Non-teaching Research Articles

Antibiotic Prescribing to Patients with Infectious and Non-Infectious Indications Admitted to Obstetrics and Gynaecology Departments in Two Tertiary Care Hospitals in Central India.

Background: Patients admitted to obstetrics and gynaecology (OBGY) departments are at high risk of infections and subsequent antibiotic prescribing, which may contribute to antibiotic resistance (ABR). Although antibiotic surveillance is one of the cornerstones to combat ABR, it is rarely performed in low- and middle-income countries. Aim: To describe and compare antibiotic prescription patterns among the inpatients in OBGY departments of two tertiary care hospitals, one teaching (TH) and one nonteaching (NTH), in Central India. Methods: Data on patients’ demographics, diagnoses and prescribed antibiotics were collected prospectively for three years. Patients were divided into two categories- infectious and non-infectious diagnosis and were further divided into three groups: surgical, nonsurgical and possible-surgical indications. The data was coded based on the Anatomical Therapeutic Chemical classification system, and the International Classification of Disease system version-10 and Defined Daily Doses (DDDs) were calculated per 1000 patients. Results: In total, 5558 patients were included in the study, of those, 81% in the TH and 85% in the NTH received antibiotics (p < 0.001). Antibiotics were prescribed frequently to the inpatients in the nonsurgical group without any documented bacterial infection (TH-71%; NTH-75%). Prescribing of broad-spectrum, fixed-dose combinations (FDCs) of antibiotics was more common in both categories in the NTH than in the TH. Overall, higher DDD/1000 patients were prescribed in the TH in both categories. Conclusions: Antibiotics were frequently prescribed to the patients with no documented infectious indications. Misprescribing of the broad-spectrum FDCs of antibiotics and unindicated prescribing of antibiotics point towards threat of ABR and needs urgent action. Antibiotics prescribed to the inpatients having nonbacterial infection indications is another point of concern that requires action. Investigation of underlying reasons for prescribing antibiotics for unindicated diagnoses and the development and implementation of antibiotic stewardship programs are recommended measures to improve antibiotic prescribing practice.

Antibiotic prescribing among patients with severe infectious diseases in two private sector hospitals in Central India \u2013 a time series analysis over 10\u2009years

BackgroundAntibiotic resistance is an emerging problem caused due to antibiotic use. In countries with high rates of infectious diseases, antibiotic resistance is a frequent cause of mortality. The aim was to analyse antibiotic prescribing practices between 2008 and 2017 in a teaching (TH) and a non-teaching (NTH) hospital, as typical hospitals of low- and middle-income countries, and to compare antibiotic prescribing for severe infectious indications for which empiric antibiotic treatment is recommended.MethodsData from adult patients registered at two Indian private-sector hospitals with one of the following indications: epiglottitis, pneumonia, peritonitis, pyelonephritis, cellulitis, erysipelas, septic arthritis, endocarditis, meningitis or sepsis; were included and analysed. Antibiotic prescription data was analyzed using the World Health Organization’s (WHO) Anatomical Therapeutic Chemical classification system and the Defined Daily Doses. Chi-square and linear regression were used to compare the data between groups. Time series analyses were conducted using linear regression. P-values < 0.05 were considered significant.ResultsIn total, 3766 patients were included, 2504 inpatients in the NTH and 1262 in the TH, of which 92 and 89% patients, respectively, were prescribed antibiotics. Sixty-one percent of total prescriptions in the TH and 40% in the NTH comprised the access category of antibiotics (i.e. the first-choice of treatment according to the WHO). The WHO’s second-choice of treatment, the watch category, comprised 29 and 40% of total prescriptions in the TH and NTH, respectively. Prescribing of fixed-dose combinations (FDCs) of antibiotics was significantly higher in the NTH (18%) than in the TH (8%, P < 0.05). Prescribing of watch antibiotics and FDCs increased significantly in both hospitals between 2008 and 2017 among patients with pneumonia, cellulitis and peritonitis (P < 0.05).ConclusionsPrescribing of watch antibiotics and FDCs of antibiotics increased over time at both hospitals, indicating under prescribing of access antibiotics and more prescribing of second-choice antibiotics. The results can be used to highlight the areas of improvement in similar settings. Implementing diagnostic routines and local prescribing guidelines could improve the prescribing practices.

