INTRODUCTION:

Antibiotics are widely used drugs due to their beneficial effects in reducing infectious symptoms. Several studies show that they are indiscriminately used leading to increased medication burden, cost and resistance among patients thus this class of drug was chosen also pediatric patients show difference with other patients with respect to their body structure and physiology requiring special care and thus they have been selected for this study purpose. Emergence of resistant pathogens has increased concerns about antibiotic prescribing patterns.¹ During last decade, antibiotic resistance is on the rise mainly due to the abuse of broad spectrum antibiotics in first line treatment² or erroneous use, and use of multiple courses or prolonged duration of treatment.³ Currently, antimicrobials are the most widely used category of drugs in the world. In 2004, the World Health Organization reported the figure for unwarranted antibiotics prescriptions standing at roughly 50%. Studies have revealed the existence of compulsive antibiotic prescribing all over the world.^{4,
5, 6}Being a populous country with rampant corruption and lax controls, India is an ideal country for multinational companies to pump in their newly developed but poorly researched drugs including antibiotics. Over prescribing of antibiotics has been widely reported.^{7, 8}

Studies also revealed that in the majority of cases antibiotic prescribing was empirically directed at the putative site of infection. Since the meager culture facilities are available in a very small number of hospitals in India, empirical antibiotic use is rampant.⁹ In spite of several available guidelines for the appropriate use of antimicrobials in preoperative patients, the fear of high morbidity and mortality associated with intra-abdominal infections and surgical site infections has led to misuse of antimicrobials in the preoperative patients. Studies have shown that the third/fourth generation cephalosporin plus an anti-anaerobic agent were preferred (84% cases) for treating intra-abdominal infections.¹⁰Although the vast majority of antibiotics are consumed in primary care, the pressure to select antimicrobial drugs in hospitals appears to be even higher than in outpatient care. Adverse drug events and excessive costs of treatment are also reasons for concern.Majority of children still receive one or two antibiotics for diarrhea, though ORS use has not been more than 38%.¹¹ Doctors compete with each other in prescribing the most recently introduced, albeit very costly, antibiotics. Often the freshly introduced antibiotic is prescribed within the first 10 minutes of introduction. Medical representatives try all means to fulfill their sale targets, and more often the doctor may not even get a chance to go through the company leaflet describing the prescribed drug. Surveillance of antimicrobial use in hospitals is therefore important to identify prescribing trends, to link results with antimicrobial resistance data, and to identify areas for improvement. In this study, we present the results of a survey conducted in 2009 to describe the prevalence of antibiotic use in hospitalized children in India.

MATERIALS AND METHODS:

This Prospective-Observational study was conducted in Rajaram Hospital and Trauma Centre, Panki, It is a 108 bedded hospital. The study was conducted for six months from Jan, 2009 to June, 2009. Data on antibiotic use were collected by reviewing medical charts of all patients treated in OPD or IPD. For each hospitalized child, information was collected on age, sex, main diagnosis at admission and the type and number of antibiotics administered. Data was also recorded on whether the antimicrobial drugs were prescribed on the basis of clinical signs suggestive of infection, but without microbiological confirmation (i.e. on an empirical basis), or administered for infections that were laboratory confirmed (i.e. based on microbiological findings), or related to prophylaxis. The study was approved by the committee of the Hospital. Data were collected by reviewing medical charts of all patients. All the patients receiving antibiotics were identified and included in the study. Patient information was obtained on a specially designed patient profile form. All the antibiotic containing prescriptions were monitored to know the frequency and extent of antibiotic use and the conditions for which it was prescribed.

RESULT:

A total of 364 hospitalized children were evaluated; their median age was 42.3 months (range 0-180 months), and 213 were males (58.52%) (Table 2). Antibiotics were prescribed for 267 of the 364 patients (73.35%). The prevalence of antibiotic use was higher in older children, ranging from 44.12% in 0-6-month-old infants (30/68) to 62.70% in children aged from seven months to five years (79/126) and 92.94% in children older than five years (158/170). No statistically significant differences by sex were noted (Table 1). Out of the total 364 children, 121 were hospitalized in medical wards, 179 in surgical wards and 64 in ICUs (Table 3). The median age of patients differed significantly, being lowest in ICUs and highest in surgical wards. The prevalence of antibiotic use was 52.07% in medical wards, 78.13 % in ICUs and 86.03% in surgical wards.

