Antibiotic Prescribing among Pediatric Inpatients with Potential Infections in Two Private Sector Hospitals in Central India
Antibiotic Prescribing among Pediatric Inpatients with Potential Infections in Two Private Sector Hospitals in Central India
Megha Sharma 0 1
Anna Damlin 0 1
Ashish Pathak 0 1
Cecilia Stålsby Lundborg 0 1
0 1 Department of Pharmacology, Ruxmaniben Deepchand Gardi Medical College , Ujjain , India , 2 Department of Public Health Sciences, Global Health-Health Systems and Policy (HSP): Medicines, focusing antibiotics, Karolinska Institutet, Tomtebodavägen 18A, 17177 Stockholm, Sweden, 3 Department of Pediatrics, Ruxmaniben Deepchand Gardi Medical College , Ujjain , India , 4 Department of Women and Children's Health, International Maternal and Child Health Unit, Uppsala University , SE 751 85 Uppsala , Sweden
1 Editor: Nades Palaniyar, The Hospital for Sick Children and The University of Toronto , CANADA
Funding: This study was funded by the Swedish
Research Council (K2007-70X-20514-01-3) and Asia
Infectious diseases are one of the major causes of child mortality in India. Pediatric patients
are commonly prescribed antibiotics for non-bacterial infections. Monitoring of local
antibiotic prescribing with respect to the diagnosis is necessary to improve the prescribing
practices. The aim of the study was to describe antibiotic prescribing for potential infections
among patients admitted in pediatric departments in two private sector hospitals; one
teaching (TH) and one non-teaching (NTH) in Central India.
Data from all patients admitted at the pediatric departments of both study hospitals was
collected manually, for 3 years (2008–2011) using a customized form. Data from inpatients
aged 0–18 years, diagnosed with; acute gastroenteritis (AGE), respiratory tract infections,
enteric fever, viral fever or unspecified fever were focused for analysis. Antibiotic
prescriptions were analysed using the WHO Anatomical Therapeutic Chemical (ATC) classification
system and defined daily doses (DDDs). Adherence to the Indian Academy of Pediatrics list
of essential medicines (IAP-LEM) was investigated. P-values <0.05 were considered
Oftotal6, 825 inpatients admitted at two pediatric departments, 510 patients from the TH
and 2,479from the NTH were selected based on the assigned potential infectious
diagnoses. Of these, 224 patients (44%) at the TH and 2,088 (84%) at the NTH were prescribed at
least one antibiotic during hospital stay (odds ratio-0.69, 95%confidence interval-0.52 to
0.93; p<0.001). Patients with AGE, viral- and enteric fever were frequently prescribed
Link (348-2006-6633). MS is a recipient of a
scholarship from Erasmus Mundus External
Cooperation Window Lot-15, India. AD is a recipient
of a scholarship for medical science research from
Karolinska Institutet, Sweden.
Competing Interests: The authors have declared
that no competing interests exist.
Abbreviations: AGE, Acute gastroenteritis; ATC,
Anatomical therapeutic chemical; CME, Continuing
medical education; DDD, Defined daily dose; DU,
Drug utilisation; ESBL, Extended spectrum
βlactamase; FDCs, Fixed dose combinations of
antibiotics; IAP-LEM, Indian academy of pediatrics list
of essential medicines for children in India; NICU,
Neonatal intensive care unit; NTH, Non-teaching
hospital; POC, Point of care; RTI, Respiratory tract
infection; TH, Teaching hospital; URTI, Upper
respiratory tract infection; WHO, The World Health
Organisation; WHOCC, The World Health
Organisation Collaborating Centre for Drug Statistics
antibiotics at both hospitals, yet higher proportion were prescribed antibiotics at the NTH
compared to the TH. Broad-spectrum antibiotics were the most commonly prescribed
antibiotic class in both hospitals, namely third generation cephalosporins, J01DD (69%) at the
TH, and new fixed dose combinations of antibiotics J01R (FDCs, 42%) at the NTH. At the
TH, 37% of the antibiotic prescriptions were comprised of antibiotics listed in the IAP-LEM,
compared to 24% at the NTH (p<0.05).
