Antibiotic Prescribing in the Acute Care in Iraq

Authors: Ola A. Nassr, Ali M. Abd Alridha, Rua A. Naser, Rasha S. Abbas

Abstract:

Background: Excessive and inappropriate use of antimicrobial agents among hospitalized patients remains an important patient safety and public health issue worldwide. Not only does this behavior incur unnecessary cost but it is also associated with increased morbidity and mortality. The objective of this study is to obtain an insight into the prescribing patterns of antibiotics in surgical and medical wards, to help identify a scope for improvement in service delivery. Method: A simple point prevalence survey included a convenience sample of 200 patients admitted to medical and surgical wards in a government teaching hospital in Baghdad between October 2017 and April 2018. Data were collected by a trained pharmacy intern using a standardized form. Patient’s demographics and details of the prescribed antibiotics, including dose, frequency of dosing and route of administration, were reported. Patients were included if they had been admitted at least 24 hours before the survey. Patients under 18 years of age, having a diagnosis of cancer or shock, or being admitted to the intensive care unit, were excluded. Data were checked and entered by the authors into Excel and were subjected to frequency analysis, which was carried out on anonymized data to protect patient confidentiality. Results: Overall, 88.5% of patients (n=177) received 293 antibiotics during their hospital admission, with a small variation between wards (80%-97%). The average number of antibiotics prescribed per patient was 1.65, ranging from 1.3 for medical patients to 1.95 for surgical patients. Parenteral third-generation cephalosporins were the most commonly prescribed at a rate of 54.3% (n=159) followed by nitroimidazole 29.4% (n=86), quinolones 7.5% (n=22) and macrolides 4.4% (n=13), while carbapenems and aminoglycosides were the least prescribed together accounting for only 4.4% (n=13). The intravenous route was the most common route of administration, used for 96.6% of patients (n=171). Indications were reported in only 63.8% of cases. Culture to identify pathogenic organisms was employed in only 0.5% of cases. Conclusion: Broad-spectrum antibiotics are prescribed at an alarming rate. This practice may provoke antibiotic resistance and adversely affect the patient outcome. Implementation of an antibiotic stewardship program is warranted to enhance the efficacy, safety and cost-effectiveness of antimicrobial agents.

Keywords: Acute care, antibiotic misuse, Iraq, prescribing.

Digital Object Identifier (DOI): doi.org/10.5281/zenodo.1474831

References:

[1] C. L. Ventola, “The antibiotic resistance crisis—part 1: causes and threats,” Pharmacy and Therapeutics, vol. 40, no. 4, pp. 277– 283, 2015.
[2] OO. Oduyebo, AT. Olayinka, KC. Iregbu, A. Versporten, H. Goossens, PI. Nwajiobi-Princewill, et al., “A point prevalence survey of antimicrobial prescribing in four Nigerian Tertiary Hospitals,” Annals of Tropical Pathology, vol. 8, no. 1: pp. 42-46, 2017.
[3] M. O. Cotta, M. S. Robertson, L. M. Upjohn, C. Marshall, D. Liew, K. L. Buising, “Using periodic point-prevalence surveys to assess appropriateness of antimicrobial prescribing in Australian private hospitals,” Intern Med J, vol. 44, no. 3: pp. 240-6, 2014.
[4] K. Baktygul, B. Marat, Z. Ashirali, Harun-Or-rashid M, J. Sakamoto, “An assessment of antibiotics prescribed at the secondary health-care level in the Kyrgyz Republic,” Nagoya J Med Sci, vol. 73: pp. 157-68, 2011.
[5] L. A. Mbam, G. L. Monekosso, E. A. Asongalem, “Indications and patterns of antibiotic prescription in the Buea Regional Hospital of Cameroon,” Health Sci Dis, vol. 16, no. 1, 2015.
[6] E. D. Chem, D. N. Anong, J. K. T. Akoachere, “Prescribing patterns and associated factors of antibiotic prescription in primary health care facilities of Kumbo East and Kumbo West Health Districts, North West Cameroon,” PLoS One, Vol. 13, no. 3: pp: e0193353, 2018.
[7] S. Mollahaliloglu, A. Alkan, B. Donertas, S. Ozgulcu, A. Akici, “Assessment of antibiotic prescribing at different hospitals and primary health care facilities,” Saudi Pharmaceutical Journal, vol. 21, no. 3: pp. 281-291, 2013.
[8] D. Ashiru-Oredope, M. Sharland, E. Charani, C. McNulty, J. Cooke, “Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart--Then Focus,” J Antimicrob Chemother, vol. 67 Suppl 1: pp. i51-63, 2012.
[9] H. Akhloufi, R. H. Streefkerk, D. C. Melles, J. E. de Steenwinkel, C. A. Schurink, R. P. Verkooijen, et al., “Point prevalence of appropriate antimicrobial therapy in a Dutch university hospital,” Eur J Clin Microbiol Infect Dis, vol. 34, no. 8: pp. 1631-7, 2015.
[10] A. Al-Yamani, F. Khamis, I. Al-Zakwani, H. Al-Noomani, J. Al-Noomani, S. Al-Abri, “Patterns of Antimicrobial Prescribing in a Tertiary Care Hospital in Oman,” Oman Med J, vol. 31, no. 1: pp. 35-9, 2016.
[11] M. A. Borg, P. Zarb, M. Ferecgh, H. Goossens, et al., “Antibiotic consumption in southern and eastern Mediterranean hospitals: results from the ARMed project,” J Antimicrob Chemother, vol. 62, no. 4: pp. 830-6, 2008.
[12] K. M. Jumaa, S.A Hussein, A. M. Jaffer, A. S. Abdel Alaziz, Abdel Latif R. A., “Antibiotic Prescription Pattern in Surgery Department in Baquba Teaching Hospital,” The New Iraqi Journal of Medicine, vol. 7, no. 2: pp. 33-40, 2011.
[13] T. K. Al Hilfi, R. Lafta, G. Burnham, “Health services in Iraq,” Lancet, vol. 381: pp. 939-48, 2013.
[14] C. Lee, S. A. Walker, N. Daneman, M. Elligsen, L. Palmay, B. Coburn, et al., “Point prevalence survey of antimicrobial utilization in a Canadian tertiary-care teaching hospital, ” J Epidemiol Glob Health, vol. 5, no. 2: pp. 143-50, 2015.
[15] V. S. Deshmukh, V. V. Khadke, A. W. Patil, P. S. Lohar, “Study of prescribing pattern of antimicrobial agents in indoor patients of a tertiary care hospital,” Vol. 2, no. 3, 281-5, 2013.
[16] Clostridium difficile infection: risk with broad spectrum antibiotics. 2015 March 2015; Available from: https://www.nice.org.uk/advice/esmpb1/resources/clostridium-difficile-infection-risk-with-broadspectrum-antibiotics-pdf-1502609568697285.
[17] Bratzler, D. W., E. P. Dellinger, K. M. Olsen, T. M. Perl, P. G. Auwaerter, M. K. Bolon, et al., Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm, vol. 70, no. 3: p. 195-283, 2013.
[18] E. Charani, C. Tarrant, K. Moorthy, N. Sevdalis, L. Brennan, A. H. Holmes, “Understanding antibiotic decision making in surgery-a qualitative analysis,” Clin Microbiol Infect, vol. 23, no. 10, pp. 752-760, 2017.
[19] S. O’Neill, P. Ross, P. McGarry, S. Yalamarthi, “Latest diagnosis and management of diverticulitis,” Br J Med Pract, vol. 4, no. 4, pp: a443, 2011.
[20] M. De Luca, D. Dona, C. Montagnani, A. Lo Vecchio, M. Romanengo, C. Tagliabue, et al, “Antibiotic Prescriptions and Prophylaxis in Italian Children. Is It Time to Change? Data from the ARPEC Project,” PLoS One, vol. 11, no. 5: pp. e0154662, 2016.
[21] British National Formulary. Edition 69. London: Royal Pharmaceutical Society of Great Britain and British Medical Association; 2015. pp 222-245.