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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 72-76  

Pharmacoepidemiological observational study of antimicrobial use in outpatients of ophthalmology department in North Indian population


1 Department of Ophthalmology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
2 Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida, U.P, India
3 Department of Pharmacology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
4 Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India

Date of Web Publication4-Jun-2018

Correspondence Address:
Dr. Deepti Chopra
Associate Professor, Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida, U.P
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JPBS.JPBS_255_17

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   Abstract 

Background: Recognition of drug usage patterns provides the basis for improving safety and plummeting risks associated with their use. Thus, this study was undertaken to explore the drug usage pattern in ophthalmology with an emphasis on antimicrobial use at a tertiary care teaching hospital. Materials and Methods: An observational study was conducted in the Department of Ophthalmology, Hakeem Abdul Hameed Centenary Hospital, Jamia Hamdard, New Delhi, India for 9 months. Newly registered patients visiting the Outpatient Department for curative complaints were included. All drugs prescribed were recorded, including dose, route, dosage form, frequency of administration, indications for prescription, and duration of therapy, and the data was audited using the indicators prescribed by the World Health Organization. Result: A total of 600 prescriptions were analyzed. The number of drugs prescribed was 1097 with an average drug per prescription being 1.8. The most common disorders diagnosed were infective conjunctivitis (21.5%) followed by stye (5.5%). Drugs were prescribed in different dosage forms with eye drops (72.6%) being the most common. Drugs were predominantly prescribed by brand name (100%). Antimicrobials (44.7%) were the most commonly prescribed drugs followed by lubricants (17.5%). Moxifloxacin (53.5%) was the most commonly prescribed antimicrobial agent. Of the antimicrobials prescribed, 89.6% were prescribed topically. Average total cost per prescription was 113 INR. Conclusion: The study concludes with an overall impression of rational prescription in terms of prescribing in consensus with the recommended treatment protocol of ocular diseases. Nevertheless, health-care professionals should be encouraged to prescribe by generic name. Creating awareness regarding selection of drugs from essential drug list to reduce the drug cost is the need of the hour. Last but not least, updating knowledge regarding appropriate antimicrobial use and the development of discreet strategies for their use should be implemented to steer clear of antimicrobial resistance.

Keywords: Antimicrobial, drug usage, prescribing indicators, rational prescription


How to cite this article:
Kauser H, Chopra D, Mukherjee S, Mohan P. Pharmacoepidemiological observational study of antimicrobial use in outpatients of ophthalmology department in North Indian population. J Pharm Bioall Sci 2018;10:72-6

How to cite this URL:
Kauser H, Chopra D, Mukherjee S, Mohan P. Pharmacoepidemiological observational study of antimicrobial use in outpatients of ophthalmology department in North Indian population. J Pharm Bioall Sci [serial online] 2018 [cited 2018 Oct 22];10:72-6. Available from: http://www.jpbsonline.org/text.asp?2018/10/2/72/233707




   Introduction Top


Medical care costs and concerns regarding benefits and risks associated with drug use have shown a tremendous increase, making periodical identification of drug usage pattern extremely important.

The ultimate goal of drug utilization research is to assess whether drug therapy is rational or not and to bestow insight into the efficiency of drug use.[1] The results of these studies can be used to lay down priorities for the rational distribution of health-care funds.[1] Antimicrobial resistance is a serious menace as a result of new resistance mechanisms that are emerging and spreading worldwide.[2] Emergence of antimicrobial resistance has posed a great challenge in health care as infections with resistant organisms are intricate to treat, requiring costly alternatives. In economic terms, expenditures on antimicrobials are increasing every year. Evidence shows that in the United States, the annual impact of resistant infections is estimated to be $20 billion in excess to direct health-care costs.[3] To add to the misery, the misuse and overzealous use of antimicrobials for diseases that do not require antimicrobial therapy is speeding up this process of resistance.[2]

