A Hospital-Based Analytical Study on Antibiotic Utilization in Pediatric Patients and Antibiotic Stewardship

Abstract

Background:

Antibiotics are prescribed frequently for children, and it has been discovered that nearly half of all antibiotics prescribed in pediatric healthcare settings are deemed inappropriate. This misuse of antibiotics leads to the rise of antimicrobial resistance, adverse drug reactions, increased morbidity, and higher hospitalization costs. If no global measures are implemented, it is estimated that antimicrobial resistance will cause 10 million deaths by 2050.

Objective:

The objective of this study is to analyze the antibiotics utilization patterns in the pediatric department for the upliftment in the adherence to the guidelines while prescribing in the hospital.

Approach:

It is a prospective observational cross-sectional study. Data of 152 patients hospitalized in the in-patient department and pediatric intensive care unit were taken for a period of 6 months. All the data were collected and designed in sheets and input into Microsoft Excel 2014, and figures and tables are presented.

Results:

The maximum number of patients (36%) receiving antibiotics fall in the 11–14 age group of years and received prescriptions of ceftriaxone only or in combination with other antibiotics to the maximum (50.7%) in hospitalized pediatric patients, with gastrointestinal system complications being the most commonly treated. 41.4% patients were on a single antibiotic.

Conclusion:

With an average of 1.8 antibiotics per patient, gastrointestinal system complications were the most commonly treated and the most common cause of hospitalization, whereas third-generation cephalosporins were prescribed mostly among pediatric patients admitted in the hospital. There is necessity of assessment of Improper Prescription Practices for Children to Inform Pediatric Antibiotic Stewardship and prevention of empirical therapy, antibiotic resistance, and associated negative impacts on health outcomes further.

INTRODUCTION

Globally, antimicrobial resistance (AMR) has emerged as a public health security and strictly associated with an improper utilization of antimicrobials contributing to the spread of AMR.[1] The rise of multi-drug-resistant (MDR) pathogens and their swift worldwide dissemination significantly affects patient outcomes, including hospital duration of stay and mortality rates, while also impacting healthcare expenses.[2]

The World Health Organization (WHO) introduced a global strategy in 2015 to tackle AMR, which included various interventions such as reducing the inappropriate use of antimicrobials. If no global action is taken, it has been projected that AMR could lead to 10 million deaths by 2050.[3] Antibiotics are prescribed frequently for children.[4] Research indicates that approximately 20–50% of antibiotics prescribed in pediatric critical care settings are deemed inappropriate. This misuse of antibiotics contributes to the emergence of AMR, adverse drug reactions, increased morbidity, and higher hospitalization expenses.[3]

Antibiotics are often administered to children with viral infections or noninfectious conditions. Broad-spectrum antibiotics are sometimes given when narrow-spectrum drugs would suffice for the infection. Many children also receive antibiotic prescriptions with incorrect total daily dosages, improper fractioning, or unnecessarily extended durations.[5]

Finding lasting solutions to the clinical, regulatory, and economic challenges posed by bacterial multidrug resistance requires enhanced support, collaboration, and involvement from regulatory bodies, governments, industries, and the scientific community. The urgency for developing new chemical classes of antimicrobials to combat MDR pathogens is now more critical than ever.[6]

To ensure the best clinical outcomes with minimal toxicity and reduced AMR development, a multidisciplinary approach is required for selecting the most suitable drug, dosage, and treatment duration. This approach, akin to antimicrobial stewardship (AMS) programs, is crucial in optimizing therapy while safeguarding patient health and combating the threat of AMR;[7] the application of this approach can enhance adherence to clinical guidelines and promote appropriate antimicrobial usage, all while positively impacting patient outcomes without any adverse effects.[8]

Moreover, antibiotic usage is linked to various adverse events such as the disturbance of healthy gut bacteria, Clostridioides difficile infections, hypersensitivity reactions, nephrotoxicity, myelosuppression, hepatitis, and other various risks.[9] Hence, there is a necessity to characterize inappropriate prescribing practices for children in order to provide guidance for pediatric AMS and minimization of associated negative impacts on health outcomes.[4]

APPROACH AND TECHNIQUES

The research was conducted as a prospective, observational, and cross-sectional study within the pediatrics department of Maharishi Markandeshwar Institute of Medical Science and Research (MMIMSR) in association with the department of pharmacy for 6 months from July to December 2023. The hospital is a 1000-bedded teaching and superspecialty hospital which is located at Mullana (Ambala) in northern India.

A total of 152 patients, aged between 1 month and 14 years, who were admitted to the pediatrics wards and the Pediatric Intensive Care Unit (PICU), were included in the study.

