





















































Original Articel


Prescribing indicators and pattern of use of antibiotics among medical outpatients

in a teaching hospital of Central Nepal

Jeetendra Kumar1, M. M. Shaik2, M. C. Kathi2, A. Deka3, S .S. Gambhir3

1Assistant Professor, 2Lecturer, 3Professor, Department of Clinical Pharmacology, College of Medical Sciences Bharatpur,

Chitwan, Nepal

Abstract

The study of prescriptions using prescribing indicators enables us to detect some common problems of

prescribing and to focus subsequent efforts to correct them. This study was designed to define the extent and

pattern of drug prescribing with emphasis on that of antibiotics among medical outpatients of teaching hospital of

College of Medical Sciences Bharatpur, Nepal. The data contained on randomly selected original prescriptions

of patients attending medical OPD in between January2008 and June2008 were collected prospectively on

duplex prescriptions and analyzed. A total of 955 drugs were prescribed to 339 patients. The average number of

drugs per encounter was 2.81. Drugs prescribed by generic name were 20.31% and those matched to national

essential drugs list were 49.63%. Encounters with antibiotics were 43.95%. Antibiotics were the most frequently

prescribed therapeutic class. Azithromycin, ciprofloxacin and amoxycillin were three most frequently prescribed

antibiotics. Respiratory tract infection was the most common indication, for which antibiotics were given. Selections

of antibiotics were rational for most of the indications but bacteriological confirmation prior to institution of

antibiotics were not done in any case. Polypharmacy, inclination for branded products and overuse of antibiotics

were revealed as problems requiring educational interventions and strict antibiotic policy as subsequent efforts to

rectify them.

Key words: Antibiotics, medical outpatients, prescribing indicators, teaching hospital.

Introduction

The drug prescribing remains the end result of most

of the medical consultations. This is one clinical skill

that almost every physician practises regularly to

transact the desired therapeutic goal. This is one

important skill as the outcome of drug therapy depends

much on this.

Drug is one of the most important components of

the health care delivery system and account for a large

percentage of its cost. These facts warrant the rational

prescribing as an essence of a cost-effective medical

care. Rational prescribing refers to prescribing of right

drug to the right patient, in the right dose, at right time

intervals and for right duration. However, irrational

prescribing has been widely reported both from the

developed as well as the developing world1. The cost

of irrational use of drugs consequent to irrational

prescribing is enormous in terms of both scarce

resources and adverse clinical consequences such asCorrespondence: Dr. Jeetendra Kumar

E-mail:drjktkhag2003@yahoo.co.in

Original Article, 7-13Journal of college of Medical Sciences-Nepal, 2010, Vol.6, No-2

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ineffective or unsafe treatment, exacerbation or

prolongation of existing illness, iatrogenic illnesses and

emergence of resistance to antimicrobials. Antibiotics

have been found to be the most commonly prescribed

and used class of drugs in several national and

international studies.2,3,4,5 The emergence of antibiotic

resistant bacterial pathogens on a large scale over last

two decades is taken as an inevitable consequence of

these over uses of antibiotics worldwide.6,7 Strategies

that optimize antibiotic use are therefore essential to

minimize this microbial threat to suffering as well as to

treating community of world. Prescribing indicators are

one of the core drug use indicators developed by World

Health Organization (WHO) in a collaborative work

with International Network for Rational Use of Drugs

(INRUD)8. These indicators can be used efficiently in

many settings of drug use study to detect problems in

drug prescribing such as polypharmacy, inclination for

branded products, over use of antibiotics or injections

and prescribing out of formulary or essential drugs list9.

Study of prescribing practices using prescribing

indicators enables us to detect these problems and to

prioritize and focus subsequent efforts to correct them.

Such studies accompanied with providing feedbacks

to prescribers at regular intervals has been proved to

be an effective strategy to optimize the use of antibiotics

and other drugs and also to reduce the resistance

related problems.8,9,10 Various problems of prescribing

including the overuse of antibiotics have been revealed

in studies carried out in hospitals of other regions of

Nepal.2,3 Polypharmacy, non-adherence to national

formulary and inclination of prescribers for branded

and fixed dose combination products were revealed

in a previous study conducted among orthopedic

outpatients in the teaching hospital of College of

Medical Sciences Bharatpur.11 However, the

information on the prescribing practices of antibiotics

and other drugs among medical outpatients in this

hospital is lacking. This study was undertaken therefore

with an objective to define the extent and pattern of

drug prescribing with a special reference to that of

antibiotics among medical outpatients in this hospital

and to delineate areas of improvement. This study was

attempted also to highlight the subsequent needed

efforts by the prescribers to correct them and to make

their practices more rational and cost-effective. This

study will serve to generate the basic data for more

comprehensive study in the future and for a comparative

study by other investigators.

