Antibiotic prescribing in two private sector hospitals; one teaching and one non-teaching: a cross-sectional study in Ujjain, India

Ten-year trends of antibiotic prescribing in surgery departments of two private sector hospitals in Central India: a prospective observational study

BACKGROUND

Inappropriate antibiotic use contributes to the global rise of antibiotic resistance, prominently in low- and middle-income countries, including India. Despite the considerable risk of surgical site infections, there is a lack of antibiotic prescribing guidelines and long-term studies about antibiotic prescribing in surgery departments in India. Therefore, this study aimed to analyse 10 years' antibiotic prescribing trends at surgery departments in two tertiary-care hospitals in Central India.

METHODS

Data was prospectively collected from 2008 to 2017 for surgery inpatients in the teaching (TH-15,016) and the non-teaching hospital (NTH-14,499). Antibiotics were classified based on the World Health Organization (WHO) Access Watch Reserve system and analysed against the diagnoses and adherence to the National List of Essential Medicines India (NLEMI) and the WHO Model List of Essential Medicines (WHOMLEM). Total antibiotic use was calculated by DDD/1000 patient days. Time trends of antibiotic prescribing were analysed by polynomial and linear regressions.

RESULTS

The most common indications for surgery were inguinal hernia (TH-12%) and calculus of the kidney and ureter (NTH-13%). The most prescribed antibiotics were fluoroquinolones (TH-20%) and 3rd generation cephalosporins (NTH-41%), and as antibiotic prophylaxis, norfloxacin (TH-19%) and ceftriaxone (NTH-24%). Access antibiotics were mostly prescribed (57%) in the TH and Watch antibiotics (66%) in the NTH. Culture and susceptibility tests were seldom done (TH-2%; NTH-1%). Adherence to the NLEMI (TH-80%; NTH-69%) was higher than adherence to the WHOMLEM (TH-77%; NTH-66%). Mean DDD/1000 patient days was two times higher in the NTH than in the TH (185 vs 90). Overall antibiotic prescribing significantly increased in the TH (β1 =13.7) until 2012, and in the NTH (β2 =0.96) until 2014, and after that decreased (TH, β2= -0.01; NTH, β3= -0.0005). The proportion of Watch antibiotic use significantly increased in both hospitals (TH, β=0.16; NTH, β=0.96).

CONCLUSION

Total antibiotic use decreased in the last three (NTH) and five years (TH), whereas consumption of Watch antibiotics increased over 10 years in both hospitals. The choice of perioperative antibiotic prophylaxis was often inappropriate and antibiotic prescribing was mostly empirical. The results of this study confirmed the need for antibiotic prescribing guidelines and implementation of antimicrobial stewardship programs.

Technology, Training, and Task Shifting at the World's Largest Mass Gathering in 2025: An Opportunity for Antibiotic Stewardship in India

The role of antibiotic overuse in intensifying selection pressures and contributing to the emergence of antimicrobial resistance is well established. The Kumbh Mela, a religious festival that occurs in 4 Indian cities of spiritual significance, is the world's largest mass gathering, attracting over 80 million pilgrims in 2013. Digital syndromic surveillance from the 2013 and 2015 Melas demonstrated a consistent pattern of antibiotic overuse, with an antibiotic prescribing rate of up to 31% for all patient encounters. As preparations for the 2025 Kumbh Mela begin, task shifting, point-of-care diagnostic and digital tools, robust clinician training, and community awareness can promote the restrained and evidence-based use of antibiotics, minimizing the potential for the emergence of antimicrobial resistance at the world's largest mass gathering.

Antibiotic resistant bacteria: A bibliometric review of literature

Antibiotic-resistant bacteria (ARB) are a serious threat to the health of people and the ecological environment. With this problem becoming more and more serious, more countries made research on the ARB, and the research number has been sharply increased particularly over the past decade. Therefore, it is quite necessary to globally retrace relevant researches on the ARB published from 2010 to 2020. This will help researchers to understand the current research situation, research trends and research hotspots in this field. This paper uses bibliometrics to examine publications in the field of ARB from 2010 to 2020 that were retrieved from the Web of Science (WOS). Our study performed a statistical analysis of the countries, institutions, journals, authors, research areas, author keywords, Essential Science Indicators (ESI) highly cited papers, and ESI hotspots papers to provide an overview of the ARB field as well as research trends, research hotspots, and future research directions in the field. The results showed that the number of related studies is increasing year by year; the USA is most published in the field of ARB; China is the most active in this field in the recent years; the Chinese Acad Sci published the most articles; Sci. Total Environ. published the greatest number of articles; CM Manaia has the most contributions; Environmental Sciences and Ecology is the most popular research area; and "antibiotic resistance," "antibiotics," and "antibiotic resistance genes" were the most frequently occurring author keywords. A citation analysis showed that aquatic environment-related antibiotic resistance is a key research area in this field, while antimicrobial nanomaterial-related research is a recent popular topic.

Antibiotic Use, Incidence and Risk Factors for Orthopedic Surgical Site Infections in a Teaching Hospital in Madhya Pradesh, India

Orthopedic surgeries contribute to the overall surgical site infection (SSI) events worldwide. In India, SSI rates vary considerably (1.6−38%); however, there is a lack of a national SSI surveillance system. This study aims to identify the SSI incidence, risk factors, antibiotic prescription and susceptibility patterns among operated orthopedic patients in a teaching hospital in India. Data for 1205 patients were collected from 2013 to 2016. SSIs were identified based on the European Centre for Disease Prevention and Control guidelines. The American Society for Anesthesiologists classification system was used to predict patients’ operative risk. Univariable and multivariable backward stepwise logistic regressions were performed. Overall, 7.6% of patients developed SSIs over three years. The most common SSIs causative microorganism was Staphylococcus aureus (7%), whose strains were resistant to penicillin (100%), erythromycin (80%), cotrimoxazole (80%), amikacin (60%) and cefoxitin (60%). Amikacin was the most prescribed antibiotic (36%). Male sex (OR 2.64; 95%CI 1.32−5.30), previous hospitalization (OR 2.15; 95%CI 1.25−3.69), antibiotic prescription during hospitalization before perioperative antibiotic prophylaxis (OR 4.19; 95%CI 2.51−7.00) and postoperative length of stay > 15 days (OR 3.30; 95%CI 1.83−5.95) were identified as significant risk factors. Additionally, preoperative shower significantly increased the SSI risk (OR 4.73; 95%CI 2.72−8.22), which is unconfirmed in the literature so far.

Differences and their contexts between teaching and nonteaching hospitals in Iran with other countries: A concurrent mixed-methods study

BACKGROUND

In terms of missions, hospitals are divided into teaching and nonteaching. In addition, differences in health-care systems in countries will lead to differences in hospitals' operation. Iran, as a specific health-care system, is different from other countries. Hence, the present study investigated differences between teaching and nonteaching hospitals and their differences in Iran and the world.

MATERIALS AND METHODS

A concurrent mixed-methods study was conducted in two stages. The first stage was a narrative review of studies (2000-2020). Using narrative inquiry and reflective analysis, the content was analyzed and the categories were extracted. The second stage was a qualitative study conducted using semi-structured interviews with forty Iranian hospital managers and policymakers through a purposive sampling in 2020. Content analysis was made using deductive approach, and MAXQDA 12 was used for data analysis.

RESULTS

According to the first stage, categories were extracted as follows: service quality, type of cases, patient satisfaction, efficiency, performance indicators, patient safety, personnel, use of drugs, access to services, technologies, justice in the type of services received, using guidelines, processes, and number of services. In the second stage, 8 main categories, 17 categories, and 45 subcategories were extracted. The extracted main categories were as follows: mission and target, management and behavioral organizations, supply chain and chain of results, human resources, costs and budget, policy demands, clients' satisfaction and patients' right, and integration of medical education.

CONCLUSION

Unlike other countries, in Iran, the combination of missions and the complete dependence of teaching hospitals on the government has caused differences. Reducing the treatment mission of teaching hospitals; differences in the budget and development of its indicators; lower tariffs for teaching hospitals; developing a cost-income management model and supply chain; preventing uncertainty other than medical students except medicine; considering the clients' right to choose hospital; and organizing research missions in hospitals were the solutions for decrease differences.

