Bangladesh Health Care Report

Bangladesh Health Care Report

By Dr.Fourkan Ali

 Introduction:

The administration of primary healthcare by the Bangladesh Government is carried out through a suprisingly extensive infrratructure of facilities within each of the 64 districts. The  districts are divided into 460 papila(sub districts) which are subdivided into unions. Each union consists of  approximately 25,000 people & health services are directed by the Ministry of Health & Family Welfare (MOHFW). Since July 1998  calls for providing an essential service package (ESP)  or a Community based healthcare scheme to the entire population at four different levels of delivery.(www.photius .com)

The Ministry of Health and Family Planning was responsible for developing, coordinating, and implementing the national health and mother-and-child health care programs. Population control also was within the purview of the ministry. The government’s policy objectives in the health care sector were to provide a minimum level of health care services for all, primarily through the construction of health facilities in rural areas and the training of health care workers. The strategy of universal health care by the year 2000 had become accepted, and government efforts toward infrastructure development included the widespread construction of rural hospitals, dispensaries, and clinics for outpatient care. Program implementation, however, was limited by severe financial constraints, insufficient program management and supervision, personnel shortages, inadequate staff performance, and insufficient numbers of buildings, equipment, and supplies. .(www.photius .com)

Primary Health Care (PHC) has been chosen by the Government of Bangladesh as the strategy to achieve the goals of “Health for all” which is now being implemented as Revitalized Primary Health Care. So we need to have a holistic and balanced approach to health workforce education and give more attention to ensuring quality of medical education, especially in the rapidly growing private sector.

Primary health care (PHC):

Primary health care, often abbreviated as PHC, is

“essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination.

Primary health care was accepted by the member countries of WHO as the key to achieving the goal of Health for all. (American Journal of Public Health, 1884-1893.)

Elements of PHC:

E – education for health                                                                                                        L – locally endemic disease control                                                                                       E – expanded program of immunization                                                                                                         M – maternal and child health                                                                                                       E – essential drugs                                                                                                                                   N – nutrition                                                                                                                                           T – treatment of communicable disease s-safe water and sanitation. (American Journal of Public Health, 1884-1893.)

Essential components of primary health care (PHC)

Equitable distribution:

Health services must be shared equally by all people irrespective of their ability to pay and all (rich or poor, urban or rural) must have access to health services. Primary health care aims to address the current imbalance in health care by shifting the centre of gravity from cities where a majority of the health budget is spent to rural areas where a majority of people live in most countries. (American Journal of Public Health, 1884-1893.)

Community participation:

There must be a continuing effort to secure meaningful involvement of the community in the planning, implementation and maintenance of health services, beside maximum reliance on local resources such as manpower, money and materials. (American Journal of Public Health, November, 94(11): 1884-1893.)

Intersect oral coordination:

Primary health care involves in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communication and other sectors. (American Journal of Public Health,1884-1893.)

Four Cornerstones in primary health care:

Active community participation

Intra and Inter-sectoral linkages

Use of appropriate Technology

Support Mechanism made Available

(American Journal of Public Health,1884-1893.)

Primary healthcare in Bangladesh:

The administration of primary healthcare by the Bangladesh government is carried out through a surprisingly extensive infrastructure of facilities within each of the 64 districts. The districts are divided into 460 upazillas (sub-district) which are subdivided into unions. Each union consists of approximately 25,000 people and health services are directed by the Ministry of Health and Family Welfare (MOHFW).The levels are: community out-reaches, health and family welfare centers/rural dispensaries, upazila health complexes as first referral system and district hospital as second referral system.  (Bangladesh Demographic & Health Survey, 2004)

Primary health care in Union-level:

A union-level health and family welfare center provided the first contact between the people and the health care system and was the nucleus of primary health care delivery. As of 1985 there were 341 functional subdistrict health centers, 1,275 rural dispensaries (to be converted to union-level health and family welfare centers), and 1,054 union-level health and family welfare centers. The total number of hospital beds at the subdistrict level and below was 8,100. (Bangladesh Demographic & Health Survey, 2004)

Primary healthcare in District level:

District hospitals and some infectious-disease and specialized hospitals constituted the second level of referral for health care. In the mid-1980s, there were 14 general hospitals (with capacities ranging from 100 to 150 beds), 43 general district hospitals (50 beds each), 12 tuberculosis hospitals (20 to 120 beds each), and 1 mental hospital (400 beds). Besides these, there were thirty-eight urban outpatient clinics, forty-four tuberculosis clinics, and twenty-three school health clinics. Ten medical college hospitals and eight postgraduate specialized institutes with attached hospitals constituted the third level of health care. (Bangladesh Demographic & Health Survey, 2004)

Status of Healthcare in Bangladesh:

In Bangladesh, the status of healthcare is similar to the one of many developing countries: medical practitioners in Bangladesh often operate in relative isolation, dealing with diverse health care needs. Worldwide there is difficulty in retaining specialists in non-urban areas. (Ministry of Local Government, Rural Development & Cooperatives,2005)

Table 1.1. Public health infrastructure in Bangladesh

Medical college and hospital	16
Specialised hospital and centre	61
National institute	5
Medical university	1
Post graduate institute and hospital	5
Infectious diseases hospital	6
TB hospital	4
Chest hospital	45
Leprosy hospital	3
Mental hospital	2
Paramedic institute	1
Dental college hospital	2
Upazila Health Complex	402
Union sub-centre	3175

                                                             ( Statistical Pocketbook Bangladesh, 2006)

The Public Sector:

The primary care in the public sector is organized around the Upazila Health Complex (UHC) at sub-district level which works as a health-care hub. These Units have both in- and out-patient services and care facilities. Most commonly, they have in-patient care support with 31 beds, while some UHC have over 50 beds. Many UHC Units have a package service called “comprehensive emergency obstetric care services” (EOC) available, with an expert gynaecologist, an anaesthetist and skilled support nurses on duty round-the-clock. and basic laboratory facilities. (National Health Accounts, 2003)

The Private Sector:

In the private sector, there are traditional healers (Kabiraj, totka, and faith healers like pir / fakirs), homeopathic practitioners, village doctors (rural medical practitioners RMPs/ Palli Chikitsoks-PCs), community health workers (CHWs) and finally, retail drugstores that sell allopathic medicine on demand.To this is added an emerging cadre of semi-qualified community health workers / volunteers, who are formally trained by the NGOs (such as BRAC, Gonoshasthya Kendra etc); their numbers have been increasing since the 1990’s with the expansion of PHC infrastructure in the country. (National Health Accounts,2003)

 Table 1.2. Health Care Indicators, Fiscal Years 1980, 1985, and 1990

Indicator	Unit	1980	1985	1990*
Infant mortality	per 1,000 live births	140.0	125.0	100.0
Maternal mortality	-do-	7.0	6.0	4.0
Life expectancy at birth	years	56.9	55.1	54.0
Hospital beds	number	21,141.0	21,637.0	40,734.0
Population per hospital bed	-do-	4,128.0	3,589.0	2,712.0
Coverage of population by primary health care services	percentage of population	25.0	30.0	65.0
Physicians	number	11,000.0	16,000.0	22,500.0
Population per physician	-do-	8,810.0	6,640.0	4,755.0

^*Target.

( Statistical Yearbook of Bangladesh, 1987, Dhaka, July 1988, 59, 372, 376, 378)

Problems in the healthcare system:

It is noted that the highest number of problems (22%) in health sector are related to inadequate number of physicians, wrong treatment, negligence towards patients, absence from duty and unwillingness of doctors to stay at rural areas and small towns. The other problems are related to supplies, equipment, beds etc (21%). Some other major problems often discussed also include lack of ambulance services as well as proper referral services. ( National Health Accounts 2003)

Antibiotics:

Antibiotics may be informally defined as the sub-group of anti-infectives that are derived from bacterial sources and are used to treat bacterial infections. Other classes of drugs, most notably the sulfonamides, may be effective antibacterials. Similarly, some antibiotics may have secondary uses, such as the use of demeclocycline (Declomycin, a tetracycline derivative) to treat the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Other antibiotics may be useful in treating protozoal infections. (Scott, Geoffrey, 2004.)

Microorganisms are very diverse. They include bacteria, fungi, archaea, and protists; microscopic plants (called green algae); and animals such as plankton, the planarian and the amoeba. Some also include viruses, but others consider these as non-living. Most microorganisms are unicellular (or single-celled), but this is not universal, since some multicellular organisms are microscopic, while some unicellular protists and bacteria, like Thiomargarita namibiensis, are macroscopic visible to the naked eye. (Scott, Geoffrey,2004)

Classification of Antibiotics:

According To Chemical structure:

Sulfonamides and related drugs:  Sulfadiazine and others,Sulfones-Dapsone(DDS), Para-aminosalicylic acid (PAS).

Diaminopyrimidines:  Trimethoprim, Pyrimethamine.

