|Year : 2020 | Volume
| Issue : 2 | Page : 103-108
Antimicrobial prescription pattern in a tertiary hospital
Adebola Tolulope Olayinka1, Olanrewaju Jimoh1, Joan Ejembi1, Oluwafemi Temidayo Ige1, Zainab Lamido1, Abdulrasul Ibrahim1, Victoria Aganabor2, Busayo Olayinka3
1 Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Department of Medical Nursing Services, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
3 Department of Pharmaceutical Microbiology, Ahmadu Bello University, Zaria, Nigeria
|Date of Submission||17-Apr-2018|
|Date of Decision||29-Oct-2018|
|Date of Acceptance||06-Dec-2018|
|Date of Web Publication||10-Jul-2020|
Dr. Joan Ejembi
Department of Medical Microbiology, Ahmadu Bello University Teaching Hospital, Zaria
Background: Antimicrobials are nonreplaceable in the treatment of bacterial infections and thus should be used judiciously. In Nigeria, there is currently no restriction on the prescription and sale of antimicrobials. This study was conducted to assess the antimicrobial prescription pattern of physicians at a tertiary hospital in Northwestern Nigeria. Materials and Methods: A point prevalence survey was carried out among all inpatients at Ahmadu Bello University Teaching Hospital in June 2015. Those receiving an antimicrobial agent during the survey period were included in the study while patients admitted on the day of the survey were excluded from the study. Data were obtained using a structured interviewer-administered questionnaire and abstraction from patient records. Information obtained included demographic data, antimicrobial agents prescribed, indication for treatment, laboratory data, and stop/review dates of prescriptions. Data were analyzed using SPSS version 20.0. Results: Twenty-three wards with a total number of 318 inpatients were enlisted. Of these, 210 (66%) patients were on treatment with antimicrobials. Male: female ratio of patients on antimicrobials was 1.2:1, and age of respondents ranged from 1 day (0.0027 years) to 75 years. The overall antimicrobial prevalence rate was 210 (66%) with surgical prophylaxis 100 (47.6%) as the most common indication. Overall, 332 antimicrobials were prescribed with cephalosporins as the most common class prescribed 96 (28.9%). Majority of the prescriptions (328, 98.8%) were based on empirical treatment, 288 (86.7%) were open prescriptions, and only 4 (1.2%) were according to treatment guidelines. Conclusion: The high prevalence of antimicrobial use highlights the need for an antimicrobial stewardship program in this facility.
Keywords: Antimicrobial prescription, prevalence rate, stewardship program
|How to cite this article:|
Olayinka AT, Jimoh O, Ejembi J, Ige OT, Lamido Z, Ibrahim A, Aganabor V, Olayinka B. Antimicrobial prescription pattern in a tertiary hospital. Sahel Med J 2020;23:103-8
|How to cite this URL:|
Olayinka AT, Jimoh O, Ejembi J, Ige OT, Lamido Z, Ibrahim A, Aganabor V, Olayinka B. Antimicrobial prescription pattern in a tertiary hospital. Sahel Med J [serial online] 2020 [cited 2020 Aug 13];23:103-8. Available from: http://www.smjonline.org/text.asp?2020/23/2/103/289346
| Introduction|| |
Globally, there has been reported increase in antimicrobial resistance. This is made worse by factors of antimicrobial abuse which includes unrequired/unnecessary prescription, subdosage, poor patient compliance to prescription, and also the prevalence of substandard drugs., Several studies have linked antimicrobial consumption to antimicrobial resistance as the exposure of microorganisms to antimicrobial agents enables them to develop resistance over time., The continual exposure of microorganisms to antimicrobial agents enables the organisms to develop mechanisms to ensure their survival so that the progeny of the resistant strain is unaffected by the drug and has the capability of producing disease while the sensitive strains are exterminated. This process, also known as selective pressure, has been a main contributor to antimicrobial resistance. It is difficult to predict how quickly resistance will develop as it depends on the type of antimicrobial agent, type of microorganism, level of exposure to the antimicrobial agent, and ability of the resistant microorganism to survive and replicate. Antimicrobial resistance makes it harder to eliminate infection from the body as drugs usually used for treatment are less effective, leading to higher cost of treatments, prolonged hospital stay, increase in morbidity, and mortality., Hence, the need for policies to regulate antimicrobial usage and institution of programs which will regulate antimicrobial use such as an antimicrobial stewardship (AMS) program provides.
AMS refers to coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy, and route of administration. AMS program reduces unnecessary antimicrobial consumption and inappropriate use. It is also important in increasing adherence to treatment guidelines. The results of AMS programs are reduction in antimicrobial resistance and drug adverse effects while also improving patient outcomes.
