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2.Literature Review Rational Use Of Antibiotics

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									2. Literature Review

Reasons for non-guideline-based antibiotic prescriptions for acute otitis media
in The Netherlands ^6

Appropriate use of antibiotics is a major issue in today's medicine. The
increasing worldwide bacterial resistance to antimicrobial agents is forcing us
to prescribe antibiotics more rationally. It is known that overuse of antibiotics
for upper respiratory tract infections exists. Little is known about the reasons
for actual prescribing of antibiotics. In order to be able to implement strategies
to restrict inappropriate antibiotic prescriptions, insight into the reasons for the
actual prescribing could be important.


 We aimed to explore the reasons, other than those stated in the guidelines of
the Dutch College of GPs, for prescribing antibiotics


 Seventy antibiotic prescriptions for acute otitis media, prescribed by 22 Dutch
GPs, were evaluated to see whether they followed the guidelines on acute
otitis media of the Dutch College of General Practitioners. Non-guideline-
based antibiotic prescriptions were discussed in stimulated recall interviews
with the prescribing GPs regarding their prescribing behaviour of antibiotics
for acute otitis media.


 In total, 77% of the antibiotic prescriptions did not follow the guidelines of the
Dutch College of General Practitioners. Medical reasons for prescribing
antibiotics were mentioned most often for non-guideline-based antibiotic
prescriptions; however, in a substantial number of cases doctors gave non-
medical reasons as well.

Conclusions.:Appropriate use of antibiotics might not be reached by focusing
only on the efficacy of these drugs. The impact of doctors' awareness of their
non-medical motives for prescribing antibiotics on more rational antibiotic
prescribing should be investigated further.

2. Literature Review
Study of prescription of injectable drugs and intravenous fluids to inpatients in
a teaching hospital in Western Nepal ^7

Unnecessary, excessive and poor injection practices in the South East Asia
region (including Nepal) have been observed previously. The authors aim to
study prescription of injectable drugs to inpatients in a teaching hospital in
Western Nepal. Prescription of injectable drugs (IDs) and intravenous fluids
(IVFs) to inpatients discharged from the wards of the Manipal Teaching
Hospital during 1st January to 30th June 2006 was studied. The mean
number of drugs, IDs and IVFs administered, median cost of drugs and of
IDs/IVFs per prescription calculated. Comparison of ID/IVF use in the four
major hospital departments (Medicine, Obstetrics and Gynecology, Pediatrics
and Surgery) was done. The administration of IDs/IVFs and injectable
antimicrobials were measured in Defined Daily Dose (DDD)/100 bed-days and
of Intravenous fluid in Liters (L)/100 bed-days. Of the 1131 patients
discharged, 938 (82.94%) patients received one or more IDs/IVFs. The mean
number of drugs, IDs and IVFs prescribed were 8.75, 4.72 and 1.42. Median
cost of drugs and IDs/IVFs per prescription were 8.26US$ and 5.12US$
respectively. IDs/IVFs accounted for 81.37% of total drug cost. The most
commonly used ID, injectable antimicrobial and IVF were Diclofenac (19.3
DDD/100 bed-days), Metronidazole (7.68 DDD/100 bed-days) and Dextrose
normal saline (8.56 L/100 bed-days), respectively. The total IVF consumption
was 24.25 L/100 bed-days. Significant differences between departments were
observed (p<0.05). In conclusion, the use of IDs/IVFs was higher compared to
other studies. Interventions to improve IDs/IVFs prescribing practices may be

Rational use effects of implementing an essential medicines list in West Bank,
Palestinian Territories. ^8

The Palestinian Ministry of Health introduced an essential medicines list
(EML) in 2000 to improve rational use of medicines and contain costs. We
have examined the effects of the EML in the Palestinian healthcare public
sector. We obtained data on prescription patterns for medicines from 3570
prescriptions given during outpatient visits in 17 healthcare facilities in the
West Bank from 1997 to 2003. We analyzed the prescriptions to measure
rational use. We modeled indicators of rational use as a function of the EML
and 16 health center indicator variables. The EML was effective in shifting all
prescribing indicators toward standard values. To improve rational medicine
use, treatment protocols for the most common diseases and continuous
education for medical staff is required.

