Assessment of inpatient antibiotic use in Halibet National Referral Hospital using WHO indicators: a retrospective study

BMC Research Notes, Dec 2018

Objective Inappropriate use of antibiotics in primary care and hospital settings is a major contributing factor to the spread of antibiotic resistance. Many microorganisms were tested in Eritrea and have proven resistant to ampicillin. The aim of this study was to investigate the prescription pattern, hospital indicator and patient care indicator of antibiotics among hospitalized patients in Halibet National Referral Hospital, Asmara, Eritrea. Results The data on prescription patterns showed 79% of hospitalizations had at least one antibiotic prescribed and on average 1.29 antibiotics were prescribed per hospitalization; prescribing using generic name was at 97%; all (100%) of the antibiotics were prescribed from the Eritrean National List of Medicines. On average an antibiotic was prescribed for 6.36 days (SD = 6.06). Ampicillin was the most commonly prescribed antibiotic (42.1%) and parenteral was the most common route prescribed (81.4%). The data on hospital indicators showed key antibiotics were out of stock on average for 78.18 days; 87.5% of key antibiotics were available on the day of the study. The data on patient care indicator showed patients taking antibiotics stayed in the hospital for 9.97 days (± 7.33 days).

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Assessment of inpatient antibiotic use in Halibet National Referral Hospital using WHO indicators: a retrospective study

BMC Research Notes December 2018, 11:904 | Cite as Assessment of inpatient antibiotic use in Halibet National Referral Hospital using WHO indicators: a retrospective study AuthorsAuthors and affiliations Nebyu Daniel AmahaYohana Haile BerheAtul Kaushik Open Access Research note First Online: 18 December 2018 104 Downloads Abstract Objective Inappropriate use of antibiotics in primary care and hospital settings is a major contributing factor to the spread of antibiotic resistance. Many microorganisms were tested in Eritrea and have proven resistant to ampicillin. The aim of this study was to investigate the prescription pattern, hospital indicator and patient care indicator of antibiotics among hospitalized patients in Halibet National Referral Hospital, Asmara, Eritrea. Results The data on prescription patterns showed 79% of hospitalizations had at least one antibiotic prescribed and on average 1.29 antibiotics were prescribed per hospitalization; prescribing using generic name was at 97%; all (100%) of the antibiotics were prescribed from the Eritrean National List of Medicines. On average an antibiotic was prescribed for 6.36 days (SD = 6.06). Ampicillin was the most commonly prescribed antibiotic (42.1%) and parenteral was the most common route prescribed (81.4%). The data on hospital indicators showed key antibiotics were out of stock on average for 78.18 days; 87.5% of key antibiotics were available on the day of the study. The data on patient care indicator showed patients taking antibiotics stayed in the hospital for 9.97 days (± 7.33 days). KeywordsAntibiotic Rational drug use WHO indicators Inpatient study Prescription  Abbreviations CDC Center for Disease Control HNRH Halibet National Referral Hospital DRC Democratic Republic of Congo DTC Drug and Therapeutic Committee EML Essential Medicines List ENLM Eritrean National List of Medicines I.V. Intravenous MoH Ministry of Health SPS Strengthening Pharmaceutical Services SPSS Statistical Package for Social Sciences STG Standard Treatment Guideline WHO World Health Organization Electronic supplementary material The online version of this article ( https://doi.org/10.1186/s13104-018-4000-7) contains supplementary material, which is available to authorized users. Introduction Irrational use of antibiotics in inpatient settings is an important issue that needs attention. Some causes for inappropriate drug use in hospitalized patients are; unnecessary use of antibiotic, inadequate regulation and monitoring, inappropriate dose, and multiple antibiotic prescribing [1, 2, 3, 4]. Lack of Standard Treatment Guideline (STGs), protocols for rational drug use, and weak or absent Drug Therapeutic Committees (DTCs) exacerbate the inappropriate antibiotic use [5]. About 70% of hospital-acquired bacterial infections are resistant to at least one antibiotic [6]. WHO has developed key indicators to measure antibiotic use in