Trends, relationships and case attribution of antibiotic resistance between children and environmental sources in rural India

Bacterial antibiotic resistance is an important global health threat and the interfaces of antibiotic resistance between humans, animals and the environment are complex. We aimed to determine the associations and overtime trends of antibiotic resistance between humans, animals and water sources from the same area and time and estimate attribution of the other sources to cases of human antibiotic resistance. A total of 125 children (aged 1-3 years old) had stool samples analysed for antibiotic-resistant bacteria at seven time points over two years, with simultaneous collection of samples of animal stools and water sources in a rural Indian community. Newey-West regression models were used to calculate temporal associations, the source with the most statistically significant relationships was household drinking water. This is supported by use of SourceR attribution modelling, that estimated the mean attribution of cases of antibiotic resistance in the children from animals, household drinking water and wastewater, at each time point and location, to be 12.6% (95% CI 4.4-20.9%), 12.1% (CI 3.4-20.7%) and 10.3% (CI 3.2-17.3%) respectively. This underlines the importance of the 'one health' concept and requires further research. Also, most of the significant trends over time were negative, suggesting a possible generalised improvement locally.

A prospective study to evaluate antimicrobial prescribing pattern among admitted patients in hilly Himalayan region of northern India

Background and Aim

Global scenario of antimicrobial (AM) utilization depicts 20-50% inappropriateness. Majority of the hospital admissions are due to unwanted effects because of non-judicial usage of these drugs. The present study focuses on utilization pattern of antimicrobials (AMs) in a tertiary care hospital in northern India.

Materials and Methods

A prospective observational study was conducted over a period of one year in seven departments of a tertiary care hospital in hilly Himalayan region. Aim of the study was to analyze the AM utilization pattern using World Health Organization (WHO) indicators and instruments.

Results

A total 700 prescriptions were analyzed in the present study. Injectable antibiotics (71%) followed by oral (29%) were most commonly prescribed. Beta lactams (79%) were the most frequently used antibiotic class. Most commonly prescribed AM was Ceftriaxone (30%). Majority of the time AMs were given empirically (44.8%), where most common indication was respiratory infections (42%). Culture and sensitivity tests were done for guiding curative therapy in 34.71% cases. The average duration of patient hospital stay was 8.81 days in the study population. The mean duration of prescribed antimicrobial treatment was 5.12 days. On an average 1.93 AMs were prescribed per patient. AMs were prescribed by International nonproprietary name (INN) in 62.19% of the admissions. The most common AM related adverse drug reaction was gastritis (96%) and skin rash (4%) with Amoxicillin + clavulanic acid being the most common causative agent. Total antimicrobial consumption was 148.24 DDD/100 bed days with Medicine department showing the highest consumption (36.25/100 bed days).

Conclusion

The present study is the first and largest antimicrobial utilization study in the hilly Himalayan region of northern India. Our study found an urgent need for improvement of prescribing patterns, patient care indicators and strict adherence to standard guidelines.

Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: A 10-year observational study

Background

Frequent antibiotic prescribing in departments with high infection risk like orthopedics prominently contributes to the global increase of antibiotic resistance. However, few studies present antibiotic prescribing patterns and trends among orthopedic inpatients.

Aim

To compare and present the patterns and trends of antibiotic prescription over 10 years for orthopedic inpatients in a teaching (TH) and a non-teaching hospital (NTH) in Central India.

Methods

Data from orthopedic inpatients (TH-6446; NTH-4397) were collected using a prospective cross-sectional study design. Patterns were compared based on the indications and corresponding antibiotic treatments, mean Defined Daily Doses (DDD)/1000 patient-days, adherence to the National List of Essential Medicines India (NLEMI) and the World Health Organization Model List of Essential Medicines (WHOMLEM). Antibiotic prescriptions were analyzed separately for the operated and the non-operated inpatients. Linear regression was used to analyze the time trends of antibiotic prescribing; in total through DDD/1000 patient-days and by antibiotic groups.

Results

Third generation cephalosporins were the most prescribed antibiotic class (TH-39%; NTH-65%) and fractures were the most common indications (TH-48%; NTH-48%). Majority of the operated inpatients (TH-99%; NTH-97%) were prescribed pre-operative prophylactic antibiotics. The non-operated inpatients were also prescribed antibiotics (TH-40%; NTH-75%), although few of them had infectious diagnoses (TH-8%; NTH-14%). Adherence to the NLEMI was lower (TH-31%; NTH-34%) than adherence to the WHOMLEM (TH-65%; NTH-62%) in both hospitals. Mean DDD/1000 patient-days was 16 times higher in the TH (2658) compared to the NTH (162). Total antibiotic prescribing increased over 10 years (TH-β = 3.23; NTH-β = 1.02).

Conclusion

Substantial number of inpatients were prescribed antibiotics without clear infectious indications. Adherence to the NLEMI and the WHOMLEM was low in both hospitals. Antibiotic use increased in both hospitals over 10 years and was higher in the TH than in the NTH. The need for developing and implementing local antibiotic prescribing guidelines is emphasized.

Change in Antibiotic Use in Secondary and Tertiary Hospitals Nationwide After a National Antimicrobial Stewardship Campaign Was Launched in China, 2011-2016: An Observational Study

BACKGROUND

An antimicrobial stewardship campaign was launched in 2011 by the Ministry of Health. This study aimed to assess the achievements and trends in the clinical use of antibiotics in secondary and tertiary hospitals following this campaign in China.

METHODS

This observational study analyzed nationwide hospital antibiotic procurement and consumption data and antibiotic-resistance surveillance data based on claims filed in 2010-2016.

RESULTS

After a 6-year national campaign, the proportion of outpatients and surgical patients who received antibiotic treatment decreased from 19.5% to 8.5% and from 97.9% to 38.3%, respectively. The intensity of antibiotic use among inpatients decreased from 85.3±29.8 defined daily dosage (DDD) per 100 patient days to 48.5±8.0 DDD per 100 patient days. Moreover, the antibiotic procurement expenditure among hospitals declined from 22.3% of total drug procurement costs in 2010 to 12.1% in 2016, although total drug procurement costs doubled during that time. The incidence of methicillin-resistant Staphylococcus aureus isolates also dropped (from 54.4% in 2010 to 34.4% in 2016), as did the proportion of carbapenem-resistant Pseudomonas aeruginosa isolates (from 30.8% to 22.3%).

CONCLUSIONS

The 6-year campaign successfully reduced antibiotic consumption and irrational drug use in Chinese hospitals which was associated with declines in the prevalence of common antibiotic-resistant bacteria.

Drug utilization, rationality, and cost analysis of antimicrobial medicines in a tertiary care teaching hospital of Northern India: A prospective, observational study

BACKGROUND:

The burden of bacterial infections is huge and grossly under-represented in the current health-care system. Inappropriate use of antimicrobial medicines (AMMs) poses a potential hazard to patients by causing antibiotic resistance. This study was conducted to assess the: (i) AMM consumption and use patterns in patients attending the outpatients and inpatients of Medicine and Surgery departments of the hospital. (ii) Appropriateness of the AMM in the treatment prescribed, and (iii) cost incurred on their use in admitted patients.

MATERIALS AND METHODS:

An observational, prospective study was conducted among inpatients and outpatients of the Medicine and Surgery departments of a tertiary care hospital of northern India. Analysis of 2128 prescriptions and 200 inpatient records was performed using a predesigned format. The use of AMMs was reviewed using anatomical therapeutic chemical classification and defined daily doses (DDDs). To evaluate the expenditure incurred on AMMs, ABC analysis was performed.

RESULTS:

AMMs were prescribed to 37.9% outpatients and 73% of admitted patients. The percentage encounters with AMMs was 40.6% (medicine) and 25.6% (surgery) outpatients. The total DDDs/100 patient days of AMMs in medicine and surgery were 3369 and 2247. Bacteriological evidence of infection and AMM sensitivity was present in only 8.5% of cases. Over 90% of AMMs were prescribed from the hospital essential medicines list. Most of the AMMs were administered parenterally (64.9%). Multiple AMMs were prescribed more to inpatients (84.2% vs. 4.2% outpatients). Overall, expenditure on AMM was 33% of the total cost of treatment on medicine. ABC analysis showed that 74% of the expenditure was due to newer, expensive AMM, which constituted only 9% of the AMM used. The AMM therapy was found to be appropriate in 88% of cases as per Kunin's criteria for rationality.

