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A Point Prevalence Survey of Antimicrobial Prescribing in a South Indian Tertiary Hospital; Using Global PPS Tool

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Identifying the targets for improving antimicrobial prescription and development of antimicrobial stewardship interventions can better serve to combat the situation of antimicrobial resistance. The primary objective was to determine the prevalence of antimicrobial use at tertiary care teaching hospital with both acute and long-term care patients. A periodical point prevalence survey was done in a tertiary care hospital of South India during 2019 using manual and web-based GLOBAL-PPS tool. Of 945 patients eligible for the study, 645 (69.5 %) received at least one antibiotic, with highest rates in the adult surgical ward and pediatrics. Of 645 therapeutic antibiotic prescriptions, 58.6% prescriptions have an infectious indication of them, 62.6% are community-acquired infections. Third-generation cephalosporins were the most prescribed antibiotics. The prevalence of antibiotic use is very high, and our study evidence that the country needs a robust antimicrobial stewardship intervention program.
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*Author for correspondence
Asian Journal of Pharmaceutical Research and Health Care, Vol 13(1), 1-9, 2021
ISSN (Online) : 2250-1460
DOI: 10.18311/ajprhc/2021/26368
Abstract
Identifying the targets for improving antimicrobial prescription and development of antimicrobial stewardship
interventions can better serve to combat the situation of antimicrobial resistance. The primary objective was to determine
the prevalence of antimicrobial use at tertiary care teaching hospital with both acute and long-term care patients. A
periodical point prevalence survey was done in a tertiary care hospital of South India during 2019 using manual and web-
based GLOBAL-PPS tool. Of 945 patients eligible for the study, 645 (69.5 %) received at least one antibiotic, with highest
rates in the adult surgical ward and pediatrics. Of 645 therapeutic antibiotic prescriptions, 58.6% prescriptions have an
infectious indication of them, 62.6% are community-acquired infections. Third-generation cephalosporins were the most
prescribed antibiotics. The prevalence of antibiotic use is very high, and our study evidence that the country needs a robust
antimicrobial stewardship intervention program.
A Point Prevalence Survey of Antimicrobial
Prescribing in a South Indian Tertiary
Hospital; Using Global PPS Tool
Vineela Chadalavada1, Manohar Babu S.2 and Balamurugan K.1*
1Department of Pharmacy, Annamalai University, Annamalai Nagar, Chidambaram - 608002,
Tamil Nadu, India; vineelach99@gmail.com, placementbala@yahoo.co.in
2Deparment of Pharmacy, Sims College of Pharmacy, Mangaldas Nagar, Guntur - 522001, India
1. Introduction
Antimicrobial drugs have revolutionized the treatment
of infectious diseases, becoming the cornerstone of
therapy for infectious diseases to reduce morbidity and
mortality1. However, there is increasing Antimicrobial
Resistance (AMR) as a result of their overuse, which has
become a serious problem worldwide2. India is the world’s
largest consumer of antibiotics for human health, which
was reported 12.9 x 109 units (10.7 units per person)
in 20103. e Indian Government has issued a National
Policy for Containment of Antimicrobial Resistance
(AMR) to promote surveillance on antimicrobial use in
the community and hospitals settings across the country.
Data about the quantity and quality of antimicrobial
prescribing constitute the cornerstone for guiding
Keywords: Antimicrobial Prescribing, Antimicrobial Resistance, Antimicrobial Stewardship, GLOBAL-PPS, India
antimicrobial stewardship (ASP’s) interventions4. India
has implemented certain measures to control irrational
antimicrobial use; “red strip labelling of antimicrobial
packages” which indicates the drug should not be
dispensed without a legal prescription5.
Antimicrobial consumption data of 65 countries
presented in the WHO report for 2015-18, found wide
discrepancies in consumption rates between countries.
