Profile Of Antibiotic Use At The Health Centre

Project and Seminar Material for Pharmaceutical Science

Profile Of Antibiotic Use At The Health Centre


Abstract


The indiscriminate use of antibiotics has become a global problem with implications for effective therapy of infections and dose resistance. The objective of this study is to determine the profile of antibiotic use at the health centre of Delta State University, Abraka. This study was a retrospective study of 592 patient prescriptions from January – June 2015. The data used for this study was obtained by assessing patients’ medical record file from the Medical Record Department and the data obtained were analysed with the aid of Statistical Package for the Social Sciences and presented in a percentage table.

In this study, 316 (53.38%) were female and 276(46.62%) were male. The age group of the patient were in category, 110(18.58%) were between 15-20 years, 20(33.95%) were between 21-25yrs, while 99(16.72%) were between 26-30years while 96(16.22%) were between 31-35 year and 86(14.53%) were greater than 36 years. Out of 592 patient evaluated, a total of 12 different single antibiotic were used, amoxyl 108(12.89%), ampiclox 88(10.50%), doxycycline 88(10.5%), flagyl 281(33.53%), azithromycin 99(11.81%) while erythromycin 38(4.53%) and septrin 42(5.01%) were most prescribed. Out of 1035 antibiotic that was prescribed, 197 were combined antibiotics, 38(19.29%) were amoxyl/flagyl, 33(16.75%) were doxycycline/flagyl, 46(23.35%) were azithromycin/ flagyl, 9(4.57%) were ciprofloxacin/ doxycycline/ flagyl/ azithromycin while 8(3.55%) were ciprofloxacin/flagyl.

The major indication for antibiotic were plasmodiasis 63(10.39%), cough and fever 42(6.81%), stooling 41(8.33%), heat rashes 45(7.35%), anaemia 48(7.84%), gastroenteritis 39(6.37%) while respiratory tract infection 31(5.06%) and helminthiasis 25(4.08) respectively. The factors that influence the profile of antibiotic use were drug availability 23(25.27%), laboratory result 13(14.29%) cost of drug 18(19.78%) and hours of operation by pharmacy 12(13.18%). In conclusion, the study observed appropriate use of antibiotic base on the standard for evaluation; however, rotational drug prescribing was a major challenge due to poor adherence/compliance of prescribers toward standard treatment guideline. Poly-pharmacy was common.


Table Of Contents


Preliminary Page(s)

  • Title
  • Declaration
  • Approval
  • Dedication
  • Acknowledgement
  • Abstract
  • Table of Content

Chapter One:

Introduction

  • 1.1 Background of Study
  • 1.2 Rationale of the Study
  • 1.3 Aim of the Study
  • 1.4 Scope of the Study
  • 1.5 General Objective
  • 1.6 Justification of the Study
  • 1.7 Significance of the Study
  • 1.8 Definition of the Terms

Chapter Two:

Literature Review


Chapter Three:

Research Methodology

  • 3.1 Methodology
  • 3.2 Study Design
  • 3.3 Study Setting
  • 3.4 Data Source and Target Population
  • 3.5 Method of Data Collection
  • 3.6 Data Collected
  • 3.7 Method of Data Analysis
  • 3.8 Data Analyzed
  • 3.9 Ethical Approval

Chapter Four:

Data Presentation And Analysis Of Result

  • 4.1 Introduction
  • 4.2 Age Distribution of Patient Base on department
  • 4.3 Gender Distribution of Patient
  • 4.4 Route of drug administration
  • 4.5 Single Antibiotic Prescribed
  • 4.6 Combined antibiotics prescribed
  • 4.7 Class of Antibiotics Prescribed
  • 4.8 Total medication order and patients who were prescribed antibiotics
  • 4.9 Prevalent Conditions Treated with Antibiotics
  • 4.10 Analysis of WHO Core Prescribing Indicators
  • 4.11 Factors that influence the profile of antibiotics use
  • 4.12 Control measure aimed at regulating antibiotic use
  • 4.13 Compliance of Physicians/Pharmacy towards Appropriate Antibiotic Use

Cheaper Five:

