Patterns of Documenting Patients' Medical Records and Antibiotic Use for Cases with Acute Respiratory Infection in Basrah hospitals

Authors

  • Riyadh AA Hussein Department of Community Medicine, College of Medicine, University of Basrah

Keywords:

Acute respiratory infection, antibiotics, inpatients, Basrah

Abstract

The present study was carried out to evaluate the process of documenting patients' medical records in addition to the pattern of antibiotic use in Basrah general hospitals. A retrospective type of study was conducted for antibiotic prescription in 562 inpatients' medical records of those who were admitted to paediatric wards in five hospitals in Basrah governorate because of acute respiratory infections.

The study shows that 86% of the patients stayed for less than 5 days at the hospital with 13% of them stayed between 5-10 days. All of the 562 patients' records were reviewed for documentation of the investigations taken during hospitalization, use of antibiotics and follow up while in hospital.

Around two thirds (65.5%) of the records were found to have no documentation for any investigation during hospitalization.  In addition, antibiotic therapy was found to be used in 83.3% of the cases. By comparing the WHO indications for using antibiotic therapy in acute respiratory infections cases, it was found that antibiotics were prescribed without justifiable indications in 44.7% of patients.

The study recommended re-enforcing the adoption of updated drugs use protocols and guidelines especially on the use of antibiotics in hospitals and specifically in inpatient pediatric age groups.

Furthermore, assigning clinical pharmacists in the clinical inpatients setting is one of the study recommendations in order to monitor the clinical use of these medications.

References

Jayakar NA, kutty A, Mathews SM. Changes in daily defined doses (DDD) of antibiotics after restricted use in medical inpatients. Journal of Applied Pharmaceutical Science. 2011; 01(06):220-222.

FDA. Antibiotics and Antibiotic Resistance. U.S Food and Drug Administration; 2012.

WHO. The management of acute respiratory infections in children, practical guidelines for outpatient care, World Health Organization, Geneva. 1995

Antonio da Cunha. Inappropriate antibiotic prescription to children with acute respiratory infection in Brazil. Indian Pediatrics 2003; 40: 7 – 12.

Abula T, Kedir M. The pattern of antibiotic usage in surgical in-patients of a teaching hospital, northwest Ethiopia: Ethiopian Journal of Health Development. 2004; 18(1):35-38.

MacDougall C, Polk RE. Antimicrobial Stewardship Programs in Health Care Systems. Clinical Microbiology Reviews, 2005: 638–656.

Holloway K. The World Medicines Situation. Geneva: World Health Organization; 2011

Aswapokee N, Heller RF. Pattern of Antibiotic Use in Medical Wards of a University Hospital. Bangkok, Thailand. Oxford Journals Medicine Clinical Infectious Diseases. 1989;12(1):136-141.

Susan J, Jennifer K, Elizabeth N. Guidelines for Antimicrobial Usage. Cleveland clinic; 2009

Marta L, Ciliento TG. Point prevalence study of antibiotic use in a pediatric hospital in Italy. Euro-surveillance. 2008; 13 (41):190-203.

WHO. Antimicrobial resistance: Fact sheet N°194. Updated on April 2015. Accessed online in February 2nd, 2016: http://www.who.int/mediacentre/factsheets/fs194/en/

Sachdeva V. (2010). Good documentation and quality management principles. WHO Prequalification of Medicines Programme. WHO: 2010

HCPro Inc., American Nurses Credentialing Center (ANCC). The products and services of.Consequences of an incomplete medical record. Staff Development Weekly: Insight on Evidence-Based Practice, November 18, 2005. Accessed online: http://www.hcpro.com/NRS-53207-975/The-consequences-of-an-incomplete-medical-record.html

The Medicare Learning Network (MLN), Department of Health and Human Services Centers for Medicare & Medicaid Services. Complying With Medical Record Documentation Requirements. November 2014. Accessed online in January20th, 2016: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

Blomberg B. Antimicrobial resistance in developing countries. Tidsskr Nor Laegeforen, 2008; 128:2462–2466.

Byarugaba D. A view on antimicrobial resistance in developing countries and responsible risk factors. Int. J. Antimicrob. Agents, 2004; 24: 105–110.

Brian T. Fisher, Peter A., Samir S. Shah, et al. Antibiotic Use in Pediatric Patients Admitted to a Referral Hospital in Botswana. The American Society of Tropical Medicine and Hygiene (AMJ Trop Med Hyg). 2009; 81(1):129-31.CDC.

Hogerzeil H. Promoting rational prescribing: an international perspective. Br. J. Clin Pharmacol., 1995; 39: 1–6.

Fonseca L, Conterno L. Audit of antibiotic use in a Brazilian University Hospital. Braz. J. Infect Dis, 2004; 8: 272–280.

Hadi U, Duerink DO, Lestari ES, Nagelkerke NJ, Keuter M, Huis In’t Veld D, et al. Audit of antibiotic prescribing in two governmental teaching hospitals in Indonesia. Clin. Microbiol. Infect, 2008; 14: 698–707.

Okuolu, O., Adedoyin O., Afolabi, J., Nwabueze C., Ernest M.,

est al. Acute respiratory Infections in the middle-Belt region of Nigeria. African Journal of Clinical and Experimental Microbiology. Vol: 15, May 2014: 1409

Arjumand F., Shafi S., Khalil U. Study of implementation and utilization of standard treatment guidelines for Acute Respiratory infections and blood in stools in Sindh, Pakistan. Primary Health Care Project. 1990

http://pdf.usaid.gov/pdf_docs/PNABW393.pdf

Habib OS, Ebrahim, SM. Acute respiratory infection: A study on case management in Basrah health centers. Health Policy and Planning 1994; 9: 213-

University Research Co., USAID. Operational research on: Recording and Reporting of Maternal Deaths in Iraq. USAID/Primary Health Care Project in Iraq. October 2012

Alves E., Lunet N., Correia S., Morais V. and Azevedo A. Medical record review to recover missing data in a Portuguese birth cohort: agreement with self-reported data collected by questionnaire and inter-rater variability. Department of Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal; Institute of Public Health. GacSanit vol.25 n.3 Barcelona Jun. 2011. Accessed online in February 5th , 2016:

http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0213-91112011000300007#bajo

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Published

2019-04-25

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