Evaluation of rational prescribing and dispensing of medicines in Mali ^9

Pharmaceutical policy in Mali is based on the concept of essential medicines
and procurement of generic medicines. Unfortunately, increasing availability
of generic medicines via different promotional programs can often be

2. Literature Review
accompanied by their irrational use. This survey was thus designed to
evaluate rational prescribing and dispensing of medicines in Mali. A cross-
sectional survey was conducted from 1998 to 2005 in 30 primary health
centers and 30 private dispensaries; in Bamako and in 6 of the 8 other
regions of the country. In each of the visited facilities, 20 prescriptions
dispensed at the time of the survey were collected. The average number of
medicines per prescription was 3.2+/-1.3 and 2.8+/-1.2 respectively in the
public and private sectors. Medicines were prescribed under generic name in
88.2% of the public sector prescriptions and in 30.9% of the private sector
ones. Antibiotics were prescribed in 70.4% of the public sector prescriptions
and in 50.0% of the private sector prescriptions. In the public sector 33.2% of
the prescriptions had injections compared with 14.3% in the private sector
(p<0.001). The median price per prescription was lower in the public sector
(1575.0 CFA F, or 2.4 Euros, of which 91.3% were actually purchased by the
patient) than in the private sector (5317.5 CFA F, or 8.1 Euros, of which
84.6% were purchased). Generic medicines are being used in the public
sector but less frequently than in private practice. As therapeutic guidelines
are already available, it would be useful to institute interactive information for
practitioners through intensive visits by more experienced supervisors. The
quality of the prescriptions could thus be optimized.

Evaluation of prescription practices and of the rational use of medicines in
Niger ^10

With the aim of evaluating an essential drugs and costs recovery program in
Niger, rational drug use and prescribing patterns were studied in 19 health
centers in Tahoua region. Drug use indicators were measured by
retrospective and prospective surveys, achieved before and after a training
intervention for nurses in using national standard treatments guideline. In the
first study period, 627 retrospective randomized prescriptions and 295
prospective prescriptions in successive consultations were collected, and in
the second period, ten months later, 665 and 274 prescriptions, respectively.
Findings were compared between the two periods, and discussed in regard to
referentials and data from other studies. The average number of drugs per
prescription increased from 2.96 to 3.14 (p < 0.01) between the two periods,
and the percentage of prescriptions with injections from 29.9 to 36.6% (p <
0.02), whereas the percentage of prescriptions containing antibiotics
decreased from 75.2 to 68% (p < 0.01). These values were higher than
regional or international standards, which were 2 for the average of drugs
17% for the injections and 50% for the antibiotics. Prescribing in essential and
generic names of the national drug list was very close to 100% for the two
periods. The average cost of prescriptions increased from 437 to 553 francs
CFA (p < 0.001), which was higher than the calculated reference cost of 400
francs, but lower than data in literature. Correct prescriptions according to
standard treatment guideline were only around 50%, in the two retrospective
surveys. The averages of consultation time were 5.4 and 6.1 minutes for the
two prospective surveys respectively, and dispensing times were 3.1 and 3.4
minutes, longer than those noticed in most of other studies in developing
countries. Prescribed drugs were actually dispensed in almost 100% of the

2. Literature Review
cases during the two periods. Drugs were properly labeled in 92.8% of the
cases in the first period survey, and in 89.7% of the cases in the second (p <
0.03), whereas the percentage of patients who knew the correct dosage for
drugs delivered increased from 64.4% to 75.5% (p < 0.01). Drug formularies
and treatment guidelines were available in all facilities except in one case.
Key drug availability ratio at the time of visit were good, in spite of a
regression from 97.6 to 85.6% between the two periods. Improving drug
purchasing and communal management in the health centers, this program
contributed to the availability of essentials generic drugs delivered in a
satisfactory way to the patients, and to set up a favorable professional
environment for the nurses. On the other hand, the training courses seemed
to have a limited impact on prescribing patterns for the nurses. However,
better availability of drugs, as well as dispatching courses on the two
retrospective surveys periods, could have underestimated this impact.
Increasing prescription cost, although remaining compatible with costs
recovery of drugs, was probably caused by the negative evolution of some
indicators: abusive use of injections, higher number of drugs prescribed, few
prescriptions according to standard treatment. These bad habits, often the
most dangerous, justify undertaking actions of adapted formation, but also of
communication with the patients, which should be regularly evaluated. For
that, it will be necessary to have more qualitative indicators, helpful for the
assessment of most efficient therapeutic attitude, tempting to value the global
impact of these actions on health populations in developing countries.

