ANTIBIOTIC USE IN PATIENTS WITH ANTIBIOTIC USE IN PATIENTS WITH FEVER OF UNKNOWN ORIGIN (FUO) FEVER OF UNKNOWN ORIGIN (FUO) AT PANTI RAPIH HOSPITAL AT PANTI RAPIH HOSPITAL YOGYAKARTA-INDONESIAYOGYAKARTA-INDONESIA

Hartayu T1 , Asdie HAH2, Suryawati S31 Faculty of Pharmacy Sanata Dharma

University2 Department of Internal Medicine and

3 Department of Clinical Pharmacology, Faculty of Medicine Gadjah Mada University,

Yogyakarta

ABSTRACTABSTRACTProblem Statement:Problem Statement: Antibiotics accounted as the biggest part of drug costs paid by patients Antibiotics accounted as the biggest part of drug costs paid by patients admitted to Panti Rapih hospital, and fever of unknown origin (FUO) was the most prominent admitted to Panti Rapih hospital, and fever of unknown origin (FUO) was the most prominent diagnosis reported. diagnosis reported. Objectives:Objectives: To evaluate the pattern of antibiotic use in patients admitted with FUO in Panti Rapih To evaluate the pattern of antibiotic use in patients admitted with FUO in Panti Rapih hospital, Indonesia.hospital, Indonesia.Design:Design: An explorative study with retrospective quantitative data collection and prospective An explorative study with retrospective quantitative data collection and prospective qualitative data collection. All patients admitted to Panti Rapih Hospital with FUO as diagnosis at qualitative data collection. All patients admitted to Panti Rapih Hospital with FUO as diagnosis at admission during the period of December 1996 to June 1997 were selected. Quantitative data admission during the period of December 1996 to June 1997 were selected. Quantitative data were collected to assess the pattern of antibiotic use in FUO and the pattern of diagnosis at both were collected to assess the pattern of antibiotic use in FUO and the pattern of diagnosis at both admission and discharge. Qualitative data were collected using in-depth interviews with admission and discharge. Qualitative data were collected using in-depth interviews with prescribers and the paramedic chiefs of the wards to explore the reasons for antibiotic use , and prescribers and the paramedic chiefs of the wards to explore the reasons for antibiotic use , and identifying final diagnoses. identifying final diagnoses. Setting and Population:Setting and Population: All patients hospitalized with FUO as diagnosis at admission in Panti Rapih All patients hospitalized with FUO as diagnosis at admission in Panti Rapih Hospital, during period of December 1996 to June 1997.Hospital, during period of December 1996 to June 1997.Outcome Measures:Outcome Measures: Pattern of diagnoses at discharge (final diagnosis), number of antibiotics Pattern of diagnoses at discharge (final diagnosis), number of antibiotics received, the kind of antibiotics received, the route and administration of antibiotics, average received, the kind of antibiotics received, the route and administration of antibiotics, average length of stay, range of drug cost during hospitalization, reasons of antibiotic usage. length of stay, range of drug cost during hospitalization, reasons of antibiotic usage. Results:Results: Out of 273 cases analyzed 48 cases (18%) had FUO as final diagnosis, and the rest were Out of 273 cases analyzed 48 cases (18%) had FUO as final diagnosis, and the rest were diagnosed as having upper respiratory infection 37 cases (14%), dengue fever35 cases (13%), no diagnosed as having upper respiratory infection 37 cases (14%), dengue fever35 cases (13%), no final diagnosis 18 cases (10%)and others 125 cases (45%). In total 90% of cases used antibiotic, final diagnosis 18 cases (10%)and others 125 cases (45%). In total 90% of cases used antibiotic, either oral or injection, despite the fact that antibiotic were not recommended for this diagnosis. either oral or injection, despite the fact that antibiotic were not recommended for this diagnosis. The average length of stay was 5 days (range:1 day – 9 days). Drug cost varied greatly, with the The average length of stay was 5 days (range:1 day – 9 days). Drug cost varied greatly, with the highest cost observed (US$45.15) being 16 times the lowest (US$ 2.90).Reasons for antibiotic use highest cost observed (US$45.15) being 16 times the lowest (US$ 2.90).Reasons for antibiotic use were generally based on personal or colleagues’ experiences, an assumption of infection despite were generally based on personal or colleagues’ experiences, an assumption of infection despite clinical observation, the absence of a standard treatment for FUO, drug promotion, and negligence clinical observation, the absence of a standard treatment for FUO, drug promotion, and negligence in updating information. in updating information. Conclusions:Conclusions: Antibiotics were used in 90 % of patients with FUO. Efforts should be pursued to Antibiotics were used in 90 % of patients with FUO. Efforts should be pursued to reduce the unnecessary use of antibiotics including provision of standard treatment guideline for reduce the unnecessary use of antibiotics including provision of standard treatment guideline for FUO.FUO.Funding Sources:Funding Sources: Self Funded. Self Funded.

