In total, 134,666 patients were admitted to the NTH, and 109,108 patients were admitted to the TH between 2008 and 2017. Data from 3,766 patients were included in the analysis (NTH: n =2,504; TH: n =1,262, Table 2, Fig 1). Overall, the patients from the TH were younger than the patients from the NTH (mean age NTH: 49.2, TH: 47.1 years, P <0.01). At both hospitals, there were smaller proportions of women admitted, compared to men (percentage of admitted women NTH: 36%, TH: 24%) (Table 3). Antibiotics were commonly prescribed in both hospitals, although a significantly higher percentage of patients admitted to the NTH were prescribed antibiotics as compared with those admitted to the TH (89% at the TH, 92% at the NTH, P <0.05) (Table 3). Among the different diagnostic groups, there were no differences in antibiotic prescribing practices between the hospitals, except for meningitis, where 90% of the patients in the NTH were prescribed antibiotics as compared with 70% in the TH (P <0.05). The number of antibiotic prescriptions per patient in the TH was higher than that in the NTH. The average number of antibiotic prescriptions, i.e. prescription of one specified antibiotic with stated dose, frequency and duration in days, per patient was 22 in the TH and 8 in the NTH (Table 3). The duration of the hospital stay of the patients in the TH was higher than that of the patients in the NTH (mean 10.1 days at the TH and 4.4 days at the NTH, P <0.05).
Table 2. Total number of admissions and included patients each year at the two Indian private-sector hospitals
|
NTH
|
TH
|
Year
|
Number of admissions, n
|
Patients included,
n (%)
|
Number of admissions, n
|
Patients included,
n (%)
|
From April 1st, 2008
|
10480
|
230 (2)
|
6965
|
80 (1)
|
2009
|
15384
|
247 (2)
|
10369
|
103 (1)
|
2010
|
16126
|
311 (2)
|
11145
|
118 (1)
|
2011
|
15136
|
288 (2)
|
12188
|
171 (1)
|
2012
|
14414
|
264 (2)
|
10454
|
139 (1)
|
2013
|
14627
|
267 (2)
|
9821
|
146 (1)
|
2014
|
16473
|
268 (2)
|
13186
|
208 (2)
|
2015
|
13740
|
249 (2)
|
12387
|
124 (1)
|
2016
|
14165
|
310 (2)
|
16741
|
128 (1)
|
Until May 31st, 2017
|
4121
|
70 (2)
|
5852
|
45 (1)
|
Total
|
134666
|
2504 (1)
|
109108
|
1262 (1)
|
Notes: Values are presented in total number of admissions, number of included patients and percentage of total number of admissions.
Abbreviations: n, number; NTH, non-teaching hospital; TH, teaching hospital.
Table 3. Clinical characteristics and antibiotic prescribing among patients with severe infections at two private sector hospitals
|
NTH,
n (%)
|
TH,
n (%)
|
Odds ratio
(95% CI)
|
P-value
|
All included patients,
n (%)
|
2504 (100)
|
1262 (100)
|
|
|
Mean age
|
49.2
|
47.1
|
|
<0.01
|
Women, n (%)
|
894 (36)
|
301 (24)
|
|
|
Men, n (%)
|
1610 (64)
|
961 (76)
|
|
|
Patients prescribed ABs, n (%)
|
2294 (92)
|
1122 (89)
|
1.36 (1.08, 1.72)
|
<0.05
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
18751 (8)
|
24956 (22)
|
|
|
Cellulitis
|
388 (15)
|
402 (32)
|
|
|
Mean age
|
50.4
|
48.7
|
