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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 23-26

Culture of cultures: Antimicrobial prescription practices in hospitalised patients at level 1 trauma centre


1 Department of Microbiology, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
2 Department of Neurosurgery, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
3 Department of Neuroanesthesia, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
4 Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Purva Mathur
Department of Microbiology, 2nd Floor, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpsic.jpsic_6_18

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  Abstract 


Introduction: Antibiotic stewardship practices require that antimicrobial treatment should be tailored according to microbiological culture. Therefore, the aim of this study was to describe the antibiotic prescription pattern and to assess how frequently the surgeons request for a specimen culture during the patient's stay.
Materials and Methods: This was an observational study; conducted in level-1 trauma center for 10 months and all consecutive neurosurgery patients, admitted in the hospital were included in the study. Detail of microbiology culture and anti-microbial-sensitivity results were recorded. Antibiotic prescriptions were recorded in each patient during their hospital stay.
Results: A total of 1216 consecutive patients admitted to the neurosurgery unit were included in the study. The mean age (± standard deviation) of patients was 33.29 (±16.27) years, predominantly male patients; 1038 (85.4%). Overall, culture-confirmed infections were present in 216 (19.4%) patients. Prevalence of Gram-negative bacteria; 195 (90.2%) was more than Gram-positive bacteria; 21 (4.7%) (P < 0.001). The most frequently used antibiotic was cephalosporin; 1030 (84.7%), followed by aminoglycoside; 952 (78.3%), fluoroquinolone; 422 (34.7%), penicillin; 311 (25.6%) and metronidazole 277 (22.8%). A total of 400 (13.15%) antibiotics were prescribed appropriately in patients with culture-confirmed infection while 2640 (86.8%), antibiotics were given inappropriately in rest of the patient in whom there was no matching culture-confirmed infection (P < 0.001).
Conclusion: A very small number of antimicrobial prescriptions were based on culture reports. Hospitals in developing countries including India need to institute surgical antibiotic policies soon since most hospitals are facing a severe problem of antimicrobial resistance.

Keywords: Anti microbial resistance, antibiotic prescription, audit, microbiology culture, neurosurgery patients


How to cite this article:
Bajpai V, Gupta D, Bindra A, Malhotra R, Mathur P. Culture of cultures: Antimicrobial prescription practices in hospitalised patients at level 1 trauma centre. J Patient Saf Infect Control 2018;6:23-6

How to cite this URL:
Bajpai V, Gupta D, Bindra A, Malhotra R, Mathur P. Culture of cultures: Antimicrobial prescription practices in hospitalised patients at level 1 trauma centre. J Patient Saf Infect Control [serial online] 2018 [cited 2018 Oct 16];6:23-6. Available from: http://www.jpsiconline.com/text.asp?2018/6/1/23/238601




  Introduction Top


Antibiotics are the most frequently prescribed drugs among hospitalised patients in Intensive Care Units (ICUs) and wards. Antibiotic prophylaxis may prevent serious complications and devastating consequences of the post-operative infections.[1],[2] However, these prescriptions are often given as empirical therapy to cover both Gram-positive and Gram-negative infections in surgical procedures.[3] This irrational use of broad-spectrum antibiotics result in other challenges, such as antibiotic abuse, unnecessary side effects of antibiotics, increased antimicrobial resistance and also increase, treatment cost in hospitalised patients.[4] Although the general principles of perioperative prophylaxis dictate that antibiotics are given for 48 h of duration, surgeons continue it until the patient's discharge at their own discretion.[5] Various studies had shown the prevalence of antibiotic prescription in patients undergoing surgical intervention which ranges from 30% to 95% in general hospitals.[6],[7],[8] Therefore, monitoring surgical antibiotic prophylaxis is crucial in ensuring appropriate use of antimicrobial agents. Antibiotic stewardship practices require that antibiotic treatment should be tailored according to culture results.

Although well-defined principles of rational antimicrobial use are available worldwide, there are no reliable data concerning the quantity of antibiotic use and the appropriateness of prescriptions in India. In the current times of increasing antimicrobial resistance and paucity of new antibiotic development, there is an urgent need for strategies to enhance rational use of antibiotics. Therefore, the aim of this study was to describe the antibiotic prescription pattern in neurosurgical patients of a level-1 trauma centre. We also wanted to assess that how frequently the surgeons request for a specimen culture during the patient's stay.