Rational use of drugs: prescribing and dispensing practices at public
health facilities in Lao PDR

To evaluate the rational use of drug (RUD) patterns with a focus on
prescribing and dispensing practices for providing information to the policy
makers for further planning and identifying intervention strategies.
A cross-sectional study conducted by interviewing 370 presenting outpatients,
checking records of 900 out- patients with any cases and 798 outpatients with
tracer diseases such as simple diarrhea, pneumonia and non-pneumonia
(Flu) within 30 public health facilities (HFs) of five geographical areas with
different socio-economic statuses grouped into high, middle and low. The
WHO Operational Package for Monitoring and Assessing Country
Pharmaceutical Situations indicators were used for data collection.
Among the 3 items of drugs prescribed per average encounter, 97% were
dispensed from HFs, of which 67% were adequately labeled, 84% were on
the national essential drug (ED) list, and 78% were prescribed by generic
name. Seventy-four percent of patients knew how to take the drugs they
received, 47% of them received antibiotics (ABs), and 18% received
injections. Forty-seven percent of under-five children with simple diarrhea
received ABs, 77% received Oral Rehydration Salts (ORS) and 5% received

2. Literature Review
anti-diarrhea drugs, and 91% of such under-five children with mid/moderate
pneumonia received one of first line ABs, 15% received more than one ABs,
and 41% of non-pneumonia (flu) patients of any age received ABs.
The use of drugs in Laos was not fully appropriate in terms of rationally
prescribing and dispensing practices. Since prescriptions for AB, injections,
non-ED, and non-generics are still high, information on drug use provided is
insufficient. Therefore, continuous health education programs among both
health staff and public are needed. Copyright © 2005 John Wiley & Sons, Ltd.

A population-based study of different antibiotic prescribing in different
areas ^11

Respiratory tract infections are the most common reason for antibiotic
prescription in Sweden as in other countries. The prescription rates vary
markedly in different countries, counties and municipalities. The reasons for
these variations in prescription rate are not obvious.
To find possible explanations for different antibiotic prescription rates in
Design of study
Prospective population based study.
All child health clinics in four municipalities in Sweden which, according to
official statistics, had high antibiotic prescription rates, and all child health
clinics in three municipalities which had low antibiotic prescription rates.
During one month, parents recorded all infectious symptoms, physician
consultations and antibiotic treatments, from 848 18-month-old children in a
log book. The parents also answered a questionnaire about socioeconomic
factors and concern about infectious diseases.
Antibiotics were prescribed to 11.6% of the children in the high prescription
area and 4.7% in the low prescription area during the study month (crude
odds ratio [OR] = 2.67; 95% confidence interval [CI] = 1.45 to 4.93). After
multiple logistic regression analyses taking account of socioeconomic factors,
concern about infectious illness, number of symptom days and physician
consultations, differences in antibiotic prescription rates remained (adjusted
OR = 2.61; 95% CI = 1.14 to 5.98). The variable that impacted most on
antibiotic prescription rates, although it was not relevant to the geographical
differences, was a high level of concern about infectious illness in the family.

The differences in antibiotic prescription rates could not be explained by
socioeconomic factors, concern about infectious illness, number of symptom

2. Literature Review
days and physician consultations. The differences may be attributable to
different prescription behaviour.

Variation in antibiotic prescribing and its impact on recovery in patients
with acute cough in primary care: prospective study in 13 countries ^12

Objective To describe variation in antibiotic prescribing for acute cough in
contrasting European settings and the impact on recovery.

Design Cross sectional observational study with clinicians from 14 primary
care research networks in 13 European countries who recorded symptoms on
presentation and management. Patients followed up for 28 days with patient

Setting Primary care.

Participants Adults with a new or worsening cough or clinical presentation
suggestive of lower respiratory tract infection.

Main outcome measures Prescribing of antibiotics by clinicians and total
symptom severity scores over time.

Results 3402 patients were recruited (clinicians completed a case report form
for 99% (3368) of participants and 80% (2714) returned a symptom diary).
Mean symptom severity scores at presentation ranged from 19 (scale range 0
to 100) in networks based in Spain and Italy to 38 in the network based in
Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90%
(53% overall), with wide variation in classes of antibiotics prescribed.
Amoxicillin was overall the most common antibiotic prescribed, but this ranged
from 3% of antibiotics prescribed in the Norwegian network to 83% in the
English network. While fluoroquinolones were not prescribed at all in three
networks, they were prescribed for 18% in the Milan network. After adjustment
for clinical presentation and demographics, considerable differences remained
in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95%
confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared
with the overall mean (proportion prescribed: 0.53). The rate of recovery was
similar for patients who were and were not prescribed antibiotics (coefficient –
0.01, P<0.01) once clinical presentation was taken into account.

