Cross-sectional study to track antibiotic consumption and its appropriateness in an intensive care setting of a tertiary care hospital using AWaRe tool of World Health Organization (WHO).

doi:10.21203/rs.3.rs-5245970/v1

Download PDF

Research Article

Cross-sectional study to track antibiotic consumption and its appropriateness in an intensive care setting of a tertiary care hospital using AWaRe tool of World Health Organization (WHO).

https://doi.org/10.21203/rs.3.rs-5245970/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background:

Incorporating AWaRe classification metrics provide a structured approach to evaluating antibiotic consumption and guiding future interventions for better antibiotic stewardship in healthcare facilities. The study aimed to quantify antibiotic consumption and assess its appropriateness in an intensive care unit of a tertiary care hospital in South India using the WHO's AWaRe tool.

Methods:

This study was conducted in a South Indian ICU over 2 months, including prescriptions with at least one antibiotic for patients admitted within 2 weeks. Around 100 prescriptions were included based on ICU admission statistics. An AWaRe tool by WHO was used to analyze antibiotic consumption and appropriateness.

Results:

201 antibiotics were prescribed, with an average of 2 antimicrobials per patient. 78.6% administered parenterally, 21.4% orally. 29% cases had clinical samples sent for Culture & Sensitivity testing. Only 29% cases showed escalation or de-escalation of antimicrobials based on clinical response.

Conclusions:

The study highlighted the empirical nature of antibiotic prescriptions, limited microbiological guidance, and inadequate adjustments based on clinical responses. These findings emphasize the need for improved guidelines and practices to optimize antibiotic use in intensive care settings, ensuring appropriateness and effectiveness in patient care.

Clinical Pharmacology

antibiotics

antibiotic consumption

AWaRe tool

Antibiotic stewardship program

ATC classification

Antimicrobial Resistance (AMR) refers to ability of the microorganisms to withstand the effects of an antibiotic over time and irrational inappropriate antibiotic use is the major contributing factor for AMR. Increased AMR may lead to prolonged hospitalization, increased costs, and mortality. The World Health Organization (WHO) has identified AMR as a “global security threat” impacting global health and economic growth of a country.¹It is estimated that approximately 700,000 deaths occur annually as a result of AMR and deaths could rise to 10 million by 2050 if no concerted action is taken.

WHO has published a global action plan on AMR to optimize the use of antibiotics. Following that AWaRe (Access, Watch, Reserve) classification was developed in 2017 by WHO Expert Committee on Selection and Use of Essential Medicines. AWaRe is a useful tool to monitor antibiotic consumption, define targets and monitor effects of stewardship policies that aim to optimize antibiotic use and curb AMR.²^,³

Access group of antibiotics are first and second choices of empirical treatment of 21 common or severe infectious diseases which are supposed to be made available in every level of care at an appropriate quantity, dose, duration, formulation, and price. WHO had specified that antibiotics from the Access category should be at least 60%. The Watch group antibiotics included drugs with higher toxicity concerns or resistance potential and Reserve group included last-resort options for specific patients in case of failure of first line drugs. Thus AWaRe tool can be used to estimate the relative use of narrow-spectrum and broad-spectrum antibiotics.⁴

Moreover, an undergraduate level of medical training to use AWaRe tool is ideal to acquire knowledge and generate beliefs and attitudes regarding antibiotics use and resistance, unlike the postgraduate level where extrinsic factors have hardly any influence on the generation of knowledge and attitudes.⁵

With the use of AWaRe tool of WHO to implement its Global Action Plan on Antimicrobial Resistance, this study has been planned with an objective to track antibiotic consumption and appropriateness in the intensive care setting of a tertiary care hospital.

Overuse and misuse of antibiotics stand as key drivers behind the development of antibiotic resistance (AMR). The extensive utilization of antibiotics, even in situations where they may not be necessary, creates a selective pressure that hampers the reproductive abilities of certain microorganisms, hastening the onset of AMR. Three crucial factors contributing to this selective pressure include the volume of antibiotics administered, its appropriateness, and the proportion of hospitalized patients under antibiotic therapy.⁶

According to literature, there was a 36% increase in global antibiotic consumption between 2000 and 2010. The countries known as BRICS, which include Brazil, Russia, India, China, and South Africa, were responsible for three-quarters of this increase, despite only representing 40% of the world's population. Among these countries, India accounted for 23% of the retail sales volume. It is worth noting that in India, regulations to control over-the-counter sales of antibiotics are not effectively enforced. Also India does not have a formal system to monitor antibiotic use.⁷

There are many individual studies confirming the direct relationship between antibiotic consumption and antimicrobial resistance.^8–10 There are different ways to measure antibiotic consumption in a tertiary care hospital which includes daily defined dose (DDD)/1000 patient days, DDD/100 patient days, DDD/1000 inhabitant days per year (DIDs), grams and average/percentage trend.¹¹ However, in 2017, the WHO has created the WHO Network, a platform that gathers antibiotic consumption data from member states through the use of the AWaRe classification system. India is one actively participating member in this effort by contributing its data through the National Antimicrobial Consumption Network (NAC-NET). WHO analyses the global qualitative trends in antimicrobial consumption using AWaRe classification to address drug resistance, and this information will guide future policy decisions on the optimal use of antimicrobials.³

The AWaRe index also serves a crucial purpose in pinpointing local infections that are prevalent at a certain time, leading to heightened usage of watch and reserve antimicrobials during that specific period.⁴ This identification is possible as long as there are no limitations in accessing antibiotics. The creation of antibiotic categorizations is intended to serve as a guideline for healthcare professionals when prescribing antibiotics, with the purpose of promoting and supporting the appropriate use of these medications. These categorizations are a significant component of the WHO AWaRe tool, to both quantify antibiotic consumption and evaluate the appropriateness of antibiotic use. The tool itself is designed to assist countries in monitoring and enhancing their antibiotic prescribing practices, with the goal of reducing the emergence and spread of antibiotic resistance.

Sharland et al.² utilized the Access, Watch, and Reserve (AWaRe) classification to categorize 180 antimicrobials listed in the WHO Essential Medicines List (EML), aiming to facilitate their safe and appropriate prescription. Antimicrobials categorized as Access (green) are considered first- or second-line treatments, recommended for widespread availability due to their efficacy in treating common infectious diseases. In contrast, Watch (amber) group antibiotics, such as carbapenems, pose a higher risk of resistance development and are thus recommended for limited use in specific indications. The Reserve (red) group comprises antibiotics reserved for critical, life-threatening situations, emphasizing their restricted use. Additionally, medications categorized as Watch and Reserve necessitate vigilant monitoring through antimicrobial stewardship programs to preserve their efficacy over time.

Koya et al. (2019) studied the consumption of antibiotics using additional dimensions of essentiality, product type (fixed dose combinations, single formulations) and central regulatory approval status (approved/unapproved) and reported a lower consumption rate compared to previous estimates with very high relative consumption of broad- spectrum antibiotics and unapproved formulations mostly outside the price-controlled essential medicines list.⁷

Another metric to measure antibiotic consumption is the utilization of the World Health Organization (WHO) Anatomic Therapeutic Clinical classification and defined daily dose (ATC/DDD) methodology enabling meaningful comparisons of antibiotic consumption, both within and between hospitals and countries.¹²Mapping antibiotics to their corresponding ATC codes enables hospitals to categorize and analyze antibiotic usage patterns. It is important to note that the ATC classification system itself does not directly measure antibiotic consumption. However, it provides a framework for organizing and analyzing data, which can be used in conjunction with other relevant information to inform decisions about antibiotic usage in hospitals. By combining data from ATC codes with additional data on antibiotic volumes, prescription rates, and patient outcomes, hospitals can obtain a comprehensive understanding of the appropriateness and effectiveness of antibiotic utilization.

To summarize, assessing antibiotic consumption in India through ATC/DDD metrics and AWaRe classification, considering factors such as product type (FDCs/single formulations), essentiality (listed in NLEM/not listed), and central regulatory approval status (CDSCO approved/unapproved), would allow for a thorough evaluation of the appropriateness of antibiotic utilization in the country.

