg/day in 3-4 divided doses
For acute uncomplicated upper UTI for adults
Cefuroxin 750mg TID for 10-14 days/Ceftazidine 1g TID for 10-14 days/Co-Amoxiclav
1.2g TID for 10-14 days /Gentamycin 80-120mgTID for 10-14 days/Ciprofloxicin 500mg
BD for 7 days/Meropenem 500mg TID for 10-14 days
For Children
20

Amoxicillin 50 mg/kg/day in 3-4 divided doses /Cotrimoxazole 48 mg/kg/day in 2

divided doses/Nitrofurantoin 5-7 mg/kg/day in 3-4 divided doses
Islamabad

Rawalpindi

Composite

Public

Private

Public

Private

Public

Private

F (%)

F (%)

F (%)

F%

F%

F%

Right Dose

30 (100.)

29 (96.6)

30(100)

30 (100)

60(100)

59(98.33)

Right Frequency

16(53.33)

16 (15.33)

21(70)

21 (70)

37(61.66) 37(61.66)

Right Duration

11(36.66)

10 (33.33)

9(30)

13(43.3)

20(33.33) 10(16.66)

Right Strength

20(66.66)

27(90)

30(100)

30(100)

30(100.0)

Right Drug

30(100)

28(93.33) 50(83.33)
30(100)

60(100)

55(91.6)
60(100)

4.5 Cost of Treatment of UTI amongst Public and Private Health Care
Facilities in Attock and Gujjar Khan:
The results indicate that the cost of treatment was comparatively higher in Attock as
compared to gujjar khan. On the other hand, cost of treatment is comparatively lower in private
sector as compared to public sector. A detailed description of estimated cost of treatment of UTI
is given in (Table 4.4).

Table 4.4: Cost of Treatment of UTI amongst Public and Private Health Care Facilities
Cities

Average Cost/ Day

Public
Private

Total Cost (for 14 days)

Public
Private
MeanS.D

MeanS.D

MeanS.D

MeanS.D

21

Attock

66.3738.153 534.57228.0

5
Gujjar
Khan

461.07266.69

76.3732.57

26
48.6741.28 70.8331.744 284.37219.0 474.10223.20
6

95

Composite
Public

Private

Average cost/day

Cost of treatment

Average cost/day

Cost of treatment

68.5239.427

409.48255.082

68.6034.869

467.58243.905

4.6 Comparison of Adherence of Prescribers in UTI with STG among Public

and Private Healthcare Facilities in Attock and Gujjar Khan:
Man Whitney test was used to compare adherence of prescribers with STGs in treatment of UTI
among different public and private healthcare facilties in Attock and Gujjar Khan. A significant
difference (p0.005) was seen in adherence of prescribers with STGs in Attock and Gujjar
Khan healthcare facilities while no significane difference (p0.005) in adherence of prescribers

22

with STGs was seen among the two sectors. A detailed description regarding adherence of
UTIs is given in (Table 4.5).

Table 4.5: Comparison of Adherence of Prescribers in UTI

Adherence
Variables

Cities

Attock=60 1.57

Attock=50.55 0.001

Gujjar

Gujjar

Khan=60

Khan=65.45

Sector

Public=60
Private=60

1.17

Mean Rank

Public=72.50

P-value

0.31

Private=65.45

Man Whitney P > 0.005

SECTION II
4.7 Demographics:
Knowledge of 200 prescribers including HOs, MOs and specialists or consultants
working in tertiary healthcare facilities with different experiences and perception regarding
management of UTI, STGs and appropriate dosage regime for treating UTI was assessed.

4.8 Management of UTI in Different Healthcare Facilities:

23

Among the physicians 73% (n=146) agreed that acute and chronic UTI in patients is well
controlled with current medication, 25% (n=50) prescribers were of the opinion that empiric
therapy for acute uncomplicated upper and lower UTI before results of culture test with broad
spectrum antibiotics was rational practice, 80% (n=160) of the precribers agreed that there was
need of educational programs to increase knowledge and awareness on prevention among public.
A detailed description is given in (Table 4.6).

