Download Antibiotic use in patients with FUO in Panti Rapih Hsp

ANTIBIOTIC USE IN PATIENTS WITH
FEVER OF UNKNOWN ORIGIN (FUO) AT
PANTI RAPIH HOSPITAL YOGYAKARTAINDONESIA
Hartayu T1 , Asdie HAH2, Suryawati S3
1
Faculty of Pharmacy Sanata Dharma University
2 Department of Internal Medicine and
3 Department of Clinical Pharmacology, Faculty of
Medicine Gadjah Mada University,
Yogyakarta
ABSTRACT
Problem Statement: Antibiotics accounted as the biggest part of drug costs paid by patients admitted to Panti
Rapih hospital, and fever of unknown origin (FUO) was the most prominent diagnosis reported.
Objectives: To evaluate the pattern of antibiotic use in patients admitted with FUO in Panti Rapih hospital,
Indonesia.
Design: An explorative study with retrospective quantitative data collection and prospective qualitative data
collection. All patients admitted to Panti Rapih Hospital with FUO as diagnosis at admission during the period
of December 1996 to June 1997 were selected. Quantitative data were collected to assess the pattern of
antibiotic use in FUO and the pattern of diagnosis at both admission and discharge. Qualitative data were
collected using in-depth interviews with prescribers and the paramedic chiefs of the wards to explore the
reasons for antibiotic use , and identifying final diagnoses.
Setting and Population: All patients hospitalized with FUO as diagnosis at admission in Panti Rapih Hospital,
during period of December 1996 to June 1997.
Outcome Measures: Pattern of diagnoses at discharge (final diagnosis), number of antibiotics received, the
kind of antibiotics received, the route and administration of antibiotics, average length of stay, range of drug
cost during hospitalization, reasons of antibiotic usage.
Results: Out of 273 cases analyzed 48 cases (18%) had FUO as final diagnosis, and the rest were
diagnosed as having upper respiratory infection 37 cases (14%), dengue fever35 cases (13%), no final
diagnosis 18 cases (10%)and others 125 cases (45%). In total 90% of cases used antibiotic, either oral or
injection, despite the fact that antibiotic were not recommended for this diagnosis. The average length of stay
was 5 days (range:1 day – 9 days). Drug cost varied greatly, with the highest cost observed (US$45.15)
being 16 times the lowest (US$ 2.90).Reasons for antibiotic use were generally based on personal or
colleagues’ experiences, an assumption of infection despite clinical observation, the absence of a standard
treatment for FUO, drug promotion, and negligence in updating information.
Conclusions: Antibiotics were used in 90 % of patients with FUO. Efforts should be pursued to reduce the
unnecessary use of antibiotics including provision of standard treatment guideline for FUO.
Funding Sources: Self Funded.
BACKGROUND
Panti Rapih is a private hospital in
Yogyakarta-Indonesia, has 367 beds
with 12 specialist departments and 10
subspecialist departments, and has
more than 80% Bed Occupation Rate.
Antibiotics accounted as the biggest
part of prescription cost and Fever of
Unknown Origin (FUO) was the most
prominent diagnosis reported.
OBJECTIVES
 General
To evaluate the pattern of antibiotic use for
patients admitted with FUO at Panti Rapih
Hospital, Yogyakarta-Indonesia.
 Specific
To find out:
 The pattern of antibiotics prescribed for FUO
 Reasons of antibiotic use
 Strategy to improve the appropriateness of
antibiotics used in FUO
METHODS
 Design:
 An explorative study with retrospective
quantitative data collection and
prospective qualitative data collection.
 Setting:
 All patients admitted to Panti Rapih
hospital with FUO as diagnosis at
admission.
