Clinical Epidemiology and Global Health 13 (2022) 100944

Contents lists available at ScienceDirect

Clinical Epidemiology and Global Health

journal homepage: www.elsevier.com/locate/cegh

Original article

Evaluation of antibiotic consumption and compliance to hospital antibiotic

policy in the surgery, orthopedics and gynecology wards of a tertiary
care hospital
Aksa Panickal Thomas a, Mahadevan Kumar b, Roshna Johnson a, Sneha Prakash More a,
Bijoy Kumar Panda a, *
a
Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra, India
b
Department of Microbiology, Bharati Vidyapeeth (Deemed to be University) Medical College and Hospital, Pune, Maharashtra, India

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: To evaluate antibiotic consumption and compliance to hospital antibiotic policy in the surgery, or­
Antibiotics thopedics and gynecology wards of a tertiary care hospital.
Consumption Methods: A prospective observational study was conducted over eight months on adult inpatients prescribed with
Compliance
antibiotics. Data were collected using a predesigned antibiotic form and evaluated using Defined Daily Dose per
Policy
100 bed-days. Antibiotics prescribed were classified using World Health Organization Access, Watch and Reserve
classification (WHO AWaRe) and assessed for compliance to the hospital antibiotic policy which is in accordance
with the National Treatment Guidelines for Antimicrobial use in Infectious Diseases (version 1.0.2016).
Results: Out of 2653 patients enrolled, 44.3% were males and 55.7% were females. The antibiotic usage rate was
29%. Cephalosporins were the most frequently prescribed class of antibiotics. The top three antibiotics pre­
scribed were cefuroxime, metronidazole, and ceftriaxone. Classification of antibiotics using WHO AWaRe policy
showed that 36% of antibiotics were prescribed from the Access group and 53% from the Watch group. The use
of antibiotic combinations from the not recommended group of AWaRe was also observed. Total compliance
observed towards the hospital’s antibiotic policy was 77.7%. The most common reason for non-compliance to
hospital policy was inappropriate duration of antibiotic therapy.
Conclusions: The use of watch group of antibiotics over access group due to concerns of antimicrobial resistance
shows the need for local adaptation of WHO AWaRe classification. Despite good adherence to the hospital’s
antibiotic policy, extended duration of antibiotic therapy requires special attention. Further optimization of
antibiotic use can be achieved by timely revision and implementation of hospital antibiotic policy.

1. Introduction Health Organization Access, Watch and Reserve classification (WHO

AWaRe) policy and hospital antibiotic policy are tools to optimize the
India is among the largest consumers of antibiotics worldwide.1 use of antibiotics in healthcare institutions. A recent meta-analysis of 89
Antibiotic sales data in India from 2000 to 2015 revealed that con­ studies assessed the effectiveness of antibiotic stewardship programs.
sumption of Watch and Reserve group antibiotics was increasing faster Policy interventions changed antibiotic treatment and this was associ­
than consumption of Access group antibiotics.2 Studies have well ated with significant improvement in outcomes. Unfortunately, there
documented the correlation between the quantities of antimicrobial were hardly any studies from low and middle income countries in this
agents used and the rate of development of antimicrobial resistance meta-analysis.3 This is an important aspect to consider since infections
(AMR).3,4 and irrational antibiotic use are widely prevalent in these countries.
Defined daily dose (DDD), drug utilization 90% (DU90%), World Only few Indian studies have focused on the pattern and amount of

* Corresponding author. Department of Clinical Pharmacy, Poona College of Pharmacy, Bharati Vidyapeeth (Deemed to be University), Pune, Maharashtra,
411038, India.
E-mail addresses: aksathomas077@gmail.com (A.P. Thomas), dr.mkumarmicro@outlook.com (M. Kumar), roshnajohnson024@gmail.com (R. Johnson),
Sneham1213@gmail.com (S.P. More), bijoy.panda@bharatividyapeeth.edu (B.K. Panda).

