Evaluation of anti-microbial usage using world health organization-anatomical therapeutic chemical methodology in tertiary care teaching hospital of Central India: A cross-sectional study :Alok Singh, Ajaya Kumar Sahoo, Suryaprakash Dhaneria, Pugazhenthan Thangraju, Dhyuti Gupta, Archives of Medicine and Health Sciences

SHORT COMMUNICATION
Year : 2021 | Volume : 9 | Issue : 1 | Page : 181--185

Evaluation of anti-microbial usage using world health organization-anatomical therapeutic chemical methodology in tertiary care teaching hospital of Central India: A cross-sectional study

Alok Singh, Ajaya Kumar Sahoo, Suryaprakash Dhaneria, Pugazhenthan Thangraju, Dhyuti Gupta
Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

Correspondence Address:
Dr. Alok Singh
Department of Pharmacology, All India Institute of Medical Sciences, Raipur, Chhattisgarh
India

Abstract

Antimicrobial agents are the most common group of drugs prescribed, especially in inpatients, as well as contribute highest in the drug-related expenses. To gather an overview regarding the utilization pattern of antimicrobials among hospitalized patients, this retrospective study was conducted for the patients admitted in 2019. The present study was conducted at All India Institute of Medical Sciences Raipur, wherein the 600 medical records (50*12) of different departments for the year 2019 were chosen randomly for evaluation. Information regarding the number of beds, occupancy, demography, strength, route, and amount of drug that prescribed was noted for each month. Antimicrobial utilization was performed using the World Health Organization Anatomical Therapeutic Chemical/Defined Daily Dose (DDD) methodology. Antimicrobial drugs which were prescribed at least 5% of patients were evaluated in detail, and their prescribed daily dose (PDD) and anti-microbial consumption index was calculated and compared with their defined-daily dose. Monthly consumption of antimicrobials was noted and summed to get consumption for the whole year. Most of the records encountered while collecting data were of female patients, with an overall mean age of 42.4 years. Moreover, the records were largely from the patients who were admitted in either of the surgical departments. For the in-patients with an average duration of hospitalization of 6.56 days, the mean number of antimicrobials prescribed per prescription was observed to be 1.41. Highest consumption units were of ceftriaxone in 2019. The PDD of azithromycin and piperacillin + tazobactam was different from their DDD. For majority of antimicrobials, the calculated PDD was close to their DDD. The consumption was noted to be disproportionately higher in the 4 months of 2019 (September–December). Moreover, ceftriaxone was found to be prescribed routinely in the clinical practice.

How to cite this article:
Singh A, Sahoo AK, Dhaneria S, Thangraju P, Gupta D. Evaluation of anti-microbial usage using world health organization-anatomical therapeutic chemical methodology in tertiary care teaching hospital of Central India: A cross-sectional study.Arch Med Health Sci 2021;9:181-185

How to cite this URL:
Singh A, Sahoo AK, Dhaneria S, Thangraju P, Gupta D. Evaluation of anti-microbial usage using world health organization-anatomical therapeutic chemical methodology in tertiary care teaching hospital of Central India: A cross-sectional study. Arch Med Health Sci [serial online] 2021 [cited 2023 Mar 23 ];9:181-185
Available from: https://www.amhsjournal.org/text.asp?2021/9/1/181/319390

