Infection Control & Hospital Epidemiology
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Fig. 1. Antimicrobial agents used at primary, secondary, and tertiary-level hospitals, southern Sri Lanka, 2017.
Microbiologists’ guidelines for common indications and (2) redundant combinations of antimicrobials.6 Guideline-discordant therapy was defined as the use of any antimicrobial not recom- mended as primary therapy for lower respiratory tract infection, cellulitis/soft-tissue infection, urinary tract infection, surgical prophylaxis, or upper respiratory infection. Redundant therapy was defined as the concurrent use of ≥2 β-lactam antibiotics or ≥2 antibiotics active against anaerobes, Pseudomonas aeruginosa, or methicillin-resistant Staphylococcus aureus.
Results Study population
In total, 1,709 patients were included in the point-prevalence surveys: 1,190 (69.6%) from the tertiary-level hospital, 371 (21.7%) from the secondary-level hospital, and 148 (8.7%) from the primary-level hospitals. Among the screened patients, 943 (55.2%) were in medical wards, 465 (27.2%) were in surgical wards, 221 (12.9%) were in pediatric wards, and 80 (4.7%) were in intensive care units. Most patients (55.6%) were male, and the median age was 42.2 years (interquartile range [IQR], 21–63 years) (Supplemental Table 1). Only 25 patients (1.5%) had a reported antimicrobial allergy, with most common allergies being to β-lactam antibiotics. Median hospitalization duration at the time of the survey was 5.9 days (IQR, 2–6days).
Prevalence of antimicrobial use
Among 1,709 patients enrolled in the study, 54.7% (95% CI, 52.3%–57.1%) were receiving ≥1 antimicrobial agent at time of survey. Prevalence of antimicrobial use did not vary across hos- pitals of different care levels (P=.439) but did vary significantly
across ward types: 43.1% in medical wards, 68.0% surgical wards, 61.1% in pediatric wards, and 97.6% in intensive care units (P<.001). Patients receiving antimicrobial therapy had a longer duration
of hospitalization at time of survey (median, 7.0 vs 4.5 days; P<.001) and were more likely to have a history of diabetes mellitus (18.5% vs 12.7%; P=.001) or chronic pulmonary disease (10.9% vs 5.4%; P<.001) than patients not receiving anti- microbials (Supplemental Table 1).
Antimicrobials prescribed
Among 935 patients who were prescribed antimicrobials, the most commonly prescribed antimicrobial was amoxicillin/clavu- lanic acid (n=316, 33.8% of patients receiving antimicrobials) (Fig. 1). Other commonly used antimicrobials included third- generation cephalosporins (n=221, 23.6%), metronidazole (n=155, 16.6%), clarithromycin (n=115, 12.3%), second- generation cephalosporins (n=100, 10.7%), and carbapenems (n=97, 10.4%). Approximately half of patients (n=451, 48.2%) were receiving 2 or more antimicrobial agents at the time of survey (Supplemental Table 2).
Indications for antimicrobial use
Among 935 patients on antimicrobial therapy, 350 (44.9%) had indications explicitly written in medical charts; 54.9% had indi- cations that were inferred by research assistants based on the clinical record; and 16.6% did not have indications that were written or could be inferred. Overall, the most common indica- tions for antimicrobial use were lower respiratory tract infection/ pneumonia (20.7% of patients receiving antimicrobials), cellulitis/ abscess/soft-tissue infection (19.4%), urinary tract infection/ pyelonephritis (9.7%), surgical prophylaxis (7.8%), and upper respiratory tract infection (4.3%; Supplemental Table 2). Among
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