Pattern of antimicrobial prescription and its cost

Sushma Dawadi, B.S.Rao, G.M.Khan Department of Pharmacy Kathmandu University, Dhulikhel, Kavre, P.O. Box: 6250, Kathmandu, Nepal. Corresponding author,
Many reports from different parts of the world show that antimicrobials are used both widely
and often indiscriminately. Indiscriminate usage could increase the cost of therapy, incidence
of adverse drug reaction, and increase in the rate of emergence of bacterial resistance. There
is evidence to show that antimicrobials are widely used in Nepal. This study relates to the
drug prescribed treatment of Respiratory Tract Infection (RTI), which is a cause of morbidity
and mortality in children and adults. This problem is important considering climate,
geographical and living condition of the people. Out of total 190 patients 20% were
diagnosed as having Upper Respiratory tract infection (URTI), 48.43% had Lower
Respiratory Tract Infection (LRTI) and 31.57% as having chronic obstructive pulmonary
disease (COPD) or asthma. 42.1% were male patients and 57.89% were females. Among the
six different antimicrobials prescribed the most commonly used therapeutic group were
penicillin's (47.36%) followed by tetracycline (43.15%), macrolides (4.2%), quinlones
(3.1%) and cephalosporins (2.1%) .14.56% of the drug was prescribed using generic name
and the remaining 85.43% of the drugs were prescribed using brand name. It was found that
the Maximum and minimum price of antimicrobial regimen in two hospitals were same
although slight difference in brands available was observed. The cheapest antimicrobial
regimen in RTI treatment was Doxycycline, 100 mg once daily for 10 days and the most
expensive was cefixime 400 mg for 7 days. The cost of the same drug varied according to
the brands.

Key words
: AMA-Antimicrobial agent, RTI-Respiratory tract infection, URIT-Upper
Respiratory tract infection, LRTI-Lower Respiratory tract infection

