|Year : 2020 | Volume
| Issue : 2 | Page : 109-115
Outpatient prescribing and antibiotic use for children in a tertiary hospital
Lawal Waisu Umar1, Abdulmuminu Isah2, Shuaibu Musa3, Bilkisu Umar4
1 Department of Paediatrics, Ahmadu Bello University, Zaria, Nigeria
2 Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria, Nsukka, Enugu State, Nigeria
3 Department of Paediatrics, Kaduna State University, Kaduna, Kaduna State, Nigeria
4 Department of Pharmaceutical Services, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Submission||24-May-2018|
|Date of Decision||16-Jul-2018|
|Date of Acceptance||02-Nov-2018|
|Date of Web Publication||10-Jul-2020|
Dr. Lawal Waisu Umar
Department of Paediatrics, Ahmadu Bello University, Zaria, Kaduna State
Background: Rational prescribing is essential to prevent medication errors, antibiotic resistance, and treatment failure. Assessment of prescribing practices helps monitor the utilization of medicines. Objectives: The aim of this study was to evaluate the prescribing pattern and utilization of antibiotics for children attending outpatient units. Materials and Methods: This was a descriptive, retrospective study of outpatient pediatric prescriptions received at the pharmacy of a Nigerian teaching hospital, using the World Health Organization (WHO) core prescribing indicators and Index of Rational Drug Prescribing (IRDP). Prescription information for a 2-year period was collected on a standardized prescribing form. Computer data entry was made into Microsoft Excel 2010 spreadsheet. Data analysis was done using SPSS Version 20(IBM, Corp., Armonk, NY, USA). Results were compared with the WHO core prescribing indicators and presented as means, frequencies, proportions, contingency tables, and charts comparing with published standards. Results: There were 3445 eligible prescriptions, with mean child age of 3.2 (±2.9) years. An average of 2.4 (±1.6) drugs were prescribed per encounter, with 48.2% written in generic names. Prescriptions containing oral antibiotics and antibiotic injections constituted 50.2% and 41.2%, respectively. Medicines prescribed were available in the essential medicines list in 95.5% of cases. The IRDP was 2.98 against the ideal of 5. Majority (71.3%) of antibiotic-containing prescriptions had one antibiotic prescribed while β-lactam penicillins and cephalosporins were the most prescribed, with ampicillin/cloxacillin being the most common combination. Conclusion: Irrational prescribing and inappropriate antibiotic use were prevalent in this tertiary hospital. Similar studies are needed to describe the trends in all Nigerian tertiary hospitals, along with retraining on rational prescribing.
Keywords: Antibiotics, children, essential medicines, outpatient, rational prescribing, tertiary hospital
|How to cite this article:|
Umar LW, Isah A, Musa S, Umar B. Outpatient prescribing and antibiotic use for children in a tertiary hospital. Sahel Med J 2020;23:109-15
| Introduction|| |
The irrational use of medicines encompasses errors of polypharmacy, inappropriate use of antibiotics, overuse of injections, and prescribing contrary to clinical practice guidelines.,The World Health Organization (WHO) has defined the rational use of medicines as when “patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community”., Although a worldwide problem, the prevalence of irrational drug use is higher in developing countries where infectious disease burden is higher, with limited choices of antibiotics and other drugs, and further worsened by poor regulation of the use of medicines. Prescribing for children poses daunting challenges because medication dosages are most often weight-based and require meticulous calculations. Wrong prescribing is among the most common types of medication errors in pediatric prescriptions., A systematic review of literature has revealed an incidence of dosing errors up to 500,000/year in pediatric prescriptions in the UK.
The consequences of irrational use of medicines may be more in children, especially as studies have revealed that younger children receive more prescriptions with the highest rates observed in preschoolers and infants. Such consequences include adverse effects, poor treatment outcome due to the development of antibiotic resistance, increase in health-care costs for families, and increased burden on National Health Systems.,, The irrational use of parenteral medication is also common and the WHO estimates suggest that up to 16 billion injections are prescribed annually worldwide, with over 70% being unnecessary and with the risk of transmission of bloodborne infections.
