รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน Antibiotics prescription pattern and cost in hospitalized patients

สรศกด เสาแกว1, บรรจรพร จนทรถาวรพงศ2, อจฉราภรณ ดวงใจ3 Surasak Saokaew1, Banjareeporn Janthawornpong2, Acharaporn Duangjai3

บทคดยอ

การศกษานมวตถประสงคเพอประเมนรปแบบการจายยาและคาใชจายของยาปฏชวนะแบบออกฤทธกวาง 7 ชนด ซงยาดงกลาวอยในโปรแกรมการประเมนการใชยาของโรงพยาบาลพะเยา การใชยาและคาใชจายของ ยาปฏชวนะแบบออกฤทธกวาง 7 ชนด (ประกอบไปดวย imipenem-cilastin, piperacillin-tazobactam, cefoperazone-sulbactam, cefpirome, ceftazidime, vancomycin, and amoxycillin-clavulanic acid) ไดรบการรวบรวมจากแบบฟอรมทบนทกไวในโปรแกรมการประเมนการใชยาเวชระเบยน และแบบสรปกอนจ าหนายคนไขกลบบาน ระหวางเดอนกนยายน 2550 ถง เดอนกมภาพนธ 2551 การศกษานรวบรวมผปวยไดทงหมด 243 คน พบวายา ceftazidime, imipenem-cilastin, amoxycillin-clavulanic acid, cefpirome, cefoperazone-sulbactam, piperacillin-tazobactam และ vancomycin มการจาย 47 ครง (19.3%), 45 ครง (18.5%), 44 ครง (18.1%), 35 ครง (14.4%), 34 ครง (14.0%), 33 ครง (13.6%), 5 ครง (2.1%) ตามล าดบ ส าหรบคาใชจายรวมของยาปฏชวนะแบบออกฤทธกวาง 7 ชนดน คดเปน 1 ใน 4 (25.9%) ของคาใชจายทงหมดของผปวยในในโรงพยาบาล ยาทมมลคาการใชจายมากทสด imipenem-cilastin (คดเปน 1,080,807 บาท) สวนการใชยาโดยวดดวย DDD1000นนพบวา การใชยาแตละชนดในแตละเดอนมลกษณะไมแตกตางกนมากนกจะเหนวารปแบบการจายยาและคาใชจายของยาปฏชวนะแบบออกฤทธกวาง 7 ชนดมแนวโนมสงมากขน และคาใชจายดงกลาวมเปนมลคาสงเมอเทยบกบคาใชจายของยาทงหมดในโรงพยาบาล ดงนนการใช ยาปฏชวนะอยางสมเหตสมผลจงนาจะสามารถลดคาใชจายจ านวนมากนลงได

ค าส าคญ : ยาปฏชวนะ, คาใชจาย, การประเมนการใชยา, การสงจายยา, การใชยา

Abstract

Our objective was to evaluate prescription pattern and cost of seven broad-spectrum antibiotics listed in the Drug Use Evaluation (DUE) program in Phayao hospital, Thailand. Utilization and costs of seven targeted broad-spectrum antibiotics (imipenem-cilastin, piperacillin-tazobactam, cefoperazone-sulbactam, cefpirome, ceftazidime, vancomycin, and amoxycillin-clavulanic acid) were collected retrospectively from individual DUE case records, medical documentations, and discharge summary from September 2007 to amoxycillin-clavulanic acid, cefpirome, cefoperazone-sulbactam, piperacillin-tazobactam, and vancomycin 1คณะเภสชศาสตร มหาวทยาลยพะเยา, 2ภาควชาเภสชศาสตร โรงพยาบาลพะเยา, 3วทยาศาสตรการแพทย มหาวทยาลยพะเยา 1School of Pharmacy, University of Phayao, 2Department of Pharmacy, Phayao Hospital, 3School of Medical Sciences, University of Phayao Corresponding author : saokaew@gmai.com, surasak.sa@up.ac.th, Received : 24 June 2011 ; Accepted : 25 August 2011

บทความวจยเบองตน (Research Article)

43Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

44Vol 4, No. 2, May-Aug 2011 รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน

Methods

Patients and data collection This retrospective study was conducted at

Phayao hospital, a 375-bed general hospital in northern part of Thailand, using data between September 2007 and February 2008.

At Phayao hospital, DUE program included hospitalized patients in all departments who were treated with at least one of following antibiotics; imipenem/cilastatin, piperacillin/ tazobactam, cefoperazone/sulbactam, cefpirome, ceftazidime, vancomycin, and amoxycillin/clavulanic acid. The DUE forms included patients’ and medication use information, i.e., gender, age, underlying diseases, drug’s indication, length of antibiotics use, antibiotics dosage regimen, and the recommendation to physician. The physicians were asked to complete the DUE forms for hospital pharmacists to dispense the drugs. The forms were reviewed daily by clinical pharmacists.

