Study on Drug Utilization Pattern of Antibiotics in Respiratory Tract Infections

 

Shafinaz1, Juno J Joel*1, Vadish S Bhat2, Angel Rose ER1

1Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences

(Nitte Deemed to be University), Derlakatte, Mangaluru

2Department of ENT, Justice K.S. Hegde Hospital, Mangaluru.

*Corresponding Author E-mail: junojoel@nitte.edu.in

 

ABSTRACT:

Objective: The aim of the study is to analyse the drug utilization pattern of antibiotics in patients with respiratory tract infections (RTIs).  Methods: A prospective observational study was conducted for a period of 8 months. The prescriptions were followed on daily basis and the prescribing frequency of various antibiotics were categorized and documented. As per the WHO-ATC system the consumption of antibiotics was determined by DDD/100 bed days. Results: Out of 136 patients, 70(51.5%) were males and 66 (48.5%) were females. Majority of patients were in the age group of 18-29 years. The most common RTIs among the patients was found to be otitis media (61%), followed by sinusitis (14.7%). Majority of the patients were prescribed with cephalosporin which includes ceftriaxone (52.2%) and cefixime (37.5%). Pseudomonas aeroginosa and staphylococcus were the most isolated organisms. Pseudomonas aeroginosa shows maximum sensitivity to ciprofloxacin, ceftazidime and staphylococcus aureus towards gentamicin and erythromycin. Conclusion: Otitis media and sinusitis were the commonly found respiratory infections and are frequently managed by cephalosporins. The study also established the consumption of various antibiotics used in the management of respiratory tract infections.

 

KEYWORDS: Antibiotic, Respiratory tract infections, Drug utilization.

 

 


INTRODUCTION:

Respiratory tract infections are considered one of the most common infections existing worldwide. It is observed as the significant cause of morbidity and mortality among the individuals of any age group [1]. Recent studies state that about 20-40% patients visiting a hospital is thought to be treated as outpatients while 12-35% of the patients are hospitalized [2]. In India, Respiratory tract infections report one million deaths, out of which 10-15% is approximated to be due to LRTIs. According to World Health Organization, about 3.9 million deaths due to RTIs were recorded so far and 6.8% deaths are reported every year [3]. Respiratory tract infections are commonly classified as Upper Respiratory Tract Infections (URTIs) and Lower Respiratory Tract Infections (LRTIs).

 

The URTI usually affects regions ranging from nose to trachea, while LRTI includes infections of lungs, bronchus and bronchioles.[4] The Upper Respiratory tract infections are said to be the most common infectious disease which involves common cold, laryngitis, pharyngitis, otitis media, sinusitis, rhinitis, tonsillitis etc. Lower Respiratory Tract Infections are regarded as the prominent cause of death among all infectious diseases. The most common LRTIs are bronchitis, pneumonia, tracheitis etc. [5] The viruses such as rhinovirus, coronavirus, adenovirus, influenza virus, parainfluenza virus, respiratory syncytial virus, parainfluenza virus, coxsackievirus and epstein- bar virus etc are the major causative organisms for RTIs [6]. Antibiotics are the mainstay of drugs for the treatment of respiratory tract infections [7]. These products should be prescribed wisely i,e use of right dose at right time for right duration of time [8]. This study analyses the drug utilization pattern and consumption of various antibiotics used in patients with respiratory tract infections.

 

 

MATERIALS AND METHODS:

A randomised prospective observational study of 8 months duration was conducted in the inpatient ENT and general medicine wards of a multispecialty teaching hospital, in Dakshina Kannada district of South India. Central research ethics committee approval was obtained before starting the study. The study includes all the inpatients of either gender of age more than 18 years who were diagnosed with RTI and received at least one antibiotic. Patient data collection form was designed as per the need of study. All relevant information’s were collected from the concerned patient treatment charts. Inpatients of the ENT and General Medicine department who received antibiotics were reviewed on a daily basis. Details of drug therapy such as drug, dosage form, frequency, route of administration, duration of treatment, length of hospital stay, and number of drugs per prescription were recorded. Anatomical therapeutical chemical (ATC) classification and defined daily dose (DDD) system was used for the quantification of drug utilization. The antibiotics were classified according to ATC system and the consumption was measured by using DDD/100 bed days and compared with WHO standards. Defined daily dose and prescribed daily dose of antibiotics was calculated by using below mentioned formula.