https://doi.org/10.1016/j.cegh.2021.100944
Received 31 October 2021; Received in revised form 15 December 2021; Accepted 24 December 2021
Available online 31 December 2021
2213-3984/© 2022 The Authors. Published by Elsevier B.V. on behalf of INDIACLEN. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
A.P. Thomas et al. Clinical Epidemiology and Global Health 13 (2022) 100944

antibiotic use as well as on the level of adherence to antibiotic usage accounted for 90% of the total volume, i.e. the DU90%, were identified
guidelines in various hospital wards to improve prescribing behavior and compared within the wards.10
and control irrational use of antibiotics.5,6
Hence, the aim of this study was to assess antibiotic consumption in 2.4. Compliance to hospital antibiotic policy
our hospital on the basis of volume using DDD and ranking antibiotic
usage according to DU90%. The proportion of antibiotics prescribed Hospital antibiotic policy version 5.0.20197 of our hospital was used
according to the WHO AWaRe classification and compliance to hospital to evaluate compliance of antibiotic prescribing in terms of indication,
antibiotic policy were also determined. The present study aims to bridge dosage, frequency and duration of treatment. Total compliance was
the gap and determine whether antibiotic policies are truly effective. defined as justifiably indicated antibiotic fulfilling the correct choice,
dosage, frequency and duration of therapy. Non-compliance was
2. Methods considered when there was prescription of a non-indicated antibiotic,
divergence from the advisable antibiotic or failure to have complete
2.1. Study setting adherence with other aspects of therapy like dosage, frequency and
duration of therapy.
This study was carried out in the surgery, orthopedics and gynecol­
ogy wards of a tertiary care teaching hospital in western India. The 2.5. Data analysis
antibiotic prescriptions of each ward were vetted by the clinical phar­
macists and microbiologist under the antimicrobial stewardship pro­ Microsoft Excel 2016 was used for data entry and analysis. Pro­
gram. The program formulates the Antibiotic Policy based on the portions and means were calculated using descriptive analysis. Data was
antibiogram, hospital antibiotic formulary (published by the Drugs and analyzed using Analysis of Variance (ANOVA). Significance was
Therapeutics Committee) and is tasked with implementation of anti­ considered at p-value <0.05.
biotic policy. The hospital antibiotic policy (version 5.0.2019)7 was
adopted in all the wards. 3. Results

