Utilisation and Price Variability of Cephalosporins in General Medicine Department of a Tertiary Care Hospital

Jibin Jose¹, Adithi K*², Rajesh K S*¹, Bharath Raj KC, Gururaj MP³, Prasanna Sham K³

¹Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences,

Nitte (deemed to be University), Mangaluru-18

²Department of General Medicine, KS Hegde Medical Academy, Nitte (deemed to be University), Mangaluru-18

³Department of Pharmacology, NGSM Institute of Pharmaceutical Sciences,

Nitte (deemed to be University), Mangaluru-18

*Corresponding Author E-mail: rajeshks@nitte.edu.in, adithibhandary@nitte.edu.in

ABSTRACT:

Objective: The aim of the study is to assess the drug utilisation pattern of cephalosporins in general medicine ward of a tertiary care hospital. Methods: A prospective observational study was conducted among 100 patients admitted in general medicine ward of the tertiary care hospital. The patients who received cephalosporins during the time were included in the study. Data of enrolled patients was collected from inpatient records and assessed by statistical analysis. Results: 100 patients were enrolled into the present study (61% male and 39% female). The majority of patients (25%) belonged to age group 50-59 years. 17% patients had to urinary tract infections followed by 15% for acute febrile illness and 13 % for lower respiratory tract diseases. The duration of treatment was found to be 4-6 days in 48% patients. The route of administration of cephalosporins was intravenous in 91% patients. Only brand drugs (100%) were prescribed in this study. Ceftriaxone (89%) was the most commonly prescribed drug followed by Cefixime (7%). 4 different brands of ceftriaxone (1gm) were prescribed with a price variability of 4.66% and 3 different brands of cefixime were prescribed with a price variability of 29.67%. Conclusion It was observed that physicians prescribed cephalosporins rationally with no newer drugs or banned drugs but showed evident price variation. The study provides an insight to the pharmacists and other health care professionals on the need to work together for promoting the rational use of antibiotics and to minimize the cost of therapy.

KEYWORDS: Cephalosporins, Drug utilisation, price variation.

INTRODUCTION:

Antibiotics are among the most common medications prescribed both in the hospital setting and the community setting [1].The overuse of antibiotics has resulted in the emergence of drug-resistant strain which is very difficult to treat, representing a major public health problem [2].

The Cephalosporin are widely prescribed for various infections every day. Their undisputed popularity is due to lesser allergenic and toxicity risks as well as a broad spectrum of activity.

It is the latter feature, however, that encourages the selection of microorganisms which are resistant to these agents [3].

For the practicing physician, the number of available agents, their similarity of names and the varying spectrum of activities comprise a bewildering number of potential treatment options [4]. Cephalosporins have proliferated to become the most diverse group of antimicrobials available. At the same time, Cephalosporins have become among the antimicrobials most frequently prescribed inappropriately and consequently, most often subject to drug utilization review [5]. Cephalosporins are divided based on generation. These medicine are divided into first generation to fifth generation depending upon their microbic spectrum [6].

Cephalosporins are used to treat a range of infections including septicaemia, pneumonia, meningitis, biliary-tract infections, peritoneal inflammation and Urinary tract infections. Despite the wide use of Cephalosporins, there is restricted range of studies investigating the drug prescribing and utilization pattern of this antibiotic within the hospital setting. Hence, this study was undertaken.

The World Health Organization (WHO) in 1997 [7] defined Drug utilization evaluation (DUE) as the “the marketing, distribution, prescription and use of drugs in a society, with special emphasis on the resulting medical, social and economic consequences”.

The main aim of Drug Utilization studies is to facilitate the rational drug use in populations. Pharmacists play an important role in the overall process of a DUE program because of their experience in the area of pharmaceutical care. DUE offers the pharmacists the opportunity to identify trends in prescribing within groups of patients with asthma, diabetes or high blood pressure. Pharmacists in collaboration with physicians and other members of healthcare professionals can initiate actions to improve drug therapy for both individual patients and patient population. Role of pharmacist include [8].

