Print ISSN: 2319-2003 | Online ISSN: 2279-0780

IJBCP International Journal of Basic & Clinical Pharmacology

DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20173280
Original Research Article

Evaluation of prescription pattern of antibiotics for surgical

prophylaxis in secondary care hospital
Devesh Kumar Joshi*, Mohd Rizwan, Preeti Kothiyal, Yogesh Joshi

ABSTRACT
Department of Pharmaceutical
sciences, Shri Guru Ram Rai Background: Antibiotic prophylaxis is the prevention and in incidence of
Institute of Technology and surgical site infection. This study evaluates the rational use of antibiotics
Science (SGRRITS), Patel prophylaxis prior to surgery amongst hospitalized patients. Objectives of the
Nagar, Dehradun, Uttarakhand, study were to investigate the utilization and evaluation pattern of antibiotics for
India surgical prophylaxis in surgery department.
Methods: A prospective observational study was conducted on 100 patients
Received: 27 May 2017 receiving antibiotics in the Department of Surgery of Brijesh Hospital Ramnagar
Revised: 24 June 2017 (Nainital) Uttarakhand. Patient undergoing antibiotic prophylaxis treatment were
Accepted: 27 June 2017 included in the study, exclusion of those patients who had age less than 18,
patients with psychiatric disease and those patients not willing to sign on inform
*Correspondence to: consent form.
Dr. Devesh Kumar Joshi, Results: The result observed in 100 patients follow up 8 weeks and evaluate the
Email: deveshkumarjoshi@ appropriate use of prophylaxis of antibiotics majority of patients were age group
gmail.com 18-30 years, followed by 41-50 years, 51-60 years, majority were reported in
female patients than male, higher utilization of cephalosporins were commonly
Copyright: © the author(s), prescribed due to their relatively lower toxicity and broader spectrum activity and
publisher and licensee Medip broader coverage of organism for several serious gram negative infection 30
Academy. This is an open- (30%) patients were prescribed penicillin with aminoglycosides, 10 (10%)
access article distributed under patients were prescribed with nitroimidazole antibiotics.
the terms of the Creative Conclusions: The overall scenario of antibiotic usage in a Hospital was as per
Commons Attribution Non- standard recommendations and all the antibiotics used were according to their
Commercial License, which standard adult and titrated doses and frequencies. In this study we found that
permits unrestricted non- Cephalosporines, Penicillins, Aminoglycosides and Nitroimidazole were mostly
commercial use, distribution, used classes of drug. Adverse Drug Reactions were minor and well managed.
and reproduction in any
medium, provided the original Keywords: Antibiotic, Adverse drug reaction, Prophylaxis, Surgical site
work is properly cited. infection

INTRODUCTION WHO defines drug utilization as “the marketing,

distribution, prescription and use of drug in a society with
Drug utilization evaluation (DUE) is a system ongoing, special emphasis on resulting medical, social and
systematic, criteria-based evaluation of drug usage that economic consequences” The aim of drug utilization
makes sure that medicines are used in an appropriate way research is to facilitate rational use of drugs in the
(at the individual patient level). If therapy is seems to be populations.2 Without knowledge, how drugs are being
inappropriate, interventions from providers or patients will prescribed and used it is complicated to suggest measure
be necessary to optimize drug therapy, a DUE is drug or to change prescribing habits for better.3
disease specific and can be arranged in such a way that it
will assess the actual process of prescribing, dispensing or A increasing number of pharmaceutical products are
administering a drug (indications, dose, drug interactions, available on the world market and there has been an
etc.), DUE is the same as drug utilization review (DUR) increase both in the consumption of the drugs and in
and terms are used synonymously.1

www.ijbcp.com International Journal of Basic & Clinical Pharmacology | August 2017 | Vol 6 | Issue 8 Page 1969
 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

expenses done on them, inspite of this, many people METHODS

throughout the world cannot get the drugs they require.4
A prospective observational study was conducted in the
There are also many people who have access to drugs but Department of Surgery of Brijesh Hospital Ramnagar
do not get the correct drug in the right dosage when they (Nainital) Uttarakhand. The study was designed to be a
require, irrational prescription of drug is of common Prospective Observational Study of four months. The
occurrence in clinical practice, important reason being lack participants enrolled in the study involved in patients
of knowledge about drug, and unethical drug promotion.5 coming to the hospital, only after filling a properly written
informed consent. Basic demographic information and
The defined daily dose (DDD) is globally accepted details of the prescribed antibiotics and their prescribing
technical unit in drug utilization studies, which reckones patterns, diseases for which they were indicated, dosage
the average maintenance dose per day of a drug for its main form of antibiotics and whether mono or multi-therapy is
manifestation in adult it must be emphasized that DDD is used, were documented in all patients. In view of
a unit of measurement and does not corelate with the collecting the aforementioned details, the data from in
prescribed daily dose, the dose of individual patient will patients was obtained every day from the clinical
however vary from the DDD as they are dependent upon assessment records, including medical records, patient
pharmacokinetic and individual characterstics eg-(age and record file, and other relevant information sources as
weight) drug utilization studies merely calculate the exact documented, including laboratory investigations.
amount of the drug consume by or recommended to the Descriptive analysis was carried out for the data obtained.
patients, this give us upper or lower estimation of real drug
use.6 Study design

