Introduction
Selman Waksman introduced the term ‘antibiotic’ for any small molecule, produced by a microbe, with antagonistic properties on the growth of other microbes.1 Over the years, there has been overuse and misuse of antibiotics leading to antimicrobial resistance, which has become a global health crisis. The antibiotics are unregulated and available over the counter without any prescription in many countries.2 Studies have shown that treatment indication, choice of agent, or duration of antibiotic therapy is incorrect in 30% to 50% of cases.3, 4 The complications like antibiotic related diarrhoea and multidrug resistant hospital acquired infections happen because of excessive use of antibiotics.5, 6
The antibiotic prescribing pattern of health care practitioners is one of the important determinant for the proper implementation of principles of the antimicrobial stewardship. These patterns determine the overuse and misuse of the antibiotics. There are multiple factors affecting these patterns such as pathogen resistance profiles, prescriber related factors and pharmaceutical industry influences.7, 8, 9 Cardiovascular thoracic surgeries refers to operations on organs in the chest, including the heart, lungs and esophagus. Examples of thoracic surgery include coronary artery bypass surgery, heart transplant, lung transplant and removal of parts of the lung affected by cancer. Such surgeries uses advanced techniques and perioperative management have made great progress in recent years, but the incidence of infection after surgery has not been significantly reduced.10, 11 Postoperative infection is one of the severe complications after cardiovascular surgery. Therefore, antibiotics are routinely prescribed during the first 48 hours after cardiovascular surgery. However, there is a deficiency in effective method for early diagnosis of infection and to determine the need of antibiotics use after the first 48 hours.12
As per WHO, antibiotic use surveillance is an important strategy for controlling antibiotic resistance.13 There should be continuous monitoring of antibiotic use and of prescribing patterns of the health care professionals. Hence, present study aimed to analyse the prescription patterns of the Cardiovascular Thoracic Surgeons of a tertiary care hospital.
Materials and Methods
A single centre retrospective study was conducted from January 2017 to October 2018 in the department of cardiovascular thoracic surgery (CVTS) at a 200-bedded tertiary care hospital. The hospital has centralised electronic medical and laboratory record database that uses unique identification numbers. Medical record department of the hospital is preserving all data files as digital copies. The records collected included age, sex, admission period, investigations performed, pre-existing comorbidities antibiotics advised during indoor stay and at discharge along with their routes, dosages and duration. The surgical intervention that the patient underwent were also recorded. The study was conducted after ethical clearance obtained from institutional ethics committee.
Results
Among the total 86 patients reviewed, 88.84% were males with the mean age of 58.7 years. Out of total, 87.21% of the patients received parenteral antibiotics. 98.83% received more than one antibiotic, either in oral or parenteral formulations.
The most commonly used generic antibiotics were cefoperazone – sulbactam (69.77%), levofloxacin (59.30%), cefuroxime (25.58%), cefoperazone (11.63%) and amoxicillin – clavulanic acid (43.02%).[Figure 1] While in admitted patients, beta lactam / beta lactamase inhibitors combination (98.83%), fluoroquinolones (69.77%), cephalosporins (34.88%), glycopeptides (3.49%) and carbapenem (2.33%) were used. [Figure 2] At the time of discharge, fluoroquinolones (43.02%), cephalosporins (32.56%) and beta lactam / beta lactamase inhibitors combination (39.53%) were prescribed. [Figure 3]
The indications for admission were Coronary artery bypass grafting (90.7%), Aortic valve replacement (5.81%), Mitral valve replacement (2.33%) and Dual valve replacement (1.16%). [Figure 4] The most common associated comorbidities were ischemic heart disease (73.26%), diabetes mellitus (47.67%), hypertension (56.98), chronic kidney disease (5.81%) and chronic obstructive pulmonary disease (3.49%). [Figure 5]
The mean duration of usage of parenteral drugs was 5.20 days whereas it was 5.14 days for the oral drugs.
Discussion
Cardiac surgery represents high operative and perioperative risk requiring professional staff and advanced equipment. Besides the diseases that require cardiac surgery, the perioperative period shows a variety of characteristic pathologies.14 Amongst them, postoperative infection is a severe complication after cardiovascular surgery, which can significantly increase mortality and hospitalisation time.15 Administration of surgical antimicrobial prophylaxis is an effective method to reduce the risk of infections.16 Few studies indicated that taking antibiotics 30min before surgery and during the first 48 hours after surgery can effectively reduce the risk of infection.17 Present study was a retrospective data collection only from the department of CVTS in a tertiary care hospital. Many point prevalence and cross sectional studies were published that highlights the antibiotic use in healthcare facility and in general public.17, 18, 19, 20
It was observed that antibiotics were primarily used for surgical prophylaxis and treatment of infections which were generally hospital acquired. Out of total 86 patients reviewed, 87.21% of the patients received parenteral antibiotics. Similarly, Labi et al.17 observed that significant proportion of patients receives parenteral antibiotics. Hence, it was concluded that parental route is preferred over other administration routes. It was noted in present study that 98.83% received more than one antibiotic, either in oral or parenteral formulations. Labi et al.17 and Newman MJ et al.21 also reported that majority of the patients received more than one antibiotics. However, requirement of more than one antibiotic should be considered based on patient’s risk factors and probability of developing postoperative infections.
A beta-lactam antibiotic is indicated as a single antibiotic of choice for standard cardiac surgical prophylaxis. Based on availability and cost, it is reasonable to use cefazolin (a first-generation agent) as the cephalosporin for prophylaxis.22 In present study, it was observed that most common antibiotics prescribed for the admitted patients were cefoperazone – sulbactam, levofloxacin, cefuroxime, cefoperazone and amoxicillin – clavulanic acid. Such usage of beta lactam / beta lactamase inhibitor along with fluoroquinolone should be an alarming signal.
To standardize the patient’s management, it is very important to emphasize on documentation and written protocols as per the surgeries. In present study, it was observed that well - documented written treatment protocol was absent. It must be emphasized that standard plan of care prevent chances of perioperative complications. Surgical site infections and particularly sternal and mediastinal infections have implications for significantly increasing both morbidity and mortality, as well as financial load on patients. The implementation of antimicrobial stewardship should be facilitated. Even at the time of discharge, an appropriate antibiotic should be prescribed for a shorter duration considering the patient’s behaviour of stopping drugs after few doses and once they start feeling better.
Hence, the overuse and misuse of antibiotics should be avoided to prevent the development of antibiotic resistance. Limitation of the study was the sample size and short study duration that does not reflect the actual population and antibiotic prescription pattern in entire region. Moreover, a single center study conducted at a tertiary level hospital, may not accord with the data to other generalized hospitals.
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