Broad-spectrum antibiotics were prescribed frequently in both hospitals also for the
un-indicated conditions such as viral fever and enteric fever. At the NTH, new FDCs were more
frequently prescribed and adherence to the IAP-LEM was substantially lower at the NTH
compared to the TH. The results demonstrate need to develop diagnosis-specific
prescribing guidelines to facilitate rational use of antibiotics and implement antibiotic stewardship
Antibiotic resistance, which is a threat to public health, is rapidly increasing globally .
Use of antibiotics, including irrational and unnecessary antibiotic treatment, contributes to
the development of antibiotic resistance [1,2].
Infectious diseases are common among pediatric patients in India and contribute to the
total mortality rate, which is the highest in the world . Pneumonia and diarrhoeal diseases
account for 50% of total 1.34 million deaths among Indian children between 1 month to 5
years of age . Appropriate use of antibiotics is vital in reducing the mortality caused by
bacterial infections . However, antibiotics are often prescribed inappropriately for un-indicated
conditions. Studies from India have shown antibiotics as one of the most commonly prescribed
drug classes in pediatric patients [4–5]. Despite the fact that high proportions of acute
respiratory tract infections and diarrhoea in pediatric patients are caused by viruses and should not be
treated with antibiotics; patients with diarrhoea were prescribed antibiotics in India [5–7].
The World Health Organisation (WHO) advises implementing national lists of essential
medicines with assured quality for rational use of medicines . In order to avoid unnecessary
antibiotic prescribing and development of antibiotic resistance, pediatric healthcare facilities in
India are advised to follow the Indian Academy of Pediatrics list of essential medicines
(IAP-LEM) . The IAP-LEM includes 16 different antibiotics with recommended dosage and
route of administration for children in India but is not a diagnosis specific guideline.
Analyses of antibiotic prescription practices provide the basis for development of diagnosis
specific antibiotic prescribing guidelines, which contribute to appropriate use of these life-
saving medicines [9,10]. According to the WHO, it is important to document antibiotic
prescribing practices among in-patients and compare it with other hospitals to identify areas for
intervention for rationalizing prescribing [11,12]. Some studies from India have shown overall
higher antibiotic prescribing rates at private sector health care facilities compared to public
sector facilities [13–16]. The private sector hospitals are major health service providers in India,
yet, most Indian studies of antibiotic prescribing practices among pediatric patients have been
conducted among out-patients and at public health care facilities [4–6, 15,16]. Absence of
studies that links antibiotic prescribing with the indication or focus of infection at pediatric
inpatient departments is one of the main barriers to estimate the extent of over- or under-
prescribing of antibiotics. Thus, for the present study, we have compared antibiotic prescribing
patterns for the patients admitted with a diagnosis of potential infection, in pediatric
departments at two private sector hospitals, and to identify the areas for improvement in antibiotic
An observational study was conducted in the pediatric departments at two tertiary care private
sector hospitals, one teaching hospital (TH) and one non-teaching hospital (NTH), in Ujjain
district, India. The TH is located in a village outside Ujjain city and has 570 beds of which 60
are pediatric beds and a 6-bed, level II neonatal intensive care unit (NICU) at the time of study.
The TH is attached to Ruxmaniben Deepchand Gardi Medical College which provides both
undergraduate and post graduate medical education. The NTH is located in the city centre and
has 350 beds including 30 were pediatric beds and15-bed, level II NICU. The consultants at the
NTH receive payments per patient admitted by them, while in the TH consultants have a fixed
monthly salary. Although both hospitals are run by the same trust, the patients at the TH are
provided with medical services and medicines free of charge, while at the NTH the patients
have to pay for the services (subsidized for all patients) and purchase the prescribed medicines.
Visits of representatives of pharmaceutical companies were restricted at the TH while there
was no such restriction at the NTH.
Antibiotic prescribing data was collected prospectively for all patients admitted at pediatric
departments at the TH or at the NTH between April 1st, 2008 and March 31st, 2011. The
'pediatric group' is defined as persons below 18 years of age and the available lists and
recommendations for rational prescribing of antibiotics are not specified according to ages and thus are
applicable for all pediatric patients. Therefore, the patients below 18 years of age that stayed for
at least one night were included in the analysis.
