Chemical compounds biosynthetically or synthetically produced which either destroy or usefully stamp down the growing or metamorphosis of a assortment of microscopic or submicroscopic signifiers of life. On the footing of their primary activity, they are more specifically called bactericide, fungicide, antiprotozoal, antiparasitic, or antiviral agents.
3.2 History of antimicrobic agents
The modern epoch of antimicrobic chemotherapy began in 1929, with Fleming ‘s find of the powerful disinfectant substance, Penicillin and Domagk ‘s find in 1935 of man-made chemicals ( sulfa drugs ) with wide antimicrobic activity. In the early 1940 ‘s spurred partly by the demand for antibacterial agents in World War II, penicillin was isolated and purified and injected into experimental animate beings, where it was found non merely to bring around infections but besides to possess improbably low toxicity for the animate beings. This fact ushered into being the age of antibiotic chemotherapy, and an intense hunt for similar antimicrobic agents of low toxicity to animate beings that might turn out utile in the intervention of infective disease. The rapid isolation of Streptomycin, Chloramphenicol and Tetracycline shortly followed, and by the 1950 ‘s, these and several other antibiotics were in clinical use ( 13 ) .
The lustre of the antimicrobic epoch shortly began to demo grounds of tarnish nevertheless, as first bacteriums, so fungi, and so viruses began to develop opposition to the antimicrobic agents directed against them. Microbial inventiveness and resiliency have ne’er been more apparent than in their singular ability to develop opposition to chemotherapeutic agents. This is particularly true of bacteriums that have modified their Deoxyribonucleic acid by chromosomal mutant and by geting opposition cistrons via junction, transmutation, and even transduction. There are apparently no boundaries to the capablenesss of some micro-organisms to develop opposition. The acquisition of Vancocin opposition in Enterococci by the assembly of multiple foreign cistrons into permutable elements and the presentation of movable fluoroquinolone opposition cistrons in Klebsiella pneumoniae are 2 graphic illustrations of this ( 14,15 ) .
Antimicrobial opposition has been fueled by inappropriate usage of antimicrobic agents, particularly those directed against bacteriums. Widespread industrial and agricultural usage of disinfectants has played a function, but the involuntariness of the medical profession to accept steps for the control of indiscriminate prescribing and inappropriate dosing of antibiotics besides need to be addressed. Clinicians have failed to cover with a potentially solvable job, and others are taking up the challenge. The grim spread of antimicrobic opposition is now of concern to bureaus of legion authoritiess and wellness bureaus worldwide, including the World Health Organization, which has attempted to supply rational solutions to the job ( 16 ) .
Several writers ( 7,8 ) have reported concern about the uninterrupted indiscriminate and inordinate usage of antimicrobic agents that promote the outgrowth of antibiotic-resistant beings. Monitoring of antimicrobic usage and cognition of prescription wonts are some of the schemes recommended to incorporate opposition to disinfectants in hospitalized patients.
3.3 Drug Utilization research
Drug Utilization research was defined by WHO as “ the selling, distribution, prescription and usage of drugs in a society, with particular accent on the ensuing medical, societal and economic effects ” . The primary importance of drug use research is to ease rational drug usage in the population. A good cognition about how drugs are prescribed aids in measuring the reason in drug use and to better prescribing patterns. It besides provides penetration into whether the prescribed drug therapy provides value for money. The part of use surveies for rational drug consists of three of import ways.
Description of drug usage forms.
Provides early signals of irrational drug usage.
Helps in follow up of intercessions to better drug usage.
The importance of Drug Utilization surveies increases in pharmacoepidemiolgy by bridging more closely with other countries such as public wellness, rational usage of drugs, grounds based drug usage, pharmacovigilance, pharmacoeconomics, eco -pharmacovigilance and pharmacogenetics ( 17 ) .
The research in this field analyses the current province and the developmental tendency in drug use at assorted degrees of the wellness attention system, whether national, regional, local or institutional. They aid in measuring drug usage at a population degree, harmonizing to age, sex, societal category, morbidity and other factors ( 18 ) .
3.4 Prescription and Ordering
Surveies of prescription and prescribing are an of import portion of use surveies. On utilizing informations on prescriptions it is possible,
To analyze forms of drug usage among patient classs defined by age, sex or diagnosing.
To analyze the relation between prescribed medical specialty and evident indicant.
Identify the unwellnesss most often treated.
Identify and analyze prescription determiners, such as the extent to which prescribing has been influenced by peculiar information or promotion runs.
Examine specific safety jobs in drug usage in the visible radiation of existent pattern ( 19 ) .
3.5 Drug Use Indexs
Datas from medical patterns and wellness installations may be used to mensurate specific facets of wellness proviso and drug usage. This information is used to bring forth indexs that provide information on ordering wonts and facets of patient attention.
These indexs can be used to find where drug usage jobs exist, provide a mechanism for monitoring and supervising and motivate wellness attention suppliers to follow established wellness attention criterions. Prescription and dispensing informations are utile for finding some of the quality indexs of drug usage recommended by the WHO. These include:
Average figure of drugs per brush
Percentage of drugs prescribed by generic name
Percentage of brushs with an antibiotic prescribed
Percentage of brushs with an injection prescribed
Percentage of drugs prescribed from indispensable drugs list or formulary
Average drug cost per brush
The indexs of ordering patterns evaluate the public presentation of wellness attention suppliers in assorted dimensions related to allow usage of drugs ( 19 ) .
3.5.1. Average figure of drugs per brush
Purpose To mensurate the grade of polypharmacy.
Prerequisites Combination drugs are counted as a individual drug prescription. Guidelines are needed on how to number certain equivocal prescribing patterns ( e.g. some standardised consecutive therapies ) .
Calculation Average, calculated by spliting the entire figure of different drug merchandises prescribed, by the figure of brushs surveyed. It is non relevant whether the patient really received the drugs.
3.5.2. Percentage of drugs prescribed by generic name
Purpose To mensurate the inclination to order by generic name.
Prerequisites Research workers must be able to detect the existent names used in the prescription instead than merely holding entree to the names of the merchandises dispensed, since these may be different ; a list must be available of specific merchandise names to be counted as generic drugs.
Calculation Percentage, calculated by spliting the figure of drugs prescribed by generic name by the entire figure of drugs prescribed, multiplied by 100.
3.5.3. Percentage of brushs with an antibiotic prescribed
Purpose To mensurate the overall degree of Antibiotic usage.
Prerequisites A list must be available of all the drug merchandises which are to be counted as antibiotics.
Calculation per centums, calculated by spliting the figure of patient brushs during which an antibiotic was prescribed, by the entire figure of brushs surveyed, multiplied by 100.
3.5.4. Percentage of brushs with an injection prescribed
Purpose To mensurate the overall degree of usage of two of import, but normally overused and dearly-won signifiers of drug therapy.
Prerequisites A list must be available of all the drug merchandises which are to be counted as antibiotics ; research workers must be instructed about which immunisations are non to be counted as injections.
Calculation Percentages calculated by spliting the figure of patient brushs during which an injection is prescribed, by the entire figure of brushs surveyed, multiplied by 100.
3.5.5 Percentage of drugs prescribed from indispensable drugs
Purpose To mensurate the grade to which patterns confirm to a national drug policy, as indicated by ordering from the national indispensable drugs list or formulary for the type of installation surveyed.
Prerequisites Transcripts of a published national indispensable drugs list or local institutional pharmacopeia to which informations on prescribed drugs can be compared ; processs are needed for finding whether or non trade name name merchandises are tantamount to 1s looking in generic signifier on the drug list or formulary.
Calculation Percentage, calculated by spliting the figure of merchandises prescribed which are listed on the indispensable drugs list or local pharmacopeia ( or which are tantamount to drugs on the list ) by the entire figure of merchandises prescribed, multiplied by 100 ( 19 ) .