Perioperative antibiotic prescribing in surgery departments of two private sector hospitals in Madhya Pradesh, India

BackgroundSingle-dose perioperative antibiotic prophylaxis (PAP) is recommended for clean, non-infectious surgeries to prevent surgical site infections. However, the common practice of unindicated use and prolonged use of antibiotics contributes to the development and spread of antibiotic resistance (ABR). The present study explores the perioperative use of antibiotics among inpatients with surgical indications at surgery departments of a teaching (TH) and a non-teaching (NTH) tertiary care hospital in Madhya Pradesh, India.MethodsData was collected manually for all inpatients for 3 years (April 2008–August 2011). Patients with non-infectious surgical indications were selected for detailed analysis at the diagnosis group level.ResultsOut of 12,434 enrolled inpatients (TH 6171 and NTH 6263), the majority (> 85%) received antibiotics. None of the inpatients received the recommended single-dose PAP. The average duration of antibiotic treatment was significantly longer at the TH compared to the NTH (9.5 vs 4.4 days, p < 0.001). Based on the study aim, 5984 patients were classified in four diagnosis groups: upper or lower urinary tract surgery indications (UUTSI and LUTSI), and routine or emergency abdominal surgery indications (RASI and EASI). In both hospitals, quinolones were the most prescribed antibiotics for UUTSI (TH 70%, NTH 37%) and LUTSI (TH 70%, NTH 61%) antibiotic. In the TH, aminoglycosides (TH 32%) were commonly prescribed for RASI and imidazole derivatives (75%) for EASI. In the NTH, cephalosporins (39%) and imidazole derivatives (56%) were the most prescribed in RASI and EASI, respectively.Conclusions and recommendationsHigh prescribing of antibiotics in all four selected diagnoses groups was observed at both hospitals. In spite of the recommended single-dose PAP, antibiotics were mainly prescribed for longer durations. The unrecommended use of antibiotics is a risk factor for the development of AMR. Improving the quality of antibiotic prescribing by a stewardship program focusing on the development and implementation of local prescribing guidelines is needed.

Practice Pattern of Fresh Gas Flow and Volatile Agent Choices among Anesthesiologists Working in Different Indian Hospitals: An Online Survey.

Background:Fresh gas flow (FGF) during volatile inhalational agent-based anesthesia is a concern for many reasons. Advancement in anesthesia workstation (WS) and monitoring of anesthesia gas concentrations has led to the feasibility of lower flow safely. However, the practice pattern is not yet well known. The information can help us in better protocol formation.Aim:The survey was aimed to know the prevailing practice pattern of FGF and volatile agent choices and compare them among anesthesiologists of different working setups and experiences.Materials and Methods:With approval, the present cross-sectional survey was conducted using SurveyMonkey® software from January 2018 to May 2018. Anesthesiologists working in different organizations across India were approached through E-mail and WhatsApp. Anonymous responses were collected, expressed in number and percentage scale, as well as compared using INSTAT software and appropriate tests; P < 0.05 was considered statistically significant.Results:A total of 251 (15.2%) responses were received and 249 were analyzed. Overall, 87% of respondents were using anesthesia WS and 71% were using nitrous oxide as balance gas. The FGF of <600 mL/min was highest with desflurane. Minimum alveolar concentration (MAC) monitoring was very poor in nonteaching (NT) hospitals as compared to teaching hospitals; P < 0.0001. The Boyle's machine was more common in use in NT hospitals as compared to medical colleges and corporate hospitals; P < 0.0001.Conclusion:Low-flow anesthesia (LFA) use is still suboptimal, and there are ample opportunities to increase and optimize the FGF used. The use of Boyle's machine is associated with higher flow use. MAC monitoring and LFA use are poor in NTs.

Antibiotic Prescribing among Pediatric Inpatients with Potential Infections in Two Private Sector Hospitals in Central India.

