Available online on 15.11.2021 at http://jddtonline.info

Journal of Drug Delivery and Therapeutics

Open Access to Pharmaceutical and Medical Research

Copyright  © 2021 The  Author(s): This is an open-access article distributed under the terms of the CC BY-NC 4.0 which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original author and source are credited

Open Access  Full Text Article                                                                                                                                       Research Article 

Retrospective Audit on Cloxacillin Prescription in Primary Health Care Facilities in Kuala Selangor, Malaysia 

*Farhani Samat¹ , Nurul Nadia Baharum² , Nor Anizah Muzaid³ , Sharifah Nurul Aida Syed Ghazali⁴ , Sharmilee Ramanathan⁵ , Nuraini Dolbasir⁶ , Noor Rafizah Aminah Binti Aziz⁷ 

¹ Klinik Kesihatan Tanjong Karang, Jalan, Sungai Kajang, 45500 Kuala Selangor, Ministry of Health, Malaysia  

² Klinik Kesihatan Bukit Cherakah, Jln Rizab Masjid, Kampung Bukit Cherakah, 45800 Jeram, Selangor

³ Klinik Kesihatan Kuala Selangor, Jalan Klinik, Bandar Malawati, 45000 Kuala Selangor, Selangor

⁴ Klinik Kesihatan Bestari Jaya, 1867, Jln Kampung, Pekan Batang Berjuntai, 45600 Batang Berjuntai, Selangor

⁵ Klinik Kesihatan Ijok, JKR 1087, Jln 14, Ijok, 45700 Batang Berjuntai, Selangor

⁶ Klinik Kesihatan Jeram, Jalan Klang 45800 Jeram Kuala Selangor

⁷ Pejabat Kesihatan Daerah Kuala Selangor, Kuala Selangor Health district, Jalan Semarak, Bandar Melawati, 45000 Kuala Selangor, Selangor

INTRODUCTION

Appropriateness of antibiotic usage must be monitored to prevent rapid development of antimicrobial resistance. Inappropriate use of antibiotics is a major concern, related to raising health care cost, mortality and ineffective treatment. Antibiotic appropriateness by definition means that the decision about not giving antibiotics is correct as far as the bacteria is susceptible to the prescribed antibiotic or the culture is negative. Meanwhile, inappropriate use of antibiotics means under-treatment (patient not receiving antibiotic that is susceptible to the bacteria) or overtreatment (patient unnecessarily treated with antibiotics)¹.

National Antibiotic Guidelines (NAG) was launched in 2008 by the Malaysia Government as a method of monitoring the appropriate use of antibiotics in all healthcare facilities in Malaysia under the Ministry of Health. Latest version of NAG 2019 has been officially launched by MOH² and recommendations for utilization of Cloxacillin as antibiotic of choice has been outlined clearly in the new guidelines. Based on the recommendation, Cloxacillin used is mainly reserved for treatment of susceptible bacterial infections, notably penicillinase-producing staphylococci infections³, especially Streptococcus pyogenes and Staphylococcus aureus infection.

In Malaysia, national surveillance on antibiotic utilization primarily looks at hospitals and intensive care units setting antibiotic prescription, rather than outpatient public health clinics. Based on the Malaysia Health Systems Research (MHSR) 2016, Malaysia is facing acute rising in health expenditures⁴ in which further steps need to be commenced including looking into appropriate utilization of antibiotics in outpatient public health clinics.

Cloxacillin is the second most prescribed antibiotic for skin and soft tissue infection in Malaysia^{5, 6}. A study on the outpatient public health clinic prescriptions⁶ showed that antibiotic prescription for skin and soft tissue infections is the second most common after upper respiratory tract infections (URTIs), whereby Cloxacillin and amoxicillin/clavulanic acid are the second and third most frequently prescribed antibiotic⁷. Further study by Shamsuddin, Akkawi, Zaidi, Ming and Manan ⁵ showed that Cloxacillin is the second most common antibiotic used in three major primary health clinics in Selangor, with 0.68 Defined Daily Dose (DDD) per 1000 inhabitants-day, with also the second-most common antibiotic prescriptions for all categories of age group, ranging from 18 to 60 years old.