4. Aim & Objectives: To quantify the antibiotic consumption and its appropriateness in an intensive care setting of a tertiary care hospital using WHO’s AWaRe tool.

This study is a cross-sectional, observational study conducted over a 2-month period in the Intensive Care Unit (ICU) of a tertiary care hospital in South India. Prescriptions or drug charts containing at least one antibiotic, prescribed to patients of all ages and gender until 2 weeks or earlier since admission were included in the study. The sample size for the study was estimated to be approximately 100 participants based on quarterly statistics of ICU admissions in the hospital. Universal sampling method was used to include all eligible participants. The study commenced only after obtaining approval from the Institute Ethics Committee, and a waiver of consent was obtained as the data were collected only from the medical records of the patients. Data was collected by scrutinizing the drug charts or prescriptions and using a standardized case report form to collect relevant information from the medical records, including details about the antibiotics prescribed, their clinical indications, microbiological culture reports, antibiotic de-escalation, and follow-up treatment. The study data was analyzed using the AWaRe tool provided by the World Health Organization (WHO) website https://aware.essentialmeds.org/list to quantify antibiotic consumption and assess appropriateness of antibiotic use. All the data were entered in Microsoft Excel sheet (Microsoft office 365) and descriptive statistics was used to analyze the data. Data was anonymized and kept confidential to protect participants privacy.

In the study conducted to track antibiotic consumption and appropriateness in an intensive care setting of a tertiary care hospital utilizing the AWaRe tool by the World Health Organization (WHO), we collected data using the case report form from 100 patients’ prescription charts admitted in the ICU over a period of two months. The prescription charts reviewed belonged to elderly patients admitted in ICU with mean age of 55.03±14.92 years representing both genders equally as shown in Fig. 1. Analysis of study characteristics revealed that out of 100 drug charts reviewed, a total of 201 antibiotics were prescribed with an average of 2 antimicrobials per patient, with 78.6% (158) of antimicrobials being administered parenterally and 21.4%(43) of antimicrobials administered orally (Table 1). Notably, all antimicrobials were empirically prescribed, with only 29% of cases having clinical samples sent for Culture & Sensitivity testing, indicating a lack of microbiological guidance in prescribing decisions. A concerning finding was the low proportion of cases (29%) where escalation or de-escalation of antimicrobials occurred, suggesting a potential gap in treatment optimization based on clinical response (Table 2).

Table 1

Study characteristics:
Parameters	Values
Total drug charts of patients reviewed	100
Mean age (years)	55.03±14.92
Total number of antimicrobials prescribed	201
Average number of antimicrobials per patient	2
Total number of oral antimicrobials prescribed n(%)	43 (21.4)
Total number of parenteral antimicrobials prescribed n(%)	158 (78.6)

Table 2

Prescription indicators:
Parameters	Values
Antimicrobials prescribed empirically (%)	100%
Clinical samples sent for Culture & sensitivity
Yes (%)	29%
No (%)	71%
Escalation/De-escalation of antimicrobials (%)	29%
Antibiotic indications documented	100%
Treatment duration of antimicrobials mentioned in drug charts	100%

The list of indications for which antimicrobials were prescribed across the reviewed drug charts are presented in Table 3 where antimicrobials were most prescribed for blood stream infections, accounting for 41% of the prescriptions. Respiratory tract infections were the second most common indication, comprising 25% of prescriptions. Prophylaxis was indicated in 19% of the cases and urinary tract infections accounted for 10% of the antimicrobial prescriptions. Skin infections and CNS infections were relatively less common, making up only 2% of the prescriptions each. Gastrointestinal infections were least common indications, with only 1% of prescriptions.