However, no countries from south-east Asia, including
India, have submitted their report while eorts are
initiated and ongoing in such countries with the national
surveillance programs. Initial reports from India stated
a very high level of consumption of third-generation
cephalosporins in all its states. e WHO reported India
as one of the countries for high irrational antimicrobial
A Point Prevalence Survey of Antimicrobial Prescribing in a South Indian Tertiary Hospital; Using Global PPS Tool
Asian Journal of Pharmaceutical Research and Health Care
2Vol 13 (1) | 2021 | www.informaticsjournals.org/index.php/ajprhc
use and inadequate surveillance and high rates of drug
resistance6.
Point Prevalence Survey (PPS) in a structured
qualitative assessment of Antimicrobial consumption at a
given point of time. It is a feasible method to access data
on antimicrobial use and helps to target improvement
in the quality of antimicrobial prescribing and establish
interventions for better ASH. Periodical PPS serve better
ASH and assist in the ght against AMR7. PPS is a based
stewardship tool in a few developed countries, but in other
countries across the globe, clinicians have just begun to
understand and explore how to use it7 - 8. In India, very few
Point prevalent surveys of antibiotic use were reported,
and most of them are registered in pediatrics7 - 12. To our
knowledge; our present study is probably the rst from
Andhra Pradesh state of South India. e data gives an
insight into the pattern of antimicrobial use and help in
improvements.
2. Materials and Methods
2.1 Study Settings and Design
Global PPS method was adopted for the present point
prevalence survey on antibiotic use at a tertiary care
hospital. Point prevalence study (PPS) carried out
periodically during January, May, August and December
2019 in a tertiary care hospital from Andhra Pradesh
state of South India. It is a private multispecialty hospital
(300 beds) located in the of Vijayawada, Andhra Pradesh
province in South India. e present PPS study was
designed and conducted using a structured web-based
Global-PPS tool. e study tools were prepared based on
point prevalence survey methodology on antibiotic use in
hospitals from WHO- version 1.1 as a reference tool13, 14.
e Institutional ethical committee at Andhra
Hospitals initially approved the study proposal. e study
is a non-experimental surveillance study with minimal
risk; however, written informed consent was obtained
from the patient or legal guardian under International
Conference on Harmonization-Good Clinical Practice
(ICH GCP) guidelines.
2.2 Inclusion and Exclusion Criteria
In the hospital, all the in-patients admitted at 8 am
receiving at least one antimicrobial, for at least one
clinical condition, prophylaxis on the day of the survey
was included for the study. A patient receiving an
antibiotic, e.g., every 48 hours but not receiving this
antibiotic on the survey day was considered ongoing
antimicrobial treatment. New-born healthy children on
a maternity ward receiving antibiotics were encoded as
a Neonatal Medical Ward (NMW) and included in the
study. Surgical ward was surveyed on the day following
the day when most elective surgical interventions usually
take place or have been planned. Data was not collected
from the out patients, patients discharged before 8 oclock
and admitted with intervention aer that study time are
excluded from the study.
2.3 Sample Size
e estimated sample size necessary for the study was
obtained using sample size calculator as 377, where ‘p’
was assumed to be 50%, allowable error ‘e’ was 5% and ‘z’
being the standard normal deviate with a value of 1.9615.
To conduct any drug utilization studies, a sample size of
at least 100 subjects was suggested by the world health
organization (WHO)16. However in our study, a sample
size of 645 was evaluated to obtain the outcomes.
2.4 Data Collection
Data of antibiotic use patterns were collected from the
hospital on a single day following the ESAC and Global-
PPS audit tool guidelines, also known as PPS tool17.
A well-structured data collection forms and
denitions of various variables are available at Global-
PPS website; ward data collection form and patient
data collection form were primarily used for the survey
Antimicrobials were classied using the World Health
Organization’s (WHO) Anatomic erapeutic Chemical
(ATC) classication16. e ATC groups included as
antimicrobial are J01 (Antibacterial for systemic use),
J02 (Antimitotics), J04A (Anti-tubercular drugs),
A07AA (Antibiotics for intestinal infections), D01BA
(Antifungals), J05 (Antiviral’s), P01AB (Antiprotozoals)
and P01B (antimalarials).
