Objective: To study and analyze the pattern of antimicrobial utilization in urinary tract infection (UTI).Methods: A descriptive retrospective study was conducted in tertiary care hospital for 6 months including both male and female patients of all agegroups. Case sheets diagnosed with UTI based on ICD-10 disease coding were collected from medical records department. The demographic dataand prescription pattern of each case sheet were evaluated in detail. Drug utilization pattern was compared among different age groups of patients.Results: A total of 108 patients were included in the study, out of which 44.4% were males, and 55.6% were females. Most of the patients were in40-60 years age group (40.7%). UTI confirmed by culture in 59.26% patients; in which Escherichia coli was isolated in 35.9% patients followedby Klebsiella species (14.06%) and Pseudomonas aeruginosa (7.8%). Cephalosporins (70.37%) were most commonly used antibiotic followed byfluoroquinolones (38.89%), penicillins (29.63%), azithromycin (17.59%), and aminoglycosides (15.74%). Among the cephalosporins, third generationparenteral was most commonly used. In penicillins, amoxicillin + clavulanic acid combination was used in 9 patients. Amikacin was most commonlyused aminoglycoside followed by gentamicin. Mean duration of treatment was 6.28Â±3.02 days.Conclusion: Third generation cephalosporins (ceftriaxone and cefixime) were used as first line drug in most of the cases irrespective of the causativeorganism. This group should be reserved for complicated UTIs.Keywords: Urinary tract infections, Escherichia coli, Cephalosporins, Fluoroquinolones