health facilities [7] and many studies [8, 9, 10, 11, 12, 13, 14, 15, 16] have reported using the WHO indicators. These indicators also known as “core drug use indicators” include prescribing, hospital and patient-care indicators were developed to be used at primary healthcare facilities and later adapted to tertiary hospitals [4] (Additional file 1: Annex S3). However, these indicators do not address factors like duration of hospital stay or the type of disease being treated which could influence antibiotic use [17]. Thus the outpatient focused WHO core drug use indicators were modified to the inpatient settings. High rate of antibiotic use has been reported in Eritrea [18], however, published research on antibiotic use in Eritrean hospitals is meager [19]. The hospital indicators focus on studying the availability and stock outs of key antibiotics. A key antibiotic for the purposes of this study is a drug having a “V” (vital drug) designation in the ENLM and that is used at a hospital level. Vital medicines are defined as life-saving, crucial medicines which are of the highest therapeutic importance for the provision of basic health service [20]. A recent study [21] in Orotta national referral Hospital in Asmara found that most of the bacterial isolates tested were resistant to ampicillin, ceftazidime, nitrofurantoin, co-trimoxazole, nalidixic acid and tetracycline. According to this study the percentage of resistance to ampicillin in E. coli was (87.5%), Klebsiella spp (75%), Citrobacter (100%), Pseudomonas (81.8%) and Salmonella (100%) [21]. Another study conducted on the antimicrobial susceptibility of S. aureus in Eritrea found that 85% were resistant to ampicillin [22]. The aim of this study was to investigate the antibiotic use in hospitalized patients in Halibet National Referral Hospital (HNRH) using an indicator based methodology designed by Strengthening Pharmaceutical Systems (SPS) [17]. Main text MethodsSetting The study was conducted at HNRH, one of the two national referral hospitals in Asmara, Eritrea. HNRH is a 180-bed national referral and teaching hospital with Surgical, Medical, Orthopedic, Burn and Emergency wards. Study design A cross-sectional, retrospective study design was used to evaluate three key drug use indicators viz. hospital indicators, prescribing indicators and patient care indicator (Additional file 1: Annex S3). The methods for collecting and evaluating these indicators were adopted from the Strengthening Pharmaceutical Systems Program [17] after studying the appropriateness of the indicators to the hospital environment (see Additional file 1: Annex S1). Eligibility criteria Patients admitted from January 1, 2017, until December 31, 2017, and had their medication dispensed from the inpatient pharmacy, irrespective of their age, gender and diagnosis were included. Sample size and data collection A clinical card list of 3654 patients was prepared according to their admission dates, those admitted in January coming first and those admitted in December appearing last. We randomly picked one number (X) from 0 to 9, then by adding 300 to the number, a second number (X + 300) was obtained. Starting from the second number every 300th card number was included to select 100 cases from the 3654 cases. The number of prescribing encounters to be studied were chosen based on the WHO’s 1993 recommendations [7]. The complete patient chart for these samples was obtained from the record office with prior permission of the Medical Director of the hospital. The data collection forms were slightly modified and the applicable data was collected for a month i.e. March to April 2018 using pre-defined data collection forms (see Additional file 1: Annex S1). Statistical analysis After checking for data completion, the necessary computations were performed according to the formulas given (Additional file 1: Annex S2). Statistical analysis such as frequencies, percentage and averages were carried out using Statistical Package for Social Sciences (IBM, SPSS Statistics for Windows, version 20. Armonk, NY: IBM Corp.). ResultsPrescribing indicators The study found that 79% of the patients received at least one antibiotic. On average 1.29 antibiotics were prescribed per hospitalization and all (100%) were prescribed from the EML while 97% of the antibiotics were prescribed using generic names. On average patients were treated with an antibiotic for 6.36 days (Table 1). Table 1 Comparison of inpatient