Prescribe Pattern of Drugs and Antimicrobials Preferences in the Department of ENT at Tertiary Care SGM Hospital, Rewa, MP, India

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1 ORIGINAL ARTICLE Prescribe Pattern of Drugs and Antimicrobials Preferences in the Department of ENT at Tertiary Care SGM Hospital, Rewa, MP, India ABSTRACT Aims and Objectives The aim of this study is to analyze the prescription, determine the drug utilisation patterns and preferences of antimicrobials used in the Department of ENT OPD at a tertiary care hospital of central India, MP. Materials and Methods The study was conducted in the Department of Pharmacology & ENT from September 2013 to June The prescriptions were collected randomly from the patients attending OPD of the ENT department; after taking the patients consent, a copy of the prescription was taken and analysed. Results Total 316 prescriptions were analysed; most of the prescriptions (35.75%) belonged to the age group of years, total 764 drugs were prescribed; in which maximum [34.29% (262)] belonged to antimicrobials group. Amongst antimicrobials (n = 262), fluoroquinolones [48.09% (126)] were the most frequently prescribed group followed by penicillin [37.40% (98)], and macrolides [11.83% (31)]. Overall, ciprofloxacin (24.42%) was most frequently prescribed antimicrobials (AMAs) followed by ofloxacin (22.13%), amoxicillin (16.03%), ampicillin (10.30%), azithromycin (7.25%), amoxicillin + cloxacillin (6.87%), amoxicillin + clavulanate (4.19%) and erythromycin (3.05%). Conclusions Results of this study showed that AMAs, non-steroidal anti-inflammatory drugs (NSAIDs) and nutritional supplements were the most frequently prescribed drug groups. Ciprofloxacin, ofloxacin, amoxicillin and ampicillin are most commonly prescribed antimicrobials in decreasing order. The total number of drugs per prescription is slightly more than that of WHO guidelines. KEYWORDS prescriptions, ear, nose and throat (ENT), outpatient department (OPD), antimicrobials, polypharmacy INTRODUCTION Infectious diseases are among the commonest causes of morbidity and mortality in most developing countries of the world. 1 Diseases of the ear, nose and throat (ENT) affect adults and children, with significant impairment in daily life. 2 Antimicrobial drugs used to treat disorders caused by bacteria, viruses, protozoa and fungi, evidently require huge prescriptions in African nations 1. Upper respiratory tract infections (URTIs) including nasopharyngitis, pharyngitis, tonsillitis and otitis media constitute a major proportion of the total episodes of respiratory infections. 3 URTI constitute the majority of respiratory tract infections and the presenting manifestations are coughs or colds. Coughs and colds are also known as the common cold, coryza, acute nasopharyngitis or acute pharyngorhinitis. 4 Pharyngitis and tonsillitis account for >10% of all visits to primary care clinics and 50% of outpatient antibiotic use. 5 The vast majority of acute URTIs are caused by viruses therefore, most cases of rhino sinusitis are resolved spontaneously without antimicrobial therapy. 3 The majority of antibiotics prescribed for respiratory and ENT infections are for rhino-pharyngitis and acute bronchitis, the antibiotic prescriptions are made in approximately 40% of all consultations for rhino-pharyngitis and 80% of those for acute bronchitis. Antibiotics were prescribed in more than 90% of cases of pharyngitis, irrespective of the age of the patients. 