Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

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I wish all success to your journal and look forward to sending you any suitable similar article in future"



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Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
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It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2010 | Month : December | Volume : 4 | Issue : 6 | Page : 3387 - 3391

A Prospective Study On Evaluation Of Antibiotic Prescription Practices In An Intensive Care Unit Of A Tertiary Care Hospital

BALINGA SHRIKALA*, KOSARAJU KRANTHI**, NAFISA***

*Professor and HOD, Department of Microbiology, Kasturba Medical College,Mangalore ; **Assistant Professor, Department of Microbiology, Kasturba Medical college, Manipal University, Manipal; ***Intern, Kasturba Medical college, Mangalore

Correspondence Address :
Dr Kranthi Kosaraju,
Assistant Professor,
Department of Microbiology,
Kasturba Medical college,
Manipal – 575104
E mail – medkranthi@yahoo.co.in
Phone – 91-9886056647

Abstract

Objective: Antibiotics are the most commonly prescribed drugs in hospitals and their irrational use is one of the important factors for the development and spread of resistance in the hospitals. The prescribing of antibiotics in the Intensive care unit (ICU) is usually empirical, given the critical condition of the patients who are hospitalized there. Since there is wide diversity in the prevalence of predominant pathogens and their antimicrobial susceptibilities, especially within individual ICUs, there is a need to formulate appropriate prescription practices, based on studies and research within the ICUs. Therefore, an audit of the antibiotic prescription practices in our Intensive care unit was planned.

Design: Prospective Hospital based cross sectional study
Setting: Intensive care unit of a tertiary care centre (Kasturba Medical College Hospital, Attavar, Mangalore)
Patients: All patients receiving a therapeutic antibiotic for the clinical suspicion of bacterial infections through to ICU discharge were included.

Interventions: Data was collected on patient demographics, date of the hospital and ICU admission, reason for the ICU admission, white cell count and the proposed site of infection.

Results: The respiratory system was the single most common site for infections in the ICU. Infections caused by Gram negative organisms were more common than those caused by Gram positive organisms. Antibiotics were administered empirically in 64% of the cases and in the rest, after microbiological confirmation.

Conclusions: The inappropriate and ineffective use of antibiotics is commonly observed in the health care system, especially in developing countries. In 32.03% of the patients who are treated on an empirical basis, microbiological reports on the antibiotic susceptibility patterns were contrary to the treatment which was given. Hence, there is a compelling reason to change the current prescribing practices by a multidisciplinary approach, in order to curtail the spread of multi-resistant pathogens in the ICUs.

Keywords

Antibiotics, Intensive care unit, Antibiotic audit, Prescription practices, ICU infections

INTRODUCTION
The rates of nosocomial infections range from 5 to 30% among the ICU patients. Although ICUs generally comprise 5% of all the hospital beds, they account for 20 to 25% of all nosocomial infections. Pneumonia and bacteraemia are currently the most commonly observed nosocomial infections in the United States and by far, the leading cause of death from nosocomial infections in critically ill patients.(1) Antibiotics are among the most commonly prescribed drugs in hospitals and around 30% of the hospitalized patients are treated with these antibiotics.(2) Irrational use of antibiotics is one of the most important factors for the development and spread of resistance in the hospitals and communities. The World Health Organization has established antibiotic use as a priority in its campaign for the rational use of medications.(3) The prescribing of antibiotics in the ICU is usually empirical, given the critical condition of patients who are hospitalized there. Appropriate antibiotic utilization in this setting is crucial, not only in ensuring an optimal outcome, but in curtailing the emergence of resistance and containing costs.(1)

The inappropriate use of antimicrobials is of special importance in the intensive care unit because of the large number of antibiotics prescribed, the chance for errors in antibiotic selection and the likelihood for the development of drug resistance.(4) The medically inappropriate, ineffective and economically inefficient use of antimicrobials is commonly observed in the health care system throughout the world, especially in developing countries. Although 50% or more of drug expenditures may be wasted through irrational prescribing, this often remains unnoticed by those who are involved in the health sector decision making or the delivery of health services.(5)

We propose that a study on the prescribing practices in the ICU is vitally important in guiding antibiotic selection and usage and therefore, in the achievement of the above-stated goals. There is wide institutional diversity in the relative prevalence of predominant pathogens and their antimicrobial susceptibilities and within the individual ICUs, there exist unique patient populations with varying risks and susceptibilities to infections and specific pathogens and appropriate prescription practices should be formulated with studies and research in the ICUs.(1) Therefore, we planned an audit to study the reasons for starting antibiotic therapy, the duration of antibiotic treatment, the reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice.