A similar pattern was seen in Kuala Selangor, in which our district demonstrated that the Defined Daily Dose (DDD) of Cloxacillin is high (3.0-8.7) compared to the recommended value from World Health Organization (WHO). Despite Cloxacillin is the second most prescribed antibiotic for skin and soft tissue infection^{5, 7}, limited studies have been conducted in looking into appropriate use of Cloxacillin in outpatient settings. Therefore, this audit aims to assess appropriate Cloxacillin use against the National Antibiotic Guideline² among prescribers in public health clinics in Kuala Selangor, Selangor. Other objectives are mainly to describe sociodemographic characteristics of patients prescribed with Cloxacillin, to investigate type of diagnosis stated in Cloxacillin prescriptions and to determine accuracy of diagnosis of Cloxacillin prescriptions.

MATERIALS AND METHODS

This is a cross-sectional study conducted in seven public health care clinics in Kuala Selangor under Kuala Selangor district health office. All prescriptions that contained Cloxacillin in the outpatient clinics were audited retrospectively. The study was conducted from January 2020 - March 2020.

A total of 259 prescriptions which contained Cloxacillin in the outpatient department from January 2020 until March 2020 were audited. Samples were drawn from PHIS system and manual records (Jan-March 2020).  Only clinical and relevant data from the subjects’ record were collected. 

Audit format was adapted from the antimicrobial stewardship protocol (AMS)⁸. All prescriptions were audited for all 16 criteria with binary outcome, ‘Yes’ or ‘No’ and converted to percentages. However, for criteria 10, 11, 12 and 13, the percentage was calculated by replacing the denominator with those who answered ‘Yes’ which was “correct antibiotic” for Criteria 9. The percentage for Criteria 4, 15 and 16 were calculated by omitting those not applicable from the denominator. Appropriate Cloxacillin usage is based on accuracy of diagnosis, indication of antibiotic, correct usage (pharmacological name, dose, frequency and duration) against NAG 2019. Data was analyzed using SPSS software. Ethical approval was obtained from Malaysia Medical Research and Ethics Committee (MMREC) prior to the study.

RESULTS

Sociodemographic characteristics of patients 

A majority of patients receiving antibiotics in this district were >40 years old 48.6%, n=126 and predominantly male 63.7%, n=165 (Table 1). 

Table 1: Sociodemographic characteristics of patients receiving Cloxacillin in Kuala Selangor district

Distribution of antibiotic prescription

Most prescriptions were recorded from Kuala Selangor health clinic 21.2% (n=55) followed by Bestari Jaya health clinic 20.1% (n=52), Jeram health clinic 18.1% (n=47). Bukit Cherakah health clinic 16.6% (n=43). Ijok health clinic 10.0% (n=26) Tanjong Karang health clinic 9.3% (n=24) and Sungai Tengi Kanan health clinic 4.6% (n=12) (Fig 1)

Figure 1: Distribution of antibiotic prescriptions by Klinik Kesihatan in Kuala Selangor

Adherence of Cloxacillin prescription

The measure of adherence utilises the fulfillment of the 16 criteria set by the National antibiotic guideline for the antimicrobial stewardship audit that is performed nationwide. 9 out of the 16 criteria achieved the standard of > 80% which were reason for coming 90.7% (n-235), physical examination 83.8% (n=217) and diagnosis documented 81.5% (n=211). (Table 2)

Only 63.7% prescriptions (n=165) were deemed accurate diagnosis by the auditors and only 50.6% (n=131) were indicated for antibiotics. 68.3% (n=177) had vital signs documented and 43.5% (n=50) had relevant investigation. Standards that were poorly scored includes statement of drug allergy 10.8% (n=28), health education 6.6% (N=17).

The audit revealed only 36.7% (n- 95) prescriptions were correct antibiotic based on the National Antibiotic guideline. Out of this total, they attained the percentage for correct pharmacological name was 100%, correct frequency was 97.9% (n=93), correct dosing was 95.8% (n=91) while correct duration was the lowest at 85.3%(n=81).