Data collection, management and analysis
A data collection form was attached to the patient record file of each patient admitted to the
pediatric wards in the two hospitals [15,16]. The form required information about the patient’s
age, sex, diagnosis, duration of hospital stay; if antibiotics were prescribed or not during the
hospital stay, duration of antibiotic treatment, type of prescribed antibiotic, dose, frequency,
and route of administration. The forms were filled in by nursesemployed by the hospital and
were a part of routine patient care practices. The nurses were trained for data collection. The
diagnoses were recorded at the time of discharge as stated by the consultant in-charge in the
patient record file. The diagnoses made by the consultant in-charge were considered as final
diagnosis and were not verified externally.
The antibiotic prescribing data included in the analysis was from patients who had one of
these five most commonly registered potential infectious diagnoses acute gastroenteritis
(including bloody diarrhoea); respiratory tract infections (RTIs including both upper and
lower respiratory tract infections, pneumonia and bronchitis); enteric fever; viral fever; or
unspecified fever. Various causes of fever were included in the analysis because fever is an
important cause of morbidity of children across pediatric age groups and also a pointer to a
potential infectious etiology. The prescribed antibiotics were classified according to the WHO
Collaborating Centre for Drug Statistics Methodology (WHOCC), Anatomical Therapeutic
Chemical (ATC) classification with defined daily dose (DDD) [17,18]. All DDDs were
calculated as DDD per 1000 patients per diagnosis group.
ATC codes were followed up to the 7th level. For those drug combinations where no ATC
code was available from the WHOCC list, advice from WHOCC was followed and the
combinations were coded with individual codes according to the WHO guidelines. The drug
utilisation (DU) 90% methodology was used to present the antibiotics accounting for 90% of all
antibiotics prescribed .
The manually collected antibiotic prescribing data was entered in EPI Info 3.1 and analysed
using STATA software version 13.0 (Stata Corp., College Station, Texas, USA) and SPSS
Statistics version 22.0 (SPSS Inc, Chicago, IL, USA) for further analysis. Crude odds ratios (OR) with
their 95% confidence intervals (CI), were calculated from two by two tables using SPSS
software. Frequency and percentage were calculated for categorical variables. Sum, median, mean,
range and standard deviations were calculated for continuous (numerical) variables. The
independent samples t-test was used for comparison of continuous (numerical) variables, after
checking for a normal distribution. The Chi-square test was used for comparisons of
categorical values. P-values <0.05 were considered significant.
A unique code was generated for each patient record to anonymize and analysis was
conducted at the group level without identifying the patients individually. The study was approved
by the ethics committee of Ruxmaniben Deepchand Gardi Medical College, Ujjain, India
(approval number: 41/2007).
During the study period overall 6825 patients were admitted in two study hospitals; 1,977
patients were admitted to the pediatric ward at the TH and 4,848 to the NTH (Table 1). Out of
these, 510 patients (26%) in the TH and 2,479 (51%) in the NTH were diagnosed with one of
the five most common infectious diagnoses and were included for further analysis. In the TH
44% (244/510) and in the NTH 84% (2,088/2,479) of children with five selected diagnoses were
prescribed at least one antibiotic (OR 0.69, 95% CI 0.52 to 0.93; p<0.001). Table 2 shows the
distribution of patients and antibiotic prescribing for the selected diagnoses.
Overall, the parenteral route of administration for antibiotics was dominating prescribed
(TH: 96%, 1,976/2,049 prescriptions, NTH: 99%, 10,185/10,324). Both the hospital stay and the
duration of antibiotic treatment were significantly longer at the TH for all diagnoses, except for
the unspecified fever group (Table 2). Generic name prescribing was more common in the TH
for all diagnoses (TH: 67%, 1,376/2,049 versus NTH: 3%, 279/10,324, OR 73.6, 95% CI 63.3 to
Table 1. Antibiotic prescribing, duration of hospital stay and antibiotic treatment duration of all patients admitted at the pediatric departments in a
teaching and a non-teaching hospital in Central India.
All patients admitted in pediatric department; N
Inpatients prescribed AB; n (%)
Duration of hospital stay; mean days (SD)
Duration of AB treatment; mean days (SD)
Abbreviations: TH = teaching hospital; NTH = non-teaching hospital; N = Overall number of inpatients, n = number of inpatients; AB = antibiotics;
SD = standard deviation. P-values@ are calculated for the Total number of inpatients or days.
