|Year : 2015 | Volume
| Issue : 2 | Page : 124-129
Patterns of antibiotic prescriptions in the outpatient department and emergency room at a Tertiary Care Center in Saudi Arabia
Muna K. A. Oqal1, Soha A Elmorsy2, Amal K Alfhmy3, Reham M Alhadhrami3, Rawan A Ekram4, Ibtihal A Althobaiti3, Sawsan S Ghoneamy5
1 Department of Pharmaceutical Care, Pharmacy Research Unit, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
2 Associate Professor of Pharmacology, Department of Pharmacology, Faculty of Medicine, Cairo University, Kingdom of Saudi Arabia
3 Department of Medicine, Um Alqura Univerisity, Makkah, Kingdom of Saudi Arabia
4 Department of Pharmacy, Um Alqura Univerisity, Makkah, Kingdom of Saudi Arabia
5 Health Education Department, King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
|Date of Web Publication||6-May-2015|
Muna K. A. Oqal
Department of Pharmaceutical Care, Pharmacy Research Unit, King Abdullah Medical City, P.O. Box 57657 Makkah, 21955
Kingdom of Saudi Arabia
Source of Support: Research Center, King Abdullah Medical
City, Conflict of Interest: We certify that there is no conflict of
interest with any financial organization regarding the material
in the manuscript.
Objective: The aim of this study was to evaluate the extent and patterns of antibiotic prescription in the outpatient and the emergency departments of a tertiary care center in Makkah, Kingdom of Saudi Arabia.
Materials and Methods: A cross-sectional study was carried out by reviewing the pharmacy electronic database from March to May 2013. The World Health Organization core drug use indicators were used. A random sample of 200 OPD and ER antibiotic prescriptions was obtained for detailed patient file review.
Results: A total of 3872 antimicrobial prescriptions were identified. This constituted 16.2% of all OPD and ER prescriptions; 10% of OPD prescriptions and 47% of ER prescriptions contained at least one antibiotic. More than 50% of antibiotic prescriptions were not associated with the type of infection on the database. Co-amoxiclav and fluoroquinolones were the most frequently prescribed antibiotics.
Conclusion: The overall percentage of antibiotic prescriptions in the OPD and the ER at the tertiary care center in Makkah are acceptable, but the percentage in the ER far exceeded the overall rate. Guidelines are needed to rationalize the prescription of antibiotics in the OPD and the ER.
ملخص البحث :
هدفت هذه الدراسة الأسترجاعية إلى تقييم أنماط الوصفات الطبية للمضادات الحيوية في قسم العيادات الخارجية وقسم الطوارئ في مستشفى تخصصي في مكة المكرمة، بمراجعة قاعدة البيانات الإلكترونية للصيدلية في الفترة من 1 مارس إلى 13 مايو 3102. استخدمت مؤشرات تعاطي الأدوية لمنظمة الصحة العالمية في الدراسة. حيث تم الحصول على 002 عينة عشوائية من وصفات المضادات الحيوية. تم تحديد 3872 وصفة طبية لمضادات الميكروبات (%2.26) من مجموع الوصفات الطبية. تبين أن %10من الوصفات الطبية من قسم العيادات الخارجية و %74 من قسم الطوارئ كانت تحتوي على مضاد حيوي واحد على الأقل. ولم تحتوي %05 من الوصفات على التشخيص. خلصت الدارسة إلى إن النسبة الإجمالية لوصفات المضادات الحيوية في العيادات الخارجية والطوارئ مقبولة عالميا، ولكن النسبة في الطوارئ تجاوزت المعدل العام. لذا هناك حاجة ماسة لوضع المبادئ التوجيهية لترشيد وصف المضادات الحيوية في العيادات الخارجية وقسم الطوارئ.
Keywords: Antibiotics, emergency room, out-patient department, prescriptions
|How to cite this article:|
Oqal MK, Elmorsy SA, Alfhmy AK, Alhadhrami RM, Ekram RA, Althobaiti IA, Ghoneamy SS. Patterns of antibiotic prescriptions in the outpatient department and emergency room at a Tertiary Care Center in Saudi Arabia. Saudi J Med Med Sci 2015;3:124-9
|How to cite this URL:|
Oqal MK, Elmorsy SA, Alfhmy AK, Alhadhrami RM, Ekram RA, Althobaiti IA, Ghoneamy SS. Patterns of antibiotic prescriptions in the outpatient department and emergency room at a Tertiary Care Center in Saudi Arabia. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Jan 20];3:124-9. Available from: https://www.sjmms.net/text.asp?2015/3/2/124/156419
| Introduction|| |
Overuse of antibiotics is a common important problem in healthcare that leads to unnecessary expenditure on prescription drugs, increased risks of adverse effects with no associated benefit, and the development of antimicrobial resistance. 
