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Year : 2017  |  Volume : 35  |  Issue : 2  |  Page : 299--301

Exploring the prescribing behaviours and the mind of antibiotic prescribers is critical for a successful antibiotic stewardship programme: Results of a survey from Eastern India

Nikhila Ravi1, Anirban Laha2, Lalawmpuia Hmar3, Suddhasatwya Chatterjee2, Jyotsna Goswami4, Gaurav Goel3, Kingshuk Dhar3, Tanushree Ghosh3, Soumyadip Chatterjee5, Soumitra Shankar Datta6, Sanjay Bhattacharya3,  
1 Department of Engineering, Downing College, University of Cambridge, Cambridge, TN, UK
2 Department of General Medicine, Tata Medical Center, Kolkata, West Bengal, India
3 Department of Microbiology, Tata Medical Center, Kolkata, West Bengal, India
4 Department of Anesthesia and Intensive Care, Tata Medical Center, Kolkata, West Bengal, India
5 Department of Infection Diseases, Tata Medical Center, Kolkata, West Bengal, India
6 Department of Psycho-oncology, Tata Medical Center, Kolkata, West Bengal, India

Correspondence Address:
Sanjay Bhattacharya
Department of Microbiology, Tata Medical Center, 14 Major Arterial Road (E-W), Newtown, Rajarhat, Kolkata - 700 156, West Bengal
India

Abstract

Quantitative and qualitative analysis were used to ascertain practices, perceptions and barriers about antibiotic stewardship program (ASP) in an oncology hospital in eastern India. In 2014 and 2017, 62% and 69.1% of the patients audited were found to be on anti infective medications respectively. Nearly 47% of patients in the study group (2014) who were on therapeutic antibiotics had an average cost of $46.48 per patient per day (inter-quartile range: $17.23–$94.76). Antibiotic related consultations from clinical microbiologists, was found to be in demand, and education of prescribers and policymakers was identified as critical to the success of ASP.

How to cite this article:
Ravi N, Laha A, Hmar L, Chatterjee S, Goswami J, Goel G, Dhar K, Ghosh T, Chatterjee S, Datta SS, Bhattacharya S. Exploring the prescribing behaviours and the mind of antibiotic prescribers is critical for a successful antibiotic stewardship programme: Results of a survey from Eastern India.Indian J Med Microbiol 2017;35:299-301

How to cite this URL:
Ravi N, Laha A, Hmar L, Chatterjee S, Goswami J, Goel G, Dhar K, Ghosh T, Chatterjee S, Datta SS, Bhattacharya S. Exploring the prescribing behaviours and the mind of antibiotic prescribers is critical for a successful antibiotic stewardship programme: Results of a survey from Eastern India. Indian J Med Microbiol [serial online] 2017 [cited 2017 Dec 13 ];35:299-301
Available from: http://www.ijmm.org/text.asp?2017/35/2/299/209591

Full Text

 Introduction



Antibiotic resistance can develop due to inappropriate use.[1] Studies indicate that between 30% and 50% of antibiotic used in hospitals are unnecessary and inappropriate.[2] The current study was conducted to determine (a) if antibiotics are being prescribed appropriately; (b) to evaluate the awareness and perceptions about antibiotic stewardship programmes (ASPs) among prescribers, (c) to investigate the barriers to effective ASP implementation.

 Materials and Methods



The study was conducted in Tata Medical Centre, an 183-bed oncology centre in Kolkata, India.

Quantitative methods

Prescription audit

The antibiotic prescription audit was conducted in 2014 and repeated in 2017 to understand the appropriateness of prescription. A cost analysis was performed.

Questionnaire survey

Survey collected information on doctors' antibiotic prescribing practices, awareness about the hospital's ASP and perceptions about antibiotic resistance and the effectiveness of stewardship.

Qualitative methods

Senior clinicians from various clinical disciplines were interviewed. The method for qualitative interviews adhered to consolidated criteria for reporting qualitative research guidelines.[3] Qualitative data from the interviews were analysed using principles of grounded theory and was led by a consultant psychiatrist well conversant in qualitative research methods.

 Results



Antibiotic prescription audit

A total of 92 patients' records were examined in July 2014 out of a total admitting 139 beds (66%). Of this group, 62% (57 patients) were found to be on therapeutic or prophylactic anti-infective medications (antibiotics, anti-fungal and anti-viral agents). In ICU and high dependency unit, 72% of patients were on anti-infective agents. In the private and general wards, 52% and 55% of patients, respectively, were on anti-infective agents. The seven most commonly prescribed anti-infective agents included meropenem, amikacin, piperacillin-tazobactam, voriconazole, co-trimoxazole, colistin and metronidazole. Voriconazole and co-trimoxazole were found to be given in a large proportion of cases for a combination of therapeutic and prophylactic purposes. The reason for anti-infective medication was therapeutic in 72% of patients, surgical prophylaxis in 7% of cases, medical prophylaxis in 9% of cases and a combination of therapy and prophylaxis in 12% of cases.

