Selection Criterion for Antiseptics and Storing and Dispensing of Antiseptics

              Selection Criterion for Antiseptics

ü   Should be safe and non toxic

ü   Microbial activity should be known

ü   Should have instructions on how to use

ü   Should not have residual effects

ü   Should be cost effective

ü   Should be active against a wide range of microorganisms

ü   Should be stable when in contact with organic matter

ü   Should be effective

ü   Should be easy to procure

•               Storing and Dispensing of Antiseptics

Ø   All antiseptics can become contaminated by microorganisms, which can then cause subsequent infection when used for hand washing or skin preparation

Ø   To prevent contamination of antiseptic solution:

ü   Use antiseptics in a small quantity at a time

ü   If antiseptics are provided in large containers, pour a small quantity at a time into a container for daily use

ü   Do not ‘top off’ antiseptic dispensers

ü   Never soak or store gauze or cotton wool in any antiseptic

ü   Prepare fresh solutions regularly (at least weekly)

ü   Clean and thoroughly dry antiseptic containers before refilling

Ø   Antiseptic solutions should be stored in a cool, dark area. Never store them in direct sunlight or in excessive heat (e.g. upper shelves in a tin-roofed building)

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What are the Different Types of Antiseptics, Mode of Actions and Uses

•               Different Types of Antiseptics, Mode of Actions and Uses

•                        Ethanol

Ø   Mode of action:

v   Has a bactericidal action against most vegetative organisms at a concentration of 60% and 95%, but is not effective against bacterial spores

Ø   Therapeutic uses

v   Evaporating lotion used for hand and skin cleaning

v   Surgical treatment for various skin lesions

v   Prevention of bedsores and diminishing sweating (reduce temperature)

v   Used as solvent in different pharmaceutical preparations

v   A concentration of 70% either alone or with chlorohexidine or iodine for disinfection of skin before surgical procedures

q   Chlorhexidine

Ø   Mode of action:

ü   An antiseptic which is effective against a wide range of vegetative gram-positive and gram-negative bacteria, although it has no activity against acid fast bacteria, bacterial spores and some viruses

Ø   Therapeutic Uses

ü   Chlorohexidine is used in disinfectant solutions, creams, gels and lozenges

ü   It is also used in various concentrations for disinfection in the following conditions:

•                         0.5% in 70% ethanol for the preoperative disinfection of the skin

•                         Chlorhexidine 0.05% solution in glycerine for urethral irrigation and catheter lubrication

•                        Chlorhexidine 0.02% solution for bladder irrigation

•                        Chlorhexidine 1% cream for use in obstetrics

•                        Chlorhexidine 0.01% as the diacetate for preservation of eye drops

q   Cetrimide

Ø   Mode of action:

ü   A quaternary ammonium disinfectant that has bacterial activity against both grampositive and gram-negative organisms

Ø   Therapeutic Uses

ü   Cetrimide 0.5% solution for preoperative skin disinfection

ü   Cetrimide 0.05% to 1% is used for the cleansing of polythene tubing and catheters, but time of immersion should not exceed 30 minutes

ü   Cetrimide in higher concentrations of 15 to 35 is used in shampoos to remove scales in seborrhoea

ü   Cetrimide 1.5% with chlorhexidine gluconate 0.15% is often used as a general purpose disinfectant

q   Povidone Iodine

Ø   Mode of action:

ü   Acts by inhibiting enzymes essential to microbial metabolism

ü   It kills on contact a broad spectrum of pathogenic bacteria, viruses, fungi, protozoa and yeasts

Ø   Therapeutic uses:

ü   Skin antiseptics and germicidal skin cleansers

ü   Disinfectant for wounds, abrasions and insect bites

ü   Medicated spray for wounds

ü   Antidandruff shampoos

ü   Medicated adhesive plasters

ü   Gargles and throat lozenges

ü   Vaginal gels and douches

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Criteria for selection of drugs

                            Criteria for selection of drugs 

The choice of drugs depends on many factors: -

• pattern of prevalent diseases 

• the treatment facilities

 • the training and experience of the available personnel 

• the financial resources 

• generic, demographic and environmental factors.

 • When several drugs are available for the same indication, select the drug, pharmaceutical product and dosage form that provide the highest benefit/risk ratio. 

 • When two or more drugs are therapeutically equivalent, preference should be given to: 

➢ the drug which has been most thoroughly investigated.

 ➢the drug with the most favourable pharmacokinetic properties, e.g. to improve compliance, to minimize risk in various pathophysiological states 

➢drug for which local, reliable manufacturing facilities for pharmaceutical products exist;

 ➢drugs, pharmaceutical products and dosage forms with favourable stability, or for which storage facilities exist.  

