|Year : 2015 | Volume
| Issue : 3 | Page : 86-89
Prescribing pattern of antibiotics in community-acquired pneumonia in a teaching hospital of Southeast Asia
Sanjay Kumar1, Divya Agrawal2, Soumya Santra1, Suhasini Dehury3, Priti Das3, Trupti Rekha Swain3
1 Department of Pharmacology, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneshwar, India
2 Department of Anatomy, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneshwar, India
3 Department of Pharmacology, Shri Ramachandra Bhanj Medical College, Utkal University, Cuttack, Odisha, India
|Date of Web Publication||27-Oct-2015|
Department of Pharmacology, Institute of Medical Sciences and SUM Hospital, Siksha 'O' Anusandhan University, Bhubaneshwar - 751 003, Odisha
Source of Support: None, Conflict of Interest: None
Objective: To study and describe the antibiotic prescribing habits of physicians for 117 patients with community-acquired pneumonia (CAP). Materials and Methods: A medicine consultant or a pulmonologist supervised and treated 45 (38%) patients. Out of 45 patients, 7 (16%) were given macrolide, 12 (26%) received beta-lactam antibiotics, 14 (31%) were given a combination of beta-lactam and macrolide, and 12 (26%) were given a combination of more than one antibiotics. Seventy-two (62%) patients were seen by other specialists, of whom 5 (6%) were given macrolide, 35 (48%) were given beta-lactam, 4 (6%) were administered a combination of beta-lactam and macrolide, 2 (3%) received quinolones, and 26 (36%) patients received various combinations. In 47 out of 117 patients, therapy was modified, which included 12 patients who underwent step-down switch. The duration of hospitalization was 26 days for those patients whose therapy was modified. Patients who underwent step-down switch had a hospital stay of 7 days, whereas those who did not have any modification in the treatment stayed for 10 days in the hospital. Results: Beta-lactam antibiotic was more commonly used, at least 3.8 times more than a macrolide. Other combinations of antibiotics were given in 28%, 68%, and 44% of patients treated by a medicine specialist, pulmonologist, and other specialties, respectively.
Conclusion: These data demonstrate that in spite of the advances of knowledge in the management of CAP, there exists variability in the prescribing habits of the attending physician.
Keywords: Beta-lactam antibiotics, community-acquired pneumonia, macrolide antibiotics
|How to cite this article:|
Kumar S, Agrawal D, Santra S, Dehury S, Das P, Swain TR. Prescribing pattern of antibiotics in community-acquired pneumonia in a teaching hospital of Southeast Asia. J Health Res Rev 2015;2:86-9
|How to cite this URL:|
Kumar S, Agrawal D, Santra S, Dehury S, Das P, Swain TR. Prescribing pattern of antibiotics in community-acquired pneumonia in a teaching hospital of Southeast Asia. J Health Res Rev [serial online] 2015 [cited 2020 Jun 2];2:86-9. Available from: http://www.jhrr.org/text.asp?2015/2/3/86/168371
| Introduction|| |
Community-acquired pneumonia (CAP) is characterized by the infection of pulmonary parenchyma of an individual residing outside the hospital or in patients who have been living in a long-term care facility for longer than 2 weeks. CAP is one of the most common and serious infectious illness in both developed and developing countries, and is associated with high morbidity and mortality and thus enlisted as a major cause of hospital admission.,,,,,,
Various scoring system for the risk assessment of CAP and use of biomarkers such as procalcitonin for stratification has been introduced.,,,,,, Several studies have been done in etiology, influence of infectious agents, the tendency of the host to be infected, and therapeutic management over last decades.,,, With new antibiotics being marketed and impact of combined antimicrobial therapy, the physician's choice of antibiotics may be influenced.,,
A prospective study was undertaken to determine the antibiotic prescribing habits of physicians in managing CAP in a teaching hospital.
| Materials and Methods|| |
Patients equal or above the age of 18 years, with radiological evidence of pneumonia, admitted in the Institute of Medical Science and SUM Hospital, Bhubaneswar, from September 2013 to August 2014, were included in this observational, prospective study. It has been confirmed with a proper history that the patient must not have been hospitalized within 10 days prior to the present admission. Each patient was intensively followed until discharge.