|
0.16
|
Women, n (%)
|
101 (26)
|
79 (20)
|
|
|
Men, n (%)
|
287 (74)
|
323 (80)
|
|
|
Patients prescribed ABs, n (%)
|
354 (91)
|
362 (90)
|
1.15 (0.69,1.91)
|
0.57
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
3505 (10)
|
8608 (24)
|
|
|
Endocarditis
|
7 (0)
|
2 (0)
|
|
|
Mean age
|
45.6
|
35.0
|
|
0.21
|
Women, n (%)
|
3 (43)
|
2 (100)
|
|
|
Men, n (%)
|
4 (57)
|
0(0)
|
|
|
Patients prescribed ABs, n (%)
|
6 (86)
|
1 (50)
|
6 (0.04,547.49)
|
0.28
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
33 (6)
|
54 (54)
|
|
|
Epiglottitis
|
12 (0)
|
1 (0)
|
|
|
Mean age
|
35.8
|
40.0
|
|
0.25
|
Women, n (%)
|
6 (50)
|
0 (0)
|
|
|
Men, n (%)
|
6 (50)
|
1 (100)
|
|
|
Patients prescribed ABs, n (%)
|
11 (92)
|
1 (100)
|
-
|
-
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
57 (5)
|
2 (2)
|
|
|
Meningitis
|
186 (7)
|
38 (3)
|
|
|
Mean age
|
40.6
|
37.0
|
|
0.24
|
Women, n (%)
|
90 (48)
|
15 (39)
|
|
|
Men, n (%)
|
96 (52)
|
23(61)
|
|
|
Patients prescribed ABs, n (%)
|
167 (90)
|
27 (71)
|
3.58 (1.37, 8.93)
|
<0.05
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
1126 (7)
|
442 (16)
|
|
|
Peritonitis
|
431 (17)
|
252 (20)
|
|
|
Mean age
|
44.4
|
44.0
|
|
0.71
|
Women, n (%)
|
52 (12)
|
35 (14)
|
|
|
Men, n (%)
|
379 (88)
|
217 (86)
|
|
|
Patients prescribed ABs, n (%)
|
402 (93)
|
233 (92)
|
1.13 (0.58, 2.14)
|
0.69
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
4909 (12)
|
6715 (29)
|
|
|
Pneumonia
|
761 (30)
|
410 (32)
|
|
|
Mean age
|
49.6
|
48.4
|
|
0.30
|
Women, n (%)
|
294 (39)
|
100 (24)
|
|
|
Men, n (%)
|
467 (61)
|
310 (76)
|
|
|
Patients prescribed ABs, n (%)
|
692 (91)
|
366 (89)
|
1.21 (0.78, 1.83)
|
0.36
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
4686 (7)
|
6179 (17)
|
|
|
Pyelonephritis
|
71 (3)
|
3 (0)
|
|
|
Mean age
|
42.3
|
26.7
|
|
<0.01
|
Women, n (%)
|
32 (45)
|
2 (67)
|
|
|
Men, n (%)
|
39 (55)
|
1 (33)
|
|
|
Patients prescribed ABs, n (%)
|
68 (96)
|
2 (67)
|
11.33 (0.14,262.11)
|
0.16
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
518 (8)
|
89 (45)
|
|
|
Septic arthritis
|
3 (0)
|
38 (3)
|
|
|
Mean age
|
43.3
|
45.0
|
|
0.93
|
Women, n (%)
|
1 (33)
|
15 (39)
|
|
|
Men, n (%)
|
2 (67)
|
23 (61)
|
|
|
Patients prescribed ABs, n (%)
|
3 (100)
|
29 (76)
|
-
|
-
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
15 (5)
|
1159 (40)
|
|
|
Sepsis
|
645 (26)
|
116 (9)
|
|
|
Mean age
|
54.9
|
49.2
|
|
<0.01
|
Women, n (%)
|
315 (49)
|
53 (46)
|
|
|
Men, n (%)
|
330 (51)
|
63 (54)
|
|
|
Patients prescribed ABs, n (%)
|
591 (92)
|
101 (87)
|
1.6 (0.82,3.0)
|
0.11
|
AB prescriptions, n (n of prescriptions per patients prescribed AB)
|
3902 (7)
|
1708 (17)
|
|
|
Notes: P-values for mean age were obtained by linear regression. Odds ratios, p-values and CIs for antibiotic prescribing were obtained by chi-square tests. Statistically significant p-values are marked in bold font.
Abbreviations: AB, antibiotic; CI, confidence interval; n, number; NTH, non-teaching hospital; OR, odds ratio; TH, teaching hospital.
