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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 8
| Issue : 2 | Page : 156-161 |
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Audit of antibiotics usage in an intensive care unit of a tertiary care hospital in South India
R Judah Rajendran, Sujitha Elan Seralathan
CRRI, Department of General Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
| Date of Submission | 08-Jun-2022 |
| Date of Decision | 20-Oct-2022 |
| Date of Acceptance | 20-Oct-2022 |
| Date of Web Publication | 23-Dec-2022 |
Correspondence Address:
R Judah Rajendran
Pondicherry Institute of Medical Sciences, Ganapathichettikulam, Kalapet, Puducherry . 605 014
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcrsm.jcrsm_47_22
Background: Antibiotics are one of the major medications used in the intensive care unit (ICU). It is a matter of concern as inappropriate usage of antibiotics in the ICU has led to the development of many infections due to multidrug-resistant (MDR) organisms. The aim was to monitor and assess the empirical antibiotic treatment initiated and the changes made in antimicrobial therapy following the culture report.
Methodology: The study was conducted from May 2018 to June 2018 after obtaining ethical clearance from the institute ethics committee which was a cross-sectional prospective type of study. One hundred patients who were on antibiotics were included in the study. A total of 249 culture samples were sent which included blood, urine, endotracheal aspirate, sputum, cerebrospinal fluid, wound swab, etc., The patients were started empirically with antibiotics ceftriaxone, imipenem, meropenem, amikacin, azithromycin, etc., The microorganisms grown in the culture were Escherichia coli, Acinetobacter species, Staphylococcus aureus, Pseudomonas aeruginosa, etc.
Results: It was observed that for 54 patients, the empirical antibiotic treatment was continued, for 39 patients, there was a change in antibiotics following the culture report, and for Seven patients, the antibiotics were stopped. Among 39 patients, for 23 patients, there was an escalation, and for 16 patients, there was a de-escalation in the usage of antibiotics from the initial empirical treatment given.
Conclusion: A proper prescription pattern and a standard antibiotic policy for prescribing antibiotics are needed to prevent the future development of MDR strains.
Keywords: Antibiotic stewardship policy, antibiotics, empirical treatment, intensive care unit, multidrug-resistant microorganisms
How to cite this article:
Rajendran R J, Seralathan SE. Audit of antibiotics usage in an intensive care unit of a tertiary care hospital in South India. J Curr Res Sci Med 2022;8:156-61 |
How to cite this URL:
Rajendran R J, Seralathan SE. Audit of antibiotics usage in an intensive care unit of a tertiary care hospital in South India. J Curr Res Sci Med [serial online] 2022 [cited 2023 Mar 20];8:156-61. Available from: https://www.jcrsmed.org/text.asp?2022/8/2/156/364501 |
| Introduction | |  |
The intensive care unit (ICU) is an important part of a hospital or a health-care setting where intensive care and treatment is provided to patients with severe and life-threatening illness and injuries.[1] The patients admitted to ICU are exposed to many health care-associated infections.[2],[3] Antibiotics are one of the major medications used in ICU for the treatment of sepsis and other health care-associated infections.[4],[5] It is estimated that 25%–30% of nosocomial infections arise from the ICUs.[6] Thus, it is a matter of concern as inappropriate usage of antibiotics in the ICU has led to the development of many infections due to multidrug-resistant (MDR) organisms.[3]
Patients admitted to ICU are also prone to device-associated infections such as ventilator-associated pneumonia (VAP), catheter-associated urinary tract infections, catheter-related bloodstream infections, and surgical site infections.[4],[6] This calls for a proper, rational, and judicious selection of an antibiotic to be administered to the patients.[1],[3],[5]
The emergence of infections due to microorganisms MDR is of concern. Patients who are infected with MDR strains are treated with high-end antibiotics such as glycopeptides and carbapenems.[2],[3],[7] These classes of antimicrobials are not only toxic but they are also expensive and cause an economic drain to the patient. Above all, very few antimicrobials are in the pipeline for the treatment of infections due to MDR and pan-drug-resistant strains.[3],[5]
It was previously known that some standard empirical therapy can be very useful and effective for infections acquired in communities and hospitals but the effectiveness has been greatly reduced due to injudicious use which leads to the resistance pattern which differs in different places. Therefore, this study is done to analyze the usage of antibiotics in the ICU and the steps to be taken for appropriate use of antibiotics to prevent the emergence of infections due to multi-drug resistant and pan-drug-resistant strains.[1],[8],[9] Thus, the principles of antibiotic prescription which include the right antibiotic, right dose, right time, and right duration should be followed.