Respiratory tract infections are a major health problem in developing countries3. Infection of
the respiratory tract is the most frequent and important cause of short-term illness in the
population. It is frequently the first infection to occur after birth, and pneumonia is too often
the final illness before death. Respiratory tract infections occur more frequently than they are
reported and are often thought of as inconveniences of life that will pass away quickly;
however, they are responsible for more days of bed disability, restricted activity and lost time
from work and school than any other category of reported acute illness in the united states1.
Respiratory infections account for more than 40% of the disability days secondary to acute
illness, and United States vital statistics indicate that pneumonia and influenza are among the
ten leading cause of death in the population overall and the fourth leading cause of death in
the elderly (65years of age or older). An estimated 2.2 million people, world wide, die yearly
because of acute respiratory infections 1.
KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. Every year Acute Respiratory in young children is responsible for an estimated 4.1 million
deaths worldwide especially pneumonia 5 .It is estimated that Bangladesh, India, Indonesia
and Nepal together account for 40% of global acute respiratory infection mortality. These
respiratory infections can manifest in any area of the respiratory tract, including the nose,
middle ear, throat, voice box, air passage and lungs. As an infection of lungs pneumonias is
one of the major causes for ARI 6. About 90% of ARI deaths are due to pneumonia, which is
usually bacterial in origin (WHO, 1999). In developing countries, where poverty and no
communicable respiratory disease have long been linked, most patients have poor access to
health care; this is even true of the poorest minorities in industrialized countries5. Lung
disease can affect people of all ages, both genders, and all incomes, but affects a
disproportionate share of minority population5.
The human respiratory tract is exposed to many potential pathogens via the smoke, soot, and
dust that are inhaled from the air. It has been calculated that the average individual ingests
about 8 microorganisms per minute or 10,000 per day 5. The respiratory tract is the most
common site for infection by pathogens. This site becomes infected frequently because it
comes into direct contact with the physical environment and is exposed to microorganisms in
the air 8.
Selection of study area: Two hospitals were selected for the study, they are: Tribhuvan
university teaching hospital, Maharajgung and Bir hospital, Kathmandu
Selection of Patient: Inclusive Criteria: Patients included in this study were patients of
different age, diagnosed with one or more RTI either, URTI (Pharyngitis, common cold,
sinusitis), LRTI (Pneumonia, Bronchitis), Chronic (Asthma, COPD) who visited OPD (out
patient department) the two hospitals of Katmandu valley only.
Exclusive criteria: Patients excluded in this study were: The in-patient of the hospitals; Unwilling to participate in the study; Suffering from tuberculosis or lung carcinoma. Size of sample: For this study 190 patients with their prescription were selected. Individual patients were interviewed using the prepared questionnaire for this study after their visit to the doctor. Tool of data collection and technique: The tool used was a set of prepared questionnaire for each patient whose diagnosis was based on clinical evidenced by the doctor and other diagnostic test reports and the technique adopted was personal interview with the patient. All the patients were asked for information about as specified in the questionnaire. Their habits, socio economic status and occupation were also asked as mentioned in the patients' information. Verbal consent was taken from every patient before enrolling in this study. This was an observational study aimed at identifying the current practice and costs associated with antimicrobial prescription. Study Variables of Data: The study variable in the study are - Age, sex, smoking, occupations, clinical diagnosis, investigation carried out, antimicrobial prescribed, other drugs prescribed, brand name, generic name, cost of antimicrobial. KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. Cost analysis of antimicrobial: The cost of antimicrobial was taken into account. Maximum and the Minimum price among the different brands were taken. All the cost of antimicrobial regimen was calculated in Nepalese Rupees. Analysis of data: Compilation of data was done Data were classified in different independent variable The data was tabulated using Excel in the computer Using SPSS did statistical analysis of the collected data. The test used to compare data was chi square at 5% level of significance. The data were significant if P<0.05 Using EXCEL-98 plotted graphs. RESULTS AND DISCUSSION
Survey of the Patient: The Table 1 shows the characteristics of the 190 patients from two hospitals of Kathmandu. It was seen that 42.10%(n=80) were males and 57.89%(n=110) were female patients. The number of smokers were 62.5% (n=50) in male and 56.36% (n=62) in female showing that smoking habit was a little lower in women than in men unlike the study conducted by prevalence of smoking as conducted by WHO in 1998 which supports the fact that percentage of smoking habit was more in male than in female. Also the relation between the smoking habit and RTI has been proven by this study (p=0.000, p<0.05). It was observed that out of 80 males 37.5%(30) were non-smokers and out of 110 females
43.6% (n=48) of them were non-smokers. In context of Nepal one study with medical doctors
by Madan in 1995 states that 65% of the male doctors and 93.75% female doctors were
non-smokers 6.
The reason of illness of the non smokers in the present study could be due to exposure to
domestic smoke caused by wood and straw fires used for cooking and heating purposes in the
ill ventilated houses without chimneys and exposure to environmental pollutions and
insecticides. It was noted that 73.68% (n=140) patients used wood or cow dung as firewood.
The maximum number of patients was farmer 100 (52.63%) .It was also seen that that the
illiterate people was more than literate people.
Pattern of drugs prescribed: The total number of drugs in each prescription was counted along
with the number of antimicrobials. Further, the number of drugs prescribed using generic and
brand names were also counted. The total number of drug prescribed was 412.

