PHARMACO-ECONOMIC ASPECTS OF ANTIBIOTIC PRESCRIPTIONS IN CLINICS OF KATHMANDU

Antibiotics (AB) are the most widely prescribed group of drugs and their use is associated with increasing rate of AB resistance. Nearly one third of prescriptions of physicians for colds, upper respiratory tract infections and bronchitis are of AB as documented in previous studies. Antibiotic use is associated with increased cost of financial burden, which may be difficult to be borne by the patients in developing countries like Nepal. The objective was study the prescribing pattern of Antibiotic preparations in various diseases and to find out how the treatment could become more pharmaco-economic without compromising the quality of service. A cross sectional study of prescription pattern of antibiotics/drugs in which antibiotics were used from randomly selected 20 private clinics of four major specialties in Kathmandu valley. Total No. of prescriptions audited were 386, average number of drugs/per prescription was 2.74. Maximum antibiotics were prescribed for age group 21-40 years in gynecological, surgical and medical problems, in Pediatrics maximum AB were prescribed between 1-12 years. Minimum antibiotics were prescribed between 13-20 years for gynecological and Pediatric problems. In medical and surgical problems, minimums AB were administered between 41-60 years. Above 60 years almost no AB were used. Males


INTRODUCTION
One of the leading causes of death is infectious disease thought the world.Discovery and development of vaccines and antibiotics AB have minimized this fatality rate to some extent.Now the major obstacle, medical science is facing is of drug resistance microorganisms, which might be due to misdiagnosis and overwhelming prescriptions of large number of drugs.
As more strong AB were discovered leading to development of more and more resistant strains of microorganisms.Finally we are digging deep into the barrel of antibiotics. 1 AB is often most used or misused drugs [2][3][4][5][6][7][8] as reported earlier.In Nepal there are few reports about antibiotic survey. 9,10  has been seen that approximately 12 million antibiotic prescriptions resulted from respiratory infections accounting for 21% of all antibiotic prescriptions to adults accounting for 47.2 million (pounds sterling) in expenditure in the United Kingdoms. 11Moreover; there is a tendency of prescribing costly and latest antibiotics.Such 'ambitious prescription' has lead to many concerns, not only the development of resistant strains of microbes but also rising health costs.Reports related to overuse of AB in Nepal is yet to be estimated.Earlier a survey of awareness of patients about the use of AB from some hospitals and clinics of Kathmandu valley was undertaken. 12n this study 178 patients were interviewed by a multi graded questionnaire, showing that 54% patients had no awareness of AB, 51.5% were ignorant about the action of AB and 89.5% had no knowledge about the side effects.
This background prompted to undertake this survey on the pattern of ABs prescriptions in 20 private clinics (Five of each of four major specialties, viz medicine, surgery, pediatrics and Gynecology) in Kathmandu valley and to work out pharmacoeconomic of these prescriptions.

SIZE OF DATA
Fifty encounters receiving AB were made from each selected sample clinic of the chosen prescriber.The total size of the sample was 386.

TOOLS OF DATA COLLECTION
Prescription audit was done with the prescriptions of patients who were prescribed AB by their physicians in their clinics.

FIELD TEST OF DATA
Field test of the data-collecting tool was done in New Boudha Pharmacy & Baudha X-ray Diagnostic center, Kathmandu valley

ANALYSIS OF DATA
Data was tabulated and analyzed using tally bars, pie diagrams and MS Excel for windows 2000.II.

I. Age distribution: of patients receiving antibiotics is as shown in Table 1 II. Sex distribution shown in Table
Males were prescribed more antibiotics (73% for surgical, 62% for medical and 53% for Pediatric problems) III.Table III      In gynecological clinics total number of prescriptions were 160,which was maximum, but minimum prescriptions were in surgical clinics that were 84.Maximum average number of drugs per prescription was 3.14 in gynecological clinics and minimum average number was 2.34 drugs /prescription in surgical clinics.
Out of prescribed drugs prescriptions of Abs were 20.25% out of which 61.84 % AB was prescribed without any proper investigations.In those cases were investigations were done only in 8.6% patients culture /sensitivity was done before AB therapy; in 29.56 % patients some investigations were done before AB used.

PHARMACO-ECONOMIC ASPECTS OF AB THERAPY
Pharmaco-economic aspects of AB treatments in different specialties are shown in Table VII.Quinolones and fluoroquinolones were the Abs of choice in private clinics.This is an alarming situation to improve this alarming situation

RECOMMENDATIONS
Following may be suggested---Effective information and dissemination strategies for public at all levels should be implemented.
A massive consumer awareness programme on the use of ABs should be conducted to produce awareness amongst the common people.
A massive education programme at school level could be ideal.Medical professionals and pharmacists should be invited by school authorities to educate the younger generation not only against antibiotics but also against other health hazards on the lines of AIDS DAY (1 st of December).
A national antibiotic policy should be formulated and standard treatment guidelines for Physicians should be issued.
Culture & sensitivity reports of commonly used AB should be available from time to time Importance of investigations should be stressed in chronic cases Prescriber should be more careful in using expensive and multiple ABs.Generally oral drugs are cheaper than injections, the 1 st generation drugs are usually cheaper then the latest generations. 13In situations where two or more then two ABs Others are equally effective, cheaper alternative should be the choice, without compromising the patient care.This practice is more pharmaco-economic.There are many common infections that can be treated efficiently with older and cheaper ABs. 14 It may be valuable to categorize ABs into different groups and hold some ABs in the reserve group for more restricted use. 15WHO expert committee (1989) has proposed that ABs like quinolones, third & fourth generation Cephalosporins and vancomycin may be kept as 'reserve' ABs for resistant hospital strains infections.16 Peer group discussions, availability of sensitivity pattern of local bacterial pathogens can be very helpful in selecting AB. 16,17

Table I : Age Distribution Number
of encounter = 386 (n1=100, n2=100, n3=86, n4=100) Bar diagram II.Shows commonest health problems and commonest AB used in different specialities in clinics The use of different AB for different health problems has been shown in bar diagram III, IV.
Table IV of this study even taking the average costs of AB 177.5, 116, 112, and 151.99.75, 84.NR spent by patients was not required.