Indo American Journal of Pharmaceutical Research, 2014

ISSN NO: 2231-6876

ANTIBIOTIC PRESCRIBING PATTERN IN PAEDIATEIC INPATIENTS FOR

RESPIRATORY TRACT INFECTIONS IN TERTIARY CARE TEACHING HOSPITAL
Puskar Kunwor*1, M. Kumaraswamy1, M.L Siddaraju2, Bipin Kafle1
1

Dept. of Pharmacy Practice, SAC college of Pharmacy, B.G Nagara, Karnataka, India.
Dept. of Paediatrics, Adichunchanagiri Hospital & Research Center, B.G Nagara, Karnataka, India.

ARTICLE INFO
Article history
Received 25/10/2014
Available online
16/12/2014

Keywords
Antibiotics,
RTI,
Paediatric.

ABSTRACT
Background: Antibiotics are currently the most commonly prescribed drugs in hospitals,
worldwide. But, excessive and inappropriate use of antibiotics renders increased drug
resistance. The rational use of antibiotics is a major health need. Objective: To describe and
obtain the data about the use of antibiotics in pediatric in patients with respiratory tract
infections (RTIs) in tertiary care teaching hospital.Methodology: This was a prospective and
observational hospital based study carried out in 100 pediatric inpatients satisfied inclusion
criteria for a period of 7 months.Result: Overall 100 patients with RTIs were enrolled in the
study in which 71 patients were prescribed with antibiotics, where 70 were male child and 30
were female child. The mean age of the patient was 4.13 0.64 years. The number of
antibiotics per prescription was 1.01. In our study, 66.20% of pediatric inpatients were on
single antibiotics and most of the pediatric patients were receiving parenteral preparation. The
most frequently prescribed antibiotics were Penicillins 53 (amoxicillin+clavulanic acid 51
[50.49%] and amoxicillin 2 [1.98%]), Cephalosporins 19 (ceftriaxone 17 [16.83%] and
cefixime 2 [1.98%]), Aminoglycosides (amikacin 15 [14.85%]), Macrolides (azithromycin 12
[11.88%]).Conclusion: Selection of antibiotic therapy should be based on the local bacterial
sensitivity pattern to improve the control program of acute respiratory infections, and to
prevent the emergence of antibiotic resistance. The guidelines used for the treatment of
paediatric patients should be upgraded periodically.

Copy right 2014 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical
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Please cite this article in press as Puskar Kunwor et al. Antibiotic Prescribing Pattern In Paediateic Inpatients For Respiratory
Tract Infections In Tertiary Care Teaching Hospital. Indo American Journal of Pharm Research.2014:4(12).

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Corresponding author
Puskar Kunwor
Dept. of Pharmacy Practice,
SAC college of Pharmacy,
B.G Nagara, Karnataka, India.

Vol 4, Issue 12, 2014.

Puskar Kunwor et al.

