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1Department of Pharmacy Practice, G.P. Pharmacy College
2B. Pharm, G.P. Pharmacy College
Antimicrobial resistance (AMR) has become a critical global public health issue, largely driven by the irrational use of antibiotics. Evaluating prescribing patterns in hospitals plays a key role in promoting rational drug use and improving patient outcomes¹²³. The present study was undertaken to assess antibiotic prescribing patterns and determine their rationality using World Health Organization (WHO) prescribing indicators in a hospital setting. A prospective observational study was carried out over six months in inpatient departments, during which 300 prescriptions containing at least one antibiotic were reviewed. Data were collected through a structured case record form and analyzed using WHO core prescribing indicators, with descriptive statistics applied to interpret the findings¹?²?. The analysis revealed that the average number of drugs per prescription was 4.2, while the mean number of antibiotics per prescription was 1.8, suggesting the presence of polypharmacy. Cephalosporins (38.6%) were identified as the most frequently prescribed class of antibiotics, with intravenous administration being the predominant route (68%). Generic prescribing accounted for 42% of cases, and 68% of the drugs were prescribed from the essential medicines list. Additionally, combination antibiotic therapy was observed in 52% of patients, and adherence to standard treatment guidelines was noted in 58% of prescriptions. Overall, the findings indicate suboptimal antibiotic prescribing practices, characterized by a high reliance on broad-spectrum and injectable antibiotics, moderate compliance with treatment guidelines, and limited use of generic names. These results highlight the need for strengthened antimicrobial stewardship programs, increased adherence to guideline-based therapy, and regular prescription audits to promote rational antibiotic use and curb the progression of antimicrobial resistance¹?¹?¹?.Antimicrobial resistance (AMR) has become a critical global public health issue, largely driven by the irrational use of antibiotics. Evaluating prescribing patterns in hospitals plays a key role in promoting rational drug use and improving patient outcomes¹²³. The present study was undertaken to assess antibiotic prescribing patterns and determine their rationality using World Health Organization (WHO) prescribing indicators in a hospital setting. A prospective observational study was carried out over six months in inpatient departments, during which 300 prescriptions containing at least one antibiotic were reviewed. Data were collected through a structured case record form and analyzed using WHO core prescribing indicators, with descriptive statistics applied to interpret the findings¹?²?. The analysis revealed that the average number of drugs per prescription was 4.2, while the mean number of antibiotics per prescription was 1.8, suggesting the presence of polypharmacy. Cephalosporins (38.6%) were identified as the most frequently prescribed class of antibiotics, with intravenous administration being the predominant route (68%). Generic prescribing accounted for 42% of cases, and 68% of the drugs were prescribed from the essential medicines list. Additionally, combination antibiotic therapy was observed in 52% of patients, and adherence to standard treatment guidelines was noted in 58% of prescriptions. Overall, the findings indicate suboptimal antibiotic prescribing practices, characterized by a high reliance on broad-spectrum and injectable antibiotics, moderate compliance with treatment guidelines, and limited use of generic names. These results highlight the need for strengthened antimicrobial stewardship programs, increased adherence to guideline-based therapy, and regular prescription audits to promote rational antibiotic use and curb the progression of antimicrobial resistance¹?¹?¹?
Antibiotics have transformed the management of infectious diseases and have greatly reduced morbidity and mortality across the globe. Nevertheless, their extensive and often inappropriate use has accelerated the development of antimicrobial resistance (AMR), which is now recognized as one of the most serious global public health threats¹². The World Health Organization (WHO) has emphasized that inappropriate prescribing practices—such as overuse, misuse, and the excessive preference for broad-spectrum antibiotics—are major contributors to the rise of resistance³?. Hospitals serve as key centers for treating severe and complicated infections, resulting in substantial antibiotic utilization. In these settings, empirical therapy is commonly initiated prior to microbiological confirmation, which can lead to inappropriate selection of drugs, incorrect dosing, or unsuitable duration of treatment??. Moreover, factors including polypharmacy, poor adherence to standard treatment guidelines, and limited use of culture and sensitivity testing further aggravate irrational prescribing practices??. Numerous studies conducted in hospital environments have revealed that a considerable proportion of antibiotic prescriptions are either unnecessary or not aligned with recommended guidelines, thereby increasing the likelihood of adverse drug reactions, therapeutic failure, and higher healthcare costs??. The excessive use of broad-spectrum antibiotics, especially cephalosporins and fluoroquinolones, has been frequently reported and is strongly linked to the emergence of multidrug-resistant organisms¹?¹¹. Drug utilization research is essential for assessing prescribing patterns and encouraging rational drug use. The WHO prescribing indicators offer a standardized approach to evaluate parameters such as the average number of drugs per encounter, proportion of antibiotics prescribed, extent of generic prescribing, and adherence to essential medicine lists?¹². These indicators aid in identifying deviations from rational prescribing and facilitate the implementation of corrective strategies. In recent years, antimicrobial stewardship programs have been advocated as effective measures to optimize antibiotic usage, enhance patient outcomes, and limit the spread of resistance¹³¹?. Key components of these programs include regular prescription audits, continuous clinician education, and strict adherence to evidence-based treatment guidelines¹?. Considering the growing burden of antimicrobial resistance and the central role of hospitals in antibiotic use, ongoing monitoring of prescribing patterns is crucial¹?¹?. Systematic evaluation through drug utilization studies helps in identifying irrational practices and provides a foundation for targeted interventions aimed at improving prescribing behavior¹?. Therefore, the present study was undertaken to assess antibiotic prescription patterns in a hospital setting using WHO prescribing indicators and to evaluate their rationality in clinical practice¹?.
