Posted on 29th Nov 2024 11:58:17 PM Medicine
1. Introduction
1.1 General considerations of prescription
Prescription is an authorized order written by a physician, dentist, veterinary surgeon or other medical practitioner to a pharmacist, to compound and dispense a specific medication for the patient the order is accompanied by directions for the pharmacist that what type of prescription is to be prepared and how much is it to be prepared. It also accompanied with the directions for the patient that how much medicament is to be taken, how many times is to be taken or at what time and how it is to be taken.
The prescription provides a common link of mutual interest between the physician, the pharmacist and the patient. It is the duty of the pharmacist to serve the medication needs to the patient according to intention of the prescriber. It is not sufficient that the pharmacist should only compound the specific medicament but he should make the patient understand about the proper route administration of the drug and ensure that the patient sticks to these (compliance)instruction. The prescriptions are generally written in the language of the area in which they originate but Latin words are frequently used in the perception writing because in the olden days the medicines were written in Latin abbreviations which was understood all over the would. Still the use of Latin abbreviations in the prescription is very common especially in dosage instruction. [1,2]
1.2 Characteristics of an Ideal prescription
Though prescription is a drug order from a doctor to a pharmacist. It must have some important criteria, which carry details information about the patient. A complete prescription should have the following parts:
1. Date: Date must be written on the prescription by the prescriber at the same time when it is written. The date on the prescription helps a pharmacist to find out the cases where prescription is bought for dispensing longtime after its issue. Narcotic or other habit forming drug containing prescription must assigned date.
2. Name, age, sex body weight and address of the patient: Name, age, sex, body weight and address of the patient must be written on the prescription. If it is not written pharmacist himself should ask the patient about these particulars and put down at the top of the prescription. Patient’s full name must be written instead of surname or the family name.
Age sex and body weight of the patient specially in the case of the children helps the pharmacist in checking the medication and the dose. Therefore there will be less danger of its during administered to the wrong member of the family or the hospital ward having similar names. The address of the patient is recorded.
3. Superscription: The superscription is represented by a symbol Rx which is always written at the beginning of the prescription, which meaning “take thou” or “you take”.
4. Inscription: This is the main part of the prescription. It contains the name and quantities of the prescribed ingredients. The name of the ingredients are written each on a separate Line. Now a days a few prescriptions are compounded by pharmacists. A majority to prescriptions are written for prepared dosage form. The pharmacist are only enquired to dispense the ready made dosage form of drugs which eliminated the compounding of prescriptions.
5. Subscription: This part of the prescription contains prescriber directions to the pharmacist regarding the dosage from to be prepared. Since now-a-days only a few prescriptions are compounded therefore such directions are less frequent.
6. Signatura: It is usually abbreviated as “sig” on the prescriptions and consist of the directions to be given to the patient regarding the administration of the drug. It is usually indicates the quality of medicament or number of dosage unit to be taken, how many times in a day and at what time it should be taken.
7. Signature address and registration number of the prescriber: All other parts of the prescription may be printed or type written but the prescriber’s name must be hand written and should be signed with ink. This eliminates the danger of dispensing medicament on a spurious order and it can therapeutics the prescription. The prescription contains narcotic or other habit forming drugs must bear the address and registration number of the prescriber.
The chief complicacy(c/c) and diagnosis diseases should also be assigned into the prescription (2).
A General form of prescription (from the collected sample) is given below:
1.3 Prescription behavior
A prescription behavior is the clarity and proper quality of the prescription. An appropriate prescribing implies the choice of a drug based on its safety, efficacy, usefulness and cost relative other drugs or treatment that may be available. Successful therapy comprises much more than choosing an appropriate drug, it require knowledge, Judgment skill, wisdom, responsibility and above all, patient and doctor compliance. [1,3]
Depending upon the number of drug prescription are two types.
1. Single drug prescription
A single drug is prescribed for the treatment of specific diseases. It requires the skill ness of the physician to find out the primary cause of a specific disease. This primary cause is responsible for secondary trouble.[24]
Advantages of single drug therapy-
2. Multiple drug prescription
A multiple drug prescription is a prescription which contain more than one drugs. In this case there is chance of drug-drug interaction. It is expensive too.
Prescription patterns
In reality, there is no mechanism or legislation exists in the country of assessing the competence of prescribing medical practitioners. No legal action is taken against them even if a serious mistake leads to a fatal outcome. The relatives of the victim accept it as fate, and no medical practitioners can prescribe anything from vitamins to vincristine, for anything from the common cold to cancer [4]. Inappropriate prescriptions are readily available due to poor consulting period (a mean of only 54 second!) of doctors in Bangladesh [5]. It is estimated more than half of medicines are inappropriately prescribed, dispensed or sold [6]. Moreover, polypharmacy is very common among the rural medical parishioners with antibiotics and vitamins prescribed widely [7].
The prescription procedure of antibiotics in Bangladesh is less than ideal as prior identification of the pathogens and its sensitivity to the drug is rarely determined before the drug is prescribed [8]. For example, one survey conducted among rural medical practitioners with an average of 11 years experience should 60% of antibiotics prescriptions written based on the symptoms alone [9]. All antimicrobial agents were prescribed mainly on the patient’s complaints, and all available antibiotics were prescribed in inappropriate doses and duration as has been showed in another similar survey [10].
