evaluation of prescribing patterns of antibiotics in

www.wjpps.com Vol 9, Issue 4, 2020.

725

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


726


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


727


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


728


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


729


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.


730


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.


731


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


732


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


733


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.


734


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


735


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.

REFERENCES

1. Prescription writing. British National Formulary 1998; No. 35 (March, 1998): 4-6.

2. WHO. Model list of essential drugs Geneva: World Health organization (1988).

3. Krishnaswamy K, Dinesh Kumar B, Radhaiah G. A drug use survey percepts and practice.

Eur J clin Pharmacology, 1985; 29: 363- 370.

4. Pradhan SC, She wade DG, Bapna JS. Drug utilization studies. National Med J India,

1988; 1: 185-189.

5. Srishyla MV, Krishnamurthy M, Naga Rani MA, Clare M, Andare C, Venkataraman BV.

Prescription audit in an Indian hospital setting using the DDD concept. Indian J

Pharmacol, 1994; (26): 23-28.

6. His Majestys Government, Department of drug Administration. National list of essential

drugs Nepal (Third revision) 2002 Varanasi. Indian J Prev Soc Med., 2003; 34(1&2):

33-39.


736


7. Bhantnagar T, Mishra CP, Mishra RN. Drug prescription practices: a house hold study in

rural Abdullah D, Ibrahim N, Ibrahim M. Medication errors among geriatrics at the out

patient Pharmacy in a teaching hospital in keltan. Malaysian J Med sci., 2004; 11(2):

11-17.s

8. Pramil T, Rajiv A, Gaurav G. Pattern of Prescribing at a paediatric outpatient setting in

northern India. Indian J Pharm Pract., 2012; 5(1): 4-8.

9. G.Parthasarathi, Kilap C Nahata. A Textbook of clinical pharmacy practice. 2nd

edition. Pg

no 235-243.

10. Antonio Clavenna, Macro Sequi, Angela bortolotti, luca Merlino, Ida Fortino and

Maurizio Bonati. Determinants of the drug utilization profile in the paediatric population

in Italys Lombardy region. Brj clin pharmacol, 2009: 565-571.

11. S.Dimri, PTiwari, S Basu and VR Pamar. Drug use pattern in children at a teaching

hospital. INDIAN PEDIATRICS, 2009; (46): 165-167.

12. Shipra Jain, Prerna Upadhyaya and Vijay V Moghe. A systematic review of prescription

pattern monitoring studies and their effectiveness in promoting rational use of medicines.

evaluation of prescribing patterns of antibiotics in

Documents