Detailed medical data including fields of specialization of attending physicians, initial antimicrobials used, modification in therapy during the course of illness, and duration of hospital stay were recorded in a clinical data form. Investigators have not influenced or intervened in the medical management of the patients.
The results were expressed using basic parameters or statistic such as mean and percentage with the aid of GraphPad Prism version 5 (©2015 GraphPad Software, Inc. USA).
| Results|| |
Most of the patients in this series were more than 70 years of age. Males have a higher incidence than females [Figure 1].
|Figure 1: Age and sex distribution of 117 patients with community-acquired pneumonia
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Twenty-six (22%) of the total patients had no underlying problems. Ninety-one (78%) had chronic illness, including 25 with chronic obstructive pulmonary disease; 42 with congestive heart failure, chronic renal disease, or cerebrovascular diseases (CVDs); 11 with malignancy; and 13 with other conditions such as diabetes mellitus, peptic ulcer disease, and acute viral hepatitis.
[Table 1] illustrates the choice of treatment in relation to the underlying conditions. Only a beta-lactam antibiotic, especially cephalosporin, was given to 47 (40%) of 117 patients. Monotherapy with fluoroquinolones was given to two patients and as a part of drug combination to eight patients.
|Table 1: Underlying conditions and the initial treatment of 117 patients with|
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The initial beta-lactam therapy given to 21 (45%) of 47 patients was subsequently modified in 8 of the patients to step-down therapy, and later in 13 patients due to the poor clinical response. Only 2 (16%) of 12 patients who were initially given a macrolide were modified to aminoglycoside in combination with beta-lactam due to poor clinical response. Six (24%) of the 26 patients without any underlying illness were given a combination therapy that included 3 patients who were suspected to have aspiration pneumonia. On the other hand, 52 (57%) of the 91 patients with underlying chronic diseases were given a combinational antibiotic therapy. The various combinational therapies administered included beta-lactam plus macrolide, beta-lactam plus clindamycin/metronidazole, and aminoglycoside plus beta-lactam/macrolide. Twenty-three (43%) of the 53 patients with underlying illness showed poor clinical response and hence modification of their antibiotics were done in 20 and step-down switch in 3 patients.
Physicians of varying specialities were consulted as CAP can affect any person with or without any underlying illness. In our study, we have noted that 45 (38%) patients were treated eitherby a medicine consultant or by a pulmonologist, 72 (62%) were managed by other specialists such as surgeons, neurologists, cardiologists and hematologists [Table 2].
|Table 2: Initial therapy and the cost of antibiotic in patients with CAP|
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The general medicine specialist used only macrolide in six patients and only beta-lactam in two patients, and a combination of both the medicines was used in three patients. However, the other specialists including the pulmonologists gave only beta-lactam in 45 patients and only macrolide in 6 patients and combination of both the medicines in 15 patients. A combinational antibiotic therapy was given by medicine specialist to 3 (28%) of the 11 patients compared to the 23 (68%) of the 34 patients seen by pulmonary specialist, and 32 (44%) of the 72 patients seen by other specialists.
The mean duration of stay in hospital of patients whose treatment was modified was 26 days. The mean duration of hospitalization was 7 days in the cases of step-down switch, whereas 10 days in cases where no treatment modification was done.
The average cost of antibiotics tendered by patients seen by a medicine specialist was INR 3,740, which is much less compared to INR 15,600 in those seen by pulmonary specialist and to INR 17,050 in cases seen by other specialists [Table 2].
| Discussion|| |
In this prospective study, most of the patients were more than 70 years old. This finding is consistent with a previous study that revealed that in contrast to persons in the age-group of 35–44 years, people aged more than 65 years have a higher incidence of pneumonia and required hospitalization. Higher incidence rates in males than females have been noted, which have also been reported earlier in the study of Rello.
Majority of the patients (91 of 117) had co-morbid diseases that is a relevant finding since its presence can influence the infectious agent and is a poor prognostic factor.