AIM:
To analyze antibiotic prescribing patterns and evaluate their rationality in a hospital setting using World Health Organization (WHO) prescribing indicators¹²?.
OBJECTIVES:
Primary Objective:
Secondary Objectives:
MATERIALS AND METHODS:
Study Design and Setting:
A prospective observational study was conducted in the inpatient departments of a teaching hospital over a duration of six months. Prospective study designs are well-suited for drug utilization research as they enable systematic, real-time data collection and help minimize recall bias¹?²?. The study included multiple departments such as general medicine, surgery, and other allied specialties where antibiotic use is prevalent.
Study Population and Sample Size:
The study included 300 in patients who were prescribed at least one antibiotic during their hospital stay. The sample size was determined based on previously published studies assessing antibiotic prescribing patterns in hospital settings??²?. Patients were recruited consecutively to reduce selection bias and to reflect routine clinical practice accurately.
Inclusion Criteria:
Exclusion Criteria:
Data Collection Procedure:
Data were collected prospectively using a predesigned and validated case record form. Information gathered included patient demographics (age and gender), diagnosis, comorbidities, details of prescribed antibiotics (name, class, dose, frequency, route, and duration), and relevant laboratory investigations such as culture and sensitivity reports. To maintain accuracy and consistency, prescriptions were reviewed on a daily basis, and any uncertainties were clarified with the treating physicians. Such systematic data collection is crucial for identifying prescribing patterns and assessing rational drug use²¹²².
Classification of Antibiotics:
The prescribed antibiotics were categorized based on their pharmacological class (such as beta-lactams, fluoroquinolones, and macrolides) and their spectrum of activity (broad-spectrum versus narrow-spectrum). This classification aids in understanding prescribing trends and their potential impact on antimicrobial resistance¹?¹¹.
Evaluation Criteria:
Antibiotic prescribing patterns were evaluated using WHO core prescribing indicators?¹², which are widely recognized for assessing rational drug use. The indicators analyzed included:
These indicators offer a standardized approach to compare prescribing practices and detect deviations from recommended standards?²?.
Assessment of Rationality and Guideline Adherence:
Each prescription was assessed for appropriateness based on standard treatment guidelines and current clinical evidence. Parameters evaluated included indication, selection of antibiotic, dosage, route, frequency, and duration of therapy. Adherence to guidelines is a key indicator of rational prescribing and helps reduce inappropriate antibiotic use²?²³.
Ethical Considerations:
The study was conducted after obtaining permission from the concerned authorities, and informed consent was obtained from all participants prior to data collection. Patient confidentiality was strictly ensured, and no personal identifiers were documented. As an observational study, it did not interfere with routine patient care. Adherence to ethical standards is essential to ensure patient safety and maintain data integrity²?.
Statistical Analysis:
Data were entered into Microsoft Excel and analyzed using descriptive statistical methods. Continuous variables were expressed as mean ± standard deviation, while categorical variables were presented as frequencies and percentages. Descriptive statistics are widely used in drug utilization studies to summarize prescribing trends and enable comparison with similar research?²?.
FINDINGS:
A total of 300 inpatient prescriptions containing at least one antibiotic were evaluated during the study period. Among the participants, 56% were male and 44% were female, indicating a slight predominance of males. Most patients belonged to the 19–40 years age group (34%), followed by 41–60 years (32%), those above 60 years (22%), and 0–18 years (12%). This demographic pattern is comparable to observations reported in similar hospital-based drug utilization studies?? (Table 1).
