Antibiotic use Profiles and Microbial Patterns in the Surgery Department of Bangil Regional General Hospital, Pasuruan
Fauna Herawati1*, Beatrix Eyleen Giovanny1, Rika Yulia1and Abdul Kadir Jaelani2
1Faculty of Pharmacy, University of Surabaya, Surabaya
2Regional General Hospital Bangil, Jl. Raya Raci - Bangil,Indonesia
Submission: September 04, 2018; Published: October 25, 2018
*Corresponding author: FaunaHerawati, Faculty of Pharmacy, University of Surabaya, Jalan Raya Kalirungkut, FF Building, 5th Floor, Surabaya 60293, Indonesia
How to cite this article: Fauna Herawati, Beatrix Eyleen Giovanny, Rika Yulia, Abdul Kadir Jaelani. AAntibiotic use Profiles and Microbial Patterns in the Surgery Department of Bangil Regional General Hospital, Pasuruan. Glob J Pharmaceu Sci. 2018; 6(3): 555689. DOI: 10.19080/GJPPS.2018.06.555689.
This study aimed to determine the profile of the use of antibiotics in units of DDD / 100 patient-days, types of bacteria as well as the sensitivity of bacteria in the Surgery Department of Bangil Regional General Hospital, Pasuruan during the period from January to June 2016. The study was conducted using a descriptive, cross-sectional study design and data collection was done retrospectively. Nineteen percent patients in the surgical ward was given antibiotic. The results showed that the 3 most-used antibiotics are ciprofloxacin (11.8 DDD / 100 patient-days), ceftazidime (6.7 DDD / 100 patient-days), and cefixime (4.3 DDD / 100 patient-days). Ciprofloxacin became the most widely used antibiotics with DU of 26% from the total antibiotic. Within six months, there are four bacteria identified from the culture test result, i.e.: Staphylococcus aureus, Klebsiella pneumoniae, Stenotrophomonas maltophilia and Acinetobacter sp. Only vancomycin is an antibiotic which has 100% sensitivity to S. aureus. The DDD / 100 patient-days for 19% patients is 45.83, this result shows that the trend of using antibiotic is more than one DDD antibiotic per day.
Keywords: Antibiotic; ATC/DDD; DU 90%; Sensitivity of bacteria; Surgical department
Key message: Antibiotic stewardship programme is urgently needed due to a high antibiotic use in the hospital
Infectious diseases are one of the causes of high morbidity and mortality. Data obtained from the World Health Organization (WHO) showed that infectious diseases have caused 1.4 million deaths per days in the world and developing countries, including Indonesia. A study conducted at several hospitals in Indonesia in 2004 showed that 9.8% of hospitalized patients suffered from nosocomial infections. According to the Ministry of Health, Republic Indonesia, in 2011, the incidence of surgical wound infections in public hospitals amounted to 55.1%.
Bacterial infections could be treated with antibiotics. However, the success of antibiotics in curing infections creates a new problem, which is the growing population of bacteria being resistant to antibiotics. Inappropriate use of antibiotics will result in bacteria or microbes becoming resistant to the antibiotic, thus causing the antibiotics to lose their functions[1-4]. Based on an assessment carried out in Dr. Soetomo General Hospital (Surabaya) and Dr. Kariadi General Hospital Medical Center (Semarang) regarding wise use of antibiotics, it was proven that 30% to 80% of the antibiotics used were not based on indications.
Controlling the use of antibiotics is considered necessary to reduce the incidence of antibiotic resistance. One way of doing so is through the implementation of an Antibiotic Stewardship Program, which is an institutional or healthcare system approach to promote and monitor the use of antibiotics appropriately to maintain its effectiveness. The Ministry of Health in Indonesia has established an Antimicrobial Resistance Control Program (ARCP) team to support and oversee the running of Antibiotic Stewardship Program, which is recommended by the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). The Health Ministerial Regulation of 2015 states that every hospital in Indonesia must implement an Antimicrobial Resistance Control Program optimally[6-8].
This research is a retrospective, descriptive, observational cross-sectional study. The research material was data on antibiotic usage in the Surgery Department of Regional General Hospital Bangil during January - June 2016 period obtained from the Pharmacy Installation of Regional General Hospital Bangil, which was then calculated and expressed in DDD units (defined daily dose) per 100 patient days, as well as calculated using Drug
Utilization 90% (DU 90%) method to discover the most widely
used antibiotics within 6 months. In addition, data on bacterial
culture obtained from the microbiology laboratory of Regional
General Hospital Bangil were also used to find out the types of
bacteria and the percentage of bacterial sensitivity in the Surgery
Department of Regional General Hospital Bangil during the
period of January - June 2016. The formula to calculate DDD per
100 patient-days is modified from DDD/1000 population/day as
Several adjustments to the formula are i. the specific period
of a month, ii. patient-day derived from the total length of stays of
the patient. The DDD is the assumed average maintenance dose
per day for a drug used for its main indication in adults.