3.6 Intensive attention unit ( ICU )
Intensive attention unit ( ICU ) is a scene where a big figure of drugs are administered to patients and where the costs of hospitalization and drug intervention are high. The usage of unequal empirical antimicrobic therapy is common in intensive attention unit patients and contributes to a figure of hapless results. In such puting choosing appropriate antimicrobic therapy is complicated by many factors, including the big figure of agents available, the presence of immune beings and the general desire among practicians to utilize the most focussed therapy available ( 20 ) .
The prescribing of antibiotics in the ICU is normally empirical, based on general status of the patients hospitalized at that place. Appropriate antibiotic use in this scene is important non merely in guaranting an optimum result, but in restricting the outgrowth of opposition and containing costs. We propose that research in the ICUs is vitally of import in steering antibiotic prescription patterns and thereby advancing rational antibiotic therapy. There is broad institutional diverseness in the comparative prevalence of prevailing pathogens and their antimicrobic susceptibleness between infirmaries. Among different ICUs of same infirmary besides there is fluctuation in prevailing pathogens and their antimicrobic susceptibleness. Therefore, appropriate antibiotic prescription patterns should be formulated based on surveillance surveies and research for single ICUs ( 21 ) .
3.7 Knowledge from old surveies
3.7.1 In the Medical Intensive attention Unit of measurements
In a drug use survey done in Western Nepal in 2003 by Shankar PR et Al ( Investigation of antimicrobic usage form in the intensive intervention unit of a teaching infirmary in western Nepal ) it was observed that Mean+/-SD drugs per patient was 3.4+/-1.8. About half ( 50.2 % ) of the patients received an antimicrobic ; 84.6 % of the disinfectants were used without obtaining bacteriologic grounds of infection. The commonest organisms isolated on civilization were Pseudomonas aeruginosa, Klebsiella pneumoniae, Streptococcus pneumoniae, and Staphylococcus aureus. A sum of 28.9 % of the disinfectants were prescribed for lower respiratory tract infections on the footing of the putative site of infection ; 61.9 % of the disinfectants were prescribed by the parenteral path and chiefly the older coevals of disinfectants were used. In 39 of the 149 patients prescribed an antimicrobic, the usage was irrational ( 22 ) .
In 2010 Vandana A Bada et Al Studied Prescribing Pattern of Antimicrobial Agents in Medicine Intensive Care Unit of a Teaching Hospital in Central India and reported that in the intensive attention unit Cefotaxime was the most normally used AMA by 32 % patients, followed by Metronidazole by 24 % patients and Ampicillin by 17.29 % patients. 77 % patients were given 1- 3 AMAs, 23 % patients were given 4 – 8 AMAs. Most common indicant for the antimicrobic therapy was infection. Harmonizing to rating usage of antimicrobic therapy was rational in merely 30 % patients. Average figure of drugs per patients were 7.5 drugs ( 23 ) .
Lisha Jenny toilet et Al during 2005-2006 studied use of antimicrobic agents in medical intensive attention unit of a third attention infirmary in Bangalore, India and reported that of the 902 patients admitted in the medical ICU during the survey period, male to female ratio was 1.9. The mean for age was 49.21A±15.84 old ages. Extensive polypharmacy ( 100 % ) was noticed. The mean figure of drugs per patient ( prescription ) was 11.6A±2.09.Cephalosporins 505 ( 69.3 % ) and aminoglycosides 263 ( 35 % ) were the normally prescribed antimicrobic drug category. Cefoperazone ( J01DD12 ) 218 ( 30 % ) , amikacin 211 ( 28.9 % ) , metronidazole 208 ( 28.6 % ) were the normally prescribed antimicrobic drug category. A sum of 228 perscriptions ( 31.3 % ) contained two antimicrobic prescription and ( 187 ) 25.7 % contained 3 drugs. Cefoperazone + sulbactam ( J01DD62 ) 224 ( 30.8 % ) was the most common FDC noticed ( 24 ) .
