International Archives of BioMedical And Clinical Research Vol 5 | Issue 3 | July – September 2019 89
Section Pharmacology Original Article
A Cross Sectional Study of Drug Utilization Pattern in Indoor Patients of Tertiary Care Teaching Hospitals in Central India
Ahmad Najmi
1, Balakrishnan S
2, Ratinder Jhaj
3, Shubham Atal
1, Pooja Singh
4, Sunil Kumar
51Assistant Professor; 2Professor & HoD,
3Additional Professor; 4Senior Resident;
5Tutor, Dept. Of Pharmacology, AIIMS, Bhopal
Background: To evaluate the pattern of drug utilization with special focus on the use of antimicrobials.
Methods: Single day hospital-wide point prevalence survey was conducted to assess drug utilization pattern. Information regarding age, gender, occupation, income group, diagnosis, patient’s present/past medical history, treatment, any adverse drug reactions, and investigations were recorded in a proforma. Drug utilization pattern was evaluated using quality indicators of drug use recommended by WHO.
Results: A total of 77 patients were included, 62% male and 38% female. Maximum number of patients was admitted for infectious diseases (34%). Pantoprazole was most commonly prescribed drug & ceftriaxone was most commonly prescribed antibiotic. The average number of drugs prescribed per encounter was 4.87. Oral route was the most preferred route. Percentage of drugs prescribed by generic name was 42.44%. Percentage of drugs prescribed from essential medical list was 49.33%. Multivitamins & Non-steroidal anti-inflammatory drugs (NSAIDS) were most commonly prescribed fixed dose combination in our study.
Conclusions: Majority of drugs were prescribed by oral route. Essential medical list and updated guidelines were available in the hospital. Poly-pharmacy, over use of proton-pump inhibitors &
multivitamins was areas of concern. Prolonged and irrational use of antibiotics for surgical prophylaxis was noted in surgical indoor patients. There was underutilization of microbiological facilities.
Keywords: Drug Utilization, Indoor Patients, Polypharmacy, Antimicrobials
Published Online: September 30’ 2019
Received: 07.08.19 Accepted: 25.08.19
Dr. Ahmad Najmi, Assistant Professor, Dept. of Pharmacology, AIIMS, Bhopal Email: ahmad.pharm@aiimsbhopal.edu.In
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IABCR is an official publication of Ibn Sina Academy of Medieval Medicine & Sciences, registered in 2001 under Indian Trusts Act, 1882.
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INTRODUCTION_____________________
Drug utilization research as defined by WHO in 1977 is ‘the marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences.1 It provides information about pattern, quality and outcome2 of drug use. Pattern of drug utilization is studied to estimate the incidence and prevalence of drug use, to analyze that the recommended guidelines for prescription are being followed or not. The aim of drug utilization study is to promote rational and appropriate use of drugs at lowest possible dose and cost.3 WHO has specified prescribing indicators,4 patient care indicators, facility indicators and complementary indicators5 for planning and conducting drug utilization studies. To compare, analyze and present statistical data of drug
utilization research, the anatomical and therapeutic chemical (ATC) classification systems is accepted worldwide and also recommended by WHOM. It is used by international drug monitoring centre Uppsala, a WHO collaborating centre for classification of adverse drug reactions. Defined daily dose (DDD) is average maintenance dose per day and used as a comparable unit.
Prescribed daily dose (PDD) may not be equal to DDD. It is a rough estimate of drug utilization.6,7 Rational prescribing of drugs is a skill, for which proper knowledge about drugs, pharmacoeconomics, pharmacovigilance and experience is mandatory. If the drugs are overused, they increase occurrence of toxic reactions, if underused, there will be therapeutic failure and chances of development of resistant
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DOI: 10.21276/iabcr.2019.5.3.27
ABSTRACT
*Corresponding Author
How to cite this article:Najmi A, Balakrishnan S, Jhaj R, Atal S, Singh P, Kumar S. A Cross Sectional Study of Drug Utilization Pattern in Indoor Patients of Tertiary Care Teaching Hospitals in Central India. Int Arch BioMed Clin Res. 2019;5(3):89- 93.