Children are mostly affected by inappropriate antibiotics prescribing in Bangladesh. [11] Pneumonia and diarrhoea are the two most common infectious diseases among children in Bangladesh with the annual deaths of about 230,000 children due to diarrhoea [12]. Misuse of drugs in the treatment of acute diarrhoea among under-five children is highly prevalent and WHO-recommended treatments were seen in only 26.7% of cases and Metronidazole was prescribed in all 18.6% cases [13]. Inappropriate antimicrobial drugs is the most common treatment errors in dysentery with failure to recommend use of oral rehydration solution [14]. Over-statements and misinformation is very common in Bangladesh, which greatly influences physician prescribing behaviors. Currently, drug companies are the only organizations in Bangladesh to provide information to health personnel and in information supplied is often not consonant with recommendations from public health bodies [15]. Along with bribe in the form of cash, a large number of doctors accept various gifts including free air ticket for foreign trips, computers, mobile phones, air conditioners, table lights, telephones, towels calendars, paperweights, pens and what not. Ultimate result is prescriptions of inappropriate or unnecessary and expensive medicines. [16]
1.4 Prescription writing
Prescription is a written order for drug should be legible and dated containing the name, age and address of the patient, and should be signed in ink by the prescriber. The age of the patient should always be mentioned in cases of prescription only drugs for children under 12 years. [3]
A prescription ordering controlled drugs must in addition specify the prescriber’s address, the formation and strength of the prescription and total quality of the preparation to be supplied in both wards and figures.
1.4.1 Prescribing for elderly patient
Elderly patients are usually more vulnerable to adverse effects of drugs. However, it is necessary to consider while prescribing for the clearly, whether the drug is essentially needed or not.
Factors responsible for adverse effects in elderly patient in multiple therapy drug absorption. So drug is likely to remain in the body of an elderly for a longer period than in a normal adult.
When a tablet or capsule is prescribed, advice should be given to swallow it with sufficient amount of water, so that there is no chance of it remaining in the mouth giving an unpleasant test [3].
1.4.2 Prescription for children
Responses of drugs in children (12 years old and younger) and in the neonates, are not the same as in adults. The risk of adverse effects are more due to relative deficiency of drug metabolizing enzymes, differing sensitivity of target organs, inefficient renal filtration and inadequate detoxifying systems. Special care should be taken while prescribing for children and neonates. The age of the child or infant should always be mentioned while ordering drugs for them. [3]
1.5 Use prescription drugs
The drug use studies involving outcomes, adverse reactions and bioavailability in Bengali population has never been seriously looked into in Bangladesh [17]. Like all other developing countries, irrational and inappropriate use of medicines is very common in Bangladesh [15]. Recent study showed that about half of the antibiotics were sold without any prescriptions, and even ordinary people without any knowledge of medicine asked the drug seller for specific antibiotics [10]. Almost every drug store salespersons illegally recommends and sells prescription medicines people often do not buy all the drugs as prescribed for them because of financial constraint. Moreover, self-medication is a common practice among laypeople [7]. Recently many pharmaceutical manufacturers have launched one such combination containing 32 ingredients including selenium, vanadium, molybdenum, tin and other less important or unnecessary minerals. But the socio-demographic conditions of Bangladesh clearly outweighs the justification of this type of combination products as most of the nutritional deficiencies are caused due to Vitamin A or B-complex, iron, calcium, iodine, or zinc deficiency. British pharmacopoeia clearly indicates that there no justification for prescribing multiple ingredient vitamin preparation [6]. In addition, drug like svntocinon (a hormonal injection which is given to pregnant women to easy labor) is being sold or used indiscriminately in home deliveries in rural Bangladesh, which is readily available without prescription there [18]. The NDP clearly indicates that no company can market a drug of similar benefits as of the existing one with minor chemical difference. But at present, there are captopril, cilazapril, enalapril, fosinopril, lisinopril, perindopril, and ramipril in use in Bangladesh [19].
Instructions for the safe use of prescriptions only drugs Includes:
1.6 Route of drug administration and related dosage forms
The route of drug administration is determined primarily by the properties of the drug (for example, water or Lipid solubility, ionization, etc) and by the therapeutic objectives (for example, the desirability of a rapid onset of action or the need for long term administration or restriction to a local site)[21]. There are different route for drug administration and dosage from, which are given in the flow chart:
1.7 Diagnosis and chief complicacy
The process for the determination/identification of disease state from which a patient is suffering. Diagnosis is one of the important part of treatment without proper diagnosis the appropriate drug cannot be choose and cure from the diseases cannot be possible.