BACKGROUNDBACKGROUNDPanti Rapih is a private hospital in Panti Rapih is a private hospital in

Yogyakarta-Indonesia, has 367 beds Yogyakarta-Indonesia, has 367 beds with 12 specialist departments and with 12 specialist departments and 10 subspecialist departments, and 10 subspecialist departments, and has more than 80% Bed Occupation has more than 80% Bed Occupation Rate.Rate.

Antibiotics accounted as the biggest Antibiotics accounted as the biggest part of prescription cost and Fever of part of prescription cost and Fever of Unknown Origin (FUO) was the most Unknown Origin (FUO) was the most prominent diagnosis reported.prominent diagnosis reported.

OBJECTIVESOBJECTIVES GeneralGeneral

To evaluate the pattern of antibiotic use for To evaluate the pattern of antibiotic use for patients admitted with FUO at Panti Rapih patients admitted with FUO at Panti Rapih Hospital, Yogyakarta-Indonesia.Hospital, Yogyakarta-Indonesia.

SpecificSpecific          To find out: To find out:

The pattern of antibiotics prescribed for FUOThe pattern of antibiotics prescribed for FUO Reasons of antibiotic use Reasons of antibiotic use Strategy to improve the appropriateness of Strategy to improve the appropriateness of

antibiotics used in FUOantibiotics used in FUO

METHODS METHODS Design:Design:

An explorative study with An explorative study with retrospective quantitative data retrospective quantitative data collection and prospective qualitative collection and prospective qualitative data collection.data collection.

Setting:Setting: All patients admitted to Panti Rapih All patients admitted to Panti Rapih

hospital with FUO as diagnosis at hospital with FUO as diagnosis at admission.admission.

Time period of data collection : Time period of data collection : December 1996 to June 1997  December 1996 to June 1997  

STUDY DESIGNSTUDY DESIGNAll patients admitted with FUO in Panti Rapih Hospital Dec ’96-June ‘97 (273 patients)

FUO as final diagnosis48 patients

Quantitative dataQuantitative data

Qualitative DataQualitative Data

Observation on prescriptions in medical record

In-depth interview with prescribers and chiefs of wards (paramedic)

Pattern of Antibiotic use

Reason of Antibiotic use

Reference:Reference:Current Medical Diagnosis and Treatment (Jacobs, 2004):•Broad spectrum antibiotic with haematological examination result

Reference:Reference:Guide to Good Prescribing (WHO,1994)

Identify Strategy to Improve the appropriateness of Antibiotic use

Other final Diagnoses• Upper respiratory infection: 37 patients

Others: 125 patients• Dengue fever : 35 patients No

final Diagnosis: 18 patients

Result 1, Diagnosis at hospital dischargeNo Diagnosis 0-5

(Years old)

5-12 (Years old)

>12(Years old)

Total

1 FUO 11 5 32 48 (18%)

2 Upper respiratory infection

29 4 4 37 (14%)

3 Dengue fever 7 13 15 35(13%)4 Others 11 1 16 125(45%

)5 No final

diagnosis31 18 76 18(10%)

