A cross-sectional observational study on knowledge, attitude and practices about indiscriminate use of antibiotics and antibiotic resistance among medical doctors at Sapthagiri Hospital, Bangalore

Background: WHO defines Antimicrobial resistance (AMR) as “the ability of a microorganism to stop an antimicrobial from working against it”. The Global burden includes increased morbidity, prolonged illness and a higher mortality rate, along with economic burden. The cause can be tracked down to irrational usage of antibiotics and lack of awareness of rational prescribing practices.Methodology: A cross-sectional questionnaire-based observational study was carried out using a standard pre-validated questionnaire, which was administered to all the medical doctors present in their respective departments during the study period, exploring their knowledge regarding rational antibiotic usage, their attitudes and awareness towards AMR. Informed consent from the participants was obtained verbally, and confidentiality assured. The collected data was analyzed as per descriptive statistics.Results: Majority of doctors (91.3%) have a good knowledge and agree that indiscriminate use of antibiotics leads to antimicrobial resistance. 96.12% of doctors identify it as a global issue but only 85.5% consider it a problem in their hospital. Doctors (78%) have a positive attitude and do not prefer to prescribe an antibiotic for minor illnesses, but only 40% think it might contribute to antimicrobial resistance.Conclusion: Our study has demonstrated that doctors have a good knowledge about the emerging problem of antimicrobial resistance, however a minor percentage of doctors fail to acknowledge this at the level of their own hospital. Regular updates on the local antimicrobial resistance rates & antibiotic stewardship might help to control the global issue of AMR.

Audit of prescriptions from the department of general medicine based on the WHO core prescribing indicators at Sapthagiri hospital, Bangalore

Background: As medical students start their clinical training, more effort goes in the direction of proper diagnosis and appropriate methods of treatment, leading to improper training in prescription writing causing prescription errors. Physicians should also be encouraged to prescribe unbranded generic medicines which are available at a cheaper price with a comparable bioavailability of drugs and not have a misconception of being less efficacious.Methods: A cross-sectional observational study was carried out over a period of 2 months (September to October 2018). Around 256 prescriptions were randomly collected from general medicine out-patient department. Informed consent was obtained verbally, and confidentiality assured. The collected data was analyzed as per descriptive statistics and compared with the derived standard values for WHO prescribing indicators.Results: The analyzed data showed an average of 2.23±1.03 drugs per prescription. 23% of the prescriptions had at least one drug prescribed by generic name, 25% of prescriptions contained an antibiotic and 31% of prescriptions had an injection. The percentage of drugs prescribed from NLEM (National list of Essential Medicines) was only 57% as compared to the recommended 100%. Additional only 22.4% of the total number of FDCs prescribed were from NLEM.Conclusions: The average number of drugs per prescription was slightly high, indicating polypharmacy. Brand name prescribing dominates as doctors are still reluctant to use generic names being doubtful of the efficacy. Regular prescription audit with reporting might help to bring awareness among doctors to follow the recommended guidelines and minimize prescription errors.

Prescription pattern of analgesics in orthopedics outpatient department at a tertiary care hospital.

Background: Analgesics are the most common class of drugs prescribed for various conditions in the orthopedics outpatient department (OPD). This study is performed for a better understanding of analgesics prescribing pattern in orthopedics and to correlate the use of selective cyclooxygenase-2 (COX-2) inhibitors, conventional non-steroidal anti-infl ammatory drugs (NSAIDs), and opioid analgesics in practice in the present scenario. Methods: The prescriptions from the OPD of Orthopedics at Dr. B. R. Ambedkar Medical College was reviewed between June 2013 and November 2013, entered in a pre-designed proforma. Pain was quantifi ed using numeric rating scale. The type of analgesics administered, whether monotherapy or combined therapy and the duration of therapy, was analyzed to obtain an overview of the current prescribing pattern. Results: A total of 300 prescriptions were analyzed. 800 drugs were prescribed with an average of 2.6 drugs per prescription. Of these, 62.3% were NSAIDs, 15.4% were opioid analgesics and 22.3% were gastroprotective agents. 61% of the NSAIDs were prescribed as monotherapy and 39% were prescribed as fi xed drug combination (FDC). The ratio of selective to non-selective NSAIDs is 1.3:1. Conclusions: The results of the present study show frequent use of selective COX-2 inhibitors, although non-selective NSAIDs topped the list of various selective NSAIDs, non-selective NSAIDs, and opioid analgesics. This suggests that gastrointestinal safety was an important concern while prescribing these drugs. Many FDCs were found to be irrational.