CONCLUSION:

AMMs are being commonly prescribed without confirmation of AMM sensitivity in the hospital. A large proportion of expenditure is being incurred on expensive AMM used in a few number of patients. There is a need for developing a policy for rational use of AMM in the health facility.

Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients' demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.

The Existence of High Bacterial Resistance to Some Reserved Antibiotics in Tertiary Hospitals in Tanzania: A Call to Revisit Their Use

Background

Antibiotic resistance poses burden to the community and health-care services. Efforts are being made at local, national and global level to combat the rise of antibiotic resistance including antibiotic stewardship. Surveillance to antibiotic resistance is of importance to aid in planning and implementing infection prevention and control measures. The study was conducted to assess the resistance pattern to cefepime, clindamycin and meropenem, which are reserved antibiotics for use at tertiary hospitals in Tanzania.

Methods

A hospital-based antibiotic resistance surveillance was conducted between July and November 2019 at Muhimbili National Hospital and Bugando Medical Center, Tanzania. All organisms isolated were identified based on colony morphology, Gram staining and relevant biochemical tests. Antibiotic susceptibility testing was performed on Muller-Hinton agar using Kirby-Bauer disc diffusion method. Antibiotic susceptibility was performed according to the protocol by National Committee for Clinical Laboratory Standards.

Results

A total of 201 clinical samples were tested in this study. Urine (39.8%, n=80) and blood (35.3%, n=71) accounted for most of the collected samples followed by pus (16.9%, n=34). The bacterial resistance to clindamycin, cefepime and meropenem was 68.9%, 73.2% and 8.5%, respectively. About 68.4% Staphylococcus aureus isolates were resistant to clindamycin whereby 56.3%, 75.6%, 93.8% and 100% of the tested Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa and Enterobacter cloacae, respectively, were cefepime resistant. About 8.5% of isolated Klebsiella spp were resistant and 6.4% had intermediate susceptibility to meropenem. Also, Pseudomonas aeruginosa was resistant by 31.2% and 25% had intermediate susceptibility to meropenem.

Conclusion

The bacterial resistance to clindamycin and cefepime is high and low in meropenem. Henceforth, culture and susceptibility results should be used to guide the use of these antibiotics. Antibiotics with low resistance rate should be introduced to the reserve category and continuous antibiotic surveillance is warranted.

Antibiotic prescribing among patients with severe infectious diseases in two private sector hospitals in Central India - a time series analysis over 10 years

BACKGROUND

Antibiotic resistance is an emerging problem caused due to antibiotic use. In countries with high rates of infectious diseases, antibiotic resistance is a frequent cause of mortality. The aim was to analyse antibiotic prescribing practices between 2008 and 2017 in a teaching (TH) and a non-teaching (NTH) hospital, as typical hospitals of low- and middle-income countries, and to compare antibiotic prescribing for severe infectious indications for which empiric antibiotic treatment is recommended.

METHODS

Data from adult patients registered at two Indian private-sector hospitals with one of the following indications: epiglottitis, pneumonia, peritonitis, pyelonephritis, cellulitis, erysipelas, septic arthritis, endocarditis, meningitis or sepsis; were included and analysed. Antibiotic prescription data was analyzed using the World Health Organization's (WHO) Anatomical Therapeutic Chemical classification system and the Defined Daily Doses. Chi-square and linear regression were used to compare the data between groups. Time series analyses were conducted using linear regression. P-values < 0.05 were considered significant.

RESULTS

In total, 3766 patients were included, 2504 inpatients in the NTH and 1262 in the TH, of which 92 and 89% patients, respectively, were prescribed antibiotics. Sixty-one percent of total prescriptions in the TH and 40% in the NTH comprised the access category of antibiotics (i.e. the first-choice of treatment according to the WHO). The WHO's second-choice of treatment, the watch category, comprised 29 and 40% of total prescriptions in the TH and NTH, respectively. Prescribing of fixed-dose combinations (FDCs) of antibiotics was significantly higher in the NTH (18%) than in the TH (8%, P < 0.05). Prescribing of watch antibiotics and FDCs increased significantly in both hospitals between 2008 and 2017 among patients with pneumonia, cellulitis and peritonitis (P < 0.05).

CONCLUSIONS

Prescribing of watch antibiotics and FDCs of antibiotics increased over time at both hospitals, indicating under prescribing of access antibiotics and more prescribing of second-choice antibiotics. The results can be used to highlight the areas of improvement in similar settings. Implementing diagnostic routines and local prescribing guidelines could improve the prescribing practices.

Assessment of the Management of Diarrhoea Among Children Under Five in Addis Ababa, Ethiopia

Purpose

Irrational antibiotic use is a worldwide problem. One of the main reasons for excessive use of antibiotics is the failure to follow the clinical guidelines. Inappropriate use of antibiotics for infectious diarrhea is associated with the risk of increasing the development of antimicrobial resistance and the cost of health care. We therefore pursued to assess the appropriateness of the management of diarrhea in children in Addis Ababa.

Materials and Methods

A retrospective cross-sectional study was conducted in the health centers of Addis Ababa, Ethiopia, between September 2014 and February 2015. Demographic characteristics, signs of dehydration, stool characteristics, drug types and other relevant information have been collected. Data analysis was performed using version 20 of the SPSS. Logistic regression was used to examine the association between dependent and independent variables. Indicators for the appropriateness of diarrhoea management have been established on the basis of the Standard Treatment Guideline and the guidelines of the World Health Organization.

Results

A total of 803 medical records of children have been checked. Of this, 54.4% had received inappropriate management. At least one antimicrobial was prescribed to 73.2% of the children who visited the health centres. Oral rehydration solution (ORS) and zinc were prescribed only in 66.7% and 47.5%, respectively. Appropriate management among children diagnosed with dysentery was found to be 6.38 times higher adjusted odds ratios (AOR=6.38 (3.11, 13.63)) than children with watery diarrhea. Although antibiotics are prescribed inappropriately for most children, it is appropriate when the diarrhea is bloody. Appropriate management of diarrhoea among infants aged 2-11 months was 54% less compared to children aged 12-59 months (AOR=0.46 (0.24, 0.90)).

Conclusion

The magnitude of inadequate antibiotic prescription while managing diarrhoea in our setting was high. On the contrary, a low prescribing rate of ORS and zinc was observed. Our result highlights the need for urgent action to prevent the development of antibiotic-resistant microorganisms. Health-care professionals should have clear information on the risks of inadequate diarrhoea treatment in children under five.

Antibiotic Consumption Trends in China: Evidence From Six-Year Surveillance Sales Records in Shandong Province

Background

The overuse of antibiotics is a serious public health problem in China, causing a high rate of antimicrobial resistance. This study identified the trends of antibiotic consumption in China to provide evidence for further intervention.

Method

The six-year surveillance data on antibiotic sales from 2012 to 2017, which served as a proxy for consumption, were collected from 39 public health care facilities in Shandong province, including three tertiary hospitals, six secondary hospitals, and 30 primary health centers. Based on the Anatomical Therapeutic Chemical (ATC)/DDD methodology, antibiotic consumption was formulated in defined daily doses (DDD) per 1,000 inhabitants per day (DID).

Results

The total antibiotic consumption among all health care settings increased from 16.07 DID in 2012 to a peak of 17.44 DID in 2015 and then decreased to 11.35 DID in 2017 with a 34.90% reduction. J01C (beta-lactam antimicrobials, penicillin), the most frequently used antibiotic class, accounted for 36.32% of the total DID. Consumption of carbapenems increased from 0.029 DID in 2012 to 0.08 DID in 2017. Parenteral antibiotics accounted for nearly 40% of the total consumption. Compared with the 2012 figures, the 2017 consumption showed a small increase in hospital sector that was compensated by the decrease in community care.

Conclusion

A substantial reduction in total antibiotic consumption was observed in China from 2012 to 2017. However, the extensive consumption of broad-spectrum antimicrobials, high proportion of parenteral antibiotic use, and increased use of last-resort antibiotics attracted public health concerns.

