Natl. J. Physiol. Pharm. Pharmacol. (2025), Vol. 15(1): 86-92

Original Research

10.5455/NJPPP.2025.v15.i1.15

Analysis of antimicrobial prescriptions in surgical wards of a tertiary care hospital using the WHO AWaRe classification

Urmila Kota¹, Meenakshi Lella^2* and Sankar Kurli³

¹Department of Pharmacology, Guntur Medical College, Guntur, India

²Department of Pharmacology, Sri Venkateswara Medical College, Tirupati, India

³Department of Pharmacology, Guntur Medical College, Guntur, India

*Corresponding Author: Meenakshi Lella. Department of Pharmacology, Sri Venkateswara Medical College, Tirupati, India. Email: drmeenu81 [at] yahoo.co.in

Submitted: 06/12/2024 Accepted: 27/12/2024 Published: 31/01/2025

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Abstract

Background: In 2019, WHO developed “AWaRe” (Access, Watch and Reserve) classification to enhance the quality of antibiotic use in hospitals and to combat antimicrobial resistance. The current study evaluated the usage of antimicrobial patterns in the surgical wards of a tertiary care hospital based on the AWaRe classification.

Materials and Methods: We have retrospectively collected prescriptions from the hospital medical records of surgery ward for the 6-month duration (January–June 2023). All prescriptions were analyzed for antimicrobial prescribing patterns using the WHO AWaRe classification. To quantify antimicrobial use, defined daily dose (DDD) and DDD/100 bed days were calculated.

Results: Out of 1209 admitted patients, 1124 (92.9%) received antibiotics. The mean age of patients was 34 ± 16.9 years. The majority of antimicrobials were prescribed to male patients (71.8%) and in patients aged 45–63 years (39.2%). A total of 15 antibiotic agents were used in the study, including 4 from the Access group, 10 from the Watch group, and one from the Reserve group. A total of 60.8% antimicrobials from the Watch group and 36.9%from the Access group were prescribed. Ceftriaxone (26.4%) and Metronidazole (24.1%) were the most frequently prescribed antimicrobials. The overall systemic doses of Piperacillin and Metronidazole used in the surgery ward were 6.6- and 7.3 g DDD/100 bed days, respectively. The average number of drugs prescribed per prescription was 5.3%, and only 49.1% of antibiotics were prescribed according to the generic name. Injectable antibiotics accounted for 76.7% of prescriptions, and 96.8% of them were prescribed from the Essential Drug List.

Conclusion: The prescribing indicators in this study surpassed the WHO standard values with the most antibiotics being prescribed from the watch group in the AWaRe classification rather than the Access group. Insufficient use of generic drugs and polypharmacy contributed to antimicrobial resistance. To reduce the use of Watch group antibiotics, strict standard treatment guidelines should be implemented in hospitals. Furthermore, motivating health care professionals to prescribe more Access group antibiotics by their generic names could support rational prescribing and aid in minimizing antimicrobial resistance.

Keywords: AWaRe classification, Antimicrobial resistance, Access, Watch, Reserve.

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Introduction

India is one of the largest consumers of antibiotics worldwide (Van Boeckel et al., 2014). Unresponsiveness of microorganism to an antimicrobial agent is called drug resistance. Drug resistance can be natural and acquired. Natural resistance may be intrinsic (always expressed) or induced (mutations/ gene transfer). The unnecessary or incorrect use of antibiotics, such as improper dosage or duration, leads to acquired antimicrobial resistance (AMR), ultimately worsening the severity of illness. Currently, organisms, such as Acinetobacter, Pseudomonas, Escherichia coli, Klebsiella pneumoniae, Salmonella enterica, Staphylococcus aureus, and Streptococcus pneumoniae, have acquired resistance to frequently used antimicrobials (Afriyie et al., 2018; Mudenda et al., 2023).

AMR is a global public health challenge affecting morbidity, mortality, and health care costs. Low-income countries face significant challenges related to antimicrobial resistance because of limited antibiotic choices and high rate of infectious diseases. This creates a double burden on their health care system and population (Tacconelli et al., 2018).Tackling this challenge requires coordinated efforts, including the rational prescribing of antibiotics; following evidence-based guidelines; and implementing local, national, and international regulations and policies limit antibiotic use (Skosana et al., 2021).