Materials and methods

This cross-sectional descriptive study was

conducted at the teaching hospital of College of

Medical Sciences Bharatpur. This is a tertiary care

hospital located in the Chitwan district of Central Nepal.

Patients were approached for their prescriptions at the

pharmacy of the hospital on a prefixed day in each

week in between January 2008 and June 2008. Only

freshly registered medical outpatients were selected

randomly for this study. Revisit cases and prescriptions

with admission order were excluded from this study.

All informations contained on each selected prescription

were recorded on the duplex prescription papers

having all the columns of an original prescription paper.

Each patient was explained the nature and purpose of

study well before recording the data from his or her

prescription. The data was collected prospectively by

this method from 339 original prescriptions belonging

to same number of patients selected for this study.

Prescriptions were analyzed strictly under WHO

guidelines to get the value of each of prescribing

indicators.8 Analysis of prescriptions were done also

Journal of college of Medical Sciences-Nepal, 2010, Vol.6, No-2

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to get the distribution of different therapeutic classes

of prescribed drugs, the distribution of classes of

antibiotics and frequently prescribed individual

antibiotics.  Prescriptions were further analyzed to get

the pattern of frequently prescribed individual antibiotics

against different diagnosis. Each of fixed dose

combination drugs was counted as a single drug.

Antitubercular drugs and anti-protozoals such as

Metronidazole and Tinidazole were not counted as

antibiotics as per the instructions of WHO.8 Prescribed

drugs were compared with those included in the latest

Essential Drugs List of Nepal12 to measure the deviation

from the national formulary. The number and the

percentage were used to express the observed data.

Results

A total of 339 prescriptions belonging to same number

of patients contained a total of 955 drugs. The average

number of drugs per encounter was 2.81. Two hundred

and thirty two patients (68.4%) were prescribed 2-3

drugs. More than three drugs were prescribed in

77(22.8%) patients. Thirty (8.8%) patients received only

one drug. Only 194 (20.31%) drugs out of total 955 drugs

were prescribed by generic name. Drugs prescribed from

essential drugs list of Nepal were 474(49.63%).

Prescribing indicators are detailed in Table-1.

Table 1: Prescribing indicators among medical

outpatients

Antibiotics were the most frequently prescribed

therapeutic class followed by drugs for peptic ulcer

syndrome, non-steroidal anti-inflammatory drugs,

multivitamins and anti-histaminics. Other commonly

prescribed classes were anthelmintics, cough and cold

remedies, anti-protozoals, bronchodilators and anti-

hypertensives. Among 149 patients who received

antibiotic, only 9 patients were exposed to two

antibiotics concurrently and rest of the patients were

exposed with only one antibiotic. Antibiotics

constituted 16.54% of totally prescribed drugs. Table-

2 shows the prescribing frequency of different

therapeutic classes.

Table 2: Therapeutic classes of drugs prescribed

Prescribing indicators No. % 

Prescriptions Analyzed 339 100 

Drugs Prescribed 955 100 

Average Number of Drugs/Encounter 2.81 - 

Encounters with an Antibiotic 149 43.95 

Encounters with an Injection 008 2.36 

Drugs Prescribed By Generic Name 194 20.31 

Drugs Prescribed From  

Essential Drugs List of Nepal 

474 49.63 

 

S.N. Therapeutic Class No. % 

1. Antibiotics 158 16.54

2. Drugs for Peptic Ulcer Syndrome 147 15.39

3. NSAIDs 122 12.77

4. Multivitamins 79 8.27 

5. Anti-histaminics 68 7.12 

6. Anthelmintics 58 6.07 

7. Cough & Cold Remedies 41 4.29 

8. Antiprotozoals 39 4.08 

9. Bronchodilators 35 3.66 

10. Antihypertensives 31 3.24 

11. Anti-emetics 24 2.51 

12. Antidepressants 24 2.51 

13. Anti-spasmodics 12 1.25 

14. Anti-diabetics 12 1.25 

15. Nasal decongestants 12 1.25 

16. Miscellaneous drugs (Antiseptics, 

Antivirals, Anti-Tb, Steroids etc.) 

93 9.73 

 Total 955 100 

 

Jeetendra Kumar et al, Prescribing indicators and pattern of use..........................

8



Macrolides ranked the first among prescribed classes

of antibiotics followed by fluoroquinolones and beta-

lactams. Figure-1 describes the prescribing frequency

of different classes of antibiotics.