Discussion, Conclusion, Summary And Recommendations

  • 5.1 Discussion
  • 5.2 Conclusion
  • 5.3 Summary
  • 5.4 Recommendation
  • References
  • Appendices

Chapter One


Introduction

1.1 Background of Study

Antibiotics account for the most commonly prescribed drugs in the hospital setting. Inappropriate antibiotic prescribing and the increasing levels of resistance are now issues of global concern (Charani et al., 2010). According to Davy et al., (2005), a significant proportion of antibiotic prescriptions within hospitals have been described as inappropriate. Up to 50% of antibiotic use is inappropriate (Ashiru-Oredope et al., 2012).

Information about antimicrobial prescribing patterns is necessary for a constructive approach to challenges that arise from the multiple antibiotics that are available (Srishyla, et al., 1994). Excessive and inappropriate use of antibiotics in hospitals, health care facilities and the community contributes to the development of bacterial resistance (Shankar et al., 2003).

Irrational prescribing habits for antibiotics lead to ineffective and unsafe treatment of medical conditions. Moreover, irrational prescribing may worsen or prolong the illness thereby leading to distress and harm to the patient. As Sharma and Kapoor (2003) argued, not only does irrational prescribing lead to exorbitant costs of medicines, its occurrence is common in clinical practice.

The decision model of prescribing antibiotics is rather complex and multiple factors other than clinical considerations can influence the decision to prescribe. These factors include patient characteristics, physician characteristics, and medical environments such as competition for clients. Patient characteristics such as age, lower socio-economic status, and higher co-morbidity have significant effects on the antibiotic prescription rate. Physician characteristics, including gender, age, time since graduation, and volume of practice, also significantly influence antibiotic prescription (Choi et al., 2008).

They also pointed out that an urban location of a medical practice and patient income level also influence antibiotic prescription rates. Other significant predictors are the physician expertise (that is specialist or generalist). Choi et al., (2008) further argued that medical environment variables such as the number of primary care clinics and number of hospital beds affect the rate of antibiotic prescription.

Sharma and Kapoor, (2003) attributed irrational prescribing to lack of knowledge about drugs, unethical drug promotions, high patient load, ineffective laboratory facilities, availability of drugs, and ineffective law enforcement by governments with subsequent failure to ensure compliance to guidelines. The irrational prescribing of antibiotics (particularly broad-spectrum antibiotics), in primary care is a major contributing factor to reduced drug efficacy, increased prevalence of resistant pathogens in the community, and the appearance of new co-infections (Sharma and Kapoor, 2003).

Antimicrobial resistance is currently the greatest challenge to the effective treatment of infections globally. Resistance adversely affects both financial and therapeutic outcomes with effects ranging from the failure of an individual patient to respond to therapy and the need for expensive or toxic alternative drugs to the social costs of higher morbidity and mortality rates, required or longer durations of hospitalisation, increased health care costs and the need for changes in empirical therapy (Essack, 2006).

Previous studies on prescribing patterns have looked at the evaluation of rational therapy, the appropriateness of prescribing antibiotics and antibiotic use, resistance development and environmental factors. These factors addressed the characteristics of individual patients and doctors, related with prescription episodes. Most studies have shown that there is inappropriate prescribing. The use of antibiotics and a large number of prescriptions did not conform to the ideal pattern (Baktygul et al., 2011).

Medicines consume a significant portion of the total health care budget. Equitable access to affordable medicines remains a challenge. The Standard Treatment Guidelines and Essential Medical List ensure the cost-effective treatment options are available to citizens of the country, and seek to build capacity in health care workers at the Primary Health Care level.

Antibiotics are among the most frequently used drugs worldwide. They are particularly utilized in developing countries, where an average of 35% of the total health budget is spent on antibiotics (Isturiz & Carbon., 2000, cited in Makhado, 2009). In Zambia for instance, the University Teaching Hospital alone spends well over 15.28 % of its medicines budget on antibiotics per quarter of the financial year (UTH Pharmacy records, 2013-unpublished data).