drug use indicators in HNRH with WHO ideal values Core drug use and In-patient antibiotic use indicator Result (SD) WHO [13, 17] Percent of hospitalization with one or more antibiotics prescribed 79% 20–26%a Average number of antibiotics prescribed per hospitalizations 1.29 1.6–1.8b Percent of antibiotics from National or Hospital Formulary 100% 100% Average number of days antibiotic treatment was prescribed 6.36 (6.06) – Percent of antibiotics prescribed by generic name 97% 100% Percentage of key antibiotics available on the day of study 87.5% 100% Average number of days that a set of key antibiotic was out of stock 78.18 – Expenditure on antimicrobials as a percentage of total hospital medicine cost 25.59% 20–40 Average number of days of patients who received antibiotics stayed in hospital 9.97(7.33) – Percent of antibiotics prescribed in injection form 81.4% 13.4–24.1a SD standard deviation aWHO optimal value for outpatient departments bWHO indicator for all medicines (including antibiotics) prescribed per encounter Hospital indicators The hospital lacks a Standard Treatment Guideline and a hospital formulary. On the day of the study 87.5% of the antibiotics were available in stock and HNRH spends 25.59% of its medicines budget on antimicrobials. A key antibiotic was out of stock for 78.18 days in 2017 (Table 1). Patient care indicator Patients taking antibiotics, on average, stayed for 9.97 days in the hospital, with the standard deviation of 7.33 days (Table 1). Intravenous injection was the most common route of administration (81.4%) and 77.2% of patients were given an antibiotic for less than 7 days. Ampicillin was the most commonly prescribed antibiotic and 77% of patients received only one antibiotic while 17% were treated with two antibiotics simultaneously and 6% were being treated with three antibiotics at the same time. Auxiliary indicators Ampicillin was the most commonly prescribed antibiotic in HNRH (Table 2). Most of the patients (77%) had only one antibiotic prescribed (Table 2). We found 77.2% patients took antibiotics 1 to 7 days (Table 2). Around quarter (26%) of the patients stayed from 10 to 20 days, while 6.5% stayed longer than 21 days (Table 2). Table 2 Route of administration, number per hospitalization, treatment days, most commonly prescribed antibiotics and hospital stay days in HNRH Antibiotic treatment days  1–7 days 77.2%  7–14 days 13.9%  15–20 days 2.53%  > 21 days 3.79% Number of antibiotics per hospitalization  One antibiotic 77%  Two antibiotics 17%  Three antibiotics 6% Most commonly prescribed antibiotics  Ampicillin 42.1%  Benzyl penicillin 13.7%  Gentamycin 9.8%  Cloxacillin 8.8%  Ceftriaxone 5.9%  Ciprofloxacin 4.9% Days spent in the Hospital  1–10 days 67.5%  11–20 days 26%  > 21 days 6.5% DiscussionPrescribing indicators We found 79% of the admitted patients had received at least one antibiotic during their hospital stay (Table 1). This figure is higher than the 73.7% found by a specialty-hospital based study in Ethiopia (Table 3). Other ward-specific hospital studies reported lower antibiotic use percentages, for instance, in Ethiopia (64.7%) [23], (73.68%) [24] and 66% in India [25]. A point-prevalence antibiotic use study in 11 hospitals in the Democratic Republic of Congo reported 68% of patients had received an antibiotic during their hospital stay [26] (Table 3). A study focusing on the surgical ward of HNRH in 2009 found antibiotic use prevalence to be 69%, with 30% used preoperatively and 39% postoperatively [27]. Table 3 Comparison of antibiotics use with other African countries Indicator    Ethiopia [8, 16, 23, 28, 34] Sudan [35] DR Congo [26] Zambia [36] Percent of hospitalization with one or more antibiotics prescribed 79% 73.7% 81.3% 68% 53.7%a Average number of antibiotics prescribed per hospitalizations 1.29 2.1 2b 1.4 2.5b Generic name prescribing 97% 90.6% 49.3% NS 56.1% Most commonly prescribed antibiotic Ampicillin Ceftriaxone NSc Ampicillin Amoxicillina Parenteral route of administering antibiotics 81% 82.4% 3.5%a 68.2% 11.8%a Percentage of patients taking two or more antibiotics 23% 65% NS 34.9%   Availability of key antibiotics 87.5% 65.7% 81.3% NS 83.3% Average days of antibiotic stock out per year 78.18 30 NS NS   Drugs prescribed from EML 100% 96.6% 57.2% NS 98.1% aOutpatient department prescriptions bNumber of all drugs prescribed including antibiotics cData not stated This study showed that on average 1.29 antibiotics were