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Essential Medicines and Policy Department  (EDM)

International Conferences on Improving Use of Medicines (ICIUM)


Reducing multiple antibiotics in treatment of acute respiratory infections (ARI): A planned intervention in Haiti

Aupont O, Health Action International, Haiti


Background: 90% of departmental and district hospital staff in Haiti are recent medical graduates who lack training in rational drug use. This leads to inappropriate use of multiple antibiotics for treatment of acute respiratory infections (ARIs). A proposed nationwide intervention aimed at improving the quality of ARI prescribing is based on a pilot study in which 12 social resident physicians assigned to 3 randomly selected community hospitals received training in the rational use of essential drugs for ARIs.

Objectives: The proposed study (based on the results of a pilot project) aims at: (1) improving the use of antibiotics for treatment of ARI; and more broadly, (2) changing the prescribing habits of young physicians during and after their first year of social residency.

Design: The pilot project employed a time-series design without comparison group. For analysis, variation in the quantity of antibiotics and other ARI treatments was monitored monthly for 12 months beginning 3 months prior to training.

Setting: Three districts hospitals in the northern, central and southern departments of Haiti.

Study Population: 12 social residents physicians in 3 randomly selected districts hospitals.

Interventions: The quality improvement intervention was delivered to social resident physicians at the State University Hospital during a 4-day period, and before the assignment to the district hospitals. The intervention delivered by personnel in Haiti’s Essential Drug Programme consisted of information on clinical management of ARIs involving the use of essential drugs. The content included guidelines for reducing use of multiple antibiotics and other potentially inappropriate ARI treatments such as multiple analgesics and cough remedies.

Outcome measure(s): Data on prescriptions written for ARIs were collected for each of the study physicians.

Results: The intervention in the pilot study resulted in a decline in antibiotic prescriptions from 78% of total ARI prescriptions to 40%.

Conclusions: Such an intervention/study clearly proves the need to train all physicians in rational drug use as a way to improve their practices and decrease the inappropriate use of drugs, especially in countries with limited resources.

Selected demographic, health and socioeconomic indicators: Haiti, 1995/1996


Total 7,200,000
Growth rate 2 percent
Density 885/square km. cultivated land
< 5 years old 15 percent
< 15 years old 40 percent
Rural 70 percent


Crude 13/1000
Infant 74/1000
Child 131/1000
Maternal 450/100,000
Life exp. at birth 55 years


Men 62.7 percent
Women 67.5 percent

Health coverage

Doctors/10,000 pop. 1.6
Nurses/10,000 pop. 1.3
Traditional medicine 100 percent
Number of TBA 11,000

Prenatal and child care

Prenatal attention 61% in rural areas, 83 to 86% in urban; 38% rural w/3 or more visits.
Deliveries 11% in rural hospital, 67% w/TBAs, 25% complicated.
Family planning 12% women, 17% men, 13% married women, 11% married men.
Vaccination TT2 12% adult women
DTP3 41%
Polio3 46%
BCG 75%
Measles 37%

Infant morbidity and mortality factors in Haiti/1995

Mortality factors

Diarrhea 27.6%
ARIs (pneumonia) 25%
Malnutrition 17%
Infectious diseases, measles, malaria...

Major causes for admission

Prematurely 23%
ARI (pneumonia) 16%
Malnutrition 8%
Meningitis 8%
Fever, diarrhea...

ARIs account for 40 to 60 percent of visits


Typical multi-prescription for ARI treatment in the 3 selected hospitals

1 cough syrup
1 analgesic/antipyretic (acetaminophen/ASA)
1 MTV (multivitamin) syrup or tablets
1 to 2 antibiotics (ampicilline + gentamycine) or cotrimoxazole
vitamin C (very frequent)
chloroquine (usually because of malaria)

In rural areas

Community health centres 4.6 drugs/ARI prescription.

District hospitals, dispensaries, etc.

In urban settings

Hospitals, health clinics 3.5 drugs/ARI prescription



Train 12 social resident physicians in rational case management of ARI and change their prescribing practices in primary care in rural Haiti (3 district hospitals) during their year of social residency.

Improving the use of antibiotics for treatment of ARI.
Changing the prescribing habits of young physicians during and after their year of social residency.



A 4-day training period in quality improvement for social resident physicians before their assignment to the district hospitals.


Integrated case management of the sick child
ARI case management and clinical surveillance
Rational prescribing of essential drugs in primary care in Haiti



Antibiotic prescriptions declined from 78% of total ARI prescriptions to 40%.


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