Diagnose-Specific Antibiotic Prescribing Patterns at Otorhinolaryngology Inpatient Departments of Two Private Sector Healthcare Facilities in Central India: A Five-Year Observational Study

Antibiotics are over-prescribed in low-and-middle-income countries, where the infection rate is high. The global paucity of standard treatment guidelines and reliable diagnose-specific prescription data from high-infection risk departments such as the otorhinolaryngology (ENT: ears, nose and throat) is a barrier to rationalize antibiotic use and combat antibiotic resistance. The study was conducted to present diagnose-specific antibiotic prescribing patterns of five years at ENT inpatient departments of two private-sector Indian hospitals. Data of all consecutive inpatients (n = 3527) were collected but analyzed for the inpatients aged >15 years (n = 2909) using the World Health Organization's methodologies. Patient records were divided into four diagnoses groups: surgical, non-surgical, chronic suppurative otitis media (CSOM), and others. Of 2909 inpatients, 51% had surgical diagnoses. An average of 83% of patients in the clean surgery group and more than 75% in the viral and non-infectious groups were prescribed antibiotics. CSOM was the most common diagnosis (31%), where 90% of inpatients were prescribed antibiotics. Overall, third-generation cephalosporins and fluoroquinolones were most commonly prescribed. This study highlights the inappropriate prescribing of antibiotics to patients of clean surgeries, viral infections, and non-infectious groups. The single-prophylactic dose of antibiotic for clean-contaminated surgeries was replaced by the prolonged empirical prescribing. The use of microbiology investigations was insignificant.

Perioperative antibiotic prescribing in surgery departments of two private sector hospitals in Madhya Pradesh, India

Background

Single-dose perioperative antibiotic prophylaxis (PAP) is recommended for clean, non-infectious surgeries to prevent surgical site infections. However, the common practice of unindicated use and prolonged use of antibiotics contributes to the development and spread of antibiotic resistance (ABR). The present study explores the perioperative use of antibiotics among inpatients with surgical indications at surgery departments of a teaching (TH) and a non-teaching (NTH) tertiary care hospital in Madhya Pradesh, India.

Methods

Data was collected manually for all inpatients for 3 years (April 2008–August 2011). Patients with non-infectious surgical indications were selected for detailed analysis at the diagnosis group level.

Results

Out of 12,434 enrolled inpatients (TH 6171 and NTH 6263), the majority (> 85%) received antibiotics. None of the inpatients received the recommended single-dose PAP. The average duration of antibiotic treatment was significantly longer at the TH compared to the NTH (9.5 vs 4.4 days, p < 0.001). Based on the study aim, 5984 patients were classified in four diagnosis groups: upper or lower urinary tract surgery indications (UUTSI and LUTSI), and routine or emergency abdominal surgery indications (RASI and EASI). In both hospitals, quinolones were the most prescribed antibiotics for UUTSI (TH 70%, NTH 37%) and LUTSI (TH 70%, NTH 61%) antibiotic. In the TH, aminoglycosides (TH 32%) were commonly prescribed for RASI and imidazole derivatives (75%) for EASI. In the NTH, cephalosporins (39%) and imidazole derivatives (56%) were the most prescribed in RASI and EASI, respectively.

Conclusions and recommendations

High prescribing of antibiotics in all four selected diagnoses groups was observed at both hospitals. In spite of the recommended single-dose PAP, antibiotics were mainly prescribed for longer durations. The unrecommended use of antibiotics is a risk factor for the development of AMR. Improving the quality of antibiotic prescribing by a stewardship program focusing on the development and implementation of local prescribing guidelines is needed.

Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India

Informal healthcare providers (IHCPs) are predominant healthcare providers in rural India, who prescribe without formal training. Antibiotic prescription by IHCPs could provide crucial information for controlling antibiotic resistance. The aim of this study is to determine the practices and seasonal changes in antibiotic prescribing for common illnesses by IHCPs. A repeated cross-sectional study was conducted over 18 months, covering different seasons in the rural demographic surveillance site, at Ujjain, India. Prescriptions given to outpatients by 12 IHCPs were collected. In total, 15,322 prescriptions for 323 different complaint combinations were analyzed, of which 11,336 (74%) included antibiotics. The results showed that 14,620 (95%) of antibiotics prescribed were broad spectrum and the most commonly prescribed were fluoroquinolones (4771,31%), followed by penicillin with an extended spectrum (4119,27%) and third-generation cephalosporin (3069,20%). Antibiotics were prescribed more frequently in oral and dental problems (1126,88%), fever (3569,87%), and upper respiratory tract infections (3273, 81%); more during the monsoon season (2350,76%); and more frequently to children (3340,81%) than to adults (7996,71%). The study concludes that antibiotics were the more commonly prescribed drugs compared to other medications for common illnesses, most of which are broad-spectrum antibiotics, a situation that warrants further investigations followed by immediate and coordinated efforts to reduce unnecessary antibiotic prescriptions by IHCPs.

MRSA: the leading pathogen of orthopedic infection in a tertiary care hospital, South India

Background

The rate of infection is high and heterogeneous in developing countries. This study aimed to find the rate and pattern of infection in a tertiary care hospital with a goal to improve the infection control practices.

Methods

The study was conducted in the orthopedic units of a multispecialty teaching hospital. Medical records of major orthopedic surgery adult patients without immunosuppression state were included. The bacterial culture report of the wound swabs were noted over a period of one year. The bacterial culture testing was performed by a recommended method.

Results

Among 2,249 orthopedic surgery patients, 83.7% were males, 49.1% had open wounds during admission and 32.2% patients were infected. Majority (64.2%) of the injuries were in the lower limb with 19.4% patients having undergone multiple surgeries during hospitalization. A total of 946 pathogens were grown from 725 specimens. Staphylococcus aureus was the maximum (48.4%) followed by Pseudomonas aeruginosa (26.3%) and E coli (16.7%). Among them, 57.3% were Methicillin Resistant Staphylococcus aureus (MRSA) and was the leading pathogen causing infection among orthopedic patients.

Conclusion

MRSA infection was high. Consequent to this, an interventional program entitled ‘Extended Infection Control Measures' was designed to reduce the burden of infection.

Antibiotic Prescribing Practices and Errors among Hospitalized Pediatric Patients Suffering from Acute Respiratory Tract Infections: A Multicenter, Cross-Sectional Study in Pakistan

Background and objective: The noncompliance of treatment guidelines by healthcare professionals, along with physiological variations, makes the pediatric population more prone to antibiotic prescribing errors. The present study aims to evaluate the prescribing practices and errors of the most frequently prescribed antibiotics among pediatric patients suffering from acute respiratory tract infections who had different lengths of stay (LOS) in public hospitals. Methods: A retrospective, cross-sectional study was conducted in five tertiary-care public hospitals of Lahore, Pakistan, between 1 January 2017 and 30 June 2017. The study population consisted of pediatric inpatients aged 0 to 9 years. Results: Among the 11,892 pediatric inpatients, 82.8% were suffering from lower acute respiratory tract infections and had long LOS (53.1%) in hospital. Penicillins (52.4%), cephalosporins (16.8%), and macrolides (8.9%) were the most frequently prescribed antibiotics. Overall, 40.8% of the cases had antibiotic prescribing errors related to wrong dose (19.9%), wrong frequency (18.9%), and duplicate therapy (18.1%). Most of these errors were found in the records of patients who had long LOS in hospital (53.1%). Logistic regression analysis revealed that the odds of prescribing errors were lower in female patients (OR = 0.6, 95% CI = 0.1⁻0.9, p-value = 0.012). Patients who were prescribed with ≥3 antibiotics per prescription (OR = 1.724, 95% CI = 1.1⁻2.1, p-value = 0.020), had long LOS (OR = 12.5, 95% CI = 10.1⁻17.6, p-value < 0.001), and were suffering from upper respiratory tract infections (URTI) (OR = 2.8, 95% CI = 1.7⁻3.9, p-value < 0.001) were more likely to experience prescribing errors. Conclusion: Antibiotics were commonly prescribed to patients who had long LOS. Prescribing errors (wrong dose, wrong frequency, and duplicate therapy) were commonly found in cases of lower respiratory tract infections (LRTIs), especially among those who had prolonged stay in hospital.

Antimicrobial use by WHO methodology at primary health care centers: a cross sectional study in Punjab, Pakistan

BACKGROUND

To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan.