prescribed per hospitalization (Table 1), lower than a study in the DRC in which 1.4 antibiotics were prescribed per patient [26] and much lower than the 2.1 antibiotics per patient reported in an Ethiopian hospital [28] (Table 3). All (100%) of the prescribed antibiotics were in the National Essential Medicines List (EML). This is because HNRH procures almost all of its medicines from one supplier, PHARMECORE, which only procures according to the EML. Therefore prescribers in HNRH are encouraged to adhere to the EML, resulting in 100% adherence to the EML. Numerous studies reported varying percentages of EML adherence; Lesotho (79%) [29], Pakistan (98.8%) [4], and India (99.8%) [9]. In HNRH an antibiotic was prescribed on average for 6.36 days (SD = 6.06) (Table 1). However 13.1% of patients were prescribed antibiotics longer than 10 days while 7% stayed on antibiotics longer than 14 days and 3% of patients were given an antibiotic longer than 20 days. Overprescribing injectable medicine is considered a case of inappropriate antibiotic use [4, 30]. Parenteral was the most common route of administration consisting 81.4% of all prescribed antibiotics. This is comparable to a study in Ethiopia (82.4%) [28] but quite higher than in the DRC (68.2%) [26] (Table 3). Thus prescribers in HNRH need to consider switching to oral route of administration which is associated with lower treatment cost, catheter-related infections, hospital stay and burden for nursing staff [31]. Hospital care indicators On the day of the study 87.5% of the key antibiotics were available in stock in the stores of HNRH. Similar studies done in developing countries found key antibiotics were available 72.4% in Pakistan [4] and 65.7% in Ethiopia [16] (Table 3). Our finding although better than what has been reported from Pakistan [4] and Ethiopia [16], it is less than ideal because key drugs should be available at all times [20]. Lack of access to key antibiotics forces prescribers to make less appropriate drug choices with higher costs and more risk of side effects and antibiotic resistance emergence. In HNRH key antibiotics were out of stock for an average of 78.18 days per year, much higher than the 30 days reported in Ethiopia [8] (Table 3). Patient care indicators The average number of hospital stay for patients in HNRH was 9.97 days (Table 1). This is much higher than the average 6 days reported by a study in a private hospital in India [25]. Furthermore, our finding shows 32.5% of the patients stayed longer than 10 days. Staying longer than 10 days is 3.086 times more likely to result in antibiotic use problems than when staying less than 10 days [31]. Prolonged hospital stay is also associated with higher treatment costs, increased risk of nosocomial infections, the emergence of resistant microorganisms and increased risk of ADR and drug–drug interaction [17, 32, 33]. We found that 6.5% of the patients in HNRH stayed longer than 20 days which could result in increased risk of antibiotic use problems. Unnecessarily longer duration of antibiotic use in HNRH needs to be addressed by developing an STG and closer therapeutic monitoring of patients taking systemic antibiotics. Limitations of the study The limitations which need to be considered are as follows. Firstly, the findings of this study could not be generalized to the whole of Eritrea since this was done in a single hospital. Secondly, this study was done in the inpatient department of the hospital and thus it does not reflect the outpatient prescribing patterns of the hospital. Notes Authors’ contributions NDA and YHB designed the study. NDA collected data and did literature review. NDA, AK and YHB analyzed and interpreted the data. NDA prepared the manuscript. NDA, YHB and AK critically reviewed it. AK and NDA prepared the revised version. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the medical director of HNRH, Dr. Yosief Yohannes for his cooperation in conducting this research. We also appreciate the help provided by the director of record office and his staff at the HNRH. Competing interests The authors declare that they have no competing interests. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Consent for publication Not applicable. Ethics approval and consent to participate Approval to conduct the study in Halibet hospital and the consent to access patients’ files were obtained from the Halibet Hospital Medical Director’s Office, Dr. Yosief Yohannes, who after reading the proposal gave his approval. Funding The authors did not receive any funding for this research. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Supplementary material 13104_2018_4000_MOESM1_ESM.docx (1 mb) Additional file 1: Annex S1. Data collection forms. Annex S2. Formulas used to calculate the indicators. Annex S3. List of the three types of drug use indicators investigated in HNRH. Annex S4. Medical Director’s ethical clearance. References 1. CDC. Antibiotic use in the United States. Antibiotic use in the United States, 2017: progress and opportunities. Atlanta: US Department of Health and Human Services, CDC; 2017.Google Scholar 2. Habte-Gabr E. Antimicrobial resistance: a global public health threat. JEMA. 2008;3:1.Google Scholar 3. Amane H, Kop P. Prescription analysis to evaluate rational use of antimicrobials. Int J Pharmacol Biol Sci. 2011;2:2.Google Scholar 4. Atif M, Sarwar MR, Azeem M, Umer D, Rauf A, Rasool A, et al. Assessment of WHO/INRUD core drug use indicators in two tertiary care hospitals of Bahawalpur, Punjab, Pakistan. J Pharm Policy Pract. 2016.  https://doi.org/10.1186/s40545-016-0076-4.CrossRefPubMedPubMedCentralGoogle Scholar 5. Pereira LP, Phillips M, Ramlal H, Teemul K, Prabhakar P. Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an antibiotic policy. BMC Infect Dis. 2004.  https://doi.org/10.1186/1471-2334-4-59.CrossRefGoogle Scholar 6. Bisht R, Katiyar A, Singh R, Mittal P. Antibiotic resistance—a global issue of concern. Asian J Pharm Clin Res. 2009;2(2):34–9.Google Scholar 7. WHO. How to investigate drug use in health facilities: selected drug use indicators. Geneva: WHO/DAP/93.1; 1993.Google Scholar 8. Sisay M, Mengistu G, Molla B, Amare F, Gabriel T. Evaluation of rational drug use based on World Health Organization core drug use indicators in selected public hospitals of eastern Ethiopia: a cross sectional study. BMC Health Serv Res. 2017.  https://doi.org/10.1186/s12913-017-2097-3.CrossRefPubMedPubMedCentralGoogle Scholar 9. Aravamuthan A, Arputhavanan M, Subramaniam K, Chander SJ. Assessment of current prescribing practices using World Health Organization core drug use and complementary indicators in selected rural community pharmacies in Southern India. J Pharm Policy Pract. 2017.  https://doi.org/10.1186/s40545-016-0074-6.CrossRefPubMedGoogle Scholar 10. Barghouthi Achalu T, Mensa M. Retrospective drug use pattern of antibiotics in pediatric ward of Shenan Gibe hospital, Oromia Region, Ethiopia. J Antibio Res. 2017.  https://doi.org/10.15744/2574-5980.1.106.CrossRefGoogle Scholar 11. Otoom S, Batieha A, Hadidi H, Hasan M, Al-Saudi K. Evaluation of drug use in Jordan using World Health Organization prescribing indicators. East Mediterr Health J. 2002;8:537–43.PubMedGoogle Scholar 12. Bashrahil KA. Indicators of rational drug use and health services in Hadramout, Yemen. East Mediterr Health J. 2010;16:2.Google Scholar 13. El Mahalli AA. WHO/INRUD drug prescribing indicators at primary health care centres in Eastern province, Saudi Arabia. East Mediterr Health J. 2012;18:11.Google Scholar 14. Vooss AT, Diefenthaeler HS. Evaluation of prescription indicators established by the WHO in Getúlio Vargas—RS. BJPS. 2011;47:2.Google Scholar 15. Hashemi S, Nasrollah A, Rajabi M. Irrational antibiotic prescribing: local issue or global concern? EXCLI J. 2013;12:384–95.PubMedPubMedCentralGoogle Scholar 16. Gidebo KD, Summoro TS, Kanche ZZ, Woticha EW. Assessment of drug use patterns in terms of the WHO patient-care and facility indicators at four hospitals in Southern Ethiopia: a cross-sectional study. BMC Health Serv Res. 2016;1:1.  https://doi.org/10.1186/s12913-016-1882-8.CrossRefGoogle Scholar 17. Strengthening Pharmaceutical Systems. How to investigate antimicrobial use in hospitals: selected indicators. Published for the U.S. Agency for International Development by the Strengthening Pharmaceutical Systems Program. Arlington: Management Sciences for Health; 2012.Google Scholar 18. Akinyandenu O, Akinyandenu A. Irrational use and non-prescription sale of antibiotics in Nigeria: a need for change. J Sci Innov Res. 2014;3(2):251–7.Google Scholar 19. WHO. Antimicrobial resistance. In: WHO, editor. Global report on surveillance. Geneva: WHO; 2014.Google Scholar 20. Ministry of Health. National List of Medicines. 