The most commonly used antibiotic was a beta-lactam, which is 3.8 times more frequently administered than macrolide. Grasela et al. who made a survey on antibiotic prescribing pattern among the US-based physicians obtained a similar data indicating that 50% of monotherapies were done using beta-lactams. The use of fluoroquinolones though recommended as a treatment option for empirical therapy for hospitalized CAP was used in the patients and in combination in eight cases., Several studies have revealed that bacteremic pneumonia with combination therapy is associated with a lower mortality.,,,, Empirical combination therapy using a beta-lactam along with a macrolide or fluoroquinolones should be initiated in patients with severe CAP as per the international guidelines.,, However, for the elderly patients who are at higher risk of gram-negative pneumonia, an aminoglycoside is recommended in combination with beta-lactams.
Out of the 117 patients, 6 (5%) died and this is a low rate in comparison to 13.7% reported by Fang.
And out of these six patients, four had CVDs and 2 had malignancy and were aged more than 65 years.
As shown in [Table 2], pulmonologists and other specialists have seen more patients with underlying chronic illness than medicine specialists, which might have accounted for difference in the cost of treatment.
These findings thus show that the variability in prescribing antibiotics as well as the presence of underlying diseases in patients with CAP affected the total cost and the mean duration of hospitalization stay.
| Conclusion|| |
This study illustrates the discrepancy in the prescribing habits of the attending consultants in the treatment of CAP.
It is summarized that
- Patients aged more than 70 years are frequently affected
- Beta-lactam antibiotic is given 3.8 times more commonly than macrolide
- Beta-lactam, in combination with aminoglycoside, was prescribed in patients above the age of 50 years
- Medicine specialists used combinational antibiotic therapy significantly lesser than the physicians of other specialities.; and
- The cost of total antibiotic regimen among patients under the treatment of medicine specialists was lower than those managed by other specialists.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest
| References|| |
Gin AS, Tailor SA. Community-acquired pneumonia. Can J Hosp Pharm 2001;54:1-16.
Mandell LA, Wunderink RG, Anzueto A, Bartlett JG, Campbell GD, Dean NC, et al
.; Infectious diseases society of America; American thoracic society. Infectious Disease Society of America/American Thoracic Society Consensus guideline on the management of community-acquired pneumonia in adults. CID 2007;44(Suppl 2):S27-72.
LaForce FM. Antimicrobial therapy for lower respiratory tract infections in adults: A review. Clin Infect Dis 1992;14:S233-7.
Pena-Miller R, Laehnemann D, Jansen G, Fuentes-Hernandez A, Rosenstiel P, Schulenburg H, et al
. When the most potent combination of antibiotics selects for the greatest bacterial load: The smile-frown transition. PLoS Biol 2013;11:e1001540.
Elek SD. Principles and problems of combined antibiotic therapy. Postgrad Med J 1956;32:324-7.
Levin S, Harris AA. Principles of combination therapy. Bull N
Y Acad Med 1975;51:1020-38.
Niederman MS. Recent advances in community-acquired pneumonia: Inpatient and outpatient. Chest 2007;131:1205-15.
Angus DC, Marrie TJ, Obrosky DS, Clermont G, Dremsizov TT, Coley C, et al
. Severe community-acquired pneumonia: Use of intensive care services and evaluation of American Thoracic Society Diagnostic criteria. Am J Respir Crit Care Med 2002;166:717-23.
Rello J, Lisboa T, Wunderink R. Severe community-acquired pneumonia and PIRO: A new paradigm of management. Curr Infect Dis Rep 2009;11:343-8.
Rello J, Rodriguez A. Severity of illness assessment for managing community-acquired pneumonia. Intensive Care Med 2007;33:2043-4.
Lim WS, van der Eerden MM, Laing R, Boersma WG, Karalus N, Town GI, et al
. Defining community-acquired pneumonia severity on presentation to hospital: An international derivation and validation study. Thorax 2003;58:377-82.
Charles PG, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, et al
. SMART-COP: A tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis 2008;47:375-84.
Salluh JI, Bozza FA, Soares M, Verdeal JC, Castro-Faria-Neto HC, Lapa E Silva JR, et al.
Adrenal response in severe community-acquired pneumonia: Impact on outcomes and disease severity. Chest 2008;134:947-54.