Quinolones:  Nalidixic acid, Norfloxacin, Ciprofloxacin etc.

β-lactam antibiotics:  Penicillins, Cephalosporins, Monobactams, Carbapenems.

Tetracyclines:  Oxytetracycline, Doxycycline etc.

Nitrobenzene derivative:  Chloramphenicol.

Aminoglycosides:  Streptomycin, Gentamicin, Neomycin etc.

Macrolide antibiotics:  Erythromycin, Roxithromycin, Azithromycin etc.

Polypeptide antibiotics:  Polymyxin-B, Colistin, Bacitracin, Tyrothricin.

Glycopeptides:  Vancomycin, Teicoplanin.

Oxazolidinone:  Linezolid.

Nitrofuran derivatives:  Nitrofurantoin, Furazolidone.

Nitroimidazoles:  Metronidazole, Tinidazole.

Nicotinic acid derivatives:  Isoniazid, Pyrazinamide, Ethionamide.

Polyene antibiotics:  Nystatin, Amphotericin-B, Hamycin.

Others:  Rifampin, Lincomycin, Clindamycin, Viomycin, Ethambutol, Thiacetazone, Clofazimine, Griseofulvin

                                                                                      (Crueger, W. Biotechnology,1989.)

Mechanism of action:

Inhibit cell wall synthesis:  Penicillins, Cephalosporins, Cycloserine, Vancomycin, Bacitracin.

Cause leakage from cell membranes:  Polypeptide – Polymyxins, Colistin, Bacitracin. Polyenes – Amphotericin B, Nystatin, Hamycin.

Inhibit protein synthesis:  Tetracyclines, Chloramphenicol, Erythromycin, Clindamycin, Linezolid.

Cause misreading of m-RNA code and affect  permeability:  Aminoglycoside, Streptomycin, Gentamycin etc.

Inhibit DNA gyrase:Fluoroquinolones, Ciprofloxacin.Interfere with DNA function:  Rifampin, Metronidazole.

Interfere with DNA synthesis: Idoxuridine, Acyclovir, Zidovudine.

Interfere with intermediary metabolism:  Sulfonamides, Sulfones, PAS, Trimethoprim, Pyrimethamine, Ethambutol. (Antibiotic Guide,2004)

Type of organisms against which primarily active:

Antibacterial:Penicillin,Aminoglycocides,Erytromycin etc.

Antifangal:Griseofulvin, AmphotercinB, Ketoconazole ect.

Antifungal:Idoxuridine, Acyclovir, Amantadine, Zidovudine ect.

Antiprotozoal:Chloroquine, Pyrimethamine,Metronidazole,Diloxanide ect.

Anthelmintic:Mebendazole,Pyrantel,Niclosamide,Diethyl carbamazine ect.

                                                                                                       (Antibiotic Guide,2004)

 Spectrum of activity:

Narrow spectrum                                         Broad spectrum

PinicillineG                                                 Tetracyclines

Streptomycin                                               Chloramphenicol

Erythromycin                                                    (Crueger, W. Biotechnology,1989.)

 Antibiotics are obtained from:

Fungi ————penicillin,cephalosporin,Griseofulvin

Bacteria ————–Polymyxin B,Colistin,Bacitracin,Tyrothricin,Aztreonam

Actinomyctes   —— . Aminoglycosides ,Tetracyclines ,Macrolides .

                                                                                   (Crueger, W. Biotechnology,1989.)

The main groups of antibiotics briefly described below:

Although there are several classification schemes for antibiotics, based on bacterial spectrum (broad versus narrow) or route of administration (injectable versus oral versus topical), or type of activity (bactericidal vs. bacteriostatic), the most useful is based on chemical structure. Antibiotics within a structural class will generally show similar patterns of effectiveness, toxicity, and allergic potential. (Crueger, W.Biotechnology,1989.)

Penicillins:

The penicillins are the oldest class of antibiotics, and have a common chemical structure which they share with the cephalopsorins. The two groups are classed as the beta-lactam antibiotics, and are generally bacteriocidal—that is, they kill bacteria rather than inhibiting growth. The penicillins can be further subdivided. The natural pencillins are based on the original penicillin G structure; penicillinase-resistant penicillins, notably methicillin and oxacillin, are active even in the presence of the bacterial enzyme that inactivates most natural penicillins.  (Crueger, W. Biotechnology,1989.)

