Prospective study for utilization review for multiple antibiotics prescribed in the specialty department in tertiary care teaching hospital

INTRODUCTION

In Europe 18^th November is considered an awareness day for the rational use of antibiotics and efforts are made using camping aimed at rationalizing and reducing the overconsumption of antimicrobial agents.¹ Antibiotics are commonly prescribed drugs nowadays in a hospital setup.² Serious infections caused by bacteria that have become resistant to commonly used antibiotics have a major global health care problem in the 21^st century. Antibiotic resistance is initially a problem in a hospital setting associated with an increased number of hospital-acquired infections.³ It is imperative to create school and community-based awareness programs by policymakers for adolescents to upgrade their knowledge on the safe use of antibiotics.⁴ Antimicrobial resistance is a global public health challenge, which has been accelerated by the overuse of antibiotics worldwide. Over-prescribing of antibiotics is associated with an increased risk of adverse effectst.⁵ Overuse and misuse of antibiotics can lead to resistance even death may occur.⁶ The role of the pharmacist in antibiotic prescription review can play an important role to optimize antimicrobial use to improve patient outcomes and minimize adverse consequences.⁷ In the COVID-19 scenario, the usage of antibiotics has achieved a new tectonic shift. This includes hydroxychloroquine, doxycycline, azithromycin, etc., are included in the management of COVID-19 complications. Thus, proper review of antibiotics prescription has become the need of the hour to streamline the prescription practice. Therefore, we have aimed to review the antibiotic usage in the specialty departments as this is the department with a maximum number of admission and multiple diagnoses. Overprescribing antibiotics is result in an increased percentage of morbidity and mortality. As a result, a physician would better retrain their prescription of antibiotics. Therefore, a case-by-case assessment of the appropriate use of antibiotics may be warranted.⁸ Antibiotics are given to all hospitalized patients with possible infections, it is unnecessary to prescribe antibiotics (or) widespread antibiotics. Moreover, clinicians fear to delay the antibiotics may increase patient risk for worse outcomes (or) it is uncomfortable to withhold the antibiotics that may have an infection (or) long stay in hospitalized patients.⁹ In the world, they have conducted a study on antibiotic overuse for acute respiratory tract infections. Most acute respiratory tract infections are a common reason for antibiotic overuse in tertiary care hospitals with influenza-like illnesses and received antibiotics although they were confirmed with influenza. In the training of physicians regarding guidelines concordant management deals with diagnostic uncertainty.¹⁰ High levels of antimicrobial drug resistance affecting the outcome of treatment with antibacterial agents are causing increased concern worldwide. Antibiotics shouldn’t be started before the results of microbiological culture are available.¹¹ Sticking to the narrow spectrum agents when possible, using broad-spectrum antibiotics such as quinolones leads to antibiotic resistance.¹² Two practices that can decrease antibiotic prescribing are electronic medical record ‘remained’ that provides physicians and antibiotic justification notes when inappropriate antibiotics are prescribed for a particular diagnosis and providing information that explains the state of the patient’s disease and diagnosis.¹³ Antibiotics use is most common in the inpatient prescription i.e.,; approximately 50% of patients have been prescribed one antibiotic prescription during their hospital stay. The overuse (or) misuse of antibiotics led to an antibiotic resistance crisis due to the lack of new drug development by the pharmaceutical industry reduced economic incentives and challenges. The objectives of the study to identify the types of various prescribed antibiotics, and also to identify and report drug related problems associated with prescribed antibiotics. To assess the effectiveness of antibiotics in a specific clinical condition, and also to provide accurate, unbiased and patient specific information about the prescribed antibiotics for better patient care.