• Fixed ratio combinations are only acceptable if the following criteria are met:

 i. clinical documentation justifies the concomitant use of more than one drug; 

ii. the therapeutic effect is greater than the sum of the effect of each; iii. the cost of the combination product is less than the sum of the individual products; 

 • compliance is improved; 

• sufficient drug ratios are provided to allow dosage adjustment satisfactory for the majority of the population

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Basis for drugs selection

               Basis for drug selection

❖ WHO Essential Drugs List as a model.

• National health policy

■ Free health care

 ■ Subsidized health care

■ Managed health care

• National drug policy

■ Free drug policy

■ Subsidized cost of drugs or cost recovery

■ Cost sharing
• Patterns and prevalence of diseases
• Quality and type of care provided

 ■ Primary
 ■ Secondary
 ■ Tertiary
• Primary Health Care
• Primary health care is the day-to-day care needed to protect, maintain or restore our health. For most people, it is both their first point of contact with the health care system and their most frequently used health service
 • Available human resources

■ Medical care (general and specialist care)

■ Nursing care (nursing, midwifery, psychiatry)
■ Pharmaceutical care (pharmacists, pharmacy technicians, clinical nurses)
• Lab medical personnel

■ Financial resources.

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what are the essential drugs ?

ESSENTIAL DRUGS
 • Ministries of health normally determine the types of drugs and dosage forms that are selected for use in a country, these are called Essential Drugs.

• Such selections ensure that available financial resources are used wisely, provide a limited list of drugs and dosage forms that are appropriate to the health problems of a country or community

• Essential medicines are those that satisfy the priority health care needs of the majority of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost effectiveness.

 • Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford.

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Why manage drugs and medical supplies?

Why manage drugs and medical supplies? 

Three reasons can be given to explain why drugs or medical supplies need to be managed properly. 

 Firstly, drugs are part of the link between the patient and health services. Consequently, their availability or absence will contribute to the positive or negative impact on health. 

 Secondly, poor drug management, particularly in the public sector of developing countries, is a critical issue, but major improvements are possible that can save money and improve access. 

Finally, drugs are no longer the responsibility of health workers only. Political, economic, financial and traditional considerations have become so crucial in health care that it has become imperative to look at drugs and health care from these perspectives. 

All of these factors contribute to appropriate financial expenditure, avoid wastage, increase access and ensure that drugs are properly used

•

Drug management functions are undertaken in four principal phases, which are interlinked and are reinforced by appropriate management support systems (i.e. tools).
• From drug selection to drug use, passing through procurement, storage and distribution, a whole range of management capacities are required and necessitate using the appropriate tools within a given legal and policy framework

•

The selection of drugs for use at health center's is usually determined at the national level by the Ministry of Health and is based on a number of factors.
• After determination of the quantities required, based on price, delivery conditions and quality, the selected drugs go through a procurement process. After storage and distribution, the use of the drugs requires prescribing, packaging, dispensing and counselling. 

•These tasks require qualified health workers or other relevant personnel with appropriate skills and attitudes.
• Management support tools are important for the acquisition of relevant skills in drug management.

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Twelve strategies or interventions to overcome irrational use of drugs. 

1.A mandated mult-disciplinary national body to coordinate medicines use policies:

• A mult-disciplinary approach is needed to develop, implement and evaluate interventions to promote more rational use of medicines.

• Many  activities  need coordination with many stakeholders such as: Health professionals, academia, the regulatory authority, pharmaceutical industry, consumer group and non-governmental organization involved in health care.

2.Clinical guidelines:

• Is a standard treatment guidelines or prescribing policies, consist of systematically developed statements to help prescribers make decisions about appropriate treatments for specific clinical conditions.

• It has been proven to promote more rational use of drug provided they are: developed in a particular way     involving end-users, easy to read, introduced with an official launch, training and wide dissemination,      Reinforced by prescription audit and feedback.

3. Essential medicines list based on treatment of choice:

•  Are those that satisfy the priority health care needs of the population.

• It makes medicines management easier in all respects like procurement, storage,  distribution, prescribing and dispensing as they deal with few items.

• National essential medicine list should be based upon national clinical guidelines.

• Medicine selection done by a central committee with agreed membership and explicit, previously agreed criteria, based on efficacy, safety, quality, cost which will vary locally and cost-effectiveness. 

4. Drug and therapeutic committees in district and hospitals:

• A drugs and therapeutic committee (DTC) or pharmacy and therapeutic committee is a committee designated  to ensure the safe and effective use of medicine in the facility or area under its jurisdiction.