The WHO has developed quantitative indicators that measure the prescribing practices of health-care providers, which are adopted as global standards to assess for rational drug use and level of implementation of antimicrobial stewardship. The WHO prescribing indicators and the Index of Rational Drug Prescribing (IRDP) represent minimal standards for rational drug use for monitoring and problem identification.,,,
To facilitate the rational use of medicines, the WHO has been advocating the concept of essential medicines over the last three decades and has developed policies to promote the quality use of medicines (QUM). The analysis of data on ten validated QUM indicators obtained from the WHO databases for 56 low- and middle-income countries for 2002–2008 revealed that 27 out of 38 WHO recommendations on essential medicine policies were associated with improved QUM. Figures for Nigeria indicated a 53.5% rate of prescribing of antibiotics, 86.8% of prescribed medicines present in the essential medicines list (EML), 41.8% rate of prescribing with generic names, and 10.95% rate of prescribing with injectable drug.
The major determinants of prescribing practices include influences of mentors and that of pharmaceutical sales representatives as well as peculiarities that differ between patients.,, For instance, Ljungberg et al., De Souza et al., and Oshikoya et al. have found that postgraduate trainees in teaching hospitals exhibited prescribing habits suggestive of immediate influence of more senior physicians and peer colleagues, respectively, whom they tended to emulate in a didactic routine.,, Other studies in developing countries using the WHO indicators on outpatient pediatric populations have shown a general trend toward irrational drug use. Such reports from Nigeria identified irrational use of antibiotics, polypharmacy, nonadherence to generic prescribing, and high use of injections., In Sierra Leone, Cole et al. reported an average of 3.77 drugs/prescription, 71% written with generic names, 74.8% had antibiotics, 21.1% had injections, and 70.6% available in the EML, with an IRDP of 2.71. In India, Sharma and Shweta  found 75.1% of pediatric medicines available in the EML, an average of 1.9 drugs/encounter, 60.2% written with generic names, with 25.7% and 4.1% of encounters containing antibiotics and injections, respectively.
There is a paucity of reports from Nigerian tertiary hospitals on pediatric outpatient prescribing based on the WHO core prescribing indicators and the IRDP. A literature search (Google Scholar, MEDLINE, HINARI, and Africa Journals Online) using appropriate search terms revealed only two such studies in Nigeria,, none of which included derivation of IRDP. We, therefore, aimed to investigate pediatric outpatient prescriptions in our hospital using the WHO standard prescribing indicators and to determine the IRDP.
| Materials and Methods|| |
The Ahmadu Bello University Teaching hospital is an 800-bed capacity referral facility in Northern Nigeria. Children are attended to as outpatients at the general outpatient department, the accidents/emergency unit, and the pediatric subspecialty clinics, as well as from the inpatient units (emergency, neonatal, medical, and surgical wards). No antibiotic stewardship program or such other drug monitoring activity was ever implemented in the hospital before the study period.
This was a descriptive retrospective observational study involving outpatient prescriptions issued at all the children's units and received at the hospital pharmacy between January 2013 and December 2014.
Study data source
All prescriptions for children under the age of 18 years received at the hospital pharmacy within the stipulated period constituted the study sample.
All child outpatient prescriptions received and considered readable (legibly written), containing one or more drugs, with client hospital number, age, and address of origin of prescription were included in the study. This approach was adopted to get uniform spread over the study period and to minimize bias from seasonal variations in illness presentations and interruptions of drug supply cycles.
Prescription orders containing only consumable items, intravenous infusions, and vaccines and those without hospital number, age, and address of origin of prescription were excluded from the study. Furthermore, excluded were prescriptions that were unreadable or belonged to patients that were on admission.
Eligible prescriptions retrieved from the central records section of the pharmacy were compiled together. Three intern pharmacists trained for the purpose of the research, checked prescription forms for compliance with standard prescription writing format including age, sex, hospital number, weight, prescriber's name and signature and extracted the relevant data. Information obtained on medicines included name, dose, route, strength, frequency, dosage form and instructions for use, number of drugs prescribed, and duration of treatment. Antibiotic dosages were assessed by comparison with doses available in the 2010/2011 British National Formulary for Children and the Emdex Pediatric Drug Guide 2013 edition used in Nigeria., The prescription forms were independently assessed by each of the interns, and the data obtained from each patient encounter were entered into a standardized prescribing indicator form adapted from the WHO prescribing indicators form. The three entries were crosschecked for consistency and interobserver concordance.