We gathered the data from DUE case records, medical documentations, and discharge summaries. Patients’ gender, age, type and frequency of antibiotics prescribed, length of antibiotics use, antibiotics dosage regimen, and length of hospital stayin inpatient departments and in all departments (inpatient plus outpatient) were collected. The costs of antibiotics therapy were derived from the sale prices of the individual antibiotics charged by the hospital pharmacy. Costs were presented in Thai Baht (THB) (US$ 1 THB 35).

The collected data were calculated in term of drug cost, proportion of the drug cost per inpatientcosts and per overall hospital drug costs, antibiotics consumption, and frequency of antibiotics prescribed over 6 months. The concept of the Anatomical Therapeutic Chemical/Define

Daily Dose (ATC/DDD) system was applied to estimate drug consumption[28]. In this system, drugs were categorized into various groups according to the organ or system upon which they act and according to their pharmacological and therapeutic properties which created by WHO Collaborating Centre for Drug Statistics Methodology [28]. We presented antibiotics consumption as define daily dose (DDD) per 1,000 patient-days (DDD1000) which calculate from total number of DDD of antibiotic use divided by total number of patient-days and then multiplied by 1,000.

Statistical analysis Patients’ characteristics, frequency of

antibiotics prescription, and cost expenditures were analyzed using descriptive statistics. The comparisons between antibiotic consumptions in each month were analyzed using ANOVA or Kruskal-Wallis test as appropriate. For all analyses, p-value<0.05 indicated statistical significance.

Results A total of 243 cases, ranging in age from 15 to 104 years (median, 62 years), were collected. The top-three antibiotics prescriptions were ceftazidime, imipenem-cilastin, and amoxycillin-clavulanic acid; 47 (19.3%), 45 (18.5%), and 44 (18.1%) times, respectively. Antibiotics were most prescribed in the patients with age>60 year-old (Table 1).

Vol 4, No. 2, May-Aug 2011 Antibiotics prescription pattern and cost in hospitalized patients

Table 2 : Antibiotic costs during September 2007 to February 2008

Antibiotics Costsa (Thai Baht, THB)

Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Total c

Ceftazidime 16 962 73 502 64 764 86 095 84 296 208 170 533 789 Imipenem/Cilastatin 56 924 274 883 268 142 242 676 196 238 41 944 1 080 807 Amoxycillin/Clavulanic acid 11 524 18 492 41 808 66 196 61 104 37 788 236 912 Cefpirome - 104 624 26 156 88 528 140 840 156 936 517 084 Cefoperazone/Sulbactam 69 650 57 710 83 580 55 720 215 915 115 420 597 995 Piperacillin/Tazobactam 24 288 15 456 87 584 174 432 182 528 110 400 594 688 Vancomycin - - 3 084 9 252 - 28 270 40 606 Total b 179 348 544 667 575 118 722 899 880 921 698 928 3 601 881 a US$ 1 THB 35 b Total of all antibiotics costs in each month c Total of each antibiotics costs over 6 months

Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08

Figure 1: Frequency of antibiotics prescribed during September 2007 to February 2008. Symbols: , Imipenem/Cilastatin; , Ceftazidime; Amoxycillin/Clavulanic acid; , Piperacillin/Tazobactam; , Cefpirome; , Cefoperazone/Sulbactam; , Vancomycin

0

2

4

6

8

10

12

14

16

Frequ

ency

of an

tibiot

ics pr

esrib

ed (ti

mes)

17.321.0

22.7

26.8

32.929.7

25.9

1.64.4 4.1

5.9 5.8 5.8 4.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 All

Percentage of seven antibiotics cost per total cost of all drugs use in inpatient Percentage of seven antibiotics cost per total cost of all drugs use in

the hospital

Perce

ntage

(%)

Figure 2: Costs of seven antibiotics use during September 2007 to February 2008

Vol 4, No. 2, May-Aug 2011 รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน

expenses and reducing of drugs resistance. Future studies that evaluating rational drug used program and cost-effectiveness of its intervention are still needed particularly in countries with scarce health resources.

Acknowledgments

The authors would especially like to acknowledge and thank to head of Department of Pharmacy and the director of Phayao hospital for data permission. This research received no specific grant from any funding agency in the public, commercial, or not-to-profit sectors.

References

1. Vaccheri A, Bjerrum L, Resi D, Bergman U, Montanaro N. Antibiotic prescribing in general practice: striking differences between Italy (Ravenna) and Denmark (Funen). J Antimicrob Chemother. 2002;50:989-97.

2. dos Santos E, Lauria-Pires L, Pereira M, Silva A, Rodrigues I, Maia M. Use of antibacterial agents in an intensive care unit in a hospital in Brazil. Braz J Infect Dis. 2007;11(3):355-9.

