|Year : 2015 | Volume
| Issue : 4 | Page : 101-104
|Prescribing pattern and pharmacoeconomics of antibiotic use in the department of pediatrics of a tertiary care medical college hospital in northern India
Ravika Kanish1, Kanchan Gupta2, Shivani Juneja2, Harmesh Singh Bains3, Sandeep Kaushal2
1 MBBS Final year Student, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Pharmacology, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
3 Department of Paediatrics, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
Click here for correspondence address and email
|Date of Web Publication||7-Aug-2015|
| Abstract|| |
Background: Systemic antibiotics account for more than one third of all prescriptions for children; hence, antibiotic prescriptions for children lead to major public health concerns. Moreover, data regarding rational antibiotic use in children are very limited. Hence, it is essential that the antibiotic prescribing pattern be evaluated periodically to determine the rationality of its use and cost. Objectives: The aim of our study is to identify the prescribing pattern and to carry out the cost-identification analysis of antibiotic use in the patients admitted in the pediatrics department of a tertiary care hospital in North India. Materials and Methods: The study was conducted for 2 months in the pediatric ward and intensive care unit (ICU). The data regarding patient demographics and antibiotic use were collected daily in a structured pro forma. A descriptive analysis of the data was done. Results: A total of 191 patients were enrolled, most of them belonging to the age group of 2-14 years. Majority of the patients were males (75.9%). On an average, 1.9 antimicrobial agents (AMAs) were prescribed per patient. The most common AMAs prescribed were cephalosporins followed by aminoglycosides. The preferred route of administration was parenteral (92%). The average cost of treatment per patient was estimated to be `3,338. The percentage of drugs prescribed by generic name was 58%. Conclusions: Since our hospital is a major referral center of the state, newer generation of antibiotics are more commonly prescribed here. Hence, the cost of therapy is high. This baseline study will help in formulating an antibiotic policy and the standard treatment guidelines (STG) for appropriate use of antibiotics.
Keywords: Antibiotics, antibiotic resistance, pediatrics, pharmacoeconomics, prescribing pattern
|How to cite this article:|
Kanish R, Gupta K, Juneja S, Bains HS, Kaushal S. Prescribing pattern and pharmacoeconomics of antibiotic use in the department of pediatrics of a tertiary care medical college hospital in northern India. Ann Trop Med Public Health 2015;8:101-4
|How to cite this URL:|
Kanish R, Gupta K, Juneja S, Bains HS, Kaushal S. Prescribing pattern and pharmacoeconomics of antibiotic use in the department of pediatrics of a tertiary care medical college hospital in northern India. Ann Trop Med Public Health [serial online] 2015 [cited 2020 Feb 22];8:101-4. Available from: http://www.atmph.org/text.asp?2015/8/4/101/162327
| Introduction|| |
Drug utilization study is the study of marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social, and economic consequences.  The pattern of drug utilization may be linked to the reasons of drug prescription.  Also, controlling cost is a vital issue since in developing countries like India compliance is primarily dependent on the cost of treatment. Therefore, it has implications not only on the medical but also on social and economic aspects.  The indiscriminate use of antibiotics often results in increased incidence of adverse drug reactions, suboptimal therapy, treatment failure, polypharmacy and most importantly, the emergence of antibiotic resistance. Drug utilization in pediatric pharmacotherapy is all the more essential since one third of the total prescriptions for preschool-going children are systemic antibiotics. ,
Moreover, the literature related to potentially inappropriate medications (PIMS) from India is scarce.  The antibiotic-resistant bacteria have become a rampant problem in the pediatric wards and intensive care unit (ICU).  This necessitates the monitoring of antibiotic use through examination of the prescribing trends in clinical settings and the associated adverse drug reactions that will serve as baseline data for formulating the standard treatment guidelines (STG) to promote rational use of antibiotic. Evaluation of the prescribing pattern will also help in minimizing the adverse drug reactions, especially in children who are more susceptible to them and it will also aid in providing cost-effective medical care. ,
Therefore, this study would help us monitor the prescribing pattern and cost of antibiotics so that these can be used judiciously.
| Materials and Methods|| |
This was a hospital-based prospective and observational study carried out over a period of 2 months (June and July of the year 2011) in the pediatric department of a tertiary care hospital in northern India. The data were collected from patients admitted in the pediatric ward and ICU over these 2 months. All the patients up to the age of 18 years who were on antibiotic prescription and were willing to give consent were included in the study. The pediatric ward and ICU were visited on all 7 days of the week, and information regarding the patient demographics and antibiotic use were recorded in a semi-structured pro forma. The consent forms in all the three languages prevalent in the region (Punjabi, Hindi, and English) were made available and consent of each patient/guardian was taken. The study was approved by the Institutional Ethics Committee. The prescriptions were analyzed for the average number of antibiotics per encounter, percentage of encounters with an antibiotic prescribed, route of administration-based prescription pattern, groupwise prescription of antibiotics, percentage of antibiotics prescribed by generic name, percentage of antibiotics prescribed from the World Health Organization (WHO) essential drug list, outcome, and cost analysis.
