Editorial
What's new in critical illness and injury science? Rationale drug usage - A long way ahead! One of the first duties of the physician is to educate the masses not to take medicines. Sir William Osler Irrational drug use is a global health problem, with far reaching economic consequences. Most common reasons cited are the lack of knowledge, unethical drug promotions, and irrational prescribing habits by the clinicians.[1] Studies done to document drug use patterns indicate that overprescription, multidrug prescription, misuse of unnecessary expensive drugs, and overuse of antibiotics and other medications are the major problems.[2] With up to 10%‑40% of healthcare budgets spent on medicines globally, evidence suggests that more than half of all medicines in developing countries, and a substantial proportion of antibiotics in developed countries are used inappropriately, thus often wasting the scarce resources.[3] Improving drug use would have important financial and public health benefits. Efforts to promote rational drug use started way back in the year 1977, when World Health Organization (WHO) introduced the concept of essential drugs.[3] In response to the mounting criticisms levelled against what was increasingly recognized as ‘‘the irrational use of drugs’’ in both the industrialized countries and the third world, the term ‘rational drug use’ was formulated at the Conference of Experts on the Rational Use of Drugs held in Nairobi in 1985: Rational drug use requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost.[3] The crisis in pharmaceuticals is an international problem which demands action at all levels‑the government, the physicians, and the citizens. Globally, there is a need for Access this article online Website: www.ijciis.org DOI: 10.4103/2229-5151.124091
Quick Response Code:
drug policies which, although changing in content from one environment to another, meet the regional health needs of the world’s population. At the national level, the weakness or absence of national drug policies has been found to be an important obstacle for implementing interventions to improve drug use. Measures required for the rational drug use include the development and revision of the national essential drug list, the national formulary development, amending the pharmacy act and the opening of drug information centers.[2] Although as far as policies are concerned the developed nations are far ahead, but the scenario remains bleak in the developing world, with no restriction on over the counter dispensing of antibiotics, no functioning national antibiotic policy or a national policy to contain antimicrobial resistance.[2] India, a developing economy, has taken a lead in this regard. As a commitment to combat antibiotic resistance, the landmark ‘‘Chennai Declaration’’ 2012 is a national initiative taken by the medical community and the Indian government.[4] Following the example, others can also take a step forward. The present edition of the journal incudes an original article wherein the, drug utilization patterns in an Indian intensive care unit have been discussed, which opens a major debate toward the international issue of rational drug use. The article reports an overuse of drugs with average number of drugs used being more than 13, most commonly the antibiotics, inotropes/vasopressor, and H2 blockers. These figures almost match the worldwide literature, with average drugs use reported varying from 5 to 15.[1,5] The average number of drugs per prescription is an important index of a prescription audit. The overuse and/or misuse of drugs can lead to significant consequences, like increased costs, bacterial resistance, drug toxicities, and drug interactions.[6] Various surveillance studies report 40%-60% irrational antibiotics prescription.[6] Increasing multidrug resistance with limited availability of newer antibiotics to treat emerging multidrug‑resistant clones emphasizes the urgent need for vigilant surveillance, stringent infection control practices, use of guidelines as well as antibiotic restriction policies.[6] While the critical care unit is the area of greatest antimicrobial use and the epicenter of antimicrobial resistance in most hospitals, the vulnerability of critical care patients and the complexity of their clinical management may hinder reductions in antimicrobial use.[7]
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
227
Sodhi and Singla: Rational drug utilisation in healthcare
In order to preserve the current antibiotic arsenal, antibiotic stewardship has been proposed to reduce overuse and the correct selection of these agents.[7] Antibiotic stewardship being a multidisciplinary endeavor, it is important to build relationships with clinicians, microbiologists and nursing staff, to have a positive impact. The Infectious Diseases Society of America recently published guidelines stating that all hospitals should develop an institutional program to enhance antimicrobial stewardship.[8] Above all, drug utilization evaluation and internal audits at the institutional level are a must. For this pharmacovigilance, many hospitals have formalized the clinical role of the pharmacist in drug selection, use, and/or monitoring through the use of drug utilization review programs.[2] Another way forward is developing and maintaining an electronic documentation of the patients’ medical records, which may serve as a valuable tool for auditing the prescriptions frequently and for implementing the antibiotic policy.[2] Although international agencies like WHO and International Network for Rational Use of Drugs have applied themselves to evolve standard drug use indicators from time to time, drug utilization remains a challenge for the medical fraternity, the governments and society at large. Thus, the onus to rationalize the drug usage is on all of us. So, let’s the whole medical fraternity come forward, for WE only can make a difference! Kanwalpreet Sodhi, Manender Kumar Singla1
1
Consultant, Department of Critical Care Consultant, Department of Cardiac Anaesthesia and Critical Care, Satguru Partap Singh Apollo Hospitals, Ludhiana, Punjab, India
Address for correspondence: Dr. Kanwalpreet Sodhi, Consultant, Department of Critical Care, Satguru Partap Singh Apollo Hospitals, Ludhiana, Punjab, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4. 5. 6. 7. 8.
