An antibiotic audit of the surgical department at a rural hospital in Western Kenya

Introduction Antibiotics are one of the most commonly prescribed medications in hospitalized patients, with up to half of prescriptions being irrational. This study aimed to assess the quality of antibiotic use among surgical inpatients at our institution. Methods A one year (January 1-December 31, 2015) retrospective chart review on antibiotic use for patients admitted to the surgical department at AIC Litein Hospital, a faith based non-governmental health institution in Western Kenya, was conducted. Data were collected from medical and nursing patient charts with a standardized questionnaire. The criteria applied to assess inappropriate antibiotic use focused on the choice, duration and indication of the antibiotics prescribed. Results A total of 394 cases were evaluated, with a mean age of 44.8 years and a mean duration of hospitalization of 7.2 days. Antibiotics were initiated either for prophylaxis (205, 56.3%) or treatment (159, 43.7%) for a mean duration of 6 days (range 1-37). The predominant route of administration was intravenous (332, 91.2%). Most antibiotics started at admission were continued till discharge and the duration of antibiotics was indicated in only 11% of the treatment sheets. At discharge, 321 (81.4%) cases had antibiotics prescribed for a mean duration of 5.7 days (range 1-60). Inappropriate prescriptions were noted in 45.4% of prophylactic antibiotics, 33.4% treatment antibiotics and 52.6% of discharge antibiotics. The most common reason for inappropriate antibiotic use during hospitalization was inappropriate duration (45.9%). Conclusion Proper documentation, daily antibiotic review and preparation of a local antibiotic policy guideline could help improve the appropriate use of antibiotics.


Introduction
Antibiotics are one of the most commonly prescribed medications in hospitalized patients, accounting for up to 50% of total drug cost [1][2][3][4]. Rational antibiotic use require that a safe, affordable, efficacious drug is given to the right patient, at the right time, at the right dose, for the right indication and for an appropriate duration [1,5,6]. A significant proportion (20-50%) of antibiotics prescribed in hospitals for prophylaxis or treatment has been reported to be irrational [1][2][3]. Absence of guidelines on rational antibiotic use, uncertainty over the differential diagnosis, presence of complex comorbidities, wrong interpretation of microbial results and poor compliance to antibiotic protocols have all been implicated in inappropriate use of antibiotics [3,6,7]. This leads to increased costs for the patient, drug toxicity, poor patient outcomes and prolonged hospitalizations [2,6,7]. One of the most important factors driving the emergence of antibiotic resistance is the volume of drug use. As the quantity of drugs prescribed has risen; driven by frequent, incorrect and/or inappropriate duration of therapy, there has been a concurrent increase in the emergence of antibiotic resistance [2,3,5,8]. Infections caused by resistant organisms are associated with prolonged length of stay, higher morbidity and mortality, and higher overall costs compared to non-resistant organisms [9]. This study aimed to assess the quality of antibiotic prescription and reasons behind irrational antibiotic use at a single institution in Western Kenya.

Results
A total of 430 files were retrieved for analysis, with 36 being rejected due to inadequate information (n = 10), missing treatment sheets (n = 10) or admission to other wards (n = 16   were the most common antibiotics prescribed ( Table 1)

Discussion
In this audit, most (92%) patients admitted received one or more antibiotics, with the drugs being invariably (91%) administered intravenously (IV). In addition, the drugs were mostly continued till or just prior to discharge. The mean length of stay (7 days), differed from the mean duration of antibiotic administration by just one day.
The percentage of patients receiving antibiotics for 1-7 days was similar to the percentage of patients whose length of stay was between 1 and 7 days, with only 8% of the patients having an antibiotic stopped prior to discharge. While prior studies have revealed a much a lower rate not only of total antibiotic administration (14-32%), but also proportion of IV formulation used (60-75%), we believe studies from other resource-limited settings may show a picture similar to ours [1,3,6]. This is because overuse of antibiotics is common in resource-limited facilities, with a preponderance for use of IV broad spectrum antibiotic formulations [3,4]. Severe or delayed disease presentation, inadequate use of bacterial culture and sensitivity studies, inadequate antimicrobial sensitivity resting capacity, higher patient expectation for antimicrobial therapy, absence of antibiotic prescription guidelines and psychological assumption of the superiority of IV antibiotics have all been stated to be reasons for the overuse of antibiotics [3,4,10]. Diagnostic uncertainty, low use of microbiology services, delay in release of antimicrobial susceptibility tests, poor compliance with guidelines, lack of awareness of international standards on antibiotic prescription have all been stated as reasons behind the predominant empirical antibiotic prescriptions [1,4,[10][11][12]. Similar to Yilmaz et al., we noted 3rd generation cephalosporins, penicillins and metronidazole to be the most common antibiotics prescribed [2].

McCallum et al noted poor documentation of antibiotics prescribed with the stop dates and indication for the antibiotics indicated in
14% and 18% respectively [12]. Similarly, in this review, the duration of antibiotics was noted in only 11% of cases. Poor documentation leads to the unnecessary continuation of antibiotics as the clinicians lack adequate information to make an appropriate decision on whether to stop or continue or switch the antibiotics [9].
A well-documented antibiotic prescription should contain the indication, dose, clear date of administration, frequency, route and duration of administration. In addition, there is a need to review the clinical diagnosis and the need for continuing the antibiotics by 48 hours [9]. We believe the minimal or absent review of indication of antibiotics and poor documentation on the duration of the antibiotics on the treatment sheet led to the continuation of the antibiotics till discharge. This led prolonged antibiotic duration to be the most common reason (46% of cases) for irrational antibiotic use during hospitalization. Switch of antibiotics from intravenous to oral (IV-PO) can be undertaken in the vast majority patients, once clinical stability has been established and an equivalent or oral formulation is available, leading to improved patient satisfaction, reduced costs, reduced rate of complications, reduced time in preparation and drug administration, and earlier hospital discharge [12][13][14]. While only 13% of the cases had their antibiotic regimen altered, with some being switched to oral formulations, a more active IV-PO switch approach in this study would have led to a higher PO antibiotic use, and an earlier hospital discharge.
The task of documenting the discharge summary is commonly

Conclusion
This audit found antibiotic prescription to be mostly inappropriate.
Too many patients were placed on intravenous antibiotics that were continued for too long, with the patients then being discharged needlessly on more antibiotics. In addition, there was minimal