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Ansam F. Sawalha, Ghada O. Al-Bishtawi, Laila S. Al- Khayyat, Waleed M. Sweileh* , Rowa J. Al-Ramahi & Pattern of Parenteral Antimicrobial Prescription among Pediatric Patients in Al-Watani Government Hospital in Palestine. Abstract
Objective: No studies were carried out in Palestine to investigate the antimicrobial prescribing
among hospitalized pediatric patients. The objective of this study was to audit and therapeutically analyze the pattern of parenteral antimicrobial prescriptions among pediatric patients in Al- Watani government hospital in Palestine. Such audit will be of great value to clinician and health Material and Methods: Data on antimicrobial prescribing were collected for 30 consecutive
days for all pediatric patients admitted to Al-Watani government hospital. Data on antimicrobial prescribing were entered and analyzed using Statistical Package for Social Sciences (SPSS) program. Analysis was done for age, sex, diagnosis, site of infection, number of antimicrobial agents given, how many times have the drug regimen been changed and the frequency of Results: Three hundred and forty pediatric patients were admitted to Al-Watani government
hospital during the study period. Gastroenteritis was the most common cause of hospitalization, while upper respiratory tract infection (URTI) was the most common cause of parenteral antimicrobial agent administration. Two hundred and ten (61.8%) patients received parenteral antimicrobial agents while 16 (4.7%) received both parenteral and oral antimicrobial agents. Single antimicrobial agent was prescribed for 172 (76.1%) patients. Cefuroxime was the main single antimicrobial agent used, it was administered to 70/226 (31%) patients. Conclusion: Treatment patterns used for most patients were nearly according to current
therapeutic recommendations. However, improving the availability of rapid diagnostic methods to differentiate between viral and bacterial infections is suggested to reduce empiric therapy numbers by antimicrobial agents so as to decrease chance for drug resistance. Key words: Antimicrobials, Pediatrics, Prescription, Palestine.
Introduction
effective and play an important role in the ccording to the 2003 annual report issued by the Palestinian Ministry of Health, 437 have serious consequences. The worldwide, deaths among infants and children less than multi-drug resistant microorganisms were five years were caused by infectious diseases (1). This suggests that more attention is widespread use of antimicrobial agents in needed for the investigation of the protocols both inpatients and outpatients (2, 3). For there is an emergence of resistant strains of Streptococcus pneumoniae to antimicrobial population groups to contract illnesses. increasing (4). The emergence of multi-drug included patient's file number, age, sex, resistant microorganisms might lead to more diagnosis, site of infection, and the drug problem associated with the irrational use of (SPSS version 11) program in terms of age, antimicrobials especially among pediatrics is sex, diagnosis, site of infection, number of the ability of strong antibiotics to disturb the colonization of gastro-intestinal microflora times have the drug regimen been changed, which may induce serious clinical symptoms Diagnosis was classified as being either single, mixed, unidentified or no infection. resistant pathogens and other complications infection is diagnosed, “mixed” is used strict antibiotic policy and rational use of “unidentified” infection was used when the antimicrobial agents which also have shown patient was given antimicrobial agents but to be cost saving and to prolong antibiotic utilization in Palestine in general and among Data analysis showed that 266/340 (7 %) of pediatrics in particular. Such knowledge is the admitted patients were below five years of age. One third of those patients were identify targets for improving antimicrobial utilization and thus optimizing costs, therapy admitted males were 203 representing (60%) and disease management. The objective of this study was to investigate the use of infection who were admitted to the hospital Hospital in Nablus which is a referral center single infection while mixed infections were for pediatrics from northern West Bank, and diagnosed in 28 patients (8.3%). Further to determine if the current utilization was infections account for most of the diagnosed Material and Methods
This study was carried out in the pediatric admitted, 210 (61.8%) received parenteral anti-infective therapy, 16 (4.7%) received department is supervised by board certified both parenteral and oral treatment, 7 (2.1%) pediatricians and pediatric-board-eligible (31.5%) didn't receive any anti-infective therapy. Beta-lactams, metronidazole and admitted pediatric patients and was carried aminoglycosides constitute the majority of out for thirty days starting from October 10th administered anti-infective agents. Among the 226 patient whom received parenteral prescriptions for all admitted patients within antimicrobial agents, cephalosporins were the 30 days were reviewed. Access to patient medical files was made possible based on an cephalosporin, was used among a total of 70 (31%) patients. It was repeatedly used for chest infection, unidentified infections and pneumonia. Ceftriaxone, a third generation cephalosporin, was used among a total of 56 (24.8%) patients. It was used for meningitis, unidentified infections and upper respiratory tract infections (URTI). Cefazolin, a first approximately 18% of the admitted patients. generation cephalosporin, was mainly used The combination consisted of ceftriaxone + for gastroenteritis. Crystalline penicillin, a parenteral penicillin, was used in 21 (9.3%) patients, half of them were having tonsillitis, patients mainly for URTI. Metronidazole, a chemotherapeutic agent effective against In the treatment of single infections, no anaerobic bacteria and certain parasites, was fixed therapeutic regimen was employed as used in 21 (9.3%) patients for treatment of shown in Table-2. For most of the admitted hospital. However in 8.2% of the cases the Table 1. Data distribution based on site of