The Figure 1 shows that a total number of 412 drugs were prescribed out of which 190 were
antimicrobials. This means that an antimicrobial was prescribed to each patient. It was also
seen in the study that only 14.56% of the drug was prescribed using generic names whereas
the remaining 85.43% of the drugs were prescribed using the brand name. This was also
supported by the Research conducted in different hospitals of Nepal (Katmandu Medical
college teaching hospital –KMC and Nepal medical college teaching hospital- NMC,) by
Nami in 2003, which implies that majority of drugs, were prescribed in brand name
rather than generic name. In KMC 92 out of 95 drugs were prescribed using brand name and
KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. in NMC 84 out of 100 drugs were prescribed using the brand name 8. Thus, there was no
apparent control over the prescribing habits of physicians. The only control was patient's
purchasing power. The drug prescribers tend to use excessive brands of drugs available in the
market. The most likely reasons could be the variation in the prices of the brands available
and the activities of the marketing groups from the pharmaceutical industries or multinational
biasness. The most probable reason for such prescribing is lack of a hospital formulary and
pharmaceutical and therapeutic committee.
The Figure 2 shows that among 190-prescription studied penicillin (47.36%) was the most
prescribed antimicrobial followed by tetracycline (43.1%), macrolides (4.2%), quinolones
(3.1%), and cephalosporin (2.1%). The reason may be due to their broad-spectrum of activity
and fewer side effects, physician's choice and also due to easy availability of these
antimicrobials in the market. Similarly, the children hospital in Winning peg
(schoolenbergand Albritton), also shows that penicillin was the most commonly prescribed
antimicrobial preferred in RTIs 3. Another study conducted in medical wards of University
Hospital, Bangkok revealed that penicillin was the most frequently use atimicrobial agents
followed by cephalosporin and gentamycin 6. 43.15% of tetracycline was chosen due to their
broad spectrum antimicrobial and their antipneumococcal activity. Also the tetracycline is the
cheapest among other antimicrobials. The least prescribed was cephalosporins (2.1%). The
probable reason could be there higher in price.

Pattern of antimicrobial distribution with respect to diagnosis: The Table 2 shows the
anitimicrobial prescribed in URTI, LRTI and chronic cases. It was seen that six different
antimicrobial were prescribed in the study. The most commonly prescribed antimicrobial was
amoxycillin 52.6% for URTIs and 54.3% for LRTI. According to the survey conducted on
antimicrobial resistance in Nepal by Bisista it was found that amoxycillin was 100%
sensitive and 0% resistance when tested in 5 strains of streptococcus pyogens, 100 %
sensitive and 0% resistance when tested in 14 strains of H.influenza and 72.7%sensitive and
27.3% resistance when tested in 11 strains of streptococcus pneumoniae (these three are the
etiological agents responsible for causing RTIs) 5. According to the findings in Sicily in 1998
the most commonly prescribed antimicrobial for URTIs was azithromycin and coamoxiclave
in LRTIs 8. Also Study conducted in UK in 1989 showed that 92% of URTI was treated using
amoxycillin and 90% of LRTI was treated using macrolides especially Azithromycin2. But in
this study only 21.7% of azithromycin was used. This difference may be due to the variation
in the choice of antimicrobial by physician. Doxycycline was the antimicrobial of choice for
chronic case comprising of 41.6% and amoxycillin 25%, unlike amoxycillin or
clarithromycin used by international standards. Clarithromycin was probably not a drug of
choice to the physicians because of its high cost.
Cost analysis: The Maximum and minimum price of antimicrobial regimen in the two
hospitals were same although slight difference in brands available was observed. All brands
of each generic were taken into account and the cost was expressed in Nepali Rupees (NRs).

The above table 3 shows that there was the variation in the price of the brand available. The
cheapest antimicrobial regimen in RTIs was Doxycycline i.e. 100 mg once a day for 10 days
and the most expensive was 400 mg cefixime for 7 days. The cost of the same drug varies
according to the brands and thus the patients had to bear the high cost of the drugs available
as per brand prescribed. This difference of cost within the brands and can be reduced by
prescribing the drugs according to the generic names.
The proper and correct use of antimicrobial is an utmost necessity of current situation in
today's world. The emerging antimicrobial resistance is a global problem directly related to
inappropriate use. This study has shown that antimicrobial is widely prescribed for RTI in all
the cases .Six antimicrobial agents being used, they are Amoxycillin, Doxycycline,
Ciprofloxacin, Azithromycin, Roxithromycin, Cefixime. However the prescribing pattern was
not based upon any laboratory test.