METHODS

A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS.

RESULTS

Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1-19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1-39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1-1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9-89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3-6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6-4.3). The PHCCs prescribed a median of 5 (range = 3-9) types of AMs, including 10 (range = 5-15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs.

CONCLUSIONS

In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Burden and Risk Factors of Antimicrobial Use in Children Less Than 5 Years of Age with Diarrheal Illness in Rural Bangladesh

Antimicrobial overuse contributes to antimicrobial resistance. Empiric use of antimicrobials for diarrheal illness is warranted only in a minority of cases, because of its self-limiting nature and multifactorial etiology. This study aims to describe the factors contributing to antimicrobial overuse for diarrheal disease among children less than 5 years of age in rural Bangladesh. A total of 3,570 children less than 5 years of age presenting with diarrhea in a tertiary level hospital were enrolled in the study. The rate of antimicrobial use at home was 1,395 (39%), compared with 2,084 (89%) during a hospital visit. In a multivariate analysis, factors associated with antimicrobial use at home included residence located more than 5 miles from a hospital; use of zinc and oral rehydration salts at home; vomiting; greater than 10 stools per 24 hours; diarrheal duration greater than 3 days; and rotavirus diarrhea (P < 0.05 for all). Characteristics of children more likely to be given antimicrobials in a health-care setting included greater than 10 stools per 24 hours; duration of diarrhea greater than 3 days; use of antimicrobials before hospital presentation; fever (≥ 37.8°C); rectal straining; and Shigella infection (P < 0.05 for all). The most commonly used drugs in rotavirus diarrhea were azithromycin and erythromycin, both before hospital presentation and during hospital admission. Our study underscores the importance of diligent vigilance on the rationale use of antimicrobials both at home and in health-care facilities with a special concern for children less than 5 years of age living in rural Bangladesh.

Determinants of Antibiotic Consumption - Development of a Model using Partial Least Squares Regression based on Data from India

Antibiotic resistance, a consequence of antibiotic use, is a threat to health, with severe consequences for resource constrained settings. If determinants for human antibiotic use in India, a lower middle income country, with one of the highest antibiotic consumption in the world could be understood, interventions could be developed, having implications for similar settings. Year wise data for India, for potential determinants and antibiotic consumption, was sourced from publicly available databases for the years 2000–2010. Data was analyzed using Partial Least Squares regression and correlation between determinants and antibiotic consumption was evaluated, formulating ‘Predictors’ and ‘Prediction models’. The ‘prediction model’ with the statistically most significant predictors (root mean square errors of prediction for train set-377.0 and test set-297.0) formulated from a combination of Health infrastructure + Surface transport infrastructure (HISTI), predicted antibiotic consumption within 95% confidence interval and estimated an antibiotic consumption of 11.6 standard units/person (14.37 billion standard units totally; standard units = number of doses sold in the country; a dose being a pill, capsule, or ampoule) for India for 2014. The HISTI model may become useful in predicting antibiotic consumption for countries/regions having circumstances and data similar to India, but without resources to measure actual data of antibiotic consumption.

Up to 89% of neonates received antibiotics in cross-sectional Indian study including those with no infections and unclear diagnoses

AIM

There is a global lack of data on antibiotic prescribing for neonates. This study compared antibiotic prescribing practices in the neonatal intensive care units (NICUs) of two private-sector, tertiary-level hospitals.

METHODS

A three-year, cross-sectional study was conducted from 2008 to 2011 in the NICUs of a teaching and nonteaching hospital in the Ujjain district of India. The data were analysed using methods recommended by the World Health Organization.

RESULTS

Of the 1789 inpatients, 89% (1399/1572) in the nonteaching hospital and 71% (154/217) in the teaching hospital were prescribed antibiotics and 123 patients died. All the antibiotics were prescribed empirically and cephalosporins and aminoglycosides were the most commonly prescribed subclasses. Fixed-dose combinations of cephalosporins were commonly prescribed in the nonteaching hospital. Neonatal sepsis was the most common diagnosis, in more than 30% of patients, and more than 93% neonates with sepsis were prescribed antibiotics. In addition, 40% of neonates in the nonteaching hospital were admitted for observation and were frequently prescribed antibiotics.

CONCLUSION

These two Indian NICUs prescribed antibiotics for noninfectious or unclear diagnoses in addition to prescribing combinations of broad-spectrum antibiotics. Such practices increase the global risk of treatment failure, neonatal mortality rates and antibiotic resistance.

Antibiotic prescribing knowledge, attitudes, and practice among physicians in teaching hospitals in South India

BACKGROUND

Antibiotic overuse is a major public health challenge worldwide. Data from India related to physician antibiotic prescribing patterns are limited.

AIMS

We assessed antibiotic prescribing knowledge, attitudes, and practices among physicians in Mangalore, South India.

MATERIALS AND METHODS

Using a cross-sectional descriptive study design, physicians at academic tertiary hospitals completed an anonymous on-site survey. The survey items incorporated Likert scales, and data were analyzed using SPSS version 15.0.

RESULTS

Of the 350 physicians approached using a convenient sampling method, 230 (66%) consented and interviewed. The physician's knowledge of resistance patterns of common bacteria was related to receiving periodic updates on resistance patterns of bacteria (P = 0.019) and participation in courses on antibiotics (P = 0.026). Individuals with more number of years of experience (mean of 11 years) were less likely to justify antibiotic use for uncomplicated bronchitis (P = 0.015) and acute gastroenteritis (P = 0.001). Most respondents (n = 204, 89%) believed that physicians overprescribed antibiotics in routine clinical practice. Forty-five percent (n = 104) stated that their hospitals did not have an infection control policy in place.

CONCLUSIONS

This study provides some understanding of physician's antibiotic prescribing patterns from teaching hospitals in India. Judicious antimicrobial use through educational and antimicrobial stewardship programs remains critical to control the spread of antibiotic resistance.

Antibiotic prescriptions for inpatients having non-bacterial diagnosis at medicine departments of two private sector hospitals in Madhya Pradesh, India: a cross-sectional study

OBJECTIVES

To present and compare antibiotic prescribing for inpatients among the most common non-bacterial diagnoses groups at medicine departments of a teaching (TH) and a non-teaching hospital (NTH) in central India.

SETTING

An observational cross-sectional study was conducted at two tertiary care settings in Ujjain district, Madhya Pradesh, India.

DATA AND PARTICIPANTS

The data were collected manually, using a customised form. Complete records of all inpatients, who were >15 years of age and had stayed for at least one night in either of the hospitals during 2008-2011, were analysed.

OUTCOME MEASURES

Inpatients were grouped according to the presence or absence of a bacterial infectious diagnosis, viral/malaria fever or cardiovascular disease. Classes of antibiotics prescribed to these groups and adherence to the available prescribing guidelines were compared between the hospitals using the notes from the patient files and the diagnoses.

RESULTS

Of 20 303 inpatients included in the study, 66% were prescribed antibiotics. Trade name prescribing and use of broad-spectrum antibiotics were more frequent at the NTH than at the TH (p<0.001). At the TH a significantly higher proportion of patients having fever without registered bacterial infection were prescribed antibiotics (82%) compared with the NTH (71%, p<0.001). Patients admitted for cardiovascular diagnosis without registered bacterial infections received antibiotic prescriptions at both hospitals (NTH 47% and TH 37%) but this was significantly higher at the NTH (p<0.001). None of the diagnoses were confirmed by microbiology reports.

CONCLUSIONS

Prescribing antibiotics, including broad-spectrum antibiotics, to inpatients without bacterial infections-that is, viral fever, malaria and cardiovascular disease, was common at both hospitals, which increases the risk for development of bacterial resistance, a global public health threat. In view of the overprescribing of antibiotics, the main recommendations are development and implementation of local prescription guidelines, encouragement to use laboratory facilities and prescription analysis, with antibiotic stewardship programmes.

Evaluation of Outpatient Antibiotic Use in Beijing General Hospitals in 2015

BACKGROUND

Medical misuse of antibiotics is associated with the acquisition and spread of antibiotic resistance, resulting in a lack of effective drugs and increased health-care cost. Nevertheless, inappropriate antibiotic use in China remains common and the situation requires urgent improvement. Here, we analyzed the prescriptions of antibiotics and evaluated the rationality of antibiotic use among outpatients in Beijing general hospitals during 2015.

