Volume 1, July-Sept 2018
Research Article:
Author’s Affiliation:
1. Pharmacy Department, Sik Hospital
2. Clinical Research Centre, Sultanah Bahiyah Hospital
3. Pharmacy Department, Yan Hospital
4. Pharmacy Department, Baling Hospital
5. Pharmacy Department, Kuala Nerang Hospital
Huan-Keat CHAN - Address: Hospital Sultanah Bahiyah, KM 6, Jalan Langgar, 05460 Alor Setar, Kedah. - Telephone number: +604-7407391 - Fax number: +604-7407373 - Email address: huankeat123@yahoo.com
Received on: 09-Aug-2018
Accepted for Publication: 23-Aug-2018
Article No: 1889Equ011741
PDF - Full Text
The Malaysia National Antibiotic Guidelines (NAG) is used to guide antibiotic prescribing, especially among public healthcare facilities without an in-house infectious disease specialist, setting-based antibiotic guidelines and clinical microbiology services.
To explore the patterns of antibiotic utilisation in children, and to assess the adherence level of antibiotic prescribing to NAG.
A three-month cross-sectional study was undertaken at four non-specialised regional hospitals in Kedah State, Malaysia. All prescriptions which contained at least one oral antibiotic for outpatients below 13 years-old were reviewed. The information including patient demographics, diagnosis, and type and dosage of antibiotics prescribed were recorded. The antibiotic regimens were then compared to NAG.
Of 3,359 paediatric prescriptions reviewed, 909 prescriptions (27.1%) contained at least one oral antibiotic and were analysed. The antibiotics were most commonly prescribed for otorhinolaryngology infections (73.6%), followed by skin and soft tissue infections (13.1%), and community acquired pneumonia (4.6%). The most frequently prescribed antibiotics were amoxicillin (34.9%), phenoxymethylpenicillin (25.6%), and cloxacillin (15.3%). Non-adherence to the NAG’s recommendations was found in 71.8% (653) of the prescriptions, particularly in the drug selection (35.8%) and the dosage used (64.1%).
The information used for the analysis was based solely on what was written on prescriptions. Furthermore, nearly a quarter of the prescriptions received were excluded from the analysis due to insufficient information on the diagnosis.
Majority of the antibiotics prescribed were discordance with the NAG recommendations. This suggests potential inappropriate antibiotic use and warrants approaches to improve the paediatric antibiotic prescribing practice among the non-specialised hospitals.
Key words: Antibiotic, Outpatients, Paediatrics, Inappropriate Prescribing, Malaysia.
Children constitute 26% of the world population, and therefore their health and well-being have been an area of concern.1 It is noteworthy that the majority of paediatric patients presenting to the hospitals have been seeking treatment for acute infections, entailing a high usage of antibiotics.2-4 Despite the introduction of the Antimicrobial Stewardship Program worldwide, inappropriate antibiotic utilisation was still commonly reported.5-8 This has resulted in increasingly severe antimicrobial resistance in paediatric patients,9,10 which eventually leads to treatment failure and increased medical costs.11-12
Hence, in order to promote the rational use of antibiotics in public health care centres, the National Antibiotic Guideline (NAG) was launched in Malaysia in 2008.13,14 It has since then been used by physicians as the most important guide for antibiotic prescribing, particularly in hospitals and health clinics where in-house infectious disease specialists, local antibiotic guidelines and clinical microbiology services are unavailable. As the previous studies related to antibiotic prescribing in Malaysia focused mainly on the adult patients and practices in health clinics,15-17 the current study was designed to specifically assess the antibiotic prescribing patterns in paediatric outpatients, and to investigate the level of adherence to the NAG among the prescribers in public secondary hospitals.
This cross-sectional study was undertaken between 1st January and 31 March 2017 at the outpatient departments of four selected secondary hospitals in Kedah state, Malaysia, which   were operated by 27 medical officers and 10 medical assistants. The study proposal was registered with the National Medical Research Register, Malaysia (NMRR-17-910-35784), and was approved by the Medical Research Ethics Committee, Malaysia.
All the prescriptions of outpatients below 13 years of age received by the four hospitals during the study period were screened by the investigators (pharmacists). The prescriptions containing at least one oral antibiotic were retained for further analysis, except for those of the patients referred from other health care centres. The information on each of the prescriptions, including patients’ age, gender, body weight, diagnosis, and the types and dosage of antibiotics prescribed, was recorded in a data collection form. Subsequently, the prescribing patterns of antibiotics were investigated, while the drug selection and dosage in each of the cases were compared with the NAG’s recommendations. The data analysis was performed using the Microsoft Excel 2010 (Microsoft, Washington), and the results were presented as frequencies and percentages.
Over the three-month study period, the pharmacy departments received a total of 3359 prescriptions of paediatric outpatients, 1194 (35.5%) of which contained at least one oral antibiotic. The patients receiving antibiotics were mostly male (53.1%), with a mean age of 5.52 ± 3.44 years. The majority of the prescriptions (99.7%) contained only one oral antibiotic, while the rest contained two oral antibiotics. The most frequently prescribed antibiotic was amoxicillin (34.9%), followed by phenoxymethylpenicillin (25.6%), and cloxacillin (15.3%). Of all the antibiotic-containing prescriptions, 285 (23.9%) were not included in the subsequent analysis, mainly due to an unclear or unspecified diagnosis (16.5%), a diagnosis for which recommendation was not made in the NAG (5.2%) and multiple diagnoses (2.1%).