Drug Utilization Evaluation (DUE), of Antibiotics use in It was a Prospective observational study conducted in the
Surgical Prophylaxis is a study of Utilization and Inpatient department of surgery ward, of Brijesh Hospital
Evaluation of Antibiotics use in surgery, surgical site Ramnagar. All subjects were receiving antimicrobials
infection is chief complication of surgical procedure, it were enrolled for the study based on the following
represents a significant burden in terms of patient inclusion and exclusion criteria.
morbidity, mortality and hospital costs, patient who
developed SSI (Surgical Site Infection) are up to 60% Inclusion criteria
more likely to spend time in the intensive care unit, five
times more likely to readmitted to hospital and twice as • Patient visited to IPD Surgery department.
likely to die as compared to patients without SSI Surgical • Patient more than 18 year of age.
antibiotic prophylaxis is administration of short acting • Patient able to understand provide inform consent
antimicrobial agent prior to surgery to prevent SSI.7 form.
• Patient of either gender.
From more than 30 years, prophylactic use of antibiotics
in hospitals before surgery showed a decrease in post Exclusion criteria
operative infection rate, on enquiring the time of
administration it was confirmed that the use of antibiotic • Patient not willing to sign on Inform consent form.
two hours prior to surgery would reduce the chance of • Patient with Psychiatric disease.
infection, however, appropriate use would reduce the • Patient with less than 18 year of age.
chance of resistance development, further the effect of
prophylactic antibiotic use other than to prevent surgical The study was conducted for a duration of six months i.e.
infection was found to be in nosocomial pneumonia where September to February.
it reduce the incidence of pneumonia but it had no effect
on mortality this occurred because antibiotic resistance All necessary and relevant were collected from Patient
bacteria colonized some patient after were difficult to record file, treatment charts, Patient history records verbal
treat.8 communication with the patients.
Rational Use of Antibiotics antibiotics are most commonly Data collection
prescribed drug their therapeutic uses increasing the
bacterial resistance, irrational use of antibiotics is a The data was collected in suitably designed CRF, which
common problem which leads to antibiotic resistance and contain demographics, disease, lab data and therapeutic
adverse reactions, it is necessary to take several steps to chart of the patient.
improve the appropriate use of antibiotic, appropriate
antibiotic selection can reduce the both cost and resistance Biostatistical analysis
to the patient.9
The data has been analysed by using descriptive statistics
using Microsoft Excel as a software.

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 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

The aim of this study was to investigate the utilization and 16 (16%) patients had renal stone and 12 (12%) patients
evaluation pattern of antibiotics for surgical prophylaxis in had adenomyosis, 11 (11%) cases was of delivery, 10
surgery department in Brijesh Hospital Ramnagar. (10%) was had ureteric stone, 4 (4%) patients had
appendicitis and 4 (4%) patients with hernia, 2 (2%)
Objectives of study patients of fistula, 1 (1%) of Haemorrhoids and 1 (1%) was
of hydatid cyst of liver (Figure 1).
• To study the Incidence of surgical site infection.
• To evaluate the prescription pattern of antibiotics. Table 1: Demographics characteristics.
• To evaluate the rational antibiotic use.
• To assess the infection developed. Variables
No. of
Percentage
participants
RESULTS Male 45 45
Gender
Female 55 55
According to disease pattern of the patients 18-30 47 47
31-40 18 18
25 41-50 18 18
Age (years) 51-60 7 7
20
61-70 7 7
15 71-80 2 2
10 81-90 1 1
5 House
41 41
wife
0
In
Occupational organized 26 26
status sector
Student 17 17
Retired 8 8
Business 8 8
Illiterate 9 9
Educational SSC 40 40
Figure 1: Disease pattern reported. status HSC 24 24
UG 27 27
The common reason for admission in surgery ward was 22 Married 80 80
Marital status
(22%) had fracture, 16 (16%) patients had cholelithiasis, Unmarried 20 20

80
70
60
50
40
30
20
10
0

Figure 2: The distribution of antibiotics.

