Online - 2455-3891

Vol 12, Issue 3, 2019 Print - 0974-2441

Research Article

EVALUATION OF ANTIBIOTICS USED IN PATIENTS WITH ACUTE RESPIRATORY INFECTIONS

IN A HOSPITAL

PRICELLA AQWILLA GINTING*, AZIZAH NASUTION, KHAIRUNNISA KHAIRUNNISA

Department of Pharmacology, Faculty of Pharmacy, University of Sumatera Utara, Medan, Indonesia. Email: [email protected]
Received: 22 November 2018, Revised and Accepted: 12 December 2018

ABSTRACT

Objective: This study evaluated the use of antibiotics in the treatment of patients with acute respiratory infection (ARI) in the outpatients installation
in Bunda Thamrin General Hospital, Medan.

Methods: This prospective descriptive cohort study analyzed the use of antibiotics provided to patients with ARI using Indonesian universal health
coverage known as Badan Penyelenggara Jaminan Sosial claims (n=130) in outpatients installations from March to May 2018. The characteristics of the
patients were organized and descriptively analyzed in Excel and SPSS programs. The antibiotics provided were grouped according to the Anatomical
Therapeutical Chemical code and class; then, the dosage form, defined daily dose (DDD) units, was converted into milligrams. DDD calculation was
done by dividing the total DDD usage with the total number of patients.

Results: Mean age of the patients was 32.12±10.579 years. The highest quantity of antibiotic use in DDD/1000 patients-day units was cefixime
reaching 1,897.435 mg DDD KPRJ.

Conclusions: Cefixime was the most widely available antibiotic for the treatment of ARI patients.

Keywords: Acute respiratory infections, Antibiotics, Anatomical therapeutical chemical/defined daily dose.

© 2019 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ajpcr.2019.v12i3.30890

INTRODUCTION Sumatera Utara; No:474/TGL/KEPK FK USU-RSUP HAM/2018). This

study was conducted to determine the amount of antibiotic use in ARI
Acute respiratory infection (ARI) disease or often referred to as ARIs is therapy and to examine the use of antibiotics in patients using the
infections caused by viruses or bacteria. This infection begins with heat Anatomical Therapeutical Chemical (ATC)/DDD methods. Inclusion
accompanied by one or more symptoms: Throat pain or pain, runny criteria in this study were outpatients diagnosed with ARI and received
nose, dry cough, or phlegm. ARI is always ranked first of the 10 most antibiotic therapy. Exclusion criteria were pregnant patients and
diseases in Indonesia [1]. suffered from HIV and cancer. As many as, 130 patients diagnosed ARI
met inclusion criteria in the study period. Patients data recorded on the
In Medan, the incidence of ARI was 225,494 cases (47.62%), and in
data collection sheet included: Patients age, gender, and medication
Deli Serdang District, the cases of ARI were 12,871 cases (31.7%) of
used. Recorded data on ARI drug types used include dosage form,
the total population. Deli Serdang Regency and Medan are regions
dosage, and number of uses.
that have high rates of morbidity of ARI in infants [2]. As many as,
40%–60% of ARI cases were outpatients, while only 15–30% of them The ATC classification is based on the antibiotic code, the DDD
were treated as outpatients [3]. In Padang Bulan Health Center, Medan, calculation of each antibiotic is obtained by the total number of
ARI patients reached 19,038 cases in 2011. Cases of ARI increased to drugs that say in milligrams. The results of the use of antibiotics
21,536 in 2012 [4]. per patients were carried out using DDD/1000 patients. Data from
the DDD/1000 patients calculations were changed in the form of
Based on Sarini’s research (2015) on antibiotic use in the North
percentages and then cumulative. All analyses patient’s characteristics
Gorontalo Regency, it was proved that there were nine types of
were done using Microsoft Excel and SPSS Statistics version 16.0
antibiotics used in ARI patients in district health centers, but only
(SPSS Inc.). p=0.05 looks statistically significant. This natural medicine
three types of antibiotics included in 90% drug utilization segment,
is obtained from an e-catalog. This research is disastrous by the
they were amoxicillin 500 mg, ciprofloxacin 500 mg, and cefadroxil
organizers of research and ethics at the University of Sumatera Utara.
500 mg [5]. A similar study conducted by Ratna found that antibiotics
It was carried out in accordance with ethical standards provided by the
that have the highest bed-days (100 defined daily dose [DDD] per bed-
University of Sumatera Utara, Faculty of Medicine.
days) are ampicillin (22.4). The highest antibiotic with prescribed daily
dose (PDD) and DDD values of 100 bed-days was cefotaxime with a PDD RESULTS
value of 154.3 and a DDD value of 100 bed-days at 16.7 [6].
Of 139 patients, only 130 patients met the inclusion criteria.
METHODS Characteristics of these patients included gender and age of patients
are presented in Table 1. Based on the gender of patients diagnosed
This research is a prospective cross-section descriptive study with ARI during March–May 2018 period, of 130 patients, it was
design. The required data were obtained from medical records and evident that most (59%) of the patients were male, while only 42% of
prescription of ARI patients at the outpatients installation of the Bunda them were female. However, based on the results of statistical analysis,
Thamrin General Hospital, Medan, for March 2018–May 2018 which there were no significant differences between the number of male and
was approved by Health Research Ethical Committee (University of female patients (p=0.586).
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Asian J Pharm Clin Res, Vol 12, Issue 3, 2019, 480-483