3. Raveh D, Muallem-Zilcha E, Greenberg A, Wiener-Well Y, Schlesinger Y, Yinnon A. Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefeprime, piperacillin-tazobactam and meropenem. Q J Med. 2006;99:397-406.

4. Kolar J, Hromadova R. Analysis of antibiotic utilization in hospitalized paediatric patients. J Chinese Clin Med. 2007;2(9):496-503.

5. Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K, Hendrickx E, Suetens C, et al. European surveillance of antimicrobial consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother. 2006;58:401-7.

6. Marra F, Patrick D, Chong M, Bowie W. Antibiotic use among children in British Columbia, Canada. J Antimicrob Chemother. 2006;58:830-9.

7. Austin D, Kristinsson K, Anderson R. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci USA. 1999;96:1152-6.

8. Marlière GLL, Ferraz MB, Quirino dos Santos J. Antibiotic consumption patterns and drug leftovers in 6000 Brazilian households. Advances In Therapy. 2000;17(1):32-44.

9. Leibovici L, Beeger R, Gruenewald T, Yahav J, Yehezkelli Y, Milo G, et al. Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link. J Antimicrob Chemother. 2001;48:535-40.

10. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579-87.

11. Lipsitch M, Samore M. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis. 2002;8:347-54.

12. Patterson JE. Antibiotic utilization: is there an effect on antimicrobial resistance? Chest. 2001;119:426-30.

13. Krivoy N, El-Ahal WA, Bar-Lavie Y, Haddad S. Antibiotic prescription and cost patterns in a general intensive care unit. Pharmacy Practice. 2007;5(2):67-73.

14. Paladino JA. Economic justification of antimicrobial management programs: implications of antimicrobial resistance. Am J Health-Syst Pharm. 2000;57(Suppl 2):10-2.

15. Loh L-C, Sani RMM, Samad NIHA, Raman S, Thayaparan T, Kumar S. Adverse hospital

45Saokaew S,et.al. Naresuan Phayao Journal

The costs during study period were

presented in Table 2. Total cost of seven antibiotics over 6 months was 3,601,881 THB. Imipenem-cilastin had the highest cost (1,080,807 THB). The cost of prescribed antibiotics tended to increase over the following month related with the trend of frequency of theirprescription (Figure 1).

Total cost of seven targeted antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB) and about one-twentieth when compared with all drugs used in the hospital (4.7%; 3,601,881 THB per 76,661,608 THB) (Figure 2).

The antibiotics utilizations were showed in Table 3 as DDD1000. There were no statistically different of DDD1000 of each drug when compared with another months.

Discussion

Our findings indicated that antibiotics tend to be prescribed increasingly and their costs were very high. These findings are consistent with previous reports in that there were an increase of antibiotics used [3, 6, 7, 9, 13] but factors contributing to such increase in our study were unknown. We speculated the increase of such seven broad-spectrum antibiotics relating to many reasons. Leibovici et al[9] demonstrated that antibiotics consumptions were increased as same as the high probability of a resistant pathogen. In addition, Marra et al[6] evaluated antibiotic use among children in Canada. They found that macrolide-antibiotics were used increasingly with the high incidence of macrolide-resistant.

The high prescriptions in our study may be associated with the empirical treatment as previous study found[23, 27, 29, 30]. Kusuma Na Ayuthya et al[23] demonstrated that 81% of antibiotics were prescribed empirically at the initial stage for treatment of nosocomial infections in patients with serious conditions like pneumonia, sepsis and febrile neutropenia. Drugs that were frequently used empirically were ceftazidime (37.9%), imipenem/cilastatin or meropenem (19.3%), and cefoperazone/sulbactam (12.1%) respectively. In addition, the study by Hanssens et al [29] showed that approximately 74% of hospitalized patients in intensive care unit were treated with antibiotics.

Likewise, Gendel et al [30] surveyed antibiotic utilization in two medical departments and found that approximately 35% of the acute admitted patients had at least one antibiotics prescribed.

