Clinical Medicine Insights. Received 5 May 2021 | Revised 10 June 2021 | Accepted 15 July 2021 | Published Online 27 July 2021 DOI: https://doi.org/xx.xxx/xxx.xx CMI 2 (3), 150−154 (2021) ISSN (O) 2694-4626 RESEARCH ARTICLE Trend And Pattern Of Antibiotic Practice In Paediatric Surgery In Bangladesh Mohammad Mahabubul Alam1 Mohammad Saiful Islam2 Shamsuzzaman Khan3 Mafia Afsin Laz4 1Assistant Professor, Department of Pediatric Surgery, Cumilla Medical College, Cumilla, Bangladesh 2Professor, Department of Pediatric Surgery, Bangabondhu Sheikh Mujib Medical University, Dhaka, Bangladesh 3Assistant Professor, Department of Pediatric Surgery, Shaheed Suhrawardi Medical College, Dhaka, Bangladesh 4Assistant Professor, Department of Pediatric Surgery, Sir Salimullah Medical College & Mitford Hospital, Dhaka, Bangladesh Abstract Introduction: Antibiotics are frequently over prescribed, misused or inappropriately used both in developed or developing countries. The extent and pattern of inappropriate use is well documented in devel- oped countries but such studies are few in developing countries like Bangladesh. Objective: To find out trend and pattern of antibiotic practice in paediatric surgery in Bangladesh Methodology: This cross sectional descriptive study was carried out on 260 paediatric patients of 0-15 years age range, to find out the pattern of antibiotic practice in pe- diatric practicing hospital and different clinic of Cumilla, Bangladesh. All the patients were studied after categorization into i) Clean ii) Clean- contaminated iii) Contaminated and iv) Dirty wounds according to their potentiality of post-operative wound infection. Total period of antibiotic practice was divided into a. Pre-operative (Up to the day before operation) b. Per-operative (during or just before operation) c. Post-operative (days after operation) and d. Post-discharge stage for the convenience of this study. Antibiotic practice in all categories during all periods mentioned were compared and evaluated. Results: More than two antibiotics were given in a single patient in 48.1% of clean and 51.9% of contaminated patients in a combination or sequentially. More than 3 antibiotics were used in a single patient. On the average total number (mean) of antibiotic use was more than two (2.64 +1.09). The highest number (mean) of antibiotics was used in contaminated category (3.29) with range of (0-7). Overall total duration (mean) of antibiotic used was 17.40 days. Keywords: Antibiotic practice, Paediatric surgery, preoperative, Post- operative Copyright : © 2021 The Authors. Published by Medical Editor and Educational Research Publishers Ltd. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by-nc-nd/4.0/). CMI 2 (3), 150−154 MEERP LTD 150 https://creativecommons.org/licenses/by-nc-nd/4.0/ 1 INTRODUCTION Antibiotics are frequently over prescribed, misused or inappropriately used both in de- veloped or developing countries1. This is not only unnecessary and wastes of resources but also increases the risk of adverse clinical conse- quences in a situation where objective benefits are doubtful2. Studies conducted in general and teaching hospitals showed that about 28% of our patients and 52%of the inpatient of a general hospital and 60.36% of the patients in a teaching hospital received antibi- otic therapy that was not appropriate3. Irrational use of antibiotic was also wide spread seen in several studies conducted in China4,5, Indonesia and Sudan6 and Thailand.7 Antibiotic misuse is also commonly seen at discharge after operation. This abuse of antibiotic prophylaxis leads to excessive surgical wound infection rates and strongly contributes to the emergence of bacterial resistance8. The number of this antibiotic resistance strains has been correlated with the number of kilograms of antibiotic used in any given hospital. The cost of such irrational drugs is enormous in terms of our scarce resources9.It has been observed that even after obtaining adequate asepsis surgical site infections are still one of the most important causes of postoperative morbidity and mortality10. Antibiotics have a key role to play in minimizing these unwanted consequences11. The risk of postoperative wound infection has been re- ported to a range from 0% to 40% depending upon the surgical procedure performed. Most surgeons tend to use antibiotic in almost all cases of surgery irrespective of their categories in order to have an infection free record12. Common errors in antibiotic prophylaxis includes selection of wrong antibiotic, administering first dose too early or too late of mak- ing incision, failure to repeat doses during prolong procedures, excessive duration of prophylaxis and inappropriate use of broad spectrum agents. The rea- sons behind this over use may be lack of confidence regarding sterilization status of operation theatre and instruments, inadequate information about sensitiv- ity pattern of local infecting agents, over reliance on newer antibiotics, preference of daily dosing to multiple dosing, affluent patients preference of costly drugs and above all aggressive sales promo- tion by pharmaceutical companies13. Although the extent and pattern of inappropriate antibiotic uses are extensively documented in the developed world14, such types of studies are now few and limited in developing countries like Bangladesh. This study will therefore be undertaken to find out the extent and pattern of antibiotic use in our paediatric surgery to identify the prescribing trend to emphasize the issue of rational usage. 