In each diagnosis
* 92 (55)
* 33 (80)
# 32 (32)
* 16 (47)
85.6; p<0.001)(Table 2). The DU 90% of the prescribed antibiotic classes and substances
among the patients with the selected most common diagnoses are presented in Table 3 and Fig
1 respectively. Laboratory diagnostics were rarely used at both study hospitals. Of all antibiotic
prescriptions, 37% in the TH versus 24% (p<0.001) in the NTH comprised of antibiotics
recommended in the IAP-LEM [8,20].
Acute gastroenteritis (AGE)
In the TH, 30% (51/168) patients diagnosed with acute gastroenteritis received antibiotic
prescriptions compared to 75% (695/925, p<0.001) in the NTH. The two commonest antibiotics
in the TH (constituting >90% of the antibiotic prescribing measured in DDD) were amikacin,
(J01GB06: 237 DDD/1000 patients) and ceftriaxone (J01DD04: 250 DDD/1000 patients). In
the NTH, ceftriaxone (J01DD04: 266 DDD/1000 patients) was the commonest followed by
fixed dose combination (FDC) of ceftriaxone with sulbactum (J01RA84: 178 DDD/1000
patients) and ceftriaxone with tazobactum (J01RA85: 252 DDD/1000 patients, Fig 1). None of
the patients in the TH were prescribed a combination of third generation cephalosporin with
an extended spectrum β-lactamase (ESBL) inhibitor.
Respiratory tract infections (RTIs)
In the TH, 55% (92/166) of patients diagnosed with RTIs were prescribed antibiotics,
compared to 92% (940/1017, p<0.001) at the NTH. The commonest antibiotics for this diagnosis
group were a FDC of ampicillin with cloxacillin (J01CR50: 536 DDD/1000 patients) and
ceftriaxone (J01DD04: 540 DDD/1000 patients) in the TH, compared to amoxicillin with clavulanic
acid (J01CR02: 340 DDD/1000 patients), ceftriaxone with sulbactum (J01RA84: 360 DDD/
Abbreviations: DDDs = defined daily doses; TH = teaching hospital; NTH = non-teaching hospital; antibacterial = antibiotic; AB = antibiotic; Gen. =
generation; cephl = cephalosporins.
Antimicrobials for systemic use; J01
β-lactam AB, penicillin; J01C
Extended spectrum penicillins
FDCs of penicillins incl. β-lactamase AB
Other β- lactam; J01D
New fixed dose combinations of AB; J01R
1000 patients) and ceftriaxone with tazobactum (J01RA85: 483 DDD/1000 patients) in the
NTH (Fig 1 and Table 3). Among the patients with RTIs, 7 (4%) patients in the THand24 (2%)
in the NTH were diagnosed with upper respiratory tract infection (URTI). In both hospitals, all
patients diagnosed with an URTI were prescribed antibiotics.
Fig 1. Graphical presentation of defined daily doses of prescribed antibiotics to the inpatients with potential infectious diagnoses at pediatric
departments in a teaching- and a non-teaching hospital in India. Abbreviations: DDDs = defined daily doses; GE = gastroenteritis; TH = teaching
hospital; NTH = non-teaching hospital; RTIs = respiratory tract infections, DU-drug utilization. 100% in the figure refers to 100% of the DU90 of prescribed
Among the patients diagnosed with enteric fever, 80% (33/41) in the TH received antibiotic,
compared to 94% (205/218, p<0.001) in the NTH. In the TH, ceftriaxone constituted 91%
(J01DD04: 4,174 DDD/1000 patients) of the antibiotics prescribed while in the NTH, the
commonest antibiotics were ceftriaxone with tazobactum (J01RA85: 1,720 DDD/1000 patients),
ceftriaxone (J01DD04: 1,221 DDD/1000 patients) and ceftriaxone with sulbactum (J01RA84:
732 DDD/1000 patients, Fig 1 and Table 3).
In the TH, 32% (32/101) patients were prescribed antibiotic for diagnosed viral fever compared
to 70% (130/185, p<0.001) at the NTH. The commonest antibiotics were ceftriaxone
(J01DD04: TH: 601 DDD/1000 patients, NTH: 629 DDD/1000 patients) followed by
cefuroxime (J01DC02: 605 DDD/1000 patients) in the NTH. The mean duration of antibiotic
treatment among patients with viral infections in the TH was 5.3 days (95% CI- 4.5–6.0 days) and
3.8 days in the NTH (95% CI 3.5–4.0 days).
