A Multicentre Point Prevalence Survey of Hospital Antimicrobial Prescribing and Quality Indices in the Kurdistan Region Government of Northern Iraq: The Need for Urgent Action

Background: Antimicrobial resistance (AMR) is a serious global public health threat and rationale antimicrobial use through surveillance and monitoring is crucial to address AMR. To date, no study has been undertaken in Iraq using validated methodologies to document current antimicrobial use and areas for improvement given high AMR rates. Methods: Point prevalence survey (PPS), using the Global PPS methodology, conducted among the three major public hospitals in the largest city in Kurdistan Regional Government (KRG) in northern Iraq from September and December 2019. Adult inpatients receiving antibiotics on the day of the survey were included. Antibiotic prescribing quality was evaluated using agreed indicators. Findings: Prevalence of antibiotic use was high (93.7%; n=192/205) and prescribed, third generation cephalosporins were most commonly prescribed (52.6%; n=140/266). Of the 166 prescriptions with diagnosis recorded, respiratory tract infections (RTI) accounted for the majority (44%, n=73/166). Reasons for treatment was recorded for only 61.7% (n=164/266) of antibiotics and high use (89.9%) of parenteral therapy was observed. All therapy was empirical, no stop/review dates were recorded and no treatment guidelines were available. Majority of the prescribed antibiotics (62%; n=165/266) were from the WHO Watch list. Interpretation: Prevalence of antibiotic use was the highest not only in the region but globally including Africa and there was significant evidence of sub-optimal prescribing practice. Swift, action is needed to develop ASPs to improve future prescribing and reduce AMR. One-two areas should initially be targeted for quality improvement including development of local clinical guidelines, documentation of antibiotic indication and stop/review dates. Funding Statement: This study was self-funded. Declaration of Interests: Nothing to declare. Ethics Approval Statement: No unique patient identifiers were recorded and all study data were anonymised completely. The study did not involve any direct contact with patients; consequently, patient consent was not required. The study protocol was approved by the Research and Ethic Committee of Sulaymaniyah General Health Directorate.