Table 1. Age wise distribution of patients

S. No	Category	Frequency	Percentage
1	Below 6 months	30	11.24
2	6 months to 5 years	79	29.59
3	Above 5 years	158	59.18

Table 2. Gender wise distribution of patients

S. No	Gender	Frequency	Percentage
1	Male	213	58.52
2	Female	151	41.48

Table 3. Treatment wise distribution

S.No	Type of treatment	No. of Patients	Treated with antibiotics	%	Prevalence
1	Medical Ward	121	63	32.97	52.07
2	Surgical Ward	179	154	48.77	86.03
3	ICU	64	50	17.44	78.13

The use of cephalosporin’s was almost evenly distributed between empirical therapy and prophylaxis, while penicillin’s were most frequently used for empirical therapy. Penicillin’s and amino glycosides were the two categories of drugs that were most commonly prescribed on the basis of microbiological data. The highest proportion of children receiving antibiotics prescribed on the basis of microbiological data was found in ICUs (25.0% vs. 5.7% and 1.5% in medical and surgical wards, respectively), while medical wards ranked first in proportion of empirical treatments (73.0% vs. 37.5% in ICUs and 27.9% in surgical wards), and surgical wards in prophylactic use (70.6% vs. 37.5% in ICUs and 21.3% in medical wards). Combination of amoxicillin and clavulanic acid is the most prescribed. Some other antibiotics were also found to be prescribed to the patients like Gentamicin, Cephalexin, Cefuroxime, Doxycycline + Lactic acid bacillus, Amoxicillin. There prevalence is as described in the table 4. The major reason for the treatment were fever, cough and dyspnea. Of the 267 patients treated with antibiotics, 205 were patients were prescribed parenteral route while 62 were prescribed oral route.

Table 4. Commonly prescribed antibiotics

S. No	Commonly Prescribed Drug	Patients
1	Amoxycillin + Clavulanic acid	100
2	Gentamicin	80
3	Cephalexin	28
4	Cefuroxime	25
5	Doxycycline + Lactic acid bacillus	21
6	Amoxicillin	13

DISCUSSION:

Although a strong positive correlation between the extent of antibiotic consumption in outpatient and inpatient care has been shown, no national data on hospital consumption have been collected in India up to now, and no national policies on the prudent use of antibiotic have been implemented. Comparison with prescription rates from other countries' pediatric populations suggests there is extensive antibiotic overuse in India. This could be associated with selection for and dissemination of antibiotic resistance. Interventions are needed to reduce consumption. In western Europe, studies on hospital use of antibiotics in children are few ^{14, 15, 16}. In comparison with these findings, our results show higher prevalence of antibiotic use than those observed in the Netherlands and Switzerland in the late 1990s and early 2000s where prevalence rates were 36%, even higher than those reported from UK in 2006 (49%)¹⁷ & Italy where prevalence is 43.9%¹⁸. The proportion of prescriptions that had been based on microbiological data was also similar to that reported by these European surveys. A number of interventions including persuasive and restrictive methods have been shown to be effective in reducing antimicrobial use in hospitals¹⁹. Variability in outpatient antibiotic prescribing profiles by geographical area has also been shown²⁰, and it is likely that antibiotic use in children would also differ by hospital. It is therefore advisable to collect data at both hospital and national level, in order to identify priority areas and design interventions tailored to specific circumstances.²¹ Chkgaidge I revealed that the incidence was lowest in age group (U.P.) to 6 months.²³ Arnold S. R. revealed that antibiotics from the class of penicillin were the most frequently prescribed. Study hospital has implemented a series of measures, including collection of data on antimicrobial resistance, introduction of guidelines for diagnosis and treatment of infectious diseases such as bronchiolitis and acute gastroenteritis, which could have affected the prescribing habits.

LIMITATIONS:

Our study has some limitations. Firstly, it was conducted in one hospital only, and its results cannot be considered representative of the whole country. Secondly, it was conducted in Jan to Mar, when the number of children admitted with infections could vary with, observed in other periods of the year. Since respiratory tract infections are one of the leading causes of antimicrobial use in children²², we could have underestimated the prevalence. Thirdly, information on the start of antibiotic therapy was not collected, so we cannot exclude the possibility that some children had already been on therapy at admission. Lastly, we did not evaluate the appropriateness of antibiotic prescriptions and we did not investigate if prescriptions were due to nosocomial infections.

CONCLUSION:
In our study, the most frequently used antibiotic was the combination of amoxicillin plus clavulanic acid, as observed in primary care. This finding confirms that hospital antimicrobial use tends to display a similar distribution pattern to that observed in the OPD. The commonly prescription pattern observed in hospitalized and outpatient children underscore the need to implement actions targeting both primary care and hospital pediatricians. An important issue identified in our results is the high proportion of children who received surgical prophylaxis. In fact, 71% of patients treated with antibiotics in surgical wards received their prescription for prophylaxis, compared to 13-42% reported in other studies.^{24, 25}. The fact that Gentamicin, a parenteral amino glycoside, ranked higher together with amoxicillin + clavulanic acid, in prescription frequency is also a reason for concern. Though we did not evaluate the appropriateness of antibiotic use, these results highlight the need to introduce guidelines for surgical prophylaxis in children, and to further investigate the reasons for prescribing parenteral antibiotic therapy in pediatric hospitals. The results showed that the duration of prescribed therapy canbe excessive. Recommendations for potential interventions toreduce antibiotic overuse in this setting are necessary.

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Received on 05.06.2009 Modified on 11.08.2009

Research J. Pharm. and Tech. 3(1): Jan.-Mar. 2010; Page 118-120