Saeed S, Saeed P, Sharma V. Current scenario of rational usage of various drugs in indoor patients. Int J Basic Clin Pharmacol 2012;1:27‑31. le Grand A, Hogerzeil HV, Haaijer‑Ruskamp FM. Intervention research in rational use of drugs: A review. Health Policy Plan 1999;14:89‑102. World Health Organization: Sixtieth world health assembly. Resolution WHA 60.22: Emergency‑care systems. Geneva: World Health Organization; Available from: http://www.who.int/gb/ebwha/pdf_files/ WHA60/A60_R22‑en.pdf. Goossens H. The Chennai declaration on antimicrobial resistance in India. Lancet Infect Dis 2013;13:105‑6. Williams A, Mathai AS, Phillips AS. Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India. J Pharm Bioallied Sci 2011;3:531‑6. Gangwar AS, Kumar N, Kothiyal P. Antibiotic prescription and cost patterns in an intensive care unit: A review of literature. Pharm J 2012;1:68‑72. Kaki R, Elligsen M, Walker S, Simor A, Palmay L, Daneman N. Impact of antimicrobial stewardship in critical care: A systematic review. J Antimicrob Chemother 2011;66:1223‑30. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159‑77.
Cite this article as: Sodhi K, Singla MK. What's new in critical illness and injury science? Rationale drug usage - A long way ahead!. Int J Crit Illn Inj Sci 2013;3:227-8. Source of Support: Nil, Conflict of Interest: None declared.
Announcement
“QUICK RESPONSE CODE” LINK FOR FULL TEXT ARTICLES The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications. 228
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
What's new in critical illness and injury science? Rationale drug usage - A long way ahead! One of the first duties of the physician is to educate the masses not to take medicines. Sir William Osler Irrational drug use is a global health problem, with far reaching economic consequences. Most common reasons cited are the lack of knowledge, unethical drug promotions, and irrational prescribing habits by the clinicians.[1] Studies done to document drug use patterns indicate that overprescription, multidrug prescription, misuse of unnecessary expensive drugs, and overuse of antibiotics and other medications are the major problems.[2] With up to 10%‑40% of healthcare budgets spent on medicines globally, evidence suggests that more than half of all medicines in developing countries, and a substantial proportion of antibiotics in developed countries are used inappropriately, thus often wasting the scarce resources.[3] Improving drug use would have important financial and public health benefits. Efforts to promote rational drug use started way back in the year 1977, when World Health Organization (WHO) introduced the concept of essential drugs.[3] In response to the mounting criticisms levelled against what was increasingly recognized as ‘‘the irrational use of drugs’’ in both the industrialized countries and the third world, the term ‘rational drug use’ was formulated at the Conference of Experts on the Rational Use of Drugs held in Nairobi in 1985: Rational drug use requires that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate period of time, and at the lowest cost.[3] The crisis in pharmaceuticals is an international problem which demands action at all levels‑the government, the physicians, and the citizens. Globally, there is a need for Access this article online Website: www.ijciis.org DOI: 10.4103/2229-5151.124091
Quick Response Code:
drug policies which, although changing in content from one environment to another, meet the regional health needs of the world’s population. At the national level, the weakness or absence of national drug policies has been found to be an important obstacle for implementing interventions to improve drug use. Measures required for the rational drug use include the development and revision of the national essential drug list, the national formulary development, amending the pharmacy act and the opening of drug information centers.[2] Although as far as policies are concerned the developed nations are far ahead, but the scenario remains bleak in the developing world, with no restriction on over the counter dispensing of antibiotics, no functioning national antibiotic policy or a national policy to contain antimicrobial resistance.[2] India, a developing economy, has taken a lead in this regard. As a commitment to combat antibiotic resistance, the landmark ‘‘Chennai Declaration’’ 2012 is a national initiative taken by the medical community and the Indian government.[4] Following the example, others can also take a step forward. The present edition of the journal incudes an original article wherein the, drug utilization patterns in an Indian intensive care unit have been discussed, which opens a major debate toward the international issue of rational drug use. The article reports an overuse of drugs with average number of drugs used being more than 13, most commonly the antibiotics, inotropes/vasopressor, and H2 blockers. These figures almost match the worldwide literature, with average drugs use reported varying from 5 to 15.