                        Number of units delivered in afixed period (mg)

DDD/100 = -------------------------------------------------------------- X 100

bed days           DDD X Number of days X Number X

                      Occupancy index (mg) in the period of beds

 

                                                  Total amount of drug (mg)       

Prescribed Daily Dose = ----------------------------------------- 

                    Duration of hospital

 

Descriptive statistics was applied for analysing the collected data. Data analysis was carried out using Statistical Package for Social Science (SPSS) 16.0 for windows.

 

RESULTS:

Demographic characteristics among the study population:

A total number of 136 inpatients who have received antibiotics were enrolled in the study. Among them 70(51.5%) were males and 66(48.5%) were females. The mean average stay of hospitalization was found to be 6.30+2.70. Most of the patients were in the age group of 18-29 years 51 (37.5%), followed by 30-39 years 37(27.2%) and other age groups. The age wise distribution of the enrolled patients is summarized in the Table1.

 

Respiratory tract infections identified in the study population.

The most common clinical condition that are treated with antibiotics was noticed to be otitis media 83(61%), followed by sinusitis 20(14.7%), tonsillitis 17(12.5%) and other clinical conditions. The details of other clinical conditions are presented in Table 2.

 

Table 1: Age wise distribution of patients treated with antibiotics

SL. No

Age (years)

Number of patients (N=136)

Percentage (%)

1

18-29

51

37.5

2

30-39

37

27.2

3

40-49

25

18.4

4

50-59

22

16.2

5

60-69

1

0.7

Mean ± SD =35.29±12.077

 

Table 2: Clinical conditions for which the antibiotics used

Sl. No

Clinical conditions

Number of patients (n=136)

Percentage (%)

1

Otitis Media

83

61%

2

Sinusitis

26

19.11%

3

Tonsillitis

17

12.5%

4

Bronchiectasis

2

1.5%

5

Laryngitis

3

2.20%

6

Myringitis

1

0.7%

7

Phenumonia

3

2.20%

8

Bronchitis

1

0.7%

 

Prescription pattern of antibiotics.

In the present study, majority of the patients were prescribed with ceftriaxone 71(52.2%), followed by cefixime 51(37.5%). The overall prescribing patterns of antibiotics in the study population are depicted in Table3.

 

Table 3: Prescription pattern of antibiotics

Sl. No

Antibiotics

No of Patients (n=136)

Percentage (%)

1

Ceftriaxone (P)

71

52.2%

2

Cefixime (O)

51

37.5%

3

Amoxicillin+clavulanic acid (P)

24

17.6%

4

Amoxicillin+clavulanic acid (O)

16

11.8%

5

Ceftriaxone/sulbactam (P)

15

11.0%

6

Cefazolin (P)

15

11.0%

7

Amikacin (P)

5

3.7%

8

Metronidazole (P)

5

3.7%

9

Azithromycin (O)

3

2.2%

10

Ciprofloxacin(O)

2

1.5%

11

Gentamicin (P)

2

1.5%

12

Cefotaxim (P)

2

1.5%

13

Linezolid (P)

2

1.5%

14

Ciprofloxacin(P)

1

0.7%

15

Levofloxacin (P)

1

0.7%

16

Levofloxacin (O)

1

0.7%

17

Clindamycin (P)

1

0.7%

18

Clindamycin (O)

1

0.7%

19

Meropenem (P)

1

0.7%

20

Piperacillin + tazobctum (P)

1

0.7%

21

Linezolid (O)

1

0.7%

P-Parenteral, O-Oral

 

ATC code and DDD/100 bed days of antibiotics prescribed:

The consumption of the antibiotics was calculated in terms of DDD/100bed days. The consumption of the Ceftriaxone was found to be highest (39.52 DDD/100bed days), followed by cefixime (15.31 DDD/100bed days). The ATC code and the DDD/100 bed days calculated for various antibiotics prescribed in the study population are summarized in Table 4.

