773216

research-article2018
TAI0010.1177/2049936118773216Therapeutic Advances in Infectious DiseaseA Kaur, R Bhagat

Therapeutic Advances in Infectious Disease Original Research

A study of antibiotic prescription

Ther Adv Infectious Dis

2018, Vol. 5(4) 63­–68

pattern in patients referred to DOI: 10.1177/

https://doi.org/10.1177/2049936118773216
https://doi.org/10.1177/2049936118773216
2049936118773216

tertiary care center in Northern India

© The Author(s), 2018.
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Amritpal Kaur, Rajan Bhagat, Navjot Kaur, Nusrat Shafiq, Vikas Gautam,
Samir Malhotra, Vikas Suri and Ashish Bhalla

Abstract
Background: Tremendous infectious disease burden and rapid emergence of multidrug
resistant pathogens continues to burden our healthcare system. Antibiotic stewardship
program often implements antibiotic policies that help in preventing unnecessary use of
antibiotics and in optimizing management. To develop such a policy for management of
infections in the emergency unit, it is important to analyze the information regarding antibiotic
prescription patterns in patients presenting to the emergency room referred from various
healthcare settings. This study was conducted with the aforementioned background.
Methods: We conducted a prospective observational study in triage area of emergency unit
of a tertiary care hospital. All the referred patients were screened for antibiotic prescription.
Data extraction form was used to capture information on patient demographics, diagnosis
and antibiotics prescribed. Antibiotic prescription details with regard to dosage, duration and Correspondence to:
frequency of antimicrobial administration were also recorded. Data were summarized using Nusrat Shafiq
Department of
descriptive statistics as appropriate. Pharmacology,
Results: Out of 517 screened patients, 300 were prescribed antimicrobials. Out of 29 Postgraduate Institute
of Medical Education &
antibiotics prescribed, 12 were prescribed in more than 90% of patients. Broad spectrum Research, Research Block
‘B’, 4th Floor, Chandigarh
antibiotics accounted for 67.3% of prescriptions. In 129 out of 300 patients, no evidence of 160012, India
infectious etiology was found. nusrat.shafiq.pgi@gmail.
com
Conclusion: Our study highlights some common but serious lapses in antibiotic prescription Amritpal Kaur
patterns in patients referred from various healthcare settings. This emphasizes the need to Antimicrobials
Stewardship, Postgraduate
provide training for rational use of antibiotics across healthcare settings. Institute of Medical
Education & Research,
Chandigarh, India
Keywords:  antimicrobial resistance, antimicrobial stewardship, prescription Rajan Bhagat
Navjot Kaur
Nusrat Shafiq
Received: 2 February 2018; accepted in revised form: 4 April 2018 Samir Malhotra
Department of
Pharmacology,
Postgraduate Institute
Introduction of Medical Education &
Research, Chandigarh,
Communicable diseases continue to be important Multidrug resistant strains have been widely doc- India
contributors of morbidity and mortality world- umented for Enterococcus faecium, Staphylococcus Vikas Gautam
wide. As per the recent estimates, the crude death aureus, Klebsiella pneumoniae, Acinetobacter bau- Department of
Medical Microbiology,
rate due to infectious causes in India is about mannii and Pseudomonas aeruginosa in India.4 The Postgraduate Institute
416.75 deaths per 100,000 persons.1 Furthermore, infections caused by aforementioned organisms of Medical Education &
Research, Chandigarh,
prevalence of multidrug resistant pathogens is are not only difficult to treat because of limited India
increasing rapidly, especially, in the hospital number of available antimicrobial choices but Vikas Suri
settings.2 High infectious disease burden, poor also lead to increased treatment duration and Ashish Bhalla
Department of Internal
living conditions and easy availability of antibiot- associated costs. Unfortunately, India represents the Medicine, Postgraduate
ics are some of the major drivers of rising antimi- country with highest antimicrobial consumption.5 Institute of Medical
Education & Research,
crobial resistance in India.1,3 Furthermore, overuse of antimicrobials is causally Chandigarh, India