Chief compliance is one of the important part for the disease diagnosis. When our body is infected with microorganism or other environmental hazardous. Then we face some complicacy which assign the specific disease. [1]
1.8 Wrong diagnosis
A proper diagnosis (correct prescription) depends on-
1.8.1 Causes of wrong diagnosis
1.8.2 Effects of wrong diagnosis
A wrong diagnosis may be made due to any one of the above points and leads to-
1. If diagnosis is wrong, a wrong prescription is written by a physician.
2. Due to a wrong prescription, a wrong treatment is provided to a patient
3. Due to wrong treatment the patient will not be cured and suffer from diseases for long time.
4. Ultimately, aggravation of disease condition.
5. Simply, psychological upset of patient, disturbance to the family member, loss of money and sparing of time.
6. Further, wrong treatment may causes adverse effects which may produce further complications, gives rises to another diseases and even death.
1.9 Diagnostic tests
The techniques applied for the determination of diseases are called diagnostic tests. Tests are primarily an aid to diagnosis and aid in determining extent of disease. The art of diagnosis depends on the skill full combination of two sets of facts-
1. Information procured from the patient at bedside (clinical problem presented by the patient)
Other obtained indirectly through the diagnostic tests- chemical or microscopic study of blood, excretions, secretions and tissues important in determining the clinical problem presented by the patient.
Routine tests for diagnosis
The serum, urine and body fluids of patients are routinely analyzed; however, the economic cost of obtaining these data must be balanced by benefits to patient outcomes. Generally, laboratory tests only should be ordered if the results of the test will affect decisions on the therapeutic management of the patient.
Clinical laboratories may analyze sample specimens by different laboratory methods; therefore, each laboratory has its own sets of normal values (which may differ from one procedure to another).
A list of routine laboratory procedures includes the following-
A. Hematology
• Erythrocyte Sedimentation Rate (ESR, “Sed Rate”)
• Hematocrit (HCT, PCV, “crit”)
• Hemoglobin (Hgb, Hb)
• White Blood Count (WBC)
• Differential (Diff.)
• Serologic Test for Syphilis (STS)
B. Urinalysis
• Specific Gravity (Sp. Gr.)
• pH
• Protein
• Glucose
• Examine Urinary Sediment
C. Feces
• Occult Blood
1.10 Commonly prescribed drug use
Type of Drugs Generic Name Proprietary Name
Antibiotics Penicillin:
Amoxicillin Amoxicap (Ranata),
Tycil (Beximco)
Flu cloxacillin Fluclox (ACI),
Flubex (Beximco)
Penicillin-V Oracyn K (Aventis),
Penvi K (Square)
Cephalosporins and other Beta-lactams:
Cephradine Lebac (Square),
SK-Cef (Sk+F)
Cefaclor Biocef (Novartis),
Loracef (Square)
Cefuroxime Cefotil (Square),
Cefurox (Aventis)
Cefpodoxime Cefodox (Bristol),
Cefdox (ACI)
Cefotaxime Maxcef (Square),
Taxim (Acme)
Ceftriaxone Ceftron (Square),
Arixon (Beximco),
Enocef (Fisons)
Cefixime Cef-3 (square),
Cefim (ACI)
Cefdinire Cefdir (Square)
Aminoglycosides:
Streptomycin Streptomycin (Opsonin),
Streptomycin (Ranata)
Type of Drugs Generic Name Proprietary Name
Antibiotics Macuolides:
Erythromycin Macrocin (Aventis),
Eromycin (Square)
Azithromycin Azyth (Novartis),
Zimax (Square)
Quinolones and Fluoroqu inotones:
Ciprofloxacin Ciprox (opsonin),
Ciprocin (Square)
Levofloxacin Leo (Acme),
Leflox (ACI)
Gatifloxacin Xegal (Beximco),
Gati (Square)
Nalidixic Acid Nalid (Square),
Naligram (Acme)
Sulphonamides and tri methoprim:
Co-Trimoxazole Fisat (Fisons),
Cotrim (Square)
Tetracyclines:
Tetracycline Cepta (Chemico),
Tetracyn (Ranata)
NSAIDs Paracetamol Apa (Opsonin),
Napa (Beximco)
Aspirin Carva (Square),
Ciprin CV (ACI)
Other NSAIDs:
Diclofenac-Na Diclofen (Opsonin),
Decafen (Ranata)
Detoprofen Keto-A (Acme),
Kop (Square)
Matenamic acid Fenamic (Beximco)
Naproxen Napro (Aristophaena),
Napro (Eskayef)
Type of Drugs Generic Name Proprietary Name
Anti histamines Non Sedative Anti histamines:
Cetirizine HCL Alatrol (Square),
Asitrol (Asiatic)
Levo cetirizine HCL Lingin (Novantis),
Rehat (Aristo Pharma)
Loxatadine Loradin (Aristo pharma),
Oradin (Eskayef)
Desloratadine Deslor (Orion),
Des (Opsonin)
Sedative Antihistamine:
Chlor phenamine maleate Histal (Opsonin),
Histasin (Jesones)
Prometherizine HCL Otosil (Opsonin)
Antiasthmatic/Broncho dilators Salbutomol Butol (Cipla),
Saltolin (Square),
Ventolin (Gsk)
Theophylline Antate (Nipa),
Asmanyl SR (Square)
Aminoplylline Broline retard (Delte)
Vitamin and minerals Multivitamin and Mulfimine ral A-Z Aristo old (Arispharme),
Filwel gold (Square)
Antioxident :
Vitamine pre Paration Bee (Opsonin)
proxid (Ranata)
Vitamin E Ovit-E (Oponing),
E-Vit (Square)
Vitamin D One alpha (Leo)
Vitamin C Ascobex (Beximco),
Cecon (Acme)
Type of Drugs Generic Name Proprietary Name
Antihypertensives
-adrenergic blocking drugs:
Proparolol Hcl Indever (ACI)
Prop ranol (opsonin)
Atenolol Betanol (Fisons)
Tenoloc (Acme)
Angiolensin converting enjyme inhibitors (ACE inhibitors) :
Captopril Acetr (Drug international), Topril (Jaysons), Fosinopril
Romipril Ripril (Square), Tritace (Aventis)
-adrenoceptor blocking drugs :
Prozosin Alphapress (Ranata)
Vasodilator Antihyper tensive drugs
Na-nitroprousside Na-nitropruside
Nitrates:
Glyceril trinitrate Nitrocap (orion), Nitrocard SR (Aristo pharma).