Conclusions Variation in clinical presentation does not explain the
considerable variation in antibiotic prescribing for acute cough in Europe.
Variation in antibiotic prescribing is not associated with clinically important
differences in recovery.

2. Literature Review

Prescription of prophylactic antibiotics for neurosurgical procedures in
teaching            hospitals             in          Iran          ^13


To assess the appropriateness of surgical antibiotic prophylaxis in
neurosurgical procedures, using the American Society of Health-System
Pharmacists (ASHP) guideline as reference, 110 patients were prospectively
evaluated. Monitoring surgical antibiotic prophylaxis is crucial in ensuring
appropriate use of antimicrobial agents in this setting. This will minimize the
consequences of antibiotic misuse such as increased drug antibiotic
resistance, adverse events, and higher costs to the institution.

We recruited 110 consecutive patients undergoing clean neurosurgical
treatment in 2 hospitals. Data were collected prospectively from patients'
medical records between February 2004 and April 2004. The data collection
forms for each patient included hospital name, patient demographics, type of
surgery, and type of antimicrobial prophylaxis regimen (drug name, dose,
interval, route of administration, number of doses and time administered, and
duration of administration).

Discrepancies about antibiotic selection, duration, and start time of
prophylaxis were seen between current administration and the ASHP
guideline. The direct cost of prophylactic antibiotics for the 110 procedures
was 14 times greater than what it would have cost to administer prophylactic
antibiotics adhering to the ASHP guideline (US $802 vs US $59; US $7.29 vs
US $0.54 per patient, respectively). This is equivalent to US $6.75 of extra
costs per procedure and patient.

This study indicates the need for interventions to improve the rational use of
antibiotic prophylaxis in Iran to prevent the complications of inappropriate
administration of antimicrobials and decrease unnecessary costs.

2. Literature Review

Changing Use of Antibiotics in Community-Based Outpatient Practice,
1991–1999 ^14


Background: Judicious use of antibiotics can slow the spread of antimicrobial
resistance. However, overall patterns of antibiotic use among ambulatory
patients are not well understood.

Objective: To study patterns of outpatient antibiotic use in the United States,
focusing on broad-spectrum antibiotics.

Design: Cross-sectional survey in three 2-year periods (1991–1992, 1994–
1995, and 1998–1999).

Setting: The National Ambulatory Medical Care Survey, a nationally
representative sample of community-based outpatient visits.

Patients: Patients visiting community-based outpatient clinics.

Measurements: Rates of overall antibiotic use and use of broad-spectrum
antibiotics (azithromycin and clarithromycin, quinolones, amoxicillin–
clavulanate, and second- and third-generation cephalosporins). All
comparisons were made between the first study period (1991–1992) and the
final study period (1998–1999).

Results: Between 1991–1992 and 1998–1999, antibiotics were used less
frequently to treat acute respiratory tract infections, such as the common cold
and pharyngitis. However, use of broad-spectrum agents increased from 24%
to 48% of antibiotic prescriptions in adults (P < 0.001) and from 23% to 40% in
children (P < 0.001). Use of broad-spectrum antibiotics increased across
many conditions, increasing two- to threefold as a percentage of total
antibiotic use for a variety of diagnoses in both adults and children. By 1998–
1999, 22% of adult and 14% of pediatric prescriptions for broad-spectrum
antibiotics were for the common cold, unspecified upper respiratory tract
infections, and acute bronchitis, conditions that are primarily viral.

Conclusions: Antibiotic use in ambulatory patients is decreasing in the
United States. However, physicians are increasingly turning to expensive,
broad-spectrum agents, even when there is little clinical rationale for their use.

2. Literature Review
 A population-based study of antibiotic prescriptions for Danish children


Background. The aim of the study was to examine the use of systemic and
topical antibiotics in relation to age and sex in Danish children.

Methods. We used the Pharmacoepidemiological Prescription Database to
identify the individual prescriptions of antibiotics provided for all 0- to 15-year-
old children in North Jutland County, Denmark, during 1997. The population
was ∼ 95 000 children.