Table 3

List of indications where antimicrobials were prescribed in reviewed drug charts.
Indications	Values
Blood stream infections	41%
Respiratory tract infections	25%
Prophylaxis	19%
Urinary tract infections	10%
Skin infections	2%
CNS infections	2%
Gastrointestinal infection	1%

Table 4 categorizes various antimicrobials according to the WHO AWaRe classification, along with the number of prescriptions and their percentage of the total. It was observed that most prescribed antimicrobials fell under the Watch category (62%), while Access antibiotics accounted for 25% of the prescriptions, and Reserve antibiotics comprised 13% of the total antimicrobial usage (Fig. 2). In the Watch category, PIPERACILLIN TAZOBACTUM was leading at 49 prescriptions (24.4%), followed by CEFTRIAXONE with 33 (16.4%), and MEROPENEM with 29 (14.4%). In the Access category, DOXYCYCLINE had 16 prescriptions (8%), and other drugs such as AMOXICILLIN CLAVULANIC ACID and GENTAMICIN had fewer, each at around 1–2%. In the Reserve category MINOCYCLINE and POLYMYXIN B were prescribed 3 (1.5%) and 2 (1%) times respectively.

Table 4

List of antimicrobials and their category according to WHO AWaRe classification:
S.No	Antimicrobials Prescribed	Category according to WHO AWaRe classification	Number of prescriptions n (%)
1	PIPERACILLIN TAZOBACTUM	Watch	49 (24.4)
2	CEFTRIAXONE	Watch	33 (16.4)
3	MEROPENEM	Watch	29 (14.4)
4	AZITHROMYCIN	Watch	24 (11.9)
5	DOXYCYCLINE	Access	16 (8)
6	VANCOMYCIN	Watch	14 (7)
7	CLINDAMYCIN	Access	10 (5)
8	AMOXICILLIN CLAVULANIC ACID	Access	3 (1.5)
9	CEFTAZIDIME	Watch	3 (1.5)
10	MINOCYCLINE	Reserve	3 (1.5)
11	POLYMYXIN B	Reserve	2(1)
12	GENTAMICIN	Access	2 (1)
13	MOXIFLOXACIN	Watch	2 (1)
14	LEVOFLOXACIN	Watch	1 (0.5)
15	IMIPENEM	Watch	1 (0.5)
16	CEFIXIME	Watch	1 (0.5)
17	FAROPENEM	Reserve	1 (0.5)
18	AMIKACIN	Access	1 (0.5)
19	CEFEPIME	Watch	1 (0.5)
20	BENZYL PENICILLIN	Access	1 (0.5)
21	CEFOPERAZONE	Watch	1 (0.5)
22	CEFOTAXIME	Watch	1 (0.5)
23	CIPROFLOXACIN	Watch	1 (0.5)
24	NORFLOXACIN	Watch	1 (0.5)

Table 5 provides detailed information on the list of antimicrobials included in the Essential Medicines List (India), along with WHO ATC category and product type. Out of the 24 antimicrobials listed, all but four drugs, namely MINOCYCLINE, POLYMYXIN B, IMIPENEM, and FAROPENEM, are included on the Essential Medicines List, marking 83.3% of the total. Every listed antimicrobial has a designated ATC classification code, facilitating standardized classification and international comparison. The product type for all listed antimicrobials is predominantly single formulation (SF), with only one being a Fixed Dose Combination (FDC), specifically AMOXICILLIN CLAVULANIC ACID.

Table 5

**List of antimicrobials included in Essential Medicines List (India), WHO ATC category and Product type**:
S.No	Antimicrobials Prescribed	ATC classification	Essentiality (EML list, India)	Product type (FDC/SF)*
1	PIPERACILLIN TAZOBACTUM	J01CR05	Listed	SF
2	CEFTRIAXONE	J01DD04	Listed	SF
3	MEROPENEM	J01DH02	Listed	SF
4	AZITHROMYCIN	J01FA10	Listed	SF
5	DOXYCYCLINE	J01AA02	Listed	SF
6	VANCOMYCIN	J01XA01	Listed	SF
7	CLINDAMYCIN	J01FF01	Listed	SF
8	AMOXICILLIN CLAVULANIC ACID	J01CR01	Listed	FDC
9	CEFTAZIDIME	J01DD02	Listed	SF
10	MINOCYCLINE	J01AA08	Unlisted	SF
11	POLYMYXIN B	J01XB02	Unlisted	SF
12	GENTAMICIN	J01GB03	Listed	SF
13	MOXIFLOXACIN	J01MA14	Listed	SF
14	LEVOFLOXACIN	J01MA12	Listed	SF
15	IMIPENEM	J01DH51	Unlisted	SF
16	CEFIXIME	J01DD08	Listed	SF
17	FAROPENEM	J01DI03	Unlisted	SF
18	AMIKACIN	J01GB06	Listed	SF
19	CEFEPIME	J01DE01	Unlisted	SF
20	BENZYL PENICILLIN	J01CE01	Listed	SF
21	CEFOPERAZONE	J01DD12	Unlisted	SF
22	CEFOTAXIME	J01DD01	Listed	SF
23	CIPROFLOXACIN	J01MA02	Listed	SF
24	NORFLOXACIN	J01MA06	Unlisted	SF
*FDC Fixed Dose Combination; SF - Single formulation