Table 1: Demographic Characteristics (n = 300)
|
Variable |
Frequency (n) |
Percentage (%) |
|
Gender |
||
|
Male |
168 |
56 |
|
Female |
132 |
44 |
|
Age Group (years) |
||
|
0-18 |
36 |
12 |
|
19–40 |
102 |
34 |
|
41–60 |
96 |
32 |
|
>60 |
66 |
22 |
Overall, the higher proportion of patients in the 19–40 years age group along with male predominance aligns with findings from earlier studies??. Evaluation of WHO prescribing indicators showed that the average number of drugs per prescription was 4.2, while the mean number of antibiotics per prescription was 1.8, suggesting the presence of polypharmacy. As per the study design, antibiotics were prescribed in 100% of encounters. Generic prescribing was observed in 42% of cases, and 68% of the drugs were from the essential medicines list. These results indicate suboptimal adherence to rational prescribing practices and are consistent with earlier reports that highlight low rates of generic prescribing¹²²? (Table 2).
Table 2: WHO Prescribing Indicators
|
Indicator |
Value |
|
Average number of drugs per prescription |
4.2 |
|
Average number of antibiotics per prescription |
1.8 |
|
Encounters with antibiotics (%) |
100% |
|
Drugs prescribed by generic name (%) |
42% |
|
Drugs from essential medicines list (%) |
68% |
Such findings reflect the presence of polypharmacy and inadequate use of generic names, in agreement with previous studies¹²²?. A total of 450 antibiotics were prescribed across the 300 prescriptions, indicating the use of multiple antibiotics in several cases. Among the various classes, cephalosporins were the most frequently prescribed (38.6%), followed by penicillins (21.4%), fluoroquinolones (17.3%), macrolides (9.2%), and other classes (13.5%). The predominance of cephalosporins suggests a preference for broad-spectrum antibiotics, a trend commonly reported in hospital settings and associated with an increased risk of antimicrobial resistance¹?¹¹ (Table 3).
Table 3: Distribution of Antibiotic Classes (n = 450)
|
Antibiotic Class |
Frequency (n) |
Percentage (%) |
|
Cephalosporins |
174 |
38.6 |
|
Penicillins |
96 |
21.4 |
|
Fluoroquinolones |
78 |
17.3 |
|
Macrolides |
42 |
9.2 |
|
Others |
60 |
13.5 |
Cephalosporins were the most commonly prescribed class, indicating preference for broad-spectrum antibiotics¹?¹¹. With respect to the route of administration, intravenous antibiotics accounted for 68% of prescriptions, whereas 32% were administered orally. The higher reliance on parenteral therapy indicates a preference for rapid therapeutic action in hospitalized patients, although such use may not always be clinically justified¹³ (Table 4).
Table 4: Route of Administration
|
Route |
Frequency (n) |
Percentage (%) |
|
Intravenous |
204 |
68 |
|
Oral |
96 |
32 |
This higher proportion of intravenous use reflects common hospital prescribing patterns¹³. Further analysis revealed that 48% of patients received a single antibiotic, 36% were prescribed two antibiotics, and 16% received three or more antibiotics. This indicates that more than half of the patients were treated with combination therapy. Although combination therapy is warranted in certain clinical situations, its excessive use may increase the risk of adverse effects and antimicrobial resistance?? (Table 5). Table 5: Number of Antibiotics per Prescription
|
Number of Antibiotics |
Frequency (n) |
Percentage (%) |
|
One |
144 |
48 |
|
Two |
108 |
36 |
|
Three or more |
48 |
16 |
Overall, the high proportion of combination therapy highlights a potential concern for resistance development??. Assessment of adherence to standard treatment guidelines showed that 58% of prescriptions were compliant, while 42% were non-compliant. This moderate level of adherence reflects gaps in rational prescribing practices and emphasizes the need for better implementation of antimicrobial stewardship strategies¹?¹? (Table 6).
Table 6: Guideline Adherence
|
Category |
Frequency (n) |
Percentage (%) |
|
Adherent |
174 |
58 |
|
Non-adherent |
126 |
42 |
Such findings underscore the importance of strengthening stewardship programs to improve prescribing behavior¹?¹?. In summary, the study findings indicate a high dependence on broad-spectrum and injectable antibiotics, moderate adherence to treatment guidelines, and inadequate generic prescribing. These trends are consistent with those reported in other hospital-based studies??²?.