The median daily cost of antibiotic therapy was Rs. 1981 ($32.75) [Table 1]. For the hospital pharmacy, the daily business with regard to antimicrobial drugs was found to be Rs. 164,000 ($ 2708.06).{Table 1}

Referral to the ASP team occurred for 25% of the patients on antibiotics. Out of the 121 antibiotics prescriptions analysed, the choice of drug was deemed appropriate in 97% prescriptions, the dose correct in 96% of prescriptions, the duration appropriate in 97% of cases, the route of administration suitable in 98% of prescriptions and the combination of drugs appropriate for 95% of patients.

The antibiotic prescription audit was repeated in 2017 [Table 2] with no major differences in the appropriateness of prescription observed.{Table 2}

Questionnaire survey

A review of prescribing practices revealed that 80% (40/50) of doctors checked whether antibiotics are delivered on time, and 84% (42/50) checked that the correct dose is delivered. However, only 58% (29/50) of doctors said that they checked whether the intended brand is being administered. Most of the advice was sought from the microbiologist (74% [37/50] of doctors), followed by the own departmental consultants (20%, 10/50) and general medicine (4%, 2/50). While 96% (48/50) of doctors felt that an ASP could reduce the problem of antibiotic resistance, Seventy-six percent (38/50) of doctors disagreed that restrictions on antibiotics would impair their ability to provide good patient care.

Qualitative data

The consultants interviewed (n = 5) were from diverse disciplines with more than 10 years of speciality experience. Median ages of these consultants were 45 years (interquartile range [IQR] 38–55 years). The median duration of the interviews was 6.12 min (IQR 3.7–8.78 min). The broad themes that emerged from the qualitative data can be grouped under the following:

Individual decision making in choosing an antibiotic: This was based on hospital protocols, training and experience of the practitioners/prescribersThe role of ASP: Most agreed about the value of ASP, but there was some scepticism as wellBarriers for rational antibiotic choice: Infrastructural factors as lack of training and knowledge can lead to inappropriate antibiotic usageSolutions for the current situation: The importance of training was highlighted by many. The need for better regulation on the part of the government was highlighted as well.

 Discussion



ASP aims to optimise patient care while minimising anti-infective cost, toxicity and resistance. Through the prescription audit, it was determined that 62% (57/92) of all in-patients in the hospital were on anti-infective medications. The figure rose to 69.1% in 2017. In a similar prescription audit conducted in the US showed 50% of the patients had been administered at least one antimicrobial drug.[4] Appropriate prescribing needs monitoring and could be handled by antibiotic pharmacists as practiced in the hospitals of the UK.[5]

Effective antibiotic stewardship can help in minimising cost due to unnecessary prescriptions. A study from the United States showed that antibiotic costs decreased from $44,181 per 1000 patient-days at baseline to $23,933 (a 45.8% decrease) by the end of the programme.[6]

Appropriate prescribing of anti-infective medications requires an understanding of the pathophysiology of diseases, probable differential diagnoses, possible micro-organisms responsible, range of anti-infective medications available, along with their side-effects, spectrum, cost, pharmacokinetic and pharmacodynamics properties. Since prescribing is a human function, certain human traits such as experience, beliefs, and individual limitations affect prescribing. Since not all conditions can be treated using a predefined algorithm, and there are numerous variations of clinical presentations which cannot be tackled even by the most exhaustive clinical guidelines, we have to rely on the physicians' individual judgements for patient care. There are constraints like work pressure, fear of patient harm, fear of litigations and unclear clinical scenarios where broad-spectrum agents and high-end antibiotic use is seen more commonly than desired. Kotwani et al. reported that in many cases, the reason for using antibiotics with enhanced spectrum is not documented, and there is a tendency to use more antibiotics with wider spectrum.[7] Understanding these limitations, adversities and beliefs are critical to correct aberrations in prescribing. This study done in an oncology hospital of a not-for-profit organisation, has attempted to do precisely that work.

 Conclusions



Antibiotic stewardship requires a thorough and holistic understanding of a patient's clinical condition, treatment options available, diagnostic possibilities, as well as strengths and limitations of existing therapeutic modalities (not just limited to antibiotics). Antibiotic stewards need adequate training to enable them to perform this critical function. This calls for close cooperation and coordination between clinical departments, infectious disease specialists, clinical microbiologists. Hospital administrators and health-care policy makers have a major role in ASP and are the key facilitators of ASPs.

Financial support and sponsorship

The primary work for the project in the Tata Medical Center hospital was carried out by an Intern participating in the Tata International Social Entrepreneurship Scheme.

Conflicts of interest

There are no conflicts of interest.

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