Material and Methods

The present study was a hospital based cross sectional study which was conducted in the intensive care unit of a 400 bedded hospital (Kasturba Medical College Hospital, Attavar, Mangalore) for a period of 3 months (from 1st June 2008 to 31st August 2008) after obtaining approval from the institutional ethical committee. A total of 262 patients were included in our study. . At the time of starting antibiotics, data was collected on patient demographics, the date of hospital and ICU admission, the primary admitting diagnosis and the reason for ICU admission, white cell count at the time of receiving antibiotics and the proposed site of infection. All patients who received a therapeutic antibiotic for the clinical suspicion of bacterial infections through to ICU discharge were included for evaluating the antibiotic prescription practice. The early discontinuation of antibiotics due to the absence of infection and patients who died during the stay in the ICU, were excluded.

The patients who were included in the study group were followed up daily to monitor the type and duration of the antibiotics used, the reasons for stopping or changing antibiotics, the microbiological results and the sensitivity pattern of the organisms which were isolated from such patients and for monitoring physician compliance with the microbiological reports. Culturing of the patients’ specimens and their identification was performed according to standard microbiological procedures and antimicrobial susceptibility testing was performed by the modified Kirby-Bauer method and was interpreted according to the CLSI guidelines.(6)

Results

The prevalence of infections in our ICU was 17%. The median age of the patients who were admitted to the ICU during the study period was 59 years. The respiratory system (35.92%) was the most common site of infection in the ICU, followed by septicaemia (19.41%) and wound infections (6.79%). The male to female ratio was 1.5:1. The median WBC count at the start of antibiotics was 12,330cells/mm3, with a majority of patients (55%) having counts > 11000. Device associated infections in the ICU were 9.7%, of which 70% were caused by endotracheal tubes, and 30% were caused by central lines. (Table/Fig 1) shows the reasons for admission in the ICU.
(Table/Fig 1): Reasons for various primary admitting diagnoses in ICU

Antibiotics were started empirically in 64% of the cases. The infections were confirmed microbiologically in 45.91% of the cases (in 5.10% before starting antibiotics and in 40.81% after starting antibiotics). The median duration of antibiotic treatment in the ICU was 6 days. The most common initial antibiotics prescribed at admission were cefaperazone-sulbactum or piperacillin-tazobactum. In 32.03% of the patients who were treated on an empirical basis, the microbiological reports were contrary to the treatment given.
Infections caused by Gram negative organisms (57.14%) were more common than those caused by Gram positive organisms (42.85%). Candida accounted for 28.57% of the Gram positive infections. (Table/Fig 2) shows the common Gram positive and Gram negative organisms which were isolated from the patients who were admitted to the ICU.

(Table/Fig 2): Percentage of various microorganisms causing infections in ICU (MRSA: Methicillin resistant Staphylococcus aureus; MSSA: Methicillin susceptible Staphylococcus aureus)

Discussion

The prevalence of infections in the ICU in our set-up was 17% and ICU-acquired infections were 20.38%. This was less as compared to those observed in few other studies from India and the West, with a reported prevalence of ICU infections between 33.5% and 44.8%.(7),(8) This could be because of better infection control practices, early recognition and treatment as well as better care of indwelling lines and catheters.

The respiratory system was the single most common site which was reported for clinically suspected and bacteriologically proven infections. The high frequency of deep organ space infections and blood stream and wound infections, and the low frequency of urinary tract infections may reflect the differences in either practice or diagnosis. Respiratory infections in the ICU are the most common infections and countering them accounts for almost 50% of all the antibiotics used. Therefore, in the ICU setting, preventing respiratory tract infections is the most cost effective method of reducing antibiotic consumption.(8) Also, out of 20% patients on the ventilator, 30% developed fever and leukocytosis with purulent ET secretions, thus growing significant pathogens.

This study demonstrates that the median duration of antibiotic therapy in this sample of ICU patients was 6 days (with a wide range from 3-14 days) and this was similar for both community and ICU acquired infections. This is in accordance with the recent guidelines in 2007, where the duration of treatment was halved.(9) This widespread use of antibiotics for a short period of 1 week or less may encourage bacterial resistance and promote relapses after therapy.(8) This strategy of using short courses of antibiotics has recently received support, although the rate of relapses, especially with resistant organisms needs to be monitored. The duration of treatment was longer for those infected with resistant organisms, in few cases with bacteriologically proven infections and in severely ill patients. Also, there is no clear evidence as to the optimal duration of therapy for these patients and many of these clinical decisions are individualised.

Antibiotics were administered empirically in 64% of the cases, whereas in the rest of the 36%, only after infection was proved microbiologically. In an Indian study, 62% of the prescriptions were therapeutic, of which 36% were therapeutic prescriptions without bacteriological support, while 59% were made on a bacteriological basis.(10) The most common initial antibiotics which were prescribed in our practice were cefoperazone-sulbactum or piperacillin-tazobactum. The adequacy of the initial empirical antimicrobial treatment is crucial in terms of outcome, although the yearly mortality rate was unaffected by the appropriateness of the empirical antibiotic therapy.(11)

Our finding that 45.91% of the infections were bacteriologically proven (only 5.10% before antibiotic prescription and 40.81% after antibiotic prescription), is less as compared to the study by Cuthbertson et al. (7) In the study conducted by Cuthbertson et al, 57% of the infections were bacteriologically proven before antibiotics were prescribed and 32% were proved only after antibiotic prescription .