Prescribing of antibiotics for all indications increased between 2008 and 2017 in the NTH (P <0.01), whereas prescribing practices did not change significantly during this period in the TH (P = 0.07, Figure 2, Table 4). Antibiotics included in the access category comprised 61% of the total antibiotics prescribed in the TH and 40% of the total prescribed in the NTH (P <0.01, Figure 3, Table 4). Prescribing of access antibiotics increased in the NTH between 2008 and 2017. Prescribing of antibiotics categorized as watch antibiotics comprised 29% of the total antibiotics prescribed in the TH and 40% of the total prescribed in the NTH. Prescribing of watch antibiotics rose in both hospitals between 2008 and 2017 (P <0.01 for both hospitals, Figure 3, Table 4). Reserve antibiotics comprised less than one percent antibiotics prescribed in both hospitals. However, prescribing of reserve antibiotics increased between 2008 and 2017 in the TH (P <0.01, Figure 3, Table 4).
The overall antibiotic prescribing among all included patients increased from 2008 to 2017 at the NTH (P <0.01) but did not significantly change at the TH (P =0.07, Figure 1, Table 4). Antibiotics included in the access category comprised 61% of the total antibiotic prescribing at the TH and 40% at the NTH. Prescribing of access antibiotics increased at the NTH from 2008 to 2017 (P <0.01, Figure 3, Table 4). Prescribing of antibiotics categorized as watch antibiotics comprised 29% of the total antibiotic prescribing at the TH and 40% at the NTH. Prescribing of watch antibiotics increased at both hospitals from 2008 to 2017 (P <0.01 for both hospitals, Figure 3, Table 4). Reserve antibiotics comprised less than one percent of the antibiotic prescribing at both hospitals, however prescribing of reserve antibiotics increased from 2008 to 2017 at the TH (P <0.01, Figure 3, Table 4). Prescribing of FDCs of antibiotics (J01R) comprised 8% of the antibiotic prescribing at the TH and 18% at the NTH. Prescribing of FDCs increased at both hospitals from 2008 to 2017 (P <0.01 for both hospitals, Figure 3, Table 4).
Table 4. Description of trends in antibiotic prescribing among patients with severe infections in Ujjain between 2008-2017
|
NTH
|
TH
|
Antibiotic prescribing among specific diagnoses
|
All antibiotics
|
13.84 (<0.01)
|
1.82 (0.07)
|
Cellulitis
|
5.72 (<0.01)
|
6.52 (<0.01)
|
Peritonitis
|
14.59 (<0.01)
|
18.52 (<0.01)
|
Pneumonia
|
4.87 (<0.01)
|
7.30 (<0.01)
|
Sepsis
|
2.18 (0.03)
|
-21.91 (<0.01)
|
Antibiotic prescribing among all included patients
|
Access antibiotics
|
11.52 (<0.01)
|
1.78 (<0.07)
|
Watch antibiotics
|
9.63 (<0.01)
|
6.49 (<0.01)
|
Reserve antibiotics
|
-0.76 (0.45)
|
2.54 (<0.01)
|
FDCs of antibiotics
|
14.28 (<0.01)
|
7.31 (<0.01)
|
Antibiotic prescribing among sepsis patients
|
Access antibiotics
|
1.49 (0.14)
|
-16.89 (<0.01)
|
Watch antibiotics
|
3.02 (<0.01)
|
-11.38 (<0.01)
|
Reserve antibiotics
|
-9.32 (<0.01)
|
Too few prescriptions
|
FDCs of antibiotics
|
3.78 (<0.01)
|
-9.93 (<0.01)
|
Notes: All values are presented with a value for the slope: t, followed by P-value in parenthesis. The t-value is obtained from linear regression analysis and indicates a postitive or negative trend of antibiotic prescribing (measured in DDDs per 1000 patients), over the study period. A positive t-value shows a positive trend of antibiotic prescribing during the study period and a negative t-value shows a negative trend of antibiotic prescribing during the study period. Statistically significant p-values indicates a significant trend and are marked in bold font.
Abbreviations: DDD, defined daily dosis; FDC, fixed dose combination; NTH, non-teaching hospital; TH, teaching hospital.
