ANTIBIOTIC USE IN PATIENTS WITH FEVER OF UNKNOWN ORIGIN (FUO) AT PANTI RAPIH HOSPITAL YOGYAKARTA-INDONESIA

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• ANTIBIOTIC USE IN PATIENTS WITH FEVER OF UNKNOWN
  ORIGIN (FUO) AT PANTI RAPIH HOSPITAL
  YOGYAKARTA-INDONESIA

Hartayu T1 , Asdie HAH2, Suryawati S3 1 Faculty
of Pharmacy Sanata Dharma University 2 Department
of Internal Medicine and 3 Department of
Clinical Pharmacology, Faculty of Medicine Gadjah
Mada University, Yogyakarta
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ABSTRACT

• Problem Statement Antibiotics accounted as the
  biggest part of drug costs paid by patients
  admitted to Panti Rapih hospital, and fever of
  unknown origin (FUO) was the most prominent
  diagnosis reported.
• Objectives To evaluate the pattern of antibiotic
  use in patients admitted with FUO in Panti Rapih
  hospital, Indonesia.
• Design An explorative study with retrospective
  quantitative data collection and prospective
  qualitative data collection. All patients
  admitted to Panti Rapih Hospital with FUO as
  diagnosis at admission during the period of
  December 1996 to June 1997 were selected.
  Quantitative data were collected to assess the
  pattern of antibiotic use in FUO and the pattern
  of diagnosis at both admission and discharge.
  Qualitative data were collected using in-depth
  interviews with prescribers and the paramedic
  chiefs of the wards to explore the reasons for
  antibiotic use , and identifying final diagnoses.
  
• Setting and Population All patients hospitalized
  with FUO as diagnosis at admission in Panti Rapih
  Hospital, during period of December 1996 to June
  1997.
• Outcome Measures Pattern of diagnoses at
  discharge (final diagnosis), number of
  antibiotics received, the kind of antibiotics
  received, the route and administration of
  antibiotics, average length of stay, range of
  drug cost during hospitalization, reasons of
  antibiotic usage.
• Results Out of 273 cases analyzed 48 cases (18)
  had FUO as final diagnosis, and the rest were
  diagnosed as having upper respiratory infection
  37 cases (14), dengue fever35 cases (13), no
  final diagnosis 18 cases (10)and others 125
  cases (45). In total 90 of cases used
  antibiotic, either oral or injection, despite the
  fact that antibiotic were not recommended for
  this diagnosis. The average length of stay was 5
  days (range1 day 9 days). Drug cost varied
  greatly, with the highest cost observed
  (US45.15) being 16 times the lowest (US
  2.90).Reasons for antibiotic use were generally
  based on personal or colleagues experiences, an
  assumption of infection despite clinical
  observation, the absence of a standard treatment
  for FUO, drug promotion, and negligence in
  updating information.
• Conclusions Antibiotics were used in 90 of
  patients with FUO. Efforts should be pursued to
  reduce the unnecessary use of antibiotics
  including provision of standard treatment
  guideline for FUO.
• Funding Sources Self Funded.

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BACKGROUND

• Panti Rapih is a private hospital in
  Yogyakarta-Indonesia, has 367 beds with 12
  specialist departments and 10 subspecialist
  departments, and has more than 80 Bed
  Occupation Rate.
• Antibiotics accounted as the biggest part of
  prescription cost and Fever of Unknown Origin
  (FUO) was the most prominent diagnosis reported.

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OBJECTIVES

• General
• To evaluate the pattern of antibiotic use for
  patients admitted with FUO at Panti Rapih
  Hospital, Yogyakarta-Indonesia.
• Specific
•      To find out
• The pattern of antibiotics prescribed for FUO
• Reasons of antibiotic use
• Strategy to improve the appropriateness of
  antibiotics used in FUO

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METHODS

• Design
• An explorative study with retrospective
  quantitative data collection and prospective
  qualitative data collection.
• Setting
• All patients admitted to Panti Rapih hospital
  with FUO as diagnosis at admission.
• Time period of data collection December 1996 to
  June 1997  