• Government encourage hospitals to have DTCs by making it an accreditation requirement to various    professional societies.

• Responsibility of DTCs:

  1. Developing, adapting or adopting clinical    guidelines for the health institution or district.

  2. selecting cost-effective and safe medicines     (hospital/ district drug formulary);

 3.Implementing and evaluating strategies to improve medicine use (including drug use evaluation, and liaison with antibiotic and infection control committees

Twelve strategies/interventions to overcome irrational use of drugs. cont.

4. Providing on-going staff education (training and printed materials);

5. Controlling access to staff by the pharmaceutical industry with its promotional activities;

 6. Monitoring and taking action to prevent adverse drug reactions and medication errors;

 7.Providing advice about other drug management issues, such as quality and expenditure.

5. Problem-based training in pharmacotherapy

    in undergraduate curricula:

•The quality of basic training in pharmacotherapy

      for undergraduate medical and paramedical students can significantly influence future prescribing.

•Rational pharmacotherapy training, linked to clinical guidelines and essential medicines lists, can help to establish good prescribing habits.

6. Continuing in-service medical education as a licensure requirement:

•Continuing in-service medical education (CME) is a requirement for licensure of health professionals in many countries.

•It is  more effective if it is problem-based, targeted, involves professional societies, universities and the ministry of health, and is face-to-face.

• CME need not be limited only to professional medical or paramedical personnel, but may also include people in the informal sector such as medicine retailers.

 

7.Supervision, audit and feedback:

•Supervision is essential to ensure good quality of care.

•Supervision that is supportive, educational and face-to-

    face, will be more effective and better accepted by prescribers than simple inspection and punishment.

•Effective forms of supervision include prescription

Audit and feedback, peer review and group processes.

•Prescribers may be told how their prescribing

   compares with accepted guidelines or with that of their peers.

 In hospitals, such audit and feedback is known as drug use evaluation.

Group process approaches amongst prescribers consist of health professionals themselves identifying a medicine use problem and developing, implementing and evaluating a strategy to correct the problem.

8. Independent medicine information

•Often, the only information about medicines that practitioners receive is provided by the pharmaceutical industry and may be biased.

•Provision of independent (unbiased) information is therefore essential.

•Drug information centres (DICs) and drug bulletins are useful ways to disseminate such information.

•Both may be run by government or a university teaching hospital or a nongovernmental organization, under the supervision of a trained health professional.

•Whoever runs the DIC or bulletin must (1) be independent of outside influences and disclose any financial or other conflict of interest, and (2) use evidence-based medicine and transparent deduction for all recommendations made.

 9. Public education about medicines:

•Without sufficient knowledge about the risks and benefits

    of using medicines and when and how to use them,

   people will often not get the expected clinical outcomes

   and may suffer adverse effects.

• Governments have a responsibility to ensure both the quality of medicines and the quality of the information about medicines available to consumers. This will require:

• Ensuring that over-the-counter medicines are sold with adequate labelling and instructions that are accurate, legible, and easily understood by laypersons.

  The information should include the medicine name, indications, contra-indications, dosages, drug interactions, and warnings concerning unsafe use or storage.

• Monitoring and regulating advertising, which may adversely influence consumers as well as prescribers,

   and which may occur through television,radio,newspapers and the internet.

Running targeted public education campaigns, which take into account cultural beliefs and the influence of social  factors. 

 

10. Avoidance of perverse financial incentives:

•Financial incentives may strongly promote rational or irrational use. Examples include:

• Prescribers who earn money from the sale of medicines e.g. dispensing doctors will prescribe more medicines, and more expensive medicines, than prescribers who do not; therefore the health system should be organized so that prescribers do not dispense or sell medicines.

•Patients prefer medicines that are free or reimbursed.

 If only essential medicines are provided free by government or reimbursed through insurance,

 patients will pressure prescribers to prescribe only essential medicines.

If medicines are only reimbursed when the prescription conforms to clinical guidelines, there may be an even stronger pressure on prescribers to prescribe rationally

 

11. Appropriate and enforced regulation

Regulation of the activities of all actors involved in the use of medicines is critical to ensuring  rational use

If regulations are to have any effect, they must be enforced, and the regulatory authority must be sufficiently funded and backed up by the judiciary.

