An evaluation of prescribing practices for community-acquired pneumonia (CAP) in Mongolia
BMC Health Services Research
An evaluation of prescribing practices for community-acquired pneumonia (CAP) in Mongolia
Gereltuya Dorj 0
Delia Hendrie 1
Richard Parsons 0
Bruce Sunderland 0
0 School of Pharmacy, Curtin University , Bentley, Western Australia , Australia
1 Centre of Population Health Research, Curtin Health Innovation Research Institute , Bentley, Western Australia , Australia
Background: Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality in all age groups worldwide. It may be classified as mild/moderate or severe, the latter usually requiring hospitalisation. Although, there are many studies reported in relation to CAP, there is relatively little known about the treatment of CAP and its antibiotic use in Mongolia. The study aim was to evaluate prescribing practices for the treatment of mild/moderate CAP in Mongolia with respect to national prescribing guidelines. Methods: Written prescriptions with a written diagnosis of CAP included were collected prospectively and sequentially for ten weeks from a purposefully selected sample of community pharmacies in rural and urban areas of Mongolia. The data collected included the patient's age, gender, medication details, frequency and number of doses prescribed. Evaluation was with respect to the Mongolian Standard Treatment Guidelines (2005, 2008). Statistical differences between groups were tested using the Chi-squared and Fisher's exact tests. Results: Prescriptions were collected from 22 pharmacies and represented the prescribing practices of 118 doctors. The study enrolled 394 (193 adults and 201 children) patients, with a median age for children of 2.0 years (range: 0.03-12) and adults of 33.0 years (range: 13-92). The most commonly prescribed drugs were aminopenicillins, vitamins, and mucolytics, with the median number of drugs being three per prescription. Inappropriate drug selection was similar for adults (57.7%) and children (56.6%), and the major reason for an overall frequency of inappropriate prescribing for adults was 89.0% and for children 78.0%. Doctors in urban areas prescribed more inappropriate drugs than those in rural areas for both children and adults, p = .0014. The proportion of prescribed injections was 28.4% for adults and 9.0% for children, and for adults was significantly higher in urban areas. The prescribing standard for non-hospitalized patients in Mongolia states that injections should not be prescribed. Conclusions: The high level of inappropriate prescribing for mild/moderate CAP highlights the need to develop comprehensive and reliable procedures nationwide to improve prescribing practices in Mongolia.
Community-acquired lower respiratory tract infection
(LRTI) is a common cause of acute illness both in
developing and developed countries. The spectrum of the
disease ranges from a mild mucosal colonisation or infection,
acute bronchitis or acute exacerbation of chronic
bronchitis/chronic obstructive pulmonary disease, to
overwhelming symptoms in the patient presenting with severe
community-acquired pneumonia. Pneumonia is broadly
classified into two categories: community-acquired (CAP)
and hospital-acquired. CAP is a significant cause of
morbidity and mortality in all age groups, especially the elderly
, which is a patient population group that continues to
grow. Death rates associated with CAP have not changed
greatly, partly because of increased numbers of patients
with comorbidity and patients at risk .
Rational drug use occurs when an appropriate drug is
prescribed and administered according to the appropriate
dosage regimen and the drug should be affordable,
available, dispensed correctly, in correct doses at adequate
time intervals . The basis for achievement of rational
drug use is conformity with standard treatment guidelines.
Moreover, rational dispensing correlates with drug supply
procedures and also the competency and knowledge of
the health care provider. The World Health Organisation
(WHO) was the first to launch a major step (Model
Essential Drug List) towards the rational use of drugs in 1977
. This list was designed to help countries to develop
their own national lists. Later, the International Network
for the Rational Use of Drugs (INRUD) was established to
conduct multidisciplinary research to promote the rational
use of drugs .
Common examples of irrational drug use include the
prescribing of antibiotics for viral infections and excessive
or unnecessary use of injections. The consequences of
irrational drug use include poor or limited quality of care
[5,6], high cost of therapy [7,8] and increased incidence of
adverse effects such as prolonged morbidity, mortality,
drug toxicity, hospitalization for longer periods, antibiotics
resistant to microorganisms and the associated infections
[9,10]. Antibiotics are one of the most commonly used
treatments in modern medicine . Excessive usage of
antibiotics can be costly, and may have a large cost impact
when there is a limited drug budget. Although it is difficult
to estimate, the global sale of antibiotics is reported as 6 to
21% of the pharmaceutical market, 3 to 25% of total
prescriptions , and 15 to 30% of drug expenditure .