Patients diagnosed of cellulitis, peritonitis, pneumonia and sepsis accounted for 88% of the admissions to the NTH and 93% of the admissions in the TH. Table 5 shows the antibiotic groups (first-choice or second-choice) prescribed for each of these four diagnoses, which accounted for 75% of all antibiotics prescribed. Total antibiotic prescribing among patients with cellulitis, peritonitis and pneumonia increased between 2008 and 2017 in both the hospitals (P <0.01 for both hospitals, Fig. 2, Table 4). Antibiotic prescribing among patients with sepsis increased between 2008 and 2017 in the NTH (P =0.03) but decreased in the TH (P <0.01, Fig. 2, Table 4). Sepsis was the only one of the four diagnoses where antibiotic consumption decreased at one of the hospitals.
Table 5 should be inserted here, it is now placed in the end of the manuscript, since it is larger than one page according to the submission guidelines
Cellulitis
In the NTH, the two most commonly prescribed antibiotics were second-choice treatments: J01D (32% of total antibiotics prescribed) and J01R (17%) [15]. Prescribing of both J01D and J01R increased during the study period, as did prescribing of the recommended treatments (J01CR and J01D) (P <0.05 for all, Table 5). In the TH, the most commonly prescribed antibiotics were from the J01CR (19%) and J01G group (21%) and prescribing of J01CR increased between 2008 and 2017. (P <0.01, Table 5). At the NTH, prescribing of access, watch and FDCs (J01R) increased from 2008 to 2017 while at the TH, prescribing of access, watch, reserve and FDCs increased (P <0.01 for all categories, at both hospitals).
Peritonitis
In the NTH, the two most commonly prescribed antibiotics were first-choice treatments for community acquired peritonitis [18]: J01D antibiotics comprised 25% of antibiotics prescribed, and J01X accounted for 20% of antibiotics prescribed. Prescribing of J01X increased during the study period (P <0.01, Table 5). In the TH, the two most commonly prescribed antibiotics were first-choice treatments: J01M (16%) and J01X (26%), and prescribing of both J01M and J01X groups increased between 2008 and 2017 (P <0.01 for both antibiotic groups, Table 5). In addition, prescribing of J01CR (first-choice treatment for community-acquired peritonitis) increased in both hospitals during the study period. At both hospitals, prescribing of access, watch, reserve and FDCs (J01R) increased from 2008 to 2017 (P <0.01 for all categories mentioned at both hospitals).
Pneumonia
In the NTH, the beta-lactam antibiotics (J01D) and combinations of penicillins (J01CR) were two most commonly prescribed. J01D antibiotics are listed as first-choice treatment for community-acquired pneumonia, and J01CR antibiotics are listed as second-choice treatment for community-acquired and as first-choice treatment for health-care acquired pneumonia (Table 5) 15. J01CR and J01D antibiotics comprised 29% and 22%, respectively, of prescribed antibiotics in the diagnosis group. Overall, the prescribing practices did not change between 2008 and 2017. In the TH, the two most commonly prescribed antibiotics were from the J01A and J01CR groups. J01A group is listed as second-choice treatment for community acquired pneumonia, and J01CR is listed as second-choice treatment for community and as first-choice treatment for health-care acquired pneumonia 15. The prescribing of J01CR increased from 2008 to 2017 (P <0.01, Table 5). J01CR and J01D antibiotics comprised 25% and 30%, respectively, of antibiotics prescribed for pneumonia in the TH. Prescribing of FDCs (J01R) declined (P <0.01) for all categories in both hospitals. In the NTH, prescribing of access, watch and FDC antibiotics increased between 2008 and 2017 and in the TH, prescribing of access and watch antibiotics rose between 2008 and 2017.
Sepsis
In both hospitals, piperacillin with tazobactam (J01CR) group was commonly prescribed, which is adherent with guidelines [19]. In the NTH, J01CR antibiotics accounted for 21% of all antibiotics prescribed, and J01D accounted for 27% of all antibiotics prescribed. Prescribing of J01D decreased between 2008 and 2017 (P <0.01, Table 5). In the TH, the most commonly prescribed antibiotics were from the J01CR (19%) and J01X groups (19%) and prescribing of both J01CR and J01X decreased between 2008 and 2017. (P <0.01 for both antibiotic groups, Table 5). At the NTH, prescribing of watch and FDCs (J01R) increased from 2008 to 2017 while prescribing of reserve antibiotics decreased. At the TH, prescribing in DDDs per 1000 patient days, of access, watch and FDCs decreased from 2008 to 2017 (Table 4).