The WHO core prescribing indicators were used to evaluate prescriptions. The IRDP, which further reveals the extent to which prescriptions met the ideal standard of rational drug use, was derived from the WHO core indicators. A validated method of indexing, also used by Cole et al., consisting of five scores derived from the WHO prescribing indicators was used. The ideal or optimal level for each indicator [Table 1],,, allots each of the WHO indicators an optimal index score of one, such that calculated indices closer to one were considered as more rational prescribing.,, This validated method of indexing was used to calculate the indices for polypharmacy, generic name use in prescribing, EML use, rational antibiotic prescribing, and injectable medication use.,, The IRDP, which has an optimal maximum value of 5 as shown in [Table 1], was then calculated by adding the five corresponding indices obtained from the results.
Data collected was entered into Microsoft Excel spreadsheet and transferred into SPSS Version 20 (IBM, Corp., Armonk, NY), which was used for the analysis. Results were compared with the core WHO prescribing indicators and presented as means, frequencies and proportions, contingency tables, and charts.
Ethical approval was obtained from Ahmadu Bello University Teaching Hospital Zaria Health Research Ethics Committee on 3rd January 2012. All research procedures complied with 2013 declaration of Geneva declaration.
| Results|| |
Out of 3768 prescription orders obtained, 3445 considered eligible were analyzed. Prescriptions for children aged up to 5 years (31.8%) combined with those for infants (28.1%) formed the majority, with a mean age of 3.2 years. There were more male (56.3%) than female [Table 2], with a male: female ratio of 1.3:1.
|Table 2: Demographic characteristics of children with eligible prescriptions|
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Prescription writing formats
Majority (93%) of the prescriptions had complete patient biodata written, while 45.6% and 87.1% had name and signature of the prescriber, respectively [Figure 1]. Furthermore, whereas majority (84.2%) had optimum dosages of antibiotics [Figure 1], 15.6% of the prescribed antibiotics were outside the range of recommended doses.
|Figure 1: Pattern of prescribing for children observed among eligible prescription orders|
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While the mean number of drugs per prescription was 2.4, most prescriptions had one (29.6%) or two (26.2%) drugs and the proportion of prescriptions with 4 or ≥5 drugs were 13.4% and 7.8%, respectively [Figure 2].
|Figure 2: Percentages of number of drugs contained in prescription orders|
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Core prescribing indicators
The average number of drugs prescribed per encounter was 2.4, while the median was 2.0. A total of 1729 (50.2%) of prescription orders contained one or more antibiotics, while prescriptions written with generic names constituted 48.2%, with 41.2% having one or more injections. Majority (95.5%) of drugs contained in the prescription orders were available in the facility's EML. The prescribing indicators obtained varied widely from previously derived values obtained from studies in Nigeria  and with the WHO standards  [Table 3].
|Table 3: The World Health Organization core prescribing indicators assessed for drug prescriptions|
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Index of Rational Drug Prescribing
The cumulative IRDP as obtained from the component indices in this study was 2.98, compared to the recommended ideal of 5. The corresponding indices for prescriptions containing injections and use of the generic name in prescribing were 0.15 and 0.48, respectively, while EML index had a score of 0.96 [Table 4].
Antibiotics contained in prescription orders
Whereas majority of prescriptions had a single antibiotic (71.3%), only 2.9% and 0.8% had three or more antibiotics, respectively, as shown in
|Figure 3: Percentage frequency of number of antibiotics written per prescription order|
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The most frequent classes of antibiotics prescribed were β-lactams (27.2%), cephalosporins (21.9%), and imidazoles (15.3%) as shown in [Figure 4].
|Figure 4: Percentage frequency of appearance of individual antibiotics among prescriptions|
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The major combinations of antibiotics prescribed include ampicillin/cloxacillin (47.0%), amoxicillin/metronidazole (11.9%), and ampicillin/cloxacillin/gentamicin (7.5%) [Table 5].
| Discussion|| |
This study found a predominance of prescriptions among the groups of infants and preschoolers, with a male preponderance (male: female ratio of 1.3:1). This is probably reflective of the younger child's vulnerability to illnesses on a background of a naïve immune system, prompting more frequent hospital presentations. With similar findings reported in other studies,,,,,, this depicts the higher chances for inappropriate prescribing for younger children exposing them to risks of adverse effects.
Compliance with standard prescribing format was inadequate as evidenced by suboptimal proportions of prescriptions with complete prescriber identity, poor use of generic names, incomplete patient biodata, and inappropriate dosages. Such observations have been reported in similar studies at other Nigerian tertiary hospitals.,,, This poor compliance underscores a need for the conduct of similar studies in other tertiary hospitals nationwide to understand the true extent of the problem of irrational medicines use for children that attend these facilities.
