J Res Pharm Pract. 2013 Apr-Jun; 2(2): 7074.

doi: 10.4103/2279-042X.117386
PMCID: PMC4076908

Antibiotic sensitivity pattern and costeffectiveness analysis of antibiotic

therapy in an Indian tertiary care
teaching hospital
Shamungum Sriram,1 Varghese Aiswaria,1 Annie Eapen Cijo,1 and Thekkinkattil
Mohankumar2
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Abstract
Objective:
The purpose of this study is to analyze the antibiotic sensitivity pattern of
microorganisms, to study the antibiotic usage pattern, and to conduct a costeffectiveness analysis (CEA) for the antibiotics prescribed in a tertiary care
teaching hospital in south India.

Methods:
This prospective study was carried out in the General Medicine and Pulmonology
departments of the hospital for a period of 6 months. The study was carried out in
three phases: A prospective analysis to check the sensitivity pattern of
microorganisms to various antibiotics, data extraction and determining the cost of
antibiotics and finally evaluation of the sensitivity pattern of microorganisms and
the antibiotic usage. A total of 796 documented records were analyzed.

Findings:
It was found that Escherichia coli was the major organism identified in 36.4% of
the isolated specimens, followed by Klebsiella sp. (18.9%), Streptococcus
pneumoniae (15.8%), Staphylococcus aureus (12.4%), and Pseudomonas (9.3%).

The sensitivity pattern data of the prospective study revealed that E. coli was
highly sensitive to Amikacin (99.3%), Klebsiella to Amikacin (93.8%),
Pseudomonas to Meropenem (97.6%), and S. pneumoniae to Ofloxacin (93.8%).
In the prescribing pattern study, it was found that the most common disease
(21.2%) was found to be lower respiratory tract infection in 51 patients.
Cephalosporins (73%), in particular Ceftriaxone (63.5%) was highly prescribed,
followed by fluoroquinolones (53.9%). In the CEA, it was revealed that
Ceftriaxone was the cost-effective antibiotic with a cost-effectiveness ratio (CER)
of 78.27 compared to Levofloxacin, which had a CER of 95.13.

Conclusion:
Continuous surveillance of susceptibility testing is necessary for cost-effective
customization of empiric antibiotic therapy. Furthermore, reliable statistics on
antibiotic resistance and policies should be made available.
Keywords: Antibiotics, cost-effectiveness analysis, prescribing pattern,
sensitivity

INTRODUCTION
Anti-microbial resistance patterns can vary regionally and even among different
hospitals within the same community. Infections are the most common reasons for
patients to seek medical advice and for antibiotics to be prescribed.[1]
Inappropriate or indiscriminate use of antibiotics can increase the cost of care by
increasing drug cost, increasing toxicity, increasing resistance, and increasing
laboratory costs. Prophylactic antibiotic use in some hospitals remains a problem.
[2] Antibiotics are prescribed unnecessarily and empirically for complaints where
no antibiotic is required or where culture and sensitivity results could be safely
awaited.[3] The key action by the clinician should be the provision of a specimen
for accurate identification of the offending pathogen by means of culture and
sensitivity method.[4] The pharmacist can present information at the point of care
regarding antibiotic susceptibility and individual patient factors to improve
antibiotic prescribing. The pharmacist can play a significant role in
recommending the prescriber about the necessary changes to be made in the
patient regimen, dose, and duration of antibiotic therapy. The costs of drug
therapy are increasing dramatically, especially as new products, derived from
biotechnology, are introduced. Cost is one among the various factors to be taken
into account in antibiotic prescribing.[5] Cost-effectiveness analysis (CEA)
evaluates the relative costs and benefits of different medical technologies,
procedures or clinical strategies as measured in physical units, for example, lives
saved or reduced morbidity.[6] CEA is considered to be the most appropriate
method for the evaluation of health economics when at least two alternatives are
being compared and when outcomes can be expressed in a common unit, such as
cost per life years saved.[7] Thus, the purpose of this study is to conduct a

detailed study on the sensitivity pattern of microorganisms, to analyze the

antibiotic usage pattern, and to conduct a CEA for the antibiotics prescribed.

