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Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 176-181

Prescribing practices of antibiotics and analgesics in orthopedic surgery in two teaching hospitals in pakistan

1 Department of Pharmacology (Pharmacovigilance), Institute of Health Sciences, Çukurova University, Adana, Turkey; Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
2 Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan
3 Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan
4 Department of Pharmacy, Quaid-i-Azam University, Islamabad, Pakistan; Department of Pharmacy, Administration and Clinical Pharmacy, School of Pharmacy, Health Science Centre, Xi'an Jiaotong University, China
5 Department of Pharmacology, Faculty of Medicine, Çukurova University; Department of Pharmacology, Pharmacovigilance Specialist, Balcali Hospital, Adana, Turkey

Date of Web Publication9-Dec-2019

Correspondence Address:
Mr. Zakir Khan
Department of Pharmacology (Pharmacovigilance), Institute of Health Sciences, Çukurova University, Adana, Turkey.

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_108_19

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Background: A judicious utilization of antibiotic prophylaxis and postoperative analgesics are an effective strategy to prevent surgical site infections and pain, respectively. Aims: The aim of this study was to assess prescription practices and guidelines adherence of antibiotics and analgesics in total knee replacement (TKR) surgery. Setting and Design: A cohort observational pilot study was conducted for a period of 2 months at two tertiary care teaching hospital (government hospital = GH and private hospital = PH) in Islamabad, Pakistan. Subjects and Methods: All the individuals aged ≥18 who underwent TKR surgery with no previous surgery and infection (n = 300) were included during the study period. The patient medication profile was analyzed through various indicators. International evidence-based guidelines were used as a reference to analyze current treatment practices. Statistical Analysis Used: Descriptive statistics such as frequencies, percentages, averages, standard deviation, and Chi-square test was used for interpretation of data in SPSS V-22.0. Results: Preoperative prophylactic antibiotics were prescribed in 94% (n = 283) cases. Of these, 61.5% adhered according to guidelines with respect to correct choice, 64.6% for timing, and 100% for the route (optimal value 100%). The prescribing behavior with respect to antibiotic choice and timing was different among GH and PH hospitals (P = 0.001). Cefazolin was the most commonly prescribed preoperative and postoperative antibiotic, followed by cefuroxime. With respect to analgesics, paracetamol and tramadol were frequently used in TKR patients. One hundred and seventy six (58.6%) patients received analgesics according to the guidlines recommendations, and 7.8% (n = 23) received more than one analgesic in their postoperative prescription. Conclusion: The low compliance rate with guidelines was observed. The choice and timing of antibiotic, selection of analgesics, and its multiple usage were main identified problems.

Keywords: Cefazolin, preoperative prophylactic antibiotics, prescription, surgery, total knee replacement

How to cite this article:
Khan Z, Ahmed N, Zafar S, ur. Rehman A, Khan FU, Karatas Y. Prescribing practices of antibiotics and analgesics in orthopedic surgery in two teaching hospitals in pakistan. Saudi J Health Sci 2019;8:176-81

How to cite this URL:
Khan Z, Ahmed N, Zafar S, ur. Rehman A, Khan FU, Karatas Y. Prescribing practices of antibiotics and analgesics in orthopedic surgery in two teaching hospitals in pakistan. Saudi J Health Sci [serial online] 2019 [cited 2022 Jan 22];8:176-81. Available from: https://www.saudijhealthsci.org/text.asp?2019/8/3/176/272434

  Introduction Top

Total knee replacement (TKR), or total knee arthroplasty (TKA), is a type of orthopedic surgical procedure to replace knee joints.[1] TKR has become one of the common surgical procedures.[2] Estimates indicate that the cases for TKR alone will exceed 3.4 million in the US annually by the year 2030.[3] Specifically, TKR has risen in volume by 154% between 1993 and 2011.[4] Infection is one of the most dreaded complications in orthopedic surgery. It is reported that approximately, 1%-5% of wounds develop infection in clean orthopedic TKR surgery.[5]

Surgical safety checklist of 19 items before any procedure to reduce complication has also been recommended by the World Health Organization (WHO).[6] It also includes preoperative prophylactic antibiotics (PPAs). PPAs have been routinely used in surgical interventions from several decades to prevent postoperative infections.[7] WHO emphasizes on review of prescribing practices of medicines which is an important indicator of quality and standard of health practices.[8],[9] As a result, irrational use of PPA (choice, timing, duration, dose, and route) leads to the increased adverse drug reaction, resistance development, and cost of therapy.[10],[11],[12],[13] Inappropriate usage of Surgical Antibiotic Prophylaxis (SAP), high prevalence of multidrug resistance, unavailability of local guidelines, and limited available research on the pattern of SAP use in Pakistani hospital are still a problem.[10],[11]

Post-operative pain after TKR surgery is responsible for negitive effect on patient suffering and delayed recovery.[14] It is reported that more than half of the surgical patients experience inappropriate level of pain after surgery.[14],[15] Orthopedic surgeries specifically TKR patients present with extreme pain immediately after surgery and have been considered difficult to manage.[14],[16] Therefore, postoperative pain management is among one of the important concerns for TKR patients.[14] Inadequate management and therapy for pain responsible for surgery-induced responses can be exacerbated surgery-induced responses and serious risk to patients.[14],[15],[16]

Prescription analysis is gaining global recognition for the assessment and evaluation prescribing practices in health care. Appropriate use of medicines is crucial for quality of pharmaceutical care.[8],[9],[17] The most common causes of irrational medicines use are inappropriate use of medicines and prescribing of medicines without following relevant clinical practice guidelines.[8],[10],[11],[18],[19] The fundamental step to limiting the irrational use of medicines is to quantify the extent to which this is occurring.[8],[9]

Inappropriate use of medicines is alarming due to lack of consensus on clinical practice guidelines and professional accountability.[10],[11],[17],[19],[20] The pattern of management varies between health care centers. A larger variety of medicines are available in the market, which may lead to the problem of irrational prescription.[8],[9],[17],[21] Appropriate use of PPAs, timing of administration, and analgesic medication audit are important aspects from both health and economical points of view. The primary objective of this pilot study was to examine prescribing patterns of antibiotic and analgesics in patients undergoing TKR surgery. A secondary objective was to assess the adherence rate with the recommendations made by international clinical practice guidelines in surgery.

  Subjects and Methods Top

Setting and study design

The current research describes a cohort observational study conducted for 2 months during January-February, 2017. Orthopedic wards of the government hospital (GH) and private hospital (PH) were selected. GH is a 600-bed tertiary care hospital. It is one of the capital city (Islamabad) region's leading tertiary level hospitals, which includes 22 medical and surgical specialist centers. PH is also a tertiary care, multispecialty 500-bed teaching hospital. Both hospitals provide medical facilities to the different areas of Rawalpindi and Islamabad regions. These are also a national-level referral hospital for Azad Jammu and Kashmir and northern areas of Khyber Pakhtunkhwa and different regions of Punjab, Pakistan. The study was carried out ethically and was approved by the Institutional Review Boards and Ethics Committees of GH (No. F.1-1/2015/ERB/SZABMU/) and PH (No. IRB-637-085-2016) before conducting the study. A written consent was also obtained from participants.

Study population

The present analysis was restricted to patients, aged ≥18 who underwent TKR surgery with no previous surgery and infection.

Data collection

TKR is frequently performed orthopedic surgery and classified as clean surgical procedure[15] and also common in our health care settings. A specialized data collection pro forma was designed to collect the desired information. Data were collected prospectively from patients' medication profile. Age, gender, weight, surgery, prescribed PPAs, timing of PPAs administration, total medication prescribed in first postoperative prescription, and postoperative analgesia were documented.

Data analysis

Pre- and post-operative antibiotics

PPAs were analyzed according to the updated Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery, which is jointly developed by ASHP/IDSA/SIS/SHEA (American Society of Health-System Pharmacists/the Infectious Diseases Society of America/the Surgical Infection Society/the Society for Healthcare Epidemiology of America)[22] and centers for disease control and prevention guideline for the prevention of surgical site infection.[23] These guidelines emphasized on the following aspects: (a) use of inexpensive narrow-spectrum antibiotic, (b) intravenous single-dose prophylaxis, (c) administration of PPA within 30-60 min before the first incision, (d) cefazolin is the first drug of choice, and vancomycin or clindamycin should be an appropriate alternative regimen. In this study, the prescribing practices were evaluated for the following aspects: (a) antibiotic selection, (b) type and class of antibiotic prescribed, (c) timing of administration, (d) route of administration, (e) frequently prescribed antibiotic as PPA, (f) prescribing pattern of postoperative antibiotics, and (g) assess the utilization pattern according to WHO anatomical therapeutic chemical classification system.[24]

Postoperative analgesic

Postoperative analgesic prescription pattern was assessed through “Guidelines for the Management of Postoperative Pain after TKA.”[14] These guidelines recommend the use of acetaminophen (paracetamol), COX-2 inhibitors, and tramadol after TKR surgery. Details about types and frequency of analgesic prescribed after TKR surgery were documented from patient case files.

Statistical analysis

IBM SPSS Statistics for Windows, Version 20.0. (IBM Corporation, Armonk, New York, USA) was used for analysis. Descriptive statistics such as frequencies, percentages, averages, standard deviation (SD), and Chi-square test were used for interpretation of data.

  Results Top

A total of 19 of 319 (6%) patients were excluded because of incomplete medical record (13 patients) and age <18 years (6 patients). Finally, 300 (n = 150 GH, n = 150 PH) patients were consecutively seen from both hospitals in the present pilot survey for comparison purposes.


Male patients were 172 (in GH = 93, PH = 79) and females were 128 (in GH = 57, in PH = 71). Mean age of patients was 54 years (±19.1 SD) in GH and 42.5 years (±17. 82 SD) in PH. Mean weight of patients were 80 kg (±10. 9 SD) in GH and 78 kg (±10. 7 SD) in PH.

Preoperative prophylactic antibiotics

Preoperative prophylactic antibiotics' indication

The PAPs were prescribed in 94% (n = 283) of surgical patients, and 17 (6%) patients did not receive PPA. Statistically significant difference was observed between prescribing practice of GH and PH (97% vs. 93%); P = 0.01 [Table 1].
Table 1: Prescribing practices and adherence to guidelines (n=300)

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Correct choice/selection of preoperative prophylactic antibiotics

The appropriate drug of choice was administered according to the guidelines in approximately 61.5% (n = 174) cases. The higher value was observed in PH (104 patients) as compared to GH (70 patients) [Table 1].

Preoperative prophylactic antibiotics' route and timing of administration

All patients received PPA through intravenous route, and about, 183 (64.6%) patients received PPA according to the recommended timing of administration. A difference was observed between prescribing practices with respect to timing of administration between GH and PH; P = 0.01. Information about the timing was missing in 10.2% (n = 29) cases [Table 1].

Prescribing pattern of preoperative prophylactic antibiotics

With respect to commonly prescribed PPA, about 61.5% (n = 174) of the participants received cefazolin, followed by cefuroxime (27.5%; n = 78). Details are given in [Table 2].
Table 2: Prescribing of preoperative prophylactic antibiotics and World Health Organization/anatomical therapeutic chemical code (n=283)

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Prescribing patterns of postoperative antibiotic

The prescribing pattern of postoperative antibiotics was different in both hospitals. More than one postoperative antibiotic was prescribed to 3% (5/150) in GH and 24% (36/150) in PH. Cefazolin was commonly prescribed postoperative antibiotics followed by cefuroxime. Combination therapy was also observed. About 3.3% (5 of 150) patients in GH and 24% (36 of 150) in PH received double postoperative antibiotic [Table 3].
Table 3: Summary of postoperative medicines (antibiotics and analgesics) in total knee replacement patients (n=300)

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Prescribing patterns of postoperative analgesics

Analgesic practices were more in GH as compared to PH. Paracetamol was mostly prescribed, followed by a combination of paracetamol plus tramadol. Patients receiving more than one analgesic were 8% (13 of 150) in GH and 6.7% (10 of 150) in PH. Analgesics prescribing was appropriate according to the guidelines in 176 (58.6%) patients, and 7.8% (n = 23) received more than one analgesic in their postoperative prescription [Table 3].

  Discussion Top

Over the last two decades, prescription analysis and antibiotic stewardship in healthcare settings have demonstrated effectiveness in decreasing inappropriate medicines utilization and ultimately associated with decreasing malprescription practices.[17],[19],[20] Inappropriate prescribing practices exist all over the globe, and ultimately, they are responsible for increased adverse drug reactions, resistance development, wastage of resources, morbidity, mortality, and cost of therapy.[10],[11],[12],[17],[19],[20],[21] PPAs are recognized approach for decreasing surgical site infections. Standard prescribing practices include administering the right therapeutic agent with respect to the dose, time, route, and duration.[22],[23] Choice of correct PPAs was appropriate in 61.5% cases in our study. This result was aligned with the study conducted in Malaysia.[25] Higher adherence rate was reported by the study carried out in the USA (97%)[26] whereas low rate was shown by research study conducted in England (39%).[27] Antibiotic should be cost-effective, nontoxic, and of limited spectrum.[28] PPAs are affective in surgeries; but, its inappropriate use decreases the potential benefits, increases the risks and costs on the patients as well as to the community.[29],[30] Nonuse of antibiotics was also observed in 6% of the patients. It is evident from literature that nonusage of antibiotics when it is recommended by the guidelines leads to increased vulnerability to wound problem, hospital stay, morbidity, and mortality rate.[10],[11],[19],[22]