  Materials and Methods Top


This was a retrospective, observational study which was conducted in the 165 bedded level-1 Trauma Centre of All India Institute of Medical Sciences, New Delhi for a period of 10 months (from January 2016 to October 2016). All consecutive patients admitted to neurosurgery ward or ICUs were included. Baseline characteristics of patients such as age, gender, duration of stay and outcome were recorded. The centre has 24 h running microbiology laboratory with an automated system of bacterial culture and antimicrobial susceptibility testing (Bact Alert and Vitek II BioMérieux, France). A hospital infection control nurse performed the audit of the type of antibiotics, their number and duration administered to each patients until the time of their discharge. Simultaneously, the detail of whether any sample was sent for culture and culture results if any was recorded. The hospital has fully functional hospital information system and indigenously made software for microbiology data entry and reporting. Patients who received antibiotics according to matching culture and sensitivity results were defined as those having received appropriately prescribed antibiotic and others as an inappropriately prescribed antibiotic.

Data analysis

The results for baseline parameters was calculated as a percentage as applicable. Student's t-test/Chi-square test was performed to determine variables to explain antibiotic prescribing. P < 0.05 was considered to be statistically significant. Analysis was carried out using SPSS version 21, (IBM, Armonk, NY, United States of America).


  Results Top


A total of 1216 consecutive patients admitted to the neurosurgery unit were included in the study. Baseline characteristics of patients are described in [Table 1]. Mean age (±standard deviation) of patients was 33.29 (±16.27) years comprising predominantly male patients; 1038 (85.4%). Overall, culture-confirmed infections were present in 216 (19.4%) patients. Prevalence of Gram-negative bacteria; 195 (90.2%) was more than Gram-positive bacteria; 21 (4.7%) which was statistically significant (P < 0.001). The most common organism isolated was Acinetobacter baumannii 125 (57.8%), followed by Pseudomonas aeruginosa 23 (10.6%), Escherichia coli 20 (9.25%)), Klebsiella pneumoniae 19 (8.79%), Staphylococcus aureus 16 (7.4%), Serratia marcescens 5 (2.31), Enterococcus faecium 4 (1.85%), Burkholderia spp. 2 (0.9%), Enterobacter spp. 1 (0.4%) and Staphylococcus epidermidis 1 (0.4%).
Table 1: Demographic characteristics of neurosurgery patients (n=1216)

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A total of 3040 antibiotics were prescribed in the 1213 (99.5%) patients, i.e., an average of 2.75/group antibiotics/patient. The most frequently used antibiotic was cephalosporins, 1030 (84.7%), followed by aminoglycosides, 952 (78.3%), fluoroquinolone 422 (34.7%), penicillin 311 (25.6%) and metronidazole 277 (22.8%). Monotherapy was given in 122 (10%) patients; 982 (80.7%) patients received 2—4 antibiotics and 233 (19.16%) patients received more than five antibiotics during their stay in the hospital. Appropriate antibiotics. i.e., according to matching culture sensitivity was prescribed to 74 (31.5%) patients while 148 (68.5%) patients received inappropriate antibiotics, i.e., not matching to culture susceptibility report (P < 0.001). A total number of 400 (13.15%) antibiotics were prescribed appropriately in patients with culture-confirmed infection while 2640 (86.8%), antibiotics were given inappropriately in rest of the patient in whom there was no matching culture-confirmed infection (P < 0.001). The pattern of prescription of antibiotics according to culture reports of patients is depicted in [Table 2].
Table 2: Pattern of prescription of antibiotics according to culture reports of patients

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The factors affecting the number of antibiotics prescribed in patients

The number of patients who were prescribed 1—2 antibiotics did not vary from those who were prescribed three or more antibiotics with respect to their age, gender and length of stay in hospital. However, the number of antibiotics prescribed significantly correlated with matching culture positivity and outcome (survival) of patients (P < 0.05). The details of the factors affecting the number of antibiotics prescribed in patients are given in [Table 3].
Table 3: Risk factors affecting the prescription of antibiotics in admitted patient

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  Discussion Top


The present study addresses an important issue of how often the antimicrobial prescriptions are based on the culture results. The key findings of this analysis included the following: the nature of antibiotic prescribing is largely empirical; antibiotics are rarely altered once commenced and cephalosporins are the commonest antibiotic prescribed. This study highlights the fact that the almost all of the patients (99.5%) initially receive antibiotics empirically, given that the surgical prophylaxis is one of the most common causes of overuse of antibiotics, this is a serious finding and this initial course of antibiotics continues unaltered for most patients (93.5%). These findings are similar to other studies in two Indonesian Governmental hospitals that showed that high proportions (84%) of inpatients were treated with antibiotics.[9],[10] Studies in low-income and developing countries have reported that almost all patients were using antibiotics in surgical and paediatric wards, during their stay.[10],[11]