Cephalosporins:

Cephalosporins and the closely related cephamycins and carbapenems, like the pencillins, contain a beta-lactam chemical structure. Consequently, there are patterns of cross-resistance and cross-allergenicity among the drugs in these classes. The “cepha” drugs are among the most diverse classes of antibiotics, and are themselves subgrouped into 1st, 2nd and 3rd generations. Each generation has a broader spectrum of activity than the one before. In addition, cefoxitin, a cephamycin, is highly active against anaerobic bacteria, which offers utility in treatment of abdominal infections. The 3rd generation drugs, cefotaxime, ceftizoxime, ceftriaxone and others, cross the blood-brain barrier and may be used to treat meningitis and encephalitis. Cephalopsorins are the usually preferred agents for surgical prophylaxis. (Crueger, W. Biotechnology,1989.)

Fluroquinolones:

The fluroquinolones are synthetic antibacterial agents, and not derived from bacteria. They are included here because they can be readily interchanged with traditional antibiotics. An earlier, related class of antibacterial agents, the quinolones, were not well absorbed, and could be used only to treat urinary tract infections. The fluroquinolones, which are based on the older group, are broad-spectrum bacteriocidal drugs that are chemically unrelated to the penicillins or the cephaloprosins. (Crueger, W. Biotechnology,1989.)

Tetracyclines:

Tetracyclines got their name because they share a chemical structure that has four rings. They are derived from a species of Streptomyces bacteria. Broad-spectrum bacteriostatic agents, the tetracyclines may be effective against a wide variety of microorganisms, including rickettsia and amebic parasites. (Crueger, W.Biotechnology,1989.)

Macrolide:

The macrolide antibiotics are derived from Streptomyces bacteria, and got their name because they all have a macrocyclic lactone chemical structure. Erythromycin, the prototype of this class, has a spectrum and use similar to penicillin. Newer members of the group, azithromycin and clarithyromycin, are particularly useful for their high level of lung penetration. Clarithromycin has been widely used to treat Helicobacter pylori infections, the cause of stomach ulcers. (Crueger, W. Biotechnology,1989.)

Others:

Other classes of antibiotics include the aminoglycosides, which are particularly useful for their effectiveness in treating Pseudomonas aeruginosa infections; the lincosamindes, clindamycin and lincomycin, which are highly active against anaerobic pathogens. There are other, individual drugs which may have utility in specific infections. (Crueger, W. Biotechnology,1989.)

Antibiotics for secondary & Tertiary level

Table .1.3.    RESPIRATORY INFECTIONS:

Condition	1st Choice antibiotic(s)	2nd Choice antibiotic(s)	Notes
Acute pharyngitis/tonsillitis, scarlet fever (Streptococcus pyogenes suspected or proven)	Penicillin V	Erythromycin	The majority of sore throats are viral in origin and antibiotics are not indicated for treatment or prevention of secondary bacterial infections.
Diphtheria (Corynebacterium diphtheriae)	Benzylpenicillin		Antibiotics are not the mainstay of treatment. Antitoxin and supportive treatment are critical in management. Close contacts should receive erythromycin. Non-immunised contacts should be immunised.
Acute otitis media and acute sinusitis (Strep pneumoniae, Haemophilus influenzae & Moraxella catarrhalis)	Ampicillin or Betalactam/ betalactamase inhibitor combination	New macrolides	Most strains of Strep pneumoniae andHaemophilus influenzae in Malaysia are sensitive to ampicillin. However many strains of Moraxella catarrhalisare resistant to ampicillin.
Acute bronchitis ( 2o bacterial infections due to Streptococcus pneumoniae & Hae-mophilus influenzae)	Ampicillin	Erythromycin or Doxycycline (adults only)	Acute bronchitis is primarily a viral infection and antibiotics are not indicated. However 20 bacterial infection may occur in severe cases.

Erythromycin is preferred if Mycoplasma is suspected on epidemiological or other grounds.

Acute exacerbations of chronic bronchitis
(Streptococcus pneumoniae, Hae-mophilus influenzae, Moraxella catarrhalis)Ampicillin
or
Betalactam/
betalacta-mase inhibitor combinationErythromycin
or
Doxycycline
(adults only) Acute bronchial asthmaAntibiotics are not indicated There is no evidence that antibiotics will significantly alter outcome.Lung abscess/ empyema
(mixed infection of anaerobes, Staphylococcus aureus, Streptococcus pneumoniae and aerobic gram negative bacilli)

Benzylpenicillin and
Gentamicin
and Metronida-zole\

Empyema in childhood is nearly always due to staphylococci. Where staphylococci is suspected substitute cloxacillin for benzyl penicillin\                                                           ( A Medical Dictionary, 2003.)

Table 1.4.URINARY TRACT INFECTIONS:

Condition	1st Choice antibiotic(s)	2nd Choice antibiotic(s)	Notes
Acute urinary tract infection (E. coli, Staphylococcus saprophyticus)	Cotrimoxa-zole or Trimethoprim or Ampicillin or Nitrofurantoin	1o/2o cephalo-sporin	Many hospital acquired pathogens are now resistant to ampicillin. In uncomplicated cystitis in adults 4 tabs cotrimoxazole in a single dose has been shown to be effective. In pregnancy ampicillin should be given for 10 days
Acute urinary infection in children (E. coli and otherEnterobacteriaceae)

Mild

SevereCotrimoxa-zole
or
Ampicillin
or
Oral 10 cephalo-sporin

20/30 cephalosporin
or
aminoglycoside In all cases assessment of renal function (cystograms, ultrasound of kidneys, ureters and bladder) should be performed.
Prophylactic antibiotics for children < 4 years is recommended in cases where anatomical abnormalities are detected.

                                                                                            ( A Medical Dictionary,2003.)

Table 1.5.GASTROINTESTINAL INFECTIONS:

Condition	1st Choice antibiotic(s)	2nd Choice antibiotic(s)	Notes
Gingivitis (Spirochaetal organisms, streptococci and oral anaerobes)	Penicillin V and Metronida-zole
Enteric fever (Salmonella typhi, Salmonella paratyphi)	Chloramphe-nicol or Cotrimoxazole or Ceftriaxone	Ampicillin or Quinolone	The majority of strains of Salmonella typhi isolated in Malaysia are still sensitive to chloramphenicol. The newer fluoroquinolones have been shown to be effective for the treatment of carriers.
Amoebic dysentery (Entamoeba histolytica)	Metronidazole	Tinidazole

                                                                                            ( A Medical Dictionary,2003.)

Table 1.6.CENTRAL NERVOUS SYSTEM INFECTIONS:

Condition	1st Choice antibiotic(s)	2nd Choice antibiotic(s)	Notes
Meningitis (Haemophilus influen-zae, Streptococcus pneumoniae, Neisseria meningitidis)

Adult

Children

Neonatal meningitis 

Benzyl penici-llin and Chlor-amphenicol
or
30 Cephalo-sporin

Ampicillin and
Chloramphe-nicol
or
30 cephalo-sporin

Ampicillin and gentamicin
or
30 cephalo-sporin When the pathogen is known the antibiotic of choice for pneumococcal and meningococcal meningitis is benzyle penicillin. For haemophilus meningitis chloramphenicol or a 3o cephalosporin is the drug of choice.

Meningitis caused by penicillin resistant pneumococci and ampicillin/chloram-phenicol resistant haemophilus are still uncommon in Malaysia.

Many laboratories have rapid diagnostic kits and results can often be obtained within a few hours.

                                                                                          ( A Medical Dictionary,2003.)

 Recommended Dosage:

Dosages of antibiotics depend on the individual, the infection that is being treated, and the presence of other medical conditions. For children, the dosage usually is based on body weight and is lower than the adult dosage. To be effective, an entire treatment with antibiotics must be completed, even if the symptoms of infection have disappeared. Furthermore, it is important to keep the level of antibiotic in the body at a constant level during treatment. Therefore, the drug should be taken on a regular schedule. If a dose is missed, it should be taken as soon as possible. If it is almost time for the next dose, the missed dose should be skipped. Doubling up doses is generally not recommended.

                                                                       (Encyclopedia of Public Health, 2002)

Average adult dosages of common antibiotics for cancer patients are as follows:

Cefepime: 500 mg to 2 gm, injected into a vein or muscle, every 8–12 hours for 7–10 days.

Ceftazidime: 250 mg to 2 gm, injected into a vein or muscle, every 8–12 hours.

Ceftriaxone: 1–2 gm, injected into a vein or muscle, every 24 hours.

Ciprofloxacin: 500–750 mg of the tablet or suspension, every 12 hours, for 3–28 days, taken two hours after meals with 8 oz of water; bone and joint infections usually are treated for at least 4–6 weeks; 200–400 mg injected every 8–12 hours.