Adherence to guidelines on timing was also assessed. About 66.6% patients received PPAs within an optimal time (within 30-60 min before surgical incision). These results were comparable to a study conducted in Sweden, which reported 57% adherence rate.[31] Higher rate was reported in Jordanian study (99%).[32] Appropriate time of administration of PPA can also reduce duration of stay and hospitalization cost.[7] Administration of PPA more than 60 min before surgical incision is associated with higher risk of surgical infection.[33] The inappropriate prescription of antibiotics in the present study may be due to unavailability of a clinical pharmacist, untrained resident in-charge, and lack of medication protocols and treatment guidelines.[10],[11],[12],[19],[22],[23] To assist surgeons in correct choice of medications according to guidelines, a clinical pharmacist can play a vital role. Proper training of the resident in-charge on prescribing practices can also enhance the rational use of medicines. Every faculty has its own treatment protocol, but there were no consensus guidelines available in these hospitals.

In the current study, cephalosporin was the commonly prescribed preoperative and postoperative antibiotic (mainly cefazolin and cefuroxime). To compare with previous studies, cephalosporin was the most commonly prescribed class of antibiotics reported in Turkey[34] and Pakistan.[10],[17] Multiple use of postoperative antibiotic was also observed. According to guidelines, there is no need of double postoperative antibiotics in TKR; but, in both hospitals, multiple use was observed. Inappropriate use of antibiotics provides a favorable environment to microbial resistance and also increased the possibility of adverse reactions.[22],[35] Current findings are supported by the studies conducted in developing countries such as Iran[36] and Saudi[37] which showed over and inappropriate prescribing of antibiotics.

Paracetamol is the most commonly prescribed single postoperative analgesic followed by a combination of paracetamol plus tramadol in TKR surgeries. These findings were aligned with the study conducted by McCartney and Nelligan.[38] Another study conducted by Sen and Bathini showed that commonly prescribed single analgesic was paracetamol followed by diclofenac, and the most common combination was paracetamol plus tramadol.[39] Present results deviated from a study conducted by García Rodríguez[40] which showed Ibuprofen as commonly prescribed analgesic and study by Ogboli-Nwasor et al. presented pethidine and pentazocine.[41] A meta-analysis was conducted to analyze the effect of COX-2 inhibitors on TKR patients. The postoperative pain score is decreasing by administering COX-2 inhibitors before surgery.[42] Furthermore, recently, etoricoxib which is COX-2 inhibitor was tested preoperative and postoperative. It was found effective without any significant increase in side effects.[43] However, in the current study, no prescription of COX-2 inhibitor medicine was observed whereas almost all patients received postoperative analgesics parenterally in both hospitals. Multiple use of analgesics causes side effects such as constipation, dizziness, and tiredness/fatigue.[44]

This study focused on specific TKR patients and analyzed current prescribing practices. The study has a novel concept, to compare the prescribing practices in two tertiary care hospitals (GH and PH) in the same area. Prescribing practices of PPAs were documented and compared with International standard guidelines. Outcomes of the present study add to a growing literature, particularly around medicines use and pharmaceutical health systems in developing countries.

The present study has several important limitations. First, it is a pilot study for a short duration of time, and these results represent the situation of the two tertiary care hospital in the capital city of Pakistan and cannot be generalized to the whole Pakistan situation. Second, this study uses published recommendations of International guidelines to measure appropriate and evidence-based international standards due to the unavailability of local consensus guidelines in selected health settings. However, the possibility exists that the recommendations given by the guidelines were not practicable in our patients or for the situation in Pakistan. The reasons for nonadherence to guidelines were beyond the scope of the current study. Finally, these findings do however add a useful information, particularly around appropriate medicines' use, adherence with standard guidelines and health systems in developing countries.

  Conclusion Top

The low compliance rate with guidelines was observed. The choice and timing of antibiotic, selection of analgesics, and its multiple usage were main identified problems.


All authors highly acknowledged both hospital authorities for their support and coordination during the study period.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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