Antibiotic utilization in general medical units in a tertiary care institution Fernando GVMC, Ratnasekera IU, Perera MSD, Wanigatunge CA

Introduction Infectious diseases account for 45% of deaths in low income countries. In the majority of them the mainstay of treatment is antibiotics. Hence antibiotics are the most widely used category of drugs in the world accounting for over 25% of hospital drug costs.

The major limiting factor for the use of these drugs is the emergence of multi-drug resistant organisms (MDRO). Reason for such event being the inappropriate use of antibiotics in terms of the choice of antibiotic, dosage, frequency, route and the duration. Increasing resistance leads to the use of broad spectrum therapy to cover the pathogens empirically paradoxically contributing to a higher incidence of MDROs.

Although antibiotics are widely used in hospitals, the utilization studies in in-ward patients are lacking in Sri Lanka.

Objectives General Objective: To ascertain the use and appropriateness of antibiotics used in medical wards at a selected tertiary care institution using available national guidelines.

Specific Objectives: 1. To identify the types of antibiotics used in different indications 2. To ascertain the routes, doses and dosing frequency of their administration. 3. To identify the factors affecting the change of antibiotic used as the first choice

4. To assess the adherence to guidelines issued by Sri Lanka Medical Association (SLMA) and Health Sector Development Programme (HSDP).

Methodology Study Design – Descriptive Cross Sectional Study Study setting – Tertiary Care Hospital in Colombo District Study Population – Bed-head tickets of patients discharged from general medical units of the tertiary care hospital between 01/02/2012 – 01/06/2012

Sampling – Systematic Random sampling: Data were collected on Mondays, Wednesdays and Fridays from the bed-head tickets of all the patients discharged from the respective wards on the previous days of the defined period.

Data collection was with the data extraction forms. Data analysis: – The regimes were assessed for concordance with the guidelines of Sri Lanka Medical Association (SLMA) and the Health Sector Development Programme (HSDP). Ethical approval - ERC FMS USJ (Proposal no. 610/12)

Results Total study population BHTs from 3 general medical units Age Distribution

Sex distribution – Males – 309/57% – Females – 234/ 43% Numbers of patients from each unit.

Commonest Infections

1. Lower Respiratory Tract infection Commonest antibiotics used 67 (71.3%) of the instances the drugs were given as combinations. (18%) out of the combinations they were co-amoxiclav and clarythromycin

Concordance with guidelines – HSDP – SLMA

Reasons for the regime to be wrong according to HSDP

2. Urinary Tract Infections Urinary Tract Infections- 60

Commonly Used Antibiotics – Commonly used antibiotics for LUTI (n= 34) Ciprofloxacin was used in 19 of the cases; 16 of the instances as monotherapy and three cases in combination with either metronidazole, co-amoxiclav or clarythromycin

– Commonly Used Antibiotics for Pyelonephritis (n=26) In 12 of the pyelonephritis cases cefotaxime was used as the first choice. Out of them in one instance cloxacillin and in another ciprofloxacin had been used in addition.

Concordance with guideline (SLMA only) – LUTI -UUTI

Reasons for the regime to be wrong – LUTI

Reasons for the regime to be wrong – UUTI

3. Infective exacerbation of bronchial asthma – Commonly used antibiotics

There is no specific guideline for the management of infective exacerbation of bronchial asthma.

Antibiotic Sensitivity Test Only 24/543 had microbiological samples collected for ABST Of these 22 had been collected prior to antibiotic therapy

Outcome of ABST

Modification of Regimes Rate of modification

Reason for modification

Conclusions 1. Antibiotics prescribed for common infections were not in accordance with guidelines available in % of instances – concordance varied between guidelines 2. Commonest reasons for discordance were wrong initial drug choice or frequency 3. Use of available guidelines for prescribing is suboptimal

Recommendations Development and effective implementation of a National Antibiotic Policy. – Multiple guidelines from different organisations should be avoided Regular updating of such guidelines in keeping with the changes in antibiotic sensitivity Auditing the use of antibiotics to minimize the hospital drug costs and development of multi- drug resistant organisms.

Acknowledgements Head of the tertiary care institution Consultants and the health-care staff of relevant medical units

Thank you!