In the 909 prescriptions (27.1%) included in the final analysis, antibiotics were most commonly prescribed for otorhinolaryngology infections (73.6%) which included tonsillitis/pharyngitis (428 prescriptions), unspecified upper respiratory tract infections (188 prescriptions), otitis media (49 prescriptions), and otitis externa (4 prescriptions). This was followed by skin and soft tissue infections (13.1%) which consisted of cellulitis (38 prescriptions), impetigo (30 prescriptions), unspecified skin and soft tissue infections (21 prescriptions), scabies (12 prescriptions), abscess (12 prescriptions), and animal bite (6 prescriptions). Meanwhile, there were 42 prescriptions (4.6%) with the diagnosis of community acquired pneumonia. However, it is found that both the antibiotic selection and dosage in only 256 (28.2%) of the prescriptions were consistent with the NAG’s recommendations. Inappropriate antibiotic selection was detected in 35.8% of the prescriptions. Meanwhile, 64.1% of the antibiotics were prescribed out of the recommended dosage range.
Of all the antibiotics used, amoxicillin (59.7%), phenoxymethylpenicillin (24.5%) and cloxacillin (11.2%) were most frequently underdosed. On the other hand, overdosing most commonly involved phenoxymethylpenicillin (2.9%) and amoxicillin (2.0%) (Table 1).
Furthermore, unnecessary antibiotic use was noticed in a number of diseases for which it was not commonly indicated, including acute gastroenteritis, otitis externa, fungal infections, and viral fever (Table 2). Besides, inappropriate antibiotic choice was found to be particularly common in animal bites (100.0%), conjunctivitis (80.0%), and pneumonia (54.8%).
The current study is, to our best knowledge, the first study to review the antibiotic use in paediatric outpatients among the secondary hospitals in Malaysia. It is important to note that these hospitals have been highly dependent on the NAG to guide the antibiotic prescribing, unlike the tertiary health centres which commonly have an in-house infectious disease specialist and are well equipped with facilities to enable the implementation of individualized antimicrobial therapy. Therefore, by comparing how the drugs were used in these hospitals with the recommendations of the NAG, the findings could be useful in disclosing the weaknesses in the current antibiotic prescribing practice. Furthermore, the current study evaluated the antibiotic use in children, adding to the existing literature in Malaysia which have been focusing primarily on adults.15
However, despite the findings on the appropriateness of antibiotics use, it is noted that more than one-third of the paediatric outpatients received at least one oral antibiotic. Similar to a number of previous studies, the antibiotic prescribing rate in paediatric patients shown in this study was relatively high as compared with the recommendation of the WHO (no more than 30%).18-20 This would be expected, as children are generally more prone to infections due to their exploratory behaviours, lack of prior exposure to various infectious agents, and association with other children.21 In addition, in comparison with adults, children more commonly seek medical treatment for acute infections.20,22
When it comes to otorhinolaryngology infections, it is clear that most of the prescribers were unaware of the latest recommendations of the NAG, which were made in accordance with to the clinical evidence. Within this context, erythromycin ethylsuccinate has long been removed from the NAG and other clinical practice guidelines for the treatment of tonsillitis and pharyngitis, mainly due to the increasing resistance rate of Streptococcus sp. to it.14,23-24 Apart from that, inappropriate dosing was of concern, particularly for amoxicillin. In this study, the rate of inappropriate dosing was found to be much higher than that reported by Ergül B, et al.25 In fact, both inappropriate selection and dosing of antibiotics have been shown to continuously result in ineffective treatment, prolonged treatment duration, unnecessary exposure of patients to adverse drug reactions, and ultimately, the development of antimicrobial resistance. Consequently, it has increased the healthcare expenses and mortality. In response to this trend, materials to promote the rational use of antibiotics in paediatric patients, such as a simplified version of the NAG and a standard weight-based antibiotic dosing table, could be helpful to the prescribers.
Additionally, the regular use of antibiotics for both the non-bacterial infections and non-infectious diseases demonstrated in the current study was worth highlighting. A recent study in Malaysia showed that several factors such as lack of confidence in choosing the right antimicrobial treatment, patient insistence for antibiotics and low awareness of antimicrobial resistance may lead to overprescribing of antibiotics.26 Hence, multifaceted approaches such as educational interventions and profiling report can be carried out to improve antibiotic prescribing practices.27,28
Nevertheless, irrespective of all the findings, the current study had several limitations.  First, the information used for the analysis, particularly the diagnosis, was based solely on what was written on prescriptions. It was likely that some of the reasons that could support the use of an antibiotic were not captured in a prescription. Also, nearly a quarter of the prescriptions received were excluded from the analysis due to insufficient information on the diagnosis. Hence, further investigation on these prescriptions is recommended to determine if the antibiotics were appropriately used.
These findings suggest an inappropriate antibiotic use in paediatric outpatients presenting to secondary hospitals in Malaysia, as the antibiotic selection and dosage used in the majority of the prescriptions was not in line with the NAG’s recommendations. While antimicrobial resistance has been posing a major challenge to the public healthcare system, a multidisciplinary approach is thus urgently required to revise the current antibiotic prescribing practice.
We wish to thank the Director General of Health, Malaysia for his permission to publish the findings for this study. Besides, all the staffs from the Sik, Yan, Baling and Kuala Nerang Hospitals, who had helped us in acquiring the data, are acknowledged.
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