6 Antibiotic prescription pattern differs from country to country, ISSN No CODEN NLM Title DOI JPBSCT Indurkar Pallavi 1, Shrivastava Roshani 2, Singh Amita 3, Singh Prabhakar 4* 1 Demonstrator, Department of ENT, S.S. Medical College, Rewa, MP, India 2 PG 3 rd year Student, Integral Institute of Medical Science & Research, Lucknow, UP, India 3 Assistant Professor, Department of Physiology, S.S. Medical College, Rewa, MP, India 4 Associate Professor, Department of Pharmacology, S.S. Medical College, Rewa, MP, India Address reprint requests to *Dr Prabhakar Singh. Associate Professor, Pharmacology, S.S. Medical College, House No: 721/11, Indra Nagar, Bara, Rewa, MP, , India prabhakarsingh999@gmail.com Article citation: Pallavi I, Roshani S, Amita S, Prabhakar S. Prescribe pattern of drugs and antimicrobials preferences in the department of ENT at tertiary care SGM hospital, Rewa, MP, India. J Pharm Biomed Sci 2016;06(02): Available at Statement of originality of work: The manuscript has been read and approved by all the authors, the requirements for authorship have been met, and that each author believes that the manuscript represents honest and original work. Sources of funding: None. J Pharm Biomed Sci Competing interest / Conflict of interest: The author(s) have no competing interests for financial support, publication of this research, patents, and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Disclaimer: Any views expressed in this paper are those of the authors and do not reflect the official policy or position of the Department of Defense. Copyright 2016 Received Date: 16 October 2015 Accepted Date: 20 December 2015 Published Online: 10 February 2016

2 90 Prabhakar Singh or even from region to region, which is attributable to various factors such as the infecting organisms and antimicrobial susceptibility, physician preference and costs. The various indicators were developed by International Network for the Rational Use of Drugs (INRUD) in collaboration with WHO that provided objective indices to allow for assessment of drug use practices. 7 Therefore, it is imperative to evaluate and monitor the drug utilisation patterns from time to time, to enable suitable modifications in prescribing patterns, to increase the therapeutic benefit and decrease the drug adverse effects and to optimizes the medical service for the patents. MATERIALS AND METHODS This observational study Prescribe pattern of drugs and antimicrobials preferences in department of ENT at tertiary care SGM Hospital, Rewa, MP, India was conducted in the Department of Pharmacology and Outpatient Department of ENT, SS Medical College and associated SGM Hospital, Rewa (MP); from September 2013 to June The prescriptions were collected randomly from the patients attending the Department of ENT OPD and prescriptions slip were taken in form of Xerox copy after taking the consent from patients. Data were analysed by Microsoft Excel 2007 and value was expressed in percentage. RESULTS In this study, total 316 prescriptions were analysed; most of the prescriptions belonged to the age group of yrs (35.75%) followed by (34.17%), (10.12%), (7.59%), (6.64%), 0 12 (4.11%) and >63 (1.58%) yrs (Fig. 1). About 59.17% (187) of these were males and 40.82% (129) were females (Fig. 2). In these 316 prescriptions, total 764 drugs were prescribed; in which maximum [34.29% (262)] belonged to antimicrobials group, 24.60% (188) non-steroidal anti-inflammatory drug (NSAID), 24.47% (n = 187) nutritional supp, 13.48% (n = 103) anti-ulcer drugs, 2.74% (n = 21) ear drops and 0.393% (n = 3) CNS drugs (Fig. 3). The average number of drugs per prescription was 2.42, and average number of antimicrobials (AMAs) per prescription was Of total prescriptions, 41.45% (131) prescriptions have four drugs, 31.01% (98) have three drugs, 17.08% (54) have two, 8.54% (27) have fives and 0.949% (3) has one or more than five drugs (Table 1). In total, 764 prescribed drugs; 41.62% (318) were prescribed by their generic names and 58.37% (446) by brand names. In 9.17% (29) prescriptions, there was no mention on the dose, dosing and schedules and in 11.39% (36) the duration of therapy was not mentioned (Table 2). Amongst antimicrobials (n = 262), fluoroquinolones 48.09% (126) was the most frequently prescribed group followed by 37.40% (98) penicillin s, 11.83% (31) macrolides, 1.14% (03) cephalosporins and 1.52% (04) others (Fig. 4). The most