The data were pooled and a descriptive analysis was done. The results were presented as mean and percentages.
| Results|| |
A total of 191 pediatric patients fulfilled the inclusion criteria and were enrolled. Out of them, 145 (75.9%) were male and 46 (24.1%) were female. The agewise distribution of patients is depicted in [Table 1]. The timing of delivery with respect to gestational period was also studied, and 169 (88%) deliveries were conducted at term gestation, 10 (5.23%) deliveries were preterm, and 12 (6.28%) deliveries were conducted at postterm gestation.
Average number of antibiotics received per patient was 1.9. Percentage of encounters with an antibiotic was 91.6%. Parenteral drugs constituted 92% of the total number of antimicrobial agents (AMAs) prescribed. During the analysis of the route of administration of drugs, 330 patients (92.21%) were given parenterally, 24 (6.70%) were given through the oral route, 2 (0.55%) were given intramuscularly, and 1 (0.27%) was given intraocularly and topically.
The most common antibiotics prescribed were cephalosporins (39%) followed by aminoglycosides (23%), fluoroquinolones (11%), and beta lactams (9.9%) (excluding cephalosporins), miscellaneous (7.9%), antianaerobic (metronidazole) (4.8%), and macrolides (4.8%). The pattern of antibiotic prescription is depicted in [Figure 1]. The subgroup analysis of prescription of cephalosporins is shown in [Figure 2]. Amikacin (87.7%) among aminoglycosides; amoxicillin plus clavulanic acid (20%) among beta lactams (except cephalosporins); and ofloxacin (52.5%) among fluoroquinolones were prescribed most commonly.
The average duration of stay of patients was found to be 10.8 days. The overall rate of single drug prescription was 17% and that of fixed drug combinations was 4%. And out of the total number of AMAs prescribed, generic prescription rate was 58%. Overall, 86% of the total drugs were from the WHO List of Essential Medicine, 2010.
A favorable outcome was seen in 84.7% of the patients. Average expenditure of the AMAs per patient for the total hospital stay was `3,338. The cost incurred on different groups of antibiotics is depicted in [Figure 3].
| Discussion|| |
The present study provides us with an overall pattern of antibiotic use profile in patients admitted in the pediatric ward and ICU in a tertiary care hospital. Majority of the patients were males, as was also seen in another study.  This can be attributed to the prevalence of gender inequality as a result of which male patients are preferentially taken to tertiary care institutes for treatment as compared to female patients with a similar severity of illness.  Another observation was the greater number of full-term deliveries that pointed toward better antenatal care of the patients treated in our hospital.
Out of the total 191 patients, 175 patients ( 91.6%) were prescribed at least one antibiotic, which is many times more than what was found in another study.  The average number of antibiotics prescribed per patient was 1.9, which was less than that observed in a similar study conducted with pediatric patients. 
As already mentioned, total antibiotic usage included both intravenous (IV) and oral antibiotics, of which beta lactams (cephalosporins the most) were maximally prescribed followed by aminoglycosides that is also the trend seen in another study.  Among the beta lactams, cephalosporins were prescribed maximally, which is similar to another study.  Third generation cephalosporins were prescribed more frequently since ours is a tertiary care hospital and patients would have already been administered and probably developed resistance to lower generation antibiotics like co-trimoxazole, chloramphenicol, penicillinase-resistant penicillins (methicillin, oxacillin, and cloxacillin) etc. Culture sensitivity was done in most of the patients but due to prior exposure to antibiotics (before reaching the hospital), the cultures were negative most of the time.
Majority of the drugs were given through the IV route followed by the oral route, as also identified in a study conducted on antibiotic use in pediatrics.  This mainly indicates that patients in pediatric wards or ICUs necessarily require drugs through the intravenous (IV) route for urgent control of infections and to minimize morbidity more quickly as compared to the oral route.
Although, there was a fairly good percentage of prescriptions by generic names according to our study, there is still a long way to go before we thoroughly inculcate this habit that will in turn help in reducing the cost, as was also concluded by another study.  Thus, more information about generic drugs and more research in the field of pediatric pharmacology are needed for increasing generic medicine prescription rate. 
The average cost incurred per patient was `3,338. Beta lactams followed by aminoglycosides accounted for the maximal cost of the antimicrobials. Miscellaneous antibiotics that included vancomycin, linezolid, tigecycline, bacitracin, and doxycycline also contributed to a significant extent to the total cost of AMAs [Figure 3]. Patients reach tertiary care hospital (like ours) in an advanced stage with prior appropriate/inappropriate exposure to antibiotics, and it becomes an absolute necessity to use higher generations of antibiotics. This leads to an increase in the cost of therapy. The antibiotics are gradually de-escalated based on the patient's response and protocol of the treatment.
