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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 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Prescription Pattern of Antibiotics in Admitted Patients of a Tertiary Care Government Teaching Hospital, Kerala, India
Correspondence Address :
Dr. Sreelakshmi Venugopal,
Nellikkottil House, Puthur PO, Kottakkal, Malappuram District-676503, Kerala, India.
E-mail: sreelakshmivenugopal123@gmail.com
Introduction: Antibiotics have a remarkable role in prolonging life, especially in underdeveloped and developing countries. Insufficient knowledge among doctors, peer pressure and patient demands, diagnostic uncertainties, lack of communication between the doctor, pharmacist and patients all implicate inappropriate antibiotic prescribing practices. Irrational antibiotic prescription can lead to antibiotic resistance, marking a global crisis.
Aim: To evaluate the prescription pattern of antibiotics in the admitted patients of a tertiary care teaching hospital and assess the prescriptions’ rationality.
Materials and Methods: This was a retrospective record-based study done in the inpatients of Government Medical College, Manjeri, Kerala, India, for three months (1st October 2017 to 31st December 2017). Data was collected using a data collection checklist which included patient identity and demographic factors, name and route of the antibiotic prescribed, usage of multiple antibiotics, usage of prophylactic antibiotic, usage of generic names, adherence to National List of Essential Medicines (NLEM) and rational use. The data was analysed using Statistical Package for the Social Sciences (SPSS) version 16.0 and frequencies and percentages were determined for each variable.
Results: Total 1,186 medical records were analysed, and 49.7% were prescribed antibiotics; 38.2% contained more than one antibiotic, and 64.8% contained parenteral antibiotics. Cefotaxime was found to be the most commonly prescribed antibiotic. An 88.3% of prescriptions were adhering to NLEM, and 29% contained generic names of antibiotics. Overall, 69 out of 589 (11.7%) were irrational prescriptions, and the use of multiple antibiotics with the same spectrum of coverage was found to be the most common reason for irrationality.
Conclusion: In this study, the most prescribed drugs were from the NLEM. Cephalosporins were the most commonly used antibiotics for the inpatients in this hospital. Prescriptions with generic names of drugs were low. Irrational prescriptions contributed a minor percentage, and reserve antibiotics were too little.
Antimicrobials, Inpatients, Rationality, Record-based
In developing countries like India, where infectious disease load is high, antibiotics are one of the most commonly used drugs (1). The era of antibiotics started with the discovery of Penicillin by Alexander Fleming in 1928. Interestingly, Alexander Fleming himself also sounded off the concept of antimicrobial resistance during his Nobel lecture in 1945 (2). Mushrooming numerous new classes of antibiotics with excellent safety reports has resulted in lax prescribing standards and significant inappropriate antibiotic usage in many parts of the world.
Rost LM et al., reported that 30-50% of antibiotics are prescribed inappropriately without adherence to prescription guidelines (3). Reports from the literature substantiate irrational and unnecessary usage of antibiotics in every sector of patient encounter viz., outpatient department, inpatient department, even in intensive care units (4),(5). This practice, if unchecked, will dramatically increase the chance of antibiotic resistance, especially in resource-limited countries (6),(7).
Antibiotic resistance annually causes 23,000 deaths in America, 25,000 deaths in the European Union, and 700,000 deaths worldwide (8). Studies have identified Extended Spectrum Beta-Lactamase (ESBLs) in 70-100% of Enterobacteriaceae in India and extensive uncontrolled use of carbapenem group of antibiotics to tackle ESBL producers which has resulted in carbapenem resistance in the form of New Delhi Metallo-Beta-Lactamase (MBL) in India (9). By 2050, it is predicted that there will be 10 million deaths annually and US$100 trillion in global economic loss caused by drug-resistant bacterial infections if antibiotic resistance continues to rise at the same pace as in the last decades (8). Irrational antibiotic prescribing leads to therapeutic failure and bacterial resistance, adverse effects, morbidity and mortality, economic burden, consultations, and fall in the quality of treatment. Thus, combating antibiotic resistance is the need of the hour. Hospital Infection Control Committees (HICC) and Antibiotic Stewardship Programs play a key role in preventing antibiotic resistance. Antibiotic Stewardship Programs are key interventional programs that continuously collect, analyse, and audit antibiotic consumption data, focusing mainly on the quality and rationality of antibiotic prescriptions. There are marked variations in the antimicrobial prescription pattern from region to region, which could be explained by variations in infecting microbes, drug susceptibility, physician preferences, and drug price. Analysis of regional variations in the pattern of antibiotic prescriptions has an important role in formulating policies and guidelines for combating antibiotic resistance, both worldwide and locally (10),(11).