2 METHODOLOGY This cross sectional descriptive study was carried out on 260 paediatric patients of 0-15 years age range, to find out the pattern of antibiotic practice in pediatric practicing hospital and different clinic of Cumilla, Bangladesh. All the patients were studied after cate- gorization into i) Clean ii) Clean-contaminated iii) Contaminated and iv) Dirty wounds according to their potentiality of post-operative wound infection. Total period of antibiotic practice was divided into a. Pre-operative (Up to the day before operation) b. Per-operative (during or just before operation) c. Post-operative (days after operation) and d. Post- discharge stage for the convenience of this study. Antibiotic practice in all categories during all periods mentioned were compared and evaluated. Table 1: Classification of Surgical wounds. Supplementary information The online version of this article (https://doi.org/xx.xxx/xxx.xx) contains supplementary material, which is available to autho- rized users. CMI 2 (3), 150−154 MEERP LTD 151 MEERP LTD ALAM ET AL. 3 RESULTS On the average total number (mean) of antibiotic use was more than two (2.64 +1.09). The highest number (mean) of antibiotics was used in contaminated cat- egory (3.29) with range of (0-7). The lowest num- ber of antibiotics was used in clean category (2.19 SD+1.06) (Table-2). The difference in the number of total antibiotics used is not significant (P>.05) be- tween clean-contaminated and dirty category. Over- all total duration (mean) of antibiotic used was 17.40 days. The duration of total antibiotic used in clean and dirty categories was around 16 days. Maximum total duration (20 days) of antibiotic use was found in clean-contaminated category (Table-3). The differ- ence between Group A, Group C and Group D was not significant revealed byANOVA (P>.05ns).Mean duration of postoperative antibiotics use was found highest in clean-contaminated category (15.07 days), lowest in dirty category (12.75 days). The duration is significantly higher in group A, group B and group C than group D revealed by ANOVA test. Table 2: Total number of antibiotic used in each patient (N=260) FIGURE 2: Table 3: Frequency of use of antibiotic at different stages (N=260) FIGURE 3: Overall 68.0% patient received pre-operative an- tibiotics. Minimum (49.6%) use seen in clean and maximum (76.6%) in dirty category. On the average 79.6% patients received per-operative antibiotics. Maximum (74.4%) per-operative use was seen in clean and minimum (40.0%) in dirty category. Over- all 95.7% of patients received post-operative antibi- otics including all the patients of clean-contaminated category. More than 80% patients in each group re- ceived antibiotic after discharge. No significant dif- ference is found in postoperative and post-discharge antibiotics use among the groups (P>0.1ns). 4 DISCUSSION This high frequency of pre-operative antibiotic usage was perhaps due to prolonged pre-operative hospital stay. Antibiotic prophylaxis has been extensively substantiated by controlled clinical trials15. Never- theless much concern has been voiced in the last few decades about indiscriminate use of antimicrobials, including broad-spectrum agents threatening emer- gence of multiple drug resistance16. It was appre- hended that indiscriminate use is ubiquitous, as such is also prevalent in our working situation. This trend of antibiotic use increases the risk of drug reaction but also diminishes their effectiveness, promote drug resistance and increases the overall treatment cost 17. The total duration of antibiotic usage during pre and postoperative periods was found unduly pro- longed (17.4 days) and had no significant difference in between clean and clean contaminated categories of wounds18 had also observed prolonged postop- erative antibiotic use where most of the antibiotics were given for more than five days. Postoperative antibiotics were also found to be used for prolong period (13 days) which exceeds the recommended limit of surgical prophylaxis of (24-48 hours) after operation15,19. It has been found that the critical period of antibiotic action for effective postoperative bacterial killing in clean or contaminated operation was up to 36 hours of operation20 and prolong post- operative antibiotic use has no added advantage or therapeutic benefit 17,21. It was found that most of the patients (98%) belonging to all categories received antibiotics at least at one of four stages of treatment irrespective of their nature of surgical disease and category of wounds. Such practice of generalized use of antibiotic has no rational basis as it has been MEERP LTD CMI 2 (3), 150−154 (2021) 152 “TREND AND PATTERN OF ANTIBIOTIC PRACTICE IN PAEDIATRIC SURGERY IN BANGLADESH” observed in studies that antibiotics were generally not needed in “clean surgery” at any stage of treat- ment 22,23 if not indicated otherwise. It was also found that about two thirds (66.5%) of all patients including about half (50.0%) of those in the clean wound category received pre-operative antibiotics. However it has been found that the length of preop- erative hospital stay is not associated with increased risk of post-operative wound infection 24. Almost all patients received post-operative antibiotics and virtually no significant difference was observed in the frequency of antibiotic usage between different categories of the patients in respect to the nature of wounds. All of the prophylactic antibiotic usage was continued beyond 48 hours of operation. The period of continuance after the recommended 48 hours 25was also much higher than the finding of Kass18 where he observed 65% of antibiotic prophy- laxis was exceeded this limit in comparison to this study where the limit was exceeded by 100%. The trend of antibiotic usage after discharge in respect to the frequency and duration of their use was found similar in the different categories of surgical wounds and virtually had no significant difference between clean and dirty category. The practice of antibiotic termination also appeared similar among different CMI 2 (3), 150−154 (2021) MEERP LTD 153 groups. Antibiotic use was found generous in all the patients of surgical diseases irrespective of their surgical wound categories. No distinct pattern of choice of antibiotic was used in different categories of patients. Postoperative antibiotics were used in a similar frequency in all the categories. Antibiotic use was continued for more than 48 hours after operation in all categories of surgical illness. Present trend of antibiotic practice in Paediatric Surgery. 5 CONCLUSION Antibiotic overuse is generalized and not categorized according to the categories of surgical wounds. A consensus and collaborated effort is crucial to min- imize this widespread indiscriminate antibiotic use. 2. Momen A, Choudhury SAR, Anwar NAKM. Extent and pattern of antibiotics used in the management of clinically diagnosed case of common cold and fever in some government and private hospitals. Bang J of Physiol and Pharmacol. 1999; 15(2): 67-9. 3. Rashid HU, Chowdhury SAR, Islam N. Pattern of antibiotic use in two teaching hospitals. Tropical Doctor. 1986; 16:152-54. 4. Yang YH, Fu FG, Peng H. Abuse of antibiotics in China and its potential interference in determining the etiology of paediatric bacterial disease. Paed Inf Dis.1993; 12: 988 - 89. 5. World Health Organization (WHO), Antibiotics: The Resistant Problem. WHO features. 1994; 89:107-10. 6. Arustyono. Promoting rational use of drugs at the community health centres in Indonesia. [Online] 1999. [Cited: 05- 05 -2005] Sep 9; Available from http://www.dec2.bumc.bu.edu/ prdu/OtherDocuments/ARUS-Indonesia PRDU/ htm. 7. Aswapokee N, Veithayapichet S, Richard FH. Pattern of antibiotic use in medical wards of university hospital, Bangkok, Thailand. Rev Inf Dis J.1990; 12(no.1):136-41. 8. Ali L, Chowdhury S.A.R. Study of drug utilization pattern at a teaching hospital. Bang. J. Physiol. Phalmacol.1993; 9 (no.1): 27 - 8. 9. Cobb PJ, Scheneig R, Hurt TK, Mandy LM. Infection and inflammation and antibiotics. 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Clinical Medicine Insights.. 2021;150−154. https://doi.org/xx.xxx/xxx.xx 14. Niher RB, Biswas RS, Pal PS, Jain SK, Malhotra SP, Gupta A. Pattern of drug use in two tertiary hospital in Delhi. Indian J Physiol Pharmacol. 2000; 44 (no.1): 109-12. 15. Stone HH, Hanry BB, Kolb LD, Geheber CE, Hooper CA, Katholi RE et al. Prophylactic and preventive antibiotic therapy: Timing duration and economical. Ann surg. Virginia. 1979; 189(no.6): 691-99. 16. Raveh DY, Levy Y, Schlesinger A, Greenburg, Rudensky, Yinnon A M. Longitudinal surveillance of antibiotic use in the Albeny Regional Hospital. Q J Med. 2001; 94:141- 52. 17. Davis A, Kiblbar C. Prevention of infection in surgical practice. In: Clinical Surgery in General, RCS Manual Course. Kirk KM, Mensfield (eds), 3rd ed. Churchill Livingstone, Philadelphia, 1999, pp 211-19. 18. Kass EH. Antimicrobial usages in general hospital in Pensylvania. Ann of Int Med. 1978; 89(no. 2): 800 - 01. 19. Davenport M, Doig CM. Wound infection in Paediatric Surgery; A Study in 1094 Neonates. J Paediatr Surg. 1993; 28(no.1): 26-30. CMI 2 (3), 150−154 (2021) 154 ALAM ET AL. MEERP LTD 20. Geircksky KE, Fuglesang, Cristiansen E, Rossen B. Short term chemotherapeutic prophylaxis in gastrointestinal operation. Surgery & gynaecology & obstetrics. 1980; 151: 349 - 52. 21. Griffith DA, Shorey BA, Simpson RA, Williams NB. 1976. Single dose antibiotic prophylaxis in gastrointestinal surgery. The Lancet. 1976; 14:325 - 28. 22. Bhattacharyya N, Kosloske NA. Post- operative wound infection in pediatric surgical patients: A study of 676 infants and children. J pediatr Surg. 1990; 25 (no.1):125 - 29. 23. Rahman MS. Comparison among no antibiotic: single antibiotic and multiple dose antibiotic prophylaxis [MS Thesis], 2003; 43 24. Ehrenkranz NJ. Surgical wound infection occurrence in clean operations; Risk stratification for interhospital comparisons. Am J Med. 1981; 70: 909-14. 25. Antibiotic Guideline. Antibiotie prophylaxis in surgery. Bangabandhu Sheikh Mujib Medical University, Dhaka. 2005; 72 - 9. MEERP LTD Introduction Methodology Results Discussion Conclusion Blank Page