2.2. Study design and outcome variables A total of 2653 (29%) patients who received antibiotics were
included in the study out of 9148 patients admitted during the study
A descriptive, prospective, cross-sectional study design was period. The rate of antibiotic use in the surgery and gynecology ward
employed. Data was collected from inpatients case files over a period of was 29.7% (1396/4700) and 25.1% (823/3274) respectively. A higher
eight months from July 2019 to February 2020. All the patients (≥18 rate of antibiotic use was found in the orthopedics ward 36.9% (434/
years of age) receiving antibiotic treatment were included in the study, 1174). Antibiotics were mostly prescribed to men in surgery (63.3%)
regardless of the indication. Sample size was determined using the and orthopedic (67.3%) wards. Overall antibiotics were prescribed on
following formula 8: average 1.8 times per patient. Antibiotics were prescribed as empiric
therapy in 657 (24.8%) patients, definitive therapy in 221 (8.3%) pa­
Z 2 p(1 − p) (1.96)2 × 0.5(1 − 0.5) tients, and surgical prophylaxis in 1775 (66.9%) patients. Among the
n= = = 1537
d2 (0.025)2 patients who received antibiotics for surgical prophylaxis, 400 (22.5%)
patients were treated for more than 24 h 360 (54.7%) of the patients
Where: n = sample size. prescribed antibiotics as empiric therapy, were treated for more than 3
days. A significant difference (p = 0.005) was observed between the LOS
P = the estimate of the proportion of patients with antibiotics = 0.5 of patients who received 1, 2 and 3 or more antibiotics as empirical
(Due to a lack of previous studies, p was set to 0.5 to obtain the therapy (Table 1).
largest sample size possible.) Bacteriological investigations were performed on 570 (21.4%) pa­
d = margin of sampling error tolerated = 0.025 (2.5%) tients, with 309/570 (54.2%) patients showing bacterial growth and
Z = the standard normal value at confidence interval of 95% = 1.96. 261/570 (45.8%) patients showing no bacterial growth. In this study,
antibiotic therapy was escalated or de-escalated based on culture
The study was approved by the institutional ethics committee (IEC) sensitivity reports in 364/570 (63.9%) patients with positive cultures.
of the hospital. Waiver of patient consent was obtained from the IEC as Empiric antibiotic therapy was not de-escalated after receiving culture
the study did not require direct contact with patients. Physicians’ orders reports in 206/570 (36.1%) patients (Table 2).
and medication charts were checked from individual patient files. Pa­ The overall systemic antibiotic use in the surgery, orthopedics, and
rameters such as patient demographics, diagnosis, antibiotics, dose, gynecology wards was 31.85, 35.7, and 23.02 DDD/100 bed-days,
reason for antibiotic use (prophylaxis, empirical, definitive), and labo­ respectively, based on defined daily dose (Table 3). A total of 21–34
ratory parameters including hematological, biochemical and microbio­ systemic antibiotic substances were used; additionally, there were 5–13
logical culture sensitivity results of each patient receiving antimicrobial different substances within the DU90% segment as shown in Fig. 1.
treatment were recorded. Antibiotics prescribed in the DU90% segment accounted for 23.8–44.8%
of total antibiotics prescribed. The survey also reveals significant vari­
2.3. Antibiotic utilization ation in the pattern and amount of antibiotics used in each ward
(Table 2; Fig. 1). Cefuroxime (6.4 DDD/100 BD), ceftriaxone (5.6 DDD/
Defined daily dose (DDD) and drug utilization index (DU90%) were 100 BD), metronidazole (4.5 DDD/100 BD), and amoxicillin-clavulanate
the metrics used for quantifying antibiotic use. The dose and duration of (3.9 DDD/100 BD) were the most commonly used antibiotics in the
prescribed antibiotics were collected from patients’ case files. Con­ surgery ward, ranking first, second, third, and fourth in terms of utili­
sumption was calculated as DDD normalized for 100 bed-days.9 DDD per zation. Cefuroxime (12 DDD/100 BD), amikacin (4.7 DDD/100 BD),
100 bed-days is an important indicator of inpatient antibiotic use. ceftriaxone (4.6 DDD/100 BD), and metronidazole (3.5 DDD/100 BD)
DDD/100 bed-days = (consumption of antibiotics during study period [g] × were the four most commonly used antibiotics in the orthopedics ward.
Whereas, cefuroxime (11.2 DDD/100 BD), metronidazole (7.2 DDD/100
100)/ (DDD coefficient [g] × total bed-days)
BD), ceftriaxone (1.1 DDD/100 BD), and amoxicillin-clavulanate (0.9
To assess the quality of drug utilization, antibiotics were ranked DDD/100 BD) were the most commonly used antibiotics in the gyne­
according to the volume of DDDs prescribed. Those antibiotics that cology ward (Fig. 1).