Source of Support: Nil, Conflict of Interest: None
International Archives of BioMedical And Clinical Research Vol 5 | Issue 3 | July – September 2019 90 strain to antibiotics, if misused will lead to unnecessary
adverse drug effects and drug interactions.8,9
Very few studies are available which have observed drug utilization in indoor patients of a tertiary health care centre in Madhya Pradesh. So the present study was planned to develop a baseline prescription pattern, to evaluate prescription as per WHO quality indicators, in indoor patients of a tertiary care teaching institute in Madhya Pradesh with special focus on the use of antimicrobials.
METHODS__________________________
This was a cross sectional point prevalence observational study. Single day hospital-wide point prevalence survey was conducted to assess drug utilization pattern. The study was conducted among inpatients admitted in the 15 wards of thirteen medical and surgical departments including super specialities – general medicine, general surgery, obstetrics & gynaecology, paediatrics, paediatric surgery, orthopaedics, nephrology, urology, pulmonary medicine, burns and plastic surgery, ophthalmology, E.N.T., and dentistry at AIIMS Bhopal hospital, Madhya Pradesh.
Department of pharmacology has approval to conduct therapeutic audits among outpatients as well as inpatients from the Institutional Human Ethics Committee of AIIMS Bhopal. Patients of both sex and all age groups admitted in all medical and surgical wards were included. Patients admitted in the ICU were excluded.
Standard data collection form devised for the study, drug list and facility care indicator form for institution, WHO core drug use indicator guidelines were used as study instruments. Seventy seven patients were found admitted in the inpatient wards, fulfilling the eligibility criteria, and included in the study. Demographic characteristics like age, gender, educational status, occupation were recorded.
Information regarding diagnosis (cause for admission), comorbidities, medical history, ongoing treatment, documented adverse drug reactions (ADRs), investigations performed, was collected from the patient records available in the wards.
Drug utilization pattern among male and female patients was evaluated using the prescribing indicators recommended by WHO - average number of drugs per prescription, percentage of prescriptions (encounters) with antibiotic prescribed, percentage of prescription (encounters) with injections prescribed, percentage of drugs prescribed by generic name, and percentage of drugs prescribed from essential drug list. Additionally, detailed information about the medications prescribed, with a focus on antimicrobials, were collected – drug class, route of administration, dose, frequency and duration of administration. The most commonly used antimicrobials were classified using the ATC Classification system.
RESULTS___________________________
A total of 77 patients were included, out of them 54 (62%) were male and 23 (38%) were female, with age range between 15-80 years. Age and gender distribution was approximately similar to that reported by Meher et al10 and Choudhary et al.11 Mean age in our study was 46.6±17.7, while mean age reported by Chaudhary et al11 was 32.5 years and by Meher et al10 was 48.12 years .Educational status varied from illiterate to post graduate level and occupations of included patients were housewives (29%),
farmers (20%), students (15.5%), labors (12.5%), businessmen (12.5%) and private or government jobs (10%). Diagnosis for which drugs were prescribed were Infectious disease (34%), Respiratory disorders (19%), CVS disorders (17%), CNS disorders (15%), GIT disorders (14%), Renal (12%), Liver disorders (10%), Anemia (7%), Cancer (6%) & congenital disorders (3%) (Figure 1). Three patients (1.5%) were admitted with complaint of hepatitis with Anti tubercular therapy. Two patients (1%) were admitted with chloroquine induced severe gastritis. Other ADRs reported were headache (26%) nausea (26%), vomiting (12%), itching (5%), rashes (2%), and urticaria (1%). Nausea and vomiting was reported mainly by the patients taking quinine and headache by the patients taking pantoprazole. No severe ADR was reported during the study. Average number of drugs per encounter was 4.87.
Percentage of encounter with antibiotic was 23.46%.
Percentage of encounter with injection was 21.36%.
Percentage of drugs prescribed by generic name was 42.44% (Table 1). Percentage of drugs prescribed from essential drug list was 49.33%. Antibiotic consumption was highest in general medicine wards & lowest was in nephrology (Figure 2). Beta lactam group of antibiotics was prescribed most while lincosamide group was prescribed least (Figure 3). Ceftriaxone was most commonly prescribed antimicrobial drug (Figure 4 & Table 2). Among non-antimicrobials, pantoprazole was most commonly prescribed drug. (Table 3 & Figure 6).Multivitamins was most commonly prescribed fixed drug combination (Table 3). Empirical treatment with antimicrobials were given in 89
% of cases, while lab based treatment was given in 11% of cases (Figure 5).