METHODS

This prospective case series analysis study was conducted for 6 months between December 2020 and May 2021. The study was conducted in the specialty departments, of Gandhi medical college and hospital, Secunderabad. The study protocol was approved by the instructional ethical committee, CMR college of pharmacy, Hyderabad. Selected cases were collected and documented in a structured data collection from the in-patient units of the above-mentioned departments daily according to study inclusion criteria which include all ages and genders in which antibiotics were identified. Confirmed antibiotic cases were included only with complete information till discharge. Study exclusion criteria include cases without antibiotic prescription, HIV-positive cases, and cases with incomplete information were excluded from the study. After the selection of the study, a structured documentation form was prepared to document relevant data. The study was initiated by visiting the selected inpatients’ departments on daily basis to review individual case sheets of the patient to identify antibiotics and report drug-related problems associated with the prescribed antibiotics. Selected cases were followed and updated daily basis to find the suggested management outcome and for any other issues. These cases were followed until discharge and a discharge summary was used to note down in the documentation form for further processing. Analysis and interpretation of data were performed according to various categories and parameters to get the result. Further discussion of the result was executed to accomplish the outcome. The statistical tool which is used to analyse the data is one-way analysis of variance was applied to compare the collected data to obtain final outcome. Sample size for the study was considered based on 90% confidence interval, with 7% margin of error and 50% of population proportion.

RESULTS

A total of 96 cases were identified, collected, documented, and analyzed for the study according to inclusion and exclusion criteria.

Gender-wise distribution of collected cases shows that male is slightly higher than female at 56% and 44% respectively. The age-wise distribution shows less than 40 years of age constituent the maximum 44% followed by more than 60 years 30% and 40-60 years 26% (Table 1).

Diagnosis-wise distribution of collected cases show that respiratory disease has slightly higher than other diseases, such as renal disease, gastrointestinal disease, and hepatic disorder 31.25%, 28.13%, 28.87%, and 18.75% respectively (Table 2).

The distribution of antibiotic prescription frequency shows a total of 11 different antibiotics were prescribed in the collected cases. The frequency of antibiotics prescription shows a total of 155 times prescribed in the collected cases. Among the prescribed antibiotics piperacillin and tazobactam (43.75%) and doxycillin (37.50%) were prescribed mostly followed by clarithromycin. Other antibiotics are prescribed with minimal frequency (Table 3).

The number of antibiotics prescribed in each prescription from the collected cases, the patient was prescribed with one antibiotic is the highest (44%) among two antibiotics (26%) then compare to three antibiotics and more than three antibiotics respectively (12% and 17%) (Table 4).

Drug-related problems (DRP) identified in collected cases are major with prescribing errors at 56% followed by drug overdose and ADR with 28% and 16% respectively. The identified type of drug interaction with prescribed antibiotics in collected cases shows that major drug interaction is higher than compared to moderate and minor 68%, 22%, and 10% respectively (Table 5).

DISCUSSION

In this prospective study, cases were collected from various inpatients units of specialty departments and a total no. of cases are 96 with da different types of antibiotics with different classes in the duration of a 6 months period. Out of 96 collected cases, 30 were diagnosed with respiratory, 27 were diagnosed with renal, 18 were diagnosed with hepatic, and, 21 were diagnosed with the abdomen. In our study there are different types of antibiotics were prescribed; they were prescribed with 2 (or) more antibiotics; 4.16% adverse drug reaction, 14.58% prescribing error, and 7.29% drug overdose were identified in the duration of a 6 months period.