These data together provide a comprehensive oversight into how antimicrobials are being utilized in the study site, highlighting the need for improved antimicrobial stewardship practices in the intensive care setting to ensure the judicious use of antibiotics and enhance patient care outcomes.

In our study on antibiotic consumption and appropriateness in an intensive care setting of a tertiary care hospital, we used the AWaRe tool developed by the World Health Organization. We collected data from 100 patients in the ICU over a two-month period. The patients in our study were sourced from various healthcare institutions, including stand-alone clinics, private nursing homes, primary and secondary public sector health centers, and hospitals. Therefore, we believe that our study sample accurately reflects the emergency settings in tertiary care facilities within our country.

The results showed that most prescribed antimicrobials fell into the Watch category (62%), followed by Access antibiotics (25%), and Reserve antibiotics (13%). The World Health Organization suggests increasing the utilization of narrow-spectrum ACCESS antibiotics to mitigate the selection pressure caused by broad-spectrum WATCH and RESERVE antibiotics. However, our study discovered that the estimated consumption of ACCESS antibiotics was lower than WATCH antibiotics (25% vs. 62%). This discrepancy contradicts the WHO recommendation of reaching a minimum of 60% consumption of ACCESS antibiotics, emphasizing the necessity of implementing alternative antimicrobial stewardship strategies like de-escalation, antibiotic restriction, and healthcare worker training.¹³ For instance, Watch antibiotics were among top four medicines used across during the study period with Piperacillin tazobactam use in 49 (24.4%) of prescriptions. Piperacillin tazobactam, is a β-lactam/β-lactamase inhibitor combination with a broad spectrum of antibacterial activity covering most gram positive and gram negative aerobic and anaerobic bacteria, including many pathogens which produces β-lactamases¹⁴. The reason for its use in most of the patients was based on the antibiotic policy of the study hospital. Our hospital's antibiotic policy was established after creating a hospital-specific antibiogram using data collected from the analysis of patient samples. This policy outlines that the initial treatment for infections should consider the potential clinical syndrome, the primary site of infection, and the likely pathogens. It also factors in the risk of drug-resistant pathogens based on indicators such as host characteristics and the severity of the disease. The data collected from the medication charts were found to be appropriate to these antibiotic policy guidelines which in turn ensures adherence to antimicrobial stewardship in the hospital.

The mean number of medications per prescription in our study was 2.1, which is consistent with the WHO standard value of 2. This finding is lower than the results reported in studies conducted by Atif et al¹⁵ (2.8 drugs per prescription), Mashalla et al.¹⁶ in Botsawna (2.8 drugs per prescription), and Mamo and Alemu et al.¹⁷ (2.5 drugs per prescription). In a positive light, the Essential Drug List (EDL) was consistently accessible in this study hospital, with 83% of the prescribed medications being derived from the list. The next point to be noted is that every patient was prescribed antimicrobials, with 78.6% of them administered through injections for systemic infection indications. It is appropriate since all the medication charts reviewed are from intensive care unit comprising of mostly sick patients.

It is important to mention that most prescriptions (> 65%) consisted of broad-spectrum antimicrobials like piperacillin tazobactam, ceftriaxone, and meropenem, which were administered as empirical therapy. However, it is concerning that only 29% of cases involved sending clinical samples for Culture & Sensitivity testing, indicating a lack of microbiological guidance in prescribing decisions. Furthermore, only 29% of cases saw adjustments in antimicrobial treatment based on clinical response, suggesting potential room for improvement in optimizing treatment. These findings highlight the need to enhance antimicrobial stewardship practices in the intensive care setting to ensure appropriate antibiotic use and improve patient care outcomes. This finding indicates a potential area for educational intervention as part of a future antibiotic stewardship program.

