A Cross-Sectional Study of Prescribing Pattern of Antimicrobial Agents Among Inpatients of a Tertiary Healthcare Centre

Background: Antimicrobial agents are the mainstay of treatment in modern medicine. In view of emerging threat of Antimicrobial Resistance (AMR), there was a requirement aimed at identifying patterns of antimicrobial prescribing. The prescribing pattern of antimicrobial agents (AMAs) among the medicine inpatients of SMS Medical College & Hospital, Jaipur, India was studied. The objectives were to evaluate, monitor and suggest rational prescribing practices. Methods: This was a cross-sectional study that was done for a period of one year from July 2016 to June 2017. The rationality of antimicrobial drug use was evaluated by analysing the prescriptions. Results: A total of 400 patients were included in the study. Percentage of indoor patients with one or more AMAs prescribed was 48.75 %. The average number of AMAs prescribed was 1.67. Percentage of AMAs prescribed consistent with the National List of Essentials Medicines (NLEM) was 89.73 %. The average AMAs duration prescribed was found to be 4.24 days. The most commonly prescribed antibacterial agent in medicine in patients was a beta-lactam AMA with 57.29 % of all prescriptions. Conclusion: AMR is strongly linked to improper antimicrobial use. This study suggests that certain interventions are required to minimise toxicity and lessen the chances of emergence of resistance. It is therefore proposed that there should be continuous education on rational use of drugs among healthcare professionals.


Introduction
Antimicrobial agents (AMAs) have continued to remain the basis of treatment in modern medicine, since their development. 1-3 AMA use has resulted in a worldwide decline in infection-associated mortality. 4,5 Today, the most commonly prescribed medication in any hospital settings is an antimicrobial agent. 6 Judicious use of antimicrobials is rapidly becoming a major public health need. 7 Inappropriate/improper antimicrobial use can result in increased adverse drug reactions (ADRs), suboptimal therapy, treatment failures, The objectives of this observational study were to describe and analyse the prescribing pattern of AMAs among medicine indoor patients of SMS Medical College and Hospital, Jaipur, India and it specifically related to the appropriateness of use of antimicrobials. The administrative permission to conduct the study was obtained from the Medicine Department & Institutional Research Review Board. The study was a cross-sectional in design. It was conducted for the duration of 12 months (in order to include seasonal variations in diseases). The inclusion and exclusion criteria are listed below.