journals.sagepub.com/home/tai 63
Therapeutic Advances in Infectious Disease 5(4)
linked to emergence of antimicrobial resistance.6,7
Thus, one of the logical ways for curtailing anti-
microbial resistance is to reduce inappropriate or
irrational antibiotic prescribing. Antibiotic stew-
ardship programs often target such irrational use
of antimicrobials.8 These programs are widely
practiced in developed countries and have been
shown to decrease antimicrobial consumption,
improve patient outcomes and combat emergence
of resistant strains.9 Antimicrobial resistance adds
to the economic burden, particularly, for lower
and middle-income countries.10 The dwindling
pipeline of new antibiotics makes the situation
very grim.11
In developing countries, antimicrobial steward-
ship programs are emerging up only recently. One
such program has been initiated in our institute
where an approach of ‘assess, propose and imple-
ment’ is being followed.12 One of the activities of
this program is to develop antibiotic policies for
management of infections in various settings.
Patients are often referred to our emergency
department from other healthcare settings such as
other hospitals, primary and secondary health
centers, nursing homes and stand-alone clinics.
These patients quite frequently need admission
either to the wards or in the intensive care units.
For want of available space, these patients some-
time continue to be managed in areas which are
called emergency wards. In these wards, certain
medications and articles required for patient
management are available free of cost. However,
for want of supplies, patients may need to make
out of pocket payments for procurement of medi-
cines, including antibiotics.
Prior to formulating antimicrobial guidelines for
patients in this area, it was felt important by
stakeholders to understand the prescription pat-
terns of antimicrobials of referring healthcare
units. Furthermore, it was also felt important to
understand the information based on which diag-
nosis of infective state was made including inves-
tigations such as culture and sensitivity reports.
As pointed out earlier, a large number of these
patients are subsequently moved to inpatient set-
tings (wards or intensive care units), where they
add to the burden of resistant organisms and con-
tribute toward elevated defined daily dosage of
restricted antimicrobials. This study was under-
taken with this background to provide an input
about the prescription patterns of antibiotics in
referred patients for formulating antibiotic policy
for the emergency medical ward.
64 journals.sagepub.com/home/tai
Methodology
We conducted a prospective observational study
over a period of 5  months (i.e. October
2016–February 2017) in the triage area of our ter-
tiary care hospital. The triage area of emergency
medical outpatient department is the place where
the patient is first met by a junior doctor. No inter-
vention is initiated unless the patient requires
emergency resuscitation. The study was initiated
after obtaining due approval from the Institute
Ethics Committee. A waiver of informed consent
of patient was obtained from the Ethics Committee.
We collected data on all patients received in the
triage area between 8 a.m. and 5 p.m. during the
study period. All patients who were referred from
any hospital, clinic and nursing home were assessed
for antibiotic use, either ongoing or preadminis-
tered (during the stay in the referring unit). Various
sources used for extracting this information
included patient referral notes, discharge sum-
mary, prescription slip, left-over medicines with
the patient, slip issued by chemists and recall by
the patient or his or her attendant (in case none of
the aforementioned sources were available).
Data extraction forms were used to record infor-
mation on demographic details, provisional/
definitive diagnosis and antibiotics received by
the patients from the point of referral. Following
information was collected from either the patient
or his or her attendant: (1) a brief description/
referral note of the current illness, (2) presenting
complaints, (3) investigations done previously,
(4) interventions done previously and (5) name of
the city/hospital of referring facility/doctor. We
further analyzed source of information for perti-
nent details such as antimicrobial dosage, fre-
quency, duration of antimicrobial use and
whether such use was indicated by documented
culture sensitivity reports or not. A possibility of
infective etiology was considered plausible if the
patient had any of the following at any time prior
to inclusion in the study: (1) fever, (2) increased
leukocyte count, (3) signs and symptoms of infec-
tion of a particular organ system and (4) sepsis.
The collected data were summarized using
descriptive statistics as appropriate. Continuous
variables were summarized as mean ± standard
deviation. Discrete variables were presented as
proportions and percentages. We further assessed
percentage of individuals in whom the initiation
of antibiotic at point of care was inappropriate
based on possibility of infective etiology as sug-
gested by above four criteria.
 A Kaur, R Bhagat et al.