Results. We identified 44 640 prescriptions for systemic antibiotics. The
annual prescription rate was highest in the 1- to 2-year-olds, with 945
prescriptions/1000 children/year. One-half of these children received at least 1
prescription, and 12% received 3 or more prescriptions. Among the 11- to 15-
year-old children 17% received one or more prescriptions. Overall 88% of the
prescriptions were penicillins and 10% were macrolides. In children younger
than 3 years 57% of prescriptions were for broad spectrum penicillins, but in
children older than 6 years penicillin V was the most frequently used
antibiotic. We identified 12 661 prescriptions for topical antibiotics used in eye
infections. The prescription rate peaked in the 1- to 2-year-old children, one-
third of whom received at least 1 prescription.

Conclusions. Almost two-thirds of the 0- to 2-year-old children in the
population were treated with either systemic or topical antibiotics during 1
year. Physicians prescribe mostly penicillins, but the proportion of broad
spectrum penicillins for young children was so high, however, that
enforcement of national guidelines should be reconsidered.

Economic impact of a rational use of antibiotics in intensive care ^16
Abstract Objective: To evaluate the economic impact of a rational policy in
antibiotic treatment. Design: Comparative study with a retrospective and a
prospective part. Setting: An 11-bed intensive care unit (ICU) in a general
hospital. Patients: All patients admitted to the unit in 1994, 1995 and 1996.
Interventions: In 1995, a program of cost control was started and a contract of
agreed objectives signed with the director of the hospital. This contract
included a commitment to refund the eventual savings in order to improve the
quality of care. Prescribing protocols were established by consensus as
guidelines for a rational policy in antibiotic therapy. Measurements and
results: The cost of antibiotic therapy, the patients' characteristics and the
incidence of nosocomial infection were compared prior to and during the
program. The expenses for antibiotic drugs decreased by 19 % in 1995 and
by 22 % in 1996. Most of the savings were refunded to the ICU and
contributed to the employment of an additional nurse and the purchase of new

2. Literature Review
material. In number of patients, type of disease, mean age, Simplified Acute
Physiology Score, occupancy rate, length of stay, omega score, artificial
ventilation, readmission within 7 days, mortality and incidence of nosocomial
infection, no significant difference was found. Conclusions: We proved a
positive economic impact of a rational policy in antibiotic therapy realized with
a contract of agreed objectives. The savings made while applying our
program of cost control were used to improve the quality of care.

Outpatient prescription of oral antibiotics in a training hospital in
Turkey:      Trends       in     the        last     decade       ^17



The aim was to evaluate the changing trends in outpatient prescription of oral
antibiotic forms at a Training Hospital in the last decade.

Material and method

All the outpatient prescriptions during April and May 2004 were evaluated.
The diagnosis, the department of the prescriber, the count and generic name
of each prescribed antibiotic were all noted.


Of the 33  491 outpatient prescripitions, 14.9% included antibiotic (n=5004).
The pediatric clinics (26.4%), Ear, Nose and Throat department (13.7%), and
the department of Gyneacology and Obstetrics (10.8%) were the leading
departments in antibiotic prescriptions. Upper respiratory tract infections
(45.4%), urinary tract infection (11.4%) and lower respiratory tract infections
(4.2%) shared the first lines of diagnosis stated. Of the antibiotic prescriptions,
96.3% included oral forms. Co-amoxiclav (26.4%), quinolones (11.7%) and
cephalosporins (16.5%) were the most frequently prescribed antibiotics.
Percent of antibiotic prescriptions based on microbial sensitivity test results
was 7.1%.


Compared with the results of the study carried out 11 years ago; though co-
amoxiclav is still the most frequently prescribed antibiotic, many other
changes have been observed in antibiotic prescription attitudes.