Fig. 1 Age-wise distribution of prescriptions of patients attending ENT OPD. Fig. 2 Sex-wise distribution of prescriptions of patients attending ENT OPD. Fig. 3 Frequency of group-wise prescribed drugs in prescriptions of patients attending ENT OPD. frequently prescribed AMAs was ciprofloxacin 24.42% (64) amongst fluoroquinolones followed by ofloxacin 22.13% (58) and levofloxacin 1.52%. Amoxicillin 16.03% (42) amongst penicillin followed by ampicillin 10.30% (27), amoxicillin + cloxacillin 6.87% (18) and amoxicillin + clavulanate 4.19% (11). Azithromycin 7.25% (19) amongst macrolides followed by erythromycin 3.05%

3 Antimicrobial prescription pattern 91 Table 1 Distribution of prescriptions on basis of number of prescribed drugs in ENT OPD. No. of drugs per prescription No. and percentage of prescriptions Numbers Percentage (%) > Table Total Essential parameters after analysis of prescriptions. WHO defined essential parameters Total number of prescriptions Total number of drugs prescribed Average number of drugs per prescription Average number of AMAs per prescription Number of drugs prescribed by generic name (n = 764) Drugs prescribed under brand name (n = 764) Dose and dosage not mentioned (n = 316) Duration of therapy not mentioned (n = 316) Numbers Percentage (%) 316 NA 764 NA 2.41 NA 2.42 NA % Fig. 4 Frequency of different antimicrobials prescribed in prescriptions of patients attending ENT OPD. (08) and roxithromycin 1.52% (04). The cefixime was most common [1.14% (03)] prescribed cephalosporins, chloroquine and metronidazole both are prescribed in 0.76% of prescriptions (Table 3). The overall prescribing frequency amongst antimicrobials are ciprofloxacin 24.42% ofloxacin 22.13%, amoxicillin 16.03% ampicillin 10.30%, azithromycin 7.25%, amoxicillin + cloxacillin 6.87%, amoxicillin + clavulanate 4.19% and erythromycin 3.05% in decreasing order. DISCUSSION Providing the right medicine to the right people at the right time is a central priority of health care system. The way to ensure this is through the effective implementation of the WHO s recommendation on rational drug policies. The audit data will be of great value to health administrators, manufacturers, distributors and health professionals group for their decision making and drafting policies. In this study the maximum prescriptions (35.75%) of patients attending ENT OPD belonged to the age group of yrs, this would probably be because this age group was more ambulatory and occupational workers who come to the clinic to meet their healthcare needs. Of these, males were predominant(59.17%) similar to the studies of Shankar 8 and Pradhan et al. 9, this may occur as they easily approach the physician. However opposite to our study, certain studies 10,11 showed that females are more sensitive to ENT infections than males, the reason might be their exposure to kitchen smoke. The AMAs were most frequently (34.29%) prescribed drugs (in 82.91% of prescriptions) followed by NSAID 24.60% (in 59.49% of prescriptions) and nutritional supplements 24.47% (in 59.17% of prescriptions) in this study, this was somehow similar to Admane et al. 12 (in which antimicrobials were prescribed 30.25% of total prescribed drugs), Lisha et al. 13 (in which antimicrobials were prescribed in 85%, analgesics 78.5% and antipyretics in 57.9% of prescriptions) and Arcojit et al. 14 study (in which antibiotics were prescribed in 74% and analgesics/antipyretics in 57% of prescriptions). Amongst antimicrobial (n = 262) drugs; the most frequently prescribed group was fluoroquinolones 48.09% followed by penicillins 37.40%, macrolides 11.83%, cephalosporins 1.14%, this was similar to a study by Das et al. 15 in which ciprofloxacin was most commonly (23.85%) prescribed fluoroquinolones followed by amoxicillin (20.06%) and combination of ampicillin + cloxacillin (9.17%). However; various 12,14 other studies showed dissimilar results to our study in which β-lactam antibiotic, amoxicillin were most commonly prescribed; however in a study by Rajesh Kumar et al. 16 amoxicillin + clavulanic acid (55%) was most commonly prescribed AMAs. The average number of drugs per prescription is an important indicator for assessing rationality of prescriptions, hence it is preferable to keep the mean number of drugs per prescription is as low as possible because