Distribution of antibiotics in study population In this study the most commonly used intravenous
antibiotic were the Inj-ceftriaxone 38 (38%), which is

International Journal of Basic & Clinical Pharmacology | August 2017 | Vol 6 | Issue 8 Page 1971
 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

accounted of 38 patients out of total 100 patients and in 18 Out of 100 prescriptions included for the study, 39 (39%)
(18%) Inj-amoxicillin+ clavulanicacid were used, in 69 prescriptions had two drugs therapy, 30 (30%)
(69%) Inj-amikacin, Inj ceftriaxone+ sulbactum 7 (7%), prescriptions had three antibiotic drugs combinations, 18
Inj- ceftriaxone+ tazobactum 10 (10%), Inj-ampicillin 25 (18 %) prescriptions had antibiotic monotherapy, 13 (13%)
(25%), Inj-metronidazole 10 (10%), Inj-ciprofloxacin 2 prescriptions were more than three antibiotic drug
(2%), Inj-gentamycin 2 (2%) in this study the most combinations shown in Figure 4.
commonly used oral antibiotic were Tab amoxicillin+
clavulanicacid 40 (40%), in 28 (28%) followed by Tab- Pattern of developing infection
cefixime+ clavulanic acid, Tab-Cefixime 3 (3%), Tab-
Cefopodoxime clavulanicacid 23 (23%), Tab-levofloxacin Out of 100 participants were involved in 36 (36%) patients
14 (14%), Tab azithromycin 1 (1%), Tab-clinadamycin 2 developed surgical site infection, remaining 64 (64%)
(2%) shown in Figure 2. patients were not developed any infection shown in Figure
5.
Distribution of antibiotics according to class
70
Distribution according to class 86 (86%) patients were
prescribed with cephalosporins, followed by 15 (15%) 60
Fluoroquinolones, 64 (64%) followed by 50
aminoglycosides, 53 (53%) followed by ampicillin and 19
(19%) patients were prescribed with antiameobiasis shown 40
in Figure 3. 30
100 20
90
80 10
70
0
60
Yes No
50
40
30 Figure 5: The pattern of developing infection.
20
10 Dosage forms used in the study
0
In our study, we also taken an account different antibiotic
dosage forms used by the patient population Out of 100
prescriptions included for the study, to most of the patients
100 (100%) antibiotics given by intravenous route and to
90 (90%) patients antibiotic given by oral route shown in
Figure 3: The distribution of antibiotics according Figure 6.
to class.
102
Pattern of use of antibiotics in surgery patients during 100
study period 98

45 96
40 94
35 92
30 90
25 88
20 86
15 84
10 Oral Intravenous
5
0 Figure 6: The dosage form of antibiotics.
Monotherapy Two drugs Three drugs More than
combination combination three drugs Duration of treatment
combination

A total 100 patients were involved in this study in which

Figure 4: The pattern uses of antibiotics. found that 52 (52%) patient had duration of treatment 5

International Journal of Basic & Clinical Pharmacology | August 2017 | Vol 6 | Issue 8 Page 1972
 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

days and less, rest of the patients had more than 5 days Out of 100 patients the average number of drugs per
shown in Figure 7. encounter is 7.85 in our study total number of antibiotics
drugs encounter shown in Figure 9.
53
Antibiotics Prescribing Pattern according to essential
52 drugs list
51
Total 100 prescriptions were involved in study in which
50 observed that in 86% prescriptions had antimicrobial
49
agents that were included in the WHO Essential drug list
and only 14% of prescriptions contained drugs that were
48 not included in the WHO Essential drug list. 100%
prescription had antimicrobial agent that were included in
47
National list of essential medicine shown in Figure 10.
46
5 days or less than 5 days More than 5 days 120

100
Figure 7: The duration of treatment.
80
Prescribing pattern of antibiotic
60
100 prescriptions were involve in study in which to the 88
40
(88%) drug were prescribed by brand name and to the
remaining 12 (12%) patient drug were prescribed by 20
generic name shown in Figure 8.
0
WHO essential were not in Included in were not in
drug list WHO essential national list of national list of
12 drug list essential essential
medicine medicine

Brand name Figure 10: Antibiotics prescribing pattern according

to essential drug list.
Generic name
DISCUSSION

Monitoring of systems and interventions are useful in

88 improving the quality of healthcare system. This is
especially relevant for appraisal of antibiotic utilization
prescription. Prescriber’s world worldwide running out of
antibiotic option.
Figure 8: Pattern of antibiotics.
As the antibiotics drug resistance is on the raise there is a
Total number of drugs per encounter need for taking steps to promote rational antibiotics use. It
is necessary to take action improve prescribing habits in
35 order to reduce the unnecessary usage of antibiotics thus
30 enhance rational antibiotic use.