FUO had contributed for 18% of all final diagnoses, and data in reference showed (10-15 %) (Jacobs, 1994)

Result (2),Types of Antibiotic Used in FUO December ‘96 –

June ‘97

Patient’s Age

(years)

Number of patients

Types of Antibiotic

0 – 5 11 Erythromycin, Amoxycilin, Ceftriaxone, Cotrimoxazole

5 - 12 5 Cotrimoxazole

>12 32 Amoxycillin, Ampicillin, Chloramphenicol Spyramycin, Ofloxacin, Pefloxacine, Cefixim,

Cefetamed, Cefprozil

• Narrow spectrum antibiotic were used for adults but were not used for children.

Age (years) Number ofpatients

Without antibiotics

Recieved 1 or 2 antibiotics

0 – 5 11 3 85 – 12 5 1 4> 12 32 1 31

Total 48 5 (10%) 43 (90%)

Result (3), Number of Patients with FUO receiving antibiotic December 1996 – June 1997

• 90% patients received 1 or 2 kind of antibiotic before the haematological examination results.

RESULT (4), REASONS OF ANTIBIOTICS USE Reasons of antibiotics use :An assumption of infection despite clinical

observationUncertainty of sterilization of hospital

environmentTakes too long to wait for laboratory examination

resultsModeling personal or colleagues’ experiencesNegligence of updating informationDrug promotion

Note: standard guideline for FUO was not available in the hospital

DISCUSSIONS (1)DISCUSSIONS (1) The data shows that narrow spectrum antibiotic The data shows that narrow spectrum antibiotic

such as Spiramycin and Chloramphenicol were such as Spiramycin and Chloramphenicol were used, despites the fact that narrow spectrum used, despites the fact that narrow spectrum antibiotics are not recommended for FUO. antibiotics are not recommended for FUO.

Jacobs (2004) recommended that broad Jacobs (2004) recommended that broad spectrum antibiotics might be given for FUO spectrum antibiotics might be given for FUO patients. Narrow spectrum antibiotic can not be patients. Narrow spectrum antibiotic can not be given unless there’s a strong evidence to a given unless there’s a strong evidence to a specific diagnosis.specific diagnosis.

The evidence of FUO as the final diagnosis in The evidence of FUO as the final diagnosis in this hospital (17,6%) was slightly higher than this hospital (17,6%) was slightly higher than that reported in reference (10 – 15%)( Jacobs, that reported in reference (10 – 15%)( Jacobs, 1994). The factor that might contribut to this 1994). The factor that might contribut to this phenomenon was insensitivity of diagnosis tools.phenomenon was insensitivity of diagnosis tools.

Discussion (2)Discussion (2) Among the reasons to use antibiotics in FUO Among the reasons to use antibiotics in FUO

was personal or colleagues’ experiences, was personal or colleagues’ experiences, eventhough experience is not always reliable. eventhough experience is not always reliable. Therefore an agreement to use the reliable Therefore an agreement to use the reliable reference such as diagnosis guideline and reference such as diagnosis guideline and hospital standard treatment guideline are hospital standard treatment guideline are urgently needed.urgently needed.

The drug costs varied widely (US$ 2.90 to US$ The drug costs varied widely (US$ 2.90 to US$ 45.15), and factor what might contribute to this 45.15), and factor what might contribute to this result is the unavailability of agreement among result is the unavailability of agreement among prescribers in this hospital on which drug and prescribers in this hospital on which drug and which brand name should be selected for FUO. which brand name should be selected for FUO.

CONCLUSIONSCONCLUSIONS Narrow spectrum antibiotics were used Narrow spectrum antibiotics were used

for adults patient with FUO eventhough for adults patient with FUO eventhough they are not recommended.they are not recommended.

Agreement among the prescribers is Agreement among the prescribers is urgently needed to standardize the urgently needed to standardize the management of FUO in Panti Rapih management of FUO in Panti Rapih Hospital.Hospital.

Effort should be sought to update the Effort should be sought to update the improving standard diagnosis and improving standard diagnosis and treatment guideline for FUO.treatment guideline for FUO.