MATERIALS AND METHODS:

A prospective observational study of 8 month duration was carried out in the General medicine department of a tertiary care hospital. Institutional Ethical Committee approval was obtained before initiating the study. Patient data collection form was designed as per the need of the study. The inpatients of general medicine department who received cephalosporins were reviewed and necessary data were collected which included demographic details, past medical history, presence of co-morbidities, laboratory reports and medication charts (name of the drug, dosage forms, frequency, and route of administration and duration of treatment). Drug therapy were collected systematically and documented in the suitable data collection form designed as per the need of the study. The primary reason for prescribing cephalosporin was also recorded. Number of prescriptions of cephalosporin with their cost was analysed. Brands and price of cephalosporin used were collected from the patient records, medical bills, hospital accounts section, interviewing the patients or patient parties, and other relevant sources. Percentage price variation were calculated for different brands of the Cephalosporin prescribed by using following formula [9].

least expensive brand Percentage Variability =

Price of most expensive brand – Price of least expensive brand

----------------------------------------------------------------------------- X 100

Price of least expensive brand

Figure 1: Distribution of patients age

Statistical analysis:

Data was analysed using descriptive statistics. Mean and standard deviation of quantitative variable was documented. The SPSS version 20.0 was used to analyse the data.

RESULTS:

1. Demographic distribution:

100 patients were enrolled into the present study. There were 61 (61%) male patients and female patients were 39 (39%). Male patients are significantly more compared to female patients.

2. Age Wise Distribution:

The majority of patients (25%) belonged to age group 50-59 years, followed by patients in age group of 60-69 and >70 had 20% each. The mean age of the study population was 53.81 + 16.59 years (figure 1).

Figure 3: Duration of treatment with cephalosporins

3. Indication for use of cephalosporins:

17 (17%) of the patients received cephalosporins for urinary tract infections followed by acute febrile illness 15(15%), Lower respiratory tract diseases 13 (13%) and COPD 12 (12%) (figure 2).

4. Duration of treatment with cephalosporins:

The duration of treatment with cephalosporins in 100 patients was found to be 4-6 days (48%), followed by 7-9days (32%) (Figure 3).

5. Route of administration:

The route of administration of cephalosporin’s were intravenous in 91(91%) of patients, oral in 8 (8%) and followed by intravenous and oral 1 (1%) of patients.

6. Different cephalosporins prescribed in hospital:

In the present study, all the patients were prescribed with 3^rd generations cephalosporins and only brand drugs were prescribed (100%) and no generic drugs were prescribed. In the study population, various 3^rd generation cephalosporins were prescribed. Among the various cephalosporins used, ceftriaxone 89 (89%) was Most common prescribed, followed by Cefixime (7) 7%, cefotaxime (2) 2%, Ceftazidime (1) 1% and cefotaxim & cefixime (1) 1%.

7. Cephalosporins co-prescribed with other antibiotics:

Out of 100 patients included in the study 61 (61%) patients did not have any co prescribed antibiotics. 39 patients were received cephalosporins along with co-prescribed other antibiotics in the treatment. The Most common co-prescribed antibiotics was azithromycin in 19 patients (19%) followed by metronidazole in 5 patients (5%), others (15%) (figure 4).

8. Co-morbidity conditions in patients:

Out of 100 patients 70 patients (70%) had co- morbidity, 14 patients were diabetics followed by 11 patients were had hypertension (figure 5).

9. Price variability:

In our study population, percentage price variability could be checked only for ceftriaxone (1gm) and cefixime, as only one single brand was used while prescribing cefotaxim, ceftazidime and ceftriaxone (2gm) and a very small group of patients were prescribed with these drugs. Four different brands were used while prescribing 1gm of ceftriaxone and three different brands were used while prescribing cefixime. Cefixime shows maximum price variation of 29.67 & ceftriaxone of only 4.66 (Table 1).