Additional quality indicators included; the
documented indication before the initiation of treatment;
the compliance of prescription to the standard guidelines
on antibiotic selection; if a stop or review information
entered in the notes; prophylaxis, empiric or targeted
treatment (based on microbiological data); the use of a
biomarker of infection (e.g., C reactive protein) to inform
antibiotic treatment was noted. Further information
Vineela Chadalavada, Manohar Babu S. and Balamurugan K
Asian Journal of Pharmaceutical Research and Health Care 3
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on the denitions used in the Global-PPS protocol is
available online17.
In the rst three months, the data from data collection
forms were veried before entering into a validation
form. Analysis of data was performed using SPSS version
16.0 soware. In the month of December, our hospital got
registered in Global-PPS web-based application system,
where the present participating hospital data is being
freely entered. e Global –PPS website team performed
statistical analysis for the month of December and
generated a report on complete antimicrobial use at our
hospital during the respective period. e data from this
report was pooled and utilized for further analysis.
3. Results
Out of 945 patients admitted with various indications
in the hospital during survey days, 645 (69.5%) received
at least one antibiotic on the day of PPS. e highest
antimicrobial use was evident in the adult surgical ward
(78.8%) pediatric (61.1%) and neonatal medical wards
(64%) (Table 1).
Of 645 therapeutic antibiotic prescriptions, 378
(58.6%) prescriptions have an infectious indication of
them, 237 (62.6%) are community-acquired infections,
and 37.3% are hospital-acquired infections while 267
(41.4%) prescriptions were issued for medical (28.4%),
surgical (67.4%) prophylaxis and 4.1% targeted therapy.
Among the top ten diagnoses for which antibiotics
were prescribed gastrointestinal infections (26.9%)
and bacteremia (23.5%) account for the highest rate.
According to the ATC classication system, antibacterial
for systemic use (J01) accounted for 82.3% (Table 2).
Table 1. Overall antimicrobial prevalence
Total (N) Treated patients
(%)
No. of hospitalised
patients 945 645 (69.5)
Antimicrobial prevalence in the medical wards
AMW = Adult
Medical Wards 455 330 (72.5)
P−AMW =
Pneumology AMW 40 40 (100)
ASW = Adult Surgical
Ward 180 142 (78.8)
AICU = Adult
Intensive Care Unit 130 40 (30.7)
PMW = Pediatric
Medical Ward 90 55 (61.1)
NICU = Neonatal
Intensive Care Unit 50 50 (100)
* Patients (N) = number of admitted adults.
Treated patients (%) = 100*(number of adults treated with at
least one antimicrobial/number of admitted adults).
Table 2. General characteristics and antibiotic
prescription patterns of patients surveyed
Indications for antimicrobial prescription
N=645 No. Of patients Percentage (%)
Infections
(n=378) (58.6%)
Community-
acquired infection
237 62.6
Hospital-acquired
infection
141 37.3
Prophylaxis
(n=267) (41.4%)
Surgical
prophylaxis
180 67.4
Medical
Prophylaxis
76 28.4
Targeted therapy 11 4.1
Top Infection for which antibiotics are prescribed n=378
Bacteremia 89 23.5
Gastro−intestinal
infections
102 26.9
Infection of central
nervous system
18 4.7
Intra−abdominal
sepsis
31 8.2
Pyrexia of
unknown origin
52 13.7
Bone/joint
infections
36 9.5
Fever neutropaenic
patient
16 4.2
Pneumonia 21 5.5
Other 13 3.4
Antimicrobial
prescription
patterns
Parenteral therapy 531 82.3
Multiple ATB
diagnosis
237 36.8
A Point Prevalence Survey of Antimicrobial Prescribing in a South Indian Tertiary Hospital; Using Global PPS Tool
Asian Journal of Pharmaceutical Research and Health Care
4Vol 13 (1) | 2021 | www.informaticsjournals.org/index.php/ajprhc
ird-generation cephalosporins (26.2%) were the
most commonly prescribed antibiotic groups, followed by
penicillins (13.5%), quinolones (9.8%). (Table 3, Figure
1). e distribution of various classes of antibiotics in
medical, surgical, ICU and pediatric units, was depicted
in (Figure 2). Among the dierent antimicrobial agents
prescribed for systemic use (J01 ATC), the overall
most frequently prescribed antibiotics were ceriaxone
(28.4%), meropenem (7.8%), Amikacin (7%) and
pipercillin with a beta-lactamase inhibitor (6.5%) and
levooxacin (11.7%); these ve antibiotics accounted
for 396 (61.4%) prescriptions (Table 4) (Figure 3).