METHODS

We collected basic medical insurance claim data from January 1, 2015 to December 31, 2015 in 507 general hospitals of Beijing. A descriptive analysis of outpatient antibiotic prescribing was performed. The Anatomical Therapeutic Chemical Classification/defined daily doses system was used to evaluate the rationality of antibiotic use.

RESULTS

Over the study, an estimated 721,930, 613,520, and 822,480 antibiotics were dispensed in primary, secondary, and tertiary general hospitals corresponding to 5.09%, 5.06%, and 2.53% of all prescriptions, respectively. Antibiotic combinations represented 2.95%, 7.74%, and 10.18% of the total antibiotic prescriptions, respectively. Expenditure for the top twenty antibiotics in primary, secondary, and tertiary general hospitals was RMB 42.92, 65.89, and 83.26 million Yuan, respectively. Cephalosporins were the most frequently prescribed class of antibiotic in clinical practice. The antibiotics used inappropriately included azithromycin enteric-coated capsules, compound cefaclor tablets and nifuratel nysfungin vaginal soft capsules in primary hospitals, amoxicillin and clavulanate potassium dispersible tablets (7:1) and cefonicid sodium for injection in secondary hospitals, cefminox sodium for injection and amoxicillin sodium and sulbactam sodium for injection in tertiary hospitals.

CONCLUSIONS

Antibiotic use in Beijing general hospitals is generally low; however, inappropriate antibiotic use still exists. Inappropriately used antibiotics should be subject to rigorous control and management, and public policy initiatives are required to promote the judicious use of antibiotics.

"If it's a broad spectrum, it can shoot better": inappropriate antibiotic prescribing in Cambodia

Background

Cambodia is affected by antibiotic resistance but interventions to reduce the level of resistance require knowledge of the phenomena that lead to inappropriate prescribing. We interviewed physicians working in public hospitals to explore the drivers of inappropriate antibiotic prescribing.

Methods

Hospitals participating in a knowledge, attitudes and practices survey prior to this study were purposively selected and physicians were randomly recruited to participate in focus group discussions. Nvivo version 10 was used to inductively code the qualitative transcripts and manage thematic data analysis.

Results

Inappropriate antibiotic prescribing was a common practice and driven by seven factors: prescribing habit, limited diagnostic capacity, lack of microbiology evidence, non-evidence-based clinical guidelines, perceived patient demand, poor hygiene and infection control, and perceived bacterial resistance to narrow spectrum antibiotics.

“Every day, doctors are not performing appropriately. We have made lots of mistakes with our antibiotic prescribing.”

When a patient’s clinical condition was not responsive to empiric treatment, physicians changed to a broader spectrum antibiotic and microbiology services were sought only after failure of a treatment with a broad-spectrum antibiotic. This habitual empirical prescribing was a common practice regardless of microbiology service accessibility. Poor hygiene and infection control practices were commonly described as reasons for ‘preventive’ prescribing with full course of antibiotics while perception of bacterial resistance to narrow-spectrum antibiotics due to unrestricted access in the community resulted in unnecessary prescribing of broad spectrum antibiotics in private practices.

Conclusions

The practice of prescribing antibiotics by Cambodian physicians is inappropriate and based on prescribing habit rather than microbiology evidence. Improvement in prescribing practice is unlikely to occur unless an education program for physicians focuses on the diagnostic capacity and usefulness of microbiology services. In parallel, hygiene and infection control in hospital must be improved, evidence-based antibiotic prescribing guidelines must be developed, and access to antibiotics in community must be restricted.

Retrospective survey of the efficacy of mandatory implementation of the Essential Medicine Policy in the primary healthcare setting in China: failure to promote the rational use of antibiotics in clinics

The objective of this study was to understand the impact of implementation of the Essential Medicine Policy (EMP) on the rational use of antibiotics in primary medical institutions in China. A retrospective survey was conducted in 39 primary medical institutions to compare the efficacy of EMP in rational antibiotic use. All institutions completed the survey 1 year before and 1 year after implementation of the EMP. In particular, antibiotic use and its rationality were closely examined. The institutions mainly dealt with common diseases, especially non-infectious chronic diseases. Antibiotic usage was very inappropriate both before and after EMP implementation. Before and after EMP implementation, respectively, the median outpatient cost was US$6.34 and US$5.05, 52.50% (2005/3819) and 53.41% (1865/3492) of the outpatient prescriptions contained antibiotics, and 76.23% (1132/1485) and 78.83% (1106/1403) of inpatients were administered antibiotics. In addition, 98.38% (425/432) and 97.52% (512/525) of surgical inpatients were administered antibiotics, respectively, and 80.76% (638/790) and 75.19% (503/669) of patients with a cold were prescribed antibiotics, respectively. The most commonly used antibiotics were broad-spectrum and injectable agents, including cephalosporins, fluoroquinolones and penicillins. This profile showed little change following implementation of the EMP. In conclusion, inappropriate antibiotic use is a serious problem in primary medical institutions in China. Whilst enforcing the EMP reduced the cost of medical services, it had little effect on promoting the rational use of antibiotics.

Self-medication practice and factors influencing it among medical and paramedical students in India: A two-period comparative cross-sectional study

Aim:

Self-medication is widely practiced with varying dimensions in India. This practice has many implications, especially among medical and paramedical students having some knowledge and good exposure to drugs. We conducted a two-period observational study to evaluate the change in knowledge and practice of self-medication, over 5 years of time period, among medical and paramedical students from different parts of India.

Materials and Methods:

A structured questionnaire was administered to medical (MBBS), dental (BDS), and paramedical students, who come to attend pan India annual cultural, literary, and sports event at New Delhi. The study was conducted in two phases (2007 and 2012) in different respondents of same categories (medical and paramedical) of students. Three-hundred and thirty students from 39 colleges in 2007 and 356 students from 38 colleges in 2012 participated in the study.

Results:

The prevalence of self-medication remained high in both 2007 and 2012 (74.6% and 69.4%), although no significant difference was observed between the two phases (P = 0.14%). Oral antibacterial agents, oral anti-inflammatory agents, and antipyretics were the most common group of drugs used in both phases of study. A significant increase was observed in number of students who took complete course of oral antibiotics (28.3-38.3%, P = 0.01).

Conclusion:

The prevalence of self-medication among undergraduate students remains unaltered over the span of 5 years. Nevertheless, there was a better sensitization toward appropriate antibiotic usage and the practice of responsible self-medication needs to be promoted among future healthcare providers.

Extensive antibiotic prescription rate among hospitalized patients in Uganda: but with frequent missed-dose days

Objectives

To describe the patterns of systemic antibiotic use and missed-dose days and detail the prescription, dispensing and administration of frequently used hospital-initiated antibiotics among Ugandan inpatients.

Methods

This was a prospective cohort of consented adult inpatients admitted on the medical and gynaecological wards of the 1790 bed Mulago National Referral Hospital.

Results

Overall, 79% (603/762; 95% CI: 76%–82%) of inpatients received at least one antibiotic during hospitalization while 39% (300/762; 95% CI: 36%–43%) had used at least one antibiotic in the 4 weeks pre-admission; 1985 antibiotic DDDs, half administered parenterally, were consumed in 3741 inpatient-days. Two-fifths of inpatients who received at least one of the five frequently used hospital-initiated antibiotics (ceftriaxone, metronidazole, ciprofloxacin, amoxicillin and azithromycin) missed at least one antibiotic dose-day (44%, 243/558). The per-day risk of missed antibiotic administration was greatest on day 1: ceftriaxone (36%, 143/398), metronidazole (27%, 67/245), ciprofloxacin (34%, 39/114) and all inpatients who missed at least one dose-day of prescribed amoxicillin and azithromycin. Most patients received fewer doses than were prescribed: ceftriaxone (74%, 273/371), ciprofloxacin (90%, 94/105) and metronidazole (97%, 222/230). Of prescribed doses, only 62% of ceftriaxone doses (1178/1895), 35% of ciprofloxacin doses (396/1130) and 27% of metronidazole doses (1043/3862) were administered. Seven percent (13/188) of patients on intravenous metronidazole and 6% (5/87) on intravenous ciprofloxacin switched to oral route.