Calcium channel bolckers:
Amlodipine besy Late Amlocard (Drug international) Camlodin (Square)
Diltiazem Hcl Dila (Nipa)
Neocard (Beximco)
Anti-ulcerative H2 receptor autagonist:
Famotidine Femotack (Square), servipep (Novartis)
Ranitidine Neoceptin-R (Beximco),
Ranidin (Acme)
Type of Drugs Generic Name Proprietary Name
Anti ulcerative Proton Pump Inhibitors (PPI):
Omeprazole Ometid (opsonin),
Seclo (Square)
Lansoprazole Lausec (Drug International),
Protolan (Beximco)
Pentoprazole Pontid (Opsonin),
Tropaz (Orion)
Sedatives Benzodiazepines:
Diazepam Sedil (Square),
Rozam (Novana)
Clobazam XeoLox (Beximco), Cosium (Acme)
Alprazolam Zolax (Beximco)
Bromarpam Xionil (Novartis), Zepam (ACI)
Steroids Glucocorticoids:
Prednisolone Prednisolone (GSK),
Rednison (Repheo)
Betamethasone Bentelan (GSK)
Dexamethosone Dexatab (Ramata(, Steron (Acme)
BACKGROUND
The Irrational use of drugs is a major problem of present day medical practice and its consequences include the development of drug resistance, ineffective treatment, adverse effects of drugs and the economic burden on the patient and society. As accepted by the World Health organization (WHO) the ‘Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time and at the lowest cost to them and their community (30). Unlimited access to and irrational use of drugs is common in many developing countries (31).
Bangladesh is considered a developing country with more than 75% of the total (142 million) Population living in rural areas. About 36% of the population continues to live below the national poverty line (<US$1/day). Basic needs of living particularly health and education remain largely unmet and only less than 40% of the population has access to basic healthcare [23,24]. Distribution of health workers (per 1000 population) in Bangladesh is physicians 0.26, nurses 0.14 and pharmacist 0.06. Per capita total expenditure on health only US$ 2.84 in comparison to US$ 30-40 per capita, the minimum required for essential health interventions in low-income countries [25]. Though majority of the population live in rural areas, the government healthcare system remains a very minor source of healthcare there [26]. Treatments in the rural areas are mainly (about 45%) provided by unqualified health personnel including medical assistants, mid-wives, village doctors, commonly health workers in comparison to that by qualified medical graduates (only10-20%) [27]. Over prescribing and inappropriate prescribing are very common in the country due to unethical practices of both health professionals and drug manufacturers [28]. In response to WHO’s essential drugs concept such as access essential medicines, quality of all medicines and rational use of drugs [29], Bangladesh pioneered a National Drug Policy (NDP) in 1982. Main objectives of this policy were to ensure easy accessibility to essential drugs with affordable price, standard quality of drugs and rational use of drugs through appropriate prescribing and dispensing the health care professionals.
Developing countries generally have small health budgets and 30-40% of this is spent on drugs. This small amount of funds spent on drugs in these countries makes it desirable to prescribe drugs rationally for optimal benefit to the patient and community. Previous studies in both private and public sector in Rajshahi district showed major prescribing problems due to polypharmacy and irrational use of drugs in children.
The assessment of current prescribing practices in a health facility helps to identify drug use problems. The study was undertaken to assess the quality of prescription and drug use patterns.
Objectives:
• To investigate the prescribing behaviors of the medical practitioners checking the age, sex, body weight, diagnosis, chief complaint, clear hand writing, generic name, test or advice.
• To investigate drug use patterns including average number of drugs per prescription, generic or brand name, types of drugs used.
• Antibiotic prescribing practice- number of antibiotics per prescription, percentage of antibiotic prescription, types of antibiotics.
• To investigate differences in prescribing behavior and drug use pattern between child and adult patient.
METHODOLOGY
Prescription was collected from the patients visiting to General practitioners.