Figure 1: Prescribing frequency of classes of antibiotics

64

44

32

8 10

0

10

20

30

40

50

60

70

N
u

m
b

e
r 

o
f 

D
ru

g
s

Macrolides FQs Penicliins Cephalosporins Miscellaneous

Five most frequently prescribed individual antibiotics

in decreasing order were azithromycin, ciprofloxacin,

amoxycillin, ofloxacin and norfloxacin. Figure-2 details

the prescribing frequency of individual antibiotics.

Figure 2: Prescribing frequency of individual antibiotics

antibiotics

53

24
21

11
9

24

0

10

20

30

40

50

60

Azithromycin Ciprofloxacin Amoxycillin Ofloxacin Norfloxacin Miscellaneous

Reasons for antibiotic institution in decreasing

order were respiratory tract infections (RTIs), urinary

tract infections (UTIs), gastrointestinal infections

(GITIs), enteric fever and pyrexia of unknown origin

(PUO). Azithromycin and Amoxycillin were two most

frequently prescribed antibiotics for respiratory tract

infections. Ciprofloxacin and Norfloxacin were

preferred for urinary tract infections. Ciprofloxacin or

Ofloxacin were used to treat cases of enteric fever.

Further analysis of prescriptions containing two

antibiotics revealed that Amoxycillin and Clarithromycin

were those two antibiotics and they had been

prescribed only for all those nine cases where

Helicobacter pylori infections were suspected as the

cause of peptic ulcer syndromes. Diagnosis was not

mentioned at all in 14 cases and antibiotics were

prescribed also for these cases. Pattern of five most

frequently prescribed antibiotics for different diagnosis

has been detailed in Table 3.

Table 3: Pattern of five most frequently prescribed

antibiotics for different diagnosis

Out of 135 patients for whom the diagnosis was

mentioned, it was made only clinically in 112(75.16%)

cases. Clinical findings and the reports of laboratory

investigations were employed to diagnose only 8 cases.

Clinical and radiological findings were combinedly

considered to diagnose 5 cases and for another each

5 cases, decision was based on the reports of either

laboratory investigations or radiological examinations.

Antibiotics were prescribed therapeutically in

103(69.12%) patients and prophylactically in

 

D
iag

n
osis 

N
o.(%

) 

A
zith

ro
m

y
cin

 

C
ip

ro
flo

xacin
 

A
m

ox
y

cillin
 

O
flo

xacin
 

RTI 79 (53.02) 43 06 14 03 

UTI 17 (11.41) 02 06 xx xx 

GITI 15 (10.07) xx 04 05 xx 

Enteric Fever 12 (8.05) xx 06 xx 06 

PUO 12 (8.05) 04 02 xx 02 

Not 

M entioned 

14 (9.4) 04 xx 02 xx 

Total 149 (100) 53 24 21 11 

Journal of college of Medical Sciences-Nepal, 2010, Vol.6, No-2

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46(30.88%) patients. The therapeutic or the

prophylactic use of antibiotics was ascertained only

clinically. Institution of antibiotic for therapeutic purpose

was empirical in all 103(69.12%) patients and a prior

bacteriological confirmation was not considered in even

a single case. Antibiotics were instituted by oral route

in 150(94.94%) instances and parenteral route was

preferred in 8(5.06 %) instances only.

Discussion

The average number of drugs per encounter is the

most commonly measured index that is used to assess

the extent of polypharmacy. The value of this index

observed in our study was 2.81. The same value for

this index was observed in a previous study conducted

among orthopedic outpatients in our hospital.11 Our

observed value represents a better figure in comparison

to those reported in studies of Eastern Nepal2(5.3),

India4(3.75), Bangladesh13(3.81), Iran5(3.43) and

Nigeria14(3.5). However this is not better than those

reported in the studies of Western Nepal3(1.5),

Pakistan15(2.7), Saudi Arabia16(2.1) and Sudan17(1.9).

The WHO recommends that the average number of

drugs per prescription should be less than two.8  The

observed value in our study therefore may be taken as

an evidence of existing polypharmacy. This index

should be kept as low as possible to avoid the

unfavorable outcomes of polypharmacy such as

increased risk of drug interactions, increased cost of

therapy, non-compliance and emergence of resistance

in case of use of antimicrobials. Five most commonly

prescribed therapeutic classes in our study were

antibiotics, drugs for peptic ulcer, NSAIDs,

multivitamins and antihistaminics.  Antibiotics, NSAIDs,

drugs for peptic ulcer and antihistaminics were

reported as most common classes also in the study of

Western Nepal.3 Antibiotics, analgesics and anti-

inflammatory drugs and vitamins were most frequently

classes observed in the study of Eastern Nepal.2

Antibiotics and NSAIDs were reported as two most

frequently prescribed classes also in the studies of

Saudi Arabia16 and Iran5. Antibiotics were the most

commonly prescribed group also in the Indian study.4

Our as well as other studies thus confirm the antibiotics

as most widely prescribed and used class of drugs. In

the studies of eastern and western Nepal, antibiotics

were prescribed in 84% and 59.9% of encounters

respectively.2,3 In the studies conducted in

Bangladesh13, Pakistan15, Nigeria14 and United

Kingdom18 encounters with one or more antibiotics

were found to be 72.5%, 52%, 54.8% and 77%

respectively. Our study revealed a better figure in this

concern as encounters with an antibiotic were less than

these reports i.e. only 43.95%. However this value is

not better than that reported in a Jordanian study19

where only 35.6% encounters contained antibiotics.