Table 1: Patients’ characteristics (n=243)

Characteristics N (%) Gender Male Female

128 (52.7) 115 (47.0)

Age (year) median (min, max) 62 (15, 104) < 20 21 – 40 41 – 60 > 60

9 (3.7) 28 (11.5) 78 (32.1)

128 (52.7) Antibiotics prescription Ceftazidime 47 (19.3) Imipenem/Cilastatin 45 (18.5) Amoxycillin/Clavulanic acid 44 (18.1) Cefpirome 35 (14.4) Cefoperazone/Sulbactam 34 (14.0) Piperacillin/Tazobactam 33 (13.6) Vancomycin 5 (2.1)

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

46Vol 4, No. 2, May-Aug 2011 Antibiotics prescription pattern and cost in hospitalized patients

Table 2 : Antibiotic costs during September 2007 to February 2008

Antibiotics Costsa (Thai Baht, THB)

Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Total c

Ceftazidime 16 962 73 502 64 764 86 095 84 296 208 170 533 789 Imipenem/Cilastatin 56 924 274 883 268 142 242 676 196 238 41 944 1 080 807 Amoxycillin/Clavulanic acid 11 524 18 492 41 808 66 196 61 104 37 788 236 912 Cefpirome - 104 624 26 156 88 528 140 840 156 936 517 084 Cefoperazone/Sulbactam 69 650 57 710 83 580 55 720 215 915 115 420 597 995 Piperacillin/Tazobactam 24 288 15 456 87 584 174 432 182 528 110 400 594 688 Vancomycin - - 3 084 9 252 - 28 270 40 606 Total b 179 348 544 667 575 118 722 899 880 921 698 928 3 601 881 a US$ 1 THB 35 b Total of all antibiotics costs in each month c Total of each antibiotics costs over 6 months

Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08

Figure 1: Frequency of antibiotics prescribed during September 2007 to February 2008. Symbols: , Imipenem/Cilastatin; , Ceftazidime; Amoxycillin/Clavulanic acid; , Piperacillin/Tazobactam; , Cefpirome; , Cefoperazone/Sulbactam; , Vancomycin

0

2

4

6

8

10

12

14

16

Frequ

ency

of an

tibiot

ics pr

esrib

ed (ti

mes)

17.321.0

22.7

26.8

32.929.7

25.9

1.64.4 4.1

5.9 5.8 5.8 4.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 All

Percentage of seven antibiotics cost per total cost of all drugs use in inpatient Percentage of seven antibiotics cost per total cost of all drugs use in

the hospital

Perce

ntage

(%)

Figure 2: Costs of seven antibiotics use during September 2007 to February 2008

Vol 4, No. 2, May-Aug 2011 Antibiotics prescription pattern and cost in hospitalized patients

Table 2 : Antibiotic costs during September 2007 to February 2008

Antibiotics Costsa (Thai Baht, THB)

Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Total c

Ceftazidime 16 962 73 502 64 764 86 095 84 296 208 170 533 789 Imipenem/Cilastatin 56 924 274 883 268 142 242 676 196 238 41 944 1 080 807 Amoxycillin/Clavulanic acid 11 524 18 492 41 808 66 196 61 104 37 788 236 912 Cefpirome - 104 624 26 156 88 528 140 840 156 936 517 084 Cefoperazone/Sulbactam 69 650 57 710 83 580 55 720 215 915 115 420 597 995 Piperacillin/Tazobactam 24 288 15 456 87 584 174 432 182 528 110 400 594 688 Vancomycin - - 3 084 9 252 - 28 270 40 606 Total b 179 348 544 667 575 118 722 899 880 921 698 928 3 601 881 a US$ 1 THB 35 b Total of all antibiotics costs in each month c Total of each antibiotics costs over 6 months

Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08

Figure 1: Frequency of antibiotics prescribed during September 2007 to February 2008. Symbols: , Imipenem/Cilastatin; , Ceftazidime; Amoxycillin/Clavulanic acid; , Piperacillin/Tazobactam; , Cefpirome; , Cefoperazone/Sulbactam; , Vancomycin

0

2

4

6

8

10

12

14

16

Frequ

ency

of an

tibiot

ics pr

esrib

ed (ti

mes)

17.321.0

22.7

26.8

32.929.7

25.9

1.64.4 4.1

5.9 5.8 5.8 4.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 All

Percentage of seven antibiotics cost per total cost of all drugs use in inpatient Percentage of seven antibiotics cost per total cost of all drugs use in

the hospital

Perce

ntage

(%)

Figure 2: Costs of seven antibiotics use during September 2007 to February 2008

Vol 4, No. 2, May-Aug 2011 รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน

expenses and reducing of drugs resistance. Future studies that evaluating rational drug used program and cost-effectiveness of its intervention are still needed particularly in countries with scarce health resources.

Acknowledgments

The authors would especially like to acknowledge and thank to head of Department of Pharmacy and the director of Phayao hospital for data permission. This research received no specific grant from any funding agency in the public, commercial, or not-to-profit sectors.

References

1. Vaccheri A, Bjerrum L, Resi D, Bergman U, Montanaro N. Antibiotic prescribing in general practice: striking differences between Italy (Ravenna) and Denmark (Funen). J Antimicrob Chemother. 2002;50:989-97.

2. dos Santos E, Lauria-Pires L, Pereira M, Silva A, Rodrigues I, Maia M. Use of antibacterial agents in an intensive care unit in a hospital in Brazil. Braz J Infect Dis. 2007;11(3):355-9.