Monitoring of prescriptions and drug utilisation studies can identify the problems and provide feedback to prescribers and other stake holders so as to create awareness about irrational use of antibiotics. This study was undertaken to investigate the prescribing and profile of antibiotics use at the Health centre of delta state University, Abraka.

This study aimed at describing the patterns of antibiotic prescribing and to suggest modifications in practitioners prescribing habits so as to make medical care rational and cost-effective.

Rational prescribing and appropriate drug use are the keys to achieving optimum therapeutic goal. This is because inappropriate prescribing can lead to therapeutic failure, toxicity, drug interactions and even death of the patient (for which the physician and the dispensing pharmacist can be held responsible for professional misconduct), which then provides basis for a claim for compensation (Brahams, 1989). Poly-pharmacy is a recipe for adverse drug interactions (Irshaid et al, 2005); increase risk of bacterial resistance (Yousif et al., 2006; WHO, 2000); non-compliance (Pearson,1982) and increased burden/ cost to both patient and the health care delivery system (George-Kutty et al., 2002).

Inappropriate prescribing is known all over the world to be a major problem to health care delivery; and tactless prescribing is widespread (Rashid et al., 1986). It is a feature in health care settings in developing countries and is characterized by poly-pharmacy, excessive use of antibiotics, and injections (Laing, 1990; Isah et al., 2001, Ohaju-Obodo et al., 1998; Akande and Ologe, 2007).

Inappropriate prescribing will have an important economic and medical impact on health care as it makes treatment of patients more costly, more risky and less rewarding. Increased generic prescribing would rationalize drug use and reduce cost of treatment to the patient and lessen the burden on the health care delivery system (Quick et al., 2002; Hogerzveil, 1995).

Rational drug prescribing has remained a global concern such that countries have established health regulations to guard against irrational, inappropriate or negligent prescribing, which is regardless of the considerable improvements that has been made in the availability and control of drugs in hospitals over time (Laing, 1990; Hogervzeil, 1995).

Outpatient’s clinics deliver therapeutic services to a large segment of patients. General Outpatients Departments (in the Teaching and General hospitals), and the outpatient clinics in the private health institutions are the ones that see and treat the patients first. It is only cases that require further medical evaluation that are referred to the specialists.

Private health institutions have substantial clientele who patronize them for various reasons; some of which include absence of long queues, convenience of opening/ consulting hours, better attitude of staff, greater confidence in a particular doctor, and increase in likelihood of privacy (Foster, 1995). Consequently large quantities of drugs are prescribed during the clinic encounters. Assessment of prescribing pattern in these important medical facilities is of great relevance to identifying problems regarding rational drug use, so as to propose interventional measures in cases of significant irrational prescribing.

Appropriate drug utilization studies are important tools used to evaluate whether drugs are properly utilized in terms of efficacy, safety, convenience, and economic aspects at all levels in the chain of drug use (Dukes, 1993). The importance of rational drug use in clinical practice is underscored by the introduction in 1975 by World Health Organization (WHO, 1977, 1991) of the “Essential Drugs List (EDL) Concept”, which was followed up with the drawing up of an EDL in 1977 and setting up of implementation program in 1981(WHO, 1987). These initial critical steps have resulted in the improved supply of essential drugs to health care facilities in developing countries (Hogervzeil et al., 1993; WHO/DAP/ INRUD/ 93.1, 1993).

With these programs in place, the need to improve rational use of the drugs became imperative and this was highlighted at the WHO sponsored multidisciplinary meeting of experts held in Nairobi in 1985 (WHO, 1987). To this end, a set of objective measures for the evaluation of prescribing practices (Drug Use Indicators: Prescribing Indicators, Patient Care Indicators, and Facility Indicators) were introduced through collaborative work of the Drug Action Program of the World Health Organization (DAP-WHO) and the International Network on the Rational Use of Drugs {(INRUD)(WHO, 1991; 1993) Isah et al.,/ICIUM, 1997).