In view of the attendant consequences of indiscriminate use of antimicrobials, this study was conducted to determine the prevalence of antimicrobial use within our facility and identify indicators associated with antimicrobial prescription pattern in a university teaching hospital in Zaria, Northwestern Nigeria, with a view to developing an AMS program in the facility.
| Materials and Methods|| |
This study was conducted in Ahmadu Bello University Teaching Hospital (ABUTH) in Northwestern Nigeria. It serves as a referral center for patients from northwestern Nigeria. The 650 bed hospital has 23 inpatient wards which reflect the various subspecialties in medicine and surgery with categorization based on age and sex. The major wards are medical; surgical; intensive care; psychiatry; ear, nose, and throat; obstetrics and gynecology; and orthopedic wards with adult male, female, and pediatric subsections. It also has a pharmacy with satellite sites at various locations within the hospital complex as well as laboratory support services, radiologic services, and other facilities. The hospital has an Infection Control Committee but as at now no AMS program, nor has an antimicrobial policy been developed or instituted.
In this prospective study, a point prevalence survey was conducted in June 2015 at ABUTH among all patients on admission in the 23 hospital wards. For ease of analysis, the wards were merged into eight parent wards, namely neonatal intensive care unit (NICU), pediatric medical, pediatric surgical, adult medical, adult surgical, orthopedic, obstetrics and gynecology, and psychiatry wards.
The study population consisted of all the inpatients being treated with an antimicrobial agent as at the time of survey while patients admitted on the day of the survey were excluded from the study.
Data collection and analysis
Data were collected using a structured form for abstraction from medical records and informal interview of managing health care workers on sociodemographics, antimicrobial agents used, indication for antimicrobial treatment, use of treatment guidelines, laboratory microbiological data, and antimicrobial stop/review dates. A web based application designed by the University of Antwerp was used for data entry (http://www.global pps.com). Data obtained were analyzed using SPSS version 20.0 (IBM SPSS Statistics 20.0, IBM Corp, Armonk New York, United States).
Categorical variables are presented as percentages. Descriptive data analysis was done using tables of frequency and charts. The guidelines for 2013 Geneva declaration was adhered to. The denominator used for antimicrobial prevalence rate (AMR) was the total number of patients on admission as at the time of survey.
The following operative definitions were used.
- AMR: Proportion of patients on admission during survey period being treated with an antimicrobial agent
- Targeted prescription: Any prescription of an antimicrobial agent guided by laboratory bacteriological profile and sensitivity pattern of microorganisms
- Empirical prescription: Any prescription of an antimicrobial agent not guided or based on laboratory bacteriological profile and sensitivity pattern of microorganisms
- Antimicrobial stop/review date: Any prescription in which the time to cease administration of antimicrobial agent prescribed is stated or date of review of prescription is stated
- Open prescription: An antimicrobial prescription in which the duration of administration of antimicrobial agent is not stated
- Guideline compliance: Refers to antimicrobial choice in accordance with local/available scientific clinical guidelines.
Ethical clearance for the study (ABUTHZ/HREC/W30/2015) was obtained from Ahmadu Bello University Teaching Hospital Health Research and Ethic Committee on 15th June 2015. The study was conducted as an operational research by the infection prevention and control unit of the hospital, and consent was obtained from each patient whose data were abstracted.
| Results|| |
Overall, 318 patients were on admission during the survey period, of which 210 (66%) who were on treatment with antimicrobial agents were recruited for the study. More than half of the patients, i.e., 114 (54.3%) were male with a male: female ratio of 1.2:1, and median age in years for older children and adults was 35 years (range: 2–75 years), of infants 9 months (range: 2–21 months), and of neonates 8 days (range: 1–30 days). The ward with the most number of recruited patients was the adult surgical ward with 52 patients (24.8%), followed by adult medical ward with 47 (22.4%) and pediatric medical ward with 34 patients (16.2%) [Table 1]. The overall AMP was 66% (210) and ward AMP ranged from 5.6% (1 of 18 patients on admission) in the psychiatry ward to 93.8% (15 of 16 patients on admission) in the NICU [Table 2]. Among the 210 patients recruited, the common indications for antimicrobial use were surgical prophylaxis 100 (48%), community-acquired infection 57 (27%), medical prophylaxis 28 (13%), health-care-associated infection 5 (2%), and others (1%) with unknown indications in 18 (9%) patients [Figure 1]. A total of 332 antimicrobials were prescribed, and the commonly prescribed classes of antimicrobials were cephalosporins 96 (28.9%) and imidazoles 70 (21.1%), followed by quinolone and penicillin combinations 49 (14.8%). The common drugs prescribed from each class were ceftriaxone 63.5% (61/96), metronidazole 100%, and ciprofloxacin 89.8% (44/49) [Table 3]. The maximum number of antimicrobial agents prescribed for a patient was four. Approximately half of the patients, i.e., 102 (48.6%) had one antimicrobial agent prescribed while 97 (46.2%) had two antimicrobial agents prescribed and only 4 (1.2%) patients had at least four antimicrobial agents prescribed [Figure 2]. Majority of the prescriptions (328, 98.8%) were based on empirical antimicrobial treatment, 288 (86.7%) were open prescriptions with no review/stop date documented, and only 4 (1.2%) of the prescriptions were according to treatment guidelines [Table 4].