Metronidazole: for bacterial infections, 7.5 mg per kg (3.4 mg per lb) of body weight up to a maximum of 1 gm, every six hours for at least seven days (capsules or tablets); 15 mg per kg (6.8 mg per lb) for the first dose, followed by half that dosage every six hours for at least seven days (injected into a vein); for protozoal infections caused by amebas, 500–750 mg of oral medicine, three times per day for 5–10 days; for trichomoniasis, 2 gm for one day or 250 mg three times per day for seven days (oral medicine); extended-release tablets for vaginal bacterial infections, 750 mg once a day for seven days.

                                                                                (Encyclopedia of Public Health, 2002)

 Side Effects:

Side effects related to particular antibiotics

All antibiotics cause risk of overgrowth by non-susceptible bacteria. Manufacturers list other major hazards by class; however, the health care provider should review each drug individually to assess the degree of risk.

Penicillins: Hypersensitivity may be common, and cross allergenicity with cephalosporins has been reported. Penicillins are classed as category B during pregnancy. ( Moellering, R. C., Jr. “Linezolid.” 2003)

Cephalosporins: Several cephalosporins and related compounds have been associated with seizures. Cefmetazole, cefoperazone, cefotetan and ceftriaxone may be associated with a fall in prothrombin activity and coagulation abnormalities. ( Moellering, R. C., Jr. “Linezolid.” 2003)

Fluoroquinolones: Lomefloxacin has been associated with increased photosensitivity. All drugs in this class have been associated with convulsions. (Moellering, R. C., Jr. “Linezolid.” 2003)

Tetracyclines: Demeclocycline may cause increased photosensitivity. Minocycline may cause dizziness. Children under the age of eight should not use tetracyclines, and specifically during periods of tooth development. Oral tetracyclines bind to anions such as calcium and iron. (Moellering, R. C., Jr. “Linezolid.” 2003)

Macrolides: Erythromycin may aggravate the weakness of patients with myasthenia gravis. Azithromycin has, rarely, been associated with allergic reactions, including angioedema, anaphylaxis, and dermatologic reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. (Moellering, R. C., Jr. “Linezolid.” 2003)

Aminoglycosides: This class of drugs causes kidney and hearing problems. These problems can occur even with normal doses. (Moellering, R. C., Jr. “Linezolid.” 2003)

 Side Effects related to indiduals:

Some individuals may have allergic reactions to antibiotics. If symptoms of an allergic reaction (such as rash, shortness of breath, swelling of the face and neck), severe diarrhea, or abdominal cramping occur, the antibiotic should be stopped and the individual should seek medical advice.

Because antibiotics can affect bacteria that are beneficial, as well as those that are harmful, women may become susceptible to infections by fungi when taking antibiotics. Vaginal itching or discharge may be symptoms of such infections. All patients may develop oral fungal infections of the mouth, indicated by white plaques in the mouth.

Injected antibiotics may result in irritation, pain, tenderness, or swelling in the vein used for injection. Antibiotics used in cancer patients may have numerous side effects, both minor and severe; however, most side effects are uncommon or rare.  (Moellering, R. C., Jr. “Linezolid.” 2003)

Interactions:

Use of all antibiotics may temporarily reduce the effectiveness of birth control pills; alternative birth control methods should be used while taking these medications.

Antacids should be avoided while on tetracyclines as the calcium can impair absorption of this antibiotic class. For this reason, tetracyclines should not be taken just before or after consuming foods rich in calcium or iron. Consult specialized references for additional interactions to specific antibiotics. (Ronning M, et al,2003)

 Rationale use of Antibiotics:

The Main basis is “SANE”

S    Specificity

A    Availability

N    Need to the community

E    Efficacy

Rationale drug use ( RDU ) is conventionally defined as the use of an appropriate, efficacious, safe and cost-effective drug given for the right indication in the right dose and formulation, at right intervals and for the right duration of time. The promotion of rationale antibiotic use involves a wide range of activities such as the adaptation of the essential drug concept, training of health professionals about rationale antibiotic use and development of evidence-based clinical guidelines. (Williams J D,1986)

The following guidelines will ensure that antibiotics are used in a way which minimizes the emergence and spread of resistant organisms, and which maximizes their efficacy and safety.Use antibiotics only when indicated. Viral and self-limiting bacterial disease does not benefit from the use of antibiotics .Appropriate, specimens for Gram stain, culture and sensitivity testing should be obtained before commencing antibiotic therapy. The choice of agent should be based on factors such as spectrum of activity in relation to the known or suspected causative organism, safety, previous clinical response, cost, ease of use and the potential for selection of resistant organisms. An adequate dose and duration of treatment is essential for all antibiotic therapy.A history of allergy or other adverse effect to the drug under consideration should always be sought Prophylactic use of antibiotics should be restricted. Empirical antibiotic therapy should be based on local epidemiological data on potential pathogens and their patterns of sensitivity.  (Williams J D,1986)

Issues of Antibiotics Resistance:

The emergence and spread of antimicrobial resistance are complex problems driven by numerous interconnected fac­tors, many of which are linked to the misuse of antimicrobi­als and thus amenable to change. In turn, antimicrobial use is influenced by an interplay of the knowledge, expectations, and interactions of prescribers and patients, economic in­centives, characteristics of a country’s health system, and the regulatory environment. (Soulsby EJ ,2005).

