Assessment of Antibiotic Utilization Pattern in Hasiya Bayero Pediatric Hospital, Kano State, Nigeria

Assessment of Antibiotic Utilization Pattern in Hasiya Bayero Pediatric Hospital, Kano State, Nigeria

Chapter One

Aim and Objectives of the Study

The study is aimed at evaluating the utilization of antibiotics in Hasiya Bayero Pediatric Hospital, Kano State, Nigeria. The specific objectives of the study include:

To assess the availability of vital information on prescriptions in Hasiya Bayero pediatric
To determine the most frequently prescribed class of antibiotics in the facility
To assess drug (antibiotic) use indicators in conformity with WHO specifications in the
To assess drug utilization using DU 90% (drug utilization 90%).
To carry out the ABC/VED analysis of the pharmacy store of Hasiya Bayero Paediatric

CHAPTER TWO

LITERATURE REVIEW

Over prescribing, multi-drug prescribing, misuse of drugs, use of unnecessary expensive drugs and overuse of antibiotics and injections are the most common problems of irrational drug use by prescribers and consumers (Grand et al., 1999)

Rational drug use study undertaken in nine health centers and nine health stations in Ethiopia, showed that the most often prescribed drugs were anti-infectives and analgesics (Desta et al., 1997). Studies have demonstrated that antimicrobial drugs are the most used drugs in Turkey accounting for 22% of all prescribed drugs (Kurt, 2003). Studies in Turkey (Usher et al., 2005) and western Nepal (Sharkar et al., 2003) showed that 30.6 % and 50.2% of patients received one or more antimicrobials. A study in a secondary health facility in Ilorin Nigeria on the prescription pattern showed that antibiotics were the third most prescribed drugs (Akande and Ologe, 2007). Prescription studies showed that antibiotics constituted 71.8% and 58% of public prescriptions in Tunisia and Islamic Republic of Iran respectively (Salam et al., 2000).

Although antimicrobial agents are appropriate treatment for acute, severe, persistent, or progressive infectious diseases (Thompson and Wright, 1998), their use is known to be a major determinant in the development of resistance (Gyssens, 2001). It has been reported that 14-50% of antimicrobial use in humans were questionable, unnecessary or inappropriate (Guven and Uzum, 2003).

Antimicrobials have been used for infections of various types and locations. The most common reasons for treatment were found to be lower respiratory tract, urinary tract, surgical wound infections and febrile neutropenia (Usher et al., 2005). Among the six different antimicrobials prescribed for respiratory tract infection in Nepal, the most commonly used therapeutic group were the penicillins followed by tetracyclines, macrolides, quinolones and cephalosporins (Dawadi et al., 2003). A study in Nigeria showed that antibiotics were contained in more than half of all the prescriptions and erythromycin and cephalosporins were the antibiotics of choice (Fehintola, 2009). The common antibiotics prescribed by hospital doctors were amoxicillin, cloxacillin, erythromycin and trimethoprim-sulphamethoxazole, but the most frequent antimicrobials reported in a Tertiary Hospital were amoxicillin, ampicillin and ciprofloxacin (Dumo et al., 1999). In a Hospital in Dubai, United Arab Emirates, amoxicillin-clavulanate was the most common antibiotics prescribed (Sharif et al., 2008). A survey on the prescription of antimicrobial drugs in ambulatory patient care in Finland showed that antimicrobial drugs were prescribed 594 times, with tetracyclines being the most commonly prescribed, followed by penicillin (Hemminki et al., 1974). The antimicrobial drugs were prescribed for infections of the upper respiratory tract in remarkable proportion and broad-spectrum antibiotics were most favored (Hemminki et al., 1974). Antibiotics are the frequently prescribed drugs in Hospital Emergency Departments, most of which were broad- spectrum penicillins, followed by quinolones, and urinary antiseptics (Laguna et al., 1996). A pharmacy based prescription audit undertaken in the medical emergency unit of a tertiary care hospital to determine the frequency of prescription of parenteral anti- infective agents, showed that of the 45.2% of patients who received parenteral antiinfective agents, cephalosporins, aminoglycosides and metronidazole accounted for about 70% of total antimicrobial use (Gupta et al., 2004).

