{"id":19363,"date":"2018-03-25T11:30:26","date_gmt":"2018-03-25T11:30:26","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=19363"},"modified":"2020-04-23T04:47:08","modified_gmt":"2020-04-23T04:47:08","slug":"antimicrobial-utilization-in-wound-infections-in-tertiary-care-hospital","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol11no1\/antimicrobial-utilization-in-wound-infections-in-tertiary-care-hospital\/","title":{"rendered":"Antimicrobial Utilization in Wound Infections in Tertiary Care Hospital"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Drug utilization research or study was defined by WHO (World health organization) in 1977 as the study of marketing, distribution, prescription, and use of drugs in a society, with special emphasis on medical, social and economic consequences.1<\/sup>\u00a0It helps in the identification of clinical use of drugs in various populations and its impact on healthcare system.<\/p>\n

Wound infections and skin and soft tissue infections (SSTIs) are rising rapidly in the last few decades with a dramatic increase of the economic burden on the patient.2<\/sup>\u00a0They can lead to complications like bacteraemia, death,3,4<\/sup>\u00a0increased hospitalization and use of antimicrobial therapy can result in significant disability.5<\/sup><\/p>\n

Antimicrobial consumption is increasing globally. Between 2000 and 2010, consumption was increased by 35%. Russia, India, China, and South Africa accounted for 76% of this increase.6<\/sup>\u00a0Increased access to antimicrobials has lowered morbidity and mortality rates to a greater extent but also lead to development of resistance. Hence rational pharmacotherapy is the need of the hour to prevent rapidly emerging antimicrobial resistance. Efforts have been made by WHO to promote rational utilization of the drugs including antimicrobials.7<\/sup><\/p>\n

To ensure quality medical care, Drug utilization pattern studies are quite essential. It in turn helps in minimization of economic burden on patient and optimal utilization of available funds.<\/p>\n

The Present Study was Carried out with these Objectives<\/strong><\/p>\n

To assess the antimicrobial utilization pattern of patients admitted in tertiary care hospital with suspected wound and skin and soft tissue infections as per WHO drug utilization indicators.<\/p>\n

To identify the associated demographic relations and co-morbid conditions.<\/p>\n

Materials and Methods<\/strong><\/p>\n

This is a cross-sectional, record based, observational study done at NRI hospital, Guntur. After obtaining Institutional Ethics committee approval, data of patients admitted in between June 2017-October 2017 was collected from the records maintained in the Medical record section (MRD) section.<\/p>\n

Inclusion Criteria<\/strong><\/p>\n

Case sheets of patients of all ages admitted into NRI hospital with suspected wound infections and SSTIs were included in the study. Case sheets with incomplete information were excluded from the study.<\/p>\n

Sample Size Calculation<\/strong><\/p>\n

On an average, 40 cases of wound infections and SSTIs were admitted in the NRI hospital in Surgery, Ortho and Gynecology wards every month. So, the 5 months admissions were around 200.<\/p>\n

Sampling Procedure<\/strong><\/p>\n

Systematic random sampling technique was followed in choosing the sample- Collecting the data from every alternative record. Hence the sample size -100 was chosen.<\/p>\n

Data Collection<\/strong><\/p>\n

Data of demographic characteristics, drug consumption, and co-morbid conditions were collected in a designed proforma.<\/p>\n

Drug consumption was analysed by WHO drug utilization indicators8<\/sup>:<\/p>\n

Average number of drugs prescribed.<\/p>\n

Percentage of antimicrobials prescribed<\/p>\n

Percentage of antimicrobials prescribed by generic name<\/p>\n

Percentage of injections of antimicrobials prescribed.<\/p>\n

Percentage of drugs prescribed from essential drug list or formulary.<\/p>\n

Statistical Analysis<\/strong><\/p>\n

Data was expressed as numbers, percentages and mean\u00b1 S.D. All the data was entered into Microsoft office 2013 version and statistically analyzed. No statistical hypothesis was tested.<\/p>\n

Results<\/strong><\/p>\n

The data of 100 patients admitted in NRI hospital over a period of 5 months were analysed. Admissions were more in the age group below 35yrs (38 patients). Majority of the admitted patients were married.<\/p>\n\n\n\n
\u00a0\"Graph<\/td>\nGraph 1: AGE DISTRIBUTION: Range of age: 10-85 years<\/strong><\/p>\n

 <\/p>\n

Click here to View\u00a0graph<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n
\u00a0\"Graph<\/td>\nGraph 2: Gender distribution<\/strong><\/p>\n

