Prescription of antimicrobial drugs to hospitalized children

Measuring antibiotic prescribing in hospitalised children in resource-poor countries: a systematic review

Antibiotic resistance represents a significant threat to global health. Widespread exposure to antibiotics drives the development of antibiotic resistance. Little is known about the exposure to antibiotics of hospitalised children, particularly in resource-poor countries where the burden of infectious disease is highest. The review sought to identify original research quantifying antibiotic use in hospitalised children in resource countries. The methods used were: A systematic search of the MEDLINE, CINAHL, EMBASE, LILACS and African Index Medicus databases. Eighteen papers were identified and the methodology varied considerably. Only seven used a recognised defined daily dose (DDD) methodology. The studies reveal a high exposure of hospitalised children to antibiotics. With the exception of data from China, the studies were limited by their design. Limited evidence of the variation in drug, dose and total exposure to antibiotic use in hospitalised children in resource-poor countries exists. An international network of surveillance of both antimicrobial prescribing and resistance using a simple standardised methodology in this context remains an important goal. A simplified paediatric version of the adult DDD methodology is required to allow international comparison between populations.

Drug use practices at pediatric hospitals of Khartoum State, Sudan

BACKGROUND

Irrational drug utilization is a major concern in developing countries. The World Health Organization (WHO) has developed first-level informative indicators in assessing drug use practices and encouraging improvement in the quality of patient care.

OBJECTIVE

To assess the current drug use practices in 4 pediatric teaching hospitals in Khartoum State, and to compare the results with studies conducted in Sudan and other developing countries.

METHODS

A descriptive, quantitative, and cross-sectional study using the WHO drug use indicators methodology was conducted in the outpatient settings of 4 pediatric hospitals. The study sample was selected using systematic random sampling. In each hospital, prescribing was assessed through a collection of 150 prescriptions, determination of consultation time and dispensing time for 150 patients, and by interview of 150 patients for the evaluation of dispensing practices and parents' knowledge.

RESULTS

The mean number of drugs prescribed per prescription was 2.0 (95% CI 1.9 to 2.1); 49.3% (95% CI 46.3 to 52.4) were prescribed by generic name, 81.3% (95% CI 77.9 to 84.3) of prescriptions involved an antibiotic, and 3.5% (95% CI 2.2 to 5.4) of prescriptions were in injection form. The mean consultation and dispensing times were 4.7 minutes (95% CI 4.4 to 5.1) and 28.2 seconds (95% CI 26.5 to 29.9), respectively. The percentage of drugs actually dispensed was 80.1% (95% CI 77.9 to 82.2), 55.7% (95% CI 52.0 to 59.4) of drugs were adequately labeled, and 83.5% (95% CI 80.2 to 86.3) of parents knew the correct dosage of all drugs dispensed for their children. The percentage of availability of key drugs was 81.3% (95% CI 77.1 to 84.9). The essential medicines list was not available at the 4 hospitals.

CONCLUSIONS

Our findings reveal problem areas in prescribing and dispensing practices in pediatric hospitals. Further in-depth quantitative research to answer the shortcomings of this study and cost-effective multifaceted interventions to improve current drug use practices are highly needed to secure the quality of medical care in pediatric hospitals.

Impact of an antibiotic policy on antibiotic use in a paediatric department. Individual based follow-up shows that antibiotics were chosen according to diagnoses and bacterial findings

Guidelines and clinical Cupertino for rational antibiotic use were implemented in a Norwegian paediatric department in 1994. From 1994 to 1998 the use of antibiotics and expenditures was reduced by 50%. There was an 80% decrease in the use of cloxacillin, a 74% decrease of aminoglycosides and a 59% decrease of cephalosporins. The use of penicillin V and G increased by 14% and ampicillins by 8%. Eight point prevalence studies showed that on average 23% (range 21-38%) of the patients were treated with antibiotics. Penicillins were used in 44% of courses, aminoglycosides in 35% of courses and cephalosporins in 9% of courses. Treatment was mostly adjusted to bacteriological findings. Compliance with guidelines was >90%. Guidelines for rational antibiotic policy and multidisciplinary co-operation lead to reduction in the use and expenses of antibiotics in a paediatric department.

Antibiotic utilisation for hospitalised paediatric patients

Antibiotics are among the most commonly prescribed drugs in paediatrics. Because of an overall rise in health care costs, lack of uniformity in drug prescribing and the emergence of antibiotic resistance, monitoring and control of antibiotic use is of growing concern and strict antibiotic policies are warranted. Before such policies can be implemented, detailed knowledge of antibiotic prescribing patterns is important. In this combined retrospective and prospective study the utilisation of antibiotics in a paediatric university hospital over three consecutive years has been analysed. Over an 8-week period (1 November-22 December) in 1994, 1995 and 1996 patient charts were reviewed with regard to antibiotic prescription (generic class, dose, duration and indication). A total of 1120 patients were admitted during the study periods. Antibiotics were prescribed at least once for 36% of hospitalised children, although only 12.3% of the patients receiving antibiotics had a proven bacterial infection. During a single hospitalisation 13, 4.7, 2.6, and 2.7% of all children received 2, 3, 4 or more than four antibiotics, respectively. Infants less than 2 years received antibiotics more frequently than older children (25 and 11% respectively, P=0.0256). More children admitted to the intensive care unit received antibiotics compared with patients admitted on medium care units (49.7 and 29.3% respectively, P < 0.0001). They received more often several different antibiotic courses (2.6 courses per patient versus 1.9 courses per patient, P < 0.0001). These children were also given more often intravenous rather than oral antibiotics (P < 0.0001) Significant differences could be found between the generic classes of antibiotics prescribed to children admitted to the intensive care unit and the medium care. However high variability in dose and duration of antibiotic therapy for the same clinical indication was shown. A high percentage of all hospitalised children receive antibiotics. In most cases antibiotics are started on an empirical basis, without proof of a bacterial infection, either before the start of therapy or afterwards. The fact that children admitted to intensive care units and patients of younger age groups are at special risk of receiving multiple courses of antibiotics, together with the knowledge that antibiotic resistance develops in this setting, suggest that strategies to control antibiotic use should focus on these patient populations.