Primary care metronidazole prescription in public and private facilities of South Benin: A register-based cross-sectional study

This register-based cross-sectional study in South Benin reveals that metronidazole is the second most prescribed antibiotic in primary care, with its usage significantly higher in private facilities and strongly associated with digestive, genitourinary, and skin symptoms, while being less common for fever, respiratory issues, or malaria.

The Gist

Imagine South Benin's healthcare system as a bustling marketplace with two main stalls: the Public Stall (run by the government) and the Private Stall (run by local entrepreneurs). In this marketplace, nurses are the main shopkeepers who help the vast majority of customers.

One specific product, a medicine called Metronidazole (let's call it the "Gut-Healer"), is a very popular item. It's supposed to be used only for specific problems like stomach bugs or certain infections, kind of like a specialized wrench meant only for fixing a specific type of pipe. However, in low-income countries, there's a growing worry that the "pipes" (bacteria) are learning to ignore this wrench, making it less effective over time.

The Investigation

The researchers decided to act like market inspectors. They didn't just guess what was happening; they went into 11 different stalls (5 public, 6 private) in the city of Abomey-Calavi and looked at the receipts (medical records) from the entire year of 2020. They picked 200 random receipts from each stall to get a fair sample, totaling 2,200 customer visits.

What They Found

Here is the story the receipts told:

1. The Top Sellers: The most common medicine handed out was for malaria (the "fever fighter"), used in about half of all visits. But when it came to antibiotics (the "bug fighters"), the Gut-Healer (Metronidazole) was the second most popular item, right behind a different antibiotic called aminopenicillins.
2. Who Gets the Gut-Healer? The inspectors noticed a clear pattern. If a customer came in complaining about:
   • Stomach trouble (digestive symptoms): They were 8.5 times more likely to get the Gut-Healer.
   • Private parts issues (genitourinary symptoms): They were almost 7 times more likely to get it.
   • Skin rashes: They were 2.4 times more likely to get it.
3. Who Didn't Get It? Interestingly, if someone came in with a fever, a cough, or a confirmed case of malaria, they were actually less likely to get the Gut-Healer. This makes sense because that medicine isn't the right tool for those jobs.
4. The Private vs. Public Gap: Here is a twist in the story. Customers visiting the Private Stall were more than twice as likely to get the Gut-Healer compared to those visiting the Public Stall, even when they had the same symptoms.

The Big Picture

The study concludes that the Gut-Healer is being used a lot in primary care, mostly because people are coming in with stomach issues. However, the researchers are raising a red flag. They want to know: Are we using the right wrench for the right pipe?

Because bacteria are getting smarter and resisting medicines, using the Gut-Healer too much or for the wrong reasons is like using a sledgehammer to crack a nut—it might work once, but eventually, you'll break the nut and ruin the hammer for everyone else.

The researchers are calling for more detective work to figure out why the private shops are handing out this medicine so much more often than the public ones, and to make sure this powerful tool is being used exactly where it's needed.

Technical Summary

Technical Summary: Primary Care Metronidazole Prescription in South Benin

1. Problem Statement
Metronidazole (MTZ) is a first-line antibiotic widely utilized for treating enteric infections in low-income countries, where nurses often manage primary care consultations. However, the indiscriminate use of antibiotics has led to a growing concern regarding antimicrobial resistance (AMR) among enteric pathogens. There is a critical need to evaluate current prescribing patterns and understand the determinants driving MTZ usage in both public and private primary healthcare settings to ensure adherence to World Health Organization (WHO) guidelines and mitigate resistance risks.

2. Methodology

• Study Design: A register-based cross-sectional study conducted over the calendar year 2020.
• Setting: 11 primary healthcare facilities in Abomey-Calavi, South Benin, comprising 5 public and 6 private institutions.
• Sampling: A systematic random sampling method was employed to select 200 medical visits per facility, resulting in a total sample size of 2,200 visits.
• Data Analysis: The primary outcome was the prevalence of MTZ prescription. Determinants influencing prescription rates were analyzed using multivariable logistic regression to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI).

3. Key Contributions

• Comprehensive Surveillance: The study provides a granular, register-based analysis of antibiotic prescribing practices specifically in South Benin, a region with limited data on primary care antimicrobial stewardship.
• Sector Comparison: It uniquely compares prescribing behaviors between public and private healthcare sectors, highlighting significant disparities in antibiotic utilization.
• Symptom-Based Correlation: The research quantitatively links specific clinical presentations (digestive, genitourinary, skin, respiratory) to the likelihood of MTZ prescription, offering evidence on whether prescribing aligns with clinical indications.

4. Key Results

• Prescription Prevalence:
  • Antibacterial agents were prescribed in the majority of visits.
  • Metronidazole was the second most frequently prescribed antibiotic (18%), trailing only aminopenicillins (27%).
  • Antimalarials were the most common non-antibiotic prescription (52%).
• Demographics: The median patient age was 19 years, with 57% of the cohort being female.
• Determinants of MTZ Prescription (Multivariable Analysis):
  • Positive Associations (Increased Odds):
    • Digestive symptoms: aOR 8.65 (95% CI: 6.49–11.6)
    • Genitourinary symptoms: aOR 6.84 (95% CI: 3.18–15.0)
    • Skin lesions: aOR 2.39 (95% CI: 1.58–3.60)
  • Negative Associations (Decreased Odds):
    • Fever: aOR 0.66 (95% CI: 0.49–0.87)
    • Respiratory symptoms: aOR 0.44 (95% CI: 0.26–0.71)
    • Malaria diagnosis: aOR 0.21 (95% CI: 0.15–0.28)
  • Facility Type: Visits in the private sector were associated with significantly higher odds of MTZ prescription compared to the public sector (aOR 2.31; 95% CI: 1.78–3.02).

5. Significance and Implications
The study reveals that Metronidazole is a cornerstone of antibiotic therapy in South Benin's primary care, primarily driven by digestive complaints. While the strong association with digestive symptoms suggests some clinical rationality, the high volume of prescriptions warrants scrutiny regarding the appropriateness of these decisions against WHO guidelines.

Crucially, the finding that the private sector prescribes MTZ at more than double the rate of the public sector highlights a systemic disparity in antimicrobial stewardship. This suggests that private facilities may be more prone to over-prescription or lack standardized treatment protocols compared to public counterparts. The authors conclude that further research is essential to validate the clinical appropriateness of these prescriptions and to investigate the specific drivers behind the elevated antimicrobial usage in the private healthcare sector, which is vital for designing targeted interventions to combat AMR.