Retrospective Drug Use pattern of Antibiotics in Pediatric Ward of Shenan Gibe Hospital, Oromia Region, Ethiopia

Retrospective Drug Use pattern of Antibiotics in Pediatric Ward of Shenan Gibe Hospital, Oromia Region, Ethiopia Achalu T1 and Mensa M*2 1B.Pharm, Jimma University, Ethiopia 2B.Pharm MSC, Clinical pharmacist, Arba Minch College of health Sciences, Ethiopia *Corresponding author: Mensa M, B.Pharm, MSC. Clinical pharmacist, Arba Minch College of health Sciences, Ethiopia, Fax: +251046881147, Tel: +251937170976, E-mail: mendemensa@gmail.com Citation: Barghouthi Achalu T, Mensa M (2017) Retrospective Drug Use pattern of Antibiotics in Pediatric Ward of Shenan Gibe Hospital, Oromia Region, Ethiopia. J Antibio Res 1(1): 106. doi: 10.15744/25745980.1.106


Introduction
The evolving public health threat of antimicrobial resistance (AMR) is driven by both appropriate and inappropriate use of antiinfective medicine for human and animal health and food production together with inadequate measures to control the spread Conclusion and Recommendation: In our study use of parenteral antibiotics was relatively higher and almost all treatments were empiric and increased error of dosing; frequency and duration of treatment with combination of therapy this call for the governing body should disseminate relevant information to the hospital to raise the level of awareness about rational use of drugs, prescribing and dispensing of drugs through a continuous in services training, seminars and workshops to reduce use of combined systemic broad spectrum antibiotics which could lead to selection of naturally resistant strains to emerge unless intervened now "No action today: No cure tomorrow. " Study from Indonesia in paediatric wards indicated that the antibiotics were given to 48.7% of the patients. The greatest user of antibiotics was the age group of 1-5 year-old, 50% of patients had been given single antibiotic and the rest given combined antibiotics. Single antibiotics used were Cefotaxime (49.4%), Amoxicillin (20.7%), and Ampicillin (11.55%). Combined antibiotics used were Ampicillin + Chloramphenicol (34.5%), Cotrimoxazole (21.8%), Cefotaxime + Amikacin (5.7%), and Cefotaxime + Cotrimoxazole (5.7%) [22].
Study conducted in Jimma university specialized hospital that the major medical conditions for which antibiotics were prescribed include severe pneumonia (31.23%) and late onset neonatal sepsis with meningitis (20.60%). The average number of antibiotics per patient was 2.17. Only one antibiotic was prescribed in 22.80%, two antibiotics in 51.47% (highest), three antibiotics in 16.91% & four or more than four antibiotics in 8.82% were prescribed. The most commonly prescribed multiple antibiotic was Ampicillin plus Gentamicin (21.9%) followed by Ceftriaxone & Gentamicin (18.1%) [23].
The study from Bishoftu Hospital explored that among the most commonly prescribed antibiotics, Ceftriaxone accounted for 73 (43.50 %) followed by Gentamicin 43 (25.60 % and also the most common reasons for which drugs was prescribed were pneumonia followed by gastroenteritis which made up 72 (56.25 %) and 12 (9.40 %) of the indications respectively. Out of the 242 total number of medication prescribed, parenteral route was accounted for 201 (83.1 %) and the proportion of drugs prescribed in generic name was high which was 234 (97.5 %) [24].
Pediatric population differs in physiology; pharmacokinetics and pharmacodynamics from adult populations. Markets for children's medicines tend to be small and the range of doses used may be wide for any drug formulation because many drugs prescribed widely for infants and children are not available in suitable dosage forms, leading to a lack of attention to pediatric medicines [13,14].
Infectious diseases cause one in every six deaths worldwide and emerging antimicrobial resistance in bacteria threatens management of bacterial infections. In Sub-Saharan, studies on antimicrobial resistance have been done, but, by large, the issue has received far too little attention [15].
Ethiopia has designed national strategic for Containment of Antimicrobial Resistance to facilitate efforts in minimizing the morbidity and mortality due to resistant infections and preserving the effectiveness of antimicrobial medicines. Even though there are indications on the misuse of AMs by health care providers' , unskilled practitioners and animal husbandry and drug users. These coupled with rapid spread of resistant bacteria and inadequate surveillance has exacerbated the problem [16].
Knowledge of drug administration in children and infants lags behind that of adults for many reasons including developmental differences that affect the pharmacodynamic and pharmacokinetic profiles of drugs, ethical and financial reasons, research capabilities, and regulatory guidelines and constraints [17].
Irrational drug use, especially antimicrobials in a pediatric population, has become a commonly noted practice. A study in the USA and Canada has shown that 50% and 85% of antibiotics, respectively, were prescribed inappropriately to children [18].
Study conducted in Mc-Gann Teaching Hospital showed that the average number of antibiotics prescribed per patient was 2.14 ± 0.62 and 92% of patients received multiple antibiotics. The most commonly prescribed single antibiotic was third generation cephalosporin. Most common prevalence of disease among the study was acute GE and it is treated commonly by Cefixime and Gentamicin. Most 75% of the antibiotic prescriptions were based on clinical diagnosis, not on culture report [21].
Studies have indicated that children are prescribed drugs frequently, with a mean number of drugs as high as 5.5. Another study conducted on pediatric drug prescribing in trinidad revealed that 44% of patients had received one or more antibiotics and pediatric patients received 70.8% antibiotics. Most frequently prescribed antibiotics to children were Ampicillin, Chloramphenicol and Gentamicin [19]. Retrospective drug utilization evaluation in pediatric patients in USA showed that large percentages (30%-50%) of antibiotics administered in the USA are given to prevent infection rather than to treat established disease [20].
A study done in Hawassa University Referral Hospital showed that the mean number of antibiotics prescribed per-prescription was 1.18 ± 0.813. The mean number of injection prescribed per-prescription was 1.48 ± 0.766. Seven hundred fifty (64.2%) of the prescriptions were mono drug prescriptions. The most frequently prescribed single antibiotic was penicillin G crystalline 146 (28.4%), followed by Ceftriaxone 128 (24.9%). Four hundred sixteen (35.6 %) of prescriptions were multiple antibiotics and from these the combination of Ampicillin and Gentamicin took the largest portion with 113(27%), followed by Chloramphenicol and Cloxacillin 60(14.4%) [25].
➢ To assess the pattern of antibiotics use among hospitalized Pediatric patients in pediatric ward of Shenen Gibe Hospital, May 2015.
➢ To assess antibiotic use pattern among hospitalized pediatric patients at Shenan Gibe district Hospital

