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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 149-152

An Audit of Antibiotic Prescribing Pattern Among Children in Emergency Settings of a Tertiary Medical College and Hospital


1 Department of Microbiology, Maulana Azad Medical College, New Delhi, India
2 Department of Microbiology, ABVIMS & Dr RML Hospital, New Delhi, India
3 Department of Pediatrics, Maulana Azad Medical College, New Delhi, India
4 Lok Nayak Hospital, New Delhi, India

Date of Submission18-Jan-2022
Date of Decision17-Feb-2022
Date of Acceptance29-Apr-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Urvashi Suman
Assistant Professor, Dept. of Microbiology, ABVIMS & Dr RMLH, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_4_22

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  Abstract 


Background: Resistance to antimicrobials is increasing, which leads to a significant increase in mortality, morbidity, and health care costs. In order to promote rational antibiotic uses, standard policies must be set and can be done only after the current antibiotic prescription has been audited. Objective: The aim of the study was to describe the antibiotic prescribing patterns in the pediatric emergency of a tertiary care hospital. Methods: The data were collected from the pediatric emergency over the period of 6 consecutive days from August 6, 2018 to August 11, 2018. The methodology recommended by the World Health Organization (WHO) for the investigation of drug use in a health facility was followed. The data were analyzed for the percentage of antibiotics prescribed by generic name, prescribed from essential medicine list of government, drugs with fixed-dose combination, and percentage of broad- and narrow-spectrum antibiotics used. Result: A total of 600 prescriptions were analyzed in the study. Most of the children were less than 1 year of age (30.8%). Combination of three antibiotics were prescribed in 8.8 % of patients. A 100% of antibiotics were prescribed from the essential drug list. Antimicrobials prescribed by generic name were 52%. Injection ceftriaxone was the commonest antibiotic prescribed (43.3%), followed by amikacin (25.2%). The broad- and narrow-spectrum antibiotics prescribed were 86.6% and 13.4 %, respectively. Conclusion: The antibiotics are used cautiously in the paediatrics emergency department of this institute. Among those who were prescribed antibiotics, all prescriptions were from the essential drug formulary. Our findings provide support for investigating antibiotic utilization in other settings and work toward developing a national rational prescribing strategy.

Keywords: Antibiotic policy, antimicrobial resistance, pediatrics, prescription audit


How to cite this article:
Manchanda V, Suman U, Jhamb U, Shaji R. An Audit of Antibiotic Prescribing Pattern Among Children in Emergency Settings of a Tertiary Medical College and Hospital. MAMC J Med Sci 2022;8:149-52

How to cite this URL:
Manchanda V, Suman U, Jhamb U, Shaji R. An Audit of Antibiotic Prescribing Pattern Among Children in Emergency Settings of a Tertiary Medical College and Hospital. MAMC J Med Sci [serial online] 2022 [cited 2022 Sep 26];8:149-52. Available from: https://www.mamcjms.in/text.asp?2022/8/2/149/354401




  Introduction Top


Antibiotics are the most commonly prescribed drug.[1] Improving the use of antibiotics is an important patient safety and public health issue as well as a national priority.[2] Prescription auditing is an indispensable and effective tool to monitor antimicrobial prescription practices. It can help treating physicians improve their antimicrobial prescription skills and help an organization to adhere to, monitor, and improve compliance with antibiotic policy.[3] Center for Disease Dynamics, Economics & Policy (CDDEP) has recently reported an enormous increase in antibiotic use (163%) over the period of 15 years (2000–2015) in lower and middle-income countries.[4] This consequently led to a higher occurrence of improper use and greater levels of resistance when compared to developed countries. In U.S. acute care hospitals, 20–50% of all antibiotics prescribed are either unnecessary or inappropriate.[5]

Pediatric age group is considered to be one of the most susceptible group to infectious diseases owing to their special environments such as day care and schools, which facilitate the transmission of drug-resistant bacteria.[6] Several studies deal with drug utilization in adults while very few studies provide information on antibiotic use patterns in pediatrics.[7],[8] Evidence from these studies confirms that antibiotics were prescribed to children inappropriately and in great amounts. Emergency observational studies report significant rates of overprescribing for acute bronchitis, with more than 75% of prescriptions being for broad-spectrum antibiotics.[9],[10],[11]

Considering the vital role of prescribing antibiotics in pediatric practice, the present study was conducted to describe the antibiotic prescribing patterns in the pediatric emergency of a tertiary care hospital.