In 1996, McGowan and Gerding, first applied the term antimicrobial stewardship (AMS), which involves choosing the most appropriate antimicrobial treatment, including the correct dosage and duration, to achieve optimal clinical outcomes while attenuating side effects for patients and reducing drug resistance (McGowan and Gerding 1996; Gerding, 2001).Provision of prescribers with regular updates on antibiotic prescribing, antibiotic resistance, and infectious disease management ensures the selection of appropriate drugs at the correct dosage, right drug route, suitable duration, and timely de-escalation to pathogen-directed therapy (Doron and Davidson, 2011).

The WHO Expert Committee developed the AWaRe classification of antibiotics in 2017 as a tool to uphold antibiotic stewardship efforts at local, national, and global levels, to enhance the quality of antibiotic use, reduce AMR, and monitor antibiotic consumption. This classification is updated every 2 years (The 2023 WHO AWaRe classification of antibiotics for evaluation and monitoring of use; World Health Organization, 2021). Over 250 antibiotics used worldwide for human treatment have been categorized into Access, Watch and Reserve groups based on their spectrum of action, drug resistance, and clinical relevance (as represented in Table 1). The traffic light color codes were suggested to represent various categories: Access antibiotics (green), Watch antibiotics (amber), and Reserve antibiotics (red) (Sharland et al ., 2022).

Data on antibiotic sales in India from 2000 to 2015 indicated that the consumption of Watch and Reserve group antibiotics was raising rapidly than that of Access group antibiotics (Tacconelli et al., 2018).Research has demonstrated the necessity for enhanced monitoring of antibiotic use patterns and adherence to antibiotic usage guidelines across different hospital wards in India. Therefore, this study was conducted to determine antimicrobial consumption in the surgery wards of a tertiary care hospital by using the Daily Defined Dose (DDD) and to analyze the prescription pattern of antimicrobials using the WHO AWaRe classification.

Table 1. WHO AWaRe classification of antibiotics.

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Materials and Methods

Study site and design

This descriptive, observational, and retrospective study was conducted among patients with various diseases admitted to general surgery wards of Government General Hospital, Guntur. Data was collected from inpatient case records over a period of 6 months from January to June 2023.

Eligibility criteria and ethical considerations

After obtaining approval (GMC/IEC/041/2023) from the Institutional Ethics Committee, data were collected from the hospital records. All prescriptions containing at least one antibiotic, prescribed to both gender, irrespective of age and the indication admitted in the general surgery ward, were considered as eligibility criteria to get participated in the study.

Data collection

Demographic details, such as patient age, and gender, and clinical information, such as diagnosis, name of the antibiotic; dose, route of administration, and duration of treatment, were recorded from patient files. The antimicrobial prescribing pattern was analyzed using, the WHO AWaRe classification (2023).

Antibiotic utilization

Based on the Anatomical Therapeutic Chemical (ATC) classification and antibiotics for systemic use (ATC code J01), antimicrobials were coded. The collected prescriptions were analyzed by calculating the DDD. The amount of antimicrobial drug in grams was converted into the number of DDDs/100 bed days using AMC Tool 2019 (World Health Organization). Antibiotic consumption was calculated as DDD normalized for 100 bed days using the following formula. DDD per 100 bed days is an important indicator of inpatient antibiotic use.

• DDD/100 bed days=(consumption of antibiotics during study period [g] × 100)/(DDD coefficient [g] × total bed days)

Data analysis

The collected data were entered in Microsoft Excel and represented in the form of tables and figures. Descriptive statistics were used to analyze the data.

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Results

Of the 1209 patients admitted during the study period, 1124 received antibiotics and the overall number of antibiotics prescribed was 1898. The percentage of patients who received antimicrobials was 92.9%. The mean age of the population was 34 ± 16.9 years. The results were as follows.

Table 2. Gender-wise distribution of antibiotics.

