The antibiotic utilization at the university dentistry clinical center of Kosovo

doi:10.4236/ojst.2013.39080

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Open Journal of Stomatology, 2013, 3, 492-496 OJST

http://dx.doi.org/10.4236/ojst.2013.39080 Published Online December 2013 (http://www.scirp.org/journal/ojst/)

The antibiotic utilization at the university dentistry clinical

center of Kosovo

Fehim Haliti1, Naim Haliti2, Ferit Koçani3, Agim Begzati1, Fatmir Dragidella4, Luljeta Ferizi1,

Lumnije Krasniqi1, Dafina Doberdoli1, Shqiprim Bajrami1, Shaip Krasniqi5

1Pediatric Dentistry, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo

2Institute of Forensic Pathology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo

3Restorative Dentistry and Endodontology, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan

Prishtina”, Prishtina, Kosovo

4Peridontology and Oral Medicine, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”,

Prishtina, Kosovo

5Institute of Pharmacology and Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Prishtina “Hasan

Prishtina”, Prishtina, Kosovo

Email: [email protected]

Received 11 October 2013; revised 16 November 2013; accepted 1 December 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Antibiotic drugs are a very important drug group

considering their frequent use, safety profile and their

impact on bacterial resistance induction. Aim: To

investigate the utilization of antibiotic drugs at the

University Dentistry Clinical Center of Kosovo

(UDCCK). Methodology: Retrospective and descrip-

tive study. Patient records were used as a data source

collected for a period of 3 months. The total number

of registered outpatients in the UDCCK was 1117

patients. The data analysis was performed using the

WHO methodology and results were expressed in

DDD per 1000 inhabitants per day. Results: The total

prescription of antibiotics at UDCCK was 7.18 DDD/

1000 inhabitants/day. Antibiotics were prescribed for

86 or 7.70% of patients. The most commonly pre-

scribed antibiotic was Amoxicillin with clavulonic

acid 3.12 (43.45%) DDD, followed by Metronidazole

2.31 DDD and Amoxicillin 1.25 DDD. Erythromycin

and Cefalexin were prescribed evidently less com-

pared to other antibiotics (0.38 and 0.12 DDD/1000

inhabitant/day, respectively). Conclusions: The quan-

titative analysis showed no rationality of prescription

of antibiotics in UDCCK. Generally, the use of anti-

biotics in both departments of UDCCK is higher

compared to other countries. We recommend the im-

plementation of restrictive prescription standards for

antibiotics.

Keywords: Antibiotic; Utilization; ATC/DDD

1. INTRODUCTION

In pharmaco-therapeutic clinical practice, antimicrobials

are considered to be a group of drugs of essential value,

due to their common prescription, therapeuticall success,

and their impact on the development of bacterial resis-

tance [1,2]. Their magnitude of prescription is significant

not only for in-patients but also fo r outpatients. Scien tific

evidence reports that antibiotics are the most commonly

prescribed medications in the USA, and they contribute

approximately 20% - 50% of the total medications used

[3]. Antibiotics are an essential group in oral health care

as well. The use of these medications requires restrictive

prescription by respecting all standards for rational use in

order to achieve the highest rate of treatment, less side

effects and not to induce the bacterial resistance [4]. The

clinical evidence reports that antibiotic prescriptions by

dental and medical practitioners are asso ciated with con-

siderable percentage of medication errors and abuse [5,

6]. To achieve the standards for rational prescription of

antibiotics by dentists requires knowledge of the bacte-

riological profile of infections in oral-facial region,

choosing of an antibiotic with adequate spectrum of ac-

tivity and selecting the safest an tibiotic possible [7,8]. To

achieve the standards for rational prescription set in a

national drug policy of various countries, there are con-

tinuing professional education programs on clinical

therapy for medical personnel including strategies for

systematic surveys on antibiotic prescribing. All these

activities provide feedback information and evaluation of

drug prescribing for implementing adequate measures

aimed at raising standards for rational prescribing prac-

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F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496 493

tices [9,10].

In daily dentist’s services, antibiotic prescription is a

frequent practice and a conclusion is drawn that a pre-

scription survey will enable us to have at our disposal

information for qualitative critical analysis of antibiotic

prescrib ing [11-13]. Therefore, the purpose of this survey

was to perform a pharmacotherapeutical analysis of an-

timicrobial us e in University Den tistry Clinical Center of

Kosovo. Simultaneously, we analyzed the structure of

diagnoses in order to reveal the quality of the antimicro-

bial prescription.

2. MATERIAL AND METHOD

The survey was a pharmaco-epidemiological, retrospec-

tive study performed in the two departments of UDCCK.