Full Text

Introduction

Drug utilization research, as defined by the World Health Organization (WHO), is the marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social, and economic consequences.[1] Therefore, it can be acknowledged that drug utilization studies are a fundamental part of pharmacoepidemiology, helping in recognizing the extent, nature, and determinants of drug exposure, especially of those which are over-utilized. Moreover, for a densely populated country like India which has a higher prevalence and incidence of infectious diseases, such studies are important.[2] The contribution to the development of antimicrobial resistance is not only by massive population but also by inappropriate or irrational prescription or use of antimicrobials, access without adequate prescription, and the huge burden of resistant microorganisms.[3] However, the resultant effect of incoherent use is just not restricted to patients (as in adverse effects, increased treatment costs), there is a negative impact on the hospital microbial environment as well (triggering superbugs and superinfections, reduced choices for treating a severe infection). To gauge the consequences of such inordinate utilization, the WHO came up with Anatomical Therapeutic Chemical/Defined Daily Dose (ATC/DDD) system to provide a uniform tool for monitoring drug utilization, wherein every antimicrobial has been assigned an average maintenance dose per day, for its main indication in adults, along with an ATC code.[4] While another indicator, DDD per 100 bed days provides a measure of antimicrobial consumption by inpatients.[5] This study was conducted on similar pattern, to assess the antimicrobial consumption for a year (2019), in our tertiary care hospital.

Materials and Methods

Study design

This was a cross-sectional study, conducted in collaboration with medical record department, and due approval for the same from Institute Ethics Committee (vide letter no. AIIMSRPR/IEC/2019/311 dated 05.08.2019) was already obtained.

Settings

This antimicrobial utilization study was first of its kind in our institute. The data collection was done from December 2019 to March 2020 by analyzing the medical records of patients who got admitted in 2019. There has been a continuous rise in the inpatients, i.e., 13,417 in the 2018 calendar year increased to 21,387 in 2019.

Study size

To conduct an appropriate antimicrobial utilization study, the WHO has defined that a minimum of 600 medical records for a year should be evaluated. For year 2019, three of the authors analyzed medical records by visiting medical records department (MRD). Fifty records from each month were chosen by the systematic random sampling technique, and relevant data were collected from them.

Outcome measures and data sources

Hospital statistics, i.e. the number of inpatients (department wise), beds, and occupancy were provided for each month by the MRD. The medical records which were selected were first scrutinized for the completeness, and then various prescription parameters such as name of the antimicrobial, strength and dosage form and amount, and whether prescribed by generic name or not were noted. Simultaneously, National List of Essential Medicines (NLEM) 2015 was reviewed to check whether the prescribed antimicrobial agent is from essential drug list or not.[6] Concurrently, data regarding patients' demographical characteristics, i.e. patients' record number, age, sex, diagnosis, and, duration of hospitalization were also collected. The medical records of pediatric patients were excluded from evaluation. Anti-microbial agents which were prescribed in at least 5% of patients in each month were evaluated in detail assuming they were the most commonly prescribed. We evaluated the following parameters:

Average duration of stay (excluding the day of discharge)Average number of anti-microbial per medical recordPercentage of anti-microbial prescribed by generic namesPercentage of anti-microbial belonging to the essential drug listDDD units, prescribed daily dose (PDD), and Anti-microbial Consumption Index (ACI).[7]

Bias

Despite fulfilling guidelines of sample size provided by the WHO, the 600 medical records screened may not provide exact representation of anti-microbial utilization pattern. An increase in the number of beds may be a source of bias, as this would relatively bring about an increment in patient admission and thus antimicrobial consumption.

Statistical methods

The data have been presented using suitable statistical parameters, i.e. as mean, range, and percentage.

Results

The study was conducted in association with the MRD from December 2019 to March 2020. During the year 2019, a total of 21387 patients were admitted, and the number of functional beds increased from 600 to 700 with a 63.2% occupancy rate (51–75.8%). A total of 600 randomly chosen medical records containing 3018 treatment charts with anti-microbial prescriptions were evaluated. Each treatment chart containing anti-microbial for an individual day was counted separately. In general, in our institute, a higher number of patient admissions occurred in the surgical department (60%) as compared to nonsurgical ones. Moreover, this similar pattern was reflected in our sample, wherein 66.8% of medical records belonged to either of the surgical specialties.

The major reasons for hospitalization were either elective or emergency surgical procedures or exacerbation of pre-existing medical illnesses. Majority of medical records (52.5%) belonged to the female patients. Moreover, the mean age of the admitted patients was 42.4 years. On an average, a patient would have hospital stay of 6.56 days (1–22 days).