Antimicrobial quality indicators presented in the hospital
Multiple ATB
patient
364 56.4
* Multiple ATB diagnosis is dened as receiving > 1 antibiotic
(J01) for a single identied reason to treat (=diagnose code) at
patient level.
Multiple ATB patients are dened as receiving > 1 antibiotic
(J01) at patient level.
Table 3. Overall proportion of antimicrobial agents prescribed
Total (%) N=645 Medical (%) Surgical (%) ICU/ (%) Paediatric /
NICU (%)
Tetracyclines (J01AA) 4 3.1 0 0.9 0
Penicillins 13.5 6.6 0 2.4 4.5
J01C 6.3 3.8 0 0.9 1.6
J01CR 6.5 2.1 0 1.5 2.9
Other beta−lactams 42.2
J01DB 0 0 0 0 0
J01DC 1.8 1.8 0 0 0
J01DD 26.2 15.2 3.2 4.4 3.4
J01DF 0.9 0.9 0 0 0
J01DH 8.2 3.2 0 3.2 1.8
J01FA 5.1 2.1 1.3 1.1 0.6
J01GB 72.4 0 1.3 3.3
J01MA 9.8 5.4 2 0.3 2.1
P01CA 5.2 3 0 1.8 0.4
Others 5.5 2.3 0.2 0 1.2
Tetracyclines (J01AA), Penicillins with extended spectrum (J01CA), Combinations of penicillins, incl. beta−lactamase inhibitors
(J01CR), Second−generation cephalosporins (J01DC), ird−generation cephalosporins (J01DD), Fourth−generation cephalosporins
(J01DF), Carbapenems (J01DH), Macrolides (J01FA), Lincosamides (J01FF), Aminoglycosides (J01GB), Quinolones (J01MA),
Nitroimidazole Derivatives (P01CA)
are shown in the (Table 5). e reason for antimicrobial
use recorded for 89% medical, 100% surgical and 74.4%
ICU prescriptions. e stop/review date was entered for
only 26 % medical and 12% surgical prescriptions. While,
43% medical, 44% surgical, 26% of ICU prescriptions
are found in compliance with the hospital antimicrobial
guidelines (Table 5).
4. Discussion
e present study is probably the rst study describing
antimicrobial use in Andhra Pradesh state in India
using a point prevalence survey (Global-PPS). A PPS
served as an inexpensive, convenient antimicrobial
consumption surveillance system. e number of patients
increased over time, as did the proportion treated with
an antimicrobial18. Such a trend is a challenge to the
hospitals surveyed and indicates that growing eorts are
needed from hospital sta. ere is no debate that the rate
of antimicrobial prescribing in India is high compared to
Vineela Chadalavada, Manohar Babu S. and Balamurugan K
Asian Journal of Pharmaceutical Research and Health Care 5
Vol 13 (1) | 2021 | www.informaticsjournals.org/index.php/ajprhc
Figure 1. Portion of antibiotic use in the study settings.