Table 4.6: Management of UTI

Strongly Disagree
Variables

Neutral

Agree

disagree
F(%)
8 (4)

Strongly
Agree

F(%)
0 (0)

F(%)
3 (1.5)

F(%)
146 (73)

F(%)
43 (21.5)

Acute and Chronic UTI in patients are

well controlled with current medication.
What is your opinion on this statement?
24

44 (22)

119(59.5)

0 (0)

30 (15)

7 (3.5)

0 (0)

20 (10)

11 (5.5)

In your opinion, empiric therapy for

acute uncomplicated upper UTI before
results of culture test with broad
spectrum antibiotics is a rational
practice?
36 (18) 133(66.5)
In your opinion, empiric therapy for
acute uncomplicated lower UTI before
results of culture test with broad
spectrum antibiotics is a rational
practice?
In your opinion, is there a need of

0(0)

0 (0)

12 (6)

13 (6.5) 175 (87.5)

5 (2.5)

3 (1.5)

3 (1.5)

132 (66)

educational programs to increase

knowledge and awareness on the
available guidelines for management of
UTI among prescribers?
In your opinion, is there a need for more
educational

programs

to

57 (28.5)

increase

knowledge & awareness on prevention

among public?

25

4.9 The Most Common Cause of UTI in Attock and Gujjar Khan? n=200:
Most of the prescribers were of the view that E-coli is the most common cause of
pylonephritis and lower UTI in 80% (n=160) adults and children. Another important cause was
gram +ive and gram ive bacteria in 40% (n=80) of children patients. Anatomical abnormalities
of urinary tract was one of the criteria and it was seen as the cause of UTI in 30% (n=50) in both
adults and children. Out of 200 prescriptions, 10% (n=20) were due to unsafe sex in adults in
both public and private healthcare facilities. Detailed description is given in table (4.7).
Table 4.7: Common causes of UTI in Attock and Gujjar Khan Healthcare facilities
Cause

In Males

In Females

Acute uncomplicated Upper UTI (pylonephritis)

E coli
Other Gram +ive and ive

Adults

Children

Adults

Children

F(%)

F(%)

F(%)

F(%)

145(72.5)

110(55)

109(54.5)

90(45)

24(12)

64(32)

63(31.5)

80(40)

21(10.5)

75(37.5)

28(14)

63(31.5)

10(5)

90(45)

bacteria
Anatomical abnormalities of
urinary tract
Unsafe sex

Acute Uncomplicated Lower UTI

Adults

Children

Adults

Children

F(%)

F(%)

F(%)

F(%)
26

E coli

129(64.5)

109(54.5)

122(61)

90(45)

Other Gram +ive and ive

55(27.5)

45(22.5)

20(10)

80(40)

10(5)

66(40.5)

30(18.4)

6(3)

46(23)

bacteria
Anatomical abnormalities of

63(31.5.)

urinary tract
Unsafe Sex

4.10 Factors that affect guideline adherence in the management of UTI?

Out of 200 prescribers, 58.5% (n=117) of the prescribers agreed that patient realted
factors affect adherence to STGs in UTI management, 47.5% (n=95) physicians agreed that
availability of guidelines affect guideline adherence, 53% (n=106) prescribers agreed that lack of
awareness on guideline availability can be the cause of lack of guideline adherence, 36.5%
(n=73) physicians agreed that personal preferences was the cause if guideline adherence, 53%
(n=106) physicians agreed that lack of guideline adherence was the hurdle in UTI management,
57.5% (n=115) physicians agreed that classical guideline availability are not up to date which
results in guideline adherence in management of UTI. A detailed description is given in Tale
(4.8).