Abusing antibiotics is a major health issue worldwide.  A study in Thailand that reviewed antibiotic prescriptions in 2010 showed increased additional hospitalization days resulting from antibiotic abuse.  Examples of the misuse of antibiotics include their use unbefitting the diagnosis, e.g., prescribing antibiotics for viral infections,  or starting therapy with a broad-spectrum agent without justification. 
A Japanese study reports that antibiotics are prescribed in 36.6-40% of cases in outpatient clinics.  Another study conducted in Germany and Europe found that 85% of the antibiotics used in humans are prescribed in the outpatient setting. 
The majority of antibiotics prescribed for adults in ambulatory care settings are broad-spectrum agents, most commonly fluoroquinolones and macrolides.  More than 25% of prescriptions are for conditions for which antibiotics are rarely indicated such as viral respiratory infections like the common cold, acute rhinosinusitis and acute bronchitis.  Furthermore, antibiotics are prescribed for 50-70% of respiratory tract infections, despite the fact that most of them have a viral etiology. A practice promoting the emergence and spread of resistant bacteria. 
In a Jordanian study on antibiotic prescriptions in outpatient and emergency clinics over a period of 3 consecutive months, it was found that they constituted about 35.6% out of 187, 822 prescriptions surveyed.  Our review of the literature on studies addressing the outpatient use of antibiotics in Saudi Arabia revealed only a single study carried out in Riyadh. This involved 327 pharmacies, 244 of which dispensed antibiotics without a medical prescription; and of the 244 pharmacies, 231 dispensed antibiotics without the patient's request.  The study was carried-out in a private hospital in the private sector, but no studies were found on antibiotic prescriptions in the outpatient departments of governmental hospitals.
The aim of this study was to evaluate the patterns of antibiotic prescriptions for out-patients department (OPD) and emergency department (ER) patients at a tertiary health care center which serves a large number of patients in Makkah, Saudi Arabia. This will make a comparison with patterns of prescribing antibiotics in the outpatient (OPD) and emergency room (ER) of other national and international centers possible. The information generated shall be used to decide the policies to govern the prescription of antibiotics in the OPD and ER. This will also guide an antibiotic stewardship program in hospitals, necessary to optimize the use of antimicrobial prescribing to improve patient care, decrease the cost of antimicrobial medications in hospitals and reduce the spread of antimicrobial resistance. Moreover, antimicrobial stewardship programs will ensure continued efficacy of available antimicrobials.
| Materials and methods|| |
Pharmacy database for all prescriptions in the period from March 1 to May 31, 2013 to identify all prescriptions containing antimicrobials was reviewed. After obtaining Institutional Review Board approval, records of those prescriptions were extracted from the pharmacy database into an excel spreadsheet and exported to the Statistical Package for the Social Sciences (SPSS) version 21.0 database (IBM Inc., SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Prescriptions were included if they contained at least one systemic (oral and parenteral) antibiotic. The following prescriptions were excluded: Those containing only topical antimicrobials or only systemic antifungals, antituberculosis, antiprotozoals other than metronidazole, antihelminthics or antiviral drugs. All records included were analyzed for the type of antibiotic, the prescribing department, route, and diagnosis, and grouped according to their chemical classes as follows: Penicillins, cephalosporins, monobactams, carbapenems, quinolones, macrolides, tetracyclines, sulfa compounds, and metronidazole. A description of the antibiotic sub-class was also made e.g., the generation of cephalosporin and the type of penicillin. For an analysis with stronger clinical implications, the spectrum was taken into consideration and antibiotics were classified into the following groups: Penicillins without beta lactamase inhibitors and first generation cephalosporins, second and third generation cephalosporins (without antipseudomonal activity), penicillins with beta lactamase inhibitors, antibiotics with antipseudomonal activity, antiatypical organisms, antianaerobes and others. It was decided to draw a random sample of 100 prescriptions from each of the ERs and the OPDs (using randomizers.com).
To evaluate the antibiotic use, it was decided to use the World Health Organization (WHO's) set of validated drug use indicators including: The percentage of encounters with antibiotic prescribed = (number of patient encounters with an antibiotic prescribed/the total number of encounters surveyed) ×100 and the percentage share of an individual antibiotic = (number of patient encounters with an individual antibiotic/total number of encounters with an antibiotic prescription) ×100. 