Factors that encourage the spread of resistance are following :

Patient-related:

Patient-related factors are major drivers of inappropriate antimicrobial use. For example, many patients believe that new and expensive medications are more efficacious than older agents. In addition to causing unnecessary health care expenditure, this perception encourages the selection of re­sistance to these newer agents as well as to older agents in their class. (Soulsby EJ ,2005).

Self-medication:

 Self-medication with antimicrobials is another major factor contributing to resistance. Self-medicated antimicrobials may be unnecessary, are often inadequately dosed, or may not contain adequate amounts of active drug, especially if they are counterfeit drugs. (Soulsby EJ ,2005).

Prescribers’ perceptions:

 Prescribers’ perceptions regarding patient expectations and demands substantially influence prescribing practice. Physi­cians can be pressured by patient expectations to prescribe antimicrobials even in the absence of appropriate indications. (Soulsby EJ ,2005).

Patient compliance:

Patient compliance with recommended treatment is another major problem. Patients forget to take medication, interrupt their treatment when they begin to feel better, or may be unable to afford a full course, thereby creating an ideal envi­ronment for microbes to adapt rather than be killed. (Soulsby EJ ,2005).

Hospitals are a critical component:

Hospitals are a critical component the antimicrobial re­sistance problem worldwide. The combination of highly sus­ceptible patients, intensive and prolonged antimicrobial use, and cross-infection has resulted in nosocomial infections with highly resistant bacterial pathogens. Resistant hospital-acquired infections are expensive to control and extremely dif­ficult to eradicate. (Soulsby EJ ,2005).

Aim / Rationale of the work:

The main aim of that survey is to see whether the antibiotics are administered rationally or not in the upazilla level of Bangladesh. The purpose of this study was to analyze a subset of data concerning Rational use of Antibiotics in Bangladesh obtained from the currently ongoing research project.

First, a comprehensive review of the literature was undertaken with the primary purpose of collecting literature pertinent to education and prevention programmes focusing on Antibiotics abuses.

 Second, the survey was administered through a series of interviews which were part of the study to collect perceptions and recommendations of mate Antibiotics users.

Thirdly, if we want to get an overview of the rational use of antibiotics than at first we need to pick out the picture of the ground level like the upazilla level of Bangladesh than we can get an idea about the level of antibiotic use in Bangladesh.

Again, we can say that, there is a good relationship with the common term Education & the Rational use of the antibiotics  because an educated person is more aware of his health & the severity of the irrational use of antibiotics than the illiterate  person & the ratio of uneducated person is higher than the district & the division level.

This prospective, study necessary to determine the feasibility of determining the risk of abuses of Antibiotics  in Bangladesh.

We can also said that the aim of this survey was to find out the possible causes of antibiotic resistance & treatment failure due to wrong prescription.

                                           Results Analysis:Chandina Upazilla Health Complex, ComillaIN & Out patient

  Group of Antibiotics Prescribed:

During this survey I collected  this data, where I found that 33.33% of the physician prescribed  Fluroquinolone group is the highest in percentage & the lowest in percentage is  Chloramphenicol is about 5.1851% & the other percentages are given in the table.

Groups of antibiotics	Frequency	% of prescribed
Penicillin	20	14.81481481
Cephalosporin	21	15.55555556
Fluroquinolone	45	33.33333333
Tetracycline	13	9.62962963
Chloramphenicol	7	5.185185185
Cotrimoxazole	8	5.925925926
Metronidazole	32	23.7037037
Macrolides	22	16.2962963

 Group of Antibiotics Prescribed

Name of The Disease In Patient:

There are a various number of diseases I found during the survey. The highest percentage is the G.I.T. infection(51.85%) & the lowest are the CNS disease & tooth ache(14.81%).Other infected diseases are given below in the table & the bar diagram.

