Geriatric Antibiotic Use in the Medical Wards of a Tertiary Care Hospital, India: A Retrospective Observational Study

Abstract

Background: The prescribing practices and the rational use of the antibiotics promote safe and cost-effective treatment of infections thereby reducing the length of the hospital stay and prevention of adverse events and polypharmacy in the elderly. The study aims at creating awareness among the healthcare professionals regarding safe antibiotic prescribing practices in the elderly population. Results The number of antibiotic prescriptions was found to be 796. 51.2 % of the patients had respiratory tract infections. Cephalosporin (318), Macrolide (139) and Penicillin (111) were the most prescribed class of antibiotics in the study population. According to WHO AWaRe classification, ‘Watch’ category had the majority with 616 prescriptions. As per WHO prescribing indicators, the average number of drugs per prescription was found to be 9. The percentage of the antibiotic prescriptions was found to be 22.27% and that of the encounters with injection at 37.77%. 4.53% of the prescriptions were given by the generic name. 33.49% of the drugs were prescribed from the essential drug list/formulary. Conclusion: The study highlighted the antibiotic prescribing practices in the elderly and helps in the formulation of new policies and procedures to strengthen the antimicrobial stewardship programme and detection of polypharmacy in the elderly.

Keywords

Introduction

Figure 1. Safety concerns with antibiotic use in elderly⁵.

DISCUSSION

Seventy percent of the elderly screened had received antibiotics. The gender distribution was almost the same among the elderly study subjects. All of them had at least eight days of hospital stay. Most of them had respiratory tract infections and urinary tract infections in the study population. The same was observed in the study conducted by Dilip Chandrasekhar et al., in which 30% of the prescriptions had antibiotics to treat respiratory tract infections¹. The elderly had diabetes mellitus and hypertension as the major comorbidities. Cephalosporins, Macrolides and penicillins were the major class of antibiotics given in the elderly population.

We observed that the elderly patient received an average of two antibiotics. The study subjects had received an average of nine drugs. “Use of more than five medications in the people who crossed 65 years old, treated as polypharmacy” as per American Geriatric Society (AGS) Beers criteria⁹. According to the WHO prescribing indicators, the number of drugs to be prescribed per patient is less than two. The study shows that the injections were prescribed more in number compared to the reference value, less than 20%. The reasons could be that the hospital where the study was conducted caters to a rural and mostly illiterate population which demands instant gratification and injections and the doctors often succumb to their pressure. Injections mean more expense, need for trained personnel and has a greater potential for serious side effects compared to oral medications. Health education of the public is needed so that their unfounded beliefs and attitudes can be rectified. It is very much essential to create an awareness regarding the use of Generic name and the selection of the medication from the Essential Medicine List while prescribing. But, only a third satisfied this criterion. Antibiotic prescriptions were found to be optimal, less than thirty percent, a good sign as per the WHO recommendations reflecting the efforts to promote the rational use of antibiotics in the hospital¹⁰.

Looking at the prescriptions according to WHO AWaRe classification, a tool to support monitoring of antibiotic prescribing, the ‘Watch’ group of antibiotics were the major one that were of higher resistance potential. WHO has introduced a new target, stating that by 2023 at least 60% of national antibiotic consumption should come from the ‘Access’ group which are considered as first- or second-line agents in the empiric treatment of common infectious syndromes and should therefore be widely available and affordable. A worldwide point prevalence survey of antibiotic prescribing patterns in adults as per WHO AWaRe classification was studied in 664 hospitals across 69 countries in which a higher use of ‘Watch’ antibiotics was noted particularly in lower and upper- middle- income countries. There were large differences in AwaRe prescribing at country level. ‘Watch’ group has a higher risk of developing resistance and are used as first- or second-line options for a limited number of indications. These are the antibiotics that need to be monitored and prioritized as targets for stewardship programmes¹¹.