2. Literature Review

Antibacterial prescribing and antibacterial resistance in English general
practice: cross sectional study ^18

Objective: To quantify the relation between community based antibacterial
prescribing and antibacterial resistance in community acquired disease.
Design: Cross sectional study of antibacterial prescribing and antibacterial
resistance of routine isolates within individual practices and primary care
Setting: 405 general practices (38 groups) in south west and north west
Main outcome measures: Correlation between antibacterial prescribing and
resistance for urinary coliforms and Streptococcus pneumoniae.
Results: Antibacterial resistance in urinary coliform isolates is common but
the correlation with prescribing rates was relatively low for individual practices
(ampicillin and amoxicillin rs=0.20, P=0.001; trimethoprim rs=0.24, P=0.0001)
and primary care groups (ampicillin and amoxicillin rs=0.44, P=0.05;
trimethoprim rs=0.31, P=0.09). Regression coefficients were also low; a
practice prescribing 20% less ampicillin and amoxicillin than average would
have about 1% fewer resistant isolates (0.94/100; 95% confidence interval
0.02 to 1.85). Resistance of S pneumoniae to both penicillin and erythromycin
remains uncommon, and no clear relation with prescribing was found.
Conclusions: Routine microbiological isolates should not be used for
surveillance of antibacterial resistance in the community or for monitoring the
outcome of any change in antibacterial prescribing by general practitioners.
Trying to reduce the overall level of antibiotic prescribing in UK general
practice may not be the most effective strategy for reducing resistance in the

Use of antibiotics and prescription drugs in general during the first 9
years of life in a Swedish community ^19


Summary. The use of antibiotic drugs and of prescription drugs in general
during the first 9 years of life was studied among all 1701 children born in a
Swedish municipality. Cumulative proportions of children who had received
one or more prescriptions for any type of drug and for different groups of
antibiotic drugs were estimated by life-table methods. The effects on drug use
of the gender and the birth order of the child along with the age, citizenship
and marital status of the mother were analysed by Cox's proportional hazards
regression model. Half of the children had received at least one prescription
for any drug after 0.6 years and at least one prescription for any antibiotic

2. Literature Review
drug after 1.8 years. Higher proportions of children with prescriptions for all
drugs and for all antibiotic drugs were found among males than females,
among those with older siblings compared with first-borns and among children
of younger mothers compared with those of older mothers.

 Can antibiotic prescriptions in respiratory tract infections be improved? A
cluster-randomized educational intervention in general practice ^20


More than half of all antibiotic prescriptions in general practice are issued for
respiratory tract infections (RTIs), despite convincing evidence that many of
these infections are caused by viruses. Frequent misuse of antimicrobial
agents is of great global health concern, as we face an emerging worldwide
threat of bacterial antibiotic resistance. There is an increasing need to identify
determinants and patterns of antibiotic prescribing, in order to identify where
clinical practice can be improved.


Approximately 80 peer continuing medical education (CME) groups in
southern Norway will be recruited to a cluster randomized trial. Participating
groups will be randomized either to an intervention- or a control group. A
multifaceted intervention has been tailored, where key components are
educational outreach visits to the CME-groups, work-shops, audit and
feedback. Prescription Peer Academic Detailers (Rx-PADs), who are trained
GPs, will conduct the educational outreach visits. During these visits,
evidence-based recommendations of antibiotic prescriptions for RTIs will be
presented and software will be handed out for installation in participants PCs,
enabling collection of prescription data. These data will subsequently be
linked to corresponding data from the Norwegian Prescription Database
(NorPD). Individual feedback reports will be sent all participating GPs during
and one year after the intervention. Main outcomes are baseline proportion of
inappropriate antibiotic prescriptions for RTIs and change in prescription
patterns compared to baseline one year after the initiation of the tailored
pedagogic intervention.


Improvement of prescription patterns in medical practice is a challenging task.
A thorough evaluation of guidelines for antibiotic treatment in RTIs may
impose important benefits, whereas inappropriate prescribing entails
substantial costs, as well as undesirable consequences like development of
antibiotic resistance. Our hypothesis is that an educational intervention
program will be effective in improving prescription patterns by reducing the

2. Literature Review
total number of antibiotic prescriptions, as well as reducing the amount of
broad-spectrum antibiotics, with special emphasis on macrolides.

An audit of prescription for rational use of fixed dose drug combinations ^21
Objectives: To study about the rationality of the different fixed dose drug
combinations (FDC) prescribed
by doctors.
Methods: A retrospective study was conducted after collecting prescription
from patients attending
private clinics and Government hospitals. The rationality of FDC formulations
was studied on the basis of
FDCs recommended by WHO in its list of essential drugs.
Results: Audit of the prescriptions reveals that 75% of the prescriptions
contained FDC formulations.
However, FDCs in accordance with recommended WHO list of FDCs were
only 11%. The most commonly
prescribed were antimicrobials and analgesics which constitute nearly 31% of
the total FDCs prescribed.
In 52% of the prescriptions, the prescribed FDCs contained ingredients which
were not essential for the
desired therapeutic effect.
Conclusion: 80% of the FDCs prescribed did not conform to the
recommended WHO list. However, the
use of certain FDCs were highly justified and rational.