The emergence of antibiotic resistance is of great concern in present modern-day medicine and this has led to the need for strict antibiotic stewardship policy in our daily health-care management.[10] Thus, various studies had been conducted worldwide owing to its importance.[8],[9],[10],[11],[12]
Numerous studies were similar to our study which showed the data of empirical antibiotics used initially and changes made in the antibiotics following the culture sample results concerning empirical, directed, and empirically directed usage of antibiotics in ICU and the similar type of study has been conducted worldwide in various hospitals.[13],[14],[15]
Thus, various studies done in various centers conclude with different antibiotic usage for different species of microorganisms isolated and with proper antibiotic stewardship programs in their respective health-care centers.[16],[17] Hence, this study attempted to assess the empirical antibiotic pattern used and the changes made following the culture results in our tertiary health-care center. The aims and objectives were to monitor the usage of antibiotics in the ICU of the tertiary care hospital, to identify the antimicrobial susceptibility pattern of the microorganisms isolated from the ICU and to assess the empirical antibiotic treatment initiated and the changes made in antimicrobial therapy following the culture report.
| Materials and Methods | | |
The study was conducted from May 2018 to June 2018 after obtaining approval from the Institute Ethics Committee (IEC: RC/18/10). A waiver of consent was granted as the study involved the collection of data without patient contact. The patients admitted to the ICU and started on empirical antibiotics were included in the study. The total number of patients included was 100. It was a cross-sectional prospective type of study which included a daily collection of data from the patients admitted to the ICU and collection of the culture samples reports along with analyzing the antimicrobial sensitivity pattern of the microorganisms from the Department of Microbiology.
All patients who started on antibiotics admitted to the medical and trauma ICU were included in the study. Patients who were not on antibiotic therapy and postoperative patients were excluded from the study. The antibiotic prescription pattern before and after the culture sample results of the patients were obtained. There was no direct contact with the patients and so a waiver of consent was requested.
The details of the patients included name, age, gender, date of admission, diagnosis, initial antibiotics used along with dosage and frequency, culture samples sent along with dates which included date of sending and date of receiving culture results, antibiotic susceptibility of the microorganism, changed made after the culture report (if any) and the clinical outcome of the patients was collected manually in printed case report forms and was entered in excel sheet. The data were analyzed using percentage proportions. Thus, a waiver of consent was requested and obtained from the IEC because the study involved the collection of data from the case sheets/patient records and there was no direct contact with the patients or their personal details.
| Results | | |
The clinical samples of the patients which were sent for culture and sensitivity were noted and their sensitivity pattern was analyzed. The culture samples sent for culture included blood, urine, endotracheal (ET) aspirate, sputum, cerebrospinal fluid (CSF), gastric lavage, wound swab, pleural fluid, ascitic fluid, tissue culture, peritoneal fluid, and aspirated fluid. A total of 249 culture samples obtained from 100 patients were analyzed. This included 86 samples sent for blood culture, 83 samples sent for urine culture, and 34 ET aspirate samples sent for culture followed by other samples such as 10 sputum samples, eight CSF samples, eight wound swabs, five ascitic fluid samples, four pleural fluid samples, four tissue culture samples, one peritoneal fluid, and one gastric lavage sample as shown in [Figure 1].
The patients were started empirically with antibiotics such as cephalosporins which included ceftriaxone, cefuroxime, cefotaxime, and cefepime, carbapenems such as imipenem and meropenem, aminoglycosides like amikacin, macrolides like azithromycin, tetracyclines like doxycycline, glycopeptide derivative like vancomycin, lincosamide antibiotic like clindamycin, and oxazolidinone derivative like linezolid.