The data were analyzed at the Research Center by SPSS version 21.0. Categorical data were presented as percentages and the Chi squared test was used to make comparisons between OPD and ER data. A two-sided alpha was set at 0.05.
| Results|| |
A total of 5775 antimicrobial prescriptions were identified in the pharmacy database. One thousand nine hundred and three prescriptions were excluded according to the exclusion criteria described earlier. Of the 3872 antibiotic prescriptions included, 2003 were from the OPD and 1869 were from the ER [Figure 1]. These prescriptions were for 1100 OPD patients and 1869 ER patients. According to validated WHO scoring, antibiotics made up around 16% of all prescriptions included. The stratified percentage showed that 10% of OPD prescriptions and 47% of ER prescriptions contained at least one systemic antibiotic [Table 1].
More than half of the patients had a single antibiotic in the reviewed period of 3-month, two patients had 21 antibiotics in the period of 3-month. Both of these patients were leukemic patients and had antibiotics spanning the whole spectrum, and antibiotics from the same class that were tried sequentially [Table 2]. Alone, co-amoxiclav made up more than 20% of the prescriptions from the OPDs. Next were ciprofloxacin and cefuroxime (a second generation cephalosporin). Surprisingly, amoxicillin did not appear on the list of the top six antibiotics [Figure 2].
In the ER, the prescriptions of co-amoxiclav constituted even a bigger fraction than that of the OPD, rising to more than 30%. Again quinolones came next in order and ceftriaxone (a third generation cephalosporin) appeared in the top six antibiotics in the list [Figure 3].
|Figure 3: Percentages of various antibiotics prescribed in the emergency department|
Click here to view
The top two antibiotic classes prescribed in the OPD, were quinolones and penicillin-beta lactamase inhibitor combinations, both with Gram negative coverage. A consideration of antibiotic spectrum and for the OPD, showed that the biggest group of prescriptions was the spectrum group of second and third generation cephalosporins and penicillins with beta lactamase inhibitors. The next largest group was antipseudomonals, mainly because this group contained ciprofloxacin and levofloxacin, both of which were heavily prescribed in the OPD.
The diagnoses documented in the pharmacy database were evaluated with regard to bacterial infection documented to justify the use of an antibiotic. Almost 50% of the total antibiotic prescriptions examined were not associated with any documentation of an indication for antibiotics. Around 8.5% of antibiotics were prescribed for conditions that did not classically require treatment with an antibiotic. In more than 60% of antibiotics prescribed in the OPD, there was no documentation of bacterial infection. The ER exceeded the OPD in antibiotic prescriptions for conditions that did not classically require treatment with an antibiotic such as the common cold and noninfective gastroenteritis [Figure 4] and [Figure 5].
Of the total of 200 randomly selected patients from the pharmacy database, 16 had to be excluded; 14 patients were excluded because their files were not available. And two who were inpatients when the antibiotics were prescribed. Our sample thus came down to 184 patients, 93 from the ER and 91 from the OPD. In the 3-month period reviewed, a total of 153 and 128 prescriptions were written for those ER and OPD patients respectively [Figure 6]. Regarding the evidence of infection, 17 out of 281 prescriptions had no diagnosis or any indication on the pharmacy database to support the use of an antibiotic. Out of 17 prescriptions, only 3 had information about the presence of infection in the patient file. Only 28 (10%) of the sampled prescriptions had an associated culture result. Two cultures were requested for OPD patients and 26 for ER patients. All culture results except one were negative for bacterial growth. Ten out of the 184 studied patient files had some documented evidence of recovery, mostly in the form of a drop in white blood cells, subsidence of fever, or relief of pain. Eleven out of the 184 required a subsequent antibiotic indicating inadequate coverage of their initial indentified infection.
|Figure 6: Results of randomly selected prescriptions for 200 patients from pharmacy database|
Click here to view
| Discussion|| |
The study provided an assessment of antimicrobial prescriptions dispensed in the OPD and the ER. The present study revealed the percentage of antibiotic prescription in the OPD and ER as 16.2%, which is considerably less than what was reported in Sudan (63%), Iran (61.9%),  England (60.7%) and Norway (48%).  According to the WHO, prescription of antibiotics on 15-25% of encounters is acceptable in the countries where an infectious disease is prevalent. , However, this picture was mainly derived from the results of the OPD where the percentage of antibiotic prescribed encounters was only 10%. The percentage found in the ER was much higher at 47%. This does not indicate that the pattern of prescription was better than in other countries since there is little documentation of the clinical conditions or definite diagnoses which led to the prescribing of an antibiotic. Almost 50% of the antibiotic prescriptions were not associated with any documentation of an indication for antibiotics, and around 8.5% of antibiotics were prescribed for conditions that did not classically warrant treatment with an antibiotic. Some reports indicate that while the worldwide use of antibiotics is falling, the use of wide-spectrum ones is dramatically increasing. In the OPD, it was noticed that the biggest group of prescriptions comprised those that contained second and third generation cephalosporins and penicillins with beta lactamase inhibitors. The next biggest group was composed of antipseudomonals, mainly because this category contained ciprofloxacin and levofloxacin, both of which were heavily prescribed in the OPD.