The defined daily dose (DDD) per 100 patient-days and DU90%
data were derived and calculated from pharmacy databases;
whereas a bacterial culture test was from any adult patient (aged
≥ 14years) specimen in the surgical ward of Regional General
Hospital Bangil in the period of January-June 2017.
The data analysis in this study is a descriptive analysis. The
calculation results of antibiotics use and percentage of bacterial
sensitivity to antibiotics are presented in the form of graphs and
From a total of 3016 patients in the surgical wards of Regional
General Hospital Bangil, 572 patients received antibiotic therapy.
In this research, 20 types of antibiotics consisting of 9 oral and 13
parenteral preparations were used. The total number of DDD /
100 patient-days in the surgical wards in January was 45.83, the
detailed data could be seen in (Table 1).
According to these data, the 3 (three) most commonly used
antibiotics in the surgical wards during January – June 2016 were
ciprofloxacin (11.78 DDD / 100 patient-days), ceftazidime (6.66
DDD / 100 patient-days), and cefixime (4.27 DDD / 100 patientdays).
The 90% DU antibiotics during the period from January
to June 2016 there were ciprofloxacin, ceftazidime, cefixime,
metronidazole, gentamicin, cefadroxil, ceftriaxone, amoxicillin,
amikacin, meropenem. Based on data obtained from the
microbiology laboratory, 35 isolates were found, and 25 antibiotics
were tested on sensitivity to 14 bacteria, as shown in (Table 2).
These bacteria are Gram-negative bacteria, such as Acinetobacter
Sp.(7), Escherichia coli(2), Enterobacteraerogenes(1),
Enterobacter agglomerous(2), Enterobactercloacae(1), Klebsiella ozaenae(1), Klebsiellapneumoniae (3), Pragia fontium(1), Shigella
dysenteriae(1), Stenotrophomonas maltophilia(4) and Grampositive
bacteria, such as Staphylococcus aureus(9), Staphylococcus
simulans(1), Streptococcus mitis (1), Streptococcus pyogenes(1).
Having tested the four isolates, it was found that Klebsiella
pneumoniae bacteria were the most resistant to antibiotics. (Table
3) shows the percentage of antibiotic resistance in Klebsiella
pneumonia. It could be seen that resistance to most of the
antibiotics tested was found, such as to gentamicin, ciprofloxacin,
ceftriaxone, ceftazidime, and meropenem. Those antibiotics were
considered as the top 10 most-used antibiotics in the Surgical
Wards of Bangil Regional General Hospital during the period of
The number of DDD / 100 patient days was 45.83. This
number is like the number of antibiotics used in the surgical
wards of Dr. Karjadi Hospital in Semarang in 2008, which was 51.8
DDD / 100 patient-days[5,11-13]. The number of antibiotics used
was a combined data from all patients in the surgical wards who
used antibiotics without looking at the diagnosis, thus the value of
DDD cannot described its appropriateness to every indication. It
is necessary to conduct further research that considers the patient
diagnosis during antibiotic therapy and other factors influencing
the use of antibiotics.
In the calculation result regarding the number of DDD /
100 patient days, the major parenteral antibiotics used during
the months of January to June 2016 were also reported, i.e.
ceftazidime (6.66 DDD / 100 patient days). The increase in the use
of ceftazidime may be due to a shortage of ceftriaxone injection
in the Pharmacy Department of Regional General Hospital Bangil
in the early 2016, which was most widely used in the surgical
wards of Regional General Hospital Bangil. A research conducted
at Dr. Kariadi Hospital in Semarang also suggested that the most
widely used antibiotics was ceftriaxone amounting to 36.9 DDD
/ 100 patient-days.5 The use of ceftazidime as a substitute for
ceftriaxone is appropriate as both ceftazidime and ceftriaxone are
in the same class of antibiotics, which are the third-generation
cephalosporins. The high level of ciprofloxacin use in the
surgical wards could be caused by several factors, such as the
administration of oral dosage after patients were discharged from
the hospital and the diagnosis during hospital stays in the Surgical
Wards of Regional General Hospital Bangil.