In the field of ophthalmology, antimicrobial use is mostly prophylactic, as physicians often do not have data from culture analysis.[4] In ophthalmic setting, often physicians lack awareness in regard to the fluctuating trends in antimicrobial resistance of many common pathogens; thus, if antimicrobials are not used appropriately, they can contribute to the emerging antimicrobial resistance problem. The point of concern is that the antimicrobial overuse can lead to resistance among ocular surface flora; infections then can become difficult to treat, which will increase the chances of severe ocular damage and vision loss.[4]

It is evident from the literature that the spectrum and diversity of ocular pathogens have not changed significantly.[5] Despite the fact that topically applied antibiotics does yield higher drug concentrations in ocular tissues, there are increasing reports of clinical failure pointing toward declining efficacy of antimicrobial agents, further emphasizing the need of antibiotic stewardship for ocular as well as nonocular infections.[5],[6]

Pharmacoepidemiology is the study of the uses and effects of drugs in well-defined populations. The study may be drug oriented, emphasizing the safety and effectiveness of individual drugs or groups of drugs, or utilization oriented, aiming to improve the quality of drug therapy through pedagogic (educational) intervention. That is the reason why drug utilization research has become an essential part of pharmacoepidemiology, and together they provide insights into various aspects of drug prescribing and drug use such as pattern of use, quality of use, determinants of use, and outcomes of use.[1]

Therefore, this study was undertaken with the aim to evaluate the prescribing practices of ophthalmologists with an emphasis on the antimicrobial utilization and to determine the cost of each prescription in the Outpatient Department (OPD) of a teaching hospital in Delhi, India.


   Materials and Methods Top


An open-label, cross-sectional, observational study was conducted in the Department of Ophthalmology in collaboration with the Department of Pharmacology, Hakeem Abdul Hameed Centenary Hospital, Jamia Hamdard, New Delhi, India. The study was undertaken after obtaining approval from the College Research Project Advisory Committee. The data were collected prospectively, visiting the OPD from 9 AM to 1 PM, twice a week, that is, every Monday and Thursday during the study period from March 2016 to November 2016. Newly registered patients of either sex who visited the Ophthalmology OPD for curative complaints were included to avoid repetition of drugs and disease during the study period.

Cases of refractive errors, cataract, postoperative follow-ups, any diagnostic test/procedure, and patients not willing to give informed consent were excluded from the study. All drugs prescribed were recorded, including dose, route, dosage form, frequency of administration, indications for prescription, and duration of therapy, and the data were audited using the indicators of drug use recommended by the World Health Organization.[1] Data analysis was carried out using the descriptive statistical methods including frequencies and percentage. Each prescription was studied for the assessment of above-mentioned variables, and the cost incurred per prescription was calculated by considering individual cost of each drug from the 2017 issue of Drug Today—India, the drug book of current medical formulations. The cost incurred per prescription to the patient to procure the drugs therein relates only to the expected cost of the drugs available in the 2017 issue of Drug Today—India. However, no attempt has been made to verify the actual cost of the medicaments in the market.


   Results Top


A total of 600 prescriptions were analyzed, among them 316 (52.7%) were for male patients and 284 (47.3%) for female. The total number of drugs prescribed in these prescriptions amounted to 1097. The number of drugs per prescription varied from 1 to 6, with an average number of drugs per prescription being 1.8. Drugs were predominantly (95%) prescribed in brand name.

The most common disorders diagnosed were infective conjunctivitis (129 [21.5%]) followed by stye (33 [5.5%]), and allergic conjunctivitis (32 [5.3%]). Phlycten, congenital dacryocystitis, episcleritis, spring catarrh, foreign body removal, iridocyclitis, dry eye, glaucoma, lid abscess, chalazion, choroiditis, blepharitis, filamentary keratitis, nummular keratitis, viral ulcers,  Meibomitis More Details, stromal keratitis, corneal abrasions, acute dacryocystitis, corneal edema, viral dendritic ulcer, trauma, preseptal cellulitis, lacrimal abscess, dacryoadenitis, corneal facet, retinal vein occlusion, pterygium, uveitis, pinguecula, bilateral concretion, and exophoria contributed in minor numbers.

The dosage form was mentioned in 100% of the prescriptions. The frequency of drug administration was recorded in 100%, whereas the duration of treatment was mentioned in 90% of the prescriptions. A total of 40% of drugs were prescribed from the National Essential Drug List (NEDL)/National Formulary of India (NFI).