As recommended by the Australian Commission on
Safety and Quality in Healthcare, antimicrobial use should
be optimised by managing through a number of
interventions, often referred to as antimicrobial stewardship
programs . An essential core to implement antimicrobial
stewardship programs is monitoring of prescribing with
respect to the guidelines on appropriate use of antibiotics,
including information regarding appropriate selection,
dosing, route, and duration of antimicrobial therapy .
Other interventions include the restriction of selected
antibiotics and stop-orders after predetermined time
periods. The goals of an antimicrobial stewardship program
include optimization of clinical outcomes while
minimizing unintended consequences of antimicrobial use such as
toxicity, and the emergence of resistance. Moreover, it is
aimed to reduce unnecessary costs associated with health
At present, clinical guidelines are widely available in
many countries [17,18]. These guidelines should consider
different risk factors, such as age, comorbidity and initial
clinical severity  and there should be evidence-based
implementation strategies at a local level in each country.
In accordance with WHO initiatives, the National
Essential Drug List of Mongolia was first published in
1991 and it has subsequently been revised five times .
Generic drugs are promoted by the Government through
its existing legislation. CAP is a significant disease that
requires urgent appropriate management, including
antibiotics. There is relatively little known about the treatment
of mild/moderate CAP in Mongolia, and in particular, the
drugs used. This study is the first community-based
assessment of the treatment of non-hospitalized patients
with mild/moderate CAP in Mongolia. The primary aim
of this study was to evaluate the appropriateness of
prescribing practices for mild/moderate CAP based on the
criteria established by the standard treatment guidelines
in Mongolia. A secondary objective was to investigate the
extent of injections prescribed for mild/moderate CAP in
Prescriptions submitted to community pharmacies in
Mongolia with only a diagnosis of mild/moderate CAP
written on the prescription by the prescriber, were
collected prospectively and sequentially. According to the
National Guideline for Good Prescribing and Dispensing
Practice of Mongolia (Regulations), all physicians must
record the diagnosis on the prescription. A data collection
form was developed and translated from English to
Mongolian and back-translated into English, in order to
assure the accuracy of data collection. All prescribed drugs,
including their dosage, duration, route of administration
and demographic information of patients were extracted
from the prescriptions. Each drug was evaluated for
rational prescribing based on the Standard Treatment
Guidelines of Mongolia (2005, 2008) [21,22].
Appropriateness was assessed for each of the following indicators: drug
selection, dosage form, single dose, frequency, prescribed
quantity and prescribed duration. A drug was classified as
inappropriate if any one of these indicators were not in
accordance with the standard treatment guidelines. The
assessment was based on a sequential cascading down
effect, e.g. if first indicator was inappropriate then drug
would be excluded from further analysis and would not
appear in the second indicator, etc.
Mongolia, a developing country located between Russia
and China, is one of the most sparsely populated countries
in the world, with a total population of 2.75 million. It is
divided into 21 provinces (aimag) and the capital city is
Ulaanbaatar. About 40% of the population lives in the
According to the National Standard Requirement for
Pharmacy , a main community pharmacy can have up
to two branches. The main pharmacy can only be owned
by pharmacists, but the pharmacy branch can be owned by
a pharmacist or pharmacy technician. According to the
latest statistics, there were 543 community pharmacies .
In addition, 302 remote pharmacies (soum) were registered
Table 1 Standard treatment guidelines for the management of mild/moderate CAP in Mongolia
Mild/ moderate CAP
Oral amoxicillin (ampicillin) 500 mg every 6 hours, or erythromycin 500 mg every 6 hours
F= 98 (48.8%)
Median age (years)
Median weight (kg)
Treatment Guidelines for Common Infants: Benzylpenicillin, aminoglycoside
Diseases in Children: Pneumonia (gentamicin) injectionUp to five years old:
Semi(Mongolian Standard) MNS 5836:2008 synthetic penicillin (50 mg/kg/4 times) +
gentamicin 7.5 mg/kg/once)-injection If
available chloramphenicol (75 mg/kg/3 times a
day) *Additional option: Cephalosporin II-III
as Revolving Drug Funds (RDFs) in 2011, provided by the
government . These can be managed by pharmacists or
The site selection was based on the WHO Operational
package for assessing, monitoring and evaluating country
pharmaceutical situations . The principle of selecting
private pharmacies in the city and in each province was to
select the closest private pharmacy to each public health
facility surveyed. However, branches and RDFs were
excluded in this study because branches of the pharmacies
are legally restricted to Over the Counter (OTC) drugs
and due to limited budget.