IntroductionInfectious diseases are one of the major causes of child mortality in India. Pediatric patients are commonly prescribed antibiotics for non-bacterial infections. Monitoring of local antibiotic prescribing with respect to the diagnosis is necessary to improve the prescribing practices. The aim of the study was to describe antibiotic prescribing for potential infections among patients admitted in pediatric departments in two private sector hospitals; one teaching (TH) and one non-teaching (NTH) in Central India.MethodsData from all patients admitted at the pediatric departments of both study hospitals was collected manually, for 3 years (2008–2011) using a customized form. Data from inpatients aged 0–18 years, diagnosed with; acute gastroenteritis (AGE), respiratory tract infections, enteric fever, viral fever or unspecified fever were focused for analysis. Antibiotic prescriptions were analysed using the WHO Anatomical Therapeutic Chemical (ATC) classification system and defined daily doses (DDDs). Adherence to the Indian Academy of Pediatrics list of essential medicines (IAP-LEM) was investigated. P-values <0.05 were considered significant.ResultsOftotal6, 825 inpatients admitted at two pediatric departments, 510 patients from the TH and 2,479from the NTH were selected based on the assigned potential infectious diagnoses. Of these, 224 patients (44%) at the TH and 2,088 (84%) at the NTH were prescribed at least one antibiotic during hospital stay (odds ratio-0.69, 95%confidence interval-0.52 to 0.93; p<0.001). Patients with AGE, viral- and enteric fever were frequently prescribed antibiotics at both hospitals, yet higher proportion were prescribed antibiotics at the NTH compared to the TH. Broad-spectrum antibiotics were the most commonly prescribed antibiotic class in both hospitals, namely third generation cephalosporins, J01DD (69%) at the TH, and new fixed dose combinations of antibiotics J01R (FDCs, 42%) at the NTH. At the TH, 37% of the antibiotic prescriptions were comprised of antibiotics listed in the IAP-LEM, compared to 24% at the NTH (p<0.05).ConclusionsBroad-spectrum antibiotics were prescribed frequently in both hospitals also for the un-indicated conditions such as viral fever and enteric fever. At the NTH, new FDCs were more frequently prescribed and adherence to the IAP-LEM was substantially lower at the NTH compared to the TH. The results demonstrate need to develop diagnosis-specific prescribing guidelines to facilitate rational use of antibiotics and implement antibiotic stewardship program.

Antibiotic prescribing in medical intensive care units – a comparison between two private sector hospitals in Central India

Background: Inappropriate antibiotic prescribing, common in India, contributes to increased risk for development of bacterial resistance. Patients admitted to intensive care units (ICUs) are often prescribed antibiotics. Paucity of local data on antibiotic prescribing hinders development of appropriate interventions. The aim of the study was to describe and compare antibiotic prescribing in medical ICUs (MICUs) at two private sector hospitals, one teaching (TH) and one non-teaching (NTH) in Ujjain, India. Methods: The study was conducted prospectively for 3 years at MICUs of both hospitals. Patients were compared for demographic variables and diagnosis, prescribed antibiotics, generic name prescribing, and route of administration. Adherence to the World Health Organization list of essential medicines (WHOLEM) and the National List of Essential Medicines of India (NLEMI) was analyzed. Results: In total, 4843 of 6141 patients admitted to the MICUs stayed at least one night. More than 70% were prescribed antibiotics. Generic name prescribing was more common at the TH than at the NTH. Prescriptions at the TH had higher compliance to WHOLEM and NLEMI compared with that at the NTH (p < 0.001). Of the 1371 patients at the TH, 189 (14%) and of 3472 at the NTH, 400 (12%) patients were diagnosed with infections. More than 75% of patients at both hospitals had no infection-associated diagnoses. Conclusions: Antibiotic prescribing was common at both hospitals. The antibiotic prescriptions at the TH had higher compliance to WHOLEM and NLEMI. However, there is a need to develop appropriate interventions to improve antibiotic prescribing at both hospitals.

Patient Safety in the Era of the 80-Hour Workweek

In 2003, duty-hour regulations (DHR) were initially implemented for residents in the United States to improve patient safety and protect resident's well-being. The effect of DHR on patient safety remains unclear. The study objective was to evaluate the effect of DHR on patient safety. Using an interrupted time series analysis, we analyzed selected patient safety indicators (PSIs) for 376 million discharges in teaching (T) vs nonteaching (NT) hospitals before and after implementation of DHR in 2003 that restricted resident work hours to 80 hours per week. The PSIs evaluated were postoperative pulmonary embolus or deep venous thrombosis (PEDVT), iatrogenic pneumothorax (PTx), accidental puncture or laceration, postoperative wound dehiscence (WD), postoperative hemorrhage or hematoma, and postoperative physiologic or metabolic derangement. Propensity scores were used to adjust for differences in patient comorbidities between T and NT hospitals and between discharge quarters. The primary outcomes were differences in the PSI rates before and after DHR implementation. The PSI differences between T and NT institutions were the secondary outcome. T and NT hospitals in the United States. Participants were 376 million patient discharges from 1998 to 2007 in the Nationwide Inpatient Sample. Declining rates of PTx in both T and NT hospitals preintervention slowed only in T hospitals postintervention (p = 0.04). Increasing PEDVT rates in both T and NT hospitals increased further only in NT hospitals (p = 0.01). There were no differences in the PSI rates over time for hemorrhage or hematoma, physiologic or metabolic derangement, accidental puncture or laceration, or WD. T hospitals had higher rates than NT hospitals both preintervention and postintervention for all the PSIs except WD. Trends in rates for 2 of the 6 PSIs changed significantly after DHR implementation, with PTx rates worsening in T hospitals and PEDVT rates worsening in NT hospitals. Lack of consistent patterns of change suggests no measurable effect of the policy change on these PSIs.