Study Area and Period
The study was conducted in Shenan Gibe Hospital from May 1 st -27 th , 2015. Shenen Gibe Hospital is one of district hospitals found in Oromia regional state and located in jimma town, which about 360 km to south west of the capital city, Addis Ababa. The hospital provides primary and secondary care to peoples Jimma town refers advanced cases to Jimma university specialized hospital.
There was no study conducted in the study area on the same and related topic, so the present study was intend to address issues about rational use of antibiotics in the study area. More ever this study will provide preliminary data to further investigators who are interested to conduct stronger studies. The finding may also call for attention of concerned bodies to make decisions and take measure in the spirit of improving drug use evaluation in particular antibiotics in Shenan Gibe Hospital.

General Objective
Specific objectives ➢ To identify reasons of hospitalization among pediatric patients at Shenan Gibe district Hospital

Study design
Hospital based retrospective descriptive cross-sectional study design was used.

Population
Source population: All pediatrics patient medical history cards in Shenan Gibe hospital.

Eligibility criteria
Study population: All pediatrics patient medical history Cards with antibiotics in Shenan Gibe Hospital at inpatient ward.

Inclusion criteria
➢ Pediatric patient admitted for 24 hour or more ➢ All complete pediatric patients' medical history cards with at least one antibiotic.

Exclusion criteria
➢ Patient received topical antibiotics like ointment and drops.
➢ Medical history record cards of patients who are admitted for less than 24hrs.
➢ Patient received ant TB drugs only.

Sample size determination
The required sample size was calculated using single population proportion formula by considering 50% proportion correct antibiotic use in hospitals because there is no similar study conducted in the study area which was published.

Journal of Antibiotics Research
The average number total Pediatric admissions per year were 1692 patients and hence less than 10,000 therefore it is corrected using finite population correction formula.

Sampling technique
Systematic random sampling technique was used to select pediatrics patient medical records with antibiotics. Every fifth pediatrics patient medical records was selected from average total 1692 pediatrics patient medical records of one year. The first number i.e. number 3 was selected randomly using lottery method. Structured data collected tools were developed after reviewing different literatures and pretested in 5% of actual sample size that is 12 patient cards were used to check the consistency and completeness of the tool. Data was collected by four 5 th year clinical pharmacy students after orientation was given by principal investigators.