A prospective study was conducted in Bogra district town where a number of Medicine specialists, MBBS and child specialists practices in private chamber. Prescription from patients himself and parents visiting to the physician were copied on request and have visited each physician at least 2/3 times on alternate day. The average number of patients visiting each physician per day is about 25-30. However, it is very difficult to collect 100% prescription because of the non co-operation of the patient guardians. The total sample size was 405. Among them 219 child prescriptions and 186 adult prescriptions. Patient characteristics and drug data were calculated and analyzed using SPSS (Statistical package for social science) version 11.5. The result were expressed in percentages (%).
RESULTS
4.1 Child prescriptions
Table 1: Characteristics of health care providers and child patients
Physician Characteristics No. of patient Percentage (%)
* Group-1 Physician 99 45%
** Group-2 Physician 66 30%
***Group-3 Physician 54 25%
Patient characteristics No. of patient Percentage (%)
Age range 1month - 12 years 219 -
Sex Male 99 45%
Female 120 55%
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS(Graduate)
Total no. of prescriptions analyzed in this work was 219 of which 45% was male and 55% was female. Patient age ranges from 1month - 12 years. The physician was classified into three groups consists of Group-1 physician includes FCPS/ Ph.D/ MD and other Post graduates, Group-2 physicians include PGT/ EMOC and other Diploma andGroup-3 physician include MBBS(Graduate) terminal degree holder in order to assess inter group variation. Prescription from Group-1 physician was 45%, Group-2 was 30% and Group-3 physician was 25% (Table 1).
Table 2: Prescription behavior of physician in case of children
Prescription behavior Assigned Not Assigned
Items No % No %
Age 162 74 57 26
Sex 0 0 219 100
Body weight 90 41 129 59
Diagnosis 120 55 99 45
Chief complain 135 62 84 38
Clear hard writing 144 66 75 34
Generic name 0 0 219 100
Test or advice 81 37 138 63
Physicians hand writing was not clear and legible in 34% prescriptions. All the drugs were prescribed in proprietary name. The age of the child patient was not mentioned in 26% prescriptions. No prescriptions include sex of the patients and in 59% prescriptions the body weight was not assigned. Although in 62% prescriptions, chief complains were mentioned but only 55% patients diseases were diagnosed. Only 37% prescription assigned the test or advice for the patient (Table 2).
Table 3: Types of drug used in children by general practitioner
Drugs No. of prescription include %
Antibiotics 144 66
NSAIDS 117 53
Antihistamine 72 33
Anti-asthmatic/ Bronchodilators 105 48
Vitamin/Minerals 63 29
Steroids 45 21
Anti-emetic 18 8
Anti-ulcerative 18 8
Anthelmintic 15 7
Others 27 12
Child patients were exposed to 66% of antibiotics includes penicillins, cephalasporin, macrolides, quinolones, sulphonamides and other types of autibiotics. NSAIDs (53%), antihistamine (33%), antiasthmatic (41%), vitamin/ minerals (29%), steroids (21%), bronchodilator (7%), antiemetic (8%), antiulcerative (8%), anthelmintic (7%) and others (12%) (Table-3, Figure -2).
Table 4. Child patient exposed to different number drug(s) and antibiotic(s) prescribed by general practitioner
Drug(s) No. of Prescriptions (%) No. of Antibiotic No. of prescriptions % of antibiotics
0 3 1.36 0 75 34
1 12 5.47 1 144 66
2 48 22
3 84 38.35
4 54 25
5 15 7
6 0 0
7 3 1.36
Total 219 100 219 100
Range 1-7 0-1
Average Mean SE = 3.070.94 Mean SE = 0.660.07
The average number of drugs per patient was 3.070.94 and average number of antibiotic per patient was 0.660.7. More than 93% of the patient were exposed to multiple drugs among which three drugs were prescribed in highest number of prescription (38.35%) and ever zero drugs was prescribed in only three prescription (1.36%). About 66% of patients were exposed to antibiotics whereas 34% of patients were not exposed to any antibiotics. Interestingly no prescriptions contained any antimicrobial combinations.
Table 5: Children exposed to different types of antibiotic prescribed by general practitioner
Penicillin group Cephalosporins Macrolides Quinolones Sulphonamide Total
Group of doctor(s) Amoxycillin Fluclox Cephra Ceftriax Cefixim Cefalexim Cefurox Cefaclor Coffazidine Azithromycin Erytheromycin Ciprofloxacin Levofloxacine Gatifloxacine Malidixic acid Co-trimoxazole
*Group-1 0 3 18 3 0 0 3 3 6 6 3 6 0 0 3 6 60
**Group-2 3 0 12 0 3 3 0 0 0 18 0 0 3 0 0 12 54
***Group-3 6 3 12 3 0 0 0 0 0 3 0 0 0 3 0 0 30
Total 15 63 30 18 18 144
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS (Graduate)
Among all the prescription, cephalosporins was the most (30%) frequently prescribed antibiotic followed by macrolides groups (14%) penicillins, quilnolones group and sulphonamides antibiotics were prescribed by 5%, 8% & 8% respectively. Rest 35% prescription was without antibiotics (Figure 1).