Regulatory measures to support rational use

• Registration of medicines to ensure that only safe

   efficacious medicines of good quality are available in the market and that unsafe non-efficacious medicines are banned;

• limiting prescription of medicines by level of prescriber;

  this includes limiting certain medicines to being available only with a prescription and not available over-the counter;

• Setting educational standards for health professionals

   and developing and enforcing codes of conduct;  this requires the cooperation of the professional societies and universities;

• licensing of health professionals – doctors, nurses, paramedics – to ensure that all practitioners have the necessary competence with regard to diagnosis, prescribing and dispensing;

• licensing of medicine outlets – retail shops, wholesalers

  – to ensure that all supply outlets maintain the necessary stocking and dispensing standards;

• Monitoring and regulating medicine promotion to ensure that it is ethical and unbiased. All promotional claims should be reliable, accurate, truthful, informative, balanced, up-to-date, capable of substantiation and in good taste.

 

12. Sufficient government expenditure to ensure availability of medicines and staff:

• Lack of essential medicines leads to the use of nonessential medicines, and lack of appropriately trained personnel leads to irrational prescribing by untrained personnel.

• Furthermore, without sufficient competent personnel and finances, it is impossible to carry out any of the core components of a national programme to promote rational use of medicines.

• Achieving these will require limiting government procurement and supply to essential medicines only, and investing in adequate training, supervision and health staff salaries.

Key Point

 The most effective approach to improving medicines use in primary care in developing countries is a combination of education and supervision of health personnel, consumer education, and ensuring an adequate supply of appropriate medicines.

 What are you planning to do to stop irrational use of drugs in your working place?

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what are the consequences of irrational use of medicines?

Consequences of irrational use of medicines

 Irrational use of medicines occurs in all countries, causing harm to people and wasting resources.

• Consequences include:

     -Antimicrobial resistance.

     -Adverse drug reactions and medication errors.

     -Lost resources.

     -Eroded patient confidence

Antimicrobial resistance.

• Overuse of antibiotics increases antimicrobial resistance and the number of medicines that are no longer effective against infectious disease.

• Many surgical procedures and cancer therapies are not possible without antibiotics to fight infection.

• Resistance prolongs illnesses and hospital stays, and can even cause death, leading to increase costs.

• Adverse drug reactions and medication errors. Harmful reactions to medicines caused by wrong     use, or allergic reactions to medicines can lead to increased illness, suffering and death.

Lost resources.

• Between 10–40% of national health budgets are spent on medicines.

• Out-of-pocket purchases of medicines can cause severe financial hardship to individuals and their families.

• If medicines are not prescribed and used properly, the income of public and personal funds are wasted.

 Eroded patient confidence.

-Exacerbated by the overuse of limited medicines, drugs may be often out of stock or at unaffordable prices and as result erode patient confidence.

-Poor or negative health outcomes due to inappropriate use of medicines may also reduce confidence.

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Irrational or non irrational use of drugs

• Irrational or non-rational use is the use of medicines in away that is not compliant with rational use.

• This incorrect use may take the form of overuse, underuse and misuse of prescription or non-prescription medicines.

Irrational use of medicines is a serious public health problem worldwide and can be seen as:

a.  use of too many medicines per patient;

(b) inappropriate use of antimicrobials, often in inadequate

     dosage and insufficient duration;

(c) overuse of injections when oral medication would be more appropriate;

(d) failure to prescribe in accordance with clinical guidelines including standard treatment guidelines and prescribing policy; and

(e) inappropriate self-medication, often of prescription-only medicines.

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why drugs or medical supplies need to be managed properly?

Why manage drugs and medical supplies? 

•Three reasons can be given to explain why drugs or medical supplies need to be managed properly. 

•  Firstly, drugs are part of the link between the patient and health services. Consequently, their availability or absence will contribute to the positive or negative impact on health. 

•  Secondly, poor drug management, particularly in the public sector of developing countries, is a critical issue, but major improvements are possible that can save money and improve access.

• Finally, drugs are no longer the responsibility of health workers only. Political, economic, financial and traditional considerations have become so crucial in health care that it has become imperative to look at drugs and health care from these perspectives. 

• All of these factors contribute to appropriate financial expenditure, avoid wastage, increase access and ensure that drugs are properly used

•

• Drug management functions are undertaken in four principal phases, which are interlinked and are reinforced by appropriate management support systems (i.e. tools). 

• From drug selection to drug use, passing through procurement, storage and distribution, a whole range of management capacities are required and necessitate using the appropriate tools within a given legal and policy framework

•

•  The selection of drugs for use at health center's is usually determined at the national level by the Ministry of Health and is based on a number of factors. 
• After determination of the quantities required, based on price, delivery conditions and quality, the selected drugs go through a procurement process. After storage and distribution, the use of the drugs requires prescribing, packaging, dispensing and counselling. 
• These tasks require qualified health workers or other relevant personnel with appropriate skills and attitudes. 
•  Management support tools are important for the acquisition of relevant skills in drug management.

Read More