Federal Ministry of Health (FMOH), Nigeria in collaboration with WHO, launched the maiden edition of National Drug Policy (NDP) in 1990 and published the revised edition in 2005; with the goals of making available at all times to the Nigerian populace adequate supplies of drugs that are effective, affordable, safe, and of good quality; to ensure the rational use of such drugs and to stimulate increase local production of essential drugs at all levels on the basis of health needs (NDP, 2005). WHO Drug Use Indicators are standard measures that have been tested in many settings and found useful in controlling inappropriate prescribing (Hogervzeil et al., 1993).

They have to a reasonable extent unified and clarified the concept of rational drug use which had until then appeared abstract, making previous research works on rational drug prescribing to be restricted to using methods, expressions and variables that were peculiar to their settings and that did not allow for direct comparison with other settings (Oviawe et al., 1989). Availability of EDL at the health care facilities (HFs) and the WHO drug prescribing indices have therefore unified and made more practicable the concept of rational drug use, and enabled comparisons of drug use practices within and between health facilities, regions and countries. They provide useful tools for supervision and monitoring of drug use practices as well as allowing for evaluations of the impacts or changes that interventional efforts might have made over time (Isa et al., 2001).


1.2 Rationale of the Study

The indiscriminate use of antibiotics has led to the antimicrobial resistance problem (World Health Organisation, 2009). According to Lukwesa, (2012- unpublished data), selected data showed that the percentage of resistance for organisms isolated from blood specimens where n=2175, ampicillin was 97.1% resistant, co-trimoxazole (86.2%), penicillin G (83.6%,) erythromycin (53.5%), chloramphenicol (43.5%), gentamycin (40.5%), ciprofloxacin (38%), tetracycline (35.5%) and cefotaxime (31.5%).

According to WHO, (2009) inappropriate antibiotic prescribing was as high as 67.6%. High patient load, prior prescription by unqualified prescribers, high prices of antibiotics, misdiagnosis, availability of antibiotics, ineffective law enforcement to ensure treatment guideline are followed and prescribers being influenced by a particular company to prescribe its medical products are some of the major reasons for inappropriate prescribing of antibiotics. Lack of systems, structures and processes or antibiotic control measures such as Antibiotic Policy Committee or their ineffectiveness could greatly contribute to inappropriate prescribing.


1.3 Aim of the Study

The aim of this study is to determine the profile of antibiotic use at the Health centre of delta state University, Abraka.


1.4 Scope of the Study

This research is limited to the profile of antibiotics use at the Health centre of Delta State University, Abraka.


1.5 General Objective

Profile of antibiotic use at the health centre of delta State University, Abraka

1.5.1 Specific objective
  1. To determine the proportion of students treated with antibiotics and other drugs.
  2. Evaluating the total number of antibiotics prescribed and their order of distribution.
  3. Determining the factors related to the antibiotics prescription pattern.
  4. To determined the single antibiotic drug that was prescribed during this study.
  5. To determined the combined antibiotic drug that was prescribed during this study

1.6 Justification of the Study

Infectious diseases constitute a significant part of the disease burden in the tropics, especially Nigeria. The irrational use of antibiotics has lead to antibiotics resistance, ineffective treatment and increased health expenditure. Therefore, necessary initiatives should be taken by Government and health practitioners in other to promote the rational use of these antibiotics.


1.7 Significance of the Study

This research study is carried out to make an assessment of the use of antibiotics at the Health centre of Delta State University, Abraka.


1.8 Definition of the Terms

Antibiotic:

A group of drugs used to treat infections caused by bacteria and to prevent bacterial infection in cases of immune system impairment (Medical Dictionary, 2008).

Prescription:

This is an instruction written by a medical practitioner that authorizes a patient to be issued with a medicine or treatment.

Pattern:

A combination of qualities, acts, tendencies etc. forming a consistent or characteristic arrangement.

Polypharmacy:

This is the use of three or more medications by a patient, generally adults.

Antibacterial drugs:

A group of drugs used to treat infections caused by bacteria.

Antimicrobial:

A drug used to treat a microbial infection. “Antimicrobial” is a general term that refers to a group of drugs that includes antibiotics, antifungals, anti-protozoals, and antivirals (Medical Dictionary, 2008).