Conclusions

High rates of antibiotic use both pre-admission and during hospitalization were observed, with low parenteral/oral switch of hospital-initiated antibiotics. Underadministration of prescribed antibiotics was common, especially on the day of prescription, risking loss of efficacy and antibiotic resistance.

Surgical Antibiotic Prophylaxis: A Descriptive Study among Thoracic Surgeons

BACKGROUND

Surgical site infections (SSIs) are common complications following surgeries and increase mortality, morbidity and healthcare costs. The use of antimicrobial prophylaxis is an effective measure to prevent development of SSIs. This study aimed to evaluate the current use of prophylactic antibiotics in thoracic surgeries in Iran.

MATERIALS AND METHODS

A descriptive study was conducted among thoracic surgeons in order to assess their knowledge, attitude and practice (KAP) about surgical antibiotic prophylaxis (SAP). A four-section multiple-choice questionnaire was designed and hand-delivered to registered thoracic surgeons. The surgeons' answers were considered correct when they were in accordance to the American Society of Health-System Pharmacist (ASHP) guidelines.

RESULTS

Seventy thoracic surgeons were requested to participate in this study and their response rate was 71.4%. Thirty-five (70%) surgeons had good knowledge about appropriate SAP. However, less than half of the respondents were aware of appropriate SAP in case of Ig E-mediated reaction to penicillin and risk of Gram-negative infections. The surgeon's attitude score about the need for local and national guidelines for SAP was 78% and 90%, respectively. Accordance of the physician's practice with ASHP guidelines regarding timing of the first dosage of SAP was acceptable while correct administration of an intraoperative dose was 40% in agreement with the guideline.

CONCLUSION

Although thoracic surgeons had a good attitude towards antibiotic prophylaxis guidelines, their knowledge and practice should be improved for proper administration of SAP.

Protocol: a 'One health' two year follow-up, mixed methods study on antibiotic resistance, focusing children under 5 and their environment in rural India

Background

Antibiotic resistance has been referred to as ‘the greatest malice of the 21^st century’ and a global action plan was adopted by the World Health Assembly in 2015. There is a wealth of independent studies regarding antibiotics and resistant bacteria in humans, animals and their environment, however, integrated studies are lacking, particularly ones that simultaneously also take into consideration the health related behaviour of participants and healthcare providers. Such, ‘One health’ studies are difficult to implement, because of the complex teamwork that they entail. This paper describes the protocol of a study that investigates ‘One health’ issues regarding antibiotic use and antibiotic resistance in children and their environment in Indian villages.

Methods/Design

Both quantitative and qualitative studies are planned for a cohort of children, from 6 villages, and their surrounding environment. Repeated or continues data collection is planned over 2 years for quantitative studies. Qualitative studies will be conducted once. Studies include parents’ health seeking behavior for their children (1–3 years of age at the onset), prescribing pattern of formal and informal healthcare providers, analysis of phenotypic antibiotic resistance of Escherichia coli from samples of stool from children and village animals, household drinking water, village source water and waste water, and investigation on molecular mechanisms governing resistance. Analysis of interrelationship of these with each other will also be done as basis for future interventions. Ethics approval has been obtained from the Institutional Ethics Committee R.D. Gardi Medical College, Ujjain, India (No: 2013/07/17-311).

Discussion

The findings of the study presented in this protocol will add to our knowledge about the multi-factorial nature of causes governing antibiotic use and antibiotic resistance from a ‘One health’ perspective. Our study will be the first of its kind addressing antibiotic use and resistance issues related to children in a One-health approach, particularly for rural India.

Antibiotic Prescribing among Pediatric Inpatients with Potential Infections in Two Private Sector Hospitals in Central India

Introduction

Infectious diseases are one of the major causes of child mortality in India. Pediatric patients are commonly prescribed antibiotics for non-bacterial infections. Monitoring of local antibiotic prescribing with respect to the diagnosis is necessary to improve the prescribing practices. The aim of the study was to describe antibiotic prescribing for potential infections among patients admitted in pediatric departments in two private sector hospitals; one teaching (TH) and one non-teaching (NTH) in Central India.

Methods

Data from all patients admitted at the pediatric departments of both study hospitals was collected manually, for 3 years (2008–2011) using a customized form. Data from inpatients aged 0–18 years, diagnosed with; acute gastroenteritis (AGE), respiratory tract infections, enteric fever, viral fever or unspecified fever were focused for analysis. Antibiotic prescriptions were analysed using the WHO Anatomical Therapeutic Chemical (ATC) classification system and defined daily doses (DDDs). Adherence to the Indian Academy of Pediatrics list of essential medicines (IAP-LEM) was investigated. P-values <0.05 were considered significant.

Results

Oftotal6, 825 inpatients admitted at two pediatric departments, 510 patients from the TH and 2,479from the NTH were selected based on the assigned potential infectious diagnoses. Of these, 224 patients (44%) at the TH and 2,088 (84%) at the NTH were prescribed at least one antibiotic during hospital stay (odds ratio-0.69, 95%confidence interval-0.52 to 0.93; p<0.001). Patients with AGE, viral- and enteric fever were frequently prescribed antibiotics at both hospitals, yet higher proportion were prescribed antibiotics at the NTH compared to the TH. Broad-spectrum antibiotics were the most commonly prescribed antibiotic class in both hospitals, namely third generation cephalosporins, J01DD (69%) at the TH, and new fixed dose combinations of antibiotics J01R (FDCs, 42%) at the NTH. At the TH, 37% of the antibiotic prescriptions were comprised of antibiotics listed in the IAP-LEM, compared to 24% at the NTH (p<0.05).

Conclusions

Broad-spectrum antibiotics were prescribed frequently in both hospitals also for the un-indicated conditions such as viral fever and enteric fever. At the NTH, new FDCs were more frequently prescribed and adherence to the IAP-LEM was substantially lower at the NTH compared to the TH. The results demonstrate need to develop diagnosis-specific prescribing guidelines to facilitate rational use of antibiotics and implement antibiotic stewardship program.

A systematic review of prescription pattern monitoring studies and their effectiveness in promoting rational use of medicines

Prescription pattern monitoring studies (PPMS) are a tool for assessing the prescribing, dispensing and distribution of medicines. The main aim of PPMS is to facilitate rational use of medicines (RUM). There is paucity of published data analysing the effectiveness of PPMS. The present review has been done to assess the effectiveness of prescription pattern monitoring studies in promoting RUM. Data search was conducted on internet. A multitude of PPMS done on different classes of drugs were collected and analyzed. PPMS using WHO prescribing indicators were also included. The present article reviews various prescription pattern monitoring studies of drugs conducted all over country and abroad. It was observed in the majority of such studies that physicians do not adhere to the guidelines made by regulatory agencies leading to irrational use of medicines. This in turn leads to increased incidence of treatment failure, antimicrobial resistance and economic burden on the patient and the community as a whole. The treatment of diseases by the use of essential drugs, prescribed by their generic names, has been emphasized by the WHO and the National Health Policy of India. We conclude that the prescription monitoring studies provide a bridge between areas like rational use of drugs, pharmacovigilance, evidence based medicine, pharmacoeconomics, pharmacogenetics and ecopharmacovigilance. In India, this is the need of the hour to utilise the data generated by so many prescription pattern monitoring studies done in every state and on every drug, so that the main aim of promoting rational use of drugs is fulfilled.

Antibiotic prescribing in medical intensive care units--a comparison between two private sector hospitals in Central India

BACKGROUND

Inappropriate antibiotic prescribing, common in India, contributes to increased risk for development of bacterial resistance. Patients admitted to intensive care units (ICUs) are often prescribed antibiotics. Paucity of local data on antibiotic prescribing hinders development of appropriate interventions. The aim of the study was to describe and compare antibiotic prescribing in medical ICUs (MICUs) at two private sector hospitals, one teaching (TH) and one non-teaching (NTH) in Ujjain, India.

METHODS

The study was conducted prospectively for 3 years at MICUs of both hospitals. Patients were compared for demographic variables and diagnosis, prescribed antibiotics, generic name prescribing, and route of administration. Adherence to the World Health Organization list of essential medicines (WHOLEM) and the National List of Essential Medicines of India (NLEMI) was analyzed.