CHAPTER THREE

MATERIALS AND METHOD

Materials

Materials used in the study include hand-held stop clock, calibrated spoons, droppers, oral syringe and WHO standardized data collection form.

Study Site

Kano State located in Northwestern Nigeria (11⁰ 30⁰ N, 8⁰ 30⁰E), has a total area of 20, 131 km² and is the most populous state in Nigeria, with a population of about 10,000,000 people (NPC, 2006).

The study site, Hasiya Bayero Paediatric Hospital (HBPH), is an 85 bed paediatric specialist hospital and one of the General Hospitals situated in Kano Municipal Local Government in the central senatorial district of Kano State. It is a secondary health care facility established solely to cater for the paediatric populace in Kano State (excluding neonates and pre-term babies). The hospital attends to patients from infancy to 18 years on outpatient and in-patient bases. An estimated number of at least 500 patients per day attend the out-patient and in-patient departments of the hospital daily.

There are 14 Physicians, out of which only four are full-time staff while the remaining 9 are either House Officers or Medical Doctors on NYSC. The workforce of the Pharmaceutical Services Department consists of only three (3) pharmacists, one (1) pharmacist on NYSC, and ten Pharmacy Technicians during the study period. The nursing department has fifty six (56) nurses, out of which eleven (11) are prescribing nurses. The Primary Health Care Department has fifty three personnel out of which forty seven (47) are either Senior Community Health Extension workers (CHEWS) or Junior Community Health Extension workers (JCHEWS), the remaining six (06) personnel consist of four (4) Dental Technicians and two (2) Dental Assistants. Out of the 47 CHEWS/JCHEWS, thirty three (33) of them prescribe medications to out- patients.

Sample Size

Based on WHO recommendation, at least 600 encounters were included in the study. The Study was carried out from November, 2016 to July, 2017.

CHAPTER FOUR

RESULTS

Demographic characteristics of patients in the study

About 544 (89.9%) of the patients within the age of 0-5years, 55 (9.1%) of the patients were within the age of 6-11years, and 6 (0.5%) of patients are within the age of 12-16 years. These age ranges are consistent with the fact that the site of study is a Pediatric Specialist Hospital. The mean age of patients in the study was 3.5 years with variance and standard deviations of 29.3 and 5.4 respectively. Out of a total of 605 encounters, male patients were the predominant paediatric population accounting for about 367 (60.7%) of patients, while 238 (39.3%) were female (table 4.1).

CHAPTER FIVE

DISCUSSION

The study site, Hasiya Bayero Paediatric Hospital, receive patients of either sex on outpatient and inpatient basis seven days a week. Majority of patients that visited the outpatient department of the hospital were within the age range of 0-5 years and this is consistent with the fact that the site of study is a paediatric specialist hospital. Out of a total of 605 encounters, 60.7% (367) were male patients while 39.3% (238) were female patients.

For a prescription to meet up to standard, it must meet certain criteria regarding the identification of patient (name, address, age, weight, sex, and diagnosis), inscription (body of the prescription which must contain name, strength, frequency and duration of therapy), identity of prescriber (name and signature), subscription and date on which prescription was written. Weight is particularly important for paediatric patients because it determines the strength of medications to be given (according to body weight i.e. mg/kg) and body surface area (mg/m²⁾ rather than age as in the case of adults. Therefore the absence of weight on any prescription portends serious consequences to the patients due to the risk of inadequate dosing (under-dosing or over dosing) of medications. For antibiotics inadequate dosing is a drug therapy problem (DTP) that can lead to the emergence of adverse effects, antibiotic resistance and treatment failure. The identification parameters such as name, weight, age and address of patient were stated in majority of the prescriptions. The name of patient was stated in 523 (86.4%) of patients, weight was stated in 96.5% of patients, while address was stated in 95.5% of patients.