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STUDY DESIGN
Quantitative data
Reference
Observation on prescriptions in medical record
Pattern of Antibiotic use

• Current Medical Diagnosis and Treatment (Jacobs,
  2004)
• Broad spectrum antibiotic with haematological
  examination result

All patients admitted with FUO in Panti Rapih
Hospital Dec 96-June 97 (273 patients)
FUO as final diagnosis 48 patients
Identify Strategy to Improve the appropriateness
of Antibiotic use
Reference
Qualitative Data
In-depth interview with prescribers and chiefs of
wards (paramedic)
Guide to Good Prescribing (WHO,1994)
Reason of Antibiotic use

• Other final Diagnoses
• Upper respiratory infection 37 patients
  ? Others 125 patients
• Dengue fever 35 patients
  ? No final Diagnosis 18 patients

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Result 1, Diagnosis at hospital discharge
No Diagnosis 0-5 (Years old) 5-12 (Years old) gt12 (Years old) Total
1 FUO 11 5 32 48 (18)
2 Upper respiratory infection 29 4 4 37 (14)
3 Dengue fever 7 13 15 35(13)
4 Others 11 1 16 125(45)
5 No final diagnosis 31 18 76 18(10)
FUO had contributed for 18 of all final
diagnoses, and data in reference showed (10-15 )
(Jacobs, 1994)
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Result (2),Types of Antibiotic Used in FUO
December 96 June 97
Patients Age (years) Number of patients Types of Antibiotic
0 5 11 Erythromycin, Amoxycilin, Ceftriaxone, Cotrimoxazole
5 - 12 5 Cotrimoxazole
gt12 32 Amoxycillin, Ampicillin, Chloramphenicol Spyramycin, Ofloxacin, Pefloxacine, Cefixim, Cefetamed, Cefprozil

• Narrow spectrum antibiotic were used for adults
  but were not used for children.

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Result (3), Number of Patients with FUO receiving
antibiotic December 1996 June 1997
Age (years) Number of patients Without antibiotics Recieved 1 or 2 antibiotics
0 5 11 3 8
5 12 5 1 4
gt 12 32 1 31
Total 48 5 (10) 43 (90)

• 90 patients received 1 or 2 kind of antibiotic
  before the haematological examination results.

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RESULT (4), REASONS OF ANTIBIOTICS USE

• Reasons of antibiotics use
• An assumption of infection despite clinical
  observation
• Uncertainty of sterilization of hospital
  environment
• Takes too long to wait for laboratory examination
  results
• Modeling personal or colleagues experiences
• Negligence of updating information
• Drug promotion

Note standard guideline for FUO was not
available in the hospital
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DISCUSSIONS (1)

• The data shows that narrow spectrum antibiotic
  such as Spiramycin and Chloramphenicol were used,
  despites the fact that narrow spectrum
  antibiotics are not recommended for FUO.
• Jacobs (2004) recommended that broad spectrum
  antibiotics might be given for FUO patients.
  Narrow spectrum antibiotic can not be given
  unless theres a strong evidence to a specific
  diagnosis.
• The evidence of FUO as the final diagnosis in
  this hospital (17,6) was slightly higher than
  that reported in reference (10 15)( Jacobs,
  1994). The factor that might contribut to this
  phenomenon was insensitivity of diagnosis tools.

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Discussion (2)

• Among the reasons to use antibiotics in FUO was
  personal or colleagues experiences, eventhough
  experience is not always reliable. Therefore an
  agreement to use the reliable reference such as
  diagnosis guideline and hospital standard
  treatment guideline are urgently needed.
• The drug costs varied widely (US 2.90 to US
  45.15), and factor what might contribute to this
  result is the unavailability of agreement among
  prescribers in this hospital on which drug and
  which brand name should be selected for FUO.

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CONCLUSIONS

• Narrow spectrum antibiotics were used for adults
  patient with FUO eventhough they are not
  recommended.
• Agreement among the prescribers is urgently
  needed to standardize the management of FUO in
  Panti Rapih Hospital.
• Effort should be sought to update the improving
  standard diagnosis and treatment guideline for
  FUO.