Table 1: Characteristics of the patients with ARI (n=130) in of azithromycin and clarithromycin, and the latter was divided into two
Bunda Thamrin Hospital types, namely levofloxacin and ciprofloxacin.

No Age group (years) Male Female n (%) DDD is the assumption that the average dose per day of antibiotic uses
1 Early teenager (12–16) 5 3 8 (6.15) for certain indications in adults. To obtain standard data and to be able
2 Late teenager (17–25) 14 13 27 (20.76) to compare data elsewhere, the WHO recommends the classification of
3 Early adult (26–35) 33 20 53 (40.76) antibiotic use by ATC classification (Table 3) [9].
4 Late adult (36–45) 18 8 26 (20)
5 Early elderly (46–55) 6 7 13 (10) Evaluation of the use of antibiotics from 130 patients in Medan
6 Late elderly (56–65) 0 3 3 (2.30) General Hospital, Medan, was carried out using the calculation of
Total number 76 54 130 (100) DDD 1000 patients-days. This study found that there are 6 types of
antibiotics that used in the treatment of ARI patient with a total value
of DDD/1000 patients-days of 7,239.73 and an average of 1,206.62 for
the 6 types of anitbiotics based on the ATC code and the standard value
of WHO DDD (in mg).

Based on the data obtained then the calculation of the quantity of

antibiotic is used by following the rules established by the WHO
Collaborating Center 2011. Antibiotics are grouped according to the
ATC code and class; then, the dosage form is adjusted to the definitive
DDD units of each antibiotic use by patients. The definitive DDD unit
uses milligram, so the unit of antibiotic dose must be converted into
milligrams first [10].

