Concerns with diagnoses and inappropriate prescriptions including polypharmacy and misuse of intravenous drugs in especially private facilities
Greetings from the National Executive Committee (NEC).
This week, the NEC 2019 – 2021 makes 100 days in office. We will in short while circulate a Newsletter highlighting the activities we have been engaged in during this time and the plans we have for the remaining part of the first year.
In our Christmas communication of 23rd December 2019, we stated we shall focus on 1) ending the problems bedevilling internship and medical training in the country, 2) promoting leadership in healthcare, ethics and professionalism; 3) financial empowerment, employment, welfare and a wellness program; 4) universal membership and improved corporate governance of U.M.A and; 5) building a home for U.M.A. In that letter, we alluded to a perception of declining public confidence in our health service. Specifically, the increasing concerns about diagnoses and prescriptions in outpatient services of private health units including polypharmacy and misuse of intravenous therapy.
A few weeks ago, I was approached by an 82-year-old lady, a BSc Chemistry Graduate, who runs a service business around Namugongo. She employs several workers. She came with several medical forms of her employees (all non-pregnant adults) who were attended to in clinics around Namugongo, Kyaliwajjala, Bweyogerere, Kira and Najjera.
- Of the five I sampled, three were treated for both malaria and typhoid and the other two for malaria and infection. The diagnosis of typhoid was based on a Widal test with no titres documented. Two of those treated for malaria and typhoid had a negative blood slide for malaria parasites and a negative RDT. They were however told the malaria parasites are hiding. The third, who also came in walking after first completing his chores, at the centre, had MPs ++ and was told he had a lot of malaria and required intravenous drugs.
- All were treated with at least 3 doses of intravenous (I.V) artesunate and then continued with either Co-artem or Duo-Cotexcin. They wore I.V cannulae for the duration of the drug treatment.
- One in addition, had a diagnosis of Brucellosis.
Last Sunday, while at church, the same old lady approached me with more cases but this time she had support from other individuals who had similar complaints. Why would the treatment of simple malaria cost over 100,000 Uganda shillings? Why are doctors not giving tablets but insist on giving I.V injections?
On Monday, a parent came to me from Entebbe and asked – where has this disease called” infection” come from? Last year alone, each of these girls was treated for infection at least six times and with ceftriaxone!! With him and running around my office chasing each other were the two girls both with their hands covered with a bandage and with an I.V cannulae. Their diagnoses – you guessed right, infection. Both received their first dose of IV ceftriaxone about 16 hours earlier and were scheduled for the second later in the evening.
A few weeks ago, I was the Consultant on duty in the Acute Care Unit of Mulago. The Sister in the Resuscitation Room called me aside and presented me with three referral notes she collected over the previous six hours. All were of children who had been unwell for 2 – 3 days with fever, were being treated for infection and malaria and all were on at least three I.V antibiotics – ceftriaxone, metronidazole and gentamicin and also on I.V artesunate. One had in addition received injection Artemether. All three children weighing 13 – 18 kg had received injection diclofenac for fever in nephrotoxic doses of over 5mg/kg per dose. Two had also received injectable hydrocortisone. Her biggest concern however were that two of the patients came from big clinics of senior doctors!!
Colleagues, we have talked enough. We need actions that preserve our calling to the Noble profession while upholding patients’ safety and interest in our day to day work.
- A person who needs I.V medication should be on a hospital bed (except in a few cases). Why are we dishing out I.V antibiotics and allowing patients to swagger around on streets and drinking joints with I.V cannulae in situ? The oral antibiotics of cefuroxime, cefixime, amoxicillin-clavulanate etc are almost as good. Can we begin a #Nocannulaonthestreet campaign?
- Second is this laziness of the diagnosis of infection. Infection where? The skin, ears, throat, tonsils, sinuses, lungs, kidneys, bladder, bones or joints? A patient presents with fever in a clinic and what the Doctor does is to send him or her straight to the laboratory for a malaria test and a complete blood count (CBC). No detailed history is taken or physical exam performed. When the malaria test comes out negative, as is now the case in most of Kampala, the Doctor is lost and tries to find an answer in the CBC and this answer turns out to be, infection?????. Surely we did not spend five years in medical school to be reduced to this.
- Moreover, it is clear that too many such colleagues, the criteria for severe malaria has long changed. Fever plus malaria parasitaemia (MPs) ++ or +++ is not severe malaria. Please give an oral anti-malaria and talk to the patient. You can only entertain this nonsense of my malaria only responds to injections if you yourself cannot explain to the patient. There must be accompanying signs of severe illness if you have to give I.V artesunate.
There are no words for those who give I.V quinine once a day for 3 days. With the coming rains, we suggest each branch schedules at least one Continuous Professional Development (CPD) on severe malaria and ensure that the CPD is well attended.
- Meanwhile, we are brewing an epidemic of antimicrobial resistance. I know this situation is not helped by the ease with which any antibiotic can be accessed over the counter or by the fact many of these prescriptions are not by doctors. However, as doctors, we can set a good example.
- Another worrying concern is the abuse of diclofenac for the control of fever. We are damaging kidneys and creating an epidemic of kidney injury! Fever is an immune response. In children, you can expose and fan the child and unless contraindicated, use paracetamol and treat the cause of the fever.
- As to why there are so many prescriptions of injectable steroids such as hydrocortisone or dexamethasone, is still a wonder.
- Lastly, that we see prescriptions with 8 – 12 drugs in a previously well ambulant outpatient persons with just 2-3 days of fever may suggest poor knowledge and skills, poor supervision by the senior doctor or sheer greed by a person who wants to sell his stock.