Statistics
The sample size at 95 % confidence level expecting 50 % use of antimicrobials (maximum variance) in the Medicine Department of the SMS Hospital. At the precision (relative allowable error) of 10 %, minimum of 384 patients were required as a sample size which was further increased and rounded up to 400 patients as a minimum sample size required for the present study (Davey et al, 2005). 11 Data collected was tabulated and analysed using descriptive statistical tools (mean, standard deviation and percentage wherever applicable   Conditions recorded on prescription and antimicrobials prescribed are listed in Table 2.
The average number of AMAs prescribed was 1.67. Indoor patients may receive more than one AMA during the course of their treatment. This prescribing may be warranted or unwarranted. Even duplication occurs in exceptional events. The study from Oman reported the average number to be 2.5, which is higher in comparison to the present study. 20 In contrast the study from Ghana reported the average number to be 1.1. 24 Since in the medicine indoor patients who were prescribed AMAs were prescribed an average of 1.67 AMA per hospitalisation, the rate is satisfactory in most situations.
National List of Essentials Medicines (NLEM) represents the medicines that fulfil the priority health care needs of the patients in a hospital, is used to rationalise the use of medicines. Non-adherence to this can have many causes including lack of awareness, not being in conformity and listed medicines (AMAs) not being available at the hospital. Percentage of AMAs prescribed consistent with the NLEM was 89.73 %. This indica-tor measures the degree of prescriber adherence to the NLEM. Since a total of 89.73 % of AMAs prescribed were on the NLEM, 25 this percentage is acceptable, and no further assessment was done to examine adherence. It can be said that the prescribers are aware and in agreement with the list. The routine training programme and workshops in SMS Medical College and Hospital can be attributed to this achievement. These academic activities in a tertiary care teaching hospital give physicians an up to date on treatment protocols. Another factor responsible for this is the fact that the NLEM is also updated regularly and revised accordingly. It can be hoped that in future this indicator would improve even further and there will be a suitable use of AMAs that are on the NLEM.
In SMS Medical College and Hospital the average AMAs duration prescribed was found to be 4.24 days. This indicator measures the strength of patient exposure to AMAs. The number of days on AMAs includes the number of days of all AMAs prescribed for treatment (not prophylaxis). It includes the duration of AMAs prescribed on discharge. Since the average duration of prescribed AMAs was 4.24 days, it conforms to other studies that suggest reducing the duration of antimicrobial use. 26 Also, this duration of therapy is at par with most international guidelines on antimicrobial use. But the discontinuing the antimicrobials post discharge may have been overlooked.
The adherence with hospital treatment standards is reflected in prescribing AMA of choice as per the STG. 27,28 Pneumonia patients who were prescribed AMAs in accordance with STG was found to be 81.58 % This indicator measures whether the patient prescription adheres to the treatment guidelines or not. The therapeutic options to pneumonia were analysed according to 2016 guidelines. 28 In SMS Medical College and Hospital, 81.58 % of pneumonia cases were treated with the recommended AMAs according to the latest guidelines. It suggests that most of the prescribers are aware of these guidelines and are in wilful compliance. Also, all prescribers used the recommended doses as well. This is contrary to the study by Sharma and Kapoor in 2003 which showed that a large number of prescriptions did not match the STG. 29 However, in the study by Hariharan et al in 2009, 67% prescriptions adhered to hospital protocol. 30 In the study hospital, it was found that the percentage of AMAs prescribed by their generic Antimicrobial prescribing among medicine in patients at SMS Medical College and Hospital, Jaipur was found to be satisfactory with an area of concern. There are chances of antimicrobial resistance and toxicity of drugs. A practical way to address this urgent need is education and awareness about AMR among prescribers. Rational use of drugs should be promoted, as advocated by the WHO. 37 Besides, it is recommended to develop a restrictive antimicrobial use policy. This would ensure not only tailored intervention for empirical therapy but adjusted antimicrobial use once drug sensitivity test results are available.

Conflict of interest
None.
There are several limitations to this study. It is a single centre, observation study describing only the prescribing indicators. A preliminary comparison and evaluation of findings with other hospitals and countries is done. More studies would be required to further monitor, modify and rationalise drug use across the country.  31 The availability of generic drugs in the Government supply and the awareness and agreement of prescribers was looked for. In Rajasthan, after the implementation of free drug scheme, there is strict adherence to generic prescribing in all the Government-run hospitals. In addition, there are Medical Council of India (MCI) guidelines for ensuring the same. 32 The myth about free drugs being not effective, toxic and contributing to resistance is found to be false in the present study.
Since it was ascertained that 100 percent of drugs were prescribed by their generic names, the role of State Government in implementation of MCI guidelines and ensuring compliance of the same is indeed commendable.
The use of AMAs depends on the knowledge of their spectrum. The rate of sensitivity tests done is a measure of the ability of the prescriber to provide rational treatment. The number of drug sensitivity tests reported per hospital admission with AMAs prescribed was found to be 8.21 %. This value is lesser in comparison to the Oman study which found that 25 % of drug sensitivity was done. 20 However, the Chinese study showed that a mere 39 specimens in the 1025 cases were sent for testing. 23 Whereas, Ider et al (2010) in Mongolia showed values similar to the present study. 33 This indicator measures the availability of drug sensitivity to establish best possible treatment to infective diseases. Here, since drug sensitivity test was performed for 8.21 % of hospital admissions treated with AMA, an intervention to improve the microbiology lab services may be required to improve this indicator to acceptable limits.
The average number of medicines prescribed was found to be 7.12. However, the study from Pakistan showed polypharmacy of 12 drugs/prescription. 34 Similarly, polypharmacy was found in GMC, Dhule by Deshmukh et al (2013). 35 The present study found that among AMAs, the antibacterial agents were prescribed for 85.84% of patients. Among antibacterials, as the beta-lactams account for 57.29 % of prescriptions; this value corresponds to the worldwide consumption of antimicrobials reported by Boeckel et al (2014) who showed that penicillins and cephalosporins accounted for 37 % and 24 % respectively. 36 Therefore, the present results correspond to the global trend in antimicrobial consumption.