Póvoa P. Serum markers in community-acquired pneumonia and ventilator-associated pneumonia. Curr Opin Infect Dis 2008;21:157-62.
Campbell GD. Overview of community-acquired pneumonia. Prognosis and clinical features. Med Clin North Am 1994;78:1035-48.
Yende S, Kong L, Weissfeld LA, Kellum J, Fink MP, Pinsky MR, et al
. Inflammatory markers prior to hospital discharge predict subsequent mortality after community-acquired pneumonia. Proc Am Thorac Soc 2006;3:A274.
Coelho L, Póvoa P, Almeida E, Fernandes A, Mealha R, Moreira P, et al.
Usefulness of C-reactive protein in monitoring the severe community-acquired pneumonia clinical course. Crit Care 2007;11:R92.
Christ-Crain M, Opal SM. Clinical review: The role of biomarkers in the diagnosis and management of community-acquired pneumonia. Crit Care 2010;14:203.
Christ-Crain M, Stolz D, Bingisser R, Müller C, Miedinger D, Huber PR, et al.
Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia: A randomized trial. Am J Respir Crit Care Med 2006;174:84-93.
Laterre PF. Monotherapy or combination therapy for hospitalized patients with community-acquired pneumonia: Not yet the end of the story? Clin Infect Dis 2008;46:1510-2.
Martin-Loeches I, Lisboa T, Rodriguez A, Putensen C, Annane D, Garnacho-Montero J, et al.
Combination antibiotic therapy with macrolides improves survival in intubated patients with community-acquired pneumonia. Intensive Care Med 2010;36:612-20.
Rello J, Quintana E, Ausina V, Net A, Prats G. A three-year study of severe community-acquired pneumonia with emphasis on outcome. Chest 1993;103:232-5.
Grasela TH Jr, Schentag JJ, Boekenoogen SJ, Crist KD, Lowes WL, Lum BL. A clinical pharmacy-oriented drug surveillance network: Results of a nationwide antibiotic utilization review of bacterial pneumonia--1987. DICP 1989;23:162-70.
Woodhead M, Blasi F, Ewig S, Garau J, Huchon G, Ieven M, et al
.; Joint Taskforce of the European Respiratory Society and European Society for Clinical Microbiology and Infectious Diseases. Guidelines for the management of adult lower respiratory tract infections-full version. Clin Microbiol Infect 2011;17(Suppl 6):E1-59.
Mufson MA, Stanek RJ. Bacteremic pneumococcal pneumonia in one American City: A 20-year longitudinal study, 1978-1997. Am J Med 1999;107:34S-43.
Baddour LM, Yu VL, Klugman KP, Feldman C, Ortqvist A, Rello J, et al.
; International Pneumococcal Study Group. Combination antibiotic therapy lowers mortality among severely ill patients with pneumococcal bacteremia. Am J Respir Crit Care Med 2004;170:440-4.
Waterer GW, Somes GW, Wunderink RG. Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia. Arch Intern Med 2001;161:1837-42.
Martínez JA, Horcajada JP, Almela M, Marco F, Soriano A, García E, et al.
Addition of a macrolide to a beta-lactam-based empirical antibiotic regimen is associated with lower in-hospital mortality for patients with bacteremic pneumococcal pneumonia. Clin Infect Dis 2003;36:389-95.
Weiss K, Low DE, Cortes L, Beaupre A, Gauthier R, Gregoire P, et al.
Clinical characteristics at initial presentation and impact of dual therapy on the outcome of bacteremic Streptococcus pneumoniae
pneumonia in adults. Can Respir J 2004;11:589-93.
Lim WS, Baudouin SV, George RC, Hill AT, Jamieson C, Le Jeune I, et al
.; Pneumonia Guidelines Committee of the BTS Standards of Care Committee. BTS guidelines for the management of community acquired pneumonia in adults: Update 2009. Thorax 2009;64(Suppl 3):iii1-55.
Fang GD, Fine M, Orloff J, Arisumi D, Yu VL, Kapoor W, et al
. New and emerging etiologies for community-acquired pneumonia with implications for therapy. A prospective multicenter study of 359 cases. Medicine (Baltimore) 1990;69:307-16.
[Table 1], [Table 2]