METHODS
This prospective cross-sectional study was carried out in a 700-bedded multispecialty private corporate hospital in South India during 6 months. All patients
hospitalized in the General Medicine and Pulmonology departments for whom at
least one antibiotic was prescribed were included in the study. The study protocol
was submitted to the Dean of the study hospital, Coimbatore. The authorization
from the Dean was procured. The author was permitted to utilize the hospital
facilities to make a follow-up of the prescriptions in the selected department. A
specially designed format was used for entering the prevalence and sensitivity
pattern of microorganisms among the patients during the study period. A separate
data entry format was designed for noting the pattern of antibiotic use.
The study was carried out in three phases. The first phase involves a prospective
analysis to check the sensitivity pattern of microorganisms to various antibiotics
for a 6 month period. The documented data were reviewed and necessary
information such as specimen collected, organism isolated, and their sensitivity
pattern were noted down. During the 2nd phase, information regarding the pattern
of antibiotics prescribed in the Pulmonology and General Medicine departments
and also the cost of the antibiotics were obtained. During the final phase, the
sensitivity pattern of microorganisms and the antibiotic usage pattern were
analyzed in detail.
A CEA was conducted by calculating the cost per failure avoided to find out the
most cost-effective antibiotic in the Pulmonology and General Medicine
departments. A decision tree was created on the basis of the data collected and this
tree was used to determine the expected value (anticipated therapeutic cost per
patient) for each antibiotic prescribed. Using the therapeutic effect of the
antibiotic against infection and the anticipated therapeutic cost per patient, the
cost-effectiveness ratio (CER) was calculated. The antibiotic with the lower CER
was found to be the most cost-effective antibiotic.

RESULTS
During the first phase, a total of 796 documented records were analyzed.
Escherichia coli was the major organism isolated in 36.4% of the specimens,
followed by Klebsiella sp. (18.9%), Streptococcus pneumonia (15.8%),
Staphylococcus aureus (12.4%), and Pseudomonas (9.3%) [Table 1]. Urine,
sputum, and pus cells were the major specimen samples collected. E. coli was
more common in urine (78.6%), Streptococcus pneumoniae was found extensively

in sputum (76.2%), and Proteus sp. was more common in urine (82.3%) samples
[Figure 1].

Table 1
Sensitivity pattern studies of antibiotics

Figure 1
Percentage of microorganisms found in different patients specimens (n = 796)
The prospective data revealed that almost all the organisms isolated were highly
sensitive to Amikacin. It was found that Amikacin showed the best sensitivity in
S. aureus (100%), E. coli (99.3) Klebsiella species (93.8%), and Pseudomonas
(96.3%) [Figure 2]. Proteus showed high sensitivity toward Tigecycline (95.8%)
and Actinobacter showed high sensitivity toward Meropenem (91.9%) [Table 1].

Figure 2
Percentage of microorganisms sensitivity to different antibiotics (n = 796)
Phase II of the study was to collect information on the antibiotic prescribing
pattern along with the cost of antibiotics from the General Medicine and
Pulmonology wards for 6 months period. Lower respiratory tract infections were
the major diseases for which antibiotics were prescribed (21.2%). Cephalosporins
were the major category of antibiotics prescribed (73%), followed by
fluoroquinolones (53.9%) [Figure 3].

Figure 3
Major antibiotics prescribed for treating infections in general medicine and
pulmonology departments (n = 241)
The third phase involved the CEA of the antibiotics prescribed. For CEA, decision
tree was created on the basis of the data collected [Figure 4]. The decision tree
was used to determine the expected value. One hundred fifty three patients
received Ceftriaxone of which 112 treatments (73.2%) were successful. Using the
drug cost only, the average cost per patient in this path was 0.92 United States
dollars (USD). Forty one patients in the Ceftriaxone arm failed therapy and were
switched over to either Levofloxacin or Amikacin. Ninety eight patients received
Levofloxacin. The total anticipated therapeutic cost per patient is calculated on the
basis of the decision-tree model, which was found out to be 1.06 USD for the
Ceftriaxone group and 1.77 USD for the Levofloxacin group. The CER was
calculated to be 1.45 for Ceftriaxone group and 1.77 for the Levofloxacin group.
CER suggests that Ceftriaxone is the most cost-effective antibiotic at our
institution. The results were limited to the drug acquisition cost only and revealed
that Ceftriaxone is a cost-effective alternative to Levofloxacin in so far as the only
drug cost was considered.

