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Lavanya et al. World Journal of Pharmacy and Pharmaceutical Sciences
EVALUATION OF PRESCRIBING PATTERNS OF ANTIBIOTICS IN
ORTHOPEDIC DEPARTMENT AT GAJJALA BRAHMAREDDY (GBR)
HOSPITAL, NARASARAOPET
V. Leela Lavanya*, R. B. Desireddy, P. Jaisree, P. Pujitha, R. Yaseswini, R. Lavanya
Department of Pharmacy Practice, Nalanda Institute of Pharmaceutical Sciences,
Kantepudi, Sattenapalli, Guntur, AP 522438.
ABSTRACT
Background: Antibiotics are substances which are used to treat
infections caused by microorganisms including fungi and protozoa.
The inappropriate and indiscriminate use of antibiotics and potentially
cause number of problems. Antibiotic resistance is not only a problem
for the individual patient; it also reduces the effectiveness of
established treatment and has become a major threat to public health
by increasing the complexity and cost of treatment and reducing
probability of successful outcome. Objective: The main objective is to
investigate the irrationality of prescribing patterns of antibiotics in
prescription. To improve rationality of antibiotics and to improve
quality of life and socio-economic status of patient. Methods: It is a
prospective observational study done at GBR Hospital, Narasaraopet.
The records of all patients who had any courses of antibiotics within given period were
isolated and screened and relevant data was extracted by using patient data collection form
and filled forms were analyzed. Results: A total of 150 patients consisting of 83 males
(55.33%) and 67 females (44.66%) were enrolled. Among these majority of patients
67(44.66%) were in the age group of 41-60 years. The most commonly prescribed antibiotics
were cephalosporin’s. Majority of drugs 52% with single drug was prescribed in orthopedic
department. 222(94.87%) were administered in IV route and 12(5.12%) were administered in
oral route. Ceftriaxone was majorly used antibiotic in the category of cephalosporin’s.
Conclusion: Of the 150 patients analyzed in various departments, it was observed that
hospital physicians prescribed antibiotics more rationally with no banned drugs and lesser
newer drugs. This study states that development of clinical pharmacy services is also
WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES
SJIF Impact Factor 7.632
Volume 9, Issue 4, 725-736 Research Article ISSN 2278 – 4357
*Corresponding Author
V. Leela Lavanya
Department of Pharmacy
Practice, Nalanda Institute
of Pharmaceutical Sciences,
Kantepudi, Sattenapalli,
Guntur, AP 522438.
Article Received on
05 Feb. 2020,
Revised on 25 Feb. 2020,
Accepted on 15 March 2020
DOI: 10.20959/wjpps20204-15826
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Lavanya et al. World Journal of Pharmacy and Pharmaceutical Sciences
necessary to improve rational prescribing of antibiotics. Utilizing of clinical pharmacy
services shows benefit of patient health related outcomes and also improves the economic
status of patients.
KEYWORDS: Antibiotics, Hospital, Prescribing pattern, Antibiotic resistance.
INTRODUCTION
Antibiotics may be informally defined as subgroup of Anti-Infectives that are derived from
bacterial sources, fungi and other organisms used to treat bacterial infections. They may
either kill or inhibit the growth of bacteria. In 1928, Alexander Fleming identified Penicillin,
the first chemical compound with antibiotic properties. Antibiotics have been found to be
most commonly prescribed and used class of drugs in several national and international
studies. The clinical use of antibiotics was introduced in the early 1940s and a short time
thereafter, their misuse and abuse potential were recognized. Drugs are “Double Edged
Weapons” since new drugs are introduced every year, hence need for an active surveillance
system. Antimicrobial resistance (AMR), the ability of microorganisms to find ways to evade
the action of the drugs used to cure the infections they cause and is increasingly recognized as
a global public health issue which would hamper the control of many infectious diseases.
They constitute a growing and global public health problem. WHO suggests that countries
should be prepared to implement hospital infection control measures to limit the spread of
multi-drug resistant strains and to reinforce national policy on prudent use of antibiotics,
reducing the generation of antibiotic resistant bacteria. “The rational use of drugs requires
that patient receives medications appropriate to their clinical needs, in doses that meet their
own individual requirements, for an adequate period of time, and at lowest cost to them and
their community”. Rational prescribing refers to prescribing of right drug to the right patient,
in the right dose, at right time intervals and for right duration. Excessive and inappropriate
use of antibiotics causes significant adverse effects such as increase of morbidity and
mortality, drug toxicity, long hospitalization period, increase of costs, resistant
microorganisms and associated infections.