Monitoring antibiotics use from time-to-time, identifying the factors leading to their inappropriate use, and suggesting interventions are essential in slowing the pace of resistance development. The World Health Organisation (WHO) (1993) and the International Network for the Rational Use of Drugs (INRUD) have developed indicators for monitoring the rational use of drugs, these indicators are widely used to assess the quality of prescribing in health delivery systems (12). The guide for the development of a program to rationalise the use of antimicrobials in hospitals, developed by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America, indicates the audit of antibiotics with interaction, intervention, and feedback to the physician who prescribe the drug as an essential strategy to promote fair and appropriate use (13).
A recent systematic review and meta-analysis study from Iran reports that, antibiotic prescribing rates surpass WHO recommendations, and educational interventions to physicians and showed a negligible effect in reducing antibiotic prescriptions (14). Even then, assessment of the antibiotic prescription pattern in medical records has its role in identifying rational use of antibiotics, assessing the status of resistance, providing feedback to the HICC and clinicians, and proposing interventions required in formulating the new antibiotic policy for the institution.
Also, understanding the prescription pattern of antibiotics is the initial step towards antimicrobial stewardship programs in resource-limited countries (6). Keeping this in mind, this study was undertaken to assess the prescribing pattern of antibiotics in the inpatient department of the institution. The aim was to study the prescription pattern of antibiotics administered to the inpatients, and to assess the rationality of prescribing antibiotics.
This was a retrospective record-based study done in the inpatients of Government Medical College, Manjeri, a tertiary care teaching hospital in Kerala, India, for three months (1st October 2017 to 31st December 2017). The study was carried out after the approval of the Institutional Review Board (IRB) and Institutional Ethics Committee (IEC) (Ref. No: IEC/GMCM/17/17). The medical records were collected from the medical records library of the institution.
Inclusion criteria: All medical records available during the study period were taken for data collection.
Exclusion criteria: Medical records which were not legible due to poor handwriting were excluded.
Study Procedure
Overall, 1,186 records were audited, and the data regarding antibiotic prescriptions were collected. Data was collected using a data collection checklist which includes patient identity and demographic factors, name and route of the antibiotic prescribed, usage of multiple antibiotics, usage of Fixed Dose Combinations (FDCs), usage of prophylactic antibiotic, usage of generic names, adherence to NLEM and rational use. The data collected were kept strictly confidential and were used for this study only. The data regarding the drugs prescribed were analysed in accordance with the WHO (15) recommended prescribing indicators and were expressed as percentages and averages:
1. The average number of antibiotics prescribed.
2. Percentage of drugs prescribed by their generic name.
3. Level of adherence in prescribing of drugs from the NLEM-2011.
4. Percentage of the prescribed antimicrobial drugs.
5. Percentage of prescriptions with parenteral antibiotics.
Statistical Analysis
The data were entered in Microsoft Excel sheet, and the entire data were analysed using SPSS version 16.0. Frequencies and percentages were determined for each variable.
Out of 1,186 medical records, the ones which included antibiotic prescriptions were 589 (49.7%). Among them, 240 (40.7%) were males and 349 (59.3) were females. The mean age of the patients was 37.43 years. Young adults (21-40 years) were the most frequently prescribed age group, which accounted for 223 out of (37.9%), and elderly patients (above 60 years of age) were the least, which represented 114 (19.3%). The medical records audited included seven departments in which majority of the prescriptions were from Department of Obstetrics and Gynaecology 185 (31.4%) (Table/Fig 1).
Of the 589 records, 364 (61.8%) were with a single antibiotic. Total 225 records (38.2%) consisted of multiple antibiotics, among which 98 (43.6%) contained accepted FDCs. Total 70 records (31.1%) were with two antibiotics, and 57 (25.3%) were with three or more antibiotics. The total number of antibiotics prescribed was 954. Among this, 326 (34.2%) were oral, 618 (64.8%) were parenteral and 10 (1%) were topical. Prophylactic antibiotics were present in 270 medical records. Generic names were prescribed in 171 records which represented about 29%. Total 520, among the 589 records with antibiotics, were rational prescriptions adhering to NLEM (Table/Fig 2).