This is a higher figure also in the context of suggestion

made by the WHO that less than 30% of encounters

should include one or more antibiotics.8 Our study

report thereby is an indication that antibiotics are

overused in our hospital. But prescribers in our hospital

seem to be rational regarding the use of antibiotics as

in majority of cases only one antibiotic has been

prescribed and only nine patients got two antibiotics

concurrently. Among those who got two antibiotics,

peptic ulcer syndrome due to Helicobacter pylori were

suspected strongly and Amoxycillin and Clarithromycin

were prescribed as a part of triple drug regimen to

eradicate this microbe. Prescribing Azithromycin and

Amoxycillin for respiratory tract infections,

Jeetendra Kumar et al, Prescribing indicators and pattern of use..........................

11



Ciprofloxacin and Norfloxacin for urinary tract

infections and Ciprofloxacin and Ofloxacin for enteric

fever cases also point towards a rational approach of

prescribers. This is also favored by this fact that

antibiotics were given only through oral route in about

95% instances. However, overuse of antibiotics should

be discouraged as this contributes to emergence of

resistance20. Institution of antibiotics only on the basis

of clinical diagnosis and without a prior bacteriological

confirmation was observed in majority of cases of this

study. This was practiced in an outpatient setting where

bacteriological confirmation was not possible in one

day. Even after this fact, this kind of practice is not

justified for the above mentioned reason and should

be discouraged as far as possible.

Encounters with an injection in our study were found

to be only 2.36%. This is a far below and favorable

figure in comparison to that set forth by WHO in this

concern i.e. less than 10%.9 This proves that

prescribers in our hospital are more awared and rational

regarding use of injections. Drugs prescribed by generic

name in our study were observed to be 20.31%. In a

previous study conducted among orthopedic

outpatients in our hospital, only 7.2% drugs were

prescribed by generic name.11 Therefore the finding of

present study proves an improvement in our hospital

regarding prescribing by generic name. However, our

observed value is low in comparison to that observed

in the study of eastern Nepal where 29.3% drugs were

prescribed by generic name.2 Our finding is a

remarkably low figure in comparison to those reported

in the studies of western Nepal 3(63.5%),

India4(96.5%), Iran5(97.2%) and Sudan17(43.6%).

Prescribers in our hospital thus seem to be inclined

towards branded products. The most likely reason

behind this inclination might be either highly powered

salesmanship of drug manufacturing companies to sell

their products or the unawareness among prescribers

for the advantages of generic prescribing. Prescribing

by generic name offers several advantages including

less cost of therapy and less dispensing errors and this

needs to be promoted among prescribers of our

hospital. Drugs prescribed from essential drugs list of

Nepal were 49.63% in the present study. The observed

value in the previous study of orthopedic outpatients

of this hospital in this regard was 46.2%.11 The

observed value of present study thus appears to be

slightly improved in comparison to previous one.

However this is not better than those observed in the

studies of western Nepal3 and Bangladesh13. Apart

from unawareness regarding benefits of prescribing

from essential drugs list, the unavailability of hospital

formulary or national list in the hospital or pharmacy

seems to be reasons for the observed deviation.

Prescribing from such list is beneficial in terms of cost-

effectiveness and safety as drugs are selected with due

regard to local disease prevalence, evidence of efficacy

and safety and the cost. Prescribing from such list should

be encouraged to ensure rational use of medicines.

Conclusion

There is a much scope for improvement consequent

to this study. Polypharmacy, non-adherence to national

formulary, inclination for branded products and overuse

of antibiotics are different problems that needs attention

by prescribers. Educational interventions emphasizing

rational prescribing along with a multidirectional effort

to create an updated local formulary and a strict

antibiotic prescribing policy can help significantly to

overcome these problems and to reduce the extent of

resistance to antibiotics.

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Acknowledgement

We sincerely acknowledge the kind support of Mr.

P. Khanal and Mr. Surya Prasad Ghimire at hospital

pharmacy along with our fourth semester students in

due course of data collection intended for this study.

We extend our thanks to these valuable persons in our

study.

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