 

Table 4: ATC code PDD and DDD/100 bed days of antibiotics prescribed

Sl. no

Drug

ATC Code

PDD (mg)

DDD (mg)

DDD/100 bed days

1

Ceftriaxone (P)

J01DD04

788.79

2000

39.52

2

Cefixime (O)

J01DD08

61.14

400

15.31

3

Amoxicillin+ Clavulanate (P)

J0ICR02

336.11

3000

11.22

4

Ceftriaxone+ Sulbactam (P)

J01DD54

294.04

3000

9.82

5

Amoxicillin+ Clavulanate(O)

J01CR02

75.11

1000

7.52

6

Cefazolin (P)

J01DB04

134.18

3000

4.48

7

Azithromycin (O)

J01FA10

7.58

300

2.53

8

Amikacin (P)

J01GB06

25.08

1000

2.51

9

Linezolid (P)

J01XX08

15.4

1200

1.20

10

Gentamicin (P)

J01GB03

1.86

240

0.77

11

Ciprofloxacin (O)

J01MA02

7.001

1000

0.70

12

Linezolid (O)

J01XX08

7.7

1200

0.64

13

Ciprofloxacin (P)

J01MA02

2.8

500

0.56

14

Piperacillin+ Tazobactam (P)

J01CR05

52.5

14000

0.37

15

Levofloxacin (O)

J01MA12

1.75

500

0.35

16

Meropenem (P)

J01DH02

7.001

2000

0.35

17

Metronidazole (P)

J0IXD01

4.9

1500

0.32

18

Clindamicin (O)

J01FF01

3.5

1200

0.29

19

Cefotaxim (P)

J01DD01

9.33

4000

0.23

20

Levofloxacin (P)

J01MA12

1.16

500

0.23

21

Clindamicin (P)

J01FF01

2.8

1800

0.15

P- Parenteral, O- Oral

 

Most isolated organism:

Among the total 136 patients, culture test was performed on18 patients. Pseudomonas aeroginosa and staphylococcus aureus were reported as the most isolated organisms from 4(12.5%) study subjects each, followed by Coagulase negative staphylococcusaureus from 3(9.4%) patients. The other isolated organisms in the study population are mentioned in the table below (Table 5).

 

Sensitivity pattern of organisms to the antibiotic:

The antibiotic sensitivity pattern of the organisms was reviewed to determine the sensitivity patterns. It was observed that, Pseudomonas aeroginosa shows maximum sensitivity to Ciprofloxacin, Ceftazidime, Cefoperazone/Sulbactam and Cefepime. Maximum sensitivity of Staphylococcus aureus was observed to be towards Gentamicin, Erythromycin, Linezolid, Teicoplanin, Vancomycin and Tetracycline and Linezolid. Staphylococcus aureus was also sensitivity to Vancomycin, Teicoplanin and Linezolid. This organism was noticed to have higher sensitivity towards Tetracycline in majority of cases.

 

Table 5: Most isolated organism

SL. No

Organism

No. of patients

Percentage (%)

1

Pseudomonas aeruginosa

4

12.5%

2

Staphylococcus aureus

4

12.5%

3

Coagulase- negative Staphylococcus aureus

3

9.4%

4

Escherichia coli

2

6.2%

5

Enterococcus species

2

6.2%

6

Klebsiella pneumoniae

1

3.1%

7

Proteus mirabilis

1

3.1%

8

 Acinetobacter baumannii

1

3.1%

 

Resistance pattern of organisms to antibiotics:

Resistance pattern of the organisms in this study sample shows, Pseudomonas aeruginosa has maximum resistance to Trimethoprim/ Sulfamethoxazole followed by Tigercycline. Maximum resistance of Staphylococcus aureus was observed to be towards Benzyl penicillin. The coagulase negative staphylococcus aureus shows maximum resistance to Benzyl penicillin and Ciprofloxacin. E.coli shows maximum resistance to Ampicillin and Nitrofurantoin. Enterococcus species shows maximum resistance to Ciprofloxacin, Erythromycin, Clindamycin, Levofloxacin and Tetracycline. The maximum resistance of Klebsiella pneumoniae was found to be towards Ampicillin. Acinetobacter baumannii shows maximum resistance to ciprofloxacin and levofloxacin.