Table 6: Physician qualification and drug use pattern in children
Total number of drug
0 1 2 3 4 5 6 7 Total
* Group-1 physician 0 3 9 21 42 18 6 0 99
** Group-2 physician 0 0 3 6 30 18 6 3 66
***Group-3 physician 0 0 0 21 12 18 3 0 54
Total 0 3 12 48 84 54 15 3 219
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS (Graduate)
The numbers of drugs prescribed by three groups of physicians were in the decreasing order 99, 66 and 54. Group1 Physician prescribed mostly multiple drug prescription ranges from 3-5 drugs/prescription with the highest quantity 6 in six cases. On the other hand group-2 physician was prescribed 4-5 drugs mostly. In comparison to others Group 3 physician generally used less drugs, however he preferred multiple drugs over single drug prescription (Table 6).
Figure1: Different types of antibiotics prescribed in children
Figure 2: Different types of drugs prescribed in children
4.2 Adults prescriptions
Table 7: Characteristics of health care providers and adult patents
Pysician Characteristics No. of patient Percentage (%)
* Group-1 Physician 63 34
** Group-2 Physician 75 40
*** Group-3 Physician 48 26
Patient characteristics No. of patient Percentage (%)
Age range >18 years 186 -
Sex Male 108 58
Female 78 42
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS(Graduate).
Total no. of prescriptions analyzed in this work was 186 of which 58% was male and 42% was female. Patient age ranges >8 year. The physician was classified into three groups consists of Group-1 physician includes FCPS/ Ph.D/ MD and other Post graduates, Group-2 physicians include PGT/ EMOC and other Diploma andGroup-3 physician include MBBS(Graduate) terminal degree holder in order to assess inter group variation. Prescription from Group-1 physician was 34%, Group-2 was 40% and Group-3 physician was 26% (Table 7).
Table 8: Prescription behavior of physician in case of adult
Prescription behavior Assigned Not Assigned
Items No % No %
Age 123 66 63 34
Sex 0 0 186 100
Body weight 6 3 120 97
Diagnosis 90 48 96 52
Chief complain 108 58 78 42
Clear hard writing 135 73 51 27
Generic name 0 0 186 100
Test or advice 75 40 111 60
Physicians hand writing was not clear and legible in 27% prescriptions. All the drugs were prescribed in proprietary name. The age of the child patient was not mentioned in 34% prescriptions. No prescriptions included sex of the patients and in 97% prescriptions the body weight was not assigned. Although in 73% prescriptions, chief complains were mentioned but only 48% patients diseases were diagnosed. Only 40% prescription assigned the test or advice for the patient (Table 8).
Table 9: Types of drug used in adult by general practitioner
Drugs No. of prescription incluid %
Antibiotics 75 40
NSAIDS 66 36
Antihistamine 30 16
Antasthmatic 15 8
Anti phisotic 27 15
Vitamin/Minerals 51 27
Antiemetic 30 16
Antihypeutensive 30 16
Antiulcerative 87 47
Sedatives 48 26
Steroids 9 5
Others 126 70
Adults patients were exposed to 40% of antibiotics such as penicillins, cephalasporin, macrolides, quinolones, sulphonamides and other types of autibiotics. NSAIDs (36%), anti-histamine (16%), anti-asthmatic (8%), anti- psichotic (15%), vitamin/ minerals (27%), anti-emetic (16%), anti-hypertensive (16%), anti-ulcerative (47%), sedatives (26%), steroids (5%), others (70%) prescription (Table 9, Figure 4).
Table 10. Adults patient exposed to different number drug(s) and antibiotic(s) prescribed by general practitioner
Drug(s) No. of Prescriptions (%) No. of Antibiotic No. %
1 3 1.6 0 111 111
2 33 17.7 1 69 69
3 51 27.4 2 6 6
4 66 35.5 Total 186 186
5 9 4.8
6 15 8.1
7 6 3.2
8 0 0
9 3 1.6
Total 186 100
Range 1-9 Range 0-2
Average Mean SE= 3.71 0.94 Average Mean SE= 1.03 0.7
The average number of drugs per patient was 3.71 and average number of antibiotic per patient was 1.03. More than 98% of the patient were exposed to multiple drugs among which four drugs were prescribed in highest number of prescription (35.5%) and ever one drug was prescribed in only three prescription (1.6%) and 9 drugs was prescribed in 1.6% of prescription. About 40% of patients were exposed to antibiotics and 60% of patients were not exposed to any antibiotics. Among the prescription 37% were single antibiotic prescription and 3% were double antibiotics prescriptions. (Table 10)
Table 11: Adult exposed to different types of antibiotic prescribed by general practitioner
Penicillin Cephalosporins Macrolides Quinolones Sulphonamide Others Total
Group of doctor(s) Amox Fluclox pen-v Cephra Ceftriaxone Cefalaxine Azithromycin Erytheromycin Ciprofloxacin Levofloxacine Gatifloxacine Malidixic acid Co-trimoxazole Tetracycline
*Group-1 3 3 0 0 0 3 0 0 0 3 0 3 0 0 15
**Group-2 3 0 3 0 3 0 9 3 12 6 0 0 0 3 42
***Group-3 3 3 0 9 0 0 0 0 0 3 0 0 0 0 18
Total 18 15 12 27 0 3 75
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS (Graduate)
Among all the prescription, quinolones was the most (15%) frequently prescribed antibiotic followed by penicillin group (10%), cephalosporin, macralides and other antibiotics were prescribed by 8%, 6% & 2% respectively. Rest 59% prescription was without antibiotic (Figure 3).