Sixty-nine were irrational prescriptions, and the most frequent reason for irrationality happened to be the use of multiple antibiotics with the same spectrum of coverage (44.9%). Switching antibiotics without any scientific reason was another fundamental cause of irrational prescriptions (Table/Fig 3).
The most prescribed antibiotic group was cephalosporins, followed by penicillins. Total 330 out of 954 antibiotics were cephalosporins, and 229 were penicillins (Table/Fig 4).
Cefotaxime (15.3%) was the most frequently prescribed antibiotic followed by amoxycillin (13.8%), ceftriaxone (8.6%), ciprofloxacin (8.4%) and metronidazole (7.2%) (Table/Fig 5).
ATC codes and frequency of nine most commonly prescribed antibiotics are shown in (Table/Fig 6).
Each department’s commonly prescribed groups of antibiotics and commonly prescribed drugs is shown in (Table/Fig 7).
The values of WHO prescribing indicators of antibiotic use in this study, along with the standard values, are described in (Table/Fig 8) (16).
In this study, 1,186 medical records were analysed, among which 589 were prescribed antibiotics. Among the medical records with antibiotics, 40.7% were male patients, and 59.3% were female patients. The gender distribution was similar to the studies conducted by Raj Shivaani MR and Selva P (males-38% and females-62%) and Ahiabu MA et al., (Males-39.1% and females-60.9%), where also females contributed more percentage (1),(12). The higher number of females can be explained by the more number of records analysed from the Department of Obstetrics and Gynaecology. In the study, the antibiotic prescription was more in the age group 21-40 years (37.9%) and less in the age group >60 years (19.3%). The inclusion of higher number of females of reproductive age group, again can be the reason for higher antibiotic prescription rate in the age group 21-60 years. Out of the 589 records with antibiotics, 38.2% consisted of multiple antibiotics. The use of FDCs {98 out of 225 (43.6%)} can explain this higher percentage of use of multiple antibiotics. This was similar to the studies conducted by Demoz GT et al., (39%) and Mani S and Hariharan TS (36%) (6),(17).
This study found that 64.8% antibiotics were parenteral, 34.2% were oral, and 1% was topical antibiotics. The percentage of parenteral antibiotics was similar to that in the study conducted by Remesh A et al., (60%) (18). Some studies, Demoz GT et al., (84.8%) and Amaha ND et al., (81.4%), reported significantly higher parenteral antibiotic prescriptions than these (6),(19). These studies were conducted in referral hospital (19) and comprehensive specialised hospital (6), where severity of illness would be higher, which could explain the higher parenteral antibiotic prescription. Various studies, Raj Shivaani MR and Selva P (26.48%), Ahiabu MA et al., (22.9%) respectively, revealed fewer parenteral antibiotic prescriptions, which is in par with the WHO prescription guidelines (1),(12). The frequently prescribed antibiotic group in this study were cephalosporins (34.5%), followed by penicillins (24%), which corresponds to the results in the recent studies conducted by Jokandan SS and Jha DK (Cephalosporins 22.03%) and Farooqui HH et al., (Cephalosporins 38.3% and Penicillins 22.8%) (20),(21). Betalactams antibiotics (60.2%) were the most common pharmacological class of drugs prescribed in the study done by Mani S and Hariharan TS (20%) and Remesh A et al., (60.2%) (17),(18). In this study, the most commonly prescribed antibiotic was cefotaxime (15.3%), followed by amoxycillin (13.8%). The newer reserve antibiotics like linezolid, meropenem so on were prescribed very little. Cefixime (8.09%) was most prescribed in the study done by Jokandan SS et al., whereas ceftriaxone (24.5%) was most prescribed in the study conducted by Demoz GT et al., (6),(20). In common, cephalosporins were the commonly prescribed group of antibiotics and the individual drugs varies according to variations in regional microbial susceptibility.