RESULTS

In total, 4843 of 6141 patients admitted to the MICUs stayed at least one night. More than 70% were prescribed antibiotics. Generic name prescribing was more common at the TH than at the NTH. Prescriptions at the TH had higher compliance to WHOLEM and NLEMI compared with that at the NTH (p < 0.001). Of the 1371 patients at the TH, 189 (14%) and of 3472 at the NTH, 400 (12%) patients were diagnosed with infections. More than 75% of patients at both hospitals had no infection-associated diagnoses.

CONCLUSIONS

Antibiotic prescribing was common at both hospitals. The antibiotic prescriptions at the TH had higher compliance to WHOLEM and NLEMI. However, there is a need to develop appropriate interventions to improve antibiotic prescribing at both hospitals.

Tackling antibiotic resistance in India

Infectious diseases are major causes of mortality in India. This is aggravated by the increasing prevalence of antimicrobial resistance (AMR) both in the community and in hospitals. Due to the emergence of resistance to all effective antibiotics in nosocomial pathogens, the situation calls for emergency measures to tackle AMR in India. India has huge challenges in tackling AMR, ranging from lack of surveillance mechanisms for monitoring AMR and use; effective hospital control policies; sanitation and non-human use of antimicrobial. The Ministry of Health and Family Welfare of Govt. of India has taken initiatives to tackle AMR. Extensive guidelines have been drafted and a model worksheet has been developed as a roadmap to tackle AMR.

High prescription of antimicrobials in a rural district hospital in India

Background

The World Health Organization (WHO) recommends surveillance of antibiotic use as part of the strategy to fight against antimicrobial resistance. However, there is little information about the antibiotic consumption in developing countries, especially in rural areas.

Objective

The objective of this study was to describe the antimicrobial consumption in a rural hospital in India

Methods

The study was performed in a district hospital situated in Anantapur, Andhra Pradesh. In accordance with WHO recommendations, we used the defined daily dose (DDD) methodology to measure the antibiotic use during one year (from 1st August 2011 to 1st August 2012). The antibiotic use was measured using DDDs/100 admissions and DDDs/100 patient-days for inpatients, and DDDs/100 visits for outpatients.

Results

During the study period, there were 15,735 admissions and 250,611 outpatient visits. Antibiotics were prescribed for 86% of inpatients and 12.5% of outpatients. Outpatient prescriptions accounted for 2/3 of the overall antibiotic consumption. For inpatients, the total antibiotic use was 222 DDDs/ 100 patient-days, 693 DDDs/ 100 admissions and the mean number of antibiotics prescribed was 1.8. For outpatients, the total antibiotic use was 86 DDDs/ 100 outpatient visits and the mean number of antibiotics prescribed was 1.2. The most common antibiotics prescribed were aminopenicillins and 3rd generation cephalosporins for inpatients, and tetracyclines and quinolones for outpatients. In a sample of patients with diarrhoea or upper respiratory tract infections (URTI), the proportion of patients who received antibiotics was 84% (95% confidence interval [CI], 67-93) and 52% (95% CI, 43-62), respectively.

Conclusion

In this rural setting, the use of antimicrobials was extremely high, even in conditions with a predominantly viral aetiology such as diarrhoea or URTI.

Analysis of quinolone-resistance in commensal and diarrheagenic Escherichia coli isolates from infants in Lima, Peru

BACKGROUND

Antibiotic resistance is an increasing problem, particularly in countries where antibiotic use is frequently not controlled. The aim of this study was to analyse the prevalence of the molecular mechanisms of quinolone-resistance in E. coli isolated from faeces of healthy Peruvian children or those presenting diarrhoea.

METHODS

The presence of target mutations, transferable quinolone-resistance mechanisms and the role of Phe-Arg-β-Naphtylamyde inhibitible efflux pumps were studied in 96 Escherichia coli (46 diarrheogenic and 50 non-diarrheogenic) isolates exhibiting resistance or diminished susceptibility to quinolones.

RESULTS

The most resistant phenotype, Nal(R) and Cip(R), was most frequently present in isolates of healthy children. The distribution of quinolone resistance mechanisms between diarrheogenic (DEC) and commensal (non DEC) isolates was equitable, although the aac(6')Ib-cr gene was mainly detected in DEC isolates: 17 (34%) vs non DEC isolates nine (20%). QnrB was present in five (10%) DEC vs three (6%) non DEC isolates.

CONCLUSIONS

Point mutations in gyrA and parC genes play a relevant role in quinolone resistance acquisition and highlight the role of efflux pumps also. This study provides knowledge about the molecular mechanisms involved in quinolone resistance in isolates in a non exposed population under high community antibiotic pressure.

Antibiotic prescribing in women during and after delivery in a non-teaching, tertiary care hospital in Ujjain, India: a prospective cross-sectional study

Objectives

Antibacterial drugs (hereafter referred to as antibiotics) are crucial to treat infections during delivery and postpartum period to reduce maternal mortality. Institutional deliveries have the potential to save lives of many women but extensive use of antibiotics, add to the development and spread of antibiotic resistance. The aim of this study was to present antibiotic prescribing among inpatients during and after delivery in a non-teaching, tertiary care hospital in the city of Ujjain, Madhya Pradesh, India.

Methods

A prospective cross-sectional study was conducted including women having had either a vaginal delivery or a cesarean section in the hospital. Trained nursing staff collected the data on daily bases, using a specific form attached to each patient file. Statistical analysis, including bivariate and multivariable logistic regression was conducted.

Results

Of the total 1077 women, 566 (53%) had a vaginal delivery and 511 (47%) had a cesarean section. Eighty-seven percent of the women that had a vaginal delivery and 98% of the women having a cesarean section were prescribed antibiotics. The mean number of days on antibiotics in hospital for the women with a vaginal delivery was 3.1 (±1.7) and for the women with cesarean section was 6.0 (±2.5). Twenty-eight percent of both the women with vaginal deliveries and the women with cesarean sections were prescribed antibiotics at discharge. The most commonly prescribed antibiotic group in the hospital for both the women that had a vaginal delivery and the women that had a cesarean section were third-generation cephalosporins (J01DD). The total number of defined daily doses (DDD) per100 bed days for women that had a vaginal delivery was 101, and 127 for women that had a cesarean section.

Conclusions

The high percentage of women having had a vaginal delivery that received antibiotics and the deviation from recommendation for cesarean section in the hospital is a cause of concern. Improved maternal health and rational use of antibiotics are intertwined. Specific policy and guidelines on how to prescribe antibiotics during delivery at health care facilities are needed. Additionally, monitoring system of antibiotic prescribing and resistance needs to be developed and implemented.

The knowledge, attitude and the perception of prescribers on the rational use of antibiotics and the need for an antibiotic policy-a cross sectional survey in a tertiary care hospital

BACKGROUND

Antibiotics are prescribed frequently and there is always an overuse with a risk of resistance and increasing costs. Rational drug prescribing is essential for minimizing the health care costs and for reducing the resistance. The implementation of a strict antibiotic policy by all the health care institutes is being made mandatory nowadays. An improving awareness among the prescribers which can be created through educational interventions, can promote the rational use of antibiotics. Hence, we considered it worthwhile to study the knowledge, attitude and the perception of the practitioners towards a rational antibiotic use.

MATERIALS AND METHODS

All the registered practitioners who were working in the hospital setting and were willing to give written informed consents, were enrolled in the study. All the participants who were enrolled in the study during a one month period, had to fill up a predesigned, structured and validated questionnaire which was used to assess the knowledge, attitude and the perception among physicians towards the rational use of antibiotics.

RESULTS

About 65% of the participants who provided complete information in the questionnaire, were included in analysis. Among them, more than 50 % agreed on the existence of an essential drug list, on the knowledge about new antibiotics and on prescribing antibiotics rationally and on the interpretation of the culture and the sensitivity results. A majority strongly agreed that they ensured that their patients completed the course, that they provided counselling and that they took special interest in the proper use of antibiotics. There was a consensus on the overuse, issues of resistance, and on the input from fellow colleagues.

CONCLUSION

The participants in our study had knowledge about the rational use of antibiotics, an attitude to prescribe drugs as per the essential drug list and a perception that antibiotics were being overused and that rational drug prescribing had an important role in the antibiotic resistance.