The data were extracted from electronic patient database

and individual hard copy records for each individual pa-

tient at the Dept. of Oral Surgery and Dept. of Perio-

dontology, respectively, for a period of (March 3rd, 2012

and June 30th, 2012) three months. During this period of

study a total of 1117 patients were officially recorded

(806 at Dept. of Oral Surgery and 311 at Dept. of Perio-

dontology). Patients were identified by their patient re-

cord number. For each individual patient we collected

information about their gender, diagnosis, daily dose of

used antimicrobial and the ATC Antimicrobial Classifi-

cation [14,15]. Parametric testing of the data was per-

formed with the statistics module of Excel® Microsoft®

Office® program. The quantitative analysis was per-

formed based on DDD/1000 inhabitants/day (daily de-

fined doses/1000 inhabitants per day) and ATC classifi-

cation according to WHO, methodologies [16].

3. RESULTS

In total, antibiotics were prescribed in 86 patients

(7.70%). There were significant differences in antibiotic

prescribing between the departments including differ-

ences in diagnoses for witch antimicrobials were pre-

scribed and other parameters as presented below (Table

1). There were no significant differences of the mean for

the age of patients between the two departments, how-

ever there were reported differences for the gender

structure with predominantly female patients in both de-

partments. In the group of patients treated with antibiot-

ics there were significant differences between the de-

partments; 18% of patients in Dept, of Periodontology vs

3.72% in the Dept. of Oral Surgery. Brand names were

mostly prescribed in both departments (93.33% in the

Oral Surgery compared to 98.21% in the Periodontology

Department). 1.61% of patients in the Oral Surgery De-

partment and 3.22% in Periodontology Department were

identified with proven hypersensitivity to penicillin.

Figures 1 and 2 show the ICD10 coded diagnoses for

Table 1. Demographic data and indicators of antibiotic pre-

scription between oral surgery and periodontology departments.

Department of Oral Surgery Department of Periodontology

Subject no = 806 Subject no = 311

Age

Mean 36.90 Mean 37.16

StDev 17.42 StDev 16.54

Median 33 Median 34

Max 80 Max 80

Min 33 Min 34

Gender

F 448 (55.58%)F 197 (63.34%)

M 358 (44.42%)M 114 (36.66%)

Therapy with antibiotics

Yes 30 (3.72%) Yes 56 (18%)

No 776 (96.28%)No 255 (82%)

Brand name vs Generic name of antibiotics

Brand name 28 (93.33%) Brand name 55 (98.21%)

Generic name2 (6.67%) Generic name 1 (1.79%)

Hypersensitivity against penicillin

13/806 (1.61%) 10/311 (3.22%)

223

139

14 4

309

117 423121

100

150

200

250

300

350

The structu re of patients by ICD10 in the Ora l

S urg e ry De part ment (n = 80 7)

Frequency

Figure 1. The structure of diagnoses of ICD10 in oral surgery

department.

214

277

1177632

100

150

200

250

300

350

B37K02 K04K05K06K07 K12K13K14L43Q38

The structu re of patien ts by ICD10 in the

P er i odontol o gyD epar tme n t (n= 31 1)

Frequency

Figure 2. The structure of diagnoses of ICD10 in periodontol-

ogy department.

F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496

494

level of antibiotic prescription in Oral Surgery Depart-

ment in particular. A total of four antibiotics were mainly

prescribed in both departments of UDCCK. The Dept. of

Oral Surgery in line with Amoxicillin and Clavulonic

acid and Metronidazole also prescribed Cefalexin. Dept.

of Periodontology on the other hand did not prescribe the

latter at all, however, they prescribed Erythromycin.

Roda R, et al, presented that in Service of Dentistry, Va-

lencia University General Hospital, 8 antibiotics were

described i n g eneral [1 7].

registered patients in both departments. In Oral Surgery

department the most frequent diagnoses were K08 (309),

K04 (223) and K05 (139) while in the Periodontology

Department the majority of diagnoses belonged to K05

category of disease.

The latter diagnosis structure has also influenced the

prescription rate of antibiotics and has reflected the dif-

ferences in total prescription of antibio tics ( Table 2). The

most prescribed antibiotic was Amoxicillin with Clavu-

lonic acid 3.12 DDD (43.45%), followed by Metronida-

zole 2.31 DDD and Amoxicillin 1.25 DDD. Erythromy-

cin and Cefalexin were prescribed evidently less com-

pared to other antibiotics (0.38 or 0.12 DDD/1000 in-

habitant/day) (Tab le 2 and Figure 3). Between the two

departments there are significant differences regarding

the type and the amount of use of antibiotics.

Although in the Oral Surgery Department, cases of

hypersensitivity to penicillin were identified, and there

are no recorded cases of antibiotic usage from macrolide

group, which are considered the first choice of treatment

for patients hypersensitive to penicillin. This aspect of

antibiotherapy remains to be verified; perhaps the state-

ment of hypersensitive patient needs to be further veri-

fied with adequate diag nostic methods.

In the Oral Surgery Department, the utilization of an-

tibiotics is approximately 5 times higher, compared to

Periodontology Department (5.97 versus 1.23 DDD/100

inhabitant/day). The prescription rate of Amoxicilin and

Clavulonic acid and Metronidazol is significantly higher

in Oral Surgery compared to Periodontology Dep artment.

