Prescribing patterns and utilization of antimicrobial drugs in a tertiary care teaching hospital of a Caribbean developing country.

This study aimed to evaluate the prescribing practices and utilization of antimicrobials in a tertiary care teaching hospital of a Caribbean developing country. A prospective observational cohort study was undertaken for a period of 12 weeks in the general wards and the intensive care unit (ICU) of the hospital. Demographic data, diagnoses on admission, antimicrobials prescribed, dosage and duration, route of administration, leukocyte count and microbiological culture and sensitivity reports were recorded. Hospital length of stay and final outcome were recorded. The usage was determined in terms of prescribed daily dose and the total costs of antimicrobials were calculated. Of 889 patients admitted, 335 (37.7 percent) received 22 different antimicrobial drugs. Overall, 67 percent of the prescriptions adhered to the hospital protocol. Median length of stay in the hospital was 7 days. Skin and soft tissue infections were the most common diagnoses for which antimicrobials were prescribed. Amoxicillin-clavulanate was the most common (32 percent) antimicrobial used. Eighty-nine percent of the antimicrobials were given through the intravenous route. Sixty percent of the patients received two antimicrobials, 26 percent received three, and 14 percent of patients were prescribed four or more antimicrobials during their stay at the hospital. There was significantly higher inappropriate choice of antimicrobials in ICU when compared with general wards (Mantel-Haenszel Odds Ratio 3.3; 95 percent Confidence Intervals 1.4, 7.7). Prescribing patterns did not strictly adhere to the hospital antimicrobial protocol. There is a need for monitoring and control of antimicrobial prescription.

Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an antibiotic policy

BACKGROUND: Tertiary care hospitals are a potential source for development and spread of bacterial resistance being in the loop to receive outpatients and referrals from community nursing homes and hospitals. The liberal use of third-generation cephalosporins (3GCs) in these hospitals has been associated with the emergence of extended-spectrum beta- lactamases (ESBLs) presenting concerns for bacterial resistance in therapeutics. We studied the 3GC utilization in a tertiary care teaching hospital, in warded patients (medical, surgical, gynaecology, orthopedic) prescribed these drugs. METHODS: Clinical data of patients (>or= 13 years) admitted to the General Hospital, Port of Spain (POSGH) from January to June 2000, and who had received 3GCs based on the Pharmacy records were studied. The Sanford Antibiotic Guide 2000, was used to determine appropriateness of therapy. The agency which procures drugs for the Ministry of Health supplied the cost of drugs. RESULTS: The prevalence rate of use of 3GCs was 9.5 per 1000 admissions and was higher in surgical and gynecological admissions (21/1000) compared with medical and orthopedic (8 /1000) services (p < 0.05). Ceftriaxone was the most frequently used 3GC. Sixty-nine (36%) patients without clinical evidence of infection received 3Gcs and prescribing was based on therapeutic recommendations in 4% of patients. At least 62% of all prescriptions were inappropriate with significant associations for patients from gynaecology (p < 0.003), empirical prescribing (p < 0.48), patients with undetermined infection sites (p < 0.007), and for single drug use compared with multiple antibiotics (p < 0.001). Treatment was twice as costly when prescribing was inappropriate. CONCLUSIONS: There is extensive inappropriate 3GC utilization in tertiary care in Trinidad. We recommend hospital laboratories undertake continuous surveillance of antibiotic resistance patterns so that appropriate changes in prescribing guidelines can be developed and implemented. Though guidelines for rational antibiotic use were developed they have not been re-visited or encouraged, suggesting urgent antibiotic review of the hospital formulary and instituting an infection control team. Monitoring antibiotic use with microbiology laboratory support can promote rational drug utilization, cut costs, halt inappropriate 3GC prescribing, and delay the emergence of resistant organisms. An ongoing antibiotic peer audit is suggested.

The prescribing of psychotropic drugs in mental health services in Trinidad

Objective: To describe, analyze, and interpret patterns of psychotropic drug prescribing in new psychiatric patients attending psychiatric outpatients clinics in the Caribbean island of Trinidad. Design and Methods: This was a cross-sectional study of psychotropic drug prescribing by psychiatrists for 132 new psychiatric outpatients who were seen at the outpatient clinics surveyed and who were entering the mental health system during the period of research, November 1998 through February 1999. Results: A single patient could be prescribed more than one psychotropic drug. Antidepressant drugs were the class of psychotropic drugs most prescribed (70 of 132 patients, 59.8 percent), followed by antipsychotropic drugs (67 of 132 patients, 50.8 percent). Tricyclic antidepressants (TCAs) were the antidepressants most prescribed (58 of the 79 patients), mainly amitriptyline (53 of the 58). Fluoxetine was the only selective serotonin reuptake inhibitor (SSRI) prescribed (21 of the 79 patients prescribed antidepressants). Of the 67 patients receiving antipsychotic drugs, phenothiazines accounted for 41 of those 67, including trifluoperazine (14 of the 41) and thioridazine (13 of the 41). The individual antipsychotic most prescribed was sulpiride (21 of the 67 patients). Anticholinergic drugs were prescribed to 20 of the 132 patients (15.1 percent). Eighty-three of the patients were prescribed more than one drug concomitantly (either more than one psychotropic or a combination of psychotropic(s) and nonpsychotropic(s). Prescription by ethnicity, age, and gender coincided with the morbidity rates encountered in these patients. The prescribing of SSRIs to persons of African or East Indian ethnicity was significantly lower than it was for persons of mixed heritage. Conclusions: The prescription patterns of psychotropic drugs in Trinidad revealed the psychiatrists' preferences for traditional psychotropic drugs, the moderate use of anticholinergic drugs, and polypharmacy in some cases, with probable predisposition to adverse drug reactions. Given our results and based on the evaluation of the individual patients, consideration should be given to a broader use of the newer antidepressants (SSRIs) and antipsychotics. Unless justified, polypharmacy should be avoided (AU)

Rational use of therapeutic drugs in the Caribbean

The concept of "Rational drug use" means the selection of the most appropriate and cost effective drugs, carefully prescribed, with an understanding of patient education needs and compliance problems. Caribbean experience and recent Drug Utilisation Review (DUR) studies indicate that drug use for common problems like hypertension, diabetes and arthritis could be greatly improved. Applying the principles of rational drug use can save money, improve treatment and bring effective drugs to more of our populations. Emphasis must be on education rather than regulation, which leads to other adverse consequences. Skilled professionals and National Drug and Therapeutics Committees are essential, to steer a rational path between the pressures of the drug industry and the realities of economies in crisis (AU)

Drug utilization review on high blood pressure and diabetes mellitus in St. Lucia - abstract

During a three-month period in 1991, the Eastern Caribbean Drug Service conducted a drug utilization review of hypertension and diabetes mellitus in St. Lucia. The survey was designe to assess the prescribing trends of drugs for these two highly prevalent diseases with emphasis on ther resulting medical and financial consequences. This prospective study utilized a quota sampling technique whereby an equal number of prescriptions were drawn from selected private and public clinics. One thousand, four hundred and eighteen prescriptions were collected. The percentage of women (68.3 percent) treated was more than double that of the men (31.7 percent). Seventy-three per cent (73 percent) of patient visits were for the treatment of hypertension, while the remaining twenty-seven per cent (27 percent) were for diabetes mellitus. As many as 10.4 percent of all prescriptions were for patients with co-existing hypertension and diabetes mellitus. The most commonly prescribed anti-hypertensive drug was bendrofluazide, which is inexpensive and highly effective in black populations. However, the traditional daily dose of 5 mg or more was usually given rather than the current recommended lower dose of 2.5 mg. Chlorpropamide was the most frequently prescribed hypoglycaemic agent (50 percent). It was surprising that metformin, useful in the treatment of obese diabetics, accounted for only 4 percent of all diabetic prescriptions. For a population of only 140,000, the Government issued 130,000 insulin syringes. The Ministry of Health could realise significant savings if patients who self-administer insulin reuse the syringe, and by conducting sharing the cost of health care with the private sector (AU)

Drug utilisation and compliance in an ambulatory population in Barbados - abstract

