Using Unannounced Standardized Patients to Assess the Quality of Tuberculosis Care and Antibiotic Prescribing: A Cross-Sectional Study on a Low/Middle-Income Country, Pakistan

<b>Background:</b> Pakistan is classified as a high-burden country for tuberculosis, and the prescription of antibiotics and fluoroquinolones complicates the detection and treatment of the disease. The existing literature primarily relies on knowledge questionnaires and prescription analyses, which focus on healthcare providers' knowledge rather than their actual clinical practices. Therefore, this study aimed to evaluate the quality of tuberculosis care using standardized patients. <b>Materials and Methods:</b> We conducted a cross-sectional study, recruiting consenting private healthcare practitioners in four cities in Punjab, Pakistan. Standardized patients were engaged from the general public to simulate four cases: two suspected tuberculosis cases (Case 1 and 2), one confirmed tuberculosis case (Case 3), and one suspected multidrug-resistant tuberculosis case (Case 4). The optimal management in Cases 1 and 2 was referral for sputum testing, chest X-ray, or referral to a public facility for directly observed treatment short-courses without dispensing antibiotics, fluoroquinolones, and steroids. In Case 3, treatment with four anti-TB medications was expected, while Case 4 should have prompted a drug-susceptibility test. Descriptive statistics using SPSS version 23 were employed to analyze disparities in referrals, ideal case management, antibiotic use, steroid administration, and the number of medications prescribed. <b>Results:</b> From July 2022 to May 2023, 3321 standardized cases were presented to private healthcare practitioners. Overall, 39.4% of tuberculosis cases were managed optimally, with Case 3 showing the highest rate (56.7%) and Case 4 showing the lowest (19.8%). City-specific analysis revealed that Rawalpindi had the highest management rate (55.8%), while Sialkot had the lowest (30.6%). Antibiotics were most frequently prescribed in Case 1 and least prescribed in Case 4, with a similar pattern for fluoroquinolones. Anti-TB medications were also prescribed in naïve and suspected tuberculosis cases (8.3% in Case 1 and 10.8% in Case 2). <b>Conclusions:</b> The quality of tuberculosis management in actual practice is suboptimal among healthcare providers in Pakistan. Furthermore, the over-prescription of antibiotics, fluoroquinolones, and anti-TB drugs presents a significant risk for the development of drug-resistant tuberculosis.