However, the difference of Amoxicillin use between the

two departments is evidently smaller (remains higher in

the Oral Surgery Department).

Based on the results of antibiotic u se, we can conclude

that we found a higher difference between departments

and we assume that this is a result of differences in the

structure of clinical diagnosis of patients treated in the

Tab le 2 . The antibiotic utilization (DDD/1000 inhabitant/day)

at university dentistry clinical center of Kosovo.

The use of Erythromycin in Periodontology Depart-

ment is 0.38 DDD/100 inhabitants/day whereas in Oral

Surgery is not prescribed at all. In the Department of

Oral Surgery we have noted low rate of prescription of

Cefalexin while this antibiotic is not prescribed in the

Periodontology Department (Figure 4).

ATC Code Antibiotic DDD/1000

inhabitant/day

J01CR02 Amoxicillin + ac. Clavulonic 3.12

J01CA04 Amoxicillin 1.25

J01XD01 Metronidazol 2.31

J01DB01 Cefalexin 0.12

J01FA01 Erythromycin 0.38

Total 7.18

4. DISCUSION

The structure of antibiotic use in UDCCK shows a higher

43.45

17.41

32.17

1.68 5.29

Amoxicillin+ac.

Clavulonic Amoxicillin MetronidazolCefalexinErythromycin

J01CR02J01CA04J01XD01J01DB01 J01FA01

Antibiotic with ATC code

Structu re

Figure 3. Antibiotic utilization at university dentistry clinical center of Kosovo.

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F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496 495

3.02

0.76

2.07

0.12

0.11

0.5

0.24

0.38

Amoxicillin+ac.

ClavulonicAmoxicillin MetronidazolCefalexinErythromycin

Structure

Ora l Surgery

Periodontolog

Figure 4. Antibiotic utilization DDD/1000 inhibitants/day by departments of

university dentistry clinical center of Kosovo.

two depart ments.

In both departments of UDCCK, there are still no ap-

proved official antimicrobial protocols in the treatment

of oral-dental infections. Therefore, we couldn’t conduct

a qualitative analysis of antibiotic prescribing practices,

or the differences in treatment protocols. Furthermore, in

the patient records, there are no request notes for micro-

biology cultures, which is essential in the process of an-

tibiotic selection using sensitivity testing.

The absence of treatment and guidelines for antibiotic

prescription also reflects another negative effect, i.e. pre-

scription of the antibiotics by brand name. According to

the presented results in both departments, the prescrip-

tion of antibiotics by their brand names is noted in over

90% of ca s e s .

The prescription of only four antibiotics in each de-

partment shows an irrationality of antibiotics selection.

Indeed, the present number of antibiotics in pharmaceu-

tical market gives us a higher opportunity for selection of

antibiotics and enabling a higher efficiency and a thera-

peutic safety.

The antibiotics expenditure in UDCCK is obviously

higher, compared to similar medical centers’ in other

countries. In a survey conducted in different dental cen-

ters’ of Norway, the rate of DDD/1000 inhabitants units

per day in 2004 was 0.5189 DDD, while in 2005 it was

0.60 DDD, which is obviously lower than the antibiotic

use in UDCCK. Also in this survey it was reported that

11 different antibiotics were used, phenoxymethylpeni-

cillin being most commonly used narrow spectrum peni-

cillin, then metronidazol, followed by erythromycin,

whilst in our survey the most prescribed antibiotics were

the broad spectrum penicillin’s (Amoxicillin and Clavu-

lonic acid, and amoxicillin) and metronidazol. Although

a higher rate of prescription of broad spectrum penicil-

lin compared with the narrow spectrum penicillin is ob-

served also in other countries of Europe like England

where the prescription of Amoxicillin was 55 .8% of pre-

scriptions, whereas phenoxymethilpencillin was only

8.2% [18]. The higher prescription of metronidazole is

consistent with the prescription rate of dental practice in

other countries, considering that metronidazole is an ef-

ficient antibiotic for the treatment of anaerobic oral-den-

tal infections.

In all dental centers of Norway involved in the survey,

the metronidazole was prescribed between 6.3% to 6.9%

of all prescriptions, however, in Great Britain the pre-

scription of metronidazole is significantly higher.

While considering the above presented facts, we con-

clude that the exp enditure of antibiotics generally in bo th

departments of UDCCK is higher especially in Oral Sur-

gery Department [19].

The prescription of antibiotics is not preceded by mi-

crobiological testing of samples and in the UDCCK the

antibiotic protocols are not in use.

Generally, we recommend performing surveys for de-

termination of microbial sensitivity and bacterial resis-

tance of organisms causing oral-facial infections. More-

over, we recommend the approval of treatment protocols

for oral-dental infections, and organization of trainings

for antibiotic use in dental practice in the framework of

continuing medical education.

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