Abuse of antibiotics increases the risk of resistance, results in treatment failure which may eventually lead to more morbidity and mortality, and increased health care costs.  It is thus not surprising that up to one-third of the community-acquired uropathogens are highly resistant to fluoroquinolones.  Increased incidence of resistance of Gram-negative isolates to fluoroquinolones has been reported in various studies in many resource-constrained countries. Indeed, studies from Pakistan, India, and Vietnam have demonstrated the emergence of resistance to quinolones of Gram-negative bacteria such as Neisseria gonorrhoeae, Salmonella typhi, Salmonella paratyphi, Shigella dysenteriae, Escherichia coli, and other Gram-negative Enterobacteria. ,,,,,,, The lack of routine drug sensitivity tests and surveillance in many countries means that antibiotics and other antimicrobial drugs are not rationally used. , This study revealed that only 28 (10%) of the sampled prescriptions had an associated culture result; two of the cultures were requested for OPD patients and 26 for ER patients. Although the empirical use of antibiotics may be essential in some situations, follow-up with a culture may result in important therapy modifications. Failure to direct antibiotic therapy properly may engender therapeutic failure and/or the emergence of resistance.
Regular audits of diagnostic and prescribing practices are required to determine and control prescribing behavior. Unfortunately, routine audits are rare. One-off audits for research purposes are more common.  However, a cultural change in how oversight is perceived is necessary. It should not, at least initially, be seen as punitive, but rather as a supportive means of arriving at the common goal of improved patient care and reduction of the development of resistance. Even then, the absence of adequate diagnostic facilities often makes a definitive statement about the appropriateness of the prescribing that was audited unfeasible. 
There are some limitations to our study. The use of data on aggregated antibiotic use made it impossible to differentiate appropriate from inappropriate use in all cases. This was only assessed in the sample of cases selected for file review. Besides, the lack of data in patients' files and inconsistency of the terminology used in documentation in the hospital information system meant that we could not assess the pharmaco-therapeutic aspects of the prescriptions in relation to health problems or diagnosis of the patients. Therefore, we cannot comment objectively on appropriateness. In addition, the study was conducted in one hospital and therefore, cannot be considered a representative study of Makkah city.
| Conclusion|| |
The overall percentage of antibiotic prescriptions in the OPD and the ER seems to be within the acceptable range as per the WHO standards. Some antibiotics may still be prescribed without a clear documented indication, e.g., for viral infections or inflammations reported to be of noninfectious etiology. In addition, it appears that some broad-spectrum antibiotics such as co-amoxiclav are overprescribed. The reason behind this is not understood, and requires further study for clarification. It is also important to study the cost impact of antibiotic misuse in OPD and ER, and focus on individual departments. Furthermore, it is recommended that this type of study be extended to other centers under the Ministry of Health as well as private centers. An effective intervention program is needed to start and foster an antibiotic stewardship to promote a more rational drug use by physicians and pharmacists.
| Acknowledgments|| |
We express our appreciation to the Pharmaceutical Care Department and Research center at KAMC, Makkah, Kingdom of Saudi Arabia for assisting us in conducting this research project.
| References|| |
Gonzales AH. Decreasing Out-of-pocket costs of antibiotics: The good, the bad, and the unknown. Comment on ambulatory antibiotic use and prescription drug coverage in older adults. JAMA Intern Med 2010;170:1314-6.
Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev 2005:CD003539.
Sumpradit N, Chongtrakul P, Anuwong K, Pumtong S, Kongsomboon K, Butdeemee P, et al.
Antibiotics smart use: A workable model for promoting the rational use of medicines in Thailand. Bull World Health Organ 2012;90:905-13.
Cadieux G, Tamblyn R, Dauphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ 2007;177:877-83.
Baktygul K, Marat B, Ashirali Z, Harun-Or-rashid M, Sakamoto J. An assessment of antibiotics prescribed at the secondary health-care level in the Kyrgyz Republic. Nagoya J Med Sci 2011;73:157-68.
Meyer E, Gastmeier P, Deja M, Schwab F. Antibiotic consumption and resistance: Data from Europe and Germany. Int J Med Microbiol 2013;303:388-95.