DISCUSSION:
The present study offers a detailed assessment of antibiotic prescribing patterns in a hospital setting using WHO prescribing indicators. The findings bring attention to several critical aspects of antibiotic use, including the frequent use of broad-spectrum antibiotics, moderate compliance with treatment guidelines, and low levels of generic prescribing. These observations are in agreement with results reported from similar healthcare settings??²?. The mean number of drugs per prescription (4.2) observed in this study reflects a tendency toward polypharmacy. While the use of multiple medications may be necessary in patients with coexisting conditions, excessive polypharmacy can increase the likelihood of drug interactions, adverse drug reactions, and medication errors¹¹. Comparable findings have been documented in other drug utilization studies, emphasizing the importance of regular prescription review and rationalization of therapy¹²²?. The average number of antibiotics per prescription (1.8), along with the observation that more than half of the patients received combination therapy, indicates a trend toward the use of multiple antibiotics. Although combination therapy is justified in severe infections or when synergistic effects are required, its unnecessary use may contribute to the development of antimicrobial resistance and increased treatment costs??. Similar patterns of antibiotic overuse have been reported in previous hospital-based studies??. A notable finding of this study is the predominance of cephalosporins (38.6%), followed by penicillins and fluoroquinolones. The preference for cephalosporins may be due to their broad-spectrum coverage, convenient administration, and widespread availability. However, excessive dependence on these antibiotics has been linked to the emergence of resistant organisms, particularly extended-spectrum beta-lactamase (ESBL) producing bacteria¹?¹¹. Similar trends have been highlighted in other studies, indicating the widespread use of broad-spectrum antibiotics in hospital settings²²²³. The high usage of intravenous antibiotics (68%) observed in this study reflects a common practice in inpatient care, where rapid therapeutic response is often prioritized. However, evidence suggests that an early transition from intravenous to oral therapy, when clinically appropriate, can reduce hospital stay, lower treatment costs, and minimize complications without affecting therapeutic outcomes¹³. Therefore, implementing IV-to-oral switch strategies should be encouraged as part of antimicrobial stewardship initiatives. Generic prescribing was noted in only 42% of cases, which falls below recommended standards. Prescribing drugs by their generic names is beneficial as it enhances accessibility, reduces healthcare costs, and promotes rational drug use¹². The relatively low rate of generic prescribing in this study aligns with findings from other studies conducted in India and may be influenced by factors such as prescriber habits, pharmaceutical marketing, and limited awareness²¹²².
Adherence to standard treatment guidelines was observed in 58% of prescriptions, indicating that a considerable proportion did not conform to recommended practices. This lack of adherence may be attributed to factors such as insufficient knowledge updates, diagnostic uncertainty, and the absence of institutional treatment protocols??. Similar levels of non-adherence have been reported in other hospital-based studies, highlighting the need for ongoing medical education and strict implementation of evidence-based guidelines??. The results of this study underscore the significance of antimicrobial stewardship programs (ASPs) in ensuring rational antibiotic use. Such programs have proven effective in improving prescribing practices, minimizing inappropriate antibiotic use, and curbing the development of resistance¹?¹?. Key strategies include regular prescription audits, feedback to clinicians, and strict adherence to standard treatment guidelines¹?¹?. Additionally, the application of WHO prescribing indicators in this study provided a structured and standardized approach for evaluating drug utilization patterns. These indicators are widely recognized in healthcare research and facilitate comparison across different settings, thereby aiding in the identification of irrational prescribing practices and supporting policy formulation?²?. Despite its strengths, the study has certain limitations. As it was conducted in a single center, the findings may not be generalizable to other healthcare settings. Furthermore, detailed analysis of microbiological data and patient outcomes was not performed, which could have offered deeper insights into the appropriateness of antibiotic use. Future research incorporating multicenter data and outcome-based evaluations is therefore recommended²?. In summary, the study indicates that antibiotic prescribing practices in the hospital setting deviate from rational use, particularly with regard to excessive use of broad-spectrum antibiotics, polypharmacy, and incomplete adherence to treatment guidelines. These findings emphasize the urgent need to strengthen antimicrobial stewardship programs, encourage rational prescribing practices, and improve awareness among healthcare professionals to address the growing challenge of antimicrobial resistance¹³¹?²?³?.
CONCLUSION:
The study indicates that antibiotic prescribing practices in the hospital setting are marked by a high use of broad-spectrum agents, the presence of polypharmacy, and only moderate adherence to standard treatment guidelines. Additionally, the comparatively low proportion of generic prescribing and the extensive use of injectable antibiotics reflect deviations from rational drug use practices¹²²?. Such prescribing trends may contribute to the increasing burden of antimicrobial resistance, highlighting the necessity for improved and more rational prescribing approaches¹²³. The adoption of antimicrobial stewardship programs, along with regular prescription audits and strict adherence to evidence-based guidelines, is crucial for optimizing antibiotic use and improving patient outcomes¹?¹?¹?.
REFERENCES
Akshaya Sre Gopinathan*, Jayasri P., Kotteeshwaran R., Mohammed Afnan K.F., Nithisha S., Assessment of Rational Antibiotic Use in a Hospital Setting Using Who Prescribing Indicators, Int. J. of Pharm. Sci., 2026, Vol 4, Issue 5, 2179-2188. https://doi.org/10.5281/zenodo.20113159
10.5281/zenodo.20113159