Data Collection Instruments and Methods
Questionnaires were prepared in English. The English versions was used for data collection after pretesting on 5% (12) of the actual sample size in Jimma university specialized Hospital pediatrics ward to ensure consistency of tool and possible amendments were made to the questionnaire based on findings. Four 5 th year clinical pharmacy students for data collection and one clinical pharmacist for working in the hospital for supervision were given orientation before data collection about principles to follow during data collection and the contents of data collection format for one day by the principal investigators. Continuous follow up and supervision was made by the principal investigator throughout the data collection period.

Data Collection procedures
The collected data was checked for completeness and consistency by principal investigators on daily basis at the spot during the data collection time. Then data entry was made using Epi-data 3.1 software. After data processing, analysis was made using SPSS version 20.0. A summary descriptive statistics was computed for variables and pattern of drug use. The result was presented by using tables, figures and texts as based on type of data.

Data Processing and Analysis
Antibiotics: Chemotherapeutic agents with activity against microorganisms. Definitive therapy: Treatment based on laboratory finding suggesting specific pathogen. Drug use evaluation: An ongoing systematic process designed to maintain the appropriate and effective use of drugs. Empiric therapy: Treatment based on sign and symptom without confirming pathogen by laboratory. Empiric treatment: Antibiotics administration without laboratory identification of sensitive bacterial pathogen. Incomplete data: Patient card lacking either one or more of the following (Age, sex, drug dose, duration of treatment and diagnosis). Infants: Individuals with Age less than 1 year Injections per prescription: Number of antibiotic injections per a given prescription. Judicious use of drugs: Using drugs with a sound judgment according to present and validated treatment protocol. Kinetic treatment: Treatment undertaken after definitive identification of the causative agent. Neonate: Individuals with birth to 28 days Nosocomial infection: An infection that is acquired in the hospital settings. Pediatrics: Individuals with age up to 14 years Rational use of drugs: A process which involves appropriate prescribing, dispensing and patient use of drugs. Resistance: Refers to irresponsiveness of microorganism to the antibiotics through developing their own mechanism.

Definition of terms
Letter was obtained from the Ethical Review Board of Jimma University, College of Public Health and Medical Science. Permission letters to conduct the study was obtained from, Jimma Zone, health department and Shenan Gibe Hospital administration.

Socio-Demographics Characteristics
Three hundred twenty three pediatrics medical history cards with antibiotics were reviewed in this study. Majority of participants 188 (58.2%) were males and 197 (61%). belongs to age group 0-4 years with mean age of 3.5 years. Regarding duration of hospitalization for 200 (61.9%) was 5 to 9 days with median duration of 5.7 days (Table 1).

Types of diagnosis and Drug use pattern
From the total 323 pediatric patients included in this study, 251 (77.7%) had got empirical diagnosis for their illness during their hospitalization and 73 (22.6%) hospitalized pediatrics had got laboratorial diagnosis for their illness. Concerning purpose of therapy, all the prescribed drugs were prescribed as empiric treatment for 245 (75.9%) and definitive treatment for 78 (24.1%) respectively ( Figure 2).
The number of diseases diagnosed per individual patient 292 (90.4%) had single diagnosis and 31 (9.6%) had two illnesses. Pneumonia was single most common reason for hospitalization which accounts 125 (38.7%) followed by Sepsis 49 (15.2%) and acute gastro enteritis 41 (12.7%). With regard to combined illnesses Pneumonia and Malnutrition accounted 42 (56.8%) followed by malaria and meningitis 23 (31.1%) and sepsis and malnutrition 9(12.2%) (   Concerning the treatment regimens used 58 (46.4%) of pneumonia patients were treated by combination of Gentamicin and Ceftriaxone for 10-days, followed by 32 (25.6%) treated by combination of crystalline penicillin and gentamicin for 7-days. Among patients with gastro-enteritis 21(51.2%) were treated by ceftriaxone and metronidazole for 10-days and majority of sepsis patients 35 (71.4%) were treated by ceftriaxone and gentamicin for 7-days while 6 (66.7%) of meningitis patients were treated by combination of ceftriaxone + gentamicin; and 13 (65%) of Cellulitis patients were treated with Cloxacillin + Gentamicin (Table 3).

Note:
The above table only describes the antibiotic regimens used for treatment it is not comprehensive management of the respective illness Table 3: Distribution of reasons of pediatric hospital admissions and their respective antibiotic treatment given at Shenan Gibe Hospital, May 2015 (n=318) Seven hundred sixty five antibiotics were prescribed for 323 patients; this indicated that 2.37 antibiotic injections per prescription were used for management of hospitalized pediatrics. Most of patients 295 (91.3%) were treated by combination of two antibiotics and 27 (8.4%) were treated with single antibiotic and 21 (6.5%) were treated with three antibiotics. Among this antibiotic combination Ceftriaxone + Gentamicin 97 (32.8%), followed by Ampicillin + Gentamicin 95 (32.1%), and Crystalline penicillin + Gentamicin 38 (12.8%) (

Dose of antibiotics prescribed, frequency and duration of administration
Antibiotics were prescribed with correct dose for 294 (91%) of followed by correct frequency and duration of administration for 280 (86.7%) and 297 (92%) of pediatrics patient respectively. By combination of dose, frequency and duration, 280 (86.7%) of drugs were prescribed appropriately whereas 33 (10.1%) were prescribed inappropriately (  In this study majority of participants 197 (61%) belongs to age group 0-4 years with mean age of pediatrics was 3.5 years. However this lower than study conducted on pediatric drug prescribing in a regional hospital in trinidad which showed that the mean age of the children was 5.52 years, with 85.6% between the age of 1 month and 5 years, and 14.4% over the age 5 years [19]. This could be explained by that the former study was done among all pediatric patients while our study subjects were hospitalized pediatrics and could also be due to difference in sample size.

Discussion
Majority 245 (75.9%) of patients had received empiric treatment while 70(24.1%) had received for definitive therapy. This is higher than Retrospective drug utilization evaluation in pediatric patients in USA showed that large percentages (30%-50%) of antibiotics administered in the USA are given to prevent infection rather than to treat established disease. This practice accounts for some of the most fragment misuses of these drugs [20]. This could be due to difference in advancement in health service delivery system like advanced laboratories for diagnosis of definitive pathogens to target and expertise on antibiotics like infectious disease specialists which are at very young stage in study area.
In our study Pneumonia was single most common reason for hospitalization which accounts 125 (38.7%) followed by Sepsis 49 (15.2%) and acute gastro enteritis 41(12.7%). This is in line with study conducted in Jimma university specialized hospital that the major medical conditions for which antibiotics were prescribed include severe pneumonia (31.23%) and late onset neonatal sepsis with meningitis (20.60%) [23]. Seven hundred sixty five antibiotics were prescribed for 323 patients; this indicated that 2.37 antibiotic per prescription. Most of patients 295 (91.3%) were treated by combination of two antibiotics and 27(8.4%) were treated with single antibiotic and 21 (6.5%) were treated with three antibiotics. This is higher than study conducted in Jimma University specialized hospital showed that the average number of antibiotics per patient was 2.17. Two hundred ten (77.20%) of the patients were exposed to at least two antibiotics [23] and study conducted in, Hawassa showed that the mean number of antibiotics prescribed per-prescription was 1.18 ± 0.813 [25]. These differences may be due to variations in prescribing habits among different hospitals or among the different physicians who may explain these finding which we were unable to determine in this study and also selection of antibiotics in the previous studies were may be based on culture sensitivity testing unlike in our case which was mostly empiric and it could be due to better technological advancement and expertise knowledge in both University specialized hospitals than the study area.
In our study the most commonly used antibiotic combinations were Ceftriaxone + Gentamicin 97(32.8%), followed by Ampicillin + Gentamicin 95 (32.1%), and Crystalline penicillin + Gentamicin 38 (12.8%). This similar to the case of Jimma University specialized hospital showed that the most commonly prescribed multiple antibiotic was Ampicillin plus Gentamicin (21.9%) followed by Ceftriaxone & Gentamicin (18.1%) [23] And study conducted in Hawassa University referral hospital showed that 416 (35.6 %) of the prescriptions were multiple antibiotic prescriptions and from these the combination of Ampicillin and Gentamicin took the largest portion with 113(27%), followed by Chloramphenicol and Cloxacillin 60(14.4%) [25].
Almost all 316(97.6%) of patients were treated with injections except for sulfamethoxazole and clarithromycin which were prescribed as discharge medication for 7 and 6 patients respectively. However this is higher than studies conducted in Dessie prescribed as discharge medication for 7 and 6 patients respectively. With regard to monotherapy used among hospitalized pediatric patients; cotrimoxazole/sulfamethoxazole +trimethoprim accounted for 7(25.9%) followed by clarithromycin 6(22.2%) and cloxacillin 5(18.5%) respectively ( Figure 2).