Thrombolytic utilization for ischemic stroke in US hospitals with neurology residency program

We aimed to compare the rates of thrombolysis utilization for acute ischemic stroke in hospitals with neurology residency (NR) to those of other teaching (OT) and nonteaching (NT) hospitals. A retrospective serial cross-sectional cohort study of a nationally representative sample of stroke patients was conducted. Accreditation Council for Graduate Medical Education-accredited NR program-affiliated hospitals in the United States were cross-matched to the hospitals in the Nationwide Inpatient Sample from 2000 to 2010. ICD-9-CM codes were used for case ascertainment. A total of 712,433 adult ischemic stroke patients from 6,839 hospital samples were included, of whom 10.1%, 29.1%, and 60.8% were treated in NR, OT, and NT hospitals, respectively. Stroke patients in NR received thrombolysis more frequently (3.74% ± 0.24% [standard error]) than in OT (2.28% ± 0.11%, p < 0.001) and NT hospitals (1.44% ± 0.06%, p < 0.001). The adjusted odds ratios (ORs) of thrombolysis rates in NR vs OT and NR vs NT increased with each decade increment in age. In multivariate analysis, NR was independently predictive of higher thrombolysis rate (adjusted OR 1.51; 95% confidence interval [CI] 1.44-1.59 [NR vs OT], and adjusted OR 1.82; 95% CI 1.73-1.91 [NR vs NT]). Acute stroke care in NR hospitals is associated with an increased thrombolytic utilization. The disparities between the thrombolysis rate in NR and that in OT and NT hospitals are greater among elderly patients.

628: Poor translation into local protocols of Dutch nationwide post partum hemorrhage guideline and MOET-instructions (Fluxim study)

628 Poor translation into local protocols of Dutch nationwide post partum hemorrhage guideline and MOET-instructions (Fluxim study) Mallory Woiski, Rosella Hermens, Richard Grol, Markus Lance, Johanna Middeldorp, Freshteh Golestani, Femke Mols, Ben Mol, Martina Porath, Hans Duvekot, Martijn Oudjjk, Fred Lotgering, Hubertina Scheepers, and the Fluxim Study group Radboud University Nijmegen Medical Center, Department of Obstetrics and Gynaecology, Nijmegen, Netherlands, Radboud University Nijmegen Medical Centre, Department of Quality of Care, IQ Healthcare, Nijmegen, Netherlands, Radboud University Nijmegen Medical Center, Department of Quality of Care, IQ Healthcare, Nijmegen, Netherlands, Maastrischt University Medical Centre, Department of Anaesthesiology, Maastrischt, Netherlands, Leiden University Medical Center, Department of Obstetrics and Gynaecology, Leiden, Netherlands, Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, Netherlands, Maxima Medical Center, Department of Obstetrics and Gynecology, Veldhoven, Netherlands, Erasmus Medical Center, Department of Obstetrics and Gynaecology, Rotterdam, Netherlands, University Medical Center Utrecht, Department of Obstetrics and Gynaecology, Utrecht, Netherlands, Maastrischt University Medical Center, Department of Obstetrics and Gynaecology, Maastricht, Netherlands, Dutch consortium for studies in women’s health and reproductivity, Fluxim study collaborators, Amsterdam, Netherlands OBJECTIVE: Despite of the development of evidence-based guidelines and efforts on skills/ team-training, post partum hemorrhage (PPH) still has a rising incidence in developed countries. This suggests poor implementation of guidelines and courses. The first step in implementation of guidelines is the translation of recommendations into comprehensible local protocols. The aim of this study was to evaluate to what extent the recommendations of the Dutch PPH-guideline and the Managing Obstetric Emergency Trauma (MOET) instructions were implemented into local hospital protocols. STUDY DESIGN: Local PPH protocols were derived from 18 different hospitals,(3 university (UH), 7 teaching (TH) and 8 non-teaching (NT)) throughout The Netherlands. 37 valid action-indicators, previously derived from the guideline and MOET instructions, were divided into 82 measurable items and used to determine the degree of implementation. Not only the presence of an item was measured but also whether timing of the intervention was accurate (expressed as the degree of blood loss). RESULTS: Overall implementation of action indicators was 46%, with a highest score of 68% (UH) and a lowest of 18% (NT) (table 1). Time-dependent indicators were mentioned in 23% of the protocols. Active management of labor was included in 33% of the protocols, and checking vital parameters continuously (heart rate, O2-saturation and blood pressure) in 11, 6, and 22%, respectively. Pre-informing the anaesthesiologist and follow local shock protocol were both included in 6%, and providing IV-access and ordering of packed cells both in 94%. CONCLUSION: This study shows that in The Netherlands the first step in implementation of the national guideline and MOET instructions is not optimal. Care is presumed to follow the content of the local protocol; therefore, we expect poor adherence to the guideline recommendations/ course instructions. Proper implementation is essential for good adherence, so mesurement of the actual care will be the next step, which should result in a tailor made implementation strategy to improve PPH care (the Fluxim study).