25 The data was subjected to descriptive analysis using

20 Microsoft Excel. Utilization of different classes of drugs
as well as individual drugs was analyzed and presented as
15 percentage.
10
Out of 100 patients, patient disseminated according to
5 gender. Female were relatively higher than male as they
0 were 55 (55%), then male as they were 45 (45%),
5 or less 6 7 8 9 10 compared to another study Napolitano F, Teresa M
than 5 conducted at Department of Experimental Medicine,
Second University of Naples, Naples, Italy in which out of
Figure 9: The no. of antibiotics per encounter. 404 patients 44.3% were males and 55.7% were females,

International Journal of Basic & Clinical Pharmacology | August 2017 | Vol 6 | Issue 8 Page 1973
 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

but differ from study Venkateswarlu B, et al. conducted at possible to minimize the rise of drug interaction, adverse
Malla Reddy Institute of Pharmaceutical Sciences, drug reaction.
Secuderabad, Telangana, India in which female were 108
(53%) were males and 94 (47%) were females.10,11 In our study 88% branded drugs were preferred by the
surgeons and frequency of drugs were disproportionate
In our study most of the hospitalization were due to compared to another study conducted by Bhansali NB. et
fracture 22%, cholelithiasis16%, 16% patients had renal al, conducted at department of pharmacology, M P Shah
stone and adenomyosis 12% this is because study center is Medical College, Jamnagar in which to the 48.57% patient
referred hospital a large number of cases indicate drugs prescribed by generic name and to the 51.43%
insufficient healthcare facilities at the region furthermore, patients drug prescribed by brand name.13
excess cares of renal stone adenomyosis, cholelithiasis
might be due to lack of awareness to get early help as well, In the study population polypharmacy was ascertained as
poverty may be a reason of late arrival of the cases. drugs per prescription were high 7.85, which contain
antimicrobial agents in the most cases followed by
But differ from Venkateswarlu B, et al, conducted at Malla NSAIDS, PPI and other drugs were given. Bhansali NB, et
Reddy Institute of Pharmaceutical Sciences, Secuderabad, al, conducted at department of pharmacology, M P Shah
Telangana, India study in which most commonly sugery Medical College, Jamnagar observed polypharmacy in
done was Hernia 29 (14.5%), Appendicitis 28 (14%), their respective regions in which the average no of
Cholelithiasis 6 (3%) and renal calculi 5 (2.5%), Fistula 5 antibiotics use was 9.2.13
(2.5%).11
The average number of drug per prescription is a valuable
In our study according to age categorization out of 100 indicator of polypharmacy, it is recommended that the
patients 47 (47%) patients had age of 18-30 years, 18 number of drugs per prescription should be kept as low as
(18%) patients had an age of 31-40 years, 18 (18%) possible to minimize the rise of drug interaction, adverse
patients had an age of 41-50, 7 (7%) patients had an age of drug reaction.
51-60 years, 7 (7%) patients had an age of 61-70 years, 2
patients had an age of 71-80 years and 1 (1%) patient had In the present study, all antibiotics which is prescribed to
an age of 81-90. We observed that majority of cases in this the patients were included in the National essential drug
sample were between the age group 18 to 40 list.
Venkateswarlu B, et al, conducted at Malla Reddy Institute
of Pharmaceutical Sciences, Secuderabad, Telangana, We have also studied on distribution of antibiotics
India and Brethis CS, et al, conducted at Mahavir Institute according to class out of 100 patients included for study in
of Medical Sciences, Hydrebad India observed the same 86 (86%) patients were prescribed with cephalosporins, 15
age group in their respective regions.11,12 This is usual (15%) patients were prescribed Fluoroquinolones, 64
trends as the fecund age group that is actively involved in (64%) patients were prescribed with aminoglycosides, 53
socioeconomic activity, making them susceptible to (53%) patients were prescribed with Penicillins 19 (19%)
disease which may further needs surgical intervention. patients were prescribed with antiameobiasis. This study is
similar to Venkateswarlu B, et al, Higher utilization of
In our study most of them were done primary education 40 cephalosporins 80.5% and fluoroquinolones 38% was
(40%), 24 (24%) participants have done secondary noticed.11
education and 27 (27%) participants have done UG and 9
(9%) participant never received any education. Similar to Higher utilization of cephalosporins 86 (86%) and
Venkateswarlu B, et al, conducted at Malla Reddy Institute aminoglycosides 64 (64%) was noticed Cephalosporins
of Pharmaceutical Sciences, Secuderabad, Telangana, are commonly prescribed due to their relatively lower
India observed that 30% were done secondary education, toxicity and broader spectrum activity. Cephalosporins
15% had received primary education, 10% had done often used in combination with aminoglycosides due
higher education.11 synergistic activity and broader coverage of organisms for
several serious gram negative infections 30 (30%) patients
In the study population polypharmacy was ascertained as were prescribed pencillins with aminoglycosides, 10
drugs per prescription were high 7.85, which contain (10%) patients were prescribed with nitroimidazole
antimicrobial agents in the most cases followed by antibiotics.
NSAIDS, PPI and other drugs were given. Bhansali NB, et
al, conducted at department of pharmacology, M P Shah The duration of treatment in hospital was 52 (52%)
Medical College, Jamnagar observed polypharmacy in patients had duration of treatment was 5 days or less than
their respective regions in which the average no of 5 days, 48 (48%) patients had duration of treatment was
antibiotics use was 9.2.13 more than 5 days, ranges was 3-10 days mean duration
recorded was 5.5 days, this study is differ from a study by
The average number of drug per prescription is a valuable Bhansali NB et al, conducted at department of
indicator of polypharmacy, it is recommended that the pharmacology, M P Shah Medical College, Jamnagar in
number of drugs per prescription should be kept as low as which mean duration of postoperative stay in was 8.77