                                  Table 3.2.Name of The Disease In Patient

Name of the diseases	Frequency	% of disease
GIT Infection	70	51.85185185
Urinery tract Infection	25	18.51851852
Respiratory Tract Infection	55	40.74074074
CNS	20	14.81481481
Tooth ache	20	14.81481481
Cold/Fever	55	40.74074074
Conjunctivitis	23	40.74074074
Injury	25	18.51851852
Dysentry	35	25.92592593

Name of The Disease In Patient

 Percent Of Patient  Course complete & Incomplete:

 This is the very important factor in the survey is whether the patient complete the course or not.Here I found that 95% were complet the course & 40% weren’t. Among the 95% maximum patient were In Patient.

                  Table 3.3.   Percent Of Patient  Course complete & Incomplete

Groups	No of Patients	%
Course complete	95	70.37037037
Incomplete	40	29.62962963

Percent Of Patient Course complete & Incomplete

Rate of buying Antibiotics at a time of the Patient:

This is a also good important issue whether the patient buying the antibiotics part by part or full course at a time, here I found  that 77.77% were buying antibiotics part by part & only 22.22% were buying full course. Here is the table & the Pie chart given below.

                                Table 3.4. Rate of buying Antibiotics at a time of the Patient

No. of patients	Frequency	% of Patients
Part by part	105	77.77777778
Full course	30	22.22222222

Rate of buying Antibiotics at a time of the Patient

 Rate of getting antibiotics from hospital:From the discussion of the patient I came to know that Only 40% of the patient  getting antibiotics from hospital & 60% weren’t. Here is the Table & the Chart of it.

                         Table 3.5. Rate of getting antibiotics from hospital

No. of patients	Frequency	% of Patient
From hospital	20	40
Not from hospital	30	60

 Rate of getting antibiotics from hospital

Reasons behind Antibiotic Prescription:

One of the most important topic is when the physician  are prescribing the antibiotics is it for the suspected  infection, Confirmed infection or both.Among the 24 physicians 68% prescribed antibiotics for Suspected infection & 24% for Confirmed infection & 4% for both. Here is the Table & the Chart of it.

                              Table 3.6. Reasons behind Antibiotic Prescription

	Suspected infection	Confirmed infection	Both
No. of doctor	17	6	1
%of doctor	68	24	4

Reasons behind Antibiotic Prescription

Discussion:

Antibiotics are the greatest contribution of the 20^th century to therapeutics. Their advent changed the outlook of the Physician about the power drugs can have on diseases. They are one of the few curative drugs. Their importance is magnified in the developing countries, where infective disease predominate. As a class they are one of the most frequently used as well as misuses drugs. This study identified the pattern of treatment procedure, antibiotics resistance occurring in the patient treated with antibiotics.

From the statistical analysis & from bar diagram of the Physicians we can see that the use of antibiotics among the  25 practitioners 68% are prescribed antibiotics for suspected infection & 24% are prescribed antibiotics for confirmed infection & 4% of them prescribed for both. Again, from the statistical analysis & from the  pie chart of the Patients we found that the percent of the patient complete the antibiotic course 95% among them maximum patients are in patient and educated one & course incomplete percent is 40%. Among the course completed person maximum patients are In patient and educated one & from the course incomplete percent maximum persons are Out patient & illiterate one Next, I have got a very real picture of the service upazilla health complex for giving the medicine from the hospital at free of cost. Where I found that only 40% of the patient are getting medicine from hospital & most of them are in patient & most of times they have to pay for it. Furthermore, the percent of purchasing antibiotics full course is only 30%  rater than buying part by part. In terms of the disease the highest percentage goes to G.I.T. infection, R.I.T. infection & cold with fever respectively 51.85%, 40.74% & 40.74%.Bangladesh has made significant progress in recent times in many of its social development indicators particularly in health. So to continue this significant progress we need to use antibiotics rationally to stop antibiotics resistance & treatment failure.

Conclusion:

Finally, we can say that any kind of survey is beneficial for getting the real condition of any particular objective. In terms of health related survey it the most important matter because it is directly related to the life of the human being. Here, from the above description we come to know a lot about the primary healthcare , primary healthcare facilities in Bangladesh ,antibiotics , antibiotics resistance , antibiotics recommended dose etc. Which are very important matter our life. The use of antibiotics is very common for any infectious disease caused by the microbs but it can be misused that can cause a severe consequence like antibiotics resistance & finally treat failure. So our objectives were to collect the information in what percentage antibiotics are misused & also create some awareness about the rational use of antibiotics in the people in the rural level.