Table 1: WHO prescribing indicators
Prescribing indicators assessed Average number of drugs per encounter
Percentage of encounter with antibiotics
Percentage of encounters with injection
Percentage of drugs prescribed by generic name
Percentage of drugs prescribed from essential drug list
Total drugs (n=375)
4.87 23.46%
21.36%
42.44%
49.33%
Table 2: Common antimicrobials prescribed & their ATC codes
Common
Antimicrobials ATC Codes Number
(n=88) Percentage
Ceftriaxone J01DD04 21 24.13
Metronidazole G01AF01 11 12.64
Ceftriaxone plus
Sulbactam J01DD62 7 8.04
Amoxicillin plus
clavulanic acid NA 7 8.04
Cefixime J01DD08 5 5.74
Piperacillin plus
tazobactam J01CR05 3 3.44
Cefotaxime J01DD01 3 3.44
Moxifloxacin S01AE07 3 3.44
Ofloxacin J01MA01 3 3.44
Amikacin J01GB06 3 3.44
Gentamycin J01GB03 3 3.44
ATT J04AM06 3 3.44
International Archives of BioMedical And Clinical Research Vol 5 | Issue 3 | July – September 2019 91 Table 3: Common Non-antimicrobials prescribed & their ATC codes
Common Non antimicrobial No. of Common Non antimicrobial
(n=287)
% age ATC CODE
Pantoprazole 115 40.25% A02BC02
Paracetamol 103 36.36% N02BE01
Ranitidine 56 20.77% A02BA02
Diclofenac 71 25.97% M01AB05
Multivitamins 126 44.15% A12CB,A12CE,A11GA01
Minerals 56 20.77% A12CB,A12CE,A11GA01
Ondansetron 34 12.98% A04AA01
Lactulose 20 7.79% A06AD11
Metoclopramide 14 5.19% A03FA01
Tramadol 14 5.19% N02AX02
Formoterol + Budesonide 14 5.19% R03AK07
Ibuprofen + Paracetamol/Acetaminophe
n 14 5.19% M01AE51, N02BE01
Tetanus Toxoid
8 3.89% J07AM01
Insulin 8 3.89% A10AD01
Methylprednisolone 8 3.89% H02AB04
Tranexamic Acid +
Mefenamic Acid 5 2.59% NA
Prednisolone 5 2.59% S03BA02
Betamethasone 5 2.59% H02AB01
Indomethacin 5 2.59% NA
Etoricoxib + Paracetamol/Acetaminophe
n 5 2.59% NA
Figure 1: Common diagnosis among patients. Infectious diseases were most common diagnosis
DISCUSSION________________________
Total number of drugs prescribed during study in indoor was 375. Percentage of drugs prescribed by generic name was 42.44%. Percentage of drugs prescribed from essential medical list was 49.33%. Out of 375 drugs, Pantoprazole was the most utilized drug amongst the non-antimicrobials, given to 40.25% of patients (Table 3). Jhaveri et al12 have observed generalized drug utilization pattern in geriatric population and they found ranitidine (58.14%), metoclopramide (54.29%), furosemide (41.12%), and cefotaxime (23.37%) as the commonly prescribed parenteral drugs.
Figure 2: Antimicrobial consumption in different wards. Maximum antimicrobials were prescribed in medicine ward.
Figure 3: Antibiotic groups prescribed. Beta lactam was most commonly prescribed group.
Figure 4: Antimicrobials prescribed. Ceftriaxone was most commonly prescribed antimicrobial.
Figure 5: Microbiological testing. Empirical treatment was given in majority of patients.
0 5 10 15 20 25
Ophthalmology Obstetrics & gynecology
General Surgery Pediatrics
General Medicine Nephrology
Pulmonary Medicine Orthopedics
Pediatric surgery Burn & plastic surgery
Urology Dentistry ENT
% age
Antibiotic Consumption in different departments
International Archives of BioMedical And Clinical Research Vol 5 | Issue 3 | July – September 2019 92 Figure 6: Common non-antimicrobial drugs prescribed.