CHAPTER SIX

SUMMARY AND CONCLUSION

Summary

Antibiotics have increased life expectancy where they have been used rationally. If used irrationally, antibiotics can lead to the development of adverse effects, resistance, treatment failure and eroded patient confidence in the health care system. The use of antibiotics in children requires special knowledge and skill because they differ from adults both in terms of pharmacokinetics and pharmacodynamics.

In Nigeria and many other developing countries, drugs are prescribed and dispensed by personnel with low level of training, widely available in the markets, often taken as self- medication not necessarily in complete dosage regimen (Chedi, 2012).

The availability of certain parameters on prescriptions was impressive, except for prescriber identity which was very low. There were very few number of professional health care workers and large number of non-professional health care workers in Hasiya Bayero Paediatric Hospital.

The analysis of drug use indicators showed better values for professional health care workers than non-professional healthcare workers. However, intervention was able to impact positively on the values obtained from the non-professional healthcare workers, as most indicators improved.

DU 90% analysis shows that the professional healthcare workers prescribed more of penicillin antibiotics than cephalosporins, whereas the non-professional healthcare workers prescribed more of the cephalosporins than the penicillins. Whereas amoxicillin/clavulanic acid was the most prescribed and utilized antibiotic by the professional healthcare workers, cefixime was the most prescribed and utilized antibiotic by the non-professional healthcare workers. Cefixime was not one of the antibiotics in the Kano state EML and was only recently (2017) listed in the WATCH group of antibiotics in the WHO EML

ABC, VED and ABC-VED matrix analysis showed that some few antibiotics which are not critical consumed the largest part of antibiotic expenditure in Hasiya Bayero paediatric hospital, while some more critical, more useful antibiotics consumed the smaller part of antibiotic expenditure. Cephalosporin antibiotics particularly consumed the largest part of the hospital’s antibiotic expenditure. There is therefore the need for more prudent spending on the purchase of antibiotics.

Conclusion

This study was designed to assess antibiotic utilization pattern in Hasiya Bayero Paediatric Hospital, Kano State, Nigeria. The prescription format in this facility was good but prescriber’s identity was poor. Drug use indicators for professional health care workers were better than drug use indicators for non-professional healthcare workers. However, intervention offered to the non-professional health care workers resulted in an improvement in most of these values. DU 90% analysis showed that amoxicillin/clavulanic acid was the most utilized antibiotic among the professional health care workers, while cefixime was the most utilized antibiotic among the non-professional health care workers. The ABC, VED and ABC-VED matrix analysis of the pharmacy store showed that some few, less critical antibiotics consumed the largest part of the hospital’s antibiotic expenditure, whereas larger, more useful antibiotics consumed least part of the hospitals’ antibiotic expenditure.

Limitations of the study

The main limitation to this study was that part of the data was collected between November, 2016 and January, 2017, a period characterized by prevalence of cough, cold and
This is a single hospital study; hence findings may not be generalized for all hospitals.

Recommendations

Governmentshould employ more professionals such as Pharmacists and
This will help in ameliorating antibiotic misuse arising from overwork of health personnel and lack of skilled personnel.

Continuing In-service medical education is advocated to improve quality of patient care by improving the skills and competence of health carepersonnel

Government should supervise the distribution and implementation of important documents such as the EML as well as its

Primary Health Care Personnel should adhere to their standing
A multidisciplinary drug and therapeutic committee should be developed to address all aspects of care in the hospital, particularly antibiotic stewardship programmes.

Contributions of the Study to Knowledge

To the best of my knowledge, this is the first of such studies to be conducted in this facility and it has brought out the following:

Lack of skilled and professional health care personnel hampers the proper use of antibiotics in Hasiya Bayero Paediatric Hospital,
The Essential Medicine List, an important document that is crucial to the rational use of drugs was not properly used. This can be seen for example, from the utilization of cefixime (most utilized antibiotic) which was not listed in the Kano State Essential medicine List,
The ABC/VED and ABC-VED matrix analysis shows that more priority can be given towards purchase of more useful drugs and medical consumables by efficient utilization of
Periodic educational interventions on the personnel can assist in improving the use of drugs including antibiotics in the health

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