The combinations used most frequently in the ICU were piperacillin + tazobactam, cefoperazone + sulbactam, and amoxicillin + clavulanic acid. Of these, piperacillin + tazobactam was given to 51 patients, ceftriaxone to 16 patients, imipenem to 16 patients, and amikacin to 10 patients followed by other antibiotics (either as a single regimen or in combination with other antibiotics) as shown in [Figure 2]. These patients were followed subsequently.
The microorganisms grown in the culture were Escherichia coli (E. coli), Acinetobacter baumannii, Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterococcus faecium, Proteus vulgaris, Streptococcus pneumoniae, Citrobacter diversus, and beta-hemolytic streptococci. Of these, 19 patients had E. coli, eight patients had A. baumannii, eight patients had P. aeruginosa, five patients had E. faecium, three patients had S. aureus, three patients had K. pneumoniae and others which included two patients with P. vulgaris, one patient with S. pneumoniae, and one patient with C. diversus in their culture samples [Figure 3].
The changes made in the antimicrobial therapy following the culture report were monitored and noted. It was found that E. coli was sensitive to most of the initial empirical antibiotics used and there was not much change in antibiotics after the culture-positive report.
Among the eight isolates of A. baumannii, 63% (n = 5) were sensitive only to polymyxin-B and colistin, and the remaining 37% (n = 3) were found sensitive to colistin, polymyxin-B, gentamicin, imipenem, meropenem, and piperacillin + tazobactam.
K. pneumoniae was sensitive to amikacin, ciprofloxacin, amoxicillin/clavulanic acid, gentamicin, imipenem, piperacillin + tazobactam, and cefoperazone + sulbactam
Other isolates included S. aureus which is one of the most common causative agents of hospital-acquired infection and was sensitive to amikacin, gentamicin, cefazolin, clindamycin, ciprofloxacin, azithromycin, ceftriaxone, and cefotaxime.
E. faecium was sensitive to gentamicin, amikacin, linezolid, vancomycin, and ciprofloxacin, whereas other microbes were sensitive to most of the antibiotics such as ceftriaxone, amikacin, gentamicin, imipenem, and piperacillin + tazobactam, cefoperazone + sulbactam which were used as empirical treatment in the ICU setup of the tertiary health care center.
Therefore, it was observed that for 54 patients the empirical antibiotic treatment was continued, for 39 patients, there was a change in antibiotics following the culture report and for seven patients the antibiotics were stopped [Figure 4].
Thus from the study conducted, it was observed that for 54% of the patients, the empirical antibiotics were continued after the culture reports were obtained which shows the rational use of antibiotics in the ICU.
Moreover, for 39 (39%) patients, there was a change in antibiotics from the initial empirical antibiotics given. Among them for 23 patients (59%), there was an escalation in the antibiotics from the initial empirical treatment to higher antibiotics according to the sensitivity of the microorganism isolated as shown in [Figure 5]. Thus, this shows that these microorganisms were resistant to the basic antibiotics used in the ICU. | Figure 5: The antibiotic course in patients who had a change in antibiotics
Click here to view |
For 16 (41%) patients, there was a de-escalation in the usage of antibiotics from the initial empirical treatment given. This shows that the microorganisms isolated were sensitive to the lower antibiotics than the commonly used ones but more powerful antibiotics were used instead of lower antibiotics which were sensitive to the microorganisms isolated and can lead to the development of more resistant strains (MDR) [Figure 5].
The antibiotic susceptibility of different microorganisms isolated from the ICU was also obtained. The empirical antibiotic prescription pattern and the subsequent changes after the culture results made in the ICU of tertiary care were analyzed and concerning the data collected and analyzed, rational use of appropriate antibiotics can be established in the ICU to prevent the development of any resistant strains of microorganisms (MDR) in the forthcoming days.
| Discussion | | |
Among the 100 patients included in the study, for 54 patient, s the empirical antibiotic treatment was continued, for 39 patients, there was a change in antibiotics, and for seven patients, the antibiotics were stopped. The strengths of the study were the easy availability of the data which will give a great insight into antibiotic usage patterns in our hospital and as a result can provide a way for future systemic reviews which can be done immediately which can be a major breakthrough. No controversies were raised by this study. The limitations of the study were the small sample size and the short span of the study period. Future related studies in collaboration with different hospital settings nationally and internationally will be a great boom.