Table 1.  List of antibiotics prescribed. Results

In this prospective study, we screened 517
S. no. Antibiotics Percentage
of antibiotics patients who reported in the aforementioned
prescribed area. Out of these 517 patients, 300 (58%) were
prescribed antimicrobials. The referral note was
1 Ceftriaxone 69 (19.2) the most frequently used source for extracting
information with regard to antibiotic prescrip-
2 Amoxicillin- 61 (16.9)
clavulanic acid tion. The prescription patterns of these patients
were taken up for further evaluation.
3 Piperacillin and 41 (11.4)
tazobactam
Demographic profile
4 Metronidazole 25 (6.9)
180 patients (60%) were men and 120 patients
5 Cefixime 16 (4.4) (40%) were women. Mean (±SD) age of the
study participants was 45 ± 18 years (ranging 13–
6 Ciprofloxacin 16 (4.4) 95 years). Maximum numbers of patients were in
7 Azithromycin 14 (3.8) the age group of 30–70 years (36%). 183 patients
(61%) were referred by public sector healthcare
8 Levofloxacin 14 (3.8) setups, 116 (38.6%) by the private clinics and 92
(30.6%) by facilities affiliated to teaching insti-
9 Norfloxacin 14 (3.8)
tutes. The patients were referred from the follow-
10 Clindamycin 11 (3.1) ing states in descending order: Punjab (40%),
Haryana (20%), Himachal Pradesh (10%) and
11 Amikacin 10 (2.7) Uttar Pradesh (5%). 25% referrals were from
12 Vancomycin 9 (2.5) Chandigarh (a union territory).

13 Moxifloxacin 8 (2.2)
Antibiotic prescription pattern
14 Ofloxacin 7 (1.9)
Different types of provisional diagnosis recorded
15 Meropenem 7 (1.9) in the referral notes were 70 in number. Fever
(with or without thrombocytopenia), acute exac-
16 Rifaximin 5 (1.4) erbation of chronic obstructive pulmonary dis-
17 Isoniazid 4 (1.1) ease (COPD), sepsis and pneumonia accounted
for 37% of cases. In total, 29 different antibiotics
18 Rifampicin 4 (1.1) were prescribed to various patients. 12 antibiotics
accounted for more than 80% of prescriptions.
19 Pyrazinamide 4 (1.1)
Out of these, ceftriaxone and amoxicillin-clavu-
20 Ethambutol 4 (1.1) lanic acid were prescribed most commonly
(19.2% and 16.9%, respectively). This was fol-
22 Gentamicin 3 (0.8) lowed by piperacillin-tazobactam given to 41
23 Amoxicillin 3 (0.8)
(11.4 %) patients. Details of different antibiotics
and their prescription frequencies have been pre-
24 Colistin 3 (0.8) sented in Table 1. Six antibiotics were prescribed
to more than 5% of patient population (Figure 1).
25 Tinidazole 2 (0.5)
Broad spectrum antibiotics accounted for 240
26 Imipenem 2 (0.5) (67.3%) of prescriptions. Details of antibiotic
prescription with respect to mention of dosage,
27 Cefuroxime 1 (0.3) frequency, duration of use and whether such use
was based on documented culture sensitivity
28 Chloramphenicol 1 (0.3)
reports are presented in Table 2. Culture sensitiv-
29 Cefoperazone and 1 (0.3) ity reports were not available in any of the case,
sulbactam which means that the antibiotics were started