Steward Program: Several strategies to optimize use of antibiotics, often referred to as
antibiotic steward programs, have been developed. Antimicrobial stewardship has been
defined as the limitation of inappropriate antimicrobial use while optimizing antimicrobial
drug selection, dosing route and duration of therapy in order to maximize clinical cure and to
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Lavanya et al. World Journal of Pharmacy and Pharmaceutical Sciences
limit unintended consequences, such as emergency of resistance, adverse drug events and the
selection of pathogenic microorganisms.
Prescription Pattern Monitoring Studies
Drug utilization research was defined by World Health Organization (WHO) in 1977 as a
marketing, distribution, prescription, and use of drugs in society, with special emphasis on
the resulting medical, social and economic consequences. Pharmacoepidemiology is the study
of the use and effects/side-effects of drugs in large numbers of people with the purpose of
supporting the rational and cost-effective use of drugs in the population thereby improving
health outcomes. Drug utilization research is thus an essential part of pharmacoepidemiology
as it describes the extent, nature and determinants of drug exposure. Over time, the
distinction between these two terms has become less sharp, and they are sometimes used
interchangeably. Together, drug utilization research and pharmacoepidemiology may provide
insights into many aspects of drug use and drug-prescribing. They provide much useful
information on indirect data on morbidity, treatment cost of illness, therapeutic compliance,
incidence of adverse reactions, effectiveness of drug consumption and choice of comparators.
Prescription pattern monitoring studies (PPMS) are drug utilization studies with the main
focus on prescribing, dispensing and administering of drugs. They promote appropriate use of
monitored drugs and reduction of abuse or misuse of monitored drugs. PPMS also guide and
support prescribers, dispensers and the general public on appropriate use of drugs, collaborate
and develop working relationship with other key organizations to achieve a rational use of
drugs. Prescription Patterns explain the extent and profile of drug use, trends, quality of
drugs, and compliance with regional, state or national guidelines like standard treatment
guidelines, usage of drugs from essential medicine list and use of generic drugs. There is
increasing importance of PPMS because of a boost in marketing of new drugs, variations in
pattern of prescribing and consumption of drugs, growing concern about delayed adverse
effects, cost of drugs and volume of prescription.
The aim of PPMS is to facilitate the rational use of drugs in a population. Irrational use of
medicines is a major problem worldwide. WHO estimates that more than half of all
medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to
take them correctly. The overuse, underuse or misuse of medicines results in wastage of
scarce resources and widespread health hazards. The Rational Use of Medicines (RUM) is
defined as “Patients receive medications appropriate to their clinical needs, in doses that meet
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Lavanya et al. World Journal of Pharmacy and Pharmaceutical Sciences
their own individual requirements, for an adequate period of time, and at the lowest cost to
them and their community. A large number of studies have been conducted to study the
prescribing pattern of physicians across the country. The studies conclude the irrational
prescribing practices of prescribers and suggest RUM at all levels of health care delivery
system. However, no systematic reviews, meta‐analysis, or randomized controlled trials are
present about the relevance of PPMS in promoting rational use of drugs. The present review
has been done to assess the effectiveness of PPMS in developing RUM. This study was
conducted with the aim of analyzing the prescribing practices of physicians and to assess the
extent to which the goal of RUM has been achieved. The drugs frequently prescribed by the
physicians for disease conditions like diabetes, schizophrenia, hypertension, epilepsy,
inflammatory conditions such as osteoarthritis have been included in this study. An effort has
been made to also include the prescribing trends of antimicrobials due to the growing concern
of antimicrobial resistance. Data search pertaining to assessment of PPMS was conducted on
the internet. A plethora of information on the prescribing trends of physicians was available
which has been summarized in this study.
The prescribing indicators that were measured included
The average number of drugs prescribed per encounter was calculated to measure the
degree of poly pharmacy. It was calculated by dividing the total number of different drug
products prescribed by the number of encounters surveyed. Combinations of drugs
prescribed for one health problem were counted as one.
Percentage of drugs prescribed by generic name is calculated to measure the tendency of
prescribing by generic name. It was calculated by dividing the number of drugs
prescribed by generic name by total number of drugs prescribed, multiplied by 100.
Percentage of encounters in which an antibiotic was prescribed was calculated to measure
the overall use of commonly overused and costly forms of drug therapy. It was calculated
by dividing the number of patient encounters in which an antibiotic was prescribed by the
total number of encounters surveyed, multiplied by 100.