In our collected cases, they have prescribed the same prophylactic therapy for surgical procedures and also some pre- eruptive Surgery results as similar to Moser et al has conducted a study on antibiotic therapy as personalized medicine-general consideration.¹⁴ In our collected cases, some of the antibiotics prescribed due to a lack of knowledge and awareness of antibiotic guidelines are reported by Machowska et al.¹⁵ Similar to the study i.e., an aim to optimize the use of antibiotics is need inappropriate use (or) is, use of antibiotics will increase the patient stay in hospital result show to similar Campion et al.¹⁶ Similar to the study it has been re-reported that t the practice of polypharmacy d injudicious usage of antibiotics in hospital settings arise ported by Abhijit et al.¹⁷ It was similar to conducting a study (or) review about the use of antibiotics in Europe and presented major factors. Most of the cases which are collected are due to a bacterial infection they are prescribed with different antibiotics following the guidelines of the antibiotic prescribing which are conducted by Al-Shimemeri et al.¹⁸ A similar study conducted on the origin and evolution of antibiotics resistively provides strict control on antibiotic use by humans, no dispense of drugs without a doctor’s prescription to enhance optimization concluded by Davies et al.¹⁹ As the study is contraindicated antibiotics in endocarditis are not done according to the guideline leads to the antibiotic resistance reported by Roduit et al.²⁰ As similarly concluded that most bacteria med wards ward is due to gram-positive cocci. As the antibiotics are prescribed without guidelines the patients are going to experience local effects which are reported by Erdelijc.²¹ As the study conducted on various strategies proposed to facilitate and improve appropriate antibiotic use has been reported by Maraha et al.²² As in the study on antibiotic use in the intensive care unit. In collected cases of lower respiratory infection, they have prescribed a different type of antibiotics without guidelines, and overprescribing of antibiotics is published by Manal and Sayed.²² This is similar to the study conducted on antibiotics misuse (or) lower maternal education. As antibiotic overprescribing will lead to antibiotic resistance the physician should follow guidelines reported by Salem.²³ A similar review conducted on antibiotics and the mechanism of resistance to the antibiotic may cause community-acquired and nosocomial infection the appropriate indications, appropriate dosage, and proper guidance should be implemented as reported by Cesurs.²⁴ A similar study reported and concluded that due to increased use of antibiotics causes resistance which is concluded by Odonkors et al.²⁵ A similar study on antibiotic misuse in hospitals, and outpatient, checking whether the drug is truly indicated in a particular scenario and whether the correct choice of dosage and route of administration prescribed is appropriate has been reported by Ashrat et al.²⁶ In a similar study on the risk associated with antibiotic overuse and reducing the problem, an increased mortality rate has been suggested by Clor et al.²⁷ As the contraindicated to the study due to shortage of doctors, unlicensed medical providers in India the patient themselves participating in the decision to treat an illness with antibiotics has been concluded by Barker et al.²⁸ A similar study conducted on the appropriateness of antibiotic usage was appropriate in 50% of patients and inappropriate in 50% of patients due to incorrect choices they result in different drug-related problems and adverse drug reaction has been reported by Madhu et al.²⁹ A similar study conducted that associated the adverse event with antibiotic use and the usage of antibiotics play a critical role when used appropriately and misuse may lead to mortality has been reported by Tomma et al.³⁰ Similar to a study conducted on evidence-based practice in the use of antibiotics of non-evidence-based prescription of antibiotics and overuse of antibiotics. Is similar to a previous study conducted by Pranita.³¹ Has concluded that antibiotics may play a critical role when used approximately 30% of the antibiotics of inpatients were unnecessary. As a previous study reported by Jindal.³¹ Has concluded that there are different policies and guidelines for the appropriate use of antibiotics. A study in contrast with the result conducted by the Ventola et al.³² Has concluded that the misuse (or) overuse of antibiotics leads to the antibiotic resistance crisis. Our study was also contributed by Mitchell et al.³³ To understand the role of antibiotic usage and knowledge and hence the value of public education about antibiotic usage intension. The study was conducted by the Sakeena et al.³⁴ Has reported that the role of the pharmacist in the area of critically ill patients with infections and diseases in the intensive care unit and education regarding infection-control practices is also important. Limitations of study are when patient is absconded or die. Antibiotic usage guidelines can be prepared for department.

CONCLUSION

Our study concluded that for the management of common infections are need to minimize the overuse and misuse of antimicrobial agents in tertiary care hospitals. Rational prescribing of antibiotics avoids polypharmacy and prevents antibiotic resistance. This study highlights the need to minimize the average number of drugs per prescription, the average percentage of antibiotics, and to minimize the percentage of infection. Therefore, a strict protocol for prescribers is required to promote rational use of antibiotics which not only prevent antibiotic resistance but also reduce treatment expenditure. The worldwide increase in antimicrobial resistance is of great concern and it is the responsibility of the prescriber to develop good prescribing habits and prescribe by WHO prescribing indicators generic prescribing should be encouraged, brand prescribing should be restricted, and an average number of drugs per prescription should be kept minimum to prevent polypharmacy.

ACKNOWLEDGEMENTS

The author would like to thanks to doctors, nurses, and other medical and paramedical staff of Gandhi hospital, who have always extended their supporting hand for the smooth conduct of this study throughout the period.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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