ISSN NO: 2231-6876

INTRODUCTION
Pediatric is among the most vulnerable population group of infectious disease. [1] Pediatric populations are prone to suffer
from recurrent infections of the respiratory tract. [2] RTI is considered as one of the major public health problems in developing
countries. It occurs both among children and adults. It is recognized as the leading cause of morbidity and mortality in many
developing countries. In developing countries 30% of all patients consultation and 25% of all pediatric admission are due to acute
respiratory tract infections and which ultimately causes death of 3.5 million children each year.[3] Out of ten, seven deaths in under 5
children are due to ARI in the developing countries.[4]
Respiratory tract infection (RTI) is defined as any infectious disease of the upper or lower respiratory tract. Upper respiratory
tract infections (URTIs) include the common cold, laryngitis, pharyngitis/tonsillitis, acute rhinitis, acute rhino sinusitis and acute otitis
media. Lower respiratory tract infections (LRTIs) include acute bronchitis, bronchiolitis, pneumonia and tracheitis. [5]
In India, it is estimated that at least 300 million episodes of ARI occur every year, out of these about 30 to 60 millions are moderate to
severe ARI. While every 6th child in the world is Indian, every 4th child who dies, comes from India. [4]
Antibiotics are the key drugs for treatment of infections and are among the most commonly prescribed drugs in Pediatrics department.
Worldwide population constitute of about 28% of children and infants who are most susceptible to diseases due to under development
of immune system. Several studies reported that 50% to 85% of children receive antibiotics in developed and developing countries
prescribed by physicians.
Antibiotic guidelines are standard set of guidelines for the treatment of infectious diseases based on local culture sensitivity
data .These guidelines help the physician to prescribe the antibiotics rationally to pediatric patients when definitely indicated (WHO
model formulary for children, 2010). In spite of these children are at high risk for opportunistic or nosocomial infections due to
intensive antibiotic therapy or prolonged hospitalization and immunosuppressed condition. An overall rise in health care costs, lack of
uniformity in drug prescribing and the emergence of antibiotic resistance, monitoring and control of antibiotic use is of growing
concern. Thus, judicious use of antibiotic is therefore an important way to reduce the problem of antimicrobial resistance. So, detailed
rationale knowledge of antibiotic prescribing pattern must be implemented in the clinical practice. Pediatric patients require more
attention while prescribing antibiotics in order to avoid the resistance, adverse drug reactions and drug-drug reactions.[5]
The objective of the present study was to describe and obtain the data about the use of antibiotics in pediatric inpatients with
respiratory tract infections (RTIs) in tertiary care teaching hospital.
MATERIALS AND METHODS
Study design: This was a prospective and observational study.
Study period: This study was conducted for a period of 7 months, from December 2013 to June 2014.
Study site: The present study was conducted in the pediatrics department of Adichunchanagiri Hospital and research center
(AH&RC), B. G. Nagara, Mandya dist., Karnataka, India. It is a 1050-bedded tertiary care teaching hospital.
Study criteria:
Inclusion criteria:
Pediatric inpatients of both sex and age less than 12 years admitted to pediatric department of the study site with respiratory tract
infection.
Exclusion criteria:
Patients admitted to NICU.
Immunosuppressed patients.

Statistical methods
The data were subjected to descriptive statistical analysis using Microsoft Excel. Descriptive statistical analysis has been
carried out in the present study. Mean SD (Min-max) are calculated. Significance is assessed at 5 % level of significance. Analysis
of variance (one sided ANOVA, student T test) has been used to find the significance of study parameters between two or more group
of patients. Antibiotics were classified into different groups based on ATC classification.

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Statistical software:
The Statistical software namely SPSS 16.0 was used for the analysis of the data and Microsoft word and Excel have been
used to generate bar graph, pie charts and tables.

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Study procedure
An approval from the institutional ethical committee of AH&RC, B.G Nagara was obtained prior to the study. Suitably designed
patient data collection form was prepared by consulting physicians, pediatrics and staffs of pharmacy practice departments which
includes patients demographic details, patients medication history and reasons for admission, any allergic reaction, medication details
and lab investigations. A total of 100 cases diagnosed with RTI were enrolled for the study only after obtaining written consent from
patient care taker. Then antibiotics prescribing pattern, duration of treatment and any adverse drug reaction of antibiotics were studied
and categorized according to Causality Assessment Scale (Naranjos Scale).

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RESULTS
Total of 100 patients admitted to pediatric units for the treatment of various respiratory tract infections were reviewed over a
period of 7 month from December 2013 to June 2014. The distribution of paediatric inpatients suffering with respiratory tract
infections based on age and sex is shown in Table 1. The mean age of patient was 4.390.654 and in that 70 (70%) were male patients
and 30 (30%) were female patients. Out of 100 patients 101 antibiotics were used in 71 patients among which 47 (66.20%) received
monoantibiotics and 24(33.80%) received polyantibiotics.
Table 1: Age and Sex wise distribution of patients.
Age in Years
0-1
1-5
5-12
Total
MeanSD