The drugs were prescribed in different dosage forms with eye drops (72.6%) being the most common of all dosage forms followed by ointments (14.2%), tablets (12.4%), syrups (0.4%), injections (0.3%), and sprays (0.2%).

Among the drugs, antimicrobials (490 [44.7%]) were the most commonly prescribed drugs followed by lubricants (192 [17.5%]), steroids (180 [16.4%]), nasal decongestants (50 [4.5%]), anti-inflammatory and analgesics (41 [3.7%]), anti-allergic (40 [3.6%]), mydriatic and miotics (40 [3.6%]), prebiotic/vitamin C/rebamipide (35 [3.2%]), antiglaucoma medications (17 [1.5%]), and proton pump inhibitors (12 [1.1%]) [Figure 1].
Figure 1: Different types of drugs prescribed

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In 389 (64.8%) of the prescriptions, antimicrobials were prescribed. Moxifloxacin (262 [53.5%]) was the most commonly prescribed antimicrobial followed by tobramycin (79 [16.1%]) [Table 1]. The antibacterials were commonly prescribed for infective conjunctivitis (33.2%), stye (8.5%), dacryocystitis (7.2%), foreign body removal (4.4%), lid abscess (3.1%), chalazion (2.6%), blepharitis (2.3%), meibomitis (1%), corneal abrasion, dacryoadenitis, lacrimal abscess, trauma, preseptal cellulitis, and lid granuloma. Antivirals were prescribed commonly for condition including nummular keratitis, viral ulcers, stromal keratitis, dendritic ulcers, and punctuate keratitis.
Table 1: Percentage of antimicrobials prescribed

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Majority (89.6%) of the antimicrobials were prescribed topically as eye drops and ointments. Eighty three (16.9%) were prescribed as fixed-dose combination with glucocorticoids.

The average cost per prescription was found to be around 113 INR for OPD patients only, and all the drugs in the prescription were supposedly procured by patients themselves.


   Discussion Top


Without understanding how drugs are being prescribed, it is not possible to remark on rational drug use or propose actions to improve prescribing habits. Thus, collecting information on prescribing patterns is the key player of any auditing system.[7]

Pharmacoepidemiology can act as a powerful gadget to promote public health by providing insight into various aspects of drug prescribing and drug usage. It can keep check and improve performance from time to time.[8]

As the average number of drugs per prescription is an important criterion for auditing prescriptions, it is recommended that the number of drugs per prescription should be limited to two.[9] Furthermore, a near linear relationship has been observed between the presence of drug-related problems and the number of drugs used.[10] In this study, an average number of drugs prescribed per encounter, that is, drugs prescribed per consultation was 1.8, which is similar to other studies reported from India.[11],[12],[13],[14] Few studies have reported higher values; in the study by Biswas et al.,[15] the average number of drugs was 3, whereas Gangwar et al. reported 2.7.[8] In this study, only 25% of the prescription had three or more drugs, which is similar to that reported by some authors[8] and is low as compared to various other studies.[15],[16]

In this study, prescriptions with generic name were just 5%, which is almost similar to that reported by Jadhav et al.,[11] and higher than what Maniyar et al.[12] studied, where barely 1% of the prescription generic names of the drugs were mentioned. Various other studies have also reported a lower rate of prescribing using generic name ranging from 25% to 40%, and this finding suggests the popularity of brand names.[8],[15],[16]

A 10% deficiency observed in mentioning the duration of treatment can be attributed to the fact that each patient is advised to come for review after a period of 7 days; hence, no drug can be purchased or continued for more than a week. However, it is prudent to encourage the ophthalmologists to mention the same and contribute to the completeness of prescription.

When the various dosage forms were compared, it was found that eye drops were commonly prescribed in OPD followed by ointments. This is in concordance with other studies.[8],[16] Biswas et al.[15] reported eye drops to be the most common dosage form followed by tablets.