A pilot survey was conducted to determine use of medicines and patient compliance with therapeutic regimes. A questionnaire was used by interviewers to obtain the relevant information. One hundred respondents were chosen randomly from all parishes in Barbados, and those from group II were selected from medical outpatient prescriptions (one in every five) filled during part of the month of August, 1988 at the Queen Elizabeth Hospital. The data showed no significant overall difference in the prevalence of noncompliance (<90 percent of tablets taken) between group I (44 per cent) and group II (40 percent). However, the degree of non-compliance within certain therapeutic categories was very severe in both groups (zero for six patients in group II). Compliance with antihypertensive medication was particularly bad (24.9 percent) for tablets taken in the non-hospital group (group I). Hoarding was noted for the six (6) patients (with zero compliance) in group II. The cost of drugs wasted as a result of non-utilization for these six (6) patients was $296.00. There was no significant difference between the groups with respect to communication with health-care providers. More than half claimed to have asked drug-related questions of physicians. There was no significant difference between the groups with regards to the reading of the label correctly and knowing the indications for the drugs prescribed. Very few patients knew the names of their medication, although the number who knew the names of their medication was slightly higher in group II. The study shows a very wide spectrum of compliance and medication use. Further and larger stdies are indicated to define reasons for the differences observed and to identify areas for education to promote better compliance (AU)

A prescription analysis study of drug utilisation in polyclinics in Barbados - abstract

A drug utilisation review was carried out in three polyclinics in Barbados by analysing prescriptions. The prescribing patterns of seven doctors were assessed with respect to (1) the total number of different drugs prescribed, (2) the therapeutic category of each drug, (3) whether they were prescribed by generic or trade name, (4) the number of drugs per patient visit, (4) the cost of one in five prescriptions and (5) the choices within the three most prescribed categories, i.e. analgesics and anti-inflammatory drugs, antibiotics and diruetics. The number of different drugs used by individual doctors was extremely modest. It ranged from 29 to 60 (mean 47). The number of drugs used correlated positively with the number of items per patient visit. The mean items per patient ranged from 1.82 to 3.12. Eighty-eight per cent of prescriptions were written by trade name. Only one doctor, the most highly trained, showed a noticeable preference for generic prescribing, and in spite of a relatively high score of items per patient visit his prescription costs were below the average. Paracetamol (cost 1.5 cents) and then bendrofluazide (cost 1.1 cents) were the two most frequently prescribed drugs. This illustrates prescriber compliance with formulary recommendations. Some other prescribing practices were much less rational and economical. Prescription analysis is an essential tool for monitoring drug use. It reveals bad prescribing practices and can assess responses to education. It provides a logical and cost-effective means of physician audit with potential for improving prescribing practices and hence health care (AU)

Patterns of antibiotic usage in children at the Queen Elizabeth Hospital, Barbados

Seven hundred and thirty-two paediatric patients treated with antibiotics at the Queen Elizabeth Hospital were reviewed. There were 522 outpatients seen in the casualty area and 230 inpatients admitted to the Paediatric wards. Six hundred and forty-seven (87 percent) patients were on the medical service and 105 (13 percent) on the surgical service respectively. Tonsillitis, otitis media and pneumonia were the most commonly documented conditions treated in inpatients whereas upper respiratory tract infections, tonsillitis and otitis media were the most commonly treated conditions in outpatients. In both patient groups, penicillin and trimethoprim-sulphamethoxazole were the most frequently prescribed antimicrobial agents. Antibiotic therapy was further classified according to the documented diagnoses into groups of (1) indicated, (2) not indicated, (3) inappropriate or (4) prophylactic. In 34 percent of inpatients and 54 percent outpatients, antibiotic therapy was classified as no indicated. Conditions in inpatients most frequently treated with "not indicated" antibiotics included cases of post-operative tonsillectomy and andenoidectomy without documented clinical or bacteriological evidence of infection, gingivostomatitis and upper respiratory tract infections. Bacterial culture negative gastroenteritis, gingivostomatitis and bronchial asthma were the most frequently treated conditions receiving "not indicated" therapy in outpatients. In most of these conditions, the infection was most frequently of viral aetiology (AU)