Table 2: Overall distribution of National antimicrobial stewardship criteria fulfilled by each health clinic.

Abbreviations: KKBJ; Bestari Jaya health clinic, KKBC; Bukit Cherakah health clinic, KKI; Ijok health clinic, KKJ; Jeram health clinic, KKKS; Kuala Selangor health clinic, KKSTK; Sungai Tengi Kanan health clinic, KKTK; Tanjong Karang health clinic

Appropriateness of Cloxacillin use prescribed

The measure of appropriateness of Cloxacillin is reflected by those fulfilling accurate diagnosis from which they have correct clinical indication for Cloxacillin, correct name, dosing, frequency and duration

Those cases that fulfill all the parameters above are deemed appropriate usage of Cloxacillin, with the overall performance of district Kuala Selangor.

Abbreviations: KKBJ; Bestari Jaya health clinic, KKBC; Bukit Cherakah health clinic, KKI; Ijok health clinic, KKJ; Jeram health clinic, KKKS; Kuala Selangor health clinic, KKSTK; Sungai Tengi Kanan health clinic, KKTK; Tanjong Karang health clinic

Disease distribution given Cloxacillin

Table 3 demonstrated majority of Cloxacillin was prescribed to infection of the skin and subcutaneous tissue, 64.1% (n=166) while other diagnosis was almost equal in distribution. However, 18.5% (n=48) prescriptions that were given had no diagnosis.

Table 3: Disease distribution based on ICD-10 classification that received cloxacillin

During a cross-tabulation of those with inaccurate diagnosis, 100% (n=48) prescriptions were the ones without diagnosis

Abbreviations: KKBJ; Bestari Jaya health clinic, KKBC; Bukit Cherakah health clinic, KKI; Ijok health clinic, KKJ; Jeram health clinic, KKKS; Kuala Selangor health clinic, KKSTK; Sungai Tengi Kanan health clinic, KKTK; Tanjong Karang health clinic

DISCUSSION

This is a preliminary study looking at appropriate Cloxacillin use in Kuala Selangor district. Findings showed that appropriate Cloxacillin use was low compared to national standards (>80%)⁸. The overuse and misuse of antibiotics have contributed to the increase bacterial resistance to the antibiotic². A majority of patients receiving antibiotics in this district were predominantly male, consistent with another study done in South India⁹. Adherence and appropriateness of Cloxacillin prescriptions was low compared to the National Antibiotic guideline, similar with a study conducted in Kedah, Malaysia^{2, 6}. Similar with the study conducted in Kedah, majority of Cloxacillin was prescribed for infection of the skin and subcutaneous tissue⁶.

Some recommendations include revising swab culture and sensitivity requirement in AMS protocol and conducting several short antibiotic courses among prescribers^{2, 10, 11}. Periodic measurement on appropriate utilization of Cloxacillin is necessary for all primary health care facilities⁸. 

Limitations of this study included missing data and clinically relevant as some prescriptions and records had no diagnosis stated, missing (failed to retrieve manually) and had double entry of the same patient. This study provided crucial platform to strengthen our measures on Cloxacillin use to prevent rapid antimicrobial resistance and jurisdiction of healthcare cost.

Concentrating into prescriber’s factors (background, knowledge, attitude and perception towards antibiotic prescription) and unnecessary Cloxacillin prescriptions for other disease than infection of skin and subcutaneous tissue should be emphasized in future study⁸.

CONCLUSION    

Adherence and appropriateness of Cloxacillin prescriptions were low at public health care clinics in Kuala Selangor District, hence there is a need to take measures to improve appropriate Cloxacillin usage and prescription to ensure adherence to the National Antibiotic Guideline (NAG) and Antimicrobial Stewardship (AMS) protocol in order to prevent rapid antimicrobial resistance.

Acknowledgement 

We would like to thank Madam Jasrinjeet Kaur (pharmacist) for her technical contribution in this study.

Conflict of Interest

Nil

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