[1,5] The average number of drugs per prescription is an important index of a prescription audit. The overuse and/or misuse of drugs can lead to significant consequences, like increased costs, bacterial resistance, drug toxicities, and drug interactions.[6] Various surveillance studies report 40%-60% irrational antibiotics prescription.[6] Increasing multidrug resistance with limited availability of newer antibiotics to treat emerging multidrug‑resistant clones emphasizes the urgent need for vigilant surveillance, stringent infection control practices, use of guidelines as well as antibiotic restriction policies.[6] While the critical care unit is the area of greatest antimicrobial use and the epicenter of antimicrobial resistance in most hospitals, the vulnerability of critical care patients and the complexity of their clinical management may hinder reductions in antimicrobial use.[7]
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
227
Sodhi and Singla: Rational drug utilisation in healthcare
In order to preserve the current antibiotic arsenal, antibiotic stewardship has been proposed to reduce overuse and the correct selection of these agents.[7] Antibiotic stewardship being a multidisciplinary endeavor, it is important to build relationships with clinicians, microbiologists and nursing staff, to have a positive impact. The Infectious Diseases Society of America recently published guidelines stating that all hospitals should develop an institutional program to enhance antimicrobial stewardship.[8] Above all, drug utilization evaluation and internal audits at the institutional level are a must. For this pharmacovigilance, many hospitals have formalized the clinical role of the pharmacist in drug selection, use, and/or monitoring through the use of drug utilization review programs.[2] Another way forward is developing and maintaining an electronic documentation of the patients’ medical records, which may serve as a valuable tool for auditing the prescriptions frequently and for implementing the antibiotic policy.[2] Although international agencies like WHO and International Network for Rational Use of Drugs have applied themselves to evolve standard drug use indicators from time to time, drug utilization remains a challenge for the medical fraternity, the governments and society at large. Thus, the onus to rationalize the drug usage is on all of us. So, let’s the whole medical fraternity come forward, for WE only can make a difference! Kanwalpreet Sodhi, Manender Kumar Singla1
1
Consultant, Department of Critical Care Consultant, Department of Cardiac Anaesthesia and Critical Care, Satguru Partap Singh Apollo Hospitals, Ludhiana, Punjab, India
Address for correspondence: Dr. Kanwalpreet Sodhi, Consultant, Department of Critical Care, Satguru Partap Singh Apollo Hospitals, Ludhiana, Punjab, India. E-mail: [email protected]
REFERENCES 1. 2. 3.
4. 5. 6. 7. 8.
Saeed S, Saeed P, Sharma V. Current scenario of rational usage of various drugs in indoor patients. Int J Basic Clin Pharmacol 2012;1:27‑31. le Grand A, Hogerzeil HV, Haaijer‑Ruskamp FM. Intervention research in rational use of drugs: A review. Health Policy Plan 1999;14:89‑102. World Health Organization: Sixtieth world health assembly. Resolution WHA 60.22: Emergency‑care systems. Geneva: World Health Organization; Available from: http://www.who.int/gb/ebwha/pdf_files/ WHA60/A60_R22‑en.pdf. Goossens H. The Chennai declaration on antimicrobial resistance in India. Lancet Infect Dis 2013;13:105‑6. Williams A, Mathai AS, Phillips AS. Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India. J Pharm Bioallied Sci 2011;3:531‑6. Gangwar AS, Kumar N, Kothiyal P. Antibiotic prescription and cost patterns in an intensive care unit: A review of literature. Pharm J 2012;1:68‑72. Kaki R, Elligsen M, Walker S, Simor A, Palmay L, Daneman N. Impact of antimicrobial stewardship in critical care: A systematic review. J Antimicrob Chemother 2011;66:1223‑30. Dellit TH, Owens RC, McGowan JE Jr, Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America; Society for Healthcare Epidemiology of America. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159‑77.
Cite this article as: Sodhi K, Singla MK. What's new in critical illness and injury science? Rationale drug usage - A long way ahead!. Int J Crit Illn Inj Sci 2013;3:227-8. Source of Support: Nil, Conflict of Interest: None declared.
Announcement
“QUICK RESPONSE CODE” LINK FOR FULL TEXT ARTICLES The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications. 228
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