microbiological culture; rather, it was based infection. GI: Gastrointestinal Infection, URTI:
on patient's clinical response, as culture Upper Respiratory Tract Infection, LRTI: Lower sensitivity test was done only for 5.6% of Respiratory Tract Infection, CNS: Central Nervous System, UTI: Urinary Tract Infection. Frequency
Infection
Discussion
GI Infection
Inappropriate utilization of antimicrobial agents forced many researchers to evaluate No Infection
the antimicrobial consumption in order to restrict and control the risk of antibiotic Unidentified
Infection
worldwide to assess this problem. A study CNS Infection
done in a tertiary hospital in Spain showed Prophylactic
extensive inappropriate third generation guidelines for rational antibiotic use were Infection
developed, but it haven't been implemented Skin Infection
URTI+UTI
practice and antibiotic prescribing pattern at a general hospital in Nigeria revealed that Liver Infection
appreciable gap in knowledge with respect CNS+ Kidney
Infection
healthcare professionals (10). Prescription Infection+ URTI
audit reveals that it's possible to achieve a change in the utilization of antibiotic in treatment of RTIs (11). Getting audit and feed back information about clinical records administered to patients was also assessed. has been shown to decrease inappropriate Single antimicrobial therapy was used in utilization of antibiotics. For continuous benefit these records should be continuously the predominant single antimicrobial therapy updated (12). Pharmacists should have a role used (15%), followed by cefazolin (9.4%), They can play a major role through clinician prescription was maximum in Paediatrics, education and focused clinical services (13). pattern in an Indian tertiary hospital has cefotaxime and cloxacillin were the most
Table 2. The most common drug regimen used

Amebiasis
Metronidazole
Cefazolin+Metronidazole
Bromchiolitis
Cefotaxime+Ampicillin
1 (12.5%)
Cefuroxime
Cellulites
Ceftriaxone+Cloxacillin
Cloxacillin
Gastroenteritis
Cefazolin
Cefazolin+Metronidazole
Ampicillin
Ceftriaxone
Ceftriaxone+Metronidazole+ TMP/SMX 2 (3%)
Laryngitis
Ampicillin
Cefazolin
Meningitis
Ceftriaxone
Ceftriaxone+Vancomycin
acyclovir+ceftriaxone+vancomycin-
amikacin+cefotaxime
Otitis Media
Ceftriaxone
Gentamycin+Ceftriaxone
Pneumonia
Aminoglycoside+Ceftriaxone
Amikacin+Ceftriaxone+Vanocomycin
Erythromycin+Cefuroxime
Ceftriaxone
Cefuroxime
Cefuroxime+Vancomycin
Erythromycin+Cefuroxime+Vancomycin 1 (7%)
Tonsillitis
Crystalline Penicillin
Ampicillin
Cefuroxime
Ceftraixone
Ampicillin
Cefuroxime
Ceftriaxone
Cefazolin
Crystalline Penicillin
Cefazolin+Gentamycin
Cefuroxime
Cefazolin
Ceftriaxone
Cefuroxime+Gentamycin
Metronidazole+Amoxy/Clavul.
million children worldwide die each year from acute respiratory illnesses, many of rates than penicillin (24). In this study, it Streptococcus pneumoniae are the most was noted that most cases of tonsillitis pneumonia (16). Mycoplasma pneumoniae and Chlamydia pneumoniae can also rotavirus infection (27). The cornerstone for treatment of gastroenteritis is fluid Antibiotic therapy use in gastroenteritis erythromycin for 5 years and older (17). ceftriaxone or cefotaxime ± macrolide ± Campylobacter (Macrolides), while no infections (30). In this study, antibiotics, one third of the admitted patients having gastroenteritis, although it's not indicated stool culture makes it difficult to judge could be used in children younger than 2 the rationality of antibiotic use in these months of age (19) or in hospital acquired Escherichia coli are responsible for most Pseudomonas aeruginosa (32). In Gaza constitute the majority of cases of URTI. proportion of isolated pathogens causing in tonsillitis is group A Streptococcus infections were resistant to amoxicillin, have faced was the non specific terms used that a susceptibility test is a must before in diagnosis as chest infection and upper prescribing these agents (33). In this study, all respiratory tract infection. Chest infection urinary tract infected patients received could be pneumonia or bronchiolitis, while antibiotics either as monotherapy or as part upper respiratory tract could be otitis media, Physicians need to be more specific in their generation cephalosporin, cefuroxime. In general, the regimens prescribed for the utilization of parenteral antimicrobial agents Meningitis is a major cause of mortality and among pediatrics in a pediatric ward, studies on which are relatively lacking. This study especially among countries where effective may be the base for more specific research vaccines are not available. Streptococcus in the future. Antimicrobial agents were used for both bacterial and viral infection. monocytogenes are the causes of bacterial meningitis in children younger than 3 month diagnostic methods to differentiate between viral and bacterial infections is suggested to Streptococcus pneumoniae or Hemophilus influenza are the active agents in older children (34, 35). For the management of bacterial meningitis in patients less than 3 month old, ampicillin plus a broad spectrum implemented were found to be according to cephalosporine (cefotaxime or ceftriaxone) cephalosprine alone is used in age group of References
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