2
A.P. Thomas et al. Clinical Epidemiology and Global Health 13 (2022) 100944

Table 1 The use of antibiotics in accordance with WHO AWaRe policy was
Demographic characteristics of patients. also documented. Throughout the study period, 42 antibiotic agents
Surgery Orthopedics Gynecology Total (Access 10, Watch 22, Reserve 6, and Not recommended 4) were
consumed. Out of 42 antibiotics consumed, 18 antibiotics (Access 6,
Total patients admitted 4700 1174 3274 9148
(9148) Watch 8, Reserve 3, and Not recommended 1) accounted for DU 90%
Patients on antibiotics 1396 434 823 2653 (Fig. 1). In the surgery and orthopedics wards, 13 antibiotics were
(2653, 29%) (29.7%) (36.9%) (25.1%) (29%) observed in the DU 90% segment, while in the gynecology ward, 5 an­
Sex distribution of patients on antibiotics tibiotics were observed in the DU 90% segment. In the orthopedic and
Males 883 292 – 1175 gynecology wards, no reserve antibiotics were observed in the DU 90%.
(63.3%) (67.3%) (44.3%) In the surgery ward, reserve antibiotics (tigecycline, polymixin B and
Females 513 142 823 (100%) 1478
linezolid) accounted for 11.5% of antibiotics use in the DU 90%
(36.7%) (32.7%) (55.7%)
segment. The use of a Not-recommended antibiotic from the AWaRe
Average number of 1.8 1.9 1.8 1.8 policy (cefoperazone-sulbactam) was observed in the DU 90% segment
antibiotics per
encounter
of surgery and orthopedic wards (Fig. 1). Not-recommended fixed-dose
combination antibiotics, namely combinations of ciprofloxacin-
Type of antibiotic therapy n = 2653
tinidazole, ofloxacin-ornidazole, cefoperazone-sulbactam, and
Empiric 403 49 (11.3%) 205 657
(28.9%) (24.9%) (24.8%) ceftriaxone-sulbactam, were also prescribed.
Definitive 141 44 (10.1%) 36 (4.4%) 221 Out of 4871 prescribed antibiotics, 3783 (77.7%) were in compliance
(10.1%) (8.3%) with all aspects of the hospital’s antibiotic policy. Non-compliance with
Prophylactic 852 341 582 1775
the hospital antibiotic policy [9] was attributed to incorrect duration of
(61%) (78.6%) (70.7%) (66.9%)
surgical prophylaxis in 725 (14.8%) prescriptions, incorrect indication
Patients with SP > 24 h 295 35 (10.2%) 70 (12%) 400 in 347 (7.1%), incorrect dose/route and incorrect antibiotic choice in 8
(34.6%) (22.5%)
(0.2%) of each prescription as shown in Table 4.
Patients with > 3days 290 35 (71.4%) 35 (17%) 360
empiric therapy (71.9%) (54.7%)
4. Discussion
LOS of patients receiving empiric therapy (mean ± SD)
1 AMA 6.2 ± 4.3 7.6 ± 4.3 6.7 ± 4.7 6.8 ± 4.3
In our study, the overall rate of antibiotic use was 29% which is
2 AMA 8.7 ± 8.5 9.4 ± 8 9.1 ± 2.6 8.9 ± 7.1
≥3 AMAs 10.4 ± 11.6 ± 9.1 9.7 ± 4.3 10.4 ± similar to the antibiotic usage rate in surgical wards of western Euro­
7.6 7.4 pean countries (28%).11 However, in a multicenter study conducted in
P-value 0.007 0.01 0.1 0.005 India,12 the antibiotic usage rate was 57.4%. Similarly, in western and
*LoS- length of stay, *AMA- Antimicrobial Agent, *SP- Surgical Prophylaxis, central Asia and North America, it was observed to be 44.7% and 44.2%,
*SD–Standard Deviation, *P-value was calculated using One way ANOVA Sig­ respectively.11 This was due to the real or perceived high prevalence of
nificant (P < 0.05). antibiotic resistance, absence or non-adherence to antibiotic treatment
guidelines. Prophylactic antibiotics were given to 66.9% of patients
(surgical). Cefuroxime (62.1%) and metronidazole (26.2%) were the
Table 2 most commonly prescribed antimicrobials for surgical prophylaxis (SP).
Bacteriological Cultures n (%); n = number of patients (570/2653). In contrast, the most commonly prescribed antibiotics for prophylaxis
Total patients 570 (21.4%) (surgical) in a multicenter study (India) were cefuroxime (36%), ami­
Positive cultures 309 (54.2%) kacin (10%), and ceftriaxone (8%).12 However, cefazolin was preferred
No microbial growth 261 (45.8%)
globally as prophylaxis11 as it provides adequate coverage against the
Antibiotic Escalation/de-escalation performed 364 (63.9%)
Antibiotic De-escalation not performed 206 (36.1%)
majority of organisms that cause postoperative infections, has fewer
adverse effects, achieves optimal tissue levels, and is relatively inex­
pensive.13 Yet, cefuroxime was used in our hospital due to a lack of

Table 3
Antibiotic consumption in DDD/100 bed days.
Antibiotics Surgery Orthopedics Gynecology Total DDD/100 BD Total %