The inappropriate usage of antibiotics is one of the important reasons for the emergence of MDR bacteria. Therefore, a thorough audit of antibiotic usage is necessary to combat this problem. Thereby knowing the importance of growing antibiotic-resistant strains, a similar type of study has been conducted at various health centers worldwide.[14],[15],[18]
A study by Malacarne et al. stated that for 93% of patients who were started on empirical antibiotics for sepsis, antibiotics had to be changed or added for 37.6% of patients after the culture reports, and the most commonly used antibiotic was third-generation cephalosporins or carbapenems.[19]
A study conducted by Krishna et al. lists the empirical antibiotic therapy for a particular disease/infection which includes ceftriaxone/levofloxacin/ciprofloxacin/moxifloxacin/ampicillin + sulbactam for VAP and ceftazidime/cefepime/imipenem/meropenem/piperacillin + tazobactam for MDR pathogens and similar antibiotic regimens for other infections and diseases. This study is in concurrence with our study concerning empirical antibiotic therapy.
In another study conducted by Shrikala et al., it is observed that the most common empirical antibiotics used were cefoperazone + sulbactam and piperacillin + tazobactam, and they were changed subsequently after the culture reports and antibiotic susceptibility patterns of the microbes were obtained. It also states that in 32.03% of the patients who were on an empirical basis, the microbiological reports were contrary to the treatment given and this study is in concurrence with our study concerning the empirical antibiotic therapy and the antibiotic change following the culture report.[20]
A study by Vincent et al. stated that according to specific patient characteristics, disease severity, and local resistance patterns, antibiotics along with their durations and dosages need to be particularized for each patient who is treated in the health care facility.[19] In a study by Kollef and Fraser, strategies on the importance of limiting the unnecessary use of antibiotics and compliance with infection control policies along with the multidisciplinary approach for antibiotics used in the ICU have been stressed.[7] This can provide us with a proper prescription pattern after similar audits like ours can give information on the current practices.
A study by McGowan shows prevention techniques like barrier isolation as a way of controlling resistant bacteria spread and concludes that the proper use of antimicrobial agents is the major way of minimizing this problem.[10] Thus, many studies stress the importance of proper antibiotics usage which can be determined by conducting and analyzing many audits in concordance with our study.
Limitations of the present study
The limitations in our study included small sample size, limited time duration and lack of previous research studies on the topic.
| Conclusion | | |
From this study, we are aware of the empirical antibiotic prescription pattern, microorganisms isolated, antibiotic susceptibility of the microorganisms isolated, and changes made in the antibiotics following the culture report in the ICU of a tertiary care hospital. Due to the standardized prescription pattern in our ICU, the development of MDR strains are controlled but still for 16 patients, there was higher antibiotics usage and yet proper guidelines for prescribing antibiotics are needed to prevent any future development of MDR strains.
This calls for the implementation of antibiotic policy and strict enforcement of antibiotic stewardship policy which is to be practiced by all health workers. Thus, similar kind of study should be done for the proper rational use of antibiotics.
An antibiotic policy or antibiotic stewardship policy can be set in each hospital or health-care setting which includes monthly audits or yearly audits on the usage of antibiotics mainly in the ICU which is a major spot for the development of MDR microorganisms. Moreover, a thorough analysis of the audit and trend of each antibiotic use along with the most common antibiotic used, the reason for its usage, duration, and the most common organism found in the ICU can be assessed and compared with the previous data obtained. This can enable us to know the usage of antibiotics and the progression of their use with respect to the previous data and thus a strict policy can be laid for future use.
Acknowledgment
Nil.