Various parameters of WHO core prescribing indicators were analysed in this study and compared with similar studies (16). The first parameter was the average number of drugs per encounter which was 1.61 in this study. The standard value proposed by WHO in this regard is <2, which was very well satisfied in this study. Higher values were obtained in other studies like Raj Shivaani MR and Selva P; Demoz GT et al., Ahiabu MA et al., and Remesh A et al., (1),(6),(12),(18).
The second parameter was the percentage of drugs prescribed with the generic name, 29% in this study. This was a lower than the standard WHO value of 100%. The physicians must be made aware in this regard. This value was higher than that obtained in the study by Remesh A et al., (18). Nevertheless, several studies report significantly higher percentages of generic name usage in antibiotic prescriptions (Table/Fig 9) (1),(6),(12),(12),(17),(18),(19),(20),(21).
The percentage of prescriptions with antibiotics in this study was 49.7% which was a higher value than the standard value, which is <30%. A lower value was found in the study conducted by Mani S and Hariharan TS (17). This study was conducted in a tertiary care teaching hospital that primarily handles serious infections which are referred from lower centers. This can be the reason why the antibiotic prescription percentage in hospital is on the higher side.
The fourth parameter was the percentage of injections encountered. The percentage obtained in this study was 66.7% higher than the standard WHO value which was <20%. This can be justified because the study population in this study were inpatients. Most of the cases handled by this institution were surgical procedures and serious infections which require parenteral dosage forms. The studies which were done in outpatients showed lower percentages (1),(12),(17). The value obtained in this study (66.7%) was comparable to the value obtained in the study done by Remesh A et al., who also studied antibiotic prescribing patterns in the inpatients (18). Raj Shivaani MR and Selva P, who studied inpatients, had a lower value (1). The last parameter was the percentage of drugs prescribed from the NLEM was 88.28% in this study. This was higher than the values obtained in other studies (Table/Fig 9).
The percentage of the rationality of prescriptions and the reasons for irrationality were not much discussed in previous studies. In this study, 520 of the 589 records with antibiotics were rational prescriptions adhering to NLEM. An 11.7% were irrational prescriptions, and the most frequent reason for irrationality happened to be the use of multiple antibiotics with the same spectrum of coverage (44.9%). In a study conducted in Bangladesh by Begum T et al., who analysed the rationality of antibiotic prescriptions in admitted patients, 14% were irrational, but the reasons for irrationality were not assessed (22). A 60% of the prescriptions were found incorrect in the study done by Hadi U et al., where irrationalities in surgical prophylaxis were the main culprit (23). The findings of this study, which was in par with several previous studies, put forward a foundation on which strong initiatives could be established for promoting rational use of antibiotics. These initiatives can effectively fight antibiotic resistance which is an upcoming danger to the world population.
Limitation(s)
The present institution was a Government medical college, and the prescription pattern depends on the government supply of drugs. In this study, all the clinical departments of institution were not included, especially the super speciality departments.
Present study puts forward the trends in the prescription of antibiotics in the inpatients of this institution, from which the rationality of antibiotic use in this hospital could be assessed. According to this study, most of the drugs were prescribed from the NLEM, and cephalosporins were the most commonly used antibiotics for the inpatients in present hospital. Cefotaxime was the most frequently prescribed antibiotic followed by amoxycillin. The use of generic names in the prescriptions was low. Awareness among the physicians must be boosted up in this regard. Irrational prescriptions contributed a minor percentage, and reserve antibiotics were too little. This data can be utilised as a reference scale for measuring and comparing the impact of steps taken to promote rational use of antibiotics. It is suggested that the process of prescription auditing must be enhanced to nullify the upcoming threat of antibiotic resistance. Similar studies must also be encouraged to improve physicians’ prescribing habits and practices.
Dr. Nandakumar, Medical Superintendent, Government Medical College, Manjeri, Institutional Research Committee for their support. The HOD and Faculties, Department of Pharmacology, Government Medical College, Manjeri, Medical Records Library staff for data collection, Finny P Thampan and Sreenath Krishnan, who did data processing and Sony Simon, who did statistical works.
DOI: 10.7860/JCDR/2022/52843.16361
Date of Submission: Oct 15, 2021
Date of Peer Review: Dec 04, 2021
Date of Acceptance: Feb 16, 2022
Date of Publishing: May 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: Funded by Institutional Research Committee, State Board for Medical Research (SBMR), Kerala, India.
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. NA
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