  Methods Top


A prospective study was conducted in a pediatric emergency of a tertiary care hospital by an infection control team. A total of 100 consecutive prescriptions were analyzed on daily basis from August 6, 2018 to August 11, 2018. Data collection was done for the 6 consecutive days to cover all the six units of the pediatrics department. A total of 600 prescriptions were screened in the study. Details were recorded from each prescription, which included the patient’s demographic details, presenting complaints and patient diagnosis, and antimicrobial prescription details (name, dose, and frequency of doses). If all such details were present, prescription was identified as a good prescription. The rationality of antibiotics was identified based on two essential elements: first, antibiotics were prescribed from the essential medicine list of Govt. of National Capital Territory (GNCT) of Delhi and, second, the prescription was as per the working diagnosis based on the draft antibiotic policy of the department.

Descriptive statistics were used for analysis. The data were analyzed for the percentage of antibiotics prescribed by generic name, the percentage of antibiotics prescribed from the essential medicine list of the GNCT of Delhi,[12] percentage of drugs with fixed-dose combination, percentage of patients prescribed more than one antibiotic, and percentage of broad- and narrow-spectrum antibiotics used as per antibiotic class.


  Results Top


A total of 600 patients were screened during the study period. Among 600 patients, 176 patients were admitted to the ward, while 424 patients were discharged from emergency after treatment under observation. Antibiotics were prescribed to 80 (13.4%) patients. The majority of these patients who were prescribed antibiotics continued to be admitted to the hospital for more than 24 hours, indicating these children were sicker than the patients who were discharged after initial treatment and observation [Table 1]. In only two cases of discharge (within 24 hours), patients were prescribed antibiotics. In three patients, antibiotics were prescribed without any symptoms or working diagnosis (two patients with injection ceftriaxone and one child with injection meropenem). Rest of the 75 cases were prescribed antibiotics based on symptoms or working diagnosis. Fever was the most common symptom (33.4%) for which antibiotics were prescribed, followed by gastrointestinal tract disease (29.4%) [Table 2].
Table 1 Details of diagnosis used for antibiotic therapy

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Table 2 Distribution of all diagnosis in admitted patient having prescribed antibiotics in emergency pediatric department (N = 75)

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Among all the prescriptions, the antibiotics were prescribed from the essential drug list of GNCT of Delhi.[12] A total of 66 children (52%) were prescribed antimicrobials by generic name. Injection ceftriaxone was the most common antibiotic prescribed and was prescribed in 55 children (43.3%). No fixed-dose combination was given. A total of 40 patients (50%) among those prescribed antibiotics were prescribed single antibiotic therapy. Combination therapy of two antibiotics and three antibiotics was prescribed in 33 (41.3%) and 7 (8.8%) children respectively. Among those who were prescribed single antibiotic therapy, diarrhea, sepsis, seizure, hypertensive encephalopathy, enteric fever, dog bite, and cellulitis were the common diagnosis. Where more than one antibiotic was prescribed, the diagnosis included liver abscess and respiratory distress.

The most common class of antibiotics prescribed were third-generation cephalosporins (45.7%), followed by aminoglycosides (26%) [Table 3]. Among the antibiotics prescribed, 110 (86.6%) were the broad-spectrum antibiotics and 17 (13.4%) were narrow-spectrum antibiotics. Watch group antibiotics such as vancomycin, amikacin, and meropenem were prescribed in 3.14%, 25.2%, and 5.5%, respectively. Diseases/symptoms in which these were prescribed are given in [Table 4].
Table 3 Distribution of all antibiotics prescribed in emergency pediatric department (N = 127)

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Table 4 Prescriptions with watch group antibiotics and diseases

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  Discussion Top


Baseline data on the prevalence of antibiotic use is the first step in encouraging drug monitoring and quality improvement. In our study, antibiotics are given to 13.4% of patients, which is a good indicator of antibiotic stewardship. According to WHO standards, antibiotic prescriptions should not exceed 30% of patient visit to the prescriber.[13] In pediatric emergency, it is much reduced. This is in contrast with other studies which have revealed higher antibiotic prescription in pediatric settings in developing countries such as Sudan (81.3%)[14] and Nigeria (71.1%)[15]. Similar finding of higher antibiotic prescription have also been reported in another study in India (81.1%).[16] All the antibiotics prescribed were from the essential drug list, which is variable in different studies, that is, 60.4%[15] to 100%.[17] A formulary list can help aid rational prescribing by encouraging the selection of medicines that are cost-effective and appropriate to local drug resistance and disease prevalence patterns. Adherence to an essential drugs list was high in our study, likely because physicians had easy access to updated formularies in the emergency department.