Drug-induced cutaneous adverse drug reactions in dermatology in Dr. B.R. Ambedkar Medical College.

Background: Cutaneous adverse drug reactions (ADRs) affect 2-3% of hospitalized patients. The severity varies from mild itching to life-threatening Stevens-Johnson syndrome (SJS). Hence, this study was undertaken to emphasize the need to report ADRs. Methods: The study was carried out in the Department of Dermatology in Dr. B.R Ambedkar Medical College Hospital from June to December 2012. Naranjo’s algorithm was used to determine the causality of an ADR. Informed consent was obtained from each patient, and thorough clinical examination was conducted. All the information was carefully recorded in a pre-designed proforma. To establish the etiologic agent for a particular type of reaction, attention was paid to the drug history, temporal correlation with the drug, duration of the reaction, morphology of the reaction, associated mucosal or systemic involvement, improvement of lesions on withdrawal of the drug. Results: In the present study, all the age groups were affected with cutaneous ADRs, with a higher incidence in age group between 31 and 40 years, non-steroidal anti-inflammatory drugs (NSAIDs) (41.66%) were most commonly observed drug, followed by anti-microbials (25%) and anti-convulsants (21.66%). Fixed drug eruptions (FDE) (46.66%) most commonly observed cutaneous reaction, followed by SJS (16.66%), erythema multiformae (16.66%) most commonly observed ADRs. Conclusions: ADRs are potentially avoidable causes for seeking medical care. FDE was most common ADR and NSAIDs were most common causative agents in our study. ADRs can be prevented by avoiding polypharmacy, obtaining history of any previous skin reaction and the causative agent.

A randomized, open-labelled study of the sedative, analgesic and anxiolytic effect of dexmedetomidine and tramadol in postoperative patients.

Background: In the post-operative period, it has always been an important consideration for clinicians, to keep the patient comfortable, calm and pain free. So there is a constant need for an ideal sedative for postoperative patients. Alpha 2 adrenoreceptor agonists such as dexmedetomidine could provide an answer to this problem because they have several relevant physiological properties like sedation, anxiolysis, analgesia and arousability. This prospective, randomized trial was conducted to compare the safety and efficacy of dexmedetomidine and tramadol in the management of postoperative pain. Methods: In the present study 60 patients operated under general anaesthesia with a pain score of 1-3 were randomly allocated into two groups to receive either dexmedetomidine (group D) or tramadol (group T). In both groups, pain score, sedation score, heart rate, blood pressure, SPO2, respiratory rate were monitored for every 5 min for first 30 min, every 10 min for next 1hr, every 15 min for next 1 h, every 30 min for the next 1 h, every 1 h for 3 h and 6th hourly till 24 h. The need for rescue analgesic was also noted. The data were tabulated and analysed using descriptive statistical tool. Mean, standard deviation and comparison between the groups was done by student’s ‘t’ test. A p value less than 0.0001 was considered significant. Results: Mean duration of sedation of dexmedetomidine was 129.6±41.02 and for tramadol was 117.3 ± 47.75 (p=0.14), mean degree of sedation in both group was -1, mean duration of analgesia 139 min in Group D and 280 min in Group T (p<0.0001), rescue analgesia was required at 169th min in Group D and 288th min in Group T (p<0.0001), mean heart rate in Group D was 67.8±5.24 and 69.4±4.79 (p=0.12), mean Mean Arterial Pressure (MAP) in Group D was 78.0±8.97 and in Group T was 89.2±10.63 (p<0.00001), mean respiratory rate in Group D was 15.8±2.33 and in Group T was 15.9±2.09 (p=0.41), mean SPO2 in Group D was 99.5±0.56 and in Group T was 99.4±0.62 (p=0.14). There was no significant difference in degree and duration of sedation, duration of analgesia, vital parameters, and adverse effects in both groups but there was a statistical difference in the duration of analgesia and the need for rescue analgesia in Group D. Conclusion: Though there is no statistical difference in both groups, dexmedetomidine significantly reduced anxiety, agitation and produced calmness in postoperative patients which was not seen with tramadol.

Selective serotonin reuptake inhibitors and the risk of bleeding.