A JADHAV, SUJATA

C KHANWELKAR, CHITRA

G NAIK, HARISH

M THORAT, VANDANA

R DESAI, ROHIT

S GIDAMUDI, SUNIL

English

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Vol 8, Issue 6, 2015 ISSN - 0974-2441ANTIMICROBIAL UTILIZATION PATTERN OF URINARY TRACT INFECTION IN TERTIARY CARE HOSPITALSUNIL S GIDAMUDI1*, SUJATA A JADHAV2, CHITRA C KHANWELKAR2, VANDANA M THORAT2, ROHIT R DESAI3, HARISH G NAIK41Department of Pharmacology, BKL Walawalkar Rural Medical College, Kasarwadi, Maharashtra, India. 2Department of Pharmacology, Krishna Institute of Medical Sciences, Karad, Maharashtra, India. 3Senior Pharmacovigilance Physician, Quintiles India Pvt. Ltd., Bengaluru, Karnataka, India. 4Department of Pharmacology, Kanachoor Institute of Medical Sciences, Deralakatte, Mangalore, Karnataka, India. Email: sunilsg.jnmc@gmail.comReceived: 23 July 2015, Revised and Accepted: 24 September 2015ABSTRACTObjective: To study and analyze the pattern of antimicrobial utilization in urinary tract infection (UTI).Methods: A descriptive retrospective study was conducted in tertiary care hospital for 6 months including both male and female patients of all age groups. Case sheets diagnosed with UTI based on ICD-10 disease coding were collected from medical records department. The demographic data and prescription pattern of each case sheet were evaluated in detail. Drug utilization pattern was compared among different age groups of patients.Results: A total of 108 patients were included in the study, out of which 44.4% were males, and 55.6% were females. Most of the patients were in 40-60 years age group (40.7%). UTI confirmed by culture in 59.26% patients; in which Escherichia coli was isolated in 35.9% patients followed by Klebsiella species (14.06%) and Pseudomonas aeruginosa (7.8%). Cephalosporins (70.37%) were most commonly used antibiotic followed by fluoroquinolones (38.89%), penicillins (29.63%), azithromycin (17.59%), and aminoglycosides (15.74%). Among the cephalosporins, third generation parenteral was most commonly used. In penicillins, amoxicillin + clavulanic acid combination was used in 9 patients. Amikacin was most commonly used aminoglycoside followed by gentamicin. Mean duration of treatment was 6.28±3.02 days.Conclusion: Third generation cephalosporins (ceftriaxone and cefixime) were used as first line drug in most of the cases irrespective of the causative organism. This group should be reserved for complicated UTIs.Keywords: Urinary tract infections, Escherichia coli, Cephalosporins, Fluoroquinolones.INTRODUCTIONDrug utilization has been defined as the marketing, distribution, prescription, and use of drugs on society with special emphasis on the resulting medical and social consequences [1]. For the past few decades, more attention is being given to rational prescribing. Drug utilization studies are playing a major role in detecting any faults in the therapy and also find out solutions to rectify the same.Rational drug prescribing is defined as “the use of the least number of drugs to obtain the best possible effect in the shortest period and at a reasonable cost” [2-4]. Monitoring of prescription and drug utilization studies could identify the associated problems and provide feedback to the prescriber so as to create awareness about the irrational use of drugs [5-7]. It is necessary to define the prescribing pattern and to target the irrational prescribing habit for sending a remedial message [8].Urinary tract infection (UTI) is defined as the presence of bacteria in urine along with symptoms of infection [9]. UTI is an extremely common condition that occurs in both male and female of all the ages. The prevalence and incidence of UTI is higher in women than in men due to several clinical factors including anatomic differences, hormonal effects, and behavioral pattern [10]. Etiology is influenced by factors such as age, diabetes, spinal cord injury, urinary catheterization, and other factors [11]. UTI is mostly caused by gram-negative aerobic bacilli found in the gastrointestinal tract. These are Escherichia coli, Klebsiella, Enterobactor, Citrobacter, and Proteus. Other common pathogens include Staphylococcus epidermidis, Staphylococcus saprophyticus, and Enterococcus species which presumably result in UTI following colonization of the vagina or perianal skin [12].The goals of the management of UTI are: (i) Prompt diagnosis of concomitant bacteremia; (ii) prevention of progressive renal disease by prompt