Tetracyclines (J01AA), Penicillins with extended spectrum
(J01CA), Combinations of penicillins, incl. beta−lactamase
inhibitors (J01CR), Second−generation cephalosporins
(J01DC), ird−generation cephalosporins (J01DD),
Fourth−generation cephalosporins (J01DF), Carbapenems
(J01DH), Macrolides (J01FA), Lincosamides (J01FF),
Aminoglycosides (J01GB), Quinolones (J01MA), Nitroi
midazole Derivatives (P01CA)
Figure 2. Antimicrobials prescribed by classication.
Figure 3. Top 5 most frequently used prescribed antibiotics
in adults and children.
many other countries, which is a concern that requires
addressing urgently.
We report a higher rate of antimicrobial use (62.6%)
similar to few studies from India 51.6% & 61.5% &
64.74%7, 9 - 10. PPS studies from various countries reported
antimicrobial use; French (32.2%), Sweden (33.3%), turkey
(30.6%), Jordan (46.2%), Belgian (27.1%), Brazil (52.2%),
Nigeria (69.7%), Switzerland (33%) Canada (65%), Egypt
(59%), Saudi (46.9%) and China (56%)19 - 30. However, this
overall prevalence masks important regional dierences:
2017 data showed that among 68 hospitals in East and
South Asia the prevalence of antimicrobial use was 48.2%,
compared with 29.6% in 106 European hospitals. ere
have been few previous studies in India. However, our
data are comparable to a study in Eastern India, which
reported antimicrobial use prevalence of 62% in 2014 and
69.1% in 20178. From (gure 2), the highest prevalence
of antibiotic use in the present study was in surgical and
pediatrics while it was in Gynecology ward reported in a
similar study done at south India7.
In our study, a signicant portion of antibiotics was
mostly used for the treatment of community-acquired
infections (62.6%), and these results are similar to studies
in Nigeria and Sweden and to two other studies conducted
in India, which reports community acquired infections
(CAI) as an indication with the highest prevalence of
antimicrobial use7, 12. e clinical sign documented for
the treatment with antimicrobials is vital to evaluate
compliance with national antimicrobial treatment guide
lines (ICMR Guidelines).
On reviewing empirical antimicrobial therapies with
CAI, the two most common antimicrobials were third
generation cephalosporins (26.2%) (Table 3) which is
similar to two other Indian studies7, 11. e similar wide use
of cephalosporins was reported in Turkey, Jordan, Brazil,
Nigeria and Saudi. However, in European countries,
wide use of Fluoroquinolones in French and Belgian,
Amoxicillin/Clavulanic acid combination in Northern
Ireland and Switzerland were reported18 - 29. Guidelines
recommend the use of third-generation Cephalosporins
only when rst-line agents are ineective31. Hence this
study identied an opportunity to improve antimicrobial
use by prescribing rst-line drugs for hospitalized CAI
patients.
Some poor-prescribing practices such as indications
for the therapy and low documentation rate of stop or
review dates to guide the scheduled antimicrobial therapy
may result in healthcare sta administering medication
A Point Prevalence Survey of Antimicrobial Prescribing in a South Indian Tertiary Hospital; Using Global PPS Tool
Asian Journal of Pharmaceutical Research and Health Care
6Vol 13 (1) | 2021 | www.informaticsjournals.org/index.php/ajprhc
5. Conclusion
is study indicated a high rate of antibiotic prescription
with increased usage of third-generation Cephalosporins.
ese ndings suggest critical areas for interventions and
propose implementation of antimicrobial stewardship
policies in the present study hospital. e current survey
was in a singles institute, and we further suggest such
periodical surveys in multiple institutions across the state
for the development of strong antibiotic policies. Our
study evidence the country needs strong antimicrobial
stewardship intervention program.
6. Conicts of Interests
No reported conicts to declare.