The use of ceftazidime in the form of injections was also
relatively high because, at the beginning of 2016, the Pharmacy
Department of Regional General Hospital Bangil had a shortage
of ceftriaxone injection, which was most widely used in the
surgical ward of Regional General Hospital Bangil. The reasons
for ceftazidime’s highly use is as a substitution for ceftriaxone
during the period of January-June 2016. These factors could be
used as a reference for further research regarding the use of
antibiotics in surgical wards. From the data on DDD / 100 patient
days of each antibiotic, the 90% DU segment was then calculated
to identify the most commonly used antibiotics in the surgical
wards. Antibiotics in the 90% DU segment in order from largest
to smallest were ciprofloxacin (26%), ceftazidime (15%), cefixime
(9%), metronidazole (9%), gentamicin (7%), cefadroxil (7%),
ceftriaxone (5%), amoxicillin (5%), amikacin (4%), meropenem
(4%). Ciprofloxacin antibiotics were the most widely used
antibiotics with DU of 26%. The antibiotics in the 90% Cumulative
list were the types of antibiotics recommended in the National
Formulary, published in 2016.
The use of antibiotics as therapy in patient care greatly affects
the growth of bacteria, in which they could become resistant
to antibiotics that do not correspond to the existing resistance
patterns. Therefore, the researchers collected data regarding the
results of bacterial culture to find out the types of bacteria that
grew and antibiotic sensitivity in the surgical wards of Regional
General Hospital Bangil during January to June 2016. The four
bacteria could grow and cause surgical site infections (SSI) in
the surgical wards. In the surgical wards of Bangil Hospital,
the culture test is not always performed on SSI patients, but also
on patients diagnosed open fractures. This is like the results of
a study carried out at a hospital in Yogyakarta during August 2013-August 2015, as the types of bacteria that grew were
the same as in the surgical wards of Regional General Hospital
Bangil, such as Staphylococcus aureus(12), AcinetobacterSp. (3),
Stenotrophomonas maltophilia(1), and Klebsiella pneumoniae(1)
The four bacteria were then calculated on the percentage of
sensitivity and resistance to antibiotics. The result showed that
Klebsiella pneumoniae bacteria were resistant to most antibiotics.
All Staphylococcus aureus bacteria sensitive to vancomycin
(100%). From these data, we cannot obtain microbial patterns
because the number of isolates of each bacterium was insufficient
and not all specimens gave positive isolate in the culture test. In
addition, it was not possible to calculate the sensitivity percentages
of several antibiotics due to the small number of isolates. These
sensitivity test bacteria to antibiotics are classified into 3
(three) categories, i.e.: usually effective clinically, if the antibiotic
sensitivity test result is more than 60% of all examinations;
intermediate effective clinically, if the antibiotic sensitivity test
result is between 30-60% of all examinations; and not effective
clinically, if the antibiotic sensitivity test result is less than 30%
based on Sanford Guide to Antimicrobial Therapy 40th ed, .
Further research is required to obtain enough isolates and results
of all antibiotic susceptibility tests.
From a total of 3016 patients in the surgical wards of Bangil
Regional General Hospital, 572 patients used antibiotics. The
number of DDD / 100 patient days was obtained from data on
antibiotics use in the surgical wards of Regional General Hospital
Bangil. The most antibiotics use in the surgical wards was
There were 14 bacteria growing during a cultural test carried
out on 35 antibiotics, which consisted of 23 gram-positive bacterial
isolates and 12 gram-negative bacterial isolates. Those bacteria
were mostly gram-negative bacteria (Acinetobacter Sp., Klebsiella
pneumoniae, Stenotrophomonas maltophilia) and gram-positive
bacteria (Staphylococcus aureus). The most commonly used
types of antibiotics resistant to Klebsiella pneumonia in the
surgical wards during January-June 2016 period were gentamicin,
ciprofloxacin, ceftriaxone, ceftazidime, and meropenem.
Based on the research that has been conducted, the following
suggestions could be given: i. Further prospective research is
necessary to obtain enough cultural isolates to determine the
microbial patterns in the Surgery Department of Regional General
Hospital Bangil, ii. Testing bacterial culture on patients who take
antibiotics after 3 days and who use prophylactic antibiotics and
suffer from a surgical site infection, iii. Further research on the
use of antibiotics about patient diagnosis is required, iv. Updating
antibiotic therapeutic guideline related to antibiotics use based
on the microbial pattern in the surgical wards.