International Journal of Basic & Clinical Pharmacology | August 2017 | Vol 6 | Issue 8 Page 1974
 Joshi DK et al. Int J Basic Clin Pharmacol. 2017 Aug;6(8):1969-1976

days and a range of 4-15 days and similar to study contained drugs that were not included in the WHO
conducted by Rasheeduddin M et al, conducted at Essential drug list.12,19
Adilabad Telangana State, India which total duration of
treatment ranges was 5 -12 days mean duration was CONCLUSION
recorded 9.2 days.13,14
Antibiotics are a key component of infection management
In our study the most common antibiotic prescribed was and prevention. In conclusion, a wide spectrum of clinical
ceftriaxone 38% a third generation cephalosporins with diagnosis and a variety of drugs were prescribe from
restricted prescription followed by Inj- various drugs classes.
amoxicillin+clavulanicacid 18%, Inj-amikacin 69%, Inj
ceftriaxone+sulbactum 7%, Inj-ceftriaxone+tazobactum The overall scenario of antibiotic usage in a Hospital was
10%, Inj-ampicillin 25%, Inj-metronidazole 10%, Inj- as per standard recommendations and all the antibiotics
ciprofloxacin 2%, Inj-gentamycin 2%, Tab used were according to their standard adult and titrated
amoxicillin+clavulanicacid 40%, Tab- doses and frequencies. In this study we found that
cefixime+clavulanic acid 28%, Tab-Cefixime 3%, Tab- Cephalosporines, Penicillins, Aminoglycosides and
Cefopodoxime clavulanicacid 23%, Tab-levofloxacin Nitroimidazole were mostly used classes of drug. Adverse
14%, Tab azithromycin 1%, Tab-clinadamycin 2%. Drug Reactions were minor and well managed. However,
Compared to another study conducted by Venkateswarlu use of culture and sensitivity and more strict prescription
B, et al, at Malla Reddy Institute of Pharmaceutical pattern should be followed in order to overcome the
Sciences, Secuderabad, Telangana, India. Brethis CS.11,12 bacterial antibiotic resistance which is a potential threat for
conducted at Mahavir Institute of Medical Sciences, use of antibiotics.
Hydrebad India. Sviestina I et al, conducted at Public
Health and Epidemiology Department, Riga Stradinš Our study suggests that there is a considerable scope for
University, Dzirciema iela, Riga, Latvia. respectively improving prescribing pattern among the practitioners and
cefotaxim 51.5% and ceftriaxone 13.39% was most minimizing the use of antibiotics in order to reduce the risk
commonly prescribed drug.15 of antibiotics resistance.

In our study mean age of the patient was 36.64±15.9 years Funding: No funding sources
(Mean±SD) and the range of ages was between 18-90 Conflict of interest: None declared
years old which is differ from study conducted by Ethical approval: The study was approved by the
Tourmousoglou CE et al, at Department of Pharmacology, Institutional Ethics Committee
Medical School, University of Athens, Athens, Greece
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