Our study was exhibiting the treatment patterns with the use of Amoxicillin and its combination with clavulaunic acid, Metronidazole, Doxycycline, Tinidazole, Nitrofurantoin, Amikacin, Gentamicin, Clindamycin which belong to ‘Access’ category. Also, Cefoperazone and sulbactam, Ceftriaxone, Cefpodoxime, Cefixime, Cefpodoxime and clavulanic acid, Cefotaxime, Cefuroxime, Azithromycin, Clarithromycin, Piperacillin and Tazobactam, Ciprofloxacin, Ofloxacin, Norfloxacin, Levofloxacin, Imipenem and Meropenem were used that belong to ‘Watch’ category. The treatment regimen also include Ceftazidime avibactum, Tigecycline, Faropenem, Linezolid and Aztreonam that belong to Reserve category. It alerts the healthcare professional to be more vigilant with the use of antibiotics, majority of them belong to watch category. The study suggests the practitioners to select antibiotics more of the category, Access group. Many at times, the severity of infections demands the extensive use of antibiotics that most of which fell into watch category. The findings urge the hospital authorities to strengthen the monitoring strategies and to formulate policies and procedures to combat antimicrobial resistance. It would help them to make informed choices while selecting the therapeutic regimen to treat infections¹²_.

‘Reserve’ group, the last resort antibiotic prescribing which was highest in Argentina, India, and Brazil according to the world-wide point prevalence study¹³. Access-to-Watch ratio was 0.27 in our study. Most of the countries had an Access-to-Watch ratio lower than 1. The lowest ratio (0.1) was observed in Armenia and Jordan, whereas Guinea had the highest Access-to-Watch ratio (2.1), followed by South Africa (1.6), Togo (1.5) and the UK (1.5). Ideally, ‘Access’ antibiotic use should be greater than ‘Watch’ group and the ratio should be more than one¹².

The above findings show that the prescribing practices for antibiotics in our study is far from recommended. The reasons could be the inadequate training of junior and senior residents on the best practices regarding antibiotic use and lack of awareness of the recently formulated local antibiotic policy. Another point noted is that doctors’ training during the Corona Virus Infectious Disease (COVID-19) pandemic suffered a setback due to obvious reasons. There is a tendency to start antibiotics for every ill or unstable patient without a systematic approach. Starting antibiotics in a sick patient without trying to find the cause gives a false sense of security and should be discouraged. In a significant segment, no likely focus of infection was documented. This group had culture sent in one, severe sepsis was documented in one and serum procalcitonin test was not sent in any. Often no attempt is made to determine if there is an infection at all and if so, what is the likely focus, the most likely bug and whether the prescribed antibiotic is appropriate and will reach the site in sufficient concentration. New doctors set a trend and changing these wrong practices is far from easy. Teaching hospitals should set standards for rational prescribing. Training of prescribers, strict monitoring of appropriateness of prescriptions and health education of rural population about the misuse/overuse of antibiotics is essential.

Pharmacokinetic and Pharmacodynamic changes are quite evident with the advancement of age. Hence, we need to be cautious with the choice of medications in the elderly. Practices contrary to guidelines noted were use of Nitrofurantoin (a potentially inappropriate medication in elderly according to Beers criteria) in urinary tract infection including those with renal failure, Nitrofurantoin was administered in our study for urinary tract infection and possess an unfavorable side effect profile such as pulmonary toxicity, hepatotoxicity and peripheral neuropathy^9,14. Also, it does not reach adequate concentration in the urinary tract in the presence of renal failure and should be avoided in elderly. Baclet et al., says that there are definitions for the various types of potentially inappropriate antibiotic prescriptions among elderly. These findings require an external validation to use it in our practice. Examples of inappropriate prescriptions are nitrofurantoin for urinary tract infection (UTI), amoxicillin-clavulanic acid as empirical therapy for UTI, ceftriaxone for pneumococcal community acquired pneumonia (CAP), macrolide for CAP except legionellosis, fluoroquinolone as first line treatment of  pneumonia and upper respiratory tract infection, treatment of diarrhea with antibiotics, amoxicillin-clavulanic acid for nosocomial gastrointestinal infections, piperacillin-tazobactam for community acquired infections, combining amoxicillin-clavulanic acid with metronidazole, giving antibiotics for more than 7 days for pneumonia and prescribing antibiotics for viral infections¹⁴.

Other common practices contrary to guidelines noted were treating asymptomatic urinary infections in elderly, using intravenous fluoroquinolones although they have good oral bioavailability, treating all COPD acute exacerbations with antibiotics, treating every acute diarrhoeal illness with fluoroquinolone and metronidazole and systemic antibiotics for skin infections without systemic manifestations and these must be emphasized during education of prescribers.