 <\/p>\n

Click here to View\u00a0graph<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Among 100 patients, 55 pus samples and 45 wound samples were sent for culture and sensitivity test to identify the causative organism and sensitive antimicrobials. 46 samples were negative for culture and 54 were positive with Escheria .coli as main causative organism followed by staphylococcus aureus. Total 578 drugs were prescribed to 100 patients. Among them, 201 antimicrobials were prescribed to all the patients irrespective of positivity or negativity of culture test.14 patients were prescribed topical antimicrobial also to be applied on the wound mostly in the form of hydroheal gel.<\/p>\n

Results of WHO drug utilization indicators were as follows<\/p>\n

Table 1: WHO drug utilization indicators<\/strong><\/p>\n\n\n\n\n\n\n\n\n
Indicator<\/strong><\/td>\nResult<\/strong><\/td>\n<\/tr>\n
Average number of drugs prescribed per patient<\/td>\n5.78<\/td>\n<\/tr>\n
Percentage of antimicrobials among total drugs<\/td>\n34.77%<\/td>\n<\/tr>\n
Percentage of antimicrobials in generic name<\/td>\n31.8%<\/td>\n<\/tr>\n
Percentage of antimicrobial Injections<\/td>\n42.78%<\/td>\n<\/tr>\n
Percentage of antimicrobials from national list of essential medicines 2015[9]<\/sup><\/td>\n94.51%<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n\n
\u00a0\"Graph<\/td>\nGraph 3: No. of Injectable antimicrobials used among 100 patients:\u00a0<\/strong>Total 86 injections were used among 100 patients<\/strong><\/p>\n

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Click here to View\u00a0graph<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

For 36 patients, antimicrobial was changed basing on the culture and sensitivity report. Sensitive antimicrobial was prescribed.<\/p>\n

The most commonly prescribed antimicrobial after obtaining the report was Inj. Amikacin followed by Inj. Augmentin.<\/p>\n

Table 2: Diagnostic pattern of wound and skin and soft tissue infections is as follows:<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n
Diagnosis<\/strong><\/td>\n\u00a0 No of Male patients<\/strong><\/td>\nNo of Female patients<\/strong><\/td>\n<\/tr>\n
1.Abscess including liver abscess<\/td>\n15<\/td>\n8<\/td>\n<\/tr>\n
2.Post surgical wound<\/td>\n9<\/td>\n5<\/td>\n<\/tr>\n
3.Diabetic foot<\/td>\n9<\/td>\n3<\/td>\n<\/tr>\n
4.Appendicitis<\/td>\n5<\/td>\n4<\/td>\n<\/tr>\n
5.Cellulitis<\/td>\n6<\/td>\n2<\/td>\n<\/tr>\n
6.others<\/td>\n17<\/td>\n17<\/td>\n<\/tr>\n
Total<\/td>\n100<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Table 3: Associated co-morbid conditions among 100 patients:<\/strong><\/p>\n\n\n\n\n\n\n\n
Co-morbidity<\/strong><\/td>\nNumber of patients<\/strong><\/td>\n<\/tr>\n
Diabetes Mellitus<\/td>\n34<\/td>\n<\/tr>\n
Hypertension<\/td>\n21<\/td>\n<\/tr>\n
others<\/td>\n11<\/td>\n<\/tr>\n
No co-morbidity<\/td>\n34<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

The most common co morbid condition associated was diabetes mellitus.<\/p>\n

Metronidazole is the most commonly utilized antimicrobial in both tablet and injection form followed by ceftriaxone among 201 antimicrobials used for 100 patients. Ceftriaxone is prescribed as Injection Monocef in all the cases.<\/p>\n\n\n\n
\u00a0\"Graph<\/td>\nGraph 4: Antimicrobial utilization pattern among 100 patients. Y axis \u2013No. of antimicrobials<\/strong><\/p>\n

 <\/p>\n

Click here to View\u00a0graph<\/a><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

Other drugs prescribed apart from antimicrobials<\/strong><\/p>\n

63 patients were prescribed multivitamins. Cap.Becosules (Vitamin B complex) is the most commonly prescribed followed by Tab.shelcal (Calcium supplement).<\/p>\n

80 patients were prescribed anti ulcer agents also. Pantoprazole is the most commonly prescribed both in tablet and in injection form followed by Cap.Omeprazole. As antimicrobial therapy can lead to gastritis, Pantoprazole is prescribed along with antimicrobial to prevent ulcers.<\/p>\n

56 patients were prescribed analgesic most commonly in the form Tab.Ultracet(Tramadol+Acitaminophen) followed by Tab.Tramadol.<\/p>\n

