title: Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an antibiotic policy.
abstract: BACKGROUND
  Tertiary care hospitals are a potential source for development and spread of bacterial resistance being in the loop to receive outpatients and referrals from community nursing homes and hospitals. The liberal use of third-generation cephalosporins (3GCs) in these hospitals has been associated with the emergence of extended-spectrum beta- lactamases (ESBLs) presenting concerns for bacterial resistance in therapeutics. We studied the 3GC utilization in a tertiary care teaching hospital, in warded patients (medical, surgical, gynaecology, orthopedic) prescribed these drugs.
  
  
  METHODS
  Clinical data of patients (>or= 13 years) admitted to the General Hospital, Port of Spain (POSGH) from January to June 2000, and who had received 3GCs based on the Pharmacy records were studied. The Sanford Antibiotic Guide 2000, was used to determine appropriateness of therapy. The agency which procures drugs for the Ministry of Health supplied the cost of drugs.
  
  
  RESULTS
  The prevalence rate of use of 3GCs was 9.5 per 1000 admissions and was higher in surgical and gynecological admissions (21/1000) compared with medical and orthopedic (8 /1000) services (p < 0.05). Ceftriaxone was the most frequently used 3GC. Sixty-nine (36%) patients without clinical evidence of infection received 3Gcs and prescribing was based on therapeutic recommendations in 4% of patients. At least 62% of all prescriptions were inappropriate with significant associations for patients from gynaecology (p < 0.003), empirical prescribing (p < 0.48), patients with undetermined infection sites (p < 0.007), and for single drug use compared with multiple antibiotics (p < 0.001). Treatment was twice as costly when prescribing was inappropriate
  
  
  CONCLUSIONS
  There is extensive inappropriate 3GC utilization in tertiary care in Trinidad. We recommend hospital laboratories undertake continuous surveillance of antibiotic resistance patterns so that appropriate changes in prescribing guidelines can be developed and implemented. Though guidelines for rational antibiotic use were developed they have not been re-visited or encouraged, suggesting urgent antibiotic review of the hospital formulary and instituting an infection control team. Monitoring antibiotic use with microbiology laboratory support can promote rational drug utilization, cut costs, halt inappropriate 3GC prescribing, and delay the emergence of resistant organisms. An ongoing antibiotic peer audit is suggested.
authors.affiliation: Department of Paraclinical Sciences, Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad. lpintopereira@fms.uwi.tt
authors.forename: Lexley M
authors.initials: LM
authors.lastname: Pinto Pereira
authors.forename: Marjorie
authors.initials: M
authors.lastname: Phillips
authors.forename: Hema
authors.initials: H
authors.lastname: Ramlal
authors.forename: Karen
authors.initials: K
authors.lastname: Teemul
authors.forename: P
authors.initials: P
authors.lastname: Prabhakar
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D002511:Cephalosporins / Q000494:pharmacology*; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D024881:Drug Resistance, Bacterial; D004363:Drug Utilization / Q000331:legislation & jurisprudence*; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D011640:Public Policy; D013030:Spain; D014300:Trinidad and Tobago
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins