WHO/INRUD prescribing indicators and prescribing trends of antibiotics in the Accident and Emergency Department of Bahawal Victoria Hospital, Pakistan

The importance of assessment and evaluation of quality in healthcare is gaining global recognition and medicines play a pivotal role in the healthcare delivery system. The appropriate use of medicines is a crucial element in the quality of health outcomes and in the appropriate medical care provided to patients (World Health Organization 1993). The most common causes of irrational medicine use are; self-medication, polypharmacy, inappropriate use of antibiotics, overuse of injectable medicines and the prescribing of medicines without following relevant clinical practice guidelines (World Health Organization 2002). Furthermore, there are numerous factors that influence irrational prescribing including; patients, healthcare professionals (HCPs), the working environment, the drug supply system (including industrial impacts), legal regulations, information and misinformation about medicines, and profiteering intentions by selling more medicines (Geest et al. 1991; Spurling et al. 2010).

The fundamental step to limiting the irrational use of medicines is to quantify the extent to which this is occurring. It is particularly important with antibiotics as resistance continues to climb and the armamentarium of new antibiotics coming to market is not on the increase. In the 1990s, the World Health Organization (WHO) in collaboration with the International Network of Rational Use of Drugs (INRUD) developed a set of indicators to measure the performance of healthcare facilities related to the utilization of drugs (World Health Organization 1993). In developing countries, assessment of drug use patterns through the WHO/INRUD indicators is on the increase which is promising (Hogerzeil et al. 1993) with the indicators having been successfully implemented in more than 30 developing countries (Laing et al. 2001).

With regard to the rational use of antibiotics, the WHO has defined this as ‘the cost-effective use of antibiotics which maximizes clinical therapeutic effect while minimizing both drug-related toxicity and the development of antimicrobial resistance (AMR)’ (World Health Organization 2001a, b). The supervision of antimicrobial use has environmental, economic and clinical implications (World Health Organization 2012). Between 30 and 50% of all hospitalized patients are prescribed at least one antibiotic and this class constitutes more than 30% of the hospital budget (Vlahovic-Palcevski et al. 2000). According to another estimate, 20–50% of antimicrobial utilization is inappropriate (Čižman 2003) and this has a significant effect on the quality of health services provided (Shao-Kang et al. 1998), treatment expenses (Segade 2000) and frequency of adverse drug reactions (ADRs). It has also been estimated that around one quarter (25%) of total ADRs can be attributed to antimicrobial use (Beringer et al. 1998). Despite these concerns, the most alarming problem associated with irrational prescribing of antimicrobials is the development of resistance (Dellit et al. 2007). This problem is exacerbated by the limited number of new antimicrobials coming through the development pipeline of large pharmaceutical companies (O’Neill 2015).

In the United States (US), the economic burden of AMR amongst outpatients is estimated to be between $400 million and $18.6 billion. The costs associated with inpatients are thought to be much higher (Okeke et al. 2005). According to the WHO, AMR costs in Europe are estimated to be €9 billion per annum (World Health Organization 2011). Unfortunately there is a scarce literature on the fiscal burden of AMR in developing countries such as Pakistan. The expenses associated with AMR could inflict significant fiscal damage, not only for the governments but also for patients living in developing countries. Thus, monitoring and supervision of antimicrobial utilization has significant benefit to society through the saving of valuable resources (World Health Organization 2012).

The aim of this study was to assess the prescribing practices in the Accident and Emergency (A & E) department of the Bahawal Victoria Hospital (BVH), Bahawalpur, Pakistan. We also report the antibiotic use patterns in this same context. The results of this study could assist the hospital administrators to develop and implement appropriate interventions to improve rational prescribing of medicines in the A & E department of the BVH. The study findings may also be applicable to other hospitals that are suspected to have similar drug use practices.

The current study demonstrates irrational prescribing practices in the A & E department of a tertiary level hospital in Pakistan. The findings in terms of prescribing indicators are divergent with the expected norms. Cephalosporins contributed the highest percentage share amongst all the antibiotic classes, while ceftriaxone was the most commonly prescribed antibiotic. The extent of antimicrobial prescribing in this setting raises concerns of AMR and highlights an ignorance of doctors towards their prescribing behavior.

This study contributes to the international literature by addressing medicines use in the context of the A & E department; a point of first contact with the health system in many developing countries. Further, this study adds to the body of knowledge surrounding antibiotic use in this A & E setting and compares use in Pakistan with other developing countries. The study adds further evidence that policy-makers, hospital administrators, doctors, nurses and pharmacists should all be wholly concerned about the developing world’s ongoing contribution to AMR. There are few antibiotic medicines in the drug development pipeline and therefore few therapeutic solutions when current agents stop being effective. The strategy must immediately be focused on curbing the current rise in AMR.

The study findings support a recommendation that continuous training and educational programs for medical staff concerning rational use of injections and antibiotics should be implemented and monitored so that the required changes in prescribing become sustainable. A feedback monitoring system on doctors’ antibiotic prescriptions would be expected to significantly improve their prescribing behavior. Knowledge and compliance with updated clinical guidelines is also recommended to enhance the degree to which generic prescribing occurs.

Further studies are encouraged to find the reasons for irrational use of medicines and to demonstrate the factors driving the irrational prescribing of antimicrobials by the physicians at BHV. Appropriate interventions regarding rational prescribing of antimicrobials should be designed and implemented in the hospital and an evaluation is required to determine whether there has been any improvement in the prescribing practices of physicians.

There are limitations with pharmaco-epidemiological approaches that compare studies across countries where the hospital context might be different. However, the authors are left with few options when the literature is scarce and limited within the context of A and E antibiotic prescribing in developing countries. In addition to international comparisons the findings from this study should not be generalized to the whole of Pakistan; but they do give a robust indication of what is happening in one hospital A and E department and may precipitate other hospitals in Pakistan to begin an audit which will give a sense of whether the high use of IV ceftriaxone is a national phenomenon. Based on the fact that a uniform healthcare policy is implemented throughout the country, and medical graduates from various institutions are working in Bahawalpur city the practices may be similar to A & E departments of other tertiary care hospitals in Pakistan. This needs to be further instigated and if it is the case then a national policy will need to be developed to address this issue. In this study, we did not explore the reasons for irrational drug use, which could be considered in future studies.