Table 1: Price variability

Drug	Dose	Brand prescribed	Maximum price (Rs)	Minimum price (Rs)	Percentage Variability (%)
Ceftriaxone	1 g	4	54.79	52.35	4.66
Ceftriaxone	2 g	1	104.70
Cefotaxime	1 g	1	34.87
Ceftazidime	2 g	1	425.2
Cefixime	200 mg	3	126.50	97.55	29.67

Percentage Variability =

Price of most expensive brand – Price of least expensive brand

---------------------------------------------------------------------------------------- X 100

Price of least expensive brand

DISCUSSION:

In the present study, a total of 100 patients were enrolled. Results shows that percentage of male (61%) patients were more than female (39%) patients. Which is similar to the study conducted by Kiran et al., [10].

Majority of patients (25%) belonged to age group 50-59 years, followed by patients in age group of 60-69 years and >70 years had 20% each. Which is in agreement with previously published study by Jyothi et al.,[11] shows 27% patients belonged to age group 51-60.

In this study, most of patients were prescribed antibiotic for UTI (17%) followed by acute febrile illness (15%) and LRTI (13%), a study conducted by Jyothi et al., [11] reported higher percentage for UTI (16.83) and Gastrointestinal infection (14.85).

Majority of patients treated with cephalosporins in this study had to stay in hospital for 4-6 days (48%) followed by 7-9 days (32%). A similar study conducted by Goudanavar et al.,[12] shows that higher percentage (66%) for 3-6 days, followed by 7-14 were 37%.

In our study 91% of patients received cephalosporins through intravenous route followed by 8% who received the oral route. When compared to the study done by Kiran et al., [10] the result is similar in which route of administration of cephalosporin was intravenous in (105) 86.78% of patients & oral in (10) 13.22% of patients.

In this study only brand drugs were prescribed (100%). The result from the study published by Kiran et al., [10] was comparable with our findings, which shows cephalosporins were prescribed to the patients (10), in which 22 (18.18%) prescriptions used generic name and 99 (81.83%) used brand drugs.

From the collected data it was found that 100% of total patients received 3^rd generation cephalosporins. The wide usage had been due to their broad-spectrum activity. A study by Kiran et al., [10] reported that 79.34% patients were prescribed with 3^rd generation cephalosporins and remaining 20.66% of patients were prescribed with 2^nd generation cephalosporins.

In our study ceftriaxone (89%) was the most common cephalosporins prescribed. Which was similar to the study conducted by Jyothi et al., [11]in which ceftriaxone (49%) was most frequently prescribed drug among cephalosporins [13].

Out of 100 patients 61% of the patients received cephalosporins alone, 39% of patients were co-prescribed other antibiotics with cephalosporins. The most common co-prescribed antibiotics was azithromycin in 19 patients (19%) followed by metronidazole in 5 patients (5%). The result was similar to the study conducted by Kiran et al., [10] reported that 66% of the patients received cephalosporins alone, 33% of patients were co-prescribed with other antibiotic.

In this study, 70 patients had other co-morbidities, whereas 30 (30%) patients did not exhibit any co-morbid conditions. These results were contrary to the study conducted by Jyothi et al. [11,13],which shows that in the study 75.25% patients did not have any co morbid condition. Whereas 24.75% patients had one and two co morbid conditions.

In our study population price variability could be checked only for ceftriaxone (1gm) and cefixime as only one single brand was used while prescribing cefotaxim, ceftaxidime and ceftriaxone (2gm) and a very small group of patients were prescribed with these drugs. Four different brands of ceftriaxone (1gm) were prescribed with a price variability of 4.66 % the cheapest and the most expensive brand prescribed per dose of the drug. Three different brands of cefixime were prescribed with a price variability of 29.67% between the cheapest and the most expensive brand prescribed per dose (200mg) of the drug. Our study showed maximum price variability for cefixime & low price variability for ceftriaxone. A study by Patel et al., [9]reported that cefixime 200 mg (0.67%) shows the least percentage price variation.