27

Table 4.8: Factors affect guideline adherence in the management of UTI

Strongly

F(%)
Patient related factors (low cost/local5(2.5)

Agree
F(%)

F(%)

F(%)

F(%)

17(8.5)

16(8)

117

45(22.5)

brand prescribing)
Ii

Availability

&

Agree Strongly

Disagree

Factors

Disagree Neutral

(58.5)
accessibility

of

the

3(1.5)

50(25)

on

guideline

10(5)

47(23.5)

personal

8(4)

65(32.5)

17(8.5) 95(47.5) 35(17.5)

guidelines for reference

iii

Lack

of

awareness

24(12)

106(53)

13(6.5)

availability
iv

Prescribers

experience

21(10.5) 73(36.5) 33(16.5)

preference
V

Lack of guideline enforcement

10(5)

47(23.5)

vi

Resistance to various antibiotics

20(10)

36(18)

18(9)

17(8.5)

Vii Classical guidelines available are not up

24(12)

106(53)

13(6.5)

21(10.5) 77(38.5)

46(23)

8(4)

115(57.5) 42(21)

to date and require revision

4.11 The effectiveness of Drugs for the treatment of acute uncomplicated

lower urinary tract infections:
Ciprofloxacin and levofloxacin were considered most effective by 97.5% (n=195) and
96% (n=192) of the physicians respectively for the treatment of acute uncomplicated lower
urinary tract infections. A detail description is given in the table (4.9).

28

Table 4.9: Effectiveness of different agents for the treatment of acute uncomplicated lower
urinary tract infections (pyelonephritis)
Effectiveness Rating Effective

Not Effective Not Sure

Drugs

F(%)

F(%)

F(%)

Amoxicillin

175(87.5)

2(1)

6(3)

Co-amoxiclave

179(89.5)

3(1.5)

1(0.5)

Cefalexin

183(91.5)

15(7.5)

2(1)

Trimethoprim

183(91.5)

12(6)

5(2.5)

Nitrofurantoin

182(91)

16(8)

1(0.5)

Ciprofloxacin

195(97.5)

5(2.5)

0(0)

Levofloxacin

192(96)

5(2.5)

3(1.5)

4.12 The effectiveness of various agents for the treatment of acute

uncomplicated upper urinary tract infections (pyelonephritis). n=200:
Ciprofloxacin and co-amoxiclave were considered most effective by 96%(n=192)% and
94%(n=188) of the physicians respectively for the treatment of acute uncomplicated upper
urinary tract infections whereas gentamycin and meropenem was considered least effective by
most of the physicians. A detail description is given in the table (4.10).

Table 4.10: Effectiveness of different agents for the treatment of acute uncomplicated
upper urinary tract infections (pyelonephritis):
29

Effectiveness

Effective

Not Effective

Not Sure

Rating
Drugs
F(%)

F(%)

F(%)

Cefuroxin

172 (86.0)

18(9.0)

10 (5.0)

Ceftazidine

182 (91.0)

17 (8.5)

1 (0.5)

Co-amoxiclav

193 (96.5)

5 (2.5)

2 (1.0)

Gentamycin

172 (86.0)

25 (12.5)

3 (1.5)

Ciprofloxacin

192 (96.0)

8 (4.0)

0 (0)

Meropenem

160 (80.0)

27 (13.5)

13 (6.5)

Levofloxacin

160 (80.0)

27 (13.5)

13 (6.5)

4.13 Comparison of Knowledge of Prescribers Regarding STG in Treatment

of UTI Among Different Variables:
Kruskal Wallis(p0.005) test was performed to compare knowledge of prescriber with
STGs in treatment of UTI among different public and private healthcare facilities in Attock ang
Gujjar Khan based on their designation, experience in medicine and experience in UTI
management. There was no significant difference in the knowledge of prescribers regarding
STGs among physicians based on their designation, experience in medicine and experience in
UTI management. Detailed description is given in table (4.11).

30

Table 4.11: Knowledge of Prescribers regarding STG in treatment of UTI and experience
in UTI management
Knowledge of Prescribers Regarding STGs
Variable

Designation

Mean Rank

House officer

99

Medical officer

56

Specialist

44

89.60

Experience in

<1 year

108

100.49

Medicine

1-5 years

55

101.90

6-10 years

29

105.22

>10 years

73.94

Experience in UTI

none

96

97.30

management

<1 year

46

101.08

1-5 years

38

6-10 years

20

102.60

>10 years

P-Value

103.31
1.92

1.981

0.799

102.32
0.38

0.576

106.78
0.850

Kruskal Wallis P > 0.005

5.1 Discussion
Rational therapy is the mainstay of effective management of diseases. The concept of
rational therapy is based on prescribing according to standard treatment guidelines and provision
of cost-effective treatment that can improve patient compliance to achieve the goal of therapy.
31