Infective conjunctivitis was the most common ocular morbidity in this study. The dusty nature of the weather during March and April, humidity during monsoon, and poor sanitation may be responsible for the high occurrence. Other studies from India have also reported conjunctivitis as the most common disease encountered in Ophthalmology OPD.[11],[13]

Acute conjunctivitis is among the most common ocular conditions affecting six million persons in the United States each year.[17],[18] Literature shows nearly 70% of all patients with acute conjunctivitis present to primary care and emergency care department.[19] More than 60% of the patients with acute conjunctivitis are of viral origin, whereas bacterial infections contribute to much smaller part of acute conjunctivitis.[18] Acute conjunctivitis is often self-limiting, thus most patients with this condition do not require antibiotic therapy.[20] In concordance with the recommendations of the American Academy of Ophthalmology (2013), immediate antibiotic therapy was deferred when the cause of conjunctivitis was unknown.[18],[21]

Antimicrobials remained the most commonly prescribed drugs in this study, as has been reported by other hospital-based studies in ophthalmology in India.[8],[11],[12],[13],[14],[16] Among the antimicrobials, fluoroquinolone was the most commonly prescribed antibiotic drug class, which coincides with the findings of earlier studies.[8],[11],[13],[14] Fluoroquinolone have been the preferred drug for most of the common ocular pathogens. Recent data show that the efficacy of fluoroquinolone monotherapy has declined, and there is an upsurge of fluoroquinolone insusceptible microorganism in accordance with the frequency of use.[5] Thus, countries where its use is high, insusceptible rates are high as compared to the countries and regions where its use is low.[5],[22],[23]

In accordance with other studies, majority (89.6%) of the antimicrobials were given topically, thus minimizing systemic adverse effects.[11],[12],[14],[16]

Prescribing of antibiotics was rightly indicated, according to the diagnosis, except for filamentary keratitis and a few cases of viral conjunctivitis, whose treatment is nonspecific; we believe that antimicrobials were prescribed to prevent secondary infections.

Limitation of the study

This study was a hospital-based quantitative drug use study confined to Ophthalmology OPD with a limited sample size. The limited sample size can be attributed to the short duration of the study and only twice a week collection of data. Further, the pattern of disease occurrence (seasonal) might have influenced the drugs prescribed by the treating physicians.


   Conclusion Top


This study concludes with an overall impression of rational prescription in accordance with the accepted patterns of treatment of ocular diseases. Nevertheless, all efforts should be made to encourage the health-care professionals to prescribe by generic name and to create awareness regarding the selection of drugs from the NEDL/NFI, and the appropriate use of antimicrobial agents to reduce the cost per prescription and the worldwide threat of antimicrobial resistance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Introduction to drug utilization research—World Health Organization. Available from: apps.who.int/medicinedocs/pdf/s4876e/s4876e.pdf. [Last accessed on 2017 July 24].  Back to cited text no. 1
    
2.
WHO. Antimicrobial resistance. Available from: www.who.int/mediacentre/factsheets/fs194/en/. [Last accessed on 2017 July 24].  Back to cited text no. 2
    
3.
Untreatable: Report by CDC details today’s drug-resistant health threats Available from: https://www.cdc.gov/media/releases/2013/p0916-untreatable.html. [Last accessed on 2018 Apr 18].  Back to cited text no. 3
    
4.
Oydanich M, Dingle TC, Hamula CL, Ghisa C, Asbell P. Retrospective report of antimicrobial susceptibility observed in bacterial pathogens isolated from ocular samples at Mount Sinai Hospital, 2010 to 2015. Antimicrob Resist Infect Control 2017;10:29.  Back to cited text no. 4
    
5.
Miller D. Update on the epidemiology and antibiotic resistance of ocular infections. Middle East Afr J Ophthalmol 2017;10:30-42.  Back to cited text no. 5
    
6.
Bertino JS Jr. Impact of antibiotic resistance in the management of ocular infections: The role of current and future antibiotics. Clin Ophthalmol 2009;10:507-21.  Back to cited text no. 6
    
7.
Desalegn AA. Assessment of drug use pattern using WHO prescribing indicators at Hawassa University teaching and referral hospital, south Ethiopia: A cross-sectional study. BMC Health Serv Res 2013;10:170.  Back to cited text no. 7
    