CONCLUSION:

The present study provides data on the pattern of utilization of cephalosporins among patients admitted in the department of general medicine. The study concluded that parenteral formulations of cephalosporins were most widely used and among third generation drugs, ceftriaxone was the most frequently prescribed agent. An overview of the study also shows that these drugs were indicated more in conditions such as UTI followed by Acute Febrile illness, LRTI and COPD. It was observed that hospital physicians prescribed cephalosporins more rationally with no newer drugs or banned drugs.

In the study, comparison of maximum and minimum cost of different brands of cephalosporins used showed evident price variation, which explains the need to produce uniformity in price, thereby decreasing the economic burden on the patients. Thus, the study provides an insight to the pharmacists and other health care professionals on the need to work together for promoting the rational use of antibiotics and to minimize the cost of therapy.

ACKNOWLEDGEMENTS:

The authors are thankful to the authorities of Nitte (Deemed to be University), Mangalore, India; Medical Superitendent, KS Hegde Charitable Hospital, Mangalore; Dr. Raghav Sharma, Head, Department of Medicine, KS Hegde Charitable Hospital, Mangalore; Dr. C.S. Shastry, Principal, NGSM Institute of Pharmaceutical Sciences, Mangalore. Mr. Krishna Bhat CH, Statistician, Nitte (Deemed to be University).

REFERENCES:

1. Meer JW, Gyssens IC. Quality of antimicrobial drug prescription in hospital. Clin Microbiol Infect. 2001;7(6):12-5.

2. Goosens H. Antibiotic consumption and link to resistance. Clin Microbiol Infect. 2009;15(3):12-5

3. Dancer SJ. The problem with Cephalosporins. J Antimicrob Chemother. 2001;48(4):463-78.

4. Morrow JD. The Oral Cephalosporins-A Review. Am J Med Sci. 1992;(1):35-9.

5. Turnidge J. The choice of Cephalosporins. Aust Prescr. 1992;15(2):1-3.

6. Khezar H. Classification of cephalosporins (INTERNET). 2013 (cited on December 10). Available from http://medimoon.com/2013/05/classification-of-cephalosporin-antibiotics.

7. Khan FA, Nizamuddin S. Salman MT. Patterns of prescription of antimicrobial agents in the Department of otorhinolaryngology in a tertiary care teaching hospital. Afr J Pharm Pharmacol. 2011;5(14):1732-1738

8. Parthasarathi G, Nyfort K, Nahatha M. Drug utilization evaluation. Sathvik BS. 2^nd edition. University press india Pvt. 2012; 447-465.

9. Patel D, Thiyagu R, Surulivelrajan M, Patel H, Pandey S. Price variability among the oral antibiotics available in a south Indian tertiary care hospital. J Clin Diagn Res. 2009; 3:1871-1875.

10. Kiran B, Ghufran MA, Kumar S, Kumar DS. The drug utilization of cephalosporin in a tertiary care hospital. World J Pharm Pharm Sci. 2015;5(01):1201-1216.

11. Jyothi K, Babu J. Drug utilization evaluation of cephalosporins in general medicine units of rural tertiary care hospital. Int J Curr Pharm Res. 2012 ;4(2):88-91

12. Goudanavar P, Panavila L, Ninan N, Pratima KC. Drug use evaluation of third generation cephalosporin in a tertiary care teaching hospital. IJTA 2016;32(1):81-85.

13. Sathyanarayanan G, Geetha P, Shanmugasundaram P. A Prospective Observational Study on Assessment and Evaluation of Cephalosporin in General Medicine Department at Tertiary Care Hospital. Research J. Pharm. and Tech 2016; 9(8):1039-1042