3. Raveh D, Muallem-Zilcha E, Greenberg A, Wiener-Well Y, Schlesinger Y, Yinnon A. Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefeprime, piperacillin-tazobactam and meropenem. Q J Med. 2006;99:397-406.

4. Kolar J, Hromadova R. Analysis of antibiotic utilization in hospitalized paediatric patients. J Chinese Clin Med. 2007;2(9):496-503.

5. Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K, Hendrickx E, Suetens C, et al. European surveillance of antimicrobial consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother. 2006;58:401-7.

6. Marra F, Patrick D, Chong M, Bowie W. Antibiotic use among children in British Columbia, Canada. J Antimicrob Chemother. 2006;58:830-9.

7. Austin D, Kristinsson K, Anderson R. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci USA. 1999;96:1152-6.

8. Marlière GLL, Ferraz MB, Quirino dos Santos J. Antibiotic consumption patterns and drug leftovers in 6000 Brazilian households. Advances In Therapy. 2000;17(1):32-44.

9. Leibovici L, Beeger R, Gruenewald T, Yahav J, Yehezkelli Y, Milo G, et al. Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link. J Antimicrob Chemother. 2001;48:535-40.

10. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579-87.

11. Lipsitch M, Samore M. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis. 2002;8:347-54.

12. Patterson JE. Antibiotic utilization: is there an effect on antimicrobial resistance? Chest. 2001;119:426-30.

13. Krivoy N, El-Ahal WA, Bar-Lavie Y, Haddad S. Antibiotic prescription and cost patterns in a general intensive care unit. Pharmacy Practice. 2007;5(2):67-73.

14. Paladino JA. Economic justification of antimicrobial management programs: implications of antimicrobial resistance. Am J Health-Syst Pharm. 2000;57(Suppl 2):10-2.

15. Loh L-C, Sani RMM, Samad NIHA, Raman S, Thayaparan T, Kumar S. Adverse hospital

47Saokaew S,et.al. Naresuan Phayao Journal

Table 3 : Antibiotics consumption during September 2007 to February 2008

Antibiotics ATC/DDD index[28]

Drug usage a P-Value

c Sep

2007 Oct

2007 Nov

2007 Dec

2007 Jan

2008 Feb

2008 Ceftazidime J01DD02 (4 g) 1 500 1 300 1 393 1 318 1 278 1 286 0.991 Imipenem/Cilastatin J01DH51 (2 g) 1 000 886 969 1 000 705 1 000 0.771 Amoxycillin/Clavulanic acid J01CR02 (3 g) 1 000 1 200 1 200 1 133 1 236 1 200 0.306 Cefpirome J01DE02 (4 g) - 1 000 1 000 1 071 1 000 1 000 0.423 Cefoperazone/Sulbactam J01DD62 (4 g) 750 750 750 750 825 813 0.632 Piperacillin/Tazobactam J01CR05 (14

g) 804 964 1 056 964 1 005 964 0.429

Vancomycin J01XA01 (2 g) - - 250 1 000 - 1 250 0.106 Total b - 5 054 6 100 6 618 7 236 6 049 7 513 0.185

a Drug usage presented in the average of define daily dose (DDD) per 1,000 patient-days calculate from (total number of DDD of a drug use / total number of patient-days) x 1,000

b Total of all antibiotics usage in each month

c Significant was set at P< 0.05------------------------------------------------*

The dangerous of high volume of antibiotic prescription is antibiotic resistant. There is strong evidence between the use of third-generation of cephalosporin, such as ceftazidime, and antibiotic resistance in Klebseilla pneumonia (extended spectrum -lactamase-producing Klebseillapneumonia;ESBL-KP). Therefore, there are many strategies for appropriate use of antibiotics such as restriction policy [21, 23] and physician education[31]. Ozkurt et al [21] found that after restriction policy implement, the antibiotic prescriptions were significantly decrease by 15%, the appropriate use was increase by 10%, and the approximately US$ 500 000 were saved. Our study has several limitations. First, it is based on retrospective data that could have caused an underestimate of prescribing data. Additionally, there are limited data of the

indications of seven antibiotics used in our study. Because the DUE is a new beginning program in this hospital, physicians are encouraged to fulfill all information in DUE forms but not enforcement. Second, we did not investigate the emergence of antibiotic resistance. However, the previous studies show the strong correlation between antibiotics use and resistant as mentioned previously. Third, due to retrospective data collection, the appropriateness of antibiotic use was not evaluated. In conclusion, this study shows the high prescription and high cost in broad-spectrum antibiotics in our setting. There is the first step toward an importance to initiate an establishment of the rational antibiotic use program in the hospital. Since the high utilization of antibiotic drugs is related to an increase risk of drug resistance, the appropriate antibiotics use should be implied for aimed at minimizing the futile

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

48Vol 4, No. 2, May-Aug 2011 รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน

expenses and reducing of drugs resistance. Future studies that evaluating rational drug used program and cost-effectiveness of its intervention are still needed particularly in countries with scarce health resources.