The study received approval from the institutional ethical committee, and a meticulously designed form sheet was utilized for data collection. All the required information comprising sociodemographic details, clinical characteristics, and patterns of antimicrobials utilization were obtained from the patient’s record files and database system of the hospital to study and examine the degree of poly pharmacy across all medications, with a specific focus on antimicrobials. It analyzed the dosage regimen, route of administration, prevalence of single and combination antimicrobial therapies, and the prevalence of disease states for which antimicrobials were prescribed.

Statistical analysis

The gathered data were organized, tabulated, and input into Microsoft Excel 2014. Mean and standard deviation were used as statistics tools in this study. The findings were displayed through the use of tables, figures, and pie charts.

RESULTS

In the present study, data of the 152 child patients were obtained, out of which 122 were admitted inward and 30 in PICU of the pediatric department with a mean age of 7.40 ± 4.91 years. The current study indicates that the proportion of female patients (52.1%) exceeded that of male patients (47.9%).

Figure 1 depicts third-generation cephalosporins were most commonly prescribed antibiotics, out of which ceftriaxone (50.7%), either alone or in combination with other antibiotics, was the most frequently prescribed medication, followed by cefixime (10.5%) and cefotaxime (7.9%). In other classes of antibiotics, amikacin (13.9%) alone and in combination was the second most commonly prescribed antibiotic in patients, followed by meropenem (5.9%), azithromycin (4.6%), vancomycin (3.9%), and piperacillin. Tazobactam (2.6%) was a minimally used antimicrobial in children who were admitted in the hospital.

Figure 1.

Antibiotics used in pediatric patients admitted in the hospital (+ indicates in combination with other antimicrobials)

Figure 2 depicts the categorization and prevalence of the systems involved in the enrolled patients. According to this, the gastrointestinal system (25.7%) was the most commonly involved, followed by systemic infections (22.4%) being the second most common. The prevalence of the respiratory system and central nervous system was 16.4%, with hematological disorders (9.9%), urogenital (3.9%) and skin disorders (3.3%), and cardiovascular system disorders being the least commonly involved, that is, 2%.

Figure 2.

Categorization of morbidities of pediatric patients in the study

Figure 3 shows the age distribution of patients according to different age groups. The maximum number of patients (36%) fall in 11–14 years of age group, followed by 1–5 years (26%) and 6–10 years (23%). An age group less than 1 year only constitutes for 15% of the total population.

Figure 3.

Age distribution of pediatric patients according to age groups

Table 1 shows the maximum admitted patients were administered drugs through the intravenous route (73%) and oral route of administration and both accounted for 8.5% and 18.5%, respectively.

Table 1.

Distribution of patients on the basis of route of administration of drugs

Routes of antibiotic administration	No. of patients
IV	111 (73%)
Oral	13 (8.5%)
Both	28 (18.5%)

Table 2 shows as par as distribution of patients on the basis of quantity of antibiotics used is concerned, most of the admitted patients (41.4%) were given only one antibiotic, whereas two antibiotics were prescribed to 35.6% of total patients and ≥3 antibiotics were prescribed to 23% of total patients.

Table 2.

Distribution of patients based on quantity of antibiotics used in patients

No. of antibiotics used	No. of patients
1	63 (41.4%)
2	54 (35.6%)
≥3	35 (23%)

Table 3 shows distribution of patients on the basis of numberof days of hospitalization is concerned, most of the patients (85.6%) were admitted for 1–7 days, 10.5% for 8–15 days, and only 3.9% patients for 16–30 days.

Table 3.

Distribution of patients on the basis of number of days of stay in the hospital

No. of days	No. of patients	Percentage (%)
1-7	130	85.6%
8-15	16	10.5%
16-30	6	3.9%

DISCUSSION

In the present study, data of total 152 pediatric patients of individuals aged between 1 month and 14 years were enrolled in the study, which was conducted in the pediatric department of MMIMSR, Ambala. The demographic data of our study were comparable to those of the other studies which were done in pediatric patients regarding antibiotic application.

The current study indicates that the proportion of female patients (52.1%) exceeded that of male patients (47.9%). Similar results were reported in the study conducted in the study on antibiotic utilization done in India by Tripathy et al.[10] Contrary results were reported in the study conducted in Nigeria by Umar et al.,[11] in which there were more males than females.

Our study found third-generation cephalosporins (ceftriaxone, cefixime and cefotaxime) to be effective, with ceftriaxone being the most commonly used antibiotic among the pediatric patients, similar to studies by Tripathy et al.[10] in India and Sviestina et al.[12] in Latvia. This finding stands in stark contrast to the research conducted by Kebede et al.[13] in Ethiopia and Gharbi et al.[14] in United Kingdom.

They reported that Penicillin G and carbapenem were more significantly associated with antibiotic prescribing.

Similarly, gastrointestinal system complications (25.7%) were the most commonly treated in the present study, similar to the study by Tripathy et al.[10] But the studies done by Gharbi et al.,[14] Sviestina et al.[12] and Kebede et al.[13] showed that lower respiratory tract infections constituted the most prevalent reasons for administering antibiotics in pediatric patients. This can be due to the effect of seasonal variations on the disease prevalence.