The following recommendations can be made regarding the use of antimicrobials in RTIs of
all age groups.
1) The prescriber should be aware of the costs of the drugs they are prescribing. In some studies from USA 61 has been reported that many prescribes have rather poor knowledge of the drug they are prescribing. Institutional and independent educational training programmed can achieve this. Institutions should encourage practioners to examine their own prescription and to compare the cost effectiveness of alternative therapeutic regimens. 2) Appropriate information about the antimicrobials should be available to the public at 3) Public should be made aware that antimicrobials are strong drugs having side effects and drug interactions. It should not be use for common cold right away because in most case they are of viral origin and antimicrobial are of no use in viral infections, therefore, should not be taken on their own unless prescribed by a doctor. Old prescriptions for any RTIs should not be used for new and recent illnesses. The patient should not discuss their disease with neighbors, friends and chemists to avoid improper use of drugs in general and antimicrobials in particular. National awareness programmes can achieve this and massive educations programmes especially at school levels. 4) Prescriber should be encouraged to use minimum of drug regimen without sacrificing the efficacy of treatment, or therapeutic benefits. 5) Effective antimicrobial national policy should be implemented. 6) Prescription of expensive drugs should be discouraged. KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. REFERENCES
Kimble M, Young L. The Clinical Use of Drugs, Applied Therapeutics, 4th edition. Yach Derek, Hawkes Corinna, J Karen, 2004. The Global Burden of Disease, 291:2616-2622. Erling V, Jalil F, Zaman S, 1999. The impact of climate on the prevalence of respiratory tract infection in early childhood in Lahore, Pakistan, Journal of public Health Medicine, 21:331-339. Pradhan S, 2003. Pattern of antibotic prescription and its cost analysis in adult respiratory tract infection unpublished work. World Health Organization, 2003. Report 2003, shaping the future, Geneva, Switzerland. World Health Organization, 2000. Health situation in South East Asia Region, 185. M. Gabriel, J.Anthony, 2004. The Epidemiology of Severe Acute Respiratory Syndrome in the 2003 Hong Kong Epidemic, 662-673. Chantler C, Griffith S, 2004. Learning from SARS in Hong Kong and Toronto, 291:2483-2487. KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. Table-1: Characteristics of study participants Characteristics %
Habit Smoker-Male 62.5 Smoker-Female 56.4 Non-Smoker-Male 37.5 30 Non-Smoker-Female 43.6 Occupation Farmer Education Literate generic name
brand name
Fig 1: Pattern of drugs prescribed to the patient KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. Antimicrobial Distribution With Respect To The Diagnosis:
Figure 2. Selection of the class of antimicrobials for RTIs % of patient treate 15
Table 2 Pattern of antimicrobial distribution with respect to diagnosis
Diagnosis Antimicrobial %(n=38,92,60)

Amox Azi Doxy Roxy Cipro Cefixim
URTI (52.6%) (13.15%) (7.8%) (26.3%) 0 0
L TI (54.34%) (21.73 %) (16.3%) 0 (5.43%) (2.17%)
CHRONIC (25%) (16.6%) (41.6%) 0 (8.3%) (8.3%)
KATHMANDU UNIVERSITY JOURNAL OF SCIENCE, ENGINEERING AND TECHNOLOGY VOL.I, No.1, SEPTEMBER, 2005. Table 3 Cost of antimicrobial regimen in NRs. 500 mg three times a day 7 days 2 Azithromycin 150 180 500 mg once daily 5 days 3 Doxycycline 35 50 100 mg once daily 10 days 4 Roxythromycin 154 196 150 mg twice daily 7 days 500 mg twice daily 7 days 400 mg once daily 7 days


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