Acknowledgments

The authors would especially like to acknowledge and thank to head of Department of Pharmacy and the director of Phayao hospital for data permission. This research received no specific grant from any funding agency in the public, commercial, or not-to-profit sectors.

References

1. Vaccheri A, Bjerrum L, Resi D, Bergman U, Montanaro N. Antibiotic prescribing in general practice: striking differences between Italy (Ravenna) and Denmark (Funen). J Antimicrob Chemother. 2002;50:989-97.

2. dos Santos E, Lauria-Pires L, Pereira M, Silva A, Rodrigues I, Maia M. Use of antibacterial agents in an intensive care unit in a hospital in Brazil. Braz J Infect Dis. 2007;11(3):355-9.

3. Raveh D, Muallem-Zilcha E, Greenberg A, Wiener-Well Y, Schlesinger Y, Yinnon A. Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefeprime, piperacillin-tazobactam and meropenem. Q J Med. 2006;99:397-406.

4. Kolar J, Hromadova R. Analysis of antibiotic utilization in hospitalized paediatric patients. J Chinese Clin Med. 2007;2(9):496-503.

5. Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K, Hendrickx E, Suetens C, et al. European surveillance of antimicrobial consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother. 2006;58:401-7.

6. Marra F, Patrick D, Chong M, Bowie W. Antibiotic use among children in British Columbia, Canada. J Antimicrob Chemother. 2006;58:830-9.

7. Austin D, Kristinsson K, Anderson R. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci USA. 1999;96:1152-6.

8. Marlière GLL, Ferraz MB, Quirino dos Santos J. Antibiotic consumption patterns and drug leftovers in 6000 Brazilian households. Advances In Therapy. 2000;17(1):32-44.

9. Leibovici L, Beeger R, Gruenewald T, Yahav J, Yehezkelli Y, Milo G, et al. Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link. J Antimicrob Chemother. 2001;48:535-40.

10. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579-87.

11. Lipsitch M, Samore M. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis. 2002;8:347-54.

12. Patterson JE. Antibiotic utilization: is there an effect on antimicrobial resistance? Chest. 2001;119:426-30.

13. Krivoy N, El-Ahal WA, Bar-Lavie Y, Haddad S. Antibiotic prescription and cost patterns in a general intensive care unit. Pharmacy Practice. 2007;5(2):67-73.

14. Paladino JA. Economic justification of antimicrobial management programs: implications of antimicrobial resistance. Am J Health-Syst Pharm. 2000;57(Suppl 2):10-2.

15. Loh L-C, Sani RMM, Samad NIHA, Raman S, Thayaparan T, Kumar S. Adverse hospital

Vol 4, No. 2, May-Aug 2011 รปแบบการจายยาและคาใชจายของยาปฏชวนะในผปวยใน

expenses and reducing of drugs resistance. Future studies that evaluating rational drug used program and cost-effectiveness of its intervention are still needed particularly in countries with scarce health resources.

Acknowledgments

The authors would especially like to acknowledge and thank to head of Department of Pharmacy and the director of Phayao hospital for data permission. This research received no specific grant from any funding agency in the public, commercial, or not-to-profit sectors.

References

1. Vaccheri A, Bjerrum L, Resi D, Bergman U, Montanaro N. Antibiotic prescribing in general practice: striking differences between Italy (Ravenna) and Denmark (Funen). J Antimicrob Chemother. 2002;50:989-97.

2. dos Santos E, Lauria-Pires L, Pereira M, Silva A, Rodrigues I, Maia M. Use of antibacterial agents in an intensive care unit in a hospital in Brazil. Braz J Infect Dis. 2007;11(3):355-9.

3. Raveh D, Muallem-Zilcha E, Greenberg A, Wiener-Well Y, Schlesinger Y, Yinnon A. Prospective drug utilization evaluation of three broad-spectrum antimicrobials: cefeprime, piperacillin-tazobactam and meropenem. Q J Med. 2006;99:397-406.

4. Kolar J, Hromadova R. Analysis of antibiotic utilization in hospitalized paediatric patients. J Chinese Clin Med. 2007;2(9):496-503.

5. Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K, Hendrickx E, Suetens C, et al. European surveillance of antimicrobial consumption (ESAC): outpatient antibiotic use in Europe. J Antimicrob Chemother. 2006;58:401-7.

6. Marra F, Patrick D, Chong M, Bowie W. Antibiotic use among children in British Columbia, Canada. J Antimicrob Chemother. 2006;58:830-9.