Even with an average of 2.4 drugs per prescription, there was a high rate of polypharmacy, with over one-fifth of prescriptions containing four or more drugs. A similar study in Gambia that found an average of 2.2 drugs per prescription, however, reported 64.3% of prescriptions containing at least one antibiotic, in contrast to our finding of 50.2% of prescriptions with antibiotics. It has been established that the risks associated with polypharmacy and use of brand names could include adverse drug reactions and increased financial costs for families.,,,
Whereas the higher proportion of prescriptions with antibiotics above the standard of <30%,, did not differ much from a previously documented rate for Nigeria, the index of rational antibiotic prescribing of 0.6 is below the recommended standard of 1.0. Similar findings were also reported in studies from some other parts of Nigeria,,,, suggesting a trend for antibiotic overuse for children in Nigerian tertiary hospitals. Inappropriate antibiotic prescribing for pediatric outpatients has also been reported in tertiary hospitals in other African countries., Well-documented drivers of inappropriate antibiotic use include influences of prescribing habits of mentors, trainers and pharmaceutical sales representatives, lack of treatment guidelines/protocols, and diagnostic facilities, as well as clients' (caregivers') demand for specific drugs.,,,, Whereas this study did not obtain data from patient case notes on clinical or microbiologic diagnoses, the results obtained are enough cause for concern. Although we did not examine the identity of prescribers, it could further be inferred that being a training center, the anticipated transfer of appropriate prescribing skills is rather inadequate and perhaps the influence of trainers with suboptimal skills on the prescribing habits of trainees cannot be ruled out.
A quarter of the prescriptions contained two antibiotics and <4% contained three or more antibiotics, suggestive of a high rate of combination therapy, supposedly to broaden the spectrum of antibacterial effect. Although alternative single agents with broad enough spectrum of activity exist on the EML, the consideration for their cost in preference for cheaper antibiotics may have influenced the choice for the combinations. This could explain the finding of oral β-lactam penicillins as the most common class from which the prescriptions were made. However, this study has as a limitation of being retrospective and lacked data on indications for antibiotic use, which could have given better insight into rationality in decision for antibiotic choices.
The core prescribing indicators obtained were at par with previously derived values in Nigeria and other resource-limited countries, but were at great variance with the WHO standards, except for drugs present in the EML. The IRDP obtained (2.98), was similarly lower than the ideal of 5.0, further affirming the prevailing irrational prescribing. In comparison with other few published studies from tertiary hospitals in developing countries, the IRDP found in this report came close to that reported in Sierra Leone, with an IRDP of 2.71. In Pakistan, the IRDP of 3.70 and 3.44 was obtained in a study comparing pediatric outpatient prescriptions in two tertiary hospitals. The low IRDP in our report has potentially far-reaching implications considering the status of the facility as a federal teaching hospital from where trainees would graduate to subsequently assume the role of prescribers in other parts of the country. The WHO has identified university teaching hospitals as resource providers with responsibility for improving the training of health workers in general and on rational medicines use in particular., These facilities also have the responsibility of serving as reviewers and implementers of training curricula, incorporating concepts such as those of essential medicines in training, continuing education, and service guidelines., To adequately discharge these responsibilities, there is a need for periodic curriculum content review and reorientation for all categories of prescribers, especially those involved in training at various levels in tertiary facilities across Nigeria.
Our study provides background information of prescribing pattern for outpatient children managed at a teaching hospital, which could be used for objective comparison with results of assessments in future, aimed to monitor and to evaluate prescribing practices. The limitations of this study include the fact that the WHO prescribing indicators, we used to assess only the quantitative aspect of drug use and do not determine qualitative issues of accuracy of diagnosis and appropriateness of drug choices. For a more complete assessment of the rational use of medicines, other important parameters, such as patient care and facility indicators, are needed; however, these were not included in this study whose objective was to assess prescribing pattern. Nevertheless, the study provides baseline information to compare with future studies to evaluate the impact of interventions.
| Conclusion and Recommendations|| |
We found the evidence of inappropriate prescribing practices, whose potential implications may include the transmission of similar practices to medical trainees at various levels, as a function of mentorship and tutelage by senior medical staff. The findings highlight a need for the implementation of antimicrobial stewardship activity for the hospital. We recommend evidence-based reorientation trainings on the rational use of medicines for all cadres of physicians in teaching hospitals along with curriculum review to include comprehensive instruction on the same subject for undergraduate training.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]