Among the patients diagnosed with an unspecified fever in the TH, 47% (16/34) were
prescribed antibiotics compared to 88% (118/134, p<0.001) at the NTH. The commonest
antibiotics were cefotaxime (J01DD01: 403 DDD/1000 patients) and ceftriaxone (J01DD04: 754 DDD/
1000 patients) in the TH compared to ceftriaxone (J01DD04: 621 DDD/1000 patients) and
cefuroxime (J01DC02: 1,179 DDD/1000 patients) in the NTH (Fig 1 and Table 3).
To our knowledge, this is the first prospective study that describes and compares antibiotic
prescribing practices at pediatric departments in Indian private sector hospitals. The study
compares the most commonly prescribed antibiotics for a spectrum of potential infectious
diagnoses in pediatric departments, namely acute gastroenteritis, respiratory tract infections,
enteric fever, viral fever and unspecified fever. This study uses the WHO ATC/DDD
methodology. A significantly higher proportion of patients admitted to the pediatric department at the
NTH were prescribed antibiotics (84%) compared to the patients at the TH (44%, p<0.001)
during the three years study period. Most commonly prescribed groups of antibiotics at the TH
were third generation cephalosporins, and new FDCs of antibiotics at the NTH. Both mean
duration of stay and mean duration of antibiotic treatment were significantly longer in the TH
compared to the NTH.
In absence of any similar published studies from comparable settings globally, we have
compared the results of our study with the results of the most comparable settings in this section.
Antibiotic prescribing and diagnosis groups
Children admitted at the NTH and diagnosed with acute gastroenteritis, viral fever and
unspecified fever were prescribed higher DDDs/1000 patients than in the TH. However, a higher
proportion of children diagnosed with RTIs and enteric fever were prescribed antibiotics at the
TH than in the NTH. Antibiotics are not considered as rational treatment for viral infections
and AGE [6,21]. However, a majority of the patients at both hospitals were prescribed
antibiotics, both for viral fever and AGE. The patients with viral fever possibly were prescribed
antibiotics for superimposed bacterial infection.
Commonly prescribed classes of antibiotics and factors influencing the
Third generation cephalosporins were the most commonly prescribed antibiotic group at the
TH but was the third most prescribed group in the NTH. The patients with enteric fever, AGE
and RTIs at both hospitals were commonly prescribed third generation cephalosporins mostly
via parenteral route, although it is only recommended for the treatment of complicated or
multi drug resistant cases of enteric fever . A previous study conducted among in-patients
with infections at the TH also presents that antibiotics were prescribed to the patients of
gastroenteritis and respiratory tract infections . According to the WHO, broad-spectrum
antibiotics are recommended only when treatment with specific antibiotics has been proven
New FDCs of antibiotics were more commonly prescribed at the NTH, than at the TH,
especially to the patients with AGE, RTIs and enteric fever. Most of the prescribed FDCs at the
NTH were irrational combinations. For example a combination of third generation
cephalosporins with beta lactamase inhibitors is recommended in infections caused by ESBL
producing E. coli and Klebsiella [14,16]. In addition, the FDCs are usually costlier than single drug
formulation thus an extra cost of treatment is directly imposed on the patients . In almost
all patients in both study settings, the antibiotics were prescribed empirically but without any
laboratory diagnostics, therefore the rationality of the prescribed FDCs could not be evaluated.
The probable unnecessary exposure to antibiotics for viral infections and broad spectrum
antibiotics including FDCs could potentially lead to the development of antibiotic resistance.