 

Number of antibiotics per prescription:

Single antibiotic therapy was received by 68(50%) subjects, while 59 (43.4%) and 9 (6.6%) of the subjects received combination antibiotic therapy. (Table 6)

 

Table 6: Number of antibiotics per prescription

Sl. No

Number of antibiotics

Frequency (n=136)

Percentage (%)

1

1

68

50%

2

2

59

43.4%

3

3

9

6.6%

 

DISCUSSION:

According to this study the male patients admitted due to RTIs was more in numbers compared to female patients. The Similar findings were observed in the study which was conducted by Errabelly P et al., and Pradhan S et al, where it was reported that male patients were higher than female. [8,9] In the present study, majority of the patients affected with RTIs were in the age group of 18-29 years followed by 30-39 years. Whereas on a study conducted by Gogoi S et al., the maximum of patients were in the age group of 15- 35 years. another study conducted by Sridevi SA et al., shows that majority of the patients were in the age group of 18-30 years. [10,11] The mean average stay of hospitalization was found to be 6.30+2.70 in the current study. In a similar study, which is conducted by Kancherla D et al., the average stay of hospitalization was found to be 6.9+5.33 days.[5] Further,in this study 50% patients received single antibiotic therapy whereas, 43.4% and 6.6% of the patients received combination therapy. Similar results reported by Erabelly P et al., where it was found that single antibiotic therapy was high when compared to combination therapy. [12,9]

 

The patients diagnosed with RTIs was prescribed with antibiotics for different types of common infection like otitis media (61%), sinusitis (14.7), tonsillitis (12.5%), laryngitis (0.7%), bronchitis (0.7%) and with LRTI (1.5%). Otitis media was the common RTI in the present study. Similar result was shown in a study carried out by Suman RK et al., and Gosh A et al., where they found that majority of the patients were infected by Otitis media. [13,14] While categorizing antibiotic prescriptions, it was found that ceftriaxone (52.2%) was the most commonly prescribed drug in the study. Similar results were reported by Naik HG et al and Kancherla D et al where the most commonly used antibiotic was ceftriaxone [6,5]. Present study result shows that the DDD/100 bed day of ceftriaxone was 39.52. Similar study conducted by Shankar PR et al where DDD/100 bed days for cephalosporins were found to be 4.6 [15]. In this study the most isolated organisms were found to be pseudomonas aeruginosa and staphylococcus aureus. Similar results were found in the study conducted by Khan FA et al. But, a study by Shankar RP et al., observed H.influenzae and E.coli as the predominant isolated organisms [16].

 

CONCLUSION:

The present study established the consumption of antibiotics in patients with respiratory tract infections. It was noticed that there was a predominance of Otitis media followed by sinusitis and tonsillitis reported during the study period. The most commonly prescribed antibiotics for respiratory tract infections were Cephalosporins which includes Ceftriaxone, Cefixime, followed by Penicillins which includes Amoxicillin/ Clavulanate. Mono antibiotic therapy (50%) was more prescribed than combination therapy. The most isolated organisms were Pseudomonas aeruginosa and Staphylococcus aureus.

 

CONFLICTS OF INTERESTS:

Nil.

 

 

 

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Received on 02.11.2018         Modified on 11.12.2018

Accepted on 25.12.2018      © RJPT All right reserved

Research J. Pharm. and Tech. 2019; 12(3): 1189-1192.

DOI: 10.5958/0974-360X.2019.00197.5