The results of the present study highlighted that in case of urinary tract infections, disease
management in the country is not satisfactory in both public and private healthcare facilities.
Prescribing practices are reflective of the treatment strategies employed for the
management of a specific disease. The result of the present study showed that the injections were
prescribed in very few cases of UTI and most of the drugs were prescribed by brand names.
Ciprofloxacin was the most commonly prescribed antibiotic in the treatment of UTIs. All the
drugs prescribed were according to essential drug list. Prescribing practices in different health
care facilities were not satisfactory. The main reasons for irrational prescribing practices were
lack of knowledge of prescribers regarding standard treatment guidelines, lack of generic
prescribing, unavailability of standard treatment guidelines and non-adherence. Similar results
were reported in Netherlands [9].
Adherence to standard treatment guidelines (STGs) is vital towards the achievement of
rational prescribing practices and goal of therapy. The results of the present study indicated that
strength, frequency and duration of treatment for antibiotics like ciprofloxacin and co-amoxiclav
were according to standard treatment guidelines in most of the cases while dose, frequency and
duration of antibiotic treatment were not mentioned in cases of Cefixime, Ofloxacin and
Levofloxacin. The prescribers at private sector were adhering relatively more to STGs as
compared to prescribers in public sector while there was no significant difference regarding
adherence with STGs between prescribers in different cities of Pakistan. This is reflective of
lack of adherence of prescribers with the standard treatment guidelines that can be attributed to
unavailability of STGs and lack of supervision on adherence to STGs. Adherence to STGs was
found low in Sudan while a study conducted in Denmark concluded that improvement in

32

performance of healthcare workers can result from supervision on adherence to STGs

[10-11].
The cost of therapy is particularly an important consideration in developing countries as
the patient compliance is largely dependent on it. Results of present study indicated that cost of
therapy for UTIs was comparatively higher in private sector than the public sector in different
cities of Pakistan; furthermore the cost of treatment of UTI was higher in different healthcare
facilities in Attock as compared to Gujarkhan. This might be due to prescribing by brand names,
prescribing of multinational brands and combination of drugs in the prescription. Noncompliance is shown if therapy is not affordable as reported in USA [13].
Knowledge of prescribers regarding STGs shows the development of healthcare system
as it is dependent on the training and upgrading the knowledge of healthcare professionals. The
results of present study showed that most of the prescribers agreed that acute and chronic UTIs
in patients are well-controlled with current medications and educational program for
management and prevention of UTI among public can be fruitful. Most of the prescribers were of
the view that the empiric therapy for upper and lower UTI should not be practiced. Prescribers
agreed that

lack of awareness regarding STGs and their availability and accessibility,

prescribers experience and resistance to various antibiotics are the major factors affecting
adherence to STGs in management of UTIs. Ciprofloxacin was recommended as the most
effective antibiotic for UTIs. The implementation of and training regarding STGs would be
effective in improving prescribers knowledge and promoting rational drug use. Irrational
prescribing may result from difference between knowledge levels and actual prescribing
practices, similar results were reported in a study conducted in Nigeria [7].

33

5.2 Limitations of the Study

Time and financial constrains were few of the limitations faced during the conduction of
the study. Secondly of reluctance of the prescribers to share data and lack of accessibility to
hospital records were also few hurdles faced during data collection.

5.3 Conclusions and Recommendations

The results of the present study concluded that unavailability of standard treatment
guidelines, relatively less knowledge of prescribers, lack of adherence with STGs and nongeneric prescribing were few of the contributing factors towards irrational prescribing practices
for UTIs in Pakistan. Higher cost of treatment in public and private sectors reduced patient
compliance. By ensuring availability of STGs and EDL in healthcare facilities, strict
implementation of standard treatment guidelines and regular training of prescribers, rational drug
use can be promoted in the country, patient compliance can be enhanced and goal of therapy will
be achievable. This will be a step forward towards effective disease management and decreasing
rates of morbidity and mortality.

34