We defined systemic antibiotics as drugs classified under the J01 group in the WHO Anatomical Therapeutic Chemical (ATC) classification system, which comprise antibacterial drugs for systemic use. It would have given an additional dimension if we had known the volume of antimicrobials used for calculating the DDD/DID or DOT which gives an idea about antimicrobial consumption.

The findings of this study suggest several implications for practice. Firstly, there is a pressing need for enhanced antimicrobial stewardship programs to promote the judicious use of antibiotics, especially considering the high proportion of antimicrobials falling under the Watch category. Secondly, optimizing the utilization of microbiological testing, as indicated by the low rate of samples sent for Culture & Sensitivity testing, is essential to guide more targeted antibiotic prescribing. Thirdly, improving treatment protocols based on clinical response, demonstrated by the limited instances of antimicrobial escalation or de-escalation, could enhance individualized therapy and patient outcomes. Lastly, ongoing education and awareness initiatives focusing on appropriate antibiotic use, understanding antibiotic categories, and the significance of microbiological testing are imperative to cultivate a culture of responsible antibiotic prescribing in intensive care settings. Implementing these implications into practice can lead to better patient care, optimized antibiotic therapy, and the mitigation of antimicrobial resistance.

Antimicrobial stewardship programs (ASP) play a vital role in optimizing antibiotic treatment and mitigating the risk of antimicrobial resistance by minimizing unnecessary antibiotic consumption. It is crucial for healthcare facilities to implement systems that can evaluate the use of antibiotics within the institution and examine the correlation between antibiotic utilization trends and the prevalence of antibiotic resistance. These strategies are essential for effectively combating the development and spread of antibiotic resistance.¹¹

In conclusion, the study findings reinforce the need for effective antibiotic stewardship programs to address antibiotic resistance. By examining antibiotic usage patterns across different categories, the study underscores the importance of monitoring and optimizing antibiotic prescribing practices. Global initiatives promoting the use of the AWaRe classification highlight the significance of data-driven interventions in promoting prudent antibiotic use and safeguarding the efficacy of antimicrobial agents. These insights emphasize the critical role of responsible antibiotic use in combating the growing threat of antibiotic resistance.

This study was conducted to track antibiotic consumption and appropriateness in an intensive care setting of a tertiary care hospital using the AWaRe tool of the World Health Organization (WHO). The study collected data from 100 patients over a two-month period and analyzed the prescriptions and drug charts. The results showed that most prescribed antimicrobials fell into the Watch category, followed by Access antibiotics and Reserve antibiotics. The study also highlighted areas for improvement, such as the lack of microbiological guidance in prescribing decisions and limited adjustment of antimicrobial treatment based on clinical response. The findings emphasize the importance of enhancing antimicrobial stewardship programs and promoting responsible antibiotic use to combat antibiotic resistance.