Percentage of encounters with an injection prescribed was calculated to measure the
overall level use of commonly overused and costly forms of drug therapy. It was
calculated by dividing the number of patient encounters in which an injection was
prescribed by the total number of encounters surveyed, multiplied by 100.
Percentage of drugs prescribed from an Essential Drug List (EDL) was calculated to
measure the degree to which practices conform to a national drug policy as indicated in
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the national drug list of Ethiopia. Percentage is calculated by dividing number of products
prescribed which are in essential drug list by the total number of drugs prescribed,
multiplied by 100.
WHO has recommended multifaceted strategies to improve hospital prescribing pattern
of antibiotics, such as
Establish infection control programmes, based on current best practice, with the
responsibility for effective management of antimicrobial resistance in hospitals and
ensure that all hospitals have access to such a programme.
Establish effective hospital therapeutics committees with the responsibility for overseeing
antimicrobial use in hospitals.
Develop and regularly update guidelines for antimicrobial treatment and prophylaxis, and
hospital antimicrobial formularies.
Monitor antimicrobial usage, including the quantity and patterns of use, and feedback
results to prescribers.
WHO advocates 12 key interventions to promote more rational use
1. Establishment of a multidisciplinary national body to coordinate policies on medicine use
2. Use of clinical guidelines
3. Development and use of national essential medicines list
4. Establishment of drug and therapeutics committees in districts and hospitals
5. Inclusion of problem-based pharmacotherapy training in undergraduate curricula
6. Continuing in-service medical education as a licensure requirement
7. Supervision, audit and feedback
8. Use of independent information on medicines
9. Public education about medicines
10. Avoidance of perverse financial incentives
11. Use of appropriate and enforced regulation
12. Sufficient government expenditure to ensure availability of medicines and staff.
Policy on the rational use of antibiotics
A coherent policy should promote simple and inexpensive measures that could have a
considerable effect on the optimal use of antibiotics. Such measure include.
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Lavanya et al. World Journal of Pharmacy and Pharmaceutical Sciences
i. Orienting the initial training and regular retraining of prescribers and dispensers so that
they learn the best ways of effectively combating infectious diseases;
ii. Providing simple and inexpensive equipment to laboratories so that they can give valid
bacteriological information;
iii. Improving the supply and distribution of antibiotics in accordance with the principles of
an essential drugs policy, thus making drugs available at locally affordable prices;
iv. Controlling information and marketing in such a way as to promote the most efficacious
antibiotics and those best adapted to the local epidemiological situation;
v. Carefully studying cultural attitudes so that the right kind of education and information
can be deployed to encourage people to accept the most appropriate treatments for each
illness.
The rational use of antibiotics would help to limit as much as possible the appearance and
spread of resistant strains, which in the long run threaten our chances of effectively
controlling the infectious diseases.
Antibiotic resistance, a global concern, is particularly pressing in developing nations,
including India, where the burden of infectious disease is high and healthcare spending is
low.
The Global Antibiotic Resistance Partnership (GARP) was established to develop actionable
policy recommendations specifically relevant to low- and middle-income countries where
suboptimal access to antibiotics - not a major concern in high-income countries - is possibly
as severe a problem as is the spread of resistant organisms.
This report summarizes the situation as it is known regarding antibiotic use and growing
resistance in India and recommends short and long term actions.
MATERIALS AND METHODS
The present research was a prospective study carried out in orthopedic department at GBR
hospital. The duration of study was three months; study was conducted from November to
January. A total of 150 prescriptions were collected and analyzed. The patients from both
outpatient and inpatient department, who were geriatric patients of age above 80 and
Intensive Care Unit patients were excluded from study. Comparison of antibiotic prescribing
practices in orthopedic department was made by using percentage method.
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RESULTS AND DISCUSSION
Table 1: Distribution based on Gender of Patients (n=150).
S.No Gender No. of patients
n=150 Percentage (%)
1. Males 83 55.33
2. Females 67 44.66
Figure 1: Distribution based on Gender of Patients (n=150).
In this study, 150 cases were prescribed with antibiotics are reviewed prospectively at GBR
hospital. Among them 55.33% (n=83) were male and 44.66% (n=67) were female.
Demographic data reveals that males are more prescribed with antibiotics when compared to
females.
Table 2: Age Distribution of Patients (n=150).
S. No Age Group (years) No. of Patients Percentage (%)
1. 0-20 14 9.33
2. 21-40 28 18.66
3. 41-60 67 44.66
4. 61-70 41 27.33
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Figure 2: Age Distribution of Patients (n=150).