A convenience selection method was applied for
pharmacies in rural areas based on discussion with local
professionals. The sites selected were privately owned community
pharmacies in towns in eight provinces (Bayankhongor,
Bulgan, Govi-Altai, Khovsgol, Ovorkhangai, Sukhbaatar, Tuv,
Uvs) and the remainder in the capital city (Ulaanbaatar).
Period of the study
The study was conducted in the winter season (mean
temperature 25C) over a period of 10 weeks, from
January until March, 2010, which is a period with a high
prevalence of acute respiratory tract infections.
The study protocol was approved by the Human
Research Ethics Committee, Curtin University, Western
All data were entered and analysed using SPSS software
(version 18.0). The drugs prescribed for the diagnosis of
Table 2 Demographic characteristics of participants
If considered necessary, any of the following could be
prescribed: Salbutamol, euphyllin, epinephrine
Prednisolone, dexamethasone Vitamin C, A or E
mild/moderate CAP were analysed against
recommendations included in the Standard Treatment Guidelines for
CAP (2005, 2008) and the National Guidelines for Good
Prescribing Practice of Mongolia (Table 1). Decisions
regarding appropriateness were made separately by two of
the authors (GD and validated by BS). Differences were
resolved by consensus. Differences in prescribing practices
between adults and children and urban and rural areas
were tested for statistical significance using the Chi-square
statistic and Fishers Exact test. A p-value < 0.05 was taken
to indicate a statistically significant association.
Data analysis of the prescribing practices for children
was limited by the lack of information in the guidelines
for children aged 615 year old (Table 1).
Thirty pharmacies consisting of 20 in the Ulaanbaatar
area and 10 in eight of the provinces were selected for
inclusion in the study, of which 22 consented. This
represented a response rate of 73%. All pharmacies that did
not consent were in the city area stating they were too
busy to participate.
Selection and characteristics of participants
The study enrolled 394 (193 adults and 201 children)
participants who were diagnosed with mild/moderate CAP.
The prescriptions represented the prescribing practices of
Table 2 shows the demographic characteristics of
participants. The proportions of adults (48.9%) and children
Table 3 Most commonly prescribed drugs for patients
with mild/moderate CAP
frequency (N=1100) (%)
Vitamin B Complex
aLocal product containing Glycyrrhiza uralensis Fisch, Thermopsis dahurica Czefr.
(51.0%) were almost equally represented,, with a median
age for children of 2.0 years (range: 0.03-12) and adults of
33.0 years (range: 1392). Male adults (49.7%) were in
similar numbers to females (50.3%).
Prescribing pattern of doctors
A total of 1100 drugs were prescribed for the 394
participants, with the most commonly prescribed being
aminopenicillins (10.4% for adults and 18.3% for children),
N= 1005 (100%)
Figure 1 Appropriateness level of prescribing for patients with mild/ moderate CAP.
Table 4 Number of drugs prescribed per prescription
No. of prescribed drugs
followed by vitamins, mucolytics (bromhexine),
ciprofloxacin and paracetamol (Table 3).
There was a low level of poly-pharmacy with the median
number of drugs being three per prescription. There
was no significant difference in the number of drugs
prescribed for adults (p=0.63) and children, or in urban and
rural locations (p = .98) (Table 4).
Frequency of inappropriate prescribing
The overall level of inappropriate prescribing for all
patients based upon application of the standard treatment
guidelines was 845 (84.0%) (Figure 1). A total of 95 were
not assessable because of lack of information about drug
selection, dosage form, dose, frequency and duration in
the current guidelines for children aged between 6 to 15
years (Figure 2).