The reason for favoring brand-name drugs may be due to concerns about the quality and safety of generic products. A generic name is recommended to reduce costs to patients. Prescribing drugs by their generic name, prescribing from essential medicine list, and rational prescribing are recommended measures that reduce the cost of drugs in patients and in health care system in government setups.[18] This is also because while a brand name may be written on the prescription, the patient will often receive the drug in generic form at the pharmacy due to frequent shortages of brand-name agents. In this study, 52% of antibiotics were prescribed by generic names. Another study in a similar setting revealed 30% of antibiotic prescriptions by generic names.[19]

Although this study demonstrates a standard rate of antibiotic prescription, in some cases inappropriate antibiotic prescriptions were found. Antibiotics were prescribed for upper respiratory tract infection (URTI) having cough/coryza, which is mostly due to viruses, particularly in infants. In our study, two infants were given antibiotics for URTI out of 19 infants (10.5%). Fever was the most common presenting symptom of patients visiting emergency followed by loose stool. Antibiotics were prescribed for fever without any other symptoms in 13.7% of patients (23 out of 168). Loose stool accounted for 14% of antibiotic prescription in 7 out of 50 children. The rationale of prescriptions in these children could not be clearly identified from the patient’s records.

Among those prescribed antibiotics, broad-spectrum antibiotics use was common with the use of third-generation cephalosporin as the most frequent class of drug. Similar findings are reported in another study.[19] Broad-spectrum antibiotics can kill or inhibit a wide range of microorganisms while narrow-spectrum antibiotic can kill or inhibit only limited species of bacteria.[20] Thus the use of broad-spectrum antibiotics as the first line of treatment should be reduced. According to the report of the 21st WHO Expert Committee on the Selection and Use of Essential Medicines, watch group antibiotics are considered to have higher resistance potential but are recommended for a limited number of indications.[21] Some of the watch group antibiotics such as vancomycin and meropenem are used frequently in pediatric emergency ward. Data also show fairly high use of the two-drug combination, which is mostly ceftriaxone and amikacin.

There are a set of distinct challenges associated with providing systematic education and oversight for antimicrobial stewardship in the emergency setting and that too in a medical college wherein we have a spectrum of prescribers from interns to much experienced doctors. These challenges include high patient load, risk of patients returning to the emergency, and the need for quick decision-making.[22]


  Conclusion Top


In the present study, the antibiotic prescribing pattern of emergency pediatrics is described, which is a part of the strengthening of the institution’s antibiotic stewardship. In comparing our results to established WHO standards of antibiotic prescription, it is found that the pediatric department is using antibiotics rationally in this institution. Adherence to the essential drug formulary is a strength for the department. Our results also suggest that there is a scope of improvement toward rational prescriptions for symptoms such as coryza, cough, fever, vomiting, and loose stools. There are further efforts required for antibiotic prescriptions for infectious conditions, with more frequent use of narrow-spectrum antibiotics rather than broad-spectrum antibiotics. The use of restricted antibiotics as first-line therapy should be limited to only local treatment algorithm prepared based on evidence-based guidelines.

Acknowledgment

The authors acknowledge the immense help received from the scholars/authors/editors/publishers whose articles are cited and included in references of this manuscript.