4 92 Prabhakar Singh Table 3 Frequency of prescribed different AMAs in the Department of ENT OPD. Class of antimicrobials Numbers and percentage of antimicrobials Name of antimicrobials Number (n = 262) In own groups Percentage In over all 1. Erythromycin Macrolides 2. Roxithromycin (n = 31) 3. Azithromycin Cephalexin Nil Cephalosporin 5. Cefixime (n = 03) 6. Cefpodoxime Nil Ampicillin Penicillin Amoxicillin (n = 98) Amoxicillin+cloxacillin Amoxicillin+clavulanate Ciprofloxacin Quinolones 12. Ofloxacin (n = 126) 13. Levofloxacin Antiamoebics Metronidazole (n = 02) Ornidazole Nil Antimalarials Chloroquine (n = 02) Quinine Nil higher numbers of drug always lead to increased risk of drug interactions, development of bacterial resistance and increased cost In our study, 41.45% (131) prescriptions have four drugs and 31.01% have three drugs; this was dissimilar to Admane et al. 12 in which three drugs were prescribed in 52.15% and four drugs in 19.78% of prescriptions. Polypharmacy was encountered in the present study, the average number of drugs per prescriptions were 2.42, this was similar to Nandimath et al. 20 and it was more than Arcojit et al. 14 study in which 1.98 drugs were prescribe per prescriptions. The average number of AMAs per prescription was 0.82, which was less than Das et al. 15 study in which average AMAs were 1.4. In present study, 41.62% drugs were prescribed by their generic names which were less than compared to the studies by Arcojit et al. 14 and Admane et al. 12 in which 60% and 79.18% drugs were prescribed by generic names respectively. CONCLUSION This study was mainly focused on prescribing pattern of drugs and antimicrobial utilization preferences in department of ENT. An antibiotic policy has been developed for the doctors treating the infectious diseases using the rational drugs and doses and prevents the development of antimicrobials resistance. Antibiotics, NSAIDs and nutritional supplements were principally prescribed drugs. Ciprofloxacin, ofloxacin, amoxicillin, ampicillin and azithromycin were preferred antimicrobials in decreasing order. The total number of drugs per prescription is slightly more than that of WHO guidelines and the prescribing rate of drugs by generic name was somehow lower than that of others study. REFERENCES 1. WHO. World Health Statistics 2008: Mortality and Burden of Disease. Geneva: WHO; pp Grace NN, Bussmann RW. Traditional management of ear, nose and throat (ENT) diseases in Central Kenya. J Ethnobiol Ethnomed. 2006;2: Jain N, Lodha R, Kabra SK. Upper respiratory tract infections. Indian J Pediatr. 2001;68: Guru Prasad NB, Kulkarni Dhananjay, Rajasekhar CH, Rajesh D, Raghavendra AY, Vinodraj K, Advaitha MV, Nikhilesh Anand. A study of prescription pattern of antimicrobial usage in ear, nose and throat infections of a rural teaching hospital. J Evolution Med Dent Sci. 2014;3(60): Linder JA. Evaluation and management of adult pharyngitis. Compr Ther. 2008;34(3 4): Needham A, Brown M, Freeborn S. Introduction and audit of general practice antibiotic formulary. J R Coll Gen Pract. 1988;38: Laporte JR, Porta M, Capella D. Drug utilization studies: a tool for determining the effectiveness of drug use. Br J Clin Pharmacol. 1983;16: Shankar PR, Upadhyay DK, Subish P, Dubey AK, Mishra P. Prescribing patterns among pediatric inpatients in a teaching hospital in western Nepal. Singapore Med J. 2006;47: Pradhan S, Jauhari AC. A study of antibiotics used in adult respiratory disorders in Kathmandu and Bhaktapur. Nepal Med Coll J. 2007;9:120 4.

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