|Table 1: Demographic characteristics of inpatients receiving antimicrobial treatment in July 2015|
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|Figure 1: Indications for prescription of antimicrobial agents among inpatients June 2015|
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|Table 3: Commonly prescribed antimicrobials agents among inpatients June 2015|
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|Figure 2: Distribution of inpatients by number of antimicrobial agent prescribed June 2015|
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|Table 4: Quality indicators of antimicrobials prescribed at Ahmadu Bello University Teaching Hospital June 2015|
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| Discussion|| |
AMR is high in this facility as compared to what has been documented in other teaching hospitals in the north west and south west of Nigeria and in Ethiopia another African country where lower rates of 34.4%, 49.2%, 36.2%, and 35.5% were found.,, The high prevalence observed in our study may be explained by the fact that the information extracted were from records of patients on admission who are more likely to require antimicrobials compared to out-patients. This finding further corroborates the observation that there is irrational use of antimicrobials in developing countries., The reason for this observed prevalence may be due to the fact that most prescriptions are empiric rather than targeted and so people who might not necessarily need antibiotics are being treated with antibiotics. Furthermore, a high proportion of prescriptions were open which also contributes to high antimicrobial use as medications may be given for longer periods than originally intended or indicated. It has been documented that more than half of hospital patients are exposed to antibiotics in one form or the other. This study was conducted among hospital patients on admission, and thus, there is a higher chance of antimicrobial use because of severity of patients' conditions requiring hospital admission and other indications for antimicrobial use. In a similar survey conducted at a teaching hospital in Canada, AMR was found to be lower than ours, and this is most likely due to the institutionalized AMS program at that center limiting the unnecessary use of antimicrobials. In addition, the hospital is located in a developed country where targeted prescribing and use of guidelines are institutionalized as compared to our study which was conducted in a developing country.
Based on the ward or unit, antimicrobial prevalence was found to be highest in the NICU. This is expected considering that an intensive care unit has patients with severe disease conditions, and in our setting, one of the common causes of illness in the NICU is infectious diseases. Furthermore, it is documented that antibiotics are the most commonly prescribed medications in NICUs, and in industrialized countries, about 1% of neonates are exposed to antibiotic therapy. The psychiatry ward where most patients on admission have noninfectious and nonsurgical pathologies had the lowest AMP. Medical and surgical wards had higher AMP with higher rates in pediatric than adult patient wards. This could also be explained by the underlying conditions which are infectious in origin or the need for prophylaxis in the case of surgical patients.
High antibiotic use for surgical prophylaxis and poor adherence to guidelines observed in this study was similar to a study in Qatar. In all cases, surgical prophylaxis was given for more than 24 h. In our setting, there were few available guidelines supporting prescriptions for various conditions, and the absence of this also fosters the unnecessary use of antimicrobials, especially the broad-spectrum antimicrobial agents.
The high usage of cephalosporin and quinolones observed in this study is similar to studies in France and the national ICU study in the US which was associated with increase in resistance to those agents secondary to high usage., Cephalosporin were the most commonly used antimicrobial agents in this study which is comparable to studies elsewhere in Nigeria, Ethiopia and India.,, However, in a study conducted in Kano Nigeria, quinolones were the antimicrobial agents commonly prescribed. The difference observed may be due to preferences of managing physicians coupled with the lack of or poor adherence to treatment guidelines.
The fact that only a minimal proportion of patients were being treated with up to four antimicrobial agents at a time is encouraging. This is because the more the number of agents being administered at a time, the higher the chance of drug interaction and poor compliance which can also propagate antimicrobial resistance.
We observed nonadherence to guidelines in this study which is similar to studies in Netherlands, India, West Bank Palestine, and Dubai.,, In The Netherland study, reasons proffered for failure of adherence to guidelines included lack of agreement to the guidelines due to lack of applicability or lack of evidence, no knowledge about existence of such guidelines, and other factors such as unclear or ambiguous guidelines. This may also be applicable in our own setting where guidelines are absent from the facilities and where present, these guidelines need to be revised regularly.
| Conclusion|| |
A high prevalence of antimicrobial utilization was observed in this facility. Factors identified include the lack of treatment guidelines and the practice of empiric therapy.
The outcome of this survey has brought to fore the urgent need for an AMS program in this facility to reduce the unnecessary and unguided use of antimicrobial agents. This will include the development and adherence to guidelines and increased utilization of laboratory services, thus highlighting the need for laboratory system and structural strengthening.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]