journals.sagepub.com/home/tai 65
Therapeutic Advances in Infectious Disease 5(4)
Figure 1.  List of six commonly prescribed antibiotics.
Table 2.  Types of inappropriate use observed in
prescriptions.
Type of inappropriate No. of
use patients (%)
Dose not mentioned 43 (14.3)
Frequency of 300 (100)
administration not
mentioned
Duration not mentioned 282 (94)
Susceptibility pattern 300 (100)
not defined
empirically and an attempt for possible de-escala-
tion subsequently was not made. In 129 out of
300 (43.9%) patients, no evidence of infectious
etiology was found with respect to presence of any
fever, elevated leucocyte counts, signs and symp-
toms of infection of organ system or sepsis. Thus,
antibiotic use was considered unnecessary in
these patients.
Discussion
To the best of our knowledge, this is the first study
to report antibiotic prescription pattern of the
patients referred from various healthcare centers
to a tertiary care hospital setup. Our emergency
department receives patients from a variety of
healthcare settings such as stand-alone clinics, pri-
vate nursing homes and hospitals, primary and
secondary level public sector health centers and
hospitals. Thus, we believe that our study sample
is largely representative of emergency settings of
tertiary care facilities of our country.
We found that antimicrobials were clearly not
indicated in more than 40% of cases, which
66 journals.sagepub.com/home/tai
represent significant overuse of antimicrobials.
Diagnosis of infection may not always be very
clear. Moreover terminologies used for categoriz-
ing infections may be highly variable. For exam-
ple, fever with and without thrombocytopenia,
tropical fever, pyrexia of unknown origin, fever
with sepsis, fever with pain abdomen and dengue
fever were all recorded as provisional diagnosis.
Furthermore, determining or ruling out bacterial
etiology as a cause of ongoing infection may be
even more challenging.13,14 Importantly, this
study was not conducted in the period when viral
infections, for example, dengue or swine flu, are
common. We believe that this percentage of
inappropriate use of antimicrobials may be fur-
ther pushed up in a scenario of increased incidence
of viral infections had the study been conducted
during such period as has been reported previously.15
A considerable percentage (>65%) of prescrip-
tions were that of broad spectrum antimicrobials
such as amoxicillin clavulanic acid, ceftriaxone,
ciprofloxacin, clindamycin and piperacillin-tazo-
bactam. This can be expected as 100% patients in
the study cohort were started on empirical antibi-
otic therapy. For empiric management of infec-
tions, it may be necessary to use broad spectrum
antimicrobials initially. Prudence may still be
exercised for instance, use of amoxicillin instead
of co-amoxiclav, minimizing use of third and
fourth generation of cephalosporins and reducing
fluoroquinolone use that have been shown to
have a bearing on decreasing antimicrobial
resistance.16 However, absence of culture sensi-
tivity reports highlights the fact that the impor-
tance of de-escalation subsequently was not
understood by most of the prescribers. This in a
way identifies a target for any educational activity
as part of antibiotic stewardship program that
may be planned subsequently.
Although the use of broad spectrum antibiotics
was high, it was interesting to observe that con-
trary to popular belief, carbapenems and poly-
myxins were prescribed to fewer than 12 (3.2%)
patients. This leaves scope for considerable
options for empirical management of infections
in the emergency unit. National Centre for
Disease Control (NCDC), India, has recently
come up with national antibiotic policy for man-
agement of infections at all levels of healthcare.17
It is important to propagate these guidelines as
these will help in guiding rational use of antibiot-
ics. Lesson can be drawn from such initiatives in
other developing countries such as South Africa18
and Namibia.19

Other important findings were incomplete dis-
charge summaries or referral notes with regard to
lack of complete data on antimicrobial use (in
terms of drug dosage, frequency and duration),
whether any diagnostic investigations were done,
and lack of data on culture and sensitivity reports.
These serious lapses not only highlight deficien-
cies in the management of patient but also makes
further patient management difficult. Therefore,
it must be emphasized that complete discharge
and referral notes be issued with details of treat-
ment given and details of all investigations and
interventions done in the patient.
Limitations of our study include failure to
include all patients who reported to triage area
after 5 p.m. This was largely because of limita-
tion of available resources in terms of personnel.
The study was not conducted in a period when
viral illnesses such as dengue, H1N1 swine flu
are common; therefore, results of this study may
not be representative of antibiotic prescribing
trends in such periods. Nevertheless, we pro-
spectively screened 517 patients and captured
pertinent information on 300 patients with
regard to prescription pattern of antibiotics and
identified different kinds of deficiencies in refer-
ral notes.
Our study has thus outlined the irrational antibi-
otic prescribing trends in the referral setups (both
public and private) of our country. This informa-
tion will be used to devise antibiotic guidelines for
empirical management of patients in emergency
area. Furthermore, the targets for intervention in
referring healthcare setups such as education
regarding making appropriate empiric antibiotic
choices, de-escalation, culture of sending cultures
and writing details of treatment given may be fur-
ther evaluated in future.
Conclusion
Our study brings to the fore some common but
serious lapses in antibiotic prescription patterns
in referred patients and emphasizes the need for
proper referral and appropriate use of antibiotics.
We have formulated an e-course on antimicrobial
stewardship taking into consideration the practice
settings and issues pertinent to developing coun-
tries. The findings of this study have helped in
designing some of the modules of the educational
intervention designed for healthcare settings with
absent or negligible access to training in rational
use of antimicrobials.
journals.sagepub.com/home/tai 67
A Kaur, R Bhagat et al.
Funding
The author(s) received no financial support for
the research, authorship and/or publication of
this article.
Conflict of interest statement
The author(s) declared no potential conflicts of
interest with respect to the research, authorship
and/or publication of this article.
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