DISCUSSION

The highest prevalence of patients in the age group of ARI patients is the
age range of 26–35 years with a percentage of 53 patients (40.76%). The
results of statistical tests for age groups showed no significant differences
with p=0.098 (p<0.05), different from the research conducted by Marniati,
Fig. 1: Characteristics of acute respiratory infection patients based
in 2017, on the analysis of causal factors on the incidence of ARI, namely
on gender
the frequency of the age of respondents with ARI in the region of West
Aceh health centers with the highest number: Age 36–40 years 38 people
Based on the characteristics of the gender group of 130 ARI patients (37.8%) [11]. According to the WHO in 2014 sStates that the causes of
from March to May 2018, there were 76 males (58.461%) and 54 females acute respiratory tract infections vary widely, the onset of symptoms can
(41.538%). Based on the results of statistical analysis, there were no take place starting from hours to days after the onset of infection. The
significant differences between the number of male and female patients symptoms of this disease consist of fever, coughing, and frequent sore
p=0.586 (p<0.05). A research conducted by Ahyanti about relationship throat, runny nose, shortness of breath, wheezing, or difficulty breathing.
between smoking and the incidence of ARI in students in tanjung reef Pathogens that cause acute respiratory tract infections are influenza
(2013), showed that various risk factors that increase the incidence of virus, parainfluenza virus, rhinovirus, respiratory syncytial virus, and
ARI are with male gender. Proven with the results of the study, from the severe respiratory syndrome coronavirus [12].
students suffering from ARI, 58.0% of them were manifold male gender,
p=0.041, meaning there is a meaningful relationship between genders Based on the data of ARI patients, it was found that the highest number
with ARI [7]. of patients based on gender were male patients with the number 76
patients (58,4%) obtained by dividing the number of male patients
The pattern of antibiotic use in outpatients with ARI based on diagnosis with the total number of patients then multiplied by 100%, this is the
is shown in Figs. 1 and 2. same as research in Mei Ahyanti’s about smoking relationship with
the incidence of ARI in students in Tanjung reef (2013). Proven with
Of the six age groups of the patients, it was found that the age group the results of the study, from the students suffering from ARI, 58.0%
of 26–35 years had the highest prevalence with amount of 53 patients of them were manifold male gender, p=0.041, meaning there is a
(40.76 %), followed by 17–25 years was 27 patients (20.76%), age meaningful relationship between genders with ARI [7].
group of 36–45 years was 26 patients (20%), and the age group of
46–55 years had a percentage of 13 patients (10%), compared to From the classification of the WHO Collaborating Center, the data
the age group of 12–16 years had a percentage of 8 patients (6.15%) obtained were 130 cases, March–May 2018 use by ARI patients,
while the lowest number of patients was in the 56–65 years age group treatment profiles of ARI patients in outpatients installations
of 3 patients (2.30%). The results of statistical tests for age groups distributed into three classes of drugs and six types of antibiotics. The
showed no significant differences with p=0.098 (p<0.05). The mean age highest use of antibiotics in patients with ARI is azithromycin antibiotic.
of the patients was 32.12±10.58 years. This is based on the activity of azithromicin which has more potent
antibacterial activity to gram negative, wider distribution volume and
In the ATC classification system, active substances are divided into longer half-life so that it is preferred for respiratory tract infections
different groups according to the organ or system where the drug works (Table 2) [13].
and produces therapeutic, pharmacological, and chemical properties [8].
Based on the classification system by the WHO Collaborating Center, Based on the data obtained, the calculation of the quantity of
classification of the antibiotic use from the 130 patients was obtained. antibiotic is used by following the rules established by the WHO
The present study found three classes of antibiotics that they were Collaborating Center 2011. Antibiotics are grouped according to the
cephalosporin, macrolide, and quinolone, consisting of cefixime, ATC code and class; then, the dosage form is adjusted to the definitive
cefadroxil, azithromycin, clarithromycin, levofloxacin, and ciprofloxacin DDD units of each antibiotic use by patients. The definitive DDD unit
of antibiotics used in the treatment of ARI (Table 3). In this study, the uses milligram, so the unit of antibiotic dose must be converted
data of the cephalosporin group were divided into two types, namely into milligrams first [10]. Based on the study, “evaluation of the
cefixime and cefadroxil, while the macrolide antibiotic group consisted use of antibiotics in ARIs in the pediatric group at the Yogyakarta

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Table 2: Class of antibiotics

Class of antibiotics ATC code Type of antibiotics Preparation Strength of preparation

Cephalosporin J01DD08 Cefixime Oral 200
J01DB05 Cefadroxil Oral 500
Macrolide J01FA10 Azithromycin Oral 500
J01FA09 Clarithromycin Oral 500
Quinolone J01MA12 Levofloxacin Oral 500
J01MA02 Ciprofloxacin Oral 500
ATC: Anatomical therapeutical chemical

Table 3: Quantity of antibiotic use in ARI patients in DDD/1000 patients‑day unit

ATC code Type of antibiotics DDD standards value of the WHO (mg) DDD/1000 patients‑day
J01DD08 Cefixime 400 1223.076
J01FA10 Azithromycin 300 1897.435
J01DB05 Cefadroxil 2000 265.38
J01MA12 Levofloxacin 500 115.38
J01MA02 Ciprofloxacin 1000 69.23
J01FA09 Clarithromycin 500 153.85
Amount 7239.73
Average 1206.62
ATC: Anatomical therapeutical chemical, DDD: Defined daily dose

Fig. 2: Characteristics of the patients according to age

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