Male
No. %
16
22.85
16
22.85
38
54.28
70
100
5.4140.756

Female
No. %
8
26.66
14
46.66
8
26.66
30
100
3.81.076

Total
No. %
24
24
30
30
46
46
100 100
4.930.654

The average number of antibiotics per prescription was 1.01. The most frequently used antibiotics were amoxicillinclavulanic acid (50.49%), ceftriaxone (16.83%), amoxicillin, aminoglycosides (14.85%), azithromycin (11.88%), cefixime (1.98%),
amoxicillin (1.98%), vancomycin (0.99%), ciprofloxacin (0.99%). The mean duration of antibiotics therapy was 5 days and maximum
number of antibiotics 62 (61.38%) were given for 5 days of duration for the treatment (Fig 1). In spectrum wise distribution of
antibiotics it was seen that broad spectrum antibiotics were mostly prescribed 66 (65.34%) (Fig 2). Frequency of each antibiotics used
for particular diagnosis shows that amoxicillin+clavulanic acid was the most frequently prescribed 51(50.49%) antibiotic to treat
bronchopneumonia (Table 2). Study showed that injections are the most commonly used dosage form of antibiotics and also showed
that age group of 0-1 years were mostly prescribed with parenteral preparation (Table 3). Some adverse drug reactions in which 1
possible reaction due to ceftriaxone and 3 probable reaction due to ceftriaxone, amoxicillin clavulanic acid and amikacin were seen
during the study. Most of the patients recovered after receiving the treatment with antibiotics. But some did not respond to antibiotics
which could be because of the viral infection.

Fig 1: Duration of antibiotic prescribed.

Numbers
66
22
13
101

Percentages (%)
65.34
21.78
12.87
100

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Spetrum of antibiotics
Broad Spectrum Antibiotics
Extended Spectrum Antibiotics
Narrow Spectrum Antibiotics
Total

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Table 2: Spectrum wise Distribution of Antibiotics.

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Table 3: Frequency of each antibiotic used for particular diagnosis.

Diseases
NS URTI
BrP
BrL
NS LRTI
HRAD
Tonsilitis
BrP
with
other dis
Sinusitis
NS URTI
with other
dis
ARI
Acute
Bronchitis
Phyarengitis
Total

Penicillin
53 (52.47%)
A+C
Amox
5
1
19
0
3
1
9
0
5
0
3
0

Cephalosporin
19 (18.81%)
Ceftri
Cefix
3
0
6
0
3
0
1
0
0
0
0
1

Aminoglycoside
15 (14.85%)
Amik
0
11
1
0
0
0

Macrolide
12(11.88%)
Azith
4
0
3
0
4
1

Glycopeptide
1 (0.99%)
Vanco
0
0
0
0
0
0

Fluroquinolone
1 (0.99%)
Cipro
0
0
0
0
0
1

0
17
(16.83%)

0
2
(1.98%)

0
15
(14.85%)

0
12
(11.88%)

0
1
(0.99%)

0
1
(0.99%)

Total
13
36
11
10
9
6

No antibiotics used
No antibiotics used
1
51
(50.49%)

0
2
(1.9%)

101

NS=Non specific, BrP=Bronchopneumonia, BrL=Bronchiolitis, HRAD= Hyper Reactive Airway Disease, A+C:
Amoxicillin+clavulanic acid (J01CR02*), Amox: Amoxicillin (J01CA04*), Ceftri: Ceftriaxone(J01DD04*), Cefix: Cefixime
(J01DD08*), Amik: Amikacin (J01GB06*), Azith: Azithromycin (J01FA10*), Vanco: Vancomycin (J01XA01*), Cipro:
Ciprofloxacin (J01MA02*), Symbol *= Represents Anatomical Therapeutic Chemical Classification (ATC) Code.
Table 4: Distribution of dosage forms in an Antibiotics.
Syrup/Suspensions
No.
%
6
30
14
70
0
0
20
100