For the whole year, the average number of anti-microbial agents prescribed per prescription was 1.41 (1.27–2.22). Moreover, more than half of the anti-microbial (57%) were prescribed by their generic name. During data analysis, we found that a total of 32 anti-microbial agents had been prescribed, out of which 84.3% were from NLEM 2015 [Table 1] and 09 were prescribed in at least 5% of the patients.{Table 1}

[Table 2] represents the detailed evaluation of these 09 frequently prescribed antimicrobial agents, i.e. month-wise and cumulative consumption for 2019 represented as DDD units, their PDD, and ACI. The highest ACI was found to be of ceftriaxone. Furthermore, the PDD and DDD of majority of anti-microbial agents were similar, except for azithromycin and piperacillin + tazobactam. The DDD units are mentioned in [Table 2].{Table 2}

After carefully analyzing the consumption values of anti-microbial agents for different months, a disproportionately higher consumption was noted in the last 4 months of the year (September–December 2019) which is usually expected to contribute to approximately one-third of the whole year consumption. Therefore, we analyzed all the relevant parameters and made a comparison between data of the first 8 months with the last 4 months [Table 3]. Upon observation, we found out that in the last 4 months, the mean number of functional beds and their occupancy increased by 50% and 8.2%, respectively, as compared to mean annual value. Similarly, the mean duration of hospital stay and mean number of anti-microbials per prescription escalated by 0.4 days and 0.02, respectively. Among the total medical records analyzed, 40% belonged to the last 4 months. This pattern was detected in both surgical and nonsurgical specialties. In the last 4 months, the consumption of all the anti-microbial agents increased (except for ciprofloxacin), and hence contributed to ≥40% of their annual consumption. The consumption in the last 4 months for piepracillin + tazobactam and metronidazole was the highest, i.e., 57.1%and 48%, respectively, of the annual value [Table 2].{Table 3}

Discussion

The period, for which the study was conducted, we could observe a consistent increase in the number of functional beds and their occupancy, indicating that our institute is in the growing phase. Since the sample taken represents the medical records accurately, this adds more validity to our findings. Although the mean duration of admission in our study was similar to the previous study, on the contrary, the medical records of female patients were more as compared to males.[8] The anti-microbial drugs prescribed by their generic name and the agents belonging to the essential medicine list were far from their optimal value prescribed by the WHO and it was different from previous studies.[9],[10],[11] Ceftriaxone was the most commonly prescribed agent akin to the previous study.[12] The equivalent values of PDD and DDD indicate the adherence to the standard guidelines of antimicrobial prescriptions; however, azithromycin and piepracillin + tazobactam were the exception. The PDD of azithromycin and piepracillin + tazobactam was more and less, respectively, as compared to their respective DDD which is not up to the mark as far as the dose is considered.[13]

The consumption of most antimicrobial agents increased in the last 4 months of the year. We did not observe maximal consumption for a particular month (September) as noted in previous studies; however, the consumption in this particular month was considerably higher than the others.[14],[15] The maximum consumption of antimicrobial in the last 4 months is mostly similar to the findings of previous study.[15] In our region, these are the months succeeding monsoon season, which can be related to the fact that post rainy season, due to poor sanitation and water contamination, there is an increase in the risk of contracting infectious diseases. The patients who have to undergo elective surgery plan so in the months of winter season, the season which is known to bring about an exacerbation in the pre-existing medical illnesses. These enlisted environmental factors could be another reason why there is a surge in the use of antimicrobials, especially in the last 4 months of year. Apart from this, the hospital-related factors, like increment in bed numbers as well as occupancy, could possibly be another reasons.

Disease severity may be another reason for this observation reflected by a more average duration of stay. The consumption of piepracillin + tazobactam and metronidazole was increased greatly in last 4 months of year [Table 2]. Their wider spectrum (against Gram positive, Gram negative, and anaerobic pathogenic microbes) and activity against resistant organisms possibly explain their higher use.