Antibiotic resistance:

The ability of bacteria and other microorganisms to withstand an antibiotic to which they were once sensitive (and were once stalled or killed outright). Also called drug resistance (Medical Dictionary, 2008).

Irrational use of medicines:

This is a major problem worldwide. It is estimated that half of all medicines are inappropriately prescribed, dispensed or sold and that half of all patients fail to take their medicine properly. The overuse, under use or misuse of medicines results in wastage of scarce resources and widespread health hazards (WHO, 2004).

Rational drug therapy:

The use of the least number of drugs to obtain the best possible effect in the shortest period and at a reasonable cost (Gross, 1981).


Chapter Five


Discussion, Conclusion, Summary And Recommendations

5.1 Discussion

In the study, it was found that the profile of antibiotics used at the Health Centre of Delta State University,Abraka was rightly prescribed. The evidence was that the antibiotics used were prescribed for therapy because 21/25 condition treated were bacterial infections confirmed by laboratory test.

The drugs of choice, duration of therapy, route of administration were mostly appropriate.

This study also found that the doctors usually refer to the following treatment guideline for prescription,

  • Standard best practice
  • British National formulary
  • Monthly index of medicines specialities

The study also revealed that national drug prescribing did not conform to set standards. Poly-pharmacy was quite common and this may lead to a high chance of drug interaction, toxic adverse effects and high cost of treatment. The evidence is the average number of drug per encounter which was found to be 2.78.

In the study, 19-22 years age group were higher with a frequency of 201(33.95%), followed by 15-18 years with a frequency of 110(18.58%), 20–26 years with a frequency 99(16.72%), 27-30 years with a frequency 96 (16.22%) and the least among them were >31 years with a frequency of 86(14.53%).

Among the study patients in pharmacy department, the female were higher with a frequency of 316(53.38%) than the male with a frequency of 276(46.62%).

Three route of drug administration were utilized. These are oral, intravenous and intramuscular. Oral route were mostly used for both male and female, followed by intravenous and intramuscular.

The study found that the most prescribed single antibiotic were flagyl, amoxyl, ampiclox, azithromycin, doxycycline and septrin. It was found that flagyl had a frequency of 281(33.53%) amoxyl 108(12.89%), azithromycin 99(11.81%), ampiclox 92(10.98%) and septrin 42(5.01%) and the least among them were ciprofloxacicin 4(0.48%) and chloramphinicol 6(0.72%).

In the study, the most combination antibiotic use were azithromycin / flagyl, amoxyl / flagyl, doxycycline / flagyl, ciprofloxacin, doxycycline / flagyl / azithromycin and septrin / flagyl, azithromycin / ampiclox. It was found that azithromycin/flagyl had a frequency of 46(23.35%), amoxyl/flagyl 38(19.29%), doxycycline / flagyl 33(16.75%) ciprofloxacin / doxycycline/ flagyl / azithromycin 9(4.54%) septrin / flagyl 8(4.06% and azithromycin / ampiclox 11(5.58%).

The beneficial effects of combination therapy was predominantly seen with b-lactams as primary therapy including, macrolides, quinolones and aminglycoside. The benefit of combination therapy was significantly for bacteremic and non-bacteremic infections.

The study also shows that penicillin group topped the table of most used class of antibiotic and this is in agreement with the finding of Chelliah et al., 2005). Other antibiotics were ranked second and followed by macrolide and tetracycline. In this study, similar to finding of Khan et al., 2012), penicillin and macrolide have continued to be the mainstay of therapy in Delta Health Centre because of their wider spectrum of activity. Clinical efficacy and favourable compliance/tolerability profile (Borg et al., 2008, Mettler et al., 2007, Singh et al., 2001).

In this study, it was found that a good number (93.92%) of the 592 patient evaluated had antibiotic prescribed.
In this study, it was observed that antibiotic was mostly used for bacteria infections, with very little for non-bacterial infection. Plasmodiasis topped the table of conditions treated. 63(10.29%), followed by stooling 51(8.33), anaemia 48(7.84%), heat rashes 45(7.35), cough and fever 42(6.84%), gastroenteritis and urinary tract infection 39(6.37%), asthma 33(4.39%) and respiratory tract infection 31(5.06%) respectively. The five (5) least condition treated were gunshot injury/wound 4(065%), appendicitis 6(0.98%) meningitis and bruised/laceration at 8(1.31%) at each and peptic ulcer disease at 11(1.80%). This was contrary to the findings of Gopal et al., (2014) that antibiotic used in their study was mostly for non bacterial infection.