Figure 4
Decision tree for cost-effectiveness analysis (USD: United States Dollar)

DISCUSSION
Hospital anti-biograms can be a useful means for guiding empiric therapy and
tracking the emergence of resistance among bacterial isolates, as it is shown in the
present study. Similar study was conducted by Gayathri et al.,[8] on antibiotic
susceptibility pattern of rapidly growing mycobacterium. Out of the 148 rapidly
growing mycobacterium isolates, 146 (98%) were susceptible to Amikacin, 138
(91%) to Gatifloxacin, 132 (87%) to Moxifloxacin, 122 (76%) to ciprofloxacin,
and 116 (74%) to Norfloxacin. In the other study conducted by Perveen et al.,[9]
on the prevalence and antimicrobial susceptibility pattern of Methicillin-Resistant

Staphylococcus aureus (MRSA) and Methicillin-Resistant Coagulase-Negative

Staphylococci (MRCoNS), out of the total 350 staphylococcal isolates from
different clinical specimens, 148 isolates (60.40%) were identified as MRSA and
46 isolates (43.80%) were screened as MRCoNS. All isolates of MRSA and
MRCoNS were multi-drug resistant. Antibiotic resistance pattern of these isolates
was high against penicillin, whereas all the MRSA strains were resistant to
penicillin and oxacillin (100%). The MRCoNS strains also showed closely similar
drug resistance pattern with 97.82% isolates being resistant to penicillin.
However, all the MRSA and MRCoNS isolates were uniformly susceptible to
vancomycin. Chloramphenicol and rifampicin also showed excellent activity
against methicillin-resistant isolates. This study indicated a high level prevalence
of MRSA and MRCoNS strains resistance against widely used antimicrobial
agents. Hoogendoorn et al.,[10] performed a study on Prevalence of Antibiotic
Resistance of the Commensal Flora in Dutch Nursing Homes. A total of 125
patients were included in the study. The resistance and intermediate susceptibility
of E. coli varied from 4% (ceftriaxone) to 43% (amoxicillin). Extended spectrum
-lactamase-producing Enterobacteriaceae were found in 6% of the patients.
Amoxicillin and/or co-amoxiclav users were significantly more resistant to these
antibiotics (69%) than non-users (38%). Antibiotic use was associated with
antibiotic resistance of E. coli.
The present study also analyzed the data obtained for any changes in the
sensitivity pattern of microorganisms and the pattern of antibiotic use in the study
department. This phase includes the CEA on the antibiotics prescribed.
Ceftriaxone was the cost-effective alternative to levofloxacin with a CER of
78.27. Similar study was conducted by Lavoie et al,[11] on the cost-effectiveness
of antibiotics used for community acquired pneumonia and acute exacerbation of
chronic bronchitis. The study was conducted on 3,610 patients and it revealed that
Azithromycin, which is widely prescribed antibiotic, appears to be the most costeffective treatment strategy for lower respiratory tract infections.
Continuous surveillance of susceptibility testing is necessary for cost-effective
customization of empiric antibiotic therapy. Furthermore, reliable statistics on
antibiotic resistance and policies that are mandatory to control spread of resistant
pathogens should be made available. Clinical pharmacists play a significant role
in promoting optimal antibiotic prescribing practice among physicians, during
their routine visit toward.

AUTHORS CONTRIBUTION
All authors of this article made substantial contributions to conception and design,
and/or acquisition of data. S. Sriram, V. Aiswaria, A. Cijo and T. Mohankumar
analyzed and interpreted data. Also participated in drafting the article, revising it
critically for important intellectual content; and all authors gave final approval of
the version to be submitted and any revised version.

Footnotes
Source of Support: Nil
Conflict of Interest: None declared.

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