eradication of the bacterial pathogen, identification of abnormalities of the urinary tract and prevention of recurrent infections; and (iii) resolution of the acute symptoms of the infection. Delay in initiation of the antibacterial therapy is associated with an increased risk of renal scarring. The initial choice of antibacterial therapy is based on the knowledge of the predominant pathogens in the patient’s age group, antibacterial sensitivity patterns in the practice area, the clinical status of the patient, and the opportunity for close follow-up. The patients with significant urinary tract abnormalities and/or frequent symptomatic UTI may benefit from prophylactic antibacterial therapy. The main long-term consequence of UTI is renal scarring which may lead to hypertension and end-stage renal disease. Prevention of recurrent UTI focuses on detection and correction if possible, of urinary tract abnormalities [13]. Empirical treatment goals should be based on accurate and up-to-date antimicrobial susceptibility. The objective was to study the distribution of UTI, to find out the antimicrobial sensitivity profile of microorganisms responsible for UTI, and to evaluate the antimicrobial utilization pattern in UTI in tertiary care hospital at Karad.METHODSThe study was conducted in the Department of Pharmacology, Krishna Institute Medical Sciences, Karad, Maharashtra. This is the retrospective record based study of patients admitted to Krishna Hospital and Research Centre, Karad, Maharashtra with a diagnosis of UTI during the period of September 2012-February 2013. The case sheets were collected from the medical records department based on the ICD-10 disease coding. The demographic data and prescription pattern of Research ArticleAsian J Pharm Clin Res, Vol 8, Issue 6, 2015, 161-164 Gidamudi et al. 162each case sheet were evaluated in detail. The relevant investigations (microbiological and hematological) were noted down along with the urine culture report wherever available with the antimicrobial sensitivity testing. Comorbid conditions were noted down. Dose, frequency and duration of treatment with antimicrobial used to treat the UTI were recorded. Antimicrobial utilization pattern was compared among different age groups (1-10; 10-20; 20-40; 40-60; >60 years) of patients. The condition of the patient at the time of discharge was also noted. Descriptive statistics were used to describe the antimicrobial utilization pattern.Permission was obtained from the Ethics Committee of the institution for conducting the study. The purpose of the study was explained, and confidentiality was ensured.RESULTSThe total of 108 patients were included in the study, out of which 44.4% (n=48) were males, and 55.6% (n=60) were females. The demographic data of patients is as shown in Table 1. UTI was more frequent in the age group of 40-60 years. UTI was equally frequent in both gender in <10 year age group; increased frequency in females from 10 to 60 years, but male had higher frequency after 60 years.Comorbid conditions with UTI are shown in Table 2. Diabetes mellitus was most common comorbid condition followed by hypertension and renal or ureteric calculi. Some patients had more than one comorbid conditions; therefore, sum total was more than 100%.Urine culture was done in 59.26% (n=64) patients, out of which culture was positive in 65.63% (n=42) patients, sterile in 26.56% (n=17) patients, and no significant growth in 7.81% (n=5) patients. In the remaining patients (n=44), the diagnosis was based on the clinical symptoms and microscopic examination of the urine which showed the presence of a significant number of bacteria or pus cells. Isolated organisms in urine culture are shown in Fig. 1. In 9 patients, 2 organisms were isolated and in 3 patients, 3 organisms were isolated; therefore, sum total of percentage was more than 100%.Since E. coli (n=23) was the most common isolated organism, so the antimicrobial sensitivity pattern of E. coli has shown in Figs. 2 and 3. E. coli was resistant to ampicillin in 86.96% (n=20) patients and to ceftriaxone in 82.61% (n=19) patients, and it was sensitive to amikacin in 91.3% (n=21) patients but to ceftriaxone only in 13.04% (n=3) patients.Distribution of antimicrobial utilization is shown in Table 3 and Fig. 4. Cephalosporins (70.37%) were most commonly used antimicrobial followed by fluoroquinolones (38.89%), penicillins (29.63%), azithromycin (17.59%), and aminoglycosides (15.74%).Among