Gender-wise distribution of antibiotics

Males (1364, 71.8%) were prescribed with a higher proportion of antibiotics than females (534, 28.1%), as shown in Table 2.

Age-wise distribution of antibiotics

Patients in the 45–63 years age group received a major number of antibiotics (n=745, 39.2%), as mentioned in Table 3.

Most common indications and antimicrobials prescribed

The most common indication for prescription of antimicrobial was hernia, and third-generation cephalosporins such as Ceftriaxone were prescribed, as mentioned in Table 4.

Prescription of antimicrobials as per WHO AWaRe classification

A total of 15 antibiotic agents were used in the study, including four from the Access group, 10 from the Watch group, and one from the Reserve group. A total of 60.8% antimicrobials from the Watch group and 36.9% antimicrobials from the Access group were prescribed, as represented in Figure 1.

Aware classification along with ATC code and DDD/100 bed days

The overall systemic doses of Piperacillin and Metronidazole used in the surgery ward were 6.6- and 7.3 g DDD/100 bed days, respectively, as mentioned in Table 5.

Percentages of various groups of antimicrobials prescribed

The majority of patients were prescribed Watch group of antibiotics and received Ceftriaxone in the highest proportion (26.4%), as mentioned in Figure 2.

Comparison of WHO core prescribing indicators with present study prescriptions

As mentioned in Table 6, in the current study, prescribing indicators exceeded the WHO standard values except for the percentage of drugs prescribed from the Essential Drug List, which was slightly below the WHO recommendation (96.8%).

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Discussion

AMR is a global health threat resulting from the overuse and misuse of antibiotics. The issue is worsened by inadequate infection control practices in hospitals and insufficient regulation of antibiotic sales. The Antimicrobial Stewardship Program has been developed to optimize antimicrobial use, reduce antimicrobial resistance, lower health care costs, and improve patient outcomes by ensuring that all health care workers adhere to appropriate protocols for antimicrobial use. The present study was carried out in the surgery wards to determine antimicrobial consumption by using the DDD and to analyze the prescription pattern of antimicrobials using the WHO AWaRe classification.

In the present study, out of 1209 patients admitted during the study period, 1124 received antibiotics. The percentage of patients who received antimicrobials was 92.9%, which is very high when compared with other studies done by Aksa et al. (2022) (29%) and Skosana et al. (2021) (33.5%). This may result from antibiotic resistance or insufficient adherence to antibiotic prescribing guidelines by health care professionals or high patient load, which prompts them to prescribe antimicrobials more readily instead of waiting for laboratory confirmation of bacterial infections or it can be due to an inadequate supply of rapid diagnostic tools (Thomas et al., 2022).

More males (69.8%) received antibiotic prescriptions than females (31.2%) in the present study, which was similar to the Aksa et al. (2022) study (Thomas et al., 2022). In general, females have stronger innate and adaptive immune response than males. Moreover, the presence of smoking, exposure to an occupational infectious environment, and greater frequency of comorbid conditions in males predispose them to infections (Klein and Flanagan 2016; Schroder et al., 2016). Patients in the age group 45–63 years received a major number of antibiotics in our study. This is in contrast to the findings of Mudenda et al. (2023) where patients with 19–44 years were prescribed a high number of antibiotics (Mudenda et al., 2023). Aging gradually weakens the immune system and a higher prevalence of chronic illnesses such as diabetes, hypertension, and respiratory diseases in middle-aged people increases the susceptibility to infections (Orzella et al., 2010; Palacios Cena et al., 2017).

Fig. 1. Prescription of antimicrobials as per WHO AWaRe classification.

Fig. 2. Percentage of various groups of antimicrobials prescribed.

The average number of drugs prescribed per prescription in the current study was 5.3, which exceeds the standard value of 1.6–1.8 drugs per prescription. This may be due to the presence of comorbid conditions that lead to polypharmacy, increasing the risk of drug interactions and contributing to drug resistance (Vineel et al., 2024).