DDD/100 BD % DDD/100 BD % DDD/100 BD %

1st generation cephalosporins 0.004 0.01 0.3 0.8 0.1 0.4 0.09 0.3
2nd generation cephalosporins 6.4 20.1 12 33.6 11.2 48.7 8.7 29
3rd generation cephalosporins 7.1 22.3 6.1 17.1 1.3 5.6 5.3 17.6
4th generation cephalosporins 0.2 0.5 0.04 0.1
Aminoglycosides 0.8 2.5 4.8 13.4 0.1 0.4 1.2 4
Quinolones 1.5 4.7 0.7 2 0.2 0.9 1 3.3
Lincosamide 0.8 2.5 0.3 0.9 0.01 0.05 0.5 1.6
Macrolide 0.4 1.3 0.7 2 0.5 2.2 0.5 1.7
Nitroimidazole 4.5 14.1 3.5 9.8 7.2 31.2 5.1 17
Nitrofurantoin 0.1 0.3 0.2 0.6 0.2 0.9 0.1 0.3
Penicillins 5.5 17.3 3.5 9.8 1.2 5.2 4 13.3
Tetracyclines 0.2 0.6 0.7 2 0.5 2.2 0.3 1
Polymixins 1.6 5 0.3 0.8 1 3.3
Carbapenems 0.6 1.9 0.7 2 0.01 0.05 0.5 1.7
Linezolid 0.6 1.9 0.3 0.8 0.5 2.2 0.5 1.7
Glycopeptides 0.3 1 1.3 3.6 0.4 1.3
Tigecycline 1.4 4.4 0.1 0.3 0.8 2.7
Fosfomycin 0.05 0.1 0.01 0.02 0.03 0.1
Total 31.854 100 35.7 100 23.02 100 30.06 100

*DDD- Defined daily dose, *BD – Bed Days.

3
A.P. Thomas et al. Clinical Epidemiology and Global Health 13 (2022) 100944

Fig. 1. Drug utilization 90% (DU90%) profiles of antibiotics using WHO AWaRe classification: (a) Surgery, (b) Orthopedics, (c) Gynecology, DDD: Defined
Daily Dose.

Table 4
Compliance of antibiotic prescriptions and non-compliance parameters within
various wards towards hospital antibiotic policy.
Surgery Orthopedics Gynecology Total

Total Compliance 1688 730 (86.3%) 1365 3783

(67.9%) (88.6%) (77.7%)

Parameters of Non- compliance to hospital antibiotic policy

Duration 489 (19.7%) 73 (8.6%) 163 (10.6%) 725 (14.8%)
Indication 299 (12%) 40 (4.7%) 8 (0.5%) 347 (7.1%)
Dose/Route 3 (0.1%) 1 (0.2%) 4 (0.3%) 8 (0.2%)
Wrong choice 7 (0.3%) 1 (0.2%) 8 (0.2%)

Total 2486 845 1540 4871

Prescriptions (100%)

cefazolin availability and concerns about antibiotic resistance. Fig. 2. Percentage of antibiotic use according to WHO AWaRe classification.
The rate of empiric antibiotic use in our study was higher (24.8%)
compared to a European study (17%), due to adherence to hospital antibiotics.19 Hence, there is a need for local and country-specific
guidelines.14 In 36.1% patients in our study, empirical therapy was not modifications to the WHO AWaRe classification due to differences in
de-escalated after receiving culture reports due to concerns of infection AMR, antibiotic use, and treatment guidelines, in order to ensure it is
in patients with immune-compromised states. Compared to our previous optimized for country-specific use. Furthermore, the use of ‘not recom­
study5 in the surgery ward, the empiric use of antibiotics has been mended’ antibiotic combinations was observed in our study, owing to a
reduced to 28.9% from 61%. The antibiotic consumption shows ceph­ perceived positive clinical effect with their use. A national study con­
alosporin as the preferred antimicrobial, with second generation ceph­ ducted in India revealed the proliferation of unapproved antibiotic
alosporins being more commonly prescribed than first and third combinations as a barrier to controlling AMR in the country.20
generations, which contradicts our previous study.5 This positive shift in The current study found that the number of antimicrobial agents in
prescribing behavior can be attributed to the implementation of our the DU90% segment ranged from 5 to 13, which is greater than the
hospital’s antibiotic policy and frequent audits by clinical pharmacist. DU90% profiles seen in other Indian (11 agents) and Ethiopian hospitals
Our hospital’s antibiotic policy recommends cefuroxime/cefazolin as (6–8 agents).21,22 The DU90% technique assumes that by employing a
surgical prophylaxis for all surgeries and cefuroxime with metronidazole small number of different items, prescribing quality would be better.11
for abdominal surgeries.7 The third most commonly prescribed agent The compliance rate of antibiotic prescribing to hospital antibiotic
was ceftriaxone. This could be attributed to its success in controlling and policy has improved to 67.9% compared to our previous study (27.2%)
treating infections due to its broad spectrum of activity against most in the surgery ward.5 Similar, compliance rate (70%) was reported in
bacterial species, particularly gram-negative microorganisms, as well as surgery wards of a study conducted in India.12 Among patients who
its widespread availability in hospital settings.15 However, in other In­ received antibiotics for surgical prophylaxis, 22.5% patients were
dian studies, higher prescription rates of ceftriaxone use was treated for more than 24 h, which contradicted the recommendations of
observed.5,16 The use of third generation cephalosporins must be the hospital antibiotic policy and this needs attention. The extended
monitored because they have been linked to the emergence of AMR.17 duration of SP could be due to the widespread belief among physicians
According to WHO AWaRe policy,18 the proportion of Access anti­ that it can prevent surgical site infections (SSIs) in surgical wound cases
biotics should be greater than 60% of total antibiotic use. However, in with a high risk of bacterial contamination. Prolonged SP is generally
our study, 53% of antibiotics were prescribed from the Watch group, unnecessary, and it raises the risk of AMR and side effects.11,12 The
while only 36% were prescribed from the Access group (Fig. 2). The hospital antibiotic policy requires appropriate cultures to be sent prior
reasons were use of cefuroxime instead of cefazolin for SP, use of empiric to the start of empiric therapy, which was not followed [54.7% of pa­
therapy without indication (7.1%) and the concerns about treatment tients received more than 3 days of empiric therapy]. According to a
failure caused by antimicrobial resistance to WHO’s Access group of systematic review and meta-analysis, guideline-compliant empirical