A survey done in 1992 by MV Srishyla et Al surveyed the Antimicrobial prescribing form in the in-patient scene of a 800-bedded third infirmary in Bangalore, India showed that 56 % of in-patients were prescribed antimicrobic agents and 44 % of them received a combination of disinfectants. In all, 36 different antimicrobic agents were prescribed. Gentamicin ( 17 % ) , Metronidazole ( 9 % ) and Ciprofloxacin ( 8 % ) were the most normally used agents. Lower respiratory tract infection was the most common. The type of usage was empirical in 34 % , directed in 27 % and contraceptive in 32 % of the prescriptions. Of the contraceptive prescriptions, 80 % were for surgical prophylaxis and 61 % of these were administered by unwritten path. Besides, the continuance of disposal exceeded 72 hours in 92 % of the patients prescribed disinfectants for surgical prophylaxis ( 25 ) .
3.7.2 In the Paediatric Intensive Care Units
In 2003, Palikhe N studied the Prescribing form of antibiotics in pediatric infirmary of Kathmandu vale and it was found that the mean figure of drugs per patient was 5.01+/-1.36 and figure of antibiotics per patient was 2.41+/-1.02. More than 98 % of the patients were exposed to, at least, two drugs. Among 121 patients clinically diagnosed with infective diseases and treated with antibiotics, specimens were taken for civilization in merely 24 instances i.e. ( 19.8 % ) to place infective beings. Merely 13 specimens showed positive civilization consequences. Infants less than 1 twelvemonth received antibiotics more often than 1-5 and 5-12 old ages ( 40, 31 and 29 % , P & lt ; 0.001, P=0.000 ) . Seventy-five per centum of the entire antibiotics were administered parenterally. Cephalosporin was the top most often prescribed antibiotic group followed by penicillin group. Significant difference was found between age group of patient and disease encountered ( chi2 = 42.95, P=0.000 ) ( 26 ) .
Shankar P R et Al studied the prescribing forms among pediatric inmates in a teaching infirmary in western Nepal during 2003-2004 and observed that 356 patients were admitted during the survey period, of which 228 were male. The average continuance of hospitalization was four yearss. The average figure of drugs prescribed per admittance was 4.5. 789 drugs ( 48.9 per centum ) were prescribed by the parenteral path. Antibiotics were prescribed in 249 admittances ( 69.9 per centum ) . Staphylococcus aureus, Escherichia coli, and Acinetobacter species were the common beings isolated, and were resistant in some instances to the commonly-used antibiotics. The mean ( +/- criterion divergence ) cost of drugs per admittance was 5.4 ( +/-1.6 ) US dollars ( 27 ) .
In the twelvemonth 2004 Ansam Sawalha et Al studied the Pattern of parenteral Antimicrobial Prescription among Pediatric Patients in Al-Watani Governmental Hospital in Palestine and found that three hundred and 40 pediatric patients were admitted to Al-Watani authorities infirmary during the survey period. Gastroenteritis was the most common cause of hospitalization, while upper respiratory piece of land infection ( URTI ) was the most common cause of parenteral antimicrobic agent disposal. Two hundred and 10s ( 61.8 % ) patients received parenteral antimicrobic agents while 16 ( 4.7 % ) received both parenteral and unwritten antimicrobic agents. Single antimicrobic agent was prescribed for ( 50.6 % ) patients. Cefuroxime was the chief individual antimicrobic agent used ; it was administered to 70/226 ( 31 % ) patients ( 28 ) .