The results of the assessment of prescription categories
for patients with mild/moderate CAP are shown for
children and adults in Tables 5 and 6 respectively. A
chiFigure 2 Inappropriateness levels of drug selection for patients with mild/ moderate CAP in urban and rural areas (y axis refers to
number of drugs prescribed).
squared analysis showed a statistically significant
difference between inappropriate prescribing for adults and
children,  (1, n=1100) =22.8, p < .001. Relatively more
adults were prescribed inappropriate drugs, largely as a
result of the dosage frequency prescribed.
Inappropriate drug selection was the major reason for
inappropriate prescribing for patients with CAP, with
the extent of inappropriate drug selection similar for
children (56.6%) and adults (57.7%). Doctors in urban
areas prescribed a higher frequency of inappropriate
drugs than those in rural areas for the population
studied,  (1, n=575) =10.25, p = .0014 (Figure 2).
Prescribing level of injectables
The proportion of drugs (n=1100) prescribed as injections
was 28.4% for adults and 9.0% for children. Prescribing of
injectables was significantly higher for adults in urban
areas compared with rural areas  (1, n=556)=21.7,
DF=1, p = < .001, but the difference between urban and
rural prescribing of injectables was not significant for
children (Table 7). In the case of antibiotics, the proportion of
injectables prescribed was 34.7% in the urban (83/239)
and 18.5% in rural areas (31/168). Since the current
guidelines for ambulatory care does not allow any use of
injectables for outpatients with moderate/mild CAP, this use of
injections is non-compliant with one of the current
prescribing standards for Mongolia . Moreover,
gentamicin is recommended for the treatment of mild/moderate
CAP for children and it was prescribed for outpatients
with mild/moderate CAP. However, this is available only
as injectable, so the guideline recommendation is
noncompliant with the prescribing standard.
This is the first study to explore prescribing practices for
mild/moderate CAP in Mongolia by comparing drugs
prescribed with respect to government initiated treatment
guidelines. The study revealed only low levels of
polypharmacy with the average number of drugs prescribed
being three per patient. This is consistent with a previous
assessment of prescribing practices of the pharmaceutical
sector undertaken in 2009 .
High levels of inappropriate prescribing were identified
when evaluation occurred with respect to government
Table 5 Assessment of the prescriptions for children with mild/moderate CAP*
A- Appropriate, IA- Inappropriate, NAI- No assessable guideline information, OPD- Overprescribed dose, UPD- Underprescribed dose.
aIncludes the number of appropriately selected drugs from the previous column.
*If the first indicator was inappropriate, then the prescription item classification was inappropriate and this drug was excluded from further analysis and would
not appear in the second indicator.
Table 6 Assessment of the prescriptions for adults with mild/moderate CAP*
A- Appropriate, IA- Inappropriate, OPD- Overprescribed dose, UPD- Underprescribed dose.
aIncludes the number of appropriately selected drugs in inappropriate dosage forms only.
*If the first indicator was inappropriate, then the prescription item classification was inappropriate and this drug was excluded from further analysis and would
not appear in the second indicator.
produced treatment guidelines for CAP in Mongolia,
with 84% of drugs inappropriately prescribed. The major
reason causing inappropriate prescribing for both adults
and children was inappropriate drug selection.
In a South African study examining the adherence to
treatment guidelines for CAP, empirical antibiotic
treatment for severe CAP accorded with local guidelines for
14 patients (8%) only. The remaining 168 patients (92%)
were given treatment that was inconsistent with the
The evaluation of prescriptions indicated diverse
prescribing practices for patients with CAP. In most cases
(93.4%) at least one antibiotic was prescribed.
Ciprofloxacin, cotrimoxazole and ketotifen (antihistamine) were
most commonly prescribed. These were inconsistent with
the current guidelines and showed a lack of practical
adoption and implementation of the treatment guidelines.
Possible explanations for these findings could include lack
of knowledge, attitude and awareness of the guidelines. In
addition, some prescribers under-prioritise the guidelines
because they may feel time and financial pressures from
external factors [29,30].