4
A.P. Thomas et al. Clinical Epidemiology and Global Health 13 (2022) 100944

therapy was associated with a 35% reduction in relative risk of mor­ 4 Olesen SW, Barnett ML, MacFadden DR, et al. The distribution of antibiotic use and
its association with antibiotic resistance. Elife. 2018;18(7), e39435.
tality.23 Prolonged SP or definitive therapy, empiric therapy without
5 Soman N, Panda BK, Banerjee JK, John SM. A study on prescribing pattern of
appropriate microbiological cultures, and noncompliance with hospital cephalosporins utilization and its compliance towards the hospital antibiotic policy
antibiotic policy can all lead to increased antibiotic prescribing and, as a in surgery ward of a tertiary care teaching hospital in India. Int Surg J. 2019;6(10):
result, an increase in antibiotic resistance.11,12,23 3614.
6 Senthilkumar S, SA AR, Padmavathi K, Dhanapal CK, Periasamy K. Study on
The study’s strength is its large sample size, which allows for a antibiotic use among geriatric patients based on anatomical therapeutic classification
diverse range of infections to be included in order to answer the research or defined daily dose methodology and world health organization-essential medicine
questions. The study makes several important recommendations to list access , watch and reserve concept in tertiary care hospital of South India. Int J
Basic Clin Pharmacol. 2020;9(7):1106–1113.
improve future antibiotic use. The study’s limitations include the lack of 7 Bharati Hospital and Research Center Antibitoic Policy Version 5.0. 2019 [Available
a hospital information system for rapid data collection and tracking of from: Microsoft Word - ANTIBIOTIC POLICY UPDATED BHARATI HOSPITAL 2019
antimicrobial prescriptions, as well as the lack of a single point of con­ Version 18.02.2020 (bharatividyapeeth.edu)].
8 Demeke B, Molla F, Assen A, et al. Evaluation of drugs utilization pattern using who
tact for antimicrobials prescribed in the hospital. As a result, a cost- prescribing indicators in Ayder referral hospital, Northern Ethiopia. Int J Pharma Sci
benefit analysis of antimicrobial consumption could not be performed. Res. 2015;6(2):343–347.
9 Sataloff RT, Johns MM, Kost KM. Guidelines for ATC Classification and DDD
Assignment. WHO; 2020 [Availabe from: 2020_guidelines_web-ATC-OMS.pdf (udec.
5. Conclusion cl)].
10 Zhang W, Shen X, Bergman U, et al. Drug utilisation 90 % ( DU90 %) profiles of
The hospital’s antibiotic policy was followed with a high degree of antibiotics in five Chinese children ’ s hospitals ( 2002 – 2006 ). Int J Antimicrob
Agents. 2008;32(3):250–255.
adherence. However, antibiotic prescriptions without indication, sur­
11 Versporten A, Zarb P, Caniaux I, et al. Antimicrobial consumption and resistance in
gical prophylaxis for longer than necessary, and empiric therapy adult hospital inpatients in 53 countries: results of an internet-based global point
without microbiological culture reports all contribute to noncompliance prevalence survey. Lancet Global Health. 2018;6(6):e619–e629.
with the hospital antibiotic policy. In comparison to access antibiotics, 12 Singh SK, Sengupta S, Antony R, et al. Variations in antibiotic use across India: multi-
centre study through Global Point Prevalence survey. J Hosp Infect. 2019;103(3):
Watch group antibiotics are used more frequently. This highlights the 280–283.
need of antibiotic surveillance programs and further development of 13 World Health Organization. Global guidelines for the prevention of surgical site
antibiotic treatment guidelines based on WHO AWaRe policy. infection. Available from http://apps.who.int/iris/bitstream/10665/250680/1/9
789241549882-eng.pdf?ua=1; 2016.
14 Kumarasamy Y, Cadwgan T, Gillanders IA, Jappy B, Laing R, Gould IM. Optimizing
Funding antibiotic therapy - the Aberdeen experience. Clin Microbiol Infect. 2003;9(5):
406–411.
15 Pinto Pereira LM, Phillips M, Ramlal H, Teemul K, Prabhakar P. Third generation
This research received no specific grant from any funding agency in cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an
the public, commercial, or not-for-profit sectors. antibiotic policy. BMC Infect Dis. 2004;4(1):59.
16 Sane RM, Shahani SR, Kalyanshetti AA. Antibiotic prescription pattern in surgical
wards of MGM hospital. Kamothe. Int J Infect. 2018;5(1), e57914.
Ethical approval 17 Park SH. Third-generation cephalosporin resistance in gram-negative bacteria in the
community: a growing public health concern. Korean J Intern Med. 2014;29(1):
Obtained. 27–30.
18 World Health Organization. AWaRe policy brief [Available from: https://adoptaware
.org/assets/pdf/aware_policy_brief.pdf; 2019.
Declaration of competing interest 19 Gandra S, Kotwani A. Need to improve availability of ‘access’ group antibiotics and
reduce the use of ‘watch’ group antibiotics in India for optimum use of antibiotics to
The authors declare that they have no competing interests. contain antimicrobial resistance. J Pharm Policy Pract. 2019;12(1):20–23.
20 Mcgettigan P, Roderick P, Kadam A, Pollock AM. Reserve antibiotics in India :
challenges for WHO stewardship. Lancet Global Health. 2011;5(11):e1075–e1076.
References 21 Bhardwaj A, Kapoor Kaveri, Singh Vivek. Trend analysis of antibiotics consumption
using WHO AWaRe classification in tertiary care hospital. Int J Basic Clin Pharmacol.
1 Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2020;9(11):1675–1680.
2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis. 2014;14(8): 22 Gutema Girma, Håkonsen Helle, Engidawork Ephrem, Toverud Else-Lydia. Multiple
742–750. challenges of antibiotic use in Ethiopia - a ward-specific study showing high rates of
2 Klein Eili Y, Milkowska-Shibata Maja, Tseng Katie K, et al. Assessment of WHO hospital-acquired infections and ineffective prophylaxis. BMC Health Serv Res. 2018;
antibiotic consumption and access targets in 76 countries, 2000–15: an analysis of 18(1):326.
pharmaceutical sales data. Lancet Infect Dis. 2020;21(1):107–115. 23 Schuts EC, Hulscher M, Mouton JW, et al. Current evidence on hospital antimicrobial
3 Bell BG, Schellevis F, Stobberingh E, Goossens H, Pringle M. A systematic review and stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis.
meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC 2016;16(7):847–856.
Infect Dis. 2014;14(13):1–25.