Maximum admitted patients were administered drugs through the intravenous route (73%) in the present study. This was comparable with the study conducted by Tripathy et al.,[10] Baidya et al.,[15] Sviestina et al.,[12] and Kebede et al.,[13] in which 82.7%, 84.1%, 86%, and 85.9% pediatric patients, respectively, received antibiotics intravenously, which is more than our study. Transitioning from intravenous (IV) to oral (PO) therapy once patients reach clinical stability has the potential to decrease hospitalization duration and reduce related expenses.[16] Additionally, physicians commonly perceive a lower risk of reinfection when administering a full IV course of antibiotics. Consequently, they typically prefer IV medications upon admission and maintain this regimen until the patient’s discharge.[17] This was also one of the reasons behind usage of maximum antibiotics intravenously in our hospital.

In the current study, the majority of patients (85.6%) were hospitalized for 1–7 days based on the duration of hospitalization. This finding is consistent with the research carried out by Tripathy et al.,[10] which has reported 70.67% patients who stayed hospitalized for 1–7 days, which is slightly lower than our study.

On the basis of age distribution, the maximum number of patients (41%) fell in the age group less than 5 years of age in our study. Similar results were reported in a study done by Yuksel et al.[18] in Turkey, in which most patients (49.1%) to get treated were falling in the age group less than 5 years of age. But the study conducted by Mustafa et al.[19] in Pakistan showed that infants of age ranging 29 days to 1 year were the most patients (30.7%) to get treated.

As far the quantity of antibiotics administered is concerned, most of the admitted patients (41.4%) were given only one antibiotic in the present study. Studies conducted by Baidya et al.[15] in India and Mustafa et al.[19] in Pakistan reported that 39.6% and 59.9% of pediatric patients received 1 and 2 antibiotics, respectively, and these are higher than our study. But Tripathy et al.[10] reported 70% patients were on a single antibiotic.

Likewise, the mean number of antibiotics per encounter was 1.8, aligning with the WHO’s recommended range of 1.6–1.8. In contrast, Tripathy et al.,[10] Mathew et al.,[20] and Baidya et al.[15] reported average antibiotic prescriptions per encounter as 1.2, 1.63, and 2, respectively, in India. But 1.90 was reported by Mustafa et al.[19] in Pakistan.

Recommendation

Continuous audits and training are recommended to make sure whether standard and national guidelines are being followed during use of antibiotics in the hospital for the prevention of negative health outcomes.

Limitation

Since the study was conducted for a duration of 6 months, the study’s outcomes failed to capture the fluctuations in medicine usage across different seasons. Moreover, its conclusions were drawn from data collected solely from a single tertiary care hospital, so it cannot be generalized to the whole country.

Moreover, due to the cross-sectional design of the present study, it cannot establish a cause-and-effect relationship between the significantly associated factors and inappropriate antimicrobial use.

Antibiotic stewardship

The antimicrobial stewardship program (ASP) is a vital multidisciplinary institutional initiative globally recognized for its role in pediatric healthcare strategies, aiming to mitigate AMR.[1]

Antibiotic stewardship is a specialized approach focused on prescribing antibiotics judiciously, emphasizing the utilization of suitable agents, optimal dosage, duration, and administration routes to enhance clinical results while minimizing the unintended repercussions of antibiotic use. Given the variations in prevalent infectious conditions, drug-related considerations, and treatment recommendation evidence between pediatric and adult populations, this statement offers tailored guidance specifically for pediatric patients.[2]

In 2017, the WHO has released a list of 12 pathogens that are highly concerning for human health due to their antibiotic resistance. This underscores the urgent need for enhanced development of pediatric ASPs, particularly focusing on improving surveillance data collection related to antimicrobial use and resistance in pediatric populations.[4]

The effectiveness of an ASP hinges on the collective responsibility of all individuals involved in prescribing, dispensing, and administering antibiotics to children. The foundational principles of pediatric ASPs are centered around collaboration and cooperation.[5]

Thus, effective teamwork among all health professions is required for antibiotic management.[6]

CONCLUSION

Since the gastrointestinal system complications were mostly involved in the admitted patients, the most commonly used antibiotic was third-generation cephalosporin.

It is imperative to avoid administering antibiotics to children with viral infections or noninfectious conditions and refrain from using broad-spectrum antibiotics when narrower options could suffice in treating infections effectively. This underscores the importance of identifying inappropriate prescribing practices in children to guide pediatric antibiotic stewardship efforts and reduce reliance on empirical therapy, antibiotic resistance, and associated negative impacts on health outcomes.

Antibiotic usage is linked to adverse effects, such as the disruption of beneficial gut bacteria (enteric bacterial flora); gut microbiome restoration practice needs to be considered at the same time.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.