Table 12: Physician qualification and drug use pattern in adult
Total number of drug(s)
1 2 3 4 5 6 7 8 9 Total
* Group-1 physician 3 9 18 21 0 9 3 0 0 63
** Group-2 physician 0 18 12 36 3 3 3 0 0 75
*** Group-3 physician 0 6 21 9 6 3 0 0 3 48
Total 3 33 51 66 9 15 6 0 3 186
* Physician - FCPS/Ph.D/MD and Other Post graduate
** Physician- PGT/EMOC and others Diploma
*** Physician-MBBS (Graduate)
The numbers of drugs prescribed by three groups of physicians were in the following order 63, 75 and 48. Group1 Physician prescribed mostly multiple drug prescription ranges from 2-4 drugs/prescription with the highest quantity 7 in three cases. On the other hand group-2 physician was prescribed 2-5 drugs mostly. In comparison to others Group 3 physician generally used highest no. of drugs, 9 in three cases however he preferred multiple drugs over single drug prescription (Table 12).
Figure 3: Different types of antibiotics prescribed in adult
Figure 4: Different types of drugs prescribed in adult
4.3 Comparison of drug use patterns in children and adults
In this survey the total no. of prescriptions analyzed was 405 of which 219 were of children and 186 were of adults. Children age ranges from 1month - 12 years comprising 45% of male and 55% of female and adult age ranges 18-65 years comprising 58% of male and 42% of female. Child prescriptions from Group-, Group-2 and Group-3 physician were 45%, 30% and 25% respectively. Adult prescriptions from Group-1, Group-2 and Group-3 physician were 34%, 40% and 26% respectively (Table 13).
Table 13: Comparison of number of drugs given in children and adults
No. of drugs given/ prescriptions Adults Children
No (%) No (%)
None 0 (0) 3(1.4)
1-2 drugs 36(19.3) 60(27.4)
3-5 drugs 126(67.7) 153(69.9)
6 and above 24(12.9) 3(1.4)
Total 186(100) 219(100)
Child patients were exposed to 66% of antibiotics and other drug includes NSAIDs (53%), antihistamine (33%), antiasthmatic (41%), vitamin/ minerals (29%), steroids (21%), bronchodilator (7%), antiemetic (8%), antiulcerative (8%), anthelmintic (7%) and others (12%) whereas the adults were exposed to 40% of antibiotics and other drug includes NSAIDs (36%), anti-histamine (16%), anti-asthmatic (8%), anti- psychotic (15%), vitamin/ minerals (27%), anti-emetic (16%), anti-hypertensive (16%), anti-ulcerative (47%), sedatives (26%), steroids (5%). It was evident that physician prescribed more NSAIDS, steroids and anti-asthmatic drug in children than in adults. Although anti-hypertensive, anti- psychotic and sedatives were prescribed in adults, not a single child prescription contained those. Interestingly, vitamin/ minerals were prescribed in both children and adult frequently.
Table 14: Comparison of different types of drugs prescribed in adults and children and adults
Indicator Category Adult (N=186)
/% Children (N=219)
/%
Prescription with antibiotic None 111(60) 75(34)
One 69(37) 144(66)
Two or more 6(3) 0(0)
Prescription with NSAIDs None 120(64) 102(47)
One 66(36) 117(53)
Prescription with Anti-histamine None 156(84) 147(67)
One 30(16) 72(33)
Prescription with Ani-asthmatic None 161(92) 129(59)
One 15(8) 90(41)
Prescription with Vitamin/Minerals None 137(73) 156(69)
One 45(24) 60(27)
Two 6(3) 3(2)
Prescription with Steroids None 177(95) 174(79)
One 9(5) 45(21)
Prescription with Antiemetic None 156(84) 201 (92)
One 30(16) 18(8)
Prescription with Antiulcerative None 99(53) 201(92)
One 87(47) 18(8)
Prescription with Antihypertensive None 156(84) 0(0)
One 20(11) 0(0)
Two 10(5) 0(0)
Prescription with Sedatives None 138(74) 0(0)
One 48(26) 0(0)
In children and adult the antibiotic prescribed were 66% and 40% respectively. Child received only single antimicrobial prescription whereas adult received only mostly single therapy. Among the antibiotics child received cephalosporins mostly (46%) followed by macrolides (21%), quilnolones (13%), sulphonamides (13%), and penicillins (8%) respectively whereas adult received quinolones mostly (38%) followed by penicillin (25%), cephalosporin (21%), macrolides (17%) and other antibiotics were prescribed (4%)(Figure 5).