the cephalosporins, third generation parenteral cephalosporins (ceftriaxone, cefotaxime, cefoperazone) were used most commonly Table 1: The demographic data of patientsAge group (years)Gender n (%)Frequency Total<10 Male 1 (50) 2 (1.9)Female 1 (50)10-20 Male 1 (25) 4 (3.7)Female 3 (75)20-40 Male 6 (31.6) 19 (17.6)Female 13 (68.4)40-60 Male 15 (34.1) 44 (40.7)Female 29 (65.9)>60 Male 25 (64.1) 39 (36.1)Female 14 (35.9)Total Male 48 (44.4) 108 (100)Female 60 (55.6)Table 2: Comorbid conditions with UTIAssociated diseases Male Female TotalDiabetes mellitus 19 13 32Hypertension 16 10 26Renal/ureteric calculi 4 8 12Renal Failure 9 1 10Malaria 4 0 4Prostatomegaly 6 - 6Chronic kidney disease 2 2 4Nephropathy 1 3 4Total 61 37 98UTI: Urinary tract infectionFig. 1: Isolated organisms in urine cultureFig. 2: Antimicrobials resistant to Escherichia coliFig. 3: Antimicrobials sensitive to Escherichia coliAsian J Pharm Clin Res, Vol 8, Issue 6, 2015, 161-164 Gidamudi et al. 163and were switched over to the third generation oral cephalosporin (cefixime) in 20 patients after the 4th or 5th day. Fourth generation cephalosporin cefepime was used in 3 patients. Ciprofloxacin (80.95%) was the most commonly used fluoroquinolone which was shifted from parenteral to oral after 4 days in 10 patients. Among penicillins, amoxicillin + clavulanic acid combination was used in 9 patients followed by piperacillin + tazobactam in 4 patients. Amikacin was the most commonly used aminoglycoside in 12.96% (n=14) patients followed by gentamicin and netilmicin.Mean duration of treatment was 6.28±3.02 days with a minimum duration of 2 days and a maximum of 15 days. 83.33% (n=90) patients improved from disease and 16.67% (n=18) patients remained unchanged at the time of discharge. There was no mortality observed during the study period.DISCUSSIONThe objective was to study the distribution of UTI, to find out the antibiotic sensitivity profile of microorganisms responsible for UTI, and to evaluate the antibiotic utilization pattern in UTI in tertiary care hospital at Karad.The present study has shown the prevalence of UTI has increased after the age of 40 years in both males and females. Higher frequency of UTI in females is in the age group of 40-60 years; whereas higher preponderance in males after 60 years of age (Table 1). Higher frequency in elderly patients may be due to increased incidence of diabetes mellitus which is more associated with male patients (Table 2). This is in accordance with the study Mahesh et al. [14] and Pargavi et al. [15] where the author states that UTI is more common in diabetic male patients with poor glycemic control. It is of equal frequency in both male and female children of <10 years age in this study. It is in contrary to the study Qureshi [16] where the author states that UTI is more frequent in boys in the first 3 months of life, with sex distribution of 5:1 (male predominance). By preschool age, the sex ratio is reversed, with the majority of UTI occurring in females.E. coli was the most common organism isolated in urine culture in the present study followed by Klebsiella species (Fig. 1). This result is similar to the study by Pargavi et al. [15] and J. Mohan et al. [17]. E. coli was more sensitive to amikacin (91.3%) [18] but least sensitive to ceftriaxone (13.04%) (Figs. 2 and 3). This result is in agreement with Arul et al. [10].The present study has shown that third generation cephalosporins were the most common prescribed antibiotic (Table 3 and Fig. 4). This is in agreement with earlier study Bay and Anacleto [19], whereas it is in contrary to the result of Mohan et al. [17] where amikacin is the most common prescribed antibiotic in the treatment of UTI.This study is not intended to speak about the decision of appropriateness in the treatment with antimicrobials against any known guidelines. Rather, the purpose is to notice the antimicrobial prescription practices in tertiary care hospital with known incidence of culture sensitivity to microorganisms. So, present study throws light for the development of guidelines for the treatment of UTI in accordance with changing susceptibility of microorganisms to the antimicrobials and changes in the empirical treatment so to cut short the morbidity of the patient and the hospital stay.CONCLUSIONThird generation cephalosporins were used most commonly as first line drug, irrespective of the causative organism. This group should be reserved for complicated UTIs. Periodic review of antimicrobial sensitivity should be done, so that change in empirical treatment can be updated. These results highlight the need for an education program for the health care system to improve the adherence toward the standard guidelines for treatment of UTI.ACKNOWLEDGMENTAuthors wish to acknowledge the Medical Director of Krishna Hospital and Research Centre, Karad and the staff of Medical Record Department for retrieving the case sheets during the study period.REFERENCES1. Hogarth J. Glossary of Health Care Terminology. Copenhagen: Regional Office for Europe, World Health Organization; 1978. p. 313.2. Vijayakumar T, Sathyavati D, Subhashini T, Sonika G, Dhanaraju M. Assessment of prescribing trends and rationality of drug prescribing. Int J Pharmacol 2011;7(1):140-3.3. Hcl H. A clinico-pharmacological study of out-patient prescribing pattern of dermatological drugs in an Indian tertiary hospital. Indian J Pharmacol 2000;32:384-5.4. Shankar RP, Roy S, Shenoy N. Patterns of prescription and drug use in a psychiatry out-patient department in a teaching hospital in western Nepal. Internet J Pharmacol 2002;1(2):41.5. Hemminki E, Ghodse H, Khan I. Factors influencing prescribing. Psychoactive Drugs: Improving Prescribing Practices. Geneva: World Health Organization; 1988. p. 22-35.Table 3: Distribution of antimicrobial class according to age groupS. No. Antibiotic class <10 10‑20 20‑40 40‑60 >60 Total n (%)1 Cephalosporins 1 2 15 31 27 76 (70.37)2 Fluoroquinolones 0 2 4 23 13 42 (38.89)3 Aminoglycosides 1 1 4 3 8 17 (15.74)4 Penicillins 1 0 3 11 17 32 (29.63)5 Azithromycin 0 1 3 7 8 19 (17.59)6 Nitrofurantoin 0 0 2 3 7 12 (11.11)7 Doxycycline 0 0 0 2 0 2 (1.85)8 Cotrimoxazole 0 0 0 0 2 2 (1.85)Fig. 4: Distribution of antimicrobial utilizationAsian J Pharm Clin Res, Vol 8, Issue 6, 2015, 161-164 Gidamudi et al. 1646. Pradhan S, Shewade D, Shashindran C, Bapna J. Drug utilization studies. Natl Med J India 1988;1:185-9.7. Soumerai SB. Factors influencing prescribing. Aust J Hosp Pharm 1988;18(3):9-16.8. Goel R, Bhati Y, Dutt H, Chopra V. Prescribing pattern of drugs in the outpatient department of a tertiary care teaching hospital in Ghaziabad, Uttar Pradesh. J Appl Pharm Sci 2013;3:S48-51.9. Ahmed SM, Swedlund SK. Evaluation and treatment of urinary tract infections in children. Am Fam Physician 1998;57(7):1573-80, 1583-4.10. Arul K, Prakasam K, Kumar D, Vijayan M. A cross sectional study on distribution of urinary tract infection and their antibiotic utilization pattern in Kerala. Int J Res Pharm Biomed Sci 2012;3(3):1125-30.11. Alós JI. Epidemiology and etiology of urinary tract infections in the community. Antimicrobial susceptibility of the main pathogens and clinical significance of resistance. Enferm Infecc Microbiol Clin 2005;23 Suppl 4:3-8.12. Chedi B, Wannang N, Halliru M, Bichi L. Seven months retrospective study on urinary tract infection among patients at Aminu Kano Teaching Hospital, Kano-Nigeria. Bayero J Pure Appl Sci 2009;2(2):95-8.13. Schlager TA. Urinary tract infections in children younger than 5 years of age: Epidemiology, diagnosis, treatment, outcomes and prevention. Paediatr Drugs 2001;3(3):219-27.14. Mahesh E, Ramesh D, Indumathi V, Punith K, Raj K, Anupama H. Complicated urinary tract infection in a tertiary care center in South India. Al Ameen J Med Sci 2010;3(2):120-7.15. Pargavi B, Mekala T, Thamarai Selvi M. Prevalence of urinary tract infection (UTI) among diabetics patients in Vandavasi, Tamil Nadu, India. Int J Biol Technol 2011;2(2):42-5.16. Qureshi AM. Clinical presentation of urinary tract infection among children at Ayub Teaching Hospital, Abbottabad. J Ayub Med Coll Abbottabad 2005;17(2):79-81.17. Mohan J, Gopal KM, Meganathan M, Sasikala P, Gowdhaman N, Balamurugan K, et al. A study on utilization pattern of antibiotics for the complicated urinary tract infections in a tertiary care centre. Glob J Pharmacol 2011;5:1-3.18. Edson RS, Terrell CL. The aminoglycosides. Mayo Clin Proc 1999;74(5):519-28.19. Bay AG, Anacleto F Jr. Clinical and laboratory profile of urinary tract infection among children at the outpatient clinic of a tertiary hospital. PIDSP J 2010;11(1):10-6.

ANTIMICROBIAL UTILIZATION PATTERN OF URINARY TRACT INFECTION IN TERTIARY CARE HOSPITAL

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ANTIMICROBIAL UTILIZATION PATTERN OF URINARY TRACT INFECTION IN TERTIARY CARE HOSPITAL

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