Factors influencing the antibiotics prescribing practices are multi-factorial and will be addressed
a. Parents' pressure. It is known that physicians perceiving prescribing pressure from the
parents prescribe antibiotics more often [23,24]. An Indian study from Delhi showed that
doctors' perceived that demand and expectations from the parents contributed to the prescribing
of antibiotics . The doctors expressed that patients who were charged a fee for medical
consultation and services had high expectations for receiving antibiotic prescriptions The pressure
was felt to prescribe antibiotics to the patients presenting with fever or gastroenteritis rather
than embrace a wait-and-see policy due to the fear of losing the patient for future consultancies
. In our study, the parents at the NTH had paid for the treatment, thus perceived pressure
from the parents might be considered as a contributory factor for higher antibiotic prescribing
rates at the NTH than in the TH where the medical services were free of charge.
b. Pressure from pharmaceutical companies and prescribers' profit motive. Generic
name prescribing is preferred over trade names for easy availability and cost effectiveness. The
generic medicines, compared to the brand medicines, also provide flexibility to choose and
dispense from the available formulations and promote access to the world’s poorest population.
According to the WHO, rational prescribing of medicines includes prescribing by generic
names rather than by the trade names . In the present study, trade names were used at both
hospitals however; almost all prescriptions at the NTH were by trade names.
A study conducted in Bangkok, Thailand included three public hospitals (one teaching
hospital) and three private not for-profit non-teaching hospitals. The public teaching hospital and
private not for-profit hospitals could be broadly compared with our TH and NTH respectively.
The use of trade names in the NTH was substantially higher than the private not for-profit
hospitals (82%) in the Thai study . The prescribing patterns at the Thai non-teaching hospital
were considered as an effect of prescribers’ profits as well as their contact with pharmaceutical
marketing representatives . Similarly high antibiotic prescribing rates, excessive prescribing
of broad-spectrum and newer FDCs of antibiotics and use of trade names at the NTH might be
related to potential pressure from pharmaceutical companies. This is further supported by a
lower trade name prescribing at the TH as medical representatives' visits are restricted due to
hospital policy and a hospital based study conducted for 5 months in the region .
The influence of pharmaceutical companies over high antibiotic prescribing has been
reported in studies conducted worldwide [15,25–27]. A study among prescribers in the United
States shows that the prescribers who had been exposed to the medical representatives,
favoured trade name prescribing, rather than generic name prescribing or nondrug treatment
options with comparable effects .
Similarly, a study of antibiotic prescribing practices in Delhi showed a tendency to prescribe
newer antibiotics at private sector clinics and its association with a profit-motive for the
c. Educational activities. The influence of educational profile and ongoing academic
activities at the TH might have resulted in higher generic name prescribing since teaching
hospitals are associated with educational institutions and are expected to be more updated about
the prescribing guidelines and recommendations through continuing medical education
(CME) programs, regular schedules of seminars, teaching and inter- and intra- departmental
d. Adherence to the available guidelines. The results show that prescribing of essential
medicines from the IAP-LEM was higher at the TH . At the TH, 37% of the antibiotic
prescriptions comprised of antibiotics recommended in the IAP-LEM, compared to 24% at the
NTH. Earlier studies have shown a reduction of broad-spectrum antibiotic use in health care
facilities after implementation of local prescribing guidelines [9,28]. Since the long-term aim of
the study is to develop local prescribing guidelines and to implement them at the pediatric
departments at both hospitals, a reduction in irrational antibiotic prescribing at the study
settings might be expected in the future.
In the Thai study, a higher proportion of antibiotics were present from the list of essential
antibiotics, at the teaching hospital compared to the non-teaching hospitals (56% vs. 43%) .
e. Antibiotic treatment duration and route of administration. The hospital stay and
antibiotic treatment duration was significantly longer for pediatric inpatients at the TH than at
the NTH. The Thai study concluded that the patients in public teaching hospital had longer
antibiotic treatment durations compared to the patients in private hospitals . The study also
showed longer treatment durations at a teaching hospital (7.2 days) compared to the
non-teaching hospitals (4.2 days) . These results are comparable to our study, where antibiotic
treatment duration was significantly longer in pediatric inpatients at the TH than at the NTH. An
antibiotic treatment duration of 5 to 7 days is recommended for children with mild or moderate
forms of community acquired pneumonia or up to 14 days for severe pneumonia [29, 30].