7. Funding
No nancial support was received by any of the authors
for conducting this survey.
for the inappropriate duration (Table 5). e condition
might be due to lack of quality-assured procedures and
guidelines32. Surprisingly, the majority of prescriptions
comply with the hospital prescribing guidelines. In
the present study settings, an antimicrobial policy was
structured and made practiced at the hospital by a clinical
pharmacist is much appreciable. Besides, a very high rate
of parenteral use of antimicrobials was reported, contrary
to the advocated practices in antimicrobial stewardship
program. ere was no utilization of biomarkers across
the study hospital because they are novel and expensive.
However, they are a viable adjunct to guide therapy in
select patients such as those in whom sepsis is suspected.
Some limitations should be acknowledged. As this was
a point prevalence survey, patients were not followed-up
in time. is study only shows a snapshot of the situation
and shallow sample size; therefore, they are not ideal
for measuring, for example, Antimicrobial use (AMR).
Good outcomes with antimicrobials (i.e., appropriate
antimicrobial prescribing and reduction of resistance
to antimicrobials) require the use of antimicrobial
stewardship approaches and completion of PPS at regular
intervals.
Table 4. Top 5 most frequently used prescribed antibiotics in adults and children
Antibiotic Medical (%)
N=330
Surgical (%)
N=180
ICU/ (%)
N=130
Paedi
atric / NICU (%)
N=140
Total
Levooxacin 5.7 0 3.4 2.6 11.7%
Meropenem 12.5 0 1.6 0 7.8 %
Amoxicillin and Clavulanic acid 3.2 0 0 3.3 6.5
Ceria
xone 16.3 3.6 8.5 0 28.4%
Amikacin 5.6 0 0 1.4 7%
Table 5. Quality indicators of antibiotic prescribing
Indicator Medical (%) Surgical (%) ICU (%)
Indication for treatment was recorded Yes 89 100 74.4
Compliance with the hospital guidelines
Compliant 43 44 26
Not compliant 20 26 19
Not-assessable 21 18 13
No information 16 12 42
Stop/review date documented Yes 26 64 0
Targeted therapy Yes 11 0 0
Biomarkers Yes 0 0 0
Vineela Chadalavada, Manohar Babu S. and Balamurugan K
Asian Journal of Pharmaceutical Research and Health Care 7
Vol 13 (1) | 2021 | www.informaticsjournals.org/index.php/ajprhc
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BackgroundA point prevalence survey (PPS) on healthcare-associated infections (HAI) and antimicrobial use was conducted in Swiss acute care hospitals in 2017.AimOur objective was to assess antimicrobial use in Swiss acute care hospitals.Methods All patients hospitalised in any acute care hospital in Switzerland were eligible. We used the most recent version of the PPS protocol of the European Centre for Disease Prevention and Control.ResultsData from 12,931 patients of 96 hospitals were collected. Of these, 4,265 (33%; 95% confidence interval (CI): 32.2-33.8) were on 5,354 antimicrobials for 4,487 indications. Most of the 2,808 therapeutic indications addressed 1,886 community-acquired infections (67.2%; 95% CI: 65.4-68.9). Of the 1,176 surgical prophylaxes, 350 (29.8%; 95% CI: 27.1-32.4) exceeded the duration of 1 day. Of the 1,090 antimicrobial regimens that were changed, 309 (28.3%; 95% CI: 25.7-31.0) were escalated and 337 (30.9%; 95% CI: 28.2-33.7) were de-escalated. Amoxicillin/clavulanic acid was the most frequent antimicrobial (18.8%; 95% CI: 17.7-19.8), prescribed mainly for therapeutic indications (76.0%; 95% CI: 73.3-78.7). A total of 1,931 (37.4%; 95% CI: 36.1-38.8) of the 5,158 antimicrobials for systemic use were broad-spectrum antibiotics, most frequently third- and fourth-generation cephalosporins (35.9%; 95% CI: 33.8-38.1).Conclusions Antimicrobial consumption was at European average, the use of broad-spectrum antibiotics in the lower third. Swiss acute care hospitals should invest in antimicrobial stewardship, particularly in reducing the use of broad-spectrum antibiotics.