Elective Abdominal Aortic Aneurysm Repair: Relationship of Hospital Teaching Status to Repair Type, Resource Use, and Outcomes

There has been a dramatic increase in the use of endovascular technology for treatment of abdominal aortic aneurysms (AAA), but practice patterns have not been well-evaluated. Hospital resource use and outcomes after elective endovascular abdominal aortic repair (EVAR) and open surgical repair were assessed by hospital type, ie, major teaching (MT), teaching affiliate, and nonteaching (NT). Elective, nonruptured AAA repairs were identified in the State Inpatient Databases for New Jersey (2001 to 2006). Descriptive statistics, univariate, multivariable, trend, and case-mix-adjustment analyses were employed. A total of 6,227 subjects were identified; 4,698 patients (mean age 73.0 +/- 8.01 years; 79.2% men) underwent elective repair of AAA. EVAR was performed 2.6 times more often in MT compared with NT (p < 0.0001) institutions. Univariate evaluation demonstrated that women had a predominance of EVAR performed (p < 0 .0002) in MT hospitals and that minorities in NT hospitals were more likely to be treated with open operations (p = 0.0148). Case-mix-adjusted mortality rates for EVAR were higher at NT (1.95%; 95% CI, 1.81 to 2.09) compared with MT (0.73%; 95% CI, 0.69 to 0.77) hospitals. After adjustment, MT hospitals were more likely to use EVAR (odds ratio = 2.4; 95% CI, 2.11 to 2.83) and less likely to have increased length of stay (odds ratio = 0.38; 95% CI, 0.32 to 0.44) compared with NT. Hospital teaching status was significantly associated with repair type, overall mortality, and hospital resource use. MT hospitals were considerably more likely to use EVAR for elective AAA repair, offered an improvement in survival, were more likely to treat women and minorities with EVAR, and demonstrated decreased length of stay and cost.

The clinical load of HIV and AIDS for genitourinary physicians.

We aimed to investigate the extent of genitourinary medicine (GUM) involvement in the clinical management of HIV. A questionnaire survey was conducted on GUM consultants in the UK and the Irish Republic. Clinics were divided into teaching hospitals (THs) undertaking both undergraduate and postgraduate training in GUM, non-teaching training (NTT) centres undertaking specialist training only and non-teaching (NT) centres. Information was obtained on 241 of the 250 consultants on the Royal College of Physician's GUM Committee's records from 117 GUM clinics (including all THs and NTT centres). Four (1 TH and 2 NTT centres) GUM clinics did not see HIV-positive patients, 62 saw 10-99 patients, 18 reported 100-999 and 4 with over 1000 patients attending in 1996. Thirty-five per cent of the 55 THs and NTT centres had over 100 HIV patients. Consultants were involved in the outpatient care of HIV patients in 99.5% and GUM trainees in 85.5% clinics. Overall 47 clinics have their own inpatient HIV beds and 176 consultants (73%) had full (100) or significant (76) input to inpatient HIV management. Only 29% of THs and 12.5% of NTT centres had none or minor input into HIV care. HIV inpatient on-call commitment by the GUM trainees was reported by 64% of training centres. GUM services provide a major input into outpatient and inpatient care of HIV-infected patients in the UK.

A Comparison of Intensive Care Unit Care of Surgical Patients in Teaching and Nonteaching Hospitals

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.

A Comparison of Intensive Care Unit Care of Surgical Patients in Teaching and Nonteaching Hospitals

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.