7. Austin D, Kristinsson K, Anderson R. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci USA. 1999;96:1152-6.

8. Marlière GLL, Ferraz MB, Quirino dos Santos J. Antibiotic consumption patterns and drug leftovers in 6000 Brazilian households. Advances In Therapy. 2000;17(1):32-44.

9. Leibovici L, Beeger R, Gruenewald T, Yahav J, Yehezkelli Y, Milo G, et al. Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link. J Antimicrob Chemother. 2001;48:535-40.

10. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet. 2005;365:579-87.

11. Lipsitch M, Samore M. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg Infect Dis. 2002;8:347-54.

12. Patterson JE. Antibiotic utilization: is there an effect on antimicrobial resistance? Chest. 2001;119:426-30.

13. Krivoy N, El-Ahal WA, Bar-Lavie Y, Haddad S. Antibiotic prescription and cost patterns in a general intensive care unit. Pharmacy Practice. 2007;5(2):67-73.

14. Paladino JA. Economic justification of antimicrobial management programs: implications of antimicrobial resistance. Am J Health-Syst Pharm. 2000;57(Suppl 2):10-2.

15. Loh L-C, Sani RMM, Samad NIHA, Raman S, Thayaparan T, Kumar S. Adverse hospital

Vol 4, No. 2, May-Aug 2011 Antibiotics prescription pattern and cost in hospitalized patients

Table 2 : Antibiotic costs during September 2007 to February 2008

Antibiotics Costsa (Thai Baht, THB)

Sep 2007 Oct 2007 Nov 2007 Dec 2007 Jan 2008 Feb 2008 Total c

Ceftazidime 16 962 73 502 64 764 86 095 84 296 208 170 533 789 Imipenem/Cilastatin 56 924 274 883 268 142 242 676 196 238 41 944 1 080 807 Amoxycillin/Clavulanic acid 11 524 18 492 41 808 66 196 61 104 37 788 236 912 Cefpirome - 104 624 26 156 88 528 140 840 156 936 517 084 Cefoperazone/Sulbactam 69 650 57 710 83 580 55 720 215 915 115 420 597 995 Piperacillin/Tazobactam 24 288 15 456 87 584 174 432 182 528 110 400 594 688 Vancomycin - - 3 084 9 252 - 28 270 40 606 Total b 179 348 544 667 575 118 722 899 880 921 698 928 3 601 881 a US$ 1 THB 35 b Total of all antibiotics costs in each month c Total of each antibiotics costs over 6 months

Sep 07 Oct 07 Nov 07 Dec 07 Jan 08 Feb 08

Figure 1: Frequency of antibiotics prescribed during September 2007 to February 2008. Symbols: , Imipenem/Cilastatin; , Ceftazidime; Amoxycillin/Clavulanic acid; , Piperacillin/Tazobactam; , Cefpirome; , Cefoperazone/Sulbactam; , Vancomycin

0

2

4

6

8

10

12

14

16

Frequ

ency

of an

tibiot

ics pr

esrib

ed (ti

mes)

17.321.0

22.7

26.8

32.929.7

25.9

1.64.4 4.1

5.9 5.8 5.8 4.7

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 All

Percentage of seven antibiotics cost per total cost of all drugs use in inpatient Percentage of seven antibiotics cost per total cost of all drugs use in

the hospital

Perce

ntage

(%)

Figure 2: Costs of seven antibiotics use during September 2007 to February 2008

49Saokaew S,et.al. Naresuan Phayao Journal

outcomes associated with the choice of empiric antibiotics in Klebsiella pneumoniae Pneumonia: a retrospective observational study. Ann Acad Med Singapore. 2007;36:642-6.

16. Khotaei GT, Fattahi F, Pourpak Z, Moinfar Z, Aghaee FM, Gholami K, et al. Adverse reactions to antibiotics in hospitalized Iranian children. J Microbiol Immunol Infect. 2008;41:160-4.

17. Cadieux G, Tamblyn R, Duaphinee D, Libman M. Predictors of inappropriate antibiotic prescribing among primary care physicians. CMAJ. 2007;177(8):877-83.

18. Edwin E. Inappropriate antibiotic use in the Philippines. Phil J Microbiol Infect Dis. 1997;26(2):77-87.

19. Wester C, Durairaj L, Evans A, Schwartz D, Husain S, Martinez E. Antibiotic resistance: a survey of physician perceptions. Arch Intern Med. 2002;162:2210-6.

20. Aydin S, Yaris F, Ozcakir A, Agalar C. Most common infections and antibiotic prescribing habits of residents: experience of three university hospitals. Turk J Med Sci. 2005;35:169-73.

21. Ozkurt Z, Erol S, Kadanali A, Ertek M, Ozden K, Tasyaran M. Changes in antibiotic use, cost, and consumption after an antibiotic restriction policy applied by infectious disease specialists. Jpn J Infect Dis. 2005;58:338-43.

22. Senn L, Burnand B, Francioli P, Zanetti G. Improving appropriateness of antibiotic therapy: randomized trial of an intervention to foster reassessment of prescription after 3 days. J Antimicrob Chemother. 2004;53:1062-7.

23. Kusuma Na Ayuthya S, Matangkasombut OP, Sirinavin S, Malathum K, Sathapatayavongs

B. Utilization of restricted antibiotics in a university hospital in Thailand. Southeast Asian J Trop Med Public Health. 2003;34(1):179-86.

24. Thamlikitkul V, Danchaivijitr S, Kongpattanakul S, Ckokloikaew S. Impact of an educational program on antibiotic use in a tertiary care hospital in a developing country. J Clin Epidemiol. 1998;51(9):773–8.

25. ASHP guidelines on the pharmacist's role in drug-use evaluation. Am J Hosp Pharm. 1988;45:385-6.

26. Chaikoolvatana A, Chaikoolvatana C, Triwakornsasrithorn B, Puthiwong S. The development of a standard drug use evaluation criteria from for Cefoperzone use at regional hospital in Northeastern Thailand. Chula Med J. 2006;50(7):471-86.

27. Tunger O, Dinc G, Ozbakkaloglu B, Atman UC, Algun U. Evaluation of rational antibiotic use. Int J Antimicrob Agents. 2000;15:131-5.

28. WHO Collaborating Centre for Drug Statistics Methodology. Complete ATC index 2008. Oslo; 2008.

29. Hanssens Y, Ismaeili BB. Antibiotic prescription pattern in a medical intensive care unit in Qatar. Saudi Med J. 2005;26:1269-76.

30. Gendel I, Azzam ZS, Braun E, Levy Y, Krivoy N. Antibiotic utilization prevalence: prosepctive comparison between two medical departments in a tertiary care university hospital. Pharmacoepidemiol Drug Safe. 2004;13:735-9.

31. Arnold S, Straus S. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Syst Rev. 2005;4:CD003539.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.

Saokaew S,et.al. Naresuan Phayao Journal

February 2008. Two hundred and forty three patients were collected. Ceftazidime, imipenem-cilastin, were prescribed 47 (19.3%), 45 (18.5%), 44 (18.1%), 35 (14.4%), 34 (14.0%), 33 (13.6%), 5 (2.1%) times, respectively. Cost of seven antibiotics was one-fourth of all drugs used for inpatients (25.9%; 3,601,881 THB per 13,895,333 THB; US$ 1 THB 35). The highest cost during study was imipenem-cilastin (1,080,807 THB). DDD1000 in over other month within each drug was similar. Focusing on seven antibiotics consumption, all of them tend to be prescribed increasingly as same as the cost of their used. The cost of seven antibiotics utilization was the vast majority of all drugs cost. The appropriate antibiotics use should be implied to minimize the futile expenses.

Keywords : Antibiotic, cost, drug use evaluation (DUE), prescriptions, utilization

Introduction

Antibiotics were used excessively worldwide in both communities and hospital settings [1-8]. Inappropriate used shown the evidences of antibiotic resistance [7,9-12], increased cost of hospitalization [13,14], and adverse drug reactions [15,16]. The inappropriate use of antibiotics is caused by a multiplicity of factors [17,18], such as community/consumer influence by misconception and financial constraints, physician’s behavior and promoted antibiotics without emphasis on cost, and adverse effects[18-20].

The rate of antibiotics resistance, both gram-positive and gram-negative organism, has significantly increased over the past decade; the broadest-spectrum antibiotics were prescribed for the empiric therapy of serious nosocomial infection. Concern about escalating rate of multi-drug-resistant organisms and increasing expenditure on antibiotics has induced most hospitals to implement a range of strategies to prevent such event [21-24]. One of these strategies is drug utilization evaluation (DUE) program[25]. This program was adapted by health professionals to assess appropriateness of various medications usage [3, 4, 23, 26, 27].

The purpose of a DUE is generally to detect possible problems with, and improve, drug utilization. DUE has traditionally focused on drugs which associated with side-effects, the expensive drugs, or complicated dosing regimens[25]. In Thailand, generally, DUE was used to monitor the expensive and narrow therapeutic index drugs particularly broad-spectrum antimicrobial agents [23,26]. The Antibiotics Smart Use program, introduced in Thailand, aims at promoting appropriate use of antibiotics.However, information of the prescribing pattern and cost in the hospitals are still the crucial needed for establishing rationale antibiotic use policy. Thus, the objective of this study was to evaluate prescription pattern and cost expenditure of seven broad-spectrum antibiotics listed in the DUE program of the hospital.