A Prospective Antibacterial Utilization Study in Pediatric Intensive Care Unit of a Tertiary Referral Center

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.

Evaluation of antibiotic prescribing pattern in pediatrics in a tertiary care hospital

Background:

The irrational use of antibiotics is a global issue and it can lead to morbidity, mortality, and increased health care costs. Hence, proper use of antibiotics is imperative and should be included in the pharmaceutical care plan.

Objective:

The objective of this study was to evaluate the prescribing pattern of antibiotics for children using WHO core prescribing indicators.

Materials and Methods:

A prospective, observational study was carried for 6 months in the pediatric department at a tertiary care hospital, Pune. The WHO prescribing indicators were used to evaluate the prescriptions, and the ideal WHO range was considered as a determining factor for rational prescription.

Results:

A total of 302 patients were included in the study, with a mean patient age of 4.92 ± 4 years. The average number of drugs per encounter was 6.12 (WHO standard is less than 2). The percentage of antibiotics prescribed was 26.3% with an average of 1.63 antibiotics per prescription. Of the 493 antibiotics, 85.59% were injectable which is higher than the WHO standard of 13.4–24.1%. A near-optimal value of 99.59% antibiotics was prescribed from the hospital formulary which is similar to WHO standards, and the antibiotics prescribed with generic names were 25.76%. The most common class of antibiotics prescribed were cephalosporins and penicillins.

Conclusion:

Polypharmacy, high injectable use, and non-adherence to generic prescription were common in our tertiary care center. Continuous audits, training, and new treatment protocols are recommended.

The use of antibiotics in the intensive care unit of a tertiary hospital in Malawi

BACKGROUND

Antibiotic resistance is on the rise. A contributing factor to antibiotic resistance is the misuse of antibiotics in hospitals. The current use of antibiotics in ICUs in Malawi is not well documented and there are no national guidelines for the use of antibiotics in ICUs. The aim of the study was to describe the use of antibiotics in a Malawian ICU.

METHODS

A retrospective review of medical records of all admissions to the main ICU in Queen Elizabeth Central Hospital in Blantyre, Malawi, between January 2017 and April 2019. Data were extracted from the ICU patient register on clinical parameters on admission, diagnoses, demographics and antibiotics both prescribed and given for all patients admitted to the ICU. Usage of antibiotics in the ICU and bacterial culture results from samples taken in the ICU and in the peri-ICU period, (from 5 days before ICU admission to 5 days after ICU discharge), were described.

RESULTS

Six hundred-and-forty patients had data available on prescribed and received medications and were included in the analyses. Of these, 577 (90.2%) were prescribed, and 522 (81.6%) received an antibiotic in ICU. The most commonly used antibiotics were ceftriaxone, given to 470 (73.4%) of the patients and metronidazole to 354 (55.3%). Three-hundred-and-thirty-three (52.0%) of the patients received more than one type of antibiotic concurrently - ceftriaxone and metronidazole was the most common combination, given to 317 patients. Forty five patients (7.0%) were given different antibiotics sequentially. One-hundred-and-thirty-seven patients (21.4%) had a blood culture done in the peri-ICU period, of which 70 (11.0% of the patients) were done in the ICU. Twenty-five (18.3%) of the peri-ICU cultures were positive and eleven different types of bacteria were grown in the cultures, of which 17.2% were sensitive to ceftriaxone.

CONCLUSION

We have found a substantial usage of antibiotics in an ICU in Malawi. Ceftriaxone, the last-line antibiotic in the national treatment guidelines, is commonly used, and bacteria appear to show high levels of resistance to it, although blood culture testing is infrequently used. Structured antibiotic stewardship programs may be useful in all ICUs.

Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center

Aims and objectives

Vancomycin is a drug of choice for various gram-positive bacterial (GPB) infections and is largely prescribed to pediatric intensive care unit (PICU) patients. Despite the different pathophysiology of these patients, limited data are available on pharmacokinetics of vancomycin. There are lack of data for critically ill Indian children; hence, study was conducted to assess the steady-state pharmacokinetics in children admitted to PICU.

Materials and methods

Twelve subjects (seven males, five females) aged 1–12 years were enrolled. Vancomycin (dose of 20 mg/kg per 8 hours) was infused for over 1 hour and steady-state pharmacokinetics was performed on day 3. Vancomycin concentrations were measured by the validated liquid chromatography mass spectrometry method. Pharmacokinetic parameters were calculated using Winnonlin (Version 6.3; Pharsight, St. Louis, MO).

Results

The steady-state mean C_ssmax was 40.94 μg/mL (±15.07), and mean AUC_{0–8 hours} was 124.15 μg/mL (±51.27). The mean t_1/2 was 4.82 hours (±2.71), Vd was 12.48 L (±4.43), and Cl was 2.08 mL/minute (±0.89). The mean AUC_0–24 among 12 subjects was 372.44 μg/mL (±153.82). Among 35 measured trough concentrations, 23 (65.71%) were below, 11 (31.43%) were within, and 1 (2.86%) was above the recommended range.

Conclusion

The pharmacokinetic parameters of vancomycin were comparable with previously reported studies. However, recommended trough levels (10–20 μg/mL) were not achievable with current recommended dosing of 60 mg/kg/day.

How to cite this article

Mali NB, Tullu MS, Wandalkar PP, Deshpande SP, Ingale VC, Deshmukh CT, et al. Steady-state Pharmacokinetics of Vancomycin in Children Admitted to Pediatric Intensive Care Unit of a Tertiary Referral Center. IJCCM 2019;23(11):497–502.