 
  References Top

1.
Mohajer KA, Al-Yami SM, Al-Jeraisy MI, Abolfotouh MA. Antibiotic prescribing in a pediatric emergency setting in central Saudi Arabia. Saudi Med J 2011;32:197–8.  Back to cited text no. 1
    
2.
Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Atlanta, GA: CDC; 2013.  Back to cited text no. 2
    
3.
World Health Organization. Regional Office for South-East Asia. Step-by-step approach for development and implementation of hospital and antibiotic policy and standard treatment guidelines. WHO Regional Office for South-East Asia. 2011. https://apps.who.int/iris/handle/10665/205912  Back to cited text no. 3
    
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Sriram A, Kalanxhi E, Kapoor G et al. State of the world’s antibiotics 2021: a global analysis of antimicrobial resistance and its drivers. Center for Disease Dynamics, Economics & Policy, Washington DC; 2021.  Back to cited text no. 4
    
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Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.  Back to cited text no. 5
    
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Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA 1998;279:875–7.  Back to cited text no. 6
    
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Hersh AL, Shapiro DJ, Pavia AT, Shah SS. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics 2011;128: 1053–61.  Back to cited text no. 7
    
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Nash DR, Harman J, Wald ER, Kelleher KJ. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Arch Pediatr Adolesc Med 2002;156:1114–9.  Back to cited text no. 8
    
9.
Bernstein SL, Aronsky D, Duseja R, Epstein S, Handel D, Hwang U et al. The effect of emergency department crowding on clinically oriented outcomes. Acad Emerg Med 2009;16:1–10.  Back to cited text no. 9
    
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Gonzales R, Camargo CA, MacKenzie T. Antibiotic treatment of acute respiratory infections in acute care settings. Acad Emerg Med 2006;13:288–94.  Back to cited text no. 10
    
11.
Metlay JP, Camargo CA, Mackenzie T, McCulloch C, Maselli J, Levin SK et al. Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments. Ann Emerg Med 2007;50:221–30.  Back to cited text no. 11
    
12.
Central Procurement Agency (CPA) - Essential medicine list 2016. Ministry Of Health & Family Welfare. Government of NCT of Delhi, http://health.delhigovt.nic.in/wps/wcm/connect/doit_health/Health/Home/Directorate+General+of+Health+Services/Central+Procurement+Agency+%28CPA%29/Essential+Medicines+List/ Last accessed on 23.06.2022.  Back to cited text no. 12
    
13.
Central Procurement Agency (CPA) - Essential medicine list 2016. Ministry Of Health & Family Welfare. Government of NCT of Delhi.. http://health.delhigovt.nic.in/wps/wcm/connect/doit_health/Health/Home/Directorate+General+of+Health+Services/Central+Procurement+Agency+%28CPA%29/Essential+Medicines+List/  Back to cited text no. 13
    
14.
Ahmed AM, Awad AI. Drug use practices at pediatric hospitals of Khartoum State, Sudan. Ann Pharmacother 2010;44:1986–93.  Back to cited text no. 14
    
15.
Fadare J, Olatunya O, Oluwayemi O, Ogundare O. Drug prescribing pattern for under-fives in a paediatric clinic in South-Western Nigeria. Ethiop J Health Sci 2015;25:73–8.  Back to cited text no. 15
    
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Akhtar MS, Vohora D, Pillai KK. Drug prescribing practices in pediatric department of a North Indian university teaching hospital. Asian J Pharm Clin Res 2011;5:146–9.  Back to cited text no. 16
    
17.
Sharif IS, Nassar AH, Al-Hamami FK. Trends of pediatric outpatients prescribing in Umm Al Quwain, United Arab Emirates. Pharmacol Pharma 2015;6:9–16.  Back to cited text no. 17
    
18.
Patel N, Shah S, Asari P, Amin A. Prescription auditing and drug utilization pattern in indoor patients of pediatrics department. Int J Cur Res Rev 2016;8:32–5.  Back to cited text no. 18
    
19.
Sharma S, Bowman C, Alladin-Karan B, Singh N. Antibiotic prescribing patterns in the pediatric emergency department at Georgetown Public Hospital Corporation: a retrospective chart review. BMC Infect Dis 2016;16:170–2.  Back to cited text no. 19
    
20.
Clark MA, Harvey RA, Finkel R, Rey JA, Whalen K, Champe PC et al. Pharmacology. 5th ed. USA: Lippincott Williams & Wilkins; 2009. p. 375–6. ISBN 978-1-4511-4320-1.  Back to cited text no. 20
    
21.
World Health Organization. Report of the 21st WHO Expert Committee on the Selection and Use of Essential Medicines WHO headquarters. Geneva: WHO; 2017.  Back to cited text no. 21
    
22.
May L, Cosgrove S, L’Archeveque M et al. Antimicrobial stewardship in the emergency department and guidelines for development. Ann Emerg Med 2013;62: 4–11.  Back to cited text no. 22
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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