In the present study, only 49.1% of antibiotics were prescribed by generic name, which is below the WHO standard value of 100% and also much lower than those in other studies conducted by Priyadharsin et al. (2022) (87.5%) (Priyadharsini et al., 2022). Most drugs are prescribed by brand names, likely due to concerns about the quality and safety of generic alternatives, as well as the considerable influence of pharmaceutical companies (Vineel et al., 2024).

Injectables were prescribed to 76.7% of patients, which exceeds the standard value of 13.4%–24.1%. This could be due to the rapid onset of action of parenteral antimicrobial administration, which helps to minimize the risk of infection in post-operative patients. However, limiting injectable use is necessary due to the risk of infection at the injection site, potential tissue injury from local irritation, and increased treatment costs (Vineel et al., 2024).

Table 3. Age-wise distribution of antibiotics.

Table 4. Most common indications and antimicrobials prescribed.

Antibiotics prescribed from the Essential Drug List account for 96.8%, which is slightly below the recommended value of 100%. This is in contrast to the study conducted by Mathew et al. (2021) (99.41%). Prescribing drugs from EDL improves patient access to medications, reduces health care costs, and encourages rational prescribing practices.

Ceftriaxone (J01DD04, 26.4%), a third-generation cephalosporin classified under the Watch group, was the most frequently prescribed antibiotic for surgical prophylaxis in the current study. This result is similar to that of a previous study conducted by Vineel et al. (2024)(30.32%) (Palacios Cena et al., 2017). This could be due to the broad-spectrum action and greater availability of this drug in hospital settings (World Health Organization 2019) Third-generation cephalosporin usage must be closely monitored due to their association with the development of AMR (Pinto Pereira et al., 2004). Metronidazole (J01XD01, 24.1%), classified as an Access group antibiotic was the second most commonly prescribed antimicrobial. In the Aksa et al. (2022) study, Cefuroxime (62.1%) and Metronidazole (26.2%) were the most frequently prescribed antimicrobials for surgical prophylaxis (Thomas et al., 2022). Metronidazole is preferred for surgical prophylaxis because of its low cost, wide availability, and its effectiveness against anaerobic bacteria, which are common pathogens in the surgical site.

Table 5. Aware classification along with ATC code and DDD/100 bed days.

Table 6. Comparison of WHO core prescribing indicators with present study prescriptions.

A total of 15 antibiotic agents were used in the present study, including four from the Access group, 10 from the Watch group, and one from the Reserve group. This is similar to the findings of Aksa et al. (2022) where 42 antibiotic agents were prescribed (Access 10, Watch 22, Reserve 6, and not recommended 4) (Thomas et al., 2022) In our study, 60.8% of prescribed antibiotics were from the Watch group and only 36.9% of them were from the Access group. This was similar to the findings of Aksa et al. (2022) (Watch 53% and Access 36%) (Thomas et al., 2022). The increased use of Watch group antibiotics, particularly second- and third-generation cephalosporins, may be due to their wide ranging availability and limited availability of access antibiotics such as Amoxycillin and Benzathine penicillin as well as demand and expectations of patients. Also, the median price ratio of the Watch group is less than the Access group (Park 2014).

However, in general, the WHO AWaRe policy recommends narrow spectrum, Access antibiotics as the first choice that should comprise over 60% of total antibiotic use and minimizes the use of broad-spectrum Watch group and last resorted Reserve group. Therefore, it is crucial for health care authorities to improve the availability of “Access” group antibiotics and encourage a reduction in the use of “Watch” group antibiotics, as these have a higher rate of resistance. Standard treatment guidelines should be developed according to current sensitivity patterns and applied in both private and public facilities to encourage physicians to use the access group antibiotics as the primary treatment option (Gandra and Kotwani 2019).

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Conclusion

This study found that prescribing indicators exceeded the WHO standard values, with Watch group antibiotics in the AWaRe classification being prescribed more frequently than the Access group antibiotics. Factors, such as polypharmacy and inadequate use of generic drugs, contribute to AMR. Regulators and policymakers should take action to enhance the availability and use of Access group antibiotics while minimizing the usage of Watch group antibiotics, which have a higher potential for resistance. Improving the quality of antibiotic prescription is essential to enhance patient care and address the critical spread of bacterial resistance through effective antibiotic stewardship.

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