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Hospital Pharmacy 54(5)

Discussion

Table 2. Prophylactic Antibiotic Use Around Surgical
Procedures in Hospitals A and B, Expressed as DDD.
Antibiotic

Hospital A

Amphenicols
Thiamphenicol
-
Penicillins with extended spectrum
Amoxicillin
0.5
Penicillins combined with beta-lactamase inhibitors
Ampicillin and enzyme inhibitor
7.3
Amoxicillin and enzyme inhibitor
17.8
Cephalosporins, first generation
Cefazolin
7.0
Cefadroxil
4.1
Cephalosporins, second generation
Cefuroxime
27.9
Cefaclor
0.2
Cephalosporins, third generation
Cefotaxime
6.8
Ceftazidime
21.3
Ceftriaxone
285.9
Ceftizoxime
25.5
Cefixime
42.5
Cefoperazone, combinations
10.0
Cephalosporins, fourth generation
Cefepime
1.0
Cefpirome
7.3
Carbapenems
Meropenem
28.0
Imipenem and enzyme inhibitor
-
Macrolides
Azithromycin
1.7
Lincosamides
Clindamycin
-
Aminoglycosides
Gentamicin
0.3
Kanamycin
-
Amikacin
1.5
Fluoroquinolones
Ciprofloxacin
5.0
Levofloxacin
5.0
Imidazole derivatives
Metronidazole
1.7
Other antibiotics
Fosfomycin
0.4
Total DDD
508.5
DDD per patient
1.5
DDD per 100 bed days
-

Hospital B
2.5
-
8.7
44.0
25.5
5.8
5.2
-
1.6
7.1
97.8
0.3
59.3
17.3
12.5
0.3
53.0
19.0
0.8