It was difficult to make out whether the cultures were sent for the patients. In case of sending culture test, we were unable to make out whether it was done before initiating antibiotics. Starting antibiotics upfront before obtaining reports may be required only in unstable patients like those with severe sepsis. There was a general reluctance to deescalate antibiotics if no obvious indication was identified. Deprescribing can be encouraged to prevent polypharmacy. The reason for starting or stopping or changing an antibiotic in the case file needs to be emphasized for better patient care. Documentation of focus of infection, basis for diagnosing sepsis, culture and chest radiographs were often absent or unclear from the records. Incomplete documentation was a major hurdle as it was a retrospective study. Also, it could lead to exaggeration of the findings.

CONCLUSION

Rational prescribing results in the reduction of cost, adverse events, and antimicrobial resistance. It is recommended to have judicious use of antibiotics while treating infections in the elderly. The older adults are highly sensitive and develop tolerance to the medications with the advancement of the age. The prescribers need to be cautious while treating the elderly to avoid drug toxicity because of age related changes in the pharmacokinetic and pharmacodynamic parameters. Cognitive impairment leads to medication non adherence in them. It is very much essential to strengthen the hospital surveillance methods such as antimicrobial stewardship programme to regulate the use of antibiotics and the emergence of antimicrobial resistant strains. Educational interventions can be implemented in the hospital to raise awareness regarding polypharmacy and optimal use of antibiotics.  Continuing Medical Education (CME) programme can be conducted to encourage the doctors to prescribe antibiotics of Access category as per WHO AWaRe classification. It would help practitioners to make informed choices while selecting the therapeutic regimen to treat infections. Further studies are required to measure the extent of polypharmacy in the hospital settings. Strategies like the restriction of hospital formulary can be devised to alert the doctors during the selection of the antibiotic. It helps in strengthening the facets of the pharmaceutical care.

LIMITATION

Being a retrospective observational study, direct patient interview and clarification of the data collected were not possible. The sample size was small and does not exhibit generalizability of the result. The study can be extrapolated to other medical departments in special population to assess the safe prescribing patterns of antibiotics. Further studies can be done to evaluate the patterns of polypharmacy and Drug Related Problem (DRP).

LIST OF ABBREVIATIONS

• AGS: American Geriatric Society
• AWaRe classification: Access, Watch, Reserve.
• CAP: Community Acquired Pneumonia
• CME: Continuing Medical Education
• CNS: Central Nervous System
• COPD: Chronic Obstructive Pulmonary disease
• COVID-19: Corona Virus Infectious Disease
• DRP: Drug Related Problem
• ENT: Ear Nose Throat
• GLASS report: Global Antimicrobial Resistance and Use Surveillance System report
• ICU: Intensive Care Unit
• IEC: Institutional Ethics Committee
• MRD: Medical Records Department
• MRSA: Methicillin Resistant Staphylococcus Aureus
• NCDC: National Centre for Disease Control
• RTI: Respiratory Tract Infection
• SPSS: Statistical Package of Social Sciences
• UTI: Urinary Tract Infection
• WHO: World Health Organization

DECLARATION

• Ethics approval and consent to participate

This retrospective observational study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Ethics Committee (IEC) of the hospital, Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research (CDSIMER) before initiating the study. (IEC No.: CDSIMER/MR/0075/IEC/2023).

Informed consent: The need for informed consent was waived off by the Institutional Ethics Committee (IEC) of the hospital, Dr. Chandramma Dayananda Sagar Institute of Medical Education and Research (CDSIMER) as it is a retrospective observational study.

• Consent to participate: Not applicable. IEC granted approval for the study as it is a retrospective observational study.
• ‘Clinical trial number: not applicable.’
• Consent for publication: No
• Availability of data and material: The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

• Competing interests

The authors have no relevant financial or non-financial interests to disclose.

• Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

• Authors' contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [Betsy Mathew], [Mamata Gurupad Kanchugar], [Prithvika Wagle], [Tayeeb Ahmed] and [Lita Susan Thomas]. The first draft of the manuscript was written by [Lita Susan Thomas] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

• Acknowledgements

The authors would like to express their heartfelt gratitude to all the healthcare and non- healthcare professionals for the smooth conduct and co-operation throughout the study.