Moreover, due to feasibility purpose, we are mentioning only the direct cost of the antibiotics but there are various indirect expenses involved in a patient's hospital stay that cost the patient many times more.
Antibiotics are the most commonly prescribed drugs in the pediatric population; thus, special measures are imperative for their rational usage to prevent the emergence of resistance. , This preliminary study has given an insight into the pattern of AMA prescribing, on which future intervention studies may be based to promote rational use of drug. Antibiotic policy and Standard Treatment Guidelines are being framed in our institute based upon the findings of this study.
Although our study has been conducted using a reasonably good sample size making various parameters quite trustworthy, the robustness of our findings could have been increased by an even larger sample size had the duration of study been longer.
Since the number of pediatric drug utilization studies is very small, we must seek ways and means to rationalize and prioritize which antibiotics must be prescribed in pediatric patients who would maximally benefit from them as was the aim of another study.  This would be best articulated through preparation and circulation of the STG, which is the ultimate goal of our study.
| Conclusion|| |
The higher cost of the therapy can be attributed to the predominant prescription of newer generation of AMAs. Beta lactams followed by aminoglycosides are the most commonly prescribed AMAs. Thus, both these groups are the major contributors to the cost. To promote judicious use of AMAs, preparation of the STG is under process.
| References|| |
Gama H. Drug utilisation studies. Arq Bras Med 2008;22:69-74.
Zuppa A, Vijaykumar S, Jayaraman B, Patel D, Narayan M, Vijaykumar K, et al
. An informatics approach to assess paediatric pharmacotherapy: Design and implementation of a hospital drug utilisation system. J Clin Pharmacol 2007;47:1172-80.
Thrane N, Olesen C, Schønheyder HC, Sørensen HT. Socioeconomic factors and prescription of antibiotics in 0- to 2-year-old Danish children. J Antimicrob Chemother 2003;51:683-9.
Majeed A, Moser K. Age- and sex-specific antibiotic prescribing patterns in general practice in England and Wales in 1996. Br J Gen Pract 1999;49:735-6.
Grohskopf LA, Huskins WC, Sinkowitz-Cochran RL, Levine GL, Goldmann DA, Jarvis WR; Paediatric Prevention Network. Use of antimicrobial agents in United States neonatal and paediatric intensive care patients. Pediatr Infect Dis J 2005;24:766-73.
Katragkou A, Kotsiou M, Antachopoulos C, Benos A, Sofianou D, Tamiolaki M, et al
. Acquisition of imipenem-resistant Acinetobacter baumannii in a paediatric intensive care unit: A case-control study. Intensive Care Med 2006;32:1384-91.
Introduction to Drug Utilisation Research. WHO International Working Group for Drug Statistics Methodology, WHO Collaborating Center for Drug Statistics Methodology, WHO Collaborating Center for Drug Utilisation Research and Clinical Pharmacological Services. Geneva: WHO; 2003. p. 1-49.
Tabatabaei SA, Fahimzad SA, Shamshiri AR, Shiva F, Salehpor S, Sayyahfar S, et al
. Assessment of a new algorithm in the management of acute respiratory tract infections in children. J Res Med Sci 2012;17:182-5.
de Bont EG, van Loo IH, Dukers-Muijrers NH, Hoebe CJ, Bruggeman CA, Dinant GJ, et al
. Oral and topical antibiotic prescriptions for children in general practice. Arch Dis Child 2013;98:228-31.
Palikhe N. Prescribing pattern of antibiotics in paediatric hospital of Kathmandu valley. Kathmandu Univ Med J (KUMJ) 2004;2:6-12.
Alvarez-Lerma F. Modification of antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group. Intensive Care Med 1996;22:387-94.
van Houten MA, Luinge K, Laseur M, Kimpen JL. Antibiotic utilisation for hospitalised paediatric patients. Int J Antimicrob Agents 1998;10:161-4.
Pandey AA, Thakre SB, Bhatkule PR. Prescription analysis of pediatric outpatient practice in Nagpur city. Indian J Community Med 2010;35:70-3.
Dimri S, Tiwari P, Basu S, Parmar VR. Drug use pattern in children at a teaching hospital. Indian Pediatr 2009;46:165-7.
Shrestha R, Shrestha JM, Gurung B. Antibiotic usage and its sensitivity pattern in the NICU. Kathmandu Univ Med J (KUML) 2012;10:27-32.
Altiner A, Berner R, Diener A, Feldmeier G, Köchling A, Löffler C, et al
. Converting habits of antibiotic prescribing for respiratory tract infections in German primary care--the cluster-randomized controlled CHANGE-2 trial. BMC Fam Pract 2012;13:124.
Department of Pharmacology, Dayanand Medical College and Hospital, Civil Lines, Ludhiana - 141 001, Punjab
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
| Article Access Statistics|
| Viewed||4377 |
| Printed||81 |
| Emailed||1 |
| PDF Downloaded||15 |
| Comments ||[Add] |