8.
Gangwar A, Singh R, Singh S, Sharma BD. Pharmacoepidemiology of drugs utilized in ophthalmic outpatient and inpatient department of a tertiary care hospital. J Appl Pharm Sci 2011;10:135-40.  Back to cited text no. 8
    
9.
Nies AS. Principles of therapeutics. In: Gilman AG, Rall TW, Nies AS, editors. The pharmacological basis of therapeutics. 8th ed. New York: Pergamon Press; 1990. p. 62-83.  Back to cited text no. 9
    
10.
Viktil KK, Blix HS, Moger TA, Reikvam A. Polypharmacy as commonly defined is an indicator of limited value in the assessment of drug-related problems. Br J Clin Pharmacol 2007;10:187-95.  Back to cited text no. 10
    
11.
Jadhav PR, Moghe VV, Deshmukh YA. Drug utilization study in ophthalmology outpatients at a tertiary care teaching hospital. ISRN Pharmacol 2013;10:768792.  Back to cited text no. 11
    
12.
Maniyar Y, Bhixavatimath P, Akkone V. A drug utilization study in the ophthalmology department of a medical college, Karnataka, India. J Clin Diagn Res 2011;10:82-4.  Back to cited text no. 12
    
13.
Dutta SB, Beg MA, Mittal S, Gupta M. Prescribing pattern in ophthalmological outpatient department of a tertiary care teaching hospital in Dehradun, Uttarakhand: A pharmaco-epidemiological study. Int J Basic Clin Pharmacol 2014;10:547-2.  Back to cited text no. 13
    
14.
Nehru M, Kohli K, Kapoor B, Sadhotra P, Chopra V, Sharma R. Drug utilization study in outpatient ophthalmology department of Government Medical College Jammu. JK Science 2005;10:149-51.  Back to cited text no. 14
    
15.
Biswas NR, Jindal S, Siddiquei MM, Maini R. Patterns of prescription and drug use in ophthalmology in a tertiary hospital in Delhi. Br J Clin Pharmacol 2001;10:267-9.  Back to cited text no. 15
    
16.
Prajwal P, Rai M, Kumar KS, Bhat US, Dsouza FV. Drug utilization pattern in ophthalmology department at a tertiary care hospital. Int Res J Pharm 2013;10:205-10.  Back to cited text no. 16
    
17.
Udeh BL, Schneider JE, Ohsfeldt RL. Cost effectiveness of a point-of-care test for adenoviral conjunctivitis. Am J Med Sci 2008;10:254-64.  Back to cited text no. 17
    
18.
Shekhawat NS, Shtein RM, Blachley TS, Stein JD. Antibiotic prescription fills for acute conjunctivitis among enrollees in a large United States managed care network. Ophthalmology 2017;10:1099-107.  Back to cited text no. 18
    
19.
Amir AA, Barney NP. Conjunctivitis a systematic review of diagnosis and treatment. JAMA 2013;10:1721-9.  Back to cited text no. 19
    
20.
Keen M, Thompson M. Treatment of acute conjunctivitis in the United States and evidence of antibiotic overuse: Isolated issue or a systematic problem? Ophthalmology 2017;10:1096-8.  Back to cited text no. 20
    
21.
American Academy of Ophthalmology. Choosing wisely: Five things physicians and patients should question. Available from: http://www.choosingwisely.org/societies/american-academy-of- ophthalmology. 2013. [Last accessed on 2018 Jan 24].  Back to cited text no. 21
    
22.
van de Sande-Bruinsma N, Grundmann H, Verloo D, Tiemersma E, Monen J, Goossens H, et al; the European Antimicrobial Resistance Surveillance System and European Surveillance of Antimicrobial Consumption Project Groups. Antimicrobial drug use and resistance in Europe. Emerg Infect Dis 2008;10:1722-30.  Back to cited text no. 22
    
23.
Ventola CL. The antibiotic resistance crisis: Part 1: causes and threats. PT 2015;10:277-83.  Back to cited text no. 23
    


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