Studies involving plants must include a statement specifying the local, national, or international guidelines and legislation and the required or appropriate permissions and/or licenses for the study: Not Applicable.

REFERENCES

1. Chandrasekhar D, Manaparambil H, Parambil JC. Outcome assessment of intervention on appropriateness of antibiotic use among geriatric patients: A prospective interventional study from a tertiary care referral hospital. Clinical Epidemiology and Global Health 2019;7:536–41. https://doi.org/10.1016/j.cegh.2018.12.005.
2. National Centre for Disease Control. National Treatment Guidelines for Antimicrobial Use in Infectious Diseases (2016). Available from: https://ncdc.mohfw.gov.in/wp-content/uploads/2024/03/16436207411618303414.pdf
3. Abdu N, Idrisnur S, Tewelde T, Tesfamariam EH. Antibiotic prescribing practice using WHO Access, Watch and Reserve classification and its determinants among outpatient prescriptions dispensed to elderly population in six community chain pharmacies in Asmara, Eritrea: a cross-sectional study. BMJ Open 2024;14:e085743. https://doi.org/10.1136/bmjopen-2024-085743.
4. Golla P, Bheemathati RR, Ramesh SPA, Edara N, Adepu R. Prescribing Pattern of Medications in Geriatric Patients in a South Indian Tertiary Care Teaching Hospital. IJOPP 2019;13:68–72. https://doi.org/10.5530/ijopp.13.1.11.
5. Soraci L, Cherubini A, Paoletti L, Filippelli G, Luciani F, Laganà P, et al. Safety and Tolerability of Antimicrobial Agents in the Older Patient. Drugs Aging 2023;40:499–526. https://doi.org/10.1007/s40266-023-01019-3.
6. Global Antimicrobial Resistance and Use Surveillance System (GLASS) Report 2022. 1st ed. Geneva: World Health Organization; 2022.
7. Gulam SM, Thomas D, Ahamed F, Baker DE. Prospective Audit and Feedback of Targeted Antimicrobials Use at a Tertiary Care Hospital in the United Arab Emirates. Antibiotics 2025;14:237. https://doi.org/10.3390/antibiotics14030237.
8. Shrestha R, Pandey B, Shakya Shrestha S, Manandhar Shrestha JT, Poudel P. Antibiotics Use among Geriatric Patients Admitted in the Department of Medicine in a Tertiary Care Centre: A Descriptive Cross-sectional Study. J Nepal Med Assoc 2023;61:522–5. https://doi.org/10.31729/jnma.8105.
9. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J American Geriatrics Society 2023;71:2052–81. https://doi.org/10.1111/jgs.18372.
10. Ofori-Asenso R. A closer look at the World Health Organization’s prescribing indicators. Journal of Pharmacology and Pharmacotherapeutics 2016;7:51–4. https://doi.org/10.4103/0976-500X.179352.
11. Pauwels I, Versporten A, Drapier N, Vlieghe E, Goossens H, the Global-PPS network, et al. Hospital antibiotic prescribing patterns in adult patients according to the WHO Access, Watch and Reserve classification (AWaRe): results from a worldwide point prevalence survey in 69 countries. Journal of Antimicrobial Chemotherapy 2021;76:1614–24. https://doi.org/10.1093/jac/dkab050.
12. Hsia Y, Lee BR, Versporten A, Yang Y, Bielicki J, Jackson C, et al. Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countries. The Lancet Global Health 2019;7:e861–71. https://doi.org/10.1016/S2214-109X(19)30071-3.
13. Mittal N, Tayal A, Kumar S, Dhawan R, Goel N, Mittal R. Longitudinal Trends in In-Patient Antibiotic Consumption According to the WHO Access, Watch, Reserve (AWaRe) Antibiotic Groups and Cost: An Analysis of Data at a National Antimicrobial Consumption Network (NAC-NET) Site in North India over 7 Years (2017–2023). Antibiotics 2024;13:673. https://doi.org/10.3390/antibiotics13070673.
14. Baclet N, Calafiore M, Fregnac C, Gavazzi G, Forestier E, Roubaud-Baudron C, et al. Explicit definitions of potentially inappropriate prescriptions of antibiotics in hospitalized older patients. Infectious Diseases Now 2022;52:214–22. https://doi.org/10.1016/j.idnow.2022.02.004.