Shapiro DJ, Hicks LA, Pavia AT, Hersh AL. Antibiotic prescribing for adults in ambulatory care in the USA, 2007-09. J Antimicrob Chemother 2014;69:234-40.
Aznar M, Mejía R, Wigton R, Fayanas R. Predictors of antibiotic prescription in respiratory tract infections by ambulatory care practitioners. Medicina (B Aires) 2005;65:501-6.
Al-Mendalawi MD. Drug use evaluation of antibiotics prescribed in a Jordanian Hospital outpatient and emergency clinics using WHO prescribing indicators. Saudi Med J 2008;29:1362.
Bin Abdulhak AA, Altannir MA, Almansor MA, Almohaya MS, Onazi AS, Marei MA, et al.
Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: A cross sectional study. BMC Public Health 2011;11:538.
Action Program on Essential Drugs and Vaccines (World Health Organization). How to Investigate Drug Use in Health Facilities: Selected Drug Use Indicators. Geneva: Action Program on Essential Drugs; 1993.
Moghadamnia AA, Mirbolooki MR, Aghili MB. General practitioner prescribing patterns in Babol city, Islamic Republic of Iran. East Mediterr Health J 2002;8:550-5.
Sharif S, Al-Shaqra M, Hajjar H, Shamout A, Wess L. Patterns of drug prescribing in a hospital in dubai, United arab emirates. Libyan J Med 2008;3:10-2.
Bhartiy SS, Shinde M, Nandeshwar S, Tiwari SC. Pattern of prescribing practices in the Madhya Pradesh, India. Kathmandu Univ Med J (KUMJ) 2008;6:55-9.
Ang BS. Bugs for the next century: The issue of antibiotic resistance. Ann Acad Med Singapore 2001;30:199-202.
Casellas JM, Tomé G, Bantar C, Bertolini P, Blázquez N, Borda N, et al.
Argentinean collaborative multicenter study on the in vitro
comparative activity of piperacillin-tazobactam against selected bacterial isolates recovered from hospitalized patients. Diagn Microbiol Infect Dis 2003;47:527-37.
Sabir N, Khan E, Sheikh L, Hasan R. Impact of antibiotic usage on resistance in microorganisms; urinary tract infections with E-coli as a case in point. J Pak Med Assoc 2004;54:472-5.
Ray K, Bala M, Kumar J, Misra RS. Trend of antimicrobial resistance in Neisseria gonorrhoeae at New Delhi, India. Int J STD AIDS 2000;11:115-8.
Jorgensen JH, Crawford SA, Fiebelkorn KR. Susceptibility of Neisseria meningitidis to 16 antimicrobial agents and characterization of resistance mechanisms affecting some agents. J Clin Microbiol 2005;43:3162-71.
Jabeen K, Khan E, Hasan R. Emergence of quinolone-resistant Neisseria gonorrhoeae in Pakistan. Int J STD AIDS 2006;17:30-3.
Tupasi TE. Quinolone use in the developing world: State of the art. Drugs 1999;58 Suppl 2:55-9.
Okeke IN, Laxminarayan R, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, et al.
Antimicrobial resistance in developing countries. Part I: Recent trends and current status. Lancet Infect Dis 2005;5:481-93.
Okeke IN, Klugman KP, Bhutta ZA, Duse AG, Jenkins P, O'Brien TF, et al.
Antimicrobial resistance in developing countries. Part II: Strategies for containment. Lancet Infect Dis 2005;5:568-80.
Dromigny JA, Perrier-Gros-Claude JD. Antimicrobial resistance of Salmonella enterica serotype Typhi in Dakar, Senegal. Clin Infect Dis 2003;37:465-6.
Okeke IN. Diagnostic insufficiency in Africa. Clin Infect Dis 2006;42:1501-3.
Petti CA, Polage CR, Quinn TC, Ronald AR, Sande MA. Laboratory medicine in Africa: A barrier to effective health care. Clin Infect Dis 2006;42:377-82.
Hadi U, Duerink DO, Lestari ES, Nagelkerke NJ, Keuter M, Huis In't Veld D, et al.
Audit of antibiotic prescribing in two governmental teaching hospitals in Indonesia. Clin Microbiol Infect 2008;14:698-707.
Hadi U, Keuter M, van Asten H, van den Broek P, Study Group 'Antimicrobial resistance in Indonesia: Prevalence and Prevention' (AMRIN). Optimizing antibiotic usage in adults admitted with fever by a multifaceted intervention in an Indonesian governmental hospital. Trop Med Int Health 2008;13:888-99.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]