Limitations

The limitations of the study are as under:

Antimicrobial agents which were prescribed ≥5% were only evaluated.The study gives the data from one institution only.Cost-analysis was not performed.

Conclusion

Despite these limitations, the study gives a generalized overview of antimicrobial consumption. Based on the results, it can be deduced that there is a need to organize frequent sensitization programs toward the rational use of drugs to improve the prescription indicators. A more accurate result would have been obtained had the number of beds remained constant throughout the year. These findings can act as a baseline data for comparing similar indicators at various levels of health facility. The present work can be extended for a longer duration which will not only increase the accuracy but will also provide comprehensive results.

Acknowledgments

The authors would like to thank Mr. Kalleshwara Iyyanahalli (In-charge MRD) for his support during the study.

Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

References

1	World Health Organization. Introduction to Drug Utilization Research. Geneva: World Health Organization; 2003. Available from: https://www.whocc.no/filearchive/publications/drug_utilization_research.pdf. [Last accessed on 2020 Jun 29].
2	Dikid T, Jain SK, Sharma A, Kumar A, Narain JP. Emerging and re-emerging infections in India: An overview. Indian J Med Res 2013;138:19-31.
3	Dixit A, Kumar N, Kumar S, Trigun V. Antimicrobial resistance: Progress in the decade since emergence of New Delhi metallo-β-lactamase in India. Indian J Community Med 2019;44:4-8.
4	History of ATC/DDD Methodology. Available from: https://www.whocc.no/atc_ddd_methodology/history. [Last accessed on 2020 Jun 30].
5	Use of ATC/DDD Methodology. Available from: https://www.whocc.no/use_of_atc_ddd/#indica. [Last accessed on 2020 Jun 30].
6	National List of Essential Medicines; 2015. Available from: https://www.mohfw.gov.in/sites/default/files/NLEM%2C%202015.pdf. [Last accessed on 2020 Jun 30].
7	Sözen H, Gönen I, Sözen A, Kutlucan A, Kalemci S, Sahan M. Application of ATC/DDD methodology to evaluate of antibiotic use in a general hospital in Turkey. Ann Clin Microbiol Antimicrob 2013;12:23.
8	Sahoo AK, Gupta D, Dhaneria S, Thangaraju P, Singh A. Retrospective analysis of drug prescription statistics in a tertiary care center in India: Recommendations for promoting prudent utilization of drugs. J Res Pharm Pract 2020;9:146-50.
9	Atif M, Azeem M, Sarwar MR, Shahid S, Javaid S, Ikram H, et al. WHO/INRUD prescribing indicators and prescribing trends of antibiotics in the Accident and Emergency Department of Bahawal Victoria Hospital, Pakistan. Springerplus 2016;5:1928.
10	Atif M, Sarwar MR, Azeem M, Naz M, Amir S, Nazir K. Assessment of core drug use indicators using WHO/INRUD methodology at primary healthcare centers in Bahawalpur, Pakistan. BMC Health Serv Res 2016;16:684.
11	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.
12	Kaur A, Bhagat R, Kaur N, Shafiq N, Gautam V, Malhotra S, et al. A study of antibiotic prescription pattern in patients referred to tertiary care center in Northern India. Ther Adv Infect Dis 2018;5:63-68.
13	Mamo DB, Alemu BK. Rational drug-use evaluation based on world health organization core drug-use indicators in a tertiary referral hospital, Northeast Ethiopia: A cross-sectional study. Drug Healthc Patient Saf 2020;12:15-21.
14	Chandy SJ, Thomas K, Mathai E, Antonisamy B, Holloway KA, StalsbyLundborg C. Patterns of antibiotic use in the community and challenges of antibiotic surveillance in a lower-middle-income country setting: A repeated cross-sectional study in Vellore, South India. J Antimicrob Chemother 2013;68:229-36.
15	Farooqui HH, Selvaraj S, Mehta A, Heymann DL. Community level antibiotic utilization in India and its comparison vis-à -vis European countries: Evidence from pharmaceutical sales data. PLoS One 2018;13:e0204805.