According to Age group Analysis, No of cases in age group of 0-20 were 14(9.33%), 21-40
were 28(18.66%), 41-60 were 67(44.66%), 61-70 were 41(27.33). This data reveals that the
patients aging between 41-60years were found to be high followed by 61-70 age group.
A total of 234 antibiotics are used in 150 prescriptions, Cephalosporin’s are most commonly
used antibiotic class when compared to other class of antibiotics. Ceftriaxone is most
commonly prescribed antibiotic in 3rd
generation Cephalosporin’s and it is the major
antibiotic prescribed by generic name.
Antibiotics used in orthopedic department: Cephalosporin’s are highly prescribed
antibiotics in orthopedic department and the data was listed in figure.
Table 3: Percentage of antibiotics used in Orthopedic department.
S.No ANTIBIOTICS PERCENTAGE USED(%)
1 Monocef forte(Ceftrioxone+Salbactum) 49.57
2 Piptaz(Piperacillin+Tazobactum) 14.95
3 Amaikacin(Aminoglycoside antibiotic) 19.65
4 Lizomac(Linezolid) 6.83
5 Ampitrust(Ampicillin+Salbactum) 0.42
6 Metrogyl(Metronidazole) 5.12
7 Cefitil(Cefuroxime) 0.85
8 Cefixime(Cefixime) 2.56
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Figure 3: Commonly Prescribed Antibiotics.
This data reveals that Cephalosporin’s are the most commonly used antibiotic class when
compared to other classes of antibiotics.
Table 4: Oral Vs IV Administration of Antibiotics in Various Departments.
S.No Oral Intravenous
1. 12(5.12%) 222(94.87%)
Figure 4: Oral Vs IV Administration of Antibiotics in Various Departments.
Generally, Antibiotics are administered in different routes like Oral, Intravenous,
Intramuscular etc., of which we compared Oral and Intravenous.
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Table 5: Single therapy Vs Combination therapy in various Departments.
S. No Single therapy Combination therapy
1. 78(52%) 72(48%)
Figure 5: Single therapy Vs Combination therapy in various Departments.
In the study population of various departments out of 234 antibiotics, the percentage of
monotherapy and combination therapy were studied. In Orthopedic department 78(52%) were
prescribed in monotherapy and 72(48%) were prescribed in combination therapy.
Table 6: Assessment of Drug (Antibiotic) Use Evaluation Using WHO Prescribing
Indicators.
S. No Parameters Percentage (%)
1. Average number of drugs per encounter 100
2. Percentage of drugs prescribed by generic name 22.22
3. Percentage of drugs with an antibiotic prescribed 100
4. Percentage of drugs with an injection prescribed 98.47
When assessed 234 antibiotics, 22.22% of individual antibiotics were Prescribed by Generic
Name (Amaikacin, Cefixime, etc.,). 6 fixed dose combinations (Piperacillin+Tazobactum,
Ceftrioxone+Sulbactum, Ampicillin+Salbactum) of antibiotics prescribed in our study were
absent in Micromedex.
CONCLUSION
The proper and correct use of antimicrobials is an almost necessity of current situation in
today’s world. Appropriate empirical antibiotic treatment is associated with a better survival
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and shortened duration of hospital stay in medical patients with bacterial infections. Irrational
prescriptions and use of drugs is a feature in health care settings and is characterized by
polypharmacy, excessive use of antibiotics and injections. Prescription analysis shows the
way towards rational use of drugs. This study provides insights into the patterns of antibiotic
use and rationalizing prescribing practices. In this project an attempt was made to study the
antibiotics prescribing pattern in GBR Hospital, Narasaraopet. The study was conducted for a
period of 3 months. A thorough literature survey was done on the area of project to review
the past work. Past knowledge was utilized in designing the present study and compare the
results of the present studies with those of the past studies.
In this study, prescriptions were collected from Inpatients. When prescriptions of male
patients were compared with female patients, it showed that male’s prescriptions contained
more antibiotics, than female patients. Majority of patients were treated with
Cephalosporin’s. The incessant use of trade names instead of generic names in the
prescriptions was also highlighted.
Out of the 150 patients analyzed in Orthopedic Department, it was observed that the hospital
physicians prescribed antibiotics more rationally with no banned drugs and less newer drugs.
This study states that development of hospital pharmacy services is also necessary to improve
the rational prescribing of antibiotics. Utilizing of hospital pharmacy services shows benefit
on patient health related outcomes and also improves the economic status of the patient.
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