Different prescribing practices between rural and urban
areas were observed, with doctors in rural areas
prescribing more appropriately than their counterparts in
urban areas. Anecdotal statements from local health
professionals suggested this could relate to the smaller
population and possibly a better control of prescribing and
dispensing practice. Another possible reason may relate to
Table 7 Proportion of prescribed injections for
participants with mild/moderate CAP
No. of injectables No. of
nonn (%)a injectables n (%)a
Total p Value
Urban adults 128 (23.0)
Rural adults 30 (5.4)
aPercentage of drugs.
rural practitioners being less accessible to visits from
pharmaceutical companies or receiving their literature.
There were reports from doctors and pharmacists about
financial incentives from the pharmaceutical companies in
the form of extra income from prescribing and dispensing
their drugs. This practice is illegal in Mongolia; however it
is still common in some countries [31-33].
Unfortunately about 8% of all drugs prescribed for
children with CAP in this study could not be assessed due to
non-existent information in the current guidelines for
children aged 5 to 16 years. This indicates that
evidencebased treatment of children with CAP cannot be assured
in the absence of guidelines.
Treatment guidelines are an important component of
assuring appropriate drug use  and for the decision
making process in health care practice. The need for and
importance of well-documented, standardized guidelines is
recognized as essential for the successful treatment of CAP
. However, despite being promulgated by well-regarded
institutions, often compliance with national guidelines for
treatment of CAP is poor [36,37]. The implementation of
guidelines depends on the clarity of the statement and
adaptability into practice. In addition, guidelines need to
be readily assessable and endorsed by senior practitioners.
A number of interventions to improve the prescribing
behaviour can be found from the literature. However, a
Cochrane review indicated that there was insufficient
evidence to support the choice of intervention . While
single interventions may be as effective as multiple ones
due to existing health infrastructure in developed
countries, multiple intervention packages have been shown to
be more beneficial in less developed countries . These
intervention packages often include building infrastructure,
such as supervisory systems, that are likely to increase their
impact . In addition, tailoring interventions to target
specific barriers to compliance was reported to be effective
in improving professional practice [39-41].
The use of unnecessary injections is a common
occurrence in developing countries and it is widely recognized
that unsafe healthcare injections can transmit HBV ,
HCV , HIV , viral haemorrhagic fever and other
bloodborne pathogens . In this study, the prescribing
level of injections for the treatment of mild/moderate
CAP was approximately 18% of all drugs. Moreover,
inconsistency between guidelines was observed.
Gentamicin is recommended in the current treatment
guideline for children with CAP . However, it is available
only as an injection and this recommendation does not
comply with the Good Prescribing and Dispensing
Practice regulations of Mongolia . According to a
study of injection practices in Mongolia, the average
number of injections was 13 per patient for one year in
Mongolia in 2002, which was the highest rate of
injection usage in the Western Pacific Region . Most of
the injections (antibiotics) were administered for the
treatment of pneumonia. Regardless of the
governments effort to develop guidelines to promote and
implement rational drug use, there are still problems with
unnecessary and inappropriate use of injections in
community settings and with the current guidelines.
The study has two main limitations. Firstly, the estimates
were based on a one point in time observation completed
in the winter period. Secondly, although the study aimed
to provide a representative sampling in location and size,
only about 4% of all main community pharmacies could
be included. However it is the habits of prescribers that
were assessed in this study. The study assessed the
prescribing practice of 118 prescribers which represents 15%
of all family group practitioners in Mongolia. Therefore,
the results should be representative of the prescribing
practice for the treatment of CAP at the national and
The study has shown unacceptably high levels of
inappropriate prescribing for mild/moderate CAP in Mongolia
and in addition has highlighted the inadequacy and
inconsistency of the current treatment guidelines. The findings
have important implications for the health status of
patients being treated for mild/moderate CAP and suggest
the need for appropriate interventions to be developed
and introduced by authorities to address the issues raised.
The authors declare that they have no competing interests.
GD carried out the study and drafted the manuscript. DH participated in the
design and revised the manuscript. RP performed the statistical analysis and
revised the manuscript. BS conceived of the study, and participated in its
design and coordination and revised the manuscript. All authors read and
approved the final manuscript.
The authors are grateful to Professor Ts. Sanjjav and staff at School of
Pharmacy, Health Sciences University of Mongolia for all help to implement
this study in Mongolia and for providing their helpful comments. The study
was partly funded by Ministry of Education, Culture and Science of Mongolia.
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