In this current study, the average number per encounter was found to be 2.78. the percentage of drugs prescribed by generic name was 37.59%, the percentage encounter with an injection and antibiotic prescribed were 88% and 70% respectively while percentage of antibiotic is 50.79% these values highly deviates the standards (table 7) provided by WHO, which is also similar o the result of a study conducted in Madhya Pradesh by Bhortiy et al., (2008).

A number of factors were reported to influence prescription. Drug availability 23(25.27%), laboratory result 13(14.29%), cost of drug 18(19.78%), hours of operations by the pharmacy 12(13.18%), disease pattern 3(3.30%), resistance to previous treatment 8(8.79%) and previous use of drug 14(15.385). in addition, hours of operation by the pharmacy came out to be the second most influencing factor to the prescribing habits because physician tended to prescribed what was available in the ward when the pharmacy was closed after 5 pm and on weekend.

In this study, it was observed that there was no control measure/process or antibiotic prescription policy in place at the health centre. This is the same with the findings of Hussein and Shobha (2014) in a tertiary care hospital in India. Lack of these control measure or process poses a serious challenge to the use of drug. The evidence is the high use of antibiotic demonstrated in this study.

In term of appropriateness, there was compliance of physicians/pharmacists towards Gyssens recommendations. However, there is poor compliance with WHO core prescribing indication; evidence is that rational prescribing was far from the mark. Poly-pharmacy was common in the health centre. Such excessive use of antibiotic may lead to toxicities as well as resistant development, although more of these were reported in this study.


5.2 Conclusion

Despite the appropriate use of antibiotics in the health centre, the main challenge remains to achieve a rational drug choice. It can be concluded therefore, that poor adherence and compliance of prescribers towards adopted standard treatment guideline such as the core drug use indicator (CDUI) is the major reason for this. To achieve the goal of rational use of medicine and improve prescribing patterns, it is pertinent to reduce the number of medicine as low as possible after consciously keeping the cost of therapy low.

5.2.1 Limitation to the study

The following limitations to the study were identified:

  1. Some condition treated could not be accurately assessed due to bad hand writing of prescribers.
  2. Sorting and filing of patients medical records was a challenge.
  3. Gyssen’s method was used as one of the standard for evaluation, it may however have its limitation depending on location and facilities.
  4. WHO core drug use indicator is not an exhaustive tool to identify all problems related to prescribing and rationality of drug use as they don’t explain exactly why drugs are prescribed.

5.3 Summary

This study evaluated the profile of antibiotic use at the health centre of Delta State University. A total of 592 patient prescriptions from pharmacy department, categories of patient were evaluated. A total of 838 antibiotic were prescribed standard used for evaluation.


5.4 Recommendation

Based on the study finding, the following recommendations are made:

  1. There is need for the hospitals to enforce adherence to standard treatment guideline to ensure rational drug prescribing.
  2. There is need to develop control measures to regulate antibiotics use.
  3. Clinical meetings should be held on a regular basis to evaluate drug use.
  4. Hospital managements should strengthen laboratory facilities so that prescriptions will remain on the basis of laboratory reports.
  5. Hospital management should ensure the availability of WHO model list of essential medicine and key drugs in the pharmacy store.
  6. Proper education programme on rational use of drug and antibiotic policies should be implemented in the hospitals.
  7. Motivating dispensary personnel to explain drug regimen thoroughly to patients as this implies patients knowledge of correct dose.
  8. Motivating generic prescribing (a safety precaution for the patient) as it gives clear identification and enables easy information exchange and allows better communication between health care provides.
  9. While this study identified poor adherence to CDUI as the main factor militating against rational drug prescribing, further studies should be conducted to prove the authenticity of this finding.

Profile Of Antibiotic Use At The Health Centre


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