 Time period of data collection :
December 1996 to June 1997
STUDY DESIGN
Quantitative data
All
patients
admitted
with FUO
in
Panti
Rapih
Hospital
Dec ’96June ‘97
(273
patients)
FUO as
final
diagnosis
Observation on
prescriptions in
medical record
Reference:
Pattern of
Antibiotic
use
Current Medical Diagnosis
and Treatment (Jacobs,
2004):
•Broad spectrum antibiotic
with haematological
examination result
48
patients
Qualitative Data
In-depth
interview with
prescribers and
chiefs of wards
(paramedic)
Reference:
Reason of
Antibiotic
use
Identify Strategy
to Improve the
appropriateness
of Antibiotic use
Guide to Good
Prescribing
(WHO,1994)
Other final Diagnoses
• Upper respiratory infection: 37 patients
125 patients
• Dengue fever : 35 patients
Diagnosis: 18 patients
 Others:
 No final
Result 1, Diagnosis at hospital
discharge
No
Diagnosis
0-5
(Years
old)
5-12
(Years
old)
>12
(Years
old)
Total
1
FUO
11
5
32
48 (18%)
2
Upper
respiratory
infection
29
4
4
37 (14%)
3
Dengue fever
7
13
15
35(13%)
4
Others
11
1
16
125(45%)
5
No final
diagnosis
31
18
76
18(10%)
FUO had contributed for 18% of all final diagnoses, and data in
reference showed (10-15 %) (Jacobs, 1994)
Result (2),Types of Antibiotic Used in
FUO December ‘96 – June ‘97
Patient’s
Age (years)
Number of
patients
Types of Antibiotic
0–5
11
Erythromycin, Amoxycilin, Ceftriaxone,
Cotrimoxazole
5 - 12
5
Cotrimoxazole
>12
32
Amoxycillin, Ampicillin, Chloramphenicol
Spyramycin, Ofloxacin, Pefloxacine, Cefixim,
Cefixim, Cefetamed, Cefprozil
• Narrow spectrum antibiotic were used for
adults but were not used for children.
Result (3),
Number of Patients with FUO receiving antibiotic
December 1996 – June 1997
Age (years)
Number of
patients
Without
antibiotics
Recieved 1 or
2 antibiotics
0–5
11
3
8
5 – 12
5
1
4
> 12
32
1
31
Total
48
5 (10%)
43 (90%)
• 90% patients received 1 or 2 kind of antibiotic
before the haematological examination results.
RESULT (4), REASONS OF ANTIBIOTICS USE
Reasons of antibiotics use :
 An assumption of infection despite clinical
observation
 Uncertainty of sterilization of hospital environment
 Takes too long to wait for laboratory examination
results
 Modeling personal or colleagues’ experiences
 Negligence of updating information
 Drug promotion
Note: standard guideline for FUO was not available
in the hospital
DISCUSSIONS (1)
 The data shows that narrow spectrum antibiotic
such as Spiramycin and Chloramphenicol were
used, despites the fact that narrow spectrum
antibiotics are not recommended for FUO.
 Jacobs (2004) recommended that broad spectrum
antibiotics might be given for FUO patients. Narrow
spectrum antibiotic can not be given unless there’s
a strong evidence to a specific diagnosis.
 The evidence of FUO as the final diagnosis in this
hospital (17,6%) was slightly higher than that
reported in reference (10 – 15%)( Jacobs, 1994).
The factor that might contribut to this phenomenon
was insensitivity of diagnosis tools.
Discussion (2)
 Among the reasons to use antibiotics in FUO was
personal or colleagues’ experiences, eventhough
experience is not always reliable. Therefore an
agreement to use the reliable reference such as
diagnosis guideline and hospital standard
treatment guideline are urgently needed.
 The drug costs varied widely (US$ 2.90 to US$
45.15), and factor what might contribute to this
result is the unavailability of agreement among
prescribers in this hospital on which drug and
which brand name should be selected for FUO.
CONCLUSIONS
 Narrow spectrum antibiotics were used for
adults patient with FUO eventhough they
are not recommended.
 Agreement among the prescribers is
urgently needed to standardize the
management of FUO in Panti Rapih
Hospital.
 Effort should be sought to update the
improving standard diagnosis and
treatment guideline for FUO.