Discussion<\/strong><\/p>\n

Prescriptions of 100 patients admitted in NRI hospital over a period of 5 months was analysed to know the drug utilization pattern with special emphasis on W.H.O drug use indicators. Among 100 admitted patients with wound infections and SSTIs the Mean \u00b1SD age of the patients admitted were 32.5\u00b17 years. Males (61%) are more when compared to females (39%) in our study which is same as the study done by Rutvij Hedamba et al.10<\/sup>\u00a0and contradicting with the study done by Niti Mittal Et al.11\u00a0\u00a0<\/sup>where male and female inpatients were almost equal (50.2% and 49.8%).<\/p>\n

Among 578 prescribed drugs, antimicrobials (201) were most commonly prescribed. This is in accordance with the study conducted by Dhamija P et al\u00a012<\/sup>\u00a0in the emergency medicine ward. In the study conducted by Jacob J et al13<\/sup> \u00a0in Karnataka which stood at antimicrobials were 20% of<\/sup> the total drugs prescribed.<\/p>\n

Metronidazole was the most commonly used antimicrobial as it covers both aerobic and anaerobic wound infections.<\/p>\n

Antimicrobial agents were prescribed even if the culture of pus or wound swab was negative in 46 patients in the present study. Even medical students were using antibiotics as self medication practice commonly which is irrational. The study of Ramya.R et al14<\/sup>\u00a0proved that antimicrobials usage incidence was as high as 24% among medicos. There should be a limit to the frequent and inappropriate prescription of antimicrobials especially the newer and costlier agents. An important step to avoid this could be implementation of antibiotic restriction program. The success of this program in has been proved previously.1<\/sup>5<\/sup>\u00a0<\/sup>Another useful strategy might be making prescription practice guidelines accessible to all the physicians before making clinical decisions.1<\/sup>6<\/sup>\u00a0<\/sup>The use of biomarkers like Procalcitonin helps in reducing the antimicrobial misuse. It has been identified as a surrogate marker for estimating the likelihood of a bacterial infection.1<\/sup>7<\/sup><\/p>\n

Diabetes and hypertension were the two most commonly associated co-morbid illnesses which are in accordance with the study done by Dawalji S et al.18<\/sup><\/p>\n

The median duration of stay in the hospital was 7 days in our study. In the study done by Tavallaae M et al.19<\/sup>\u00a0the average duration of stay is around 5 days among intensive care unit patients.<\/p>\n

On average 5\u00b12 drugs were prescribed for 100 patients. It is differing with the study done by Muhit MA et al.20<\/sup><\/p>\n

Percentage of drugs prescribed by their generic name was 28.8% in our study .It is contradicting with suggestions of W.H.O which advised 100%8<\/sup>\u00a0Generic drug prescriptions in our study was less when compared to study done by Maharani et al.21<\/sup><\/p>\n

Majority of the drugs (94.51%) were from National list of essential medicines 2015-India which is more compliant than W.H.O recommendation of 70%.<\/p>\n

Lethal adverse events observed during the study period were nil.<\/p>\n

Our study has few limitations. It was conducted in a single tertiary care centre, so the results cannot be extrapolated to the general population. Pharmaco-economic analysis was not done.<\/p>\n

Conclusion<\/strong><\/p>\n

This drug utilization study has highlighted the strengths and shortcomings of the drug utilization pattern of patients admitted in a tertiary care hospital. The information derived from this research work will be handed over to the stakeholders for implementing the modifications wherever needed for the betterment of the patient and the community.<\/p>\n

Acknowledgement<\/strong><\/p>\n

The authors would like to thank Medical Record Section, NRI hospital for their valuable help in data collection.<\/p>\n

Conflicts of Interest<\/strong><\/p>\n

There is no conflicts of interest<\/p>\n

Funding sources<\/strong><\/p>\n

There is no funding sources<\/p>\n

References<\/strong><\/p>\n

    \n
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  2. Esposito S,\u00a0Noviello S,\u00a0Leone S. Epidemiology and microbiology of skin and soft tissue infections.\u00a0Curr Opin Infect Dis.\u00a0<\/em>2016 Apr;29(2):109-15. doi: 10.1097\/QCO.0000000000000239.
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  21. \u00a0Maharani1 B, Lourdu A, Jafrin M, Prakash P. Priyadarshini.Prescription pattern of patients admitted in the intensive care unit of a tertiary care hospital in Puducherry, India: a cross sectional study.\u00a0IJBCP.<\/em>\u00a0 2017 Dec; 6(12):2822-2826.
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