5th ed. Asmara: Sabur Printing Press; 2005. p. 30.Google Scholar 21. Seyoum Y, Adgoy ET, Siele K, Elfatih M, Gebreleul N. A retrospective documentary review study of bacterial pathogen resistance to antimicrobials: a six months (July to December, 2016), at National Health Laboratory, Asmara, Eritrea. J Bacteriol Mycol Open Access. 2017;5:3.Google Scholar 22. Naik D, Teclu A. A study on antimicrobial susceptibility pattern in clinical isolates of Staphylococcus aureus in Eritrea. Pan Afr Med J. 2009;3:1.PubMedPubMedCentralGoogle Scholar 23. Gube AA, Gonfa R, Tadesse T. Evaluation of antibiotic use in medical ward of Fitche district hospital, North Showa Zone, Oromia Region. Ethiopia. Adv Pharmacoepidemiol Drug Saf. 2017.  https://doi.org/10.4172/2167-1052.1000216.CrossRefGoogle Scholar 24. Sebsibie G, Gultie T. Retrospective assessment of irrational use of antibiotics to children attending in Mekelle general hospital. Sci J Clin Med. 2014.  https://doi.org/10.11648/j.sjcm.20140303.14.CrossRefGoogle Scholar 25. Landstedt K, Sharma A, Johansson F, Lundborg CS, Sharma M. Antibiotic prescriptions for in-patients having non-bacterial diagnosis at medicine departments of two private sector hospitals in Madhya Pradesh, India: a cross-sectional study. BMJ Open. 2017;1:1.  https://doi.org/10.1136/bmjopen-2016-012974.CrossRefGoogle Scholar 26. Wambale JM, Iyamba JL, Mathe DM, Kavuo SK, Takaisi-Kikuni. Point prevalence study of antibiotic use in hospitals in Butembo. Int J Med Med Sci. 2016.  https://doi.org/10.5897/ijmms2016.1249.CrossRefGoogle Scholar 27. Yohannes Y, Mengesha Y, Tewelde Y. Timing, choice and duration of perioperative prophylactic antibiotic use in surgery: a teaching hospital based experience from Eritrea, in. JEMA. 2009;2009:65–7.Google Scholar 28. Gutema G, Håkonsen H, Engidawork E, Toverud E. Multiple challenges of antibiotic use in a large hospital in Ethiopia—a ward-specific study showing high rates of hospital-acquired infections and ineffective prophylaxis. BMC Health Serv Res. 2018.  https://doi.org/10.1186/s12913-018-3107-9.CrossRefPubMedPubMedCentralGoogle Scholar 29. Ntšekhe M, Hoohlo-Khotle N, Tlali M, Tjipura D. Antibiotic prescribing patterns at six hospitals in Lesotho. Submitted to the US Agency for International Development by the Strengthening Pharmaceutical Systems (SPS) Program; 2011.Google Scholar 30. Kallen MC, Prins JM. A systematic review of quality indicators for appropriate antibiotic use in hospitalized adult patients. Infect Dis Rep. 2017.  https://doi.org/10.4081/idr.2017.6821.CrossRefPubMedPubMedCentralGoogle Scholar 31. Tanaka A, Yano A, Watanabe S, Tanaka M, Araki H. Impact of switching from intravenous to oral linezolid therapy in Japanese patients: a retrospective cohort study. J Pharm Policy Pract. 2016.  https://doi.org/10.1186/s40545-016-0087-1.CrossRefPubMedPubMedCentralGoogle Scholar 32. Yadesa TM, Gudina EK, Angamo MT. Antimicrobial use-related problems and predictors among hospitalized medical in-patients in southwest Ethiopia: prospective observational study. PLoS ONE. 2015.  https://doi.org/10.1371/journal.pone.0138385.CrossRefPubMedPubMedCentralGoogle Scholar 33. Gentile I, Landolfo D, Buonomo AR, Crispo M, Iula VD, Minei G, Catania MR, Borgia G. A survey on antibiotic therapy knowledge among physicians of a tertiary care and university hospital. Le Infezioni in Medicina. 2015;1:12–7.Google Scholar 34. Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University teaching and referral hospital, south Ethiopia: a cross-sectional study. BMC Health Serv Res. 2013;13:170.CrossRefGoogle Scholar 35. Ahmed AM, Awad AI. Drug use practices at pediatric hospitals of Khartoum State, Sudan. Ann Pharmacother. 2010;44:1986–93.CrossRefGoogle Scholar 36. Mudenda W, Chikatula E, Chambula E, Mwanashimbala B, Chikuta M, Masaninga F, Songolo P, Vwalika B, Kachimba JS, Mufunda J, Mweetwa B. Prescribing patterns and medicine use at the university teaching hospital, Lusaka, Zambia. Med J Zambia. 2016;43(2):94–102.Google Scholar Copyright information © The Author(s) 2018 Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Authors and Affiliations Nebyu Daniel Amaha1Email authorYohana Haile Berhe2Atul Kaushik11.School of PharmacyAsmara College of Health SciencesAsmaraEritrea2.Pharmacy, Halibet National Referral HospitalAsmaraEritrea


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Nebyu Daniel Amaha, Yohana Haile Berhe, Atul Kaushik. Assessment of inpatient antibiotic use in Halibet National Referral Hospital using WHO indicators: a retrospective study, BMC Research Notes, 2018, 904, DOI: 10.1186/s13104-018-4000-7