Background: Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed agents for various conditions in general psychiatry. There is a strong consensus that blockade of serotonin reuptake affects primary hemostasis, namely platelet activity, thus resulting in a bleeding tendency. Considering that SSRIs are commonly prescribed, this study was conducted to assess if they were associated with an increased risk of bleeding. Methods: This was a prospective, open-label study of 30 patients attending the Psychiatry out-patient department, Dr. B. R. Ambedkar Medical College, Bangalore who satisfied DSM-IV criteria for a primary diagnosis of depression, treated with SSRIs. Bleeding time, clotting time, prothrombin time, partial thromboplastin time and platelet count were assessed at baseline and at the end of 6 weeks of treatment or occurrence of bleeding symptom. Results: The patients aged between 18-55 years of whom 21 were females, were treated with an SSRI (fluoxetine 12, escitalopram 12 and sertraline 6 patients). Six patients had overt symptoms of bleeding (upper gastrointestinal bleeding (hematemesis) 4; epistaxis 2 and petechiae 2) of whom one patient gave a history of both hematemesis and petechiae and another of hematemesis and epistaxis. The average day after treatment beginning, on which patients reported with bleeding was 30.33 (26-40 days). There was a significant increase in the bleeding time (p=0.028) and clotting time (p=0.042), implying derangement in platelet aggregation. There was no significant change in the other parameters. Conclusion: Treatment with SSRIs increases the risk of bleeding. However, large, randomized controlled trials are required to re-affirm these findings.

An Observational Study of Essentiale-L in the Treatment of Patients with Fatty Liver Disease.

Background: The most common forms of liver disease are alcoholic fatty liver disease and nonalcoholic fatty liver disease (NAFLD), which lead to cirrhosis, liver failure and death. Essential phospholipids play an important role in the management of these conditions. Polyenephosphatidylcholine (PPC) is a major active ingredient in essential phospholipids. It has a high bioavailability and affinity for cellular and subcellular membranes, and helps to maintain membrane fluidity and function. Essentiale-L comprises of PPC, which is a mixture of 94-96% of polyunsaturated phosphatidylcholine. It is prescribed in the management of viral hepatitis and fatty liver disease. Objective: There are only few recent clinical studies conducted in India regarding the role of Essentiale-L in the management of fatty liver disease therefore, we undertook this openlabel, nonrandomized, real clinical practice study, on adult patients diagnosed with fatty liver disease including NAFLD as well as alcoholic fatty liver disease (AFLD). Methods: All adult patients satisfying the inclusion and exclusion criteria were included in the study. Patients diagnosed with fatty liver disease including NAFLD as well as AFLD were treated for 90 days with Essentiale-L two capsules thrice-daily. Vital signs, adverse effects and laboratory evaluations (liver function tests, lipid profile and fasting blood glucose tests) were recorded at baseline (Day 0), Day 7, Day 21, Day 30, Day 60 and Day 90. Results: Essentiale-L showed a consistent improvement in both clinical as well as laboratory parameters in patients with fatty liver disease. The decrease in the liver enzyme levels from baseline was significant at Days 60 and 90 (p < 0.05). However, the decrease in serum total cholesterol, low-density lipoprotein (LDL) cholesterol and triglyceride levels was significant only at Day 90 (p < 0.05). The change in fasting blood glucose levels from baseline were not significant. Conclusion: Essentiale-L is a safe and effective option in patients with fatty liver disease. It can be safely recommended in patients with type 2 diabetes along with fatty liver disease since it did not alter the blood glucose levels significantly.

Identifying learning techniques among high achievers.

Background: In every college, it is noticed that in spite of being exposed to the same teaching modalities and adopting seemingly similar strategies, some students perform much better than their peers. This can be evaluated in the form of better academic performance in the internal assessments they undertake. This project is an endeavor to identify the learning techniques among high achievers which they employ to outperform others. We can also suggest the same to the medium and low achievers so that they can improve their academic performance. This study was conducted to identify different learning techniques adopted by high achievers and suggesting the same to medium and low achievers. Methods: After obtaining clearance from the institutional ethics committee, the high achievers were identified by selecting the upper third of the students in the ascending order of marks obtained in the consecutive three internal assessments in three consecutive batches. The identity of the students was not revealed. They were then administered an open ended questionnaire which addressed relevant issues. The most common and feasible techniques will be suggested to the medium and low achievers. Results: The respondents’ (n=101) replies were analyzed by calculating the percentages of responses, and assessing based on that, which were the most frequently adapted techniques by these high achievers Conclusions: High-achievers have a diligent study pattern; they not only study regularly, but also involve in group discussions and approach their teachers when in doubt. Additionally, they refer to other sources of information like the internet, demonstrating a proactive attitude towards studies.