Irrational drug use in India: A prescription survey from Goa ^22

BACKGROUND: There is concern regarding the irrational production,
prescription and use of drugs in India. This study aimed to describe the quality
of prescriptions by medical practitioners, including both the layout of the
prescription and the type and number of drugs prescribed. MATERIALS AND
METHODS: A survey of all prescriptions dispensed at a busy pharmacy in the
state of Goa, India, was carried out over a consecutive seven-day period.
Each prescription was rated on the basis of a priori and pilot-tested variable
list. The prescriptions by private practitioners were compared with those from
practitioners in the public healthcare system. RESULTS: Nine hundred and
ninety prescriptions were collected. The majority (83.9%) were from private
practitioners. The quality of the layout of the prescriptions was unsatisfactory:
information to identify the practitioner was incomplete in more than a third of
the prescriptions and information to identify the patient was incomplete in
more than half. Clarity of written instructions on how to take the medicines
was unsatisfactory in the majority of prescriptions. Polypharmacy was the
norm, with more than half (52.7%) the prescriptions containing at least 3

2. Literature Review
medicines. Forty per cent of prescriptions included a vitamin or tonic
preparation and a quarter of the prescriptions included an antibiotic and an
analgesic. Over 90% of prescriptions contained only branded medicines.
Private practitioners prescribed significantly greater number of medicines and
were more likely to prescribe vitamins and antibiotics, and branded medicines.
DISCUSSION: This study confirms that the quality of prescriptions, both in
terms of layout and the content of the drugs prescribed, is inadequate. There
is a need to standardize the format of prescriptions in India so that all
essential information is included. There is a need to strengthen an
independent mechanism for continuing professional development of
practitioners to ensure that patients are always given evidence-based, cost-
effective treatments.

Prescribing Behaviour of Physicians ^23

To improve drug-use-related problems appropriately, demonstration of the
inappropriate use of drugs alone is not sufficient. Data on its causation and
suitable interventions are essential. Hence, a prospective randomised
controlled study was conducted with the objective to identify drug-use-related
problems in acute upper respiratory infections and non-specific acute diarrhea
with a special focus on use of antibiotics in 32 dispensaries and seven colony
(15-bedded) hospitals in Delhi. An educational intervention in the form of small
group discussions was introduced in the study group to improve the
appropriate use of antibiotics. The control group did not participate in the small
group discussions. The principal finding of the qualitative assessment was that
the prescriber's knowledge of anti biotic use and risks was generally sufficient,
yet they overused antibiotics. The reasons or underlying factors encouraging
the use of antibiotics in ARI and non- rehydration therapy (antidiarrhoeals,
antibiotics, antiamoebics) and hindering the use of oral rehydration therapy in
diarrhoea were worries regarding precise aetiology, to prevent secondary
infections, the deterioration of the patient's con dition, to meet the demand of
patients and the fear of losing patients. The aver age number of drugs
prescribed in ARI reduced significantly in both the groups (control group
2.82±0.88 vs. 2.63±0.58; study group 2.72±0.38 vs. 2.54±0.38) following
intervention (p < 0.001). There was a significant reduction in the use of
antibiotics in ARI in the study group from 64.86 to 51.30 per cent after inter
vention (p < 0.003). There was no change (60.5 vs. 63.9 per cent) in the
control group in ARI. In diarrhoea too the average number of drugs prescribed
reduced significantly (p < 0.0001) in both the groups (study group 2.25±0.59
vs. 2.27±0.77; control group 2.31±1.76 vs. 2.76±0.73). Antibiotic use declined
significantly in all health facilities in both the study groups (intervention group
82.1 per cent vs. 68.90 per cent; control group 80.3 vs. 62.3 per cent). In

2. Literature Review
diarrhoea all the health facilities in the study group fell in the category of 50 to
80 per cent or more antibiotic use before intervention. About 75 per cent of the
drugs were prescribed by generic names and more than 90 per cent were
from the essential drugs list.

The results of the study show that though antibiotic use declined after inter
vention, there is a need for such interventions regularly to bring about long-
lasting changes in prescribing behaviour.


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