Wall S. Prevention of antibiotic resistance - an epidemiological scoping review to identify research categories and knowledge gaps. Glob Health Action. 2019 Dec 13;12(1):1756191.
Sharland M, Pulcini C, Harbarth S, Zeng M, Gandra S, Mathur S, et al. Classifying antibiotics in the WHO Essential Medicines List for optimal use-be AWaRe. Lancet Infect Dis. 2018 Jan;18(1):18–20.
Hsia Y, Lee BR, Versporten A, Yang Y, Bielicki J, Jackson C, et al. Use of the WHO Access, Watch, and Reserve classification to define patterns of hospital antibiotic use (AWaRe): an analysis of paediatric survey data from 56 countries. Lancet Glob Health. 2019 Jul;7(7):e861–71.
Mugada V, Mahato V, Andhavaram D, Vajhala SM. Evaluation of Prescribing Patterns of Antibiotics Using Selected Indicators for Antimicrobial Use in Hospitals and the Access, Watch, Reserve (AWaRe) Classification by the World Health Organization. Turk J Pharm Sci. 2021 Jun 18;18(3):282–8.
Nogueira-Uzal N, Zapata-Cachafeiro M, Vázquez-Cancela O, López-Durán A, Herdeiro MT, Figueiras A. Does the problem begin at the beginning? Medical students’ knowledge and beliefs regarding antibiotics and resistance: a systematic review. Antimicrob Resist Infect Control. 2020 Dec;9(1):172.
Amaha ND, Weldemariam DG, Berhe YH. Antibiotic consumption study in two hospitals in Asmara from 2014 to 2018 using WHO’s defined daily dose (DDD) methodology. PloS One. 2020;15(7):e0233275.
Koya SF, Ganesh S, Selvaraj S, Wirtz VJ, Galea S, Rockers PC. Consumption of systemic antibiotics in India in 2019. Lancet Reg Health Southeast Asia. 2022 Sep;4:100025.
Lai CC, Wang CY, Chu CC, Tan CK, Lu CL, Lee YL, et al. Correlation between antimicrobial consumption and resistance among Staphylococcus aureus and enterococci causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009. Eur J Clin Microbiol Infect Dis. 2011 Feb;30(2):265–71.
McLaughlin M, Advincula MR, Malczynski M, Qi C, Bolon M, Scheetz MH. Correlations of Antibiotic Use and Carbapenem Resistance in Enterobacteriaceae. Antimicrob Agents Chemother. 2013 Oct;57(10):5131–3.
Baditoiu L, Axente C, Lungeanu D, Muntean D, Horhat F, Moldovan R, et al. Intensive care antibiotic consumption and resistance patterns: a cross-correlation analysis. Ann Clin Microbiol Antimicrob. 2017 Dec;16(1):71.
Abejew AA, Wubetu GY, Fenta TG. Relationship between Antibiotic Consumption and Resistance: A Systematic Review. Can J Infect Dis Med Microbiol J Can Mal Infect Microbiol Medicale. 2024;2024:9958678.
Pathak A, Mahadik K, Dhaneria SP, Sharma A, Eriksson B, Lundborg CS. Surveillance of antibiotic consumption using the “focus of infection” approach in 2 hospitals in Ujjain, India. PloS One. 2012;7(6):e38641.
Sharland M, Gandra S, Huttner B, Moja L, Pulcini C, Zeng M, et al. Encouraging AWaRe-ness and discouraging inappropriate antibiotic use—the new 2019 Essential Medicines List becomes a global antibiotic stewardship tool. Lancet Infect Dis. 2019 Dec;19(12):1278–80.
Perry CM, Markham A. Piperacillin/Tazobactam: An Updated Review of its Use in the Treatment of Bacterial Infections. Drugs. 1999;57(5):805–43.
Atif M, Sarwar MR, Azeem M, Umer D, Rauf A, Rasool A, et al. Assessment of WHO/INRUD core drug use indicators in two tertiary care hospitals of Bahawalpur, Punjab, Pakistan. J Pharm Policy Pract. 2016;9:27.
Mashalla Y, Setlhare V, Massele A, Sepako E, Tiroyakgosi C, Kgatlwane J, et al. Assessment of prescribing practices at the primary healthcare facilities in Botswana with an emphasis on antibiotics: Findings and implications. Int J Clin Pract. 2017 Dec;71(12).
Mamo DB, Alemu BK. Rational Drug-Use Evaluation Based on World Health Organization Core Drug-Use Indicators in a Tertiary Referral Hospital, Northeast Ethiopia: A Cross-Sectional Study. Drug Healthc Patient Saf. 2020;12:15–21.

The authors declare no competing interests.

Download PDF

Version 1

posted

You are reading this latest preprint version

Cross-sectional study to track antibiotic consumption and its appropriateness in an intensive care setting of a tertiary care hospital using AWaRe tool of World Health Organization (WHO).

Status:

Version 1

Abstract

Figures

Introduction

Review of literature

Materials and Methods

Observations and Results

Discussion

Conclusion

Summary

References

Additional Declarations

Status:

Version 1