The goal of antibiotic stewardship program is to optimise the treatment of patients and to ensure that patients receive the right antibiotic at the right dose and for the right length of time. Various factors are responsible as incorrect prescription of antimicrobial agents in patients. Treating surgeons or physician frequently starts an antibiotic course without an adequate clinical evaluation in hospitalised patients. Even when an antibiotic is indicated, the inappropriateness of the prescription sometimes results from an incorrect drug choice, dosage, or duration of treatment. Most common reason for inappropriate antibiotics prescription is incorrect duration (40.5%), lack of indication for antibiotic use (28.4%), incorrect antibiotic choice (24.3%) and incorrect dose (8.1%).[12]

A multifaceted approach is required to combat the above problem. Health care workers, administrators of health-care facilities, public health organisations, governmental agencies, educational entities and the general population will all need to be involved in the solution. Focus has to be directed towards educating medical students, post-graduate trainees, pharmacy students and residents in established concepts of antimicrobial stewardship. Hospitals in India need to institute surgical antibiotic policies soon, since most hospitals are facing severe problem of antimicrobial resistance. Most importantly, there is a need to formulate strict antibiotic restriction policy and implement protocols for antibiotic usage to streamline the judicious use of these drugs. Antibiotics prescribing surgeon must ensure that initial antibiotic choice should be appropriate, i.e., in accordance with hospital own antibiogram policy, and is subject to on-going review as part of antibiotic stewardship. Regular audits and feedback reviews are useful tools to check the use of irrational antibiotic therapy in the ICUs. Education of the antibiotics prescriber is the cornerstone of any successful antibiotic stewardship programme and teaching of guidelines and clinical pathways will aid in improving antimicrobial prescribing behaviour to a large extent.


  Conclusion Top


A very small percentage of antimicrobial prescription was based on culture reports. At the trauma centre, a large bulk of prescriptions of antibiotics can be reduced if we apply the policy of 'stop orders' if no culture were sent at 48 h of antimicrobial administration.

Acknowledgement

The authors wish to acknowledge to our hospital infection control nurses for performing the audit and collecting data regarding the type of antibiotics in patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Williams A, Mathai AS, Phillips AS. Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India. J Pharm Bioallied Sci 2011;3:531-6.  Back to cited text no. 1
    
2.
Li Z, Wu X, Yu J, Wu X, Du Z, Sun Y, et al. Empirical combination antibiotic therapy improves the outcome of nosocomial meningitis or ventriculitis in neuro-critical care unit patients. Surg Infect (Larchmt) 2016;17:465-72.  Back to cited text no. 2
    
3.
Leekha S, Terrell CL, Edson RS. General principles of antimicrobial therapy. Mayo Clin Proc 2011;86:156-67.  Back to cited text no. 3
    
4.
Llor C, Bjerrum L. Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014;5:229-41.  Back to cited text no. 4
    
5.
Antibiotic Prophylaxis in Surgery. Available from: https://www.choc.org/userfiles/AntibioticProphylaxisForSurgeryGuideline.pdf. [Last updated on 2018 Jan 06].  Back to cited text no. 5
    
6.
Shankar RP, Partha P, Shenoy NK, Easow JM, Brahmadathan KN. Prescribing patterns of antibiotics and sensitivity patterns of common microorganisms in the internal medicine ward of a teaching hospital in Western Nepal: A prospective study. Ann Clin Microbiol Antimicrob 2003;2:7.  Back to cited text no. 6
    
7.
Cook PP, Catrou PG, Christie JD, Young PD, Polk RE. Reduction in broad-spectrum antimicrobial use associated with no improvement in hospital antibiogram. J Antimicrob Chemother 2004;53:853-9.  Back to cited text no. 7
    
8.
ESPAUR_Report_2017.pdf. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/656611/ESPAUR_report_2017.pdf. [Last accessed on 2018 Jan 06].  Back to cited text no. 8
    
9.
Audit of Antibiotic Prescribing in Two Governmental Teaching Hospitals in INDONESIA — Science Direct. Available from: http://www.sciencedirect.com/science/article/pii/S1198743X14621649. [Last accessed on 2018 Jan 06].  Back to cited text no. 9
    
10.
Anderson JE, Erickson A, Funzamo C, Bendix P, Assane A, Rose J, et al. Surgical conditions account for the majority of admissions to three primary referral hospitals in rural Mozambique. World J Surg 2014;38:823-9.  Back to cited text no. 10
    
11.
Baidya S, Hazra A, Datta S, Das AK. A study of antimicrobial use in children admitted to pediatric medicine ward of a tertiary care hospital. Indian J Pharmacol 2017;49:10-5.  Back to cited text no. 11
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12.
Ashraf MS, Shah K, Dhillon M, Nguyen H, Abubaker A, Stang A, Cook P, et al. Can prospective audit and feedback decrease inappropriate antibiotic use in long-term care facilities? San Diego, CA; 7-11 October, 2015.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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