Figure 5: Comparison of different types of antibiotic prescribed in children and adults
Group 2 physician prescribed highest antibiotics compare to Group 1 and Group 3 physicians. The prescription pattern of antibiotics among Group 1 and Group 3 physicians were comparable. The Group1, Group 2 and Group 3 physicians preferred penicillin, quinolones and cephalosporines respectively (Figure 6).
Figure 6: Prescription of antibiotics by different groups of physician in adults
Child received antibiotics in the form of injection, pediatric drops and even in tablet and capsule. The mostly preferred dosage form in children was powder for suspension and no suppositories were used. For adults the preferred dosage forms were in the order of tablet, capsule and injection.
Figure 7: Dosage forms of antibiotics used in children and adults
DISCUSSION
Inappropriate prescribing is a recognized worldwide problem of the health care delivery system. In the last two decades, the WHO and others have promoted rational drug prescription in order to assess problems of clinical or economically inappropriate drug use, to make comparisons between groups or to measure changes over time. Unlimited access to and irrational use of drugs is common in many developing countries. Inappropriate prescriptions are readily available due to poor consulting period (a mean of only 54 second!) of doctors in Bangladesh [5]. It is estimated more than half of medicines are inappropriately prescribed, dispensed or sold [6]. Moreover, polypharmacy is very common among the rural medical practitioners with antibiotics and vitamins prescribed widely [7]. In reality, there is no mechanism or legislation exists in the country of assessing the competence of prescribing medical practitioners. No professional or moral judgment on the part of individual practitioners was intended. The first aim to improving the rational use of drugs is to understand prescribing patterns. This study has described the drug use patterns and prescribing behaviors of general practitioner, while the main objective of this study was to draw inference on the use of drugs by these health providers in child and adults.
In this survey the total no. of prescriptions analyzed was 405 of which 219 were of children and 186 were of adults. Our results indicated that in both children and adults the physicians prescribed mostly 3-5 drugs and even 6 or more drugs were advised in adults (24%). Over-statements and misinformation is very common in Bangladesh, which greatly influences physician prescribing behaviors. Currently, drug companies are the only organization in Bangladesh to provide information to health personnel and information supplied is often not consonant with recommendations from public health bodies [15]. Ultimate results prescriptions of inappropriate or unnecessary and expensive medicines [16]. It was evident that physician prescribed more NSAIDS, steroids and anti-asthmatic drug in children than in adults. Although anti-hypertensive, anti- psychotic and sedatives were prescribed in adults, not a single child prescription contained those. Interestingly, anti-ulcerative and vitamin/ minerals were prescribed in both children and adult frequently.
Group-1 physician prescribed the lowest number of antibiotics whereas Group-2 physician prescribed the highest number of antibiotics. The prescription pattern of antibiotics among Group 1 and Group 3 physicians were comparable, however, the reason of use of high percentage of antibiotics by the Group 2 physicians were doubtful and probably due to lack of experience and inappropriate diagnosis. The prescription procedure of antibiotics in Bangladesh is less than ideal as prior identification of the pathogens and its sensitivity to the drug is rarely determined before the drug is prescribed [8]. For example, one survey conducted among rural medical practitioners with an average of 11 years experience should 60% of antibiotics prescriptions written based on the symptoms alone [9]. All antimicrobial agents were prescribed mainly on the patient’s complaints, and all available antibiotics were prescribed in inappropriate doses and duration as has been showed in another similar survey [10].
Children are mostly affected by inappropriate antibiotics prescribing in Bangladesh [11]. Misuse of drugs in the treatment of various diseases among children under-five children is highly prevalent. In children and adult the antibiotic prescribed were 66% and 40% respectively. Child received only single antimicrobials whereas adult received mostly single along with combination of antimicrobials. Among the antibiotics child received cephalosporins mostly (46%) followed by macrolides (18) whereas adult received quinolones mostly (38%) followed by penicillin (25%), cephalosporin (21%), macrolides (14).
Child received antibiotics in the form of injection, pediatric drops and even in tablet and capsule. The mostly preferred dosage form in children was powder for suspension and no suppositories were used. For adults the preferred dosage forms were in the order of tablet, capsule and injection.
CONCLUSION
This study aimed to describe the prescribing patterns of drugs in private practices in both child and adult patients in Bogra district, Bangladesh. No drugs were prescribed in generic form and the prescription information was not complete. The incomplete natures of prescription were a cause for concern. Multi-drugs prescription was very common among the general practitioners with antibiotics and steroids prescribed widely. Physician use more cephalosporins and steroids in children and anti-ulcerative in adults. High proportions of antibiotic prescriptions issued by all physicians that might be appeared to be a lack of confidence or disuse of microbiological laboratory services and absence of policies on antimicrobial use and above all poor consulting period. The main challenges in prescription of antibiotics/drugs are to achieve a rational choice and appropriate use of antibiotics/drugs and to recognize their potential adverse effects. Consequently, physicians must keep a clear understanding of needs of bacteriological examination for diagnosis, use of antimicrobials/drugs and make a good judgment in clinical practice. The extent of inappropriate prescribing in both patients call for in-depth investigations of the system factors and motivations that underline problem practices and the development of interventions that target the causative factors.
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