Device associated infections in the ICU were 20.38%. In the Center for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, U.S. reported the mean rates of central venous catheter (CVC)–related bloodstream infections, ventilator-associated pneumonia and catheter-associated urinary tract infections to be 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days and 3.9 per Foley catheter days, respectively. Device associated infections in the ICUs of the developing countries pose greater threats to patient safety. Active infection control programs that perform the surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority.(12) In our study, 20% of the patients were on ventilator, of whom 30% developed infections, as stated previously. Catheter related infections were the second commonest device related infections in the ICU.

In 32.03% of the patients who were treated on an empirical basis, the microbiological reports were contrary to the treatment given, which means that these isolates were a) either resistant to the antibiotics being administered or b) sensitive to the first-line agent and hence, needed a step down from the prescribed antibiotics. Among these, only 57.57% of the patients had the shift of antibiotics accordingly, whereas in the rest of the 42.42% patients, the same treatment was continued irrespective of the sensitivity reports.
Despite numerous guidelines from governmental and professional groups, there is broad evidence that antibiotics are prescribed inappropriately in upto 50% of the cases. Goldmann et al stated that ‘previous efforts have not worked because medical practice is locally driven, and national guidelines simply do not reflect or determine the system of care and the pattern of practice in individual hospitals’.(9)

Several studies have also shown that the administration of antibiotics was inappropriate in 22% to 65% of the patients that received treatment.(13) Clinicians are warned of the dire consequences that the overuse of antibiotics would bring; now, these predictions have become a reality, with a multitude of antibiotic resistant organisms and inflated hospital pharmacy costs.(13)

Conclusion

Audit is a firmly established quality assurance method and can answer the question ‘What is the effect of what we are doing?’
Since there is a compelling reason to change the current prescribing practices by a multidisciplinary approach to curtail the spread of multi-resistant pathogens in the ICUs, an important question which can be asked is: ‘How can these practices be altered?’ Educating Physicians alone is generally not effective. The control of antibiotic use seems to require a multidisciplinary approach involving ID physicians, microbiologists, pharmacists and administrators.
To be effective, we need to bring discipline in the prescriptions of antibiotics in all settings – hospital, ambulatory including office practice and primary care.

The areas that require further investigation and improvement include the following:
• Prescribing recommendations for choice of empiric antibiotic for the seriously ill and for those infected with MDR organisms
• Lack of adherence/follow-up of Microbiology team recommendations
• Conducting further audits that specifically focus on the need to step down of antibiotics which are prescribed according to microbiological reports and the adherence to antibiotic test based prescriptions.

References

1.
Nina Singh and Victor L.Yu. Rational empiric antibiotic prescription in the ICU. Chest 2000; 117:1496-1499
2.
Ravi Pathiyil Shankar, Praveen Partha, Nagesh Kumar Shenoy, Joshy Maducolil Easow and Kottallur Narayanan Brahmadathan. 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. Annals of Clinical Microbiology and Antimicrobials 2003; 2:7
3.
Laura Guimaraes Fonseca and Lucieni de Oliveira Conterno. Audit of antibiotic use in a Brazilian university hospital. The Brazilian Journal of Infectious diseases 2004; 8(4):272-280
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Shankar, P. Ravi, Partha et al. Investigation of antimicrobial use pattern in the intensive treatment unit of a teaching hospital in western Nepal. American Journal of Infection Control 2003; 31(7):410-414.
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Raju C. Shah and Pratima Shah. Antimicrobial Stewardship in Institutions and Office Practices. Indian Journal of Pediatrics 2008; 75:815-820
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Performance Standards for Antimicrobial susceptibility testing; 17th Informational Supplement. CLSI M 100-S17; 27(1)
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Agarwal R, Gupta D, Ray P, Aggarwal AN, Jindal SK. Epidemiology, risk factors and outcome of nosocomial infections in a Respiratory intensive care unit in North India. J Infect 2006; 53(2):98-105
8.
Cuthbertson BH, Thompson M, Sherry A, Wright MM, Bellingan GJ. Antibiotic treated infections in intensive care patients in UK. Anaesthesia 2004; 59(9):885-90
9.
Elisabeth Meyer, Juergen Buttler, Christian Schneider et al. Modified guidelines impact on antibiotic use and costs: duration of treatment for pneumonia in a neurosurgical ICU is reduced. Journal of Antimicrobial Chemotherapy 2007. doi:10.1093/jac/dkm088
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Srishyla MV, Naga Rani MA, Venkataraman BV. Drug utilisation of antimicrobials in the in patient setting of a tertiary hospital. Indian Journal of Pharmacology 1994; 26: 282 – 287
11.
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