title: Anti-malarial prescribing practices in Sudan eight years after introduction of artemisinin-based combination therapies and implications for development of drug resistance.
abstract: BACKGROUND
  The World Health Organization (WHO) recommends artemisinin-based combination therapies (ACTs) as first-line treatment for uncomplicated malaria. Sudan revised its malaria treatment policy accordingly in 2004. However, eight years after ACTs were introduced in Sudan the patterns of ACT prescribing practices among health care providers remain unclear. We systematically analyzed use of ACTs in a large number of primary health facilities and we discuss the public health implications of our findings.
  
  
  METHODS
  This cross-sectional study was based on WHO's guidance for investigating drug use in health facilities. Data were collected from 40 randomly selected primary health centers in five localities in Gezira State, Sudan. The primary outcome of the study was the proportion of patients who were adequately managed according to Sudan's recommended malaria treatment guidelines. Twelve drug-use indicators were used to assess key ACT prescribing practices.
  
  
  RESULTS
  One thousand and two hundred patients diagnosed with uncomplicated malaria were recruited into the study. ACT was prescribed for 88.6%patients and artemether injections were (incorrectly) prescribed in 9.5% of cases. Only 40.9% of patients in the study were correctly diagnosed and 26.9% were adequately managed according to the nationally recommended treatment guidelines. Incorrect prescribing activities included failure to use generic medicine names (88.2%), incorrect dosage (27.7%), and unexplained antibiotic co-prescription (24.2%). Dispensing practices were also poor, with labeling practices inadequate (97.1%) and insufficient information given to patients about their prescribed treatment (50.5%).
  
  
  CONCLUSIONS
  Irrational malaria treatment practices are common in Sudan. This has important public health implications since failure to adhere to nationally recommended guidelines could play a role in the future development of drug resistance. As such, identifying ways to improve the anti-malarial prescribing practices of heath workers in Sudan may be a priority.
authors.affiliation: Al Neelain University, Steen Street, P.O. Box 7294, Code: 11123, Khartoum, Sudan. abeeratta@gmail.com.
authors.forename: Abeer Abuzeid Atta
authors.initials: AA
authors.lastname: Elmannan
authors.affiliation: Federal Ministry of Health, Khartoum, Sudan. khalid.elmardi@gmail.com.
authors.forename: Khalid Abdelmutalab
authors.initials: KA
authors.lastname: Elmardi
authors.affiliation: Gezira State Ministry of Health, Wad Medani, Sudan. yassir.idris@gmail.com.
authors.forename: Yassir Ali
authors.initials: YA
authors.lastname: Idris
authors.affiliation: Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA. spectorjm@gmail.com.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Spector
authors.affiliation: Federal Ministry of Health, Khartoum, Sudan. nahid100@hotmail.com.
authors.forename: Nahid Abdelgadir
authors.initials: NA
authors.lastname: Ali
authors.affiliation: Gezira State Ministry of Health, Wad Medani, Sudan. fatihmmalik@gmail.com.
authors.forename: Elfatih Mohamed
authors.initials: EM
authors.lastname: Malik
mesh_terms: D000962:Antimalarials / Q000008:administration & dosage / Q000627:therapeutic use*; D037621:Artemisinins / Q000008:administration & dosage / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D004351:Drug Resistance; D004359:Drug Therapy, Combination / Q000706:statistics & numerical data*; D006801:Humans; D008288:Malaria / Q000188:drug therapy*; D008508:Medication Errors / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D013397:Sudan
chemical_list: D000962:Antimalarials; D037621:Artemisinins; C031327:artemisinin