Financial support and sponsorship
The financial support for the research work was provided by the Indian Council of Medical Research under Short-term Studentship program.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Singh N, Yu VL. Rational empiric antibiotic prescription in the ICU. Chest 2000;117:1496-9.  |
| 2. | Garnacho-Montero J, Garcia-Garmendia JL, Barrero-Almodovar A, Jimenez-Jimenez FJ, Perez-Paredes C, Ortiz-Leyba C. Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis. Crit Care Med 2003;31:2742-51. |
| 3. | Hulscher ME, Grol RP, van der Meer JW. Antibiotic prescribing in hospitals: A social and behavioural scientific approach. Lancet Infect Dis 2010;10:167-75. |
| 4. | Ena J, Wenzel RP. Prevention and Control of Nosocomial Infections. 3 rd ed. Baltimore: Williams & Wilkins; 1997. |
| 5. | Berild D, Ringertz SH, Lelek M. Appropriate antibiotic use according to diagnoses and bacteriological findings: Report of 12 point-prevalence studies on antibiotic use in a university hospital. Scand J Infect Dis 2002;34:56-60. |
| 6. | Weber DJ, Raasch R, Rutala WA. Nosocomial infections in the ICU: The growing importance of antibiotic-resistant pathogens. Chest 1999;115:34S-41S. |
| 7. | Vincent JL, Bassetti M, François B, Karam G, Chastre J, Torres A, et al. Advances in antibiotic therapy in the critically ill. Crit Care 2016;20:133. |
| 8. | Kollef MH, Fraser VJ. Antibiotic resistance in the intensive care unit. Ann Intern Med 2001;134:298-314. |
| 9. | McGowan JE Jr. Antimicrobial resistance in hospital organisms and its relation to antibiotic use. Rev Infect Dis 1983;5:1033-48. |
| 10. | Arnold HM, Micek ST, Skrupky LP, Kollef MH. Antibiotic stewardship in the intensive care unit. Semin Respir Crit Care Med 2011;32:215-27. |
| 11. | Lipsitch M, Bergstrom CT, Levin BR. The epidemiology of antibiotic resistance in hospitals: Paradoxes and prescriptions. Proc Natl Acad Sci U S A 2000;97:1938-43. |
| 12. | Textoris J, Wiramus S, Martin C, Leone M. Overview of antimicrobial therapy in intensive care units. Expert Rev Anti Infect Ther 2011;9:97-109. |
| 13. | Schurink CA, Hoitsma M, Rozenberg-Arska M, Joore JC, Hoepelman IM, Bonten MJ. Do cultures contribute to optimisation of antibiotic therapy in the intensive care unit? Int J Antimicrob Agents 2004;23:325-31. |
| 14. | Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals. Clin Infect Dis 2006;42 Suppl 2:S90-5. |
| 15. | Fonseca LG, de Oliveira Conterno L. Audit of antibiotic use in a Brazilian University Hospital. Braz J Infect Dis 2004;8:272-80. |
| 16. | Fridkin SK, Steward CD, Edwards JR, Pryor ER, McGowan JE Jr., Archibald LK, et al. Surveillance of antimicrobial use and antimicrobial resistance in United States hospitals: Project ICARE phase 2. Project intensive care antimicrobial resistance epidemiology (ICARE) hospitals. Clin Infect Dis 1999;29:245-52. |
| 17. | Shah RC, Shah P. Antimicrobial stewardship in institutions and office practices. Indian J Pediatr 2008;75:815-20. |
| 18. | Shankar PR, Partha P, Shenoy N, Brahmadathan KN. Investigation of antimicrobial use pattern in the intensive treatment unit of a teaching hospital in western Nepal. Am J Infect Control 2003;31:410-4. |
| 19. | Malacarne P, Rossi C, Bertolini G, GiViTI Group. Antibiotic usage in intensive care units: A pharmaco-epidemiological multicentre study. J Antimicrob Chemother 2004;54:221-4. |
| 20. | Shrikala B, Kranthi K, Nafisa. A prospective study on evaluation of antibiotic prescription practices in an intensive care unit of a tertiary care hospital. J Clin Diagn Res 2010;4:3387-91. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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