In a study conducted among pediatric patients in Uttar Pradesh, India, parenteral route
administration of antibiotics was higher in private health care facilities compared to the public
facilities . This result was in concordance to the results of our study, where almost all
antibiotics were administered parenterally at both hospitals. The reason behind this practice could be
explained as the patients in the department are mainly young and sick thus might have
difficulty in oral administration of medicines.
f. Use of laboratory services. Earlier studies of antibiotic prescribing for pediatric patients
in Indian healthcare facilities show that prescribers tend to consider fever as a sign of a bacterial
infection and prescribe antibiotics [5,14]. In the present study, the doctors neither at the TH
nor at the NTH routinely sent samples for microbiology testing, which means that they might
also have prescribed antibiotics symptomatically and continued with the empiric treatment
without any evidence based adjustments. Antibiotics are rational treatment when a correct
substance is prescribed for an appropriate indication with appropriate dose, frequency and
duration. Thus, as no laboratory confirmatory diagnostics were performed to adjust the initial
empiric therapy it is possible that some pediatric patients in both hospitals might have been
prescribed antibiotics unnecessarily or that the wrong antibiotic was used.
Inappropriate antibiotic prescribing can be reduced by better use of laboratory based
diagnostics or point of care (POC) diagnostics. However, cost effective POC diagnostics that
differentiate bacterial and viral infections are not easily available. In both the settings of our study,
laboratories were underutilized both for biochemical and microbiological confirmation of
bacterial infections, despite of easy and free availability. The reasons for underutilization of the
laboratory facilities need to be explored further.
Since antibiotic prescribing data were prospectively recorded from all inpatients at the pediatric
departments, the study populations were representative for the pediatric patients admitted to
the hospitals. Data were comparable between the hospitals since the same form for data
collection was used at both hospitals. At both hospitals, the nurses were trained for data collection to
ensure the quality of data. The same person supervised the training and data collection process
in both hospitals. Despite this, in view of high turnover of nurses and because data collection
was done manually the risk of missing data of some patients could not be denied. This was an
observational study with no intention to intervene in the on-going treatment, thus the final
diagnoses registered for each patient were not confirmed by results from microbiology tests,
unless ordered by the consultant in-charge. Further, the aim of the study was to present the
pattern of antibiotic prescribing thus, the confirmation of diagnosis was beyond the aim. As a
result some patients might have been incorrectly diagnosed. The absence of results from
microbiology tests makes it difficult to decide whether antibiotic treatment was rational or not.
Measurement of the amount of antibiotic prescribing among pediatric patients is a challenge since
the DDD are based on the antibiotic dose in adults, but as it is a technical unit intended for
comparisons it can still be used for the comparative purposes as the ages of patients were
similar in both study hospitals. Also DDD is internationally considered to be the best method for
comparisons of antibiotic prescribing [16,23].
Overalls significant differences in prescribing patterns of antibiotics between the TH and the
NTH were seen in terms of percentage of patients prescribed antibiotics, duration of stay and
antibiotic treatment and use of generic name in the prescriptions, for the 5 most common
diagnoses studied in present communication. The antibiotic prescribing was high for all inpatients
at both hospitals, but a lower proportion of patients were prescribed antibiotics at the TH
compared to the NTH. Broad-spectrum antibiotics were prescribed frequently at both hospitals but
third generation cephalosporins were most commonly prescribed at the TH and new FDCs of
antibiotics at the NTH. There was a significant difference in the proportion of patients with
RTIs prescribed antibiotics between the two hospitals. Compliance to the IAP-LEM for
children and generic name prescribing was higher at the TH than NTH.
This study highlights need for development and implementation of relevant,
diagnosis-specific antibiotic prescribing guidelines for pediatric inpatients. The development of a pediatric
DDD is suggested which would enable appropriate comparisons of antibiotic prescribing
among the pediatric inpatients.
There is need for development of evidence based treatment protocols for common clinical
conditions to rationalize the use of antibiotics, as indicated in this paper.
The authors acknowledge the nurses at both hospitals for collecting the data and the
management of both hospitals for the permission and Dr. V. K. Mahadik, Medical Director, for the
support during the study.
Conceived and designed the experiments: MS CSL. Performed the experiments: MS CSL.
Analyzed the data: AD MS. Contributed reagents/materials/analysis tools: AD MS CSL. Wrote the
paper: AD MS CSL AP. Conducted repeated training sessions for nursing personal for
recording the data: MS. Responsible for coordination with the nurses, monitoring and supervision of
the data quality, data entry and cleaning of the data: MS.
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