Tablets
No. %
0
0
1
5.55
17
94.44
18
100

Injections
No. %
25
40.98
21
34.42
15
24.59
61
100

DISCUSSION
Respiratory infections produce diseases with global impact in children. [6] The burden of respiratory tract infections in
pediatrics is extremely high, in both industrialized and developing countries. [7] ARI contributes to 15-30% of all under-five deaths in
India and most of these deaths are preventable. [8] In India, ARI has been given top priority in all Government programs including the
current Reproductive and Child Health Program, Phase-II (RCH-II).[9] The majority of common childhood illnesses are caused by
viruses which do not require antibiotics. The emerging problem of antibiotic resistance has become a major threat to the medical field.
Excessive and inappropriate use of antibiotics has been a major contributor to this ever-growing problem.[10] The development and
spread of antibacterial resistance in bacteria that commonly cause community acquired RTIs is a major global healthcare problem.
Unnecessary antibiotic therapy (overuse) and poor therapeutic choice, dosage and/or duration (misuse) both contribute to bacterial
resistance, avoidable toxicity and increased costs. Hence, improving antibacterial use in childhood RTIs is an important challenge for
the physicians in charge.[7]
In the present study we found that the disease was more prevalent among male children however, there was no significant
statistical difference between gender (p>0.05). This result was similar to the findings of other studies conducted in Indonesia (Maksum
Radji et.al) and Meerut district, India (Kapil Goel et.al) showing male was more prone as compared to female. In this study, Out of
100 patients, antibiotics were prescribed in 71 patients, more number of patients received mono antibiotics similar to the study
conducted by choudhary et al. In contrast, most of the studies have shown the varying percentage of antibiotics prescription to
Paediatric patients (Palikhe, 2004; & Sriram et al., 2008). These variations in antibiotic prescription to Paediatric patients may be
caused due to difference in clinical setting and hospital protocol from one region to another.
Average number of antibiotics received per patient was 1.01, which was less than the study conducted by sharonjeet kaur et.al
in pediatric population. The average duration of the antibiotics therapy was 5 days and maximum number of antibiotics 62 (61.38%)
were given for the five days followed by seven days 27(26.73%) (Fig1). Similar study was done by Choudhury Dk et al where
maximum number of antibiotics 55 (30%) were given for the five days of duration. From this data it is understood that the

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0-1
1-5
5-12
Total

Capsules
No. %
0
0
0
0
2
100
2
100

Page

Age

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administration of antibiotics was appropriate as the duration of treatment was sufficient. Broad spectrum antibiotics contributed to
65.34% of the total antibiotics followed by extended spectrum antibiotics 21.78% (Table 2).
Among the various group of antibiotics Penicillins 53 (amoxicillin+clavulanic acid 51 [50.49%] and amoxicillin 2 [1.98%]),
were the most frequently prescribed antibiotics followed by Cephalosporins 19 (ceftriaxone 17 [ 16.83%] and cefixime 2 [ 1.98%]),
Aminoglycosides (amikacin 15 [ 14.85%]), Macrolides (azithromycin 12 [ 11.88%]) as shown in Table 3. Amoxicillin+Clavulanic acid
was the leading prescribed antibiotic combination because it is the preferred drug of choice for both URTI and LRTI according to
center for disease control and prevention (CDC) recommendations. Similar results were found in the studies conducted by Jha V et al
(amoxicillin clavulanic acid 40.74%) and Ciofi Degli Atti M L. Maximum antibiotics were prescribed for bronchopneumonia patients
as shown in Table 3, which was similar to the study carried out by Choudhury Dk et al.
In our study maximum use of antibiotics prescriptions were found in the age group of 1 -5 years followed by 5 -12 years and
0 - 1 year of age group. Similarly, study conducted by Choudhary Dk et al and palikhe et al has found that varying age group of
pediatric inpatients received antibiotics. Most of the paediatric inpatients received antibiotics through parenteral route at the age group
of 0-1 years (Table 4). Similar study conducted by K Shamsy et al and orrett et al have shown the varying percentages of antibiotics
were prescribed parenterally.
CONCLUSION
In our study, 71% paediatric inpatients had received the antibiotic prescriptions, out of these maximum numbers of antibiotic
prescriptions were found in the age group of 1 -5 years. As per our findings, monoantibiotic prescription (single
antibiotic/prescription) was high. Almost 60.39% of the antibiotics were given parenterally. Antibiotics were prescribed to paediatric
patients based on empirical therapy without sensitivity test.
Generic prescribing of antibiotics was comparatively lower and mainly prescribed from Essential Drug List. Our study
suggests that the selection of antibiotic therapy should be based on the local bacterial sensitivity pattern to improve the control
program of acute respiratory infections, and to prevent the emergence of antibiotic resistance. The guidelines used for the treatment of
paediatric patients should be upgraded periodically.

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ACKNOWLEDGEMENTS
The authors are thankful to ethical committee of AH&RC for permitting permission to conduct the study and also thankful to
all the doctors and nurses of the Paediatric department, AH&RC for their kind cooperation in collection of data. We would like to
acknowledge the principal, staff members of Pharmacy practice department, SAC College of pharmacy, for providing necessary
facilities to carry out this work.

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15. Kaur S, Gupta K, Bains H S, Kaushal S. Prescribing pattern and cost-identification analysis of antimicrobial use in respiratory
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