Aparna Williams et Al ( Antibiotic prescription forms at admittance into a third degree intensive attention unit in Northern India ) analysed Antibiotic prescription forms at admittance into a third degree intensive attention unit in Northern India and found that a sum of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an norm of 6.23 ( A± SD 2.73 ) drugs/prescription and 2.09 ( A± SD 1.27 ) antibiotics/prescription. Antibiotics were prescribed on 190 patients ( 95 % ) at admittance. There was a important correlativity between the figure of patients prescribed three or more antibiotics and mortality rates 53 % nonsurvivors vs. 33.5 % subsisters ( P = 0.015 ) . The mean cost of the antibiotics was Rupees 1995.08 ( A± SD 2099.99 ) per patient and antibiotics outgo accounted for 73.2 % of the entire drug costs ( 29 ) .
3.7.3In the Neonatal Intensive Care Units
Warrier cubic decimeter et Al studied the Pattern of drug use in a neonatal intensive attention unit in Children ‘s Hospital of Michigan during 1997 to 2004 and reported that average drug usage was 3.6/infant, with the highest usage in the 24- to 27-week gestational age group ( 11.7/infant ) . Ampicillin and Claforan had the highest exposure rates. Premature babies had high usage of wetting agent, vasoconstrictor agents, and water pills. Caucasians, males, gestational age & lt ; 28 hebdomads, and birthweight & lt ; 1000 g were the hazard factors for higher drug exposure ( 30 ) .
T. B. Yves Liem et al did a survey during 2005 by roll uping informations from all third attention NICUs in the Netherlands on clinical and demographic features and the type and measure of systemic antibiotic usage were analysed. It was found that Antibiotic ingestion ranged from 130 to 360 DDD/100 admittances. In entire, 9-24 different antibiotics were used, of which 3-10 were in the Drug Utilization 90 % section. In the bulk of the NICUs ( 6 out of 10 ) , extended-spectrum penicillins ( Amoxil and amoxicillin/clavulanic acid ) , ?-lactamase resistant and sensitive penicillins ( flucloxacillin and penicillin G, severally ) , aminoglycosides ( Garamycin and amikacin ) , Cephalosporins ( first and 3rd coevals ) and glycopeptides ( Vancocin and teicoplanin ) were used ( 31 ) .
Another survey done by Fanos V et Al found that penicillins, Mefoxins, aminoglycosides, glycopeptides, monobactams and carbapenems are the categories of disinfectants often used in NICU. Chloromycetin, cotrimoxazole, macrolides, clindamycin, rifampicin and Flagyl are seldom used ( 32 ) .
In 2007 Natalie Schellack et Al analysed antibiotic prescribing forms in a neonatal intensive attention unit of the Dr George Mukhari Academic Hospital in Ga-Rankuwa and reported that Of the 100 patients followed, 95 were prescribed endovenous antibiotics. All prescribed antibiotics for 77 patients are listed in the antibiotic policy. Nineteen different antibiotics were prescribed, and 11 of the 19 prescribed antibiotics appear in the antibiotic policy. Most patients received more than two antibiotics during their stay, as the mean figure of antibiotics used per patient during the survey period was 3.4. The mean continuance of usage for all antibiotics, except cefepime and Rocephin, was for longer than seven yearss. Although antibiotics were used harmonizing to the ward protocol in the bulk of patients, divergences from the protocol were associated with patients ‘ clinical status and/or consequences from blood civilizations ( 33 ) .
There are no sufficient informations available about the use form of antimicrobic agents in the Intensive attention Units of third attention infirmaries of South India, particularly Tamilnadu. Current ordering form of Antimicrobial Drugs in a geographical country is needed to analyze the reason in use and to do necessary alterations in the use form if needed. It will besides assist to explicate antibiotic policy for the establishment which will assist in the bar of farther outgrowth of antibiotic opposition. So this survey is done to analyze the current use form of Antimicrobial agents in the Intensive Care Units: NICU ( Neonatal Intensive Care Unit ) , PICU ( Paediatric Intensive Care Unit ) and MICU ( Medical Intensive Care Unit ) of Mahatma Gandhi Medical College and Research Institute, Puduche