Pantoprazole was most commonly prescribed drug & multivitamins were most commonly prescribed fixed dose combination.
The results are similar if groups of drug utilized are compared, as pantoprazole was the maximum utilized drug in our study and ceftriaxone was maximum utilized antibiotic in their study. Multivitamins (20.65%) & non-steroidal anti- inflammatory drugs (NSAIDS) (11.61%) & & were most commonly prescribed fixed dose combination in our study.
Etofylline + theophylline (deriphylline; 14.05%) and multivitamins (7.1%) were the commonly prescribed fixed dose combinations (FDCs) in study by Jhaveri et al. In study by Jhaveri et al average number of antimicrobials prescribed per patient was 0.91 (95% CI: 0.82-0.99). In our study percentage of encounters with antibiotic was 23%
average number of antibiotics prescribed per patient was 1.97, which is much higher than their study. Though the population of both studies is different, the pattern may vary according to health needs of population, availability and drug choice of prescribers. In our study, mean number of drugs prescribed per patient was 4.87±2.36 which indicate poly-pharmacy, while 4.05 and 4.02 was reported by Choudhary et al and Meher et al respectively, and 4.01±2.24 by Jimoh & Biswas et al 13,14 15. Total number of drugs administered by IV route was 189 (50.10%), oral route 165(42.89%), IV + Oral route 58 (3.94%), inhalational route 26 (1.76%), IM route 12(0.8%) and by SC route 7(0.48%). In study by Choudhary et al total number of drugs administered by oral route was 12%, by injectable route 81% and remaining 7% were used by both routes 12. In our study oral route was preferred route as compared to study by Choudhary et al.12 The difference is significant and indicates towards less aggressiveness of the therapy and avoidance of unnecessary selection of parenteral route which is encouraging. In our study cephalosporins were the most commonly used antimicrobial drug (28.91%), followed by antiprotozoal drugs (21.38%), Penicilllins (12.34%), Fluroquinolones (9.03%), Tetracyclines (8.13%), Clindamycin (7.22%), Aminoglycosides (1.80%), Macrolides (1.5%) and Vancomycin (1.2%). Total number of antibiotics prescribed was 88. Total number of patients to whom antibiotics were prescribed was 17 (23.46%). Total number of antibiotics prescribed per prescription was 1.97. The pattern of antibiotics prescription was approximately similar to that observed by Choudhary et al and Meher et al.12,13 (Table 3)
Drug utilization studies are conducted to monitor and evaluate prescribing pattern. They also suggest
modification and improvement in prescribing practices and promote rational prescribing practices.11 Study of prescription patterns is an important tool to determine and improvise rational drug therapy. Rational prescribing optimizes benefits and safety, and maximizes utilization of resources. International agencies like WHO and International Network for the rational use of drugs (INRUD) have evolved standard drug use indicators. Present study was conducted to describe and evaluate pattern of drug utilization by application of WHO indicators, which are highly standardized and recommended. Antibiotics are important category of drugs and its improper use can result in antibiotic resistance which may contribute in enhanced cost, patient morbidity and mortality.17,18 Therefore monitoring and evaluation of prescribing patterns of antimicrobial agents and recommendations to improve and modify the prescribing pattern are one of the recommended strategies to control resistance and also to improve the prescribing practices.19,20 Out of 77 patients culture and sensitivity test was done only in 9 (11%) of cases only (Figure 5). Prolonged & irrational use of antibiotics for surgical prophylaxis was noted in surgical indoor patients.
Study limitations
Since it was single day point prevalence study, so patients could not be followed. Cost was not calculated. Sample size was relatively small. Multicentric studies are required with large sample size to generalize the findings.
CONCLUSION_______________________
Majority of drugs were prescribed by oral route. Essential medical list and updated guidelines were available in the hospital. Poly-pharmacy, over use of multivitamins and proton-pump inhibitors was areas of concern. Prolonged and irrational use of antibiotics for surgical prophylaxis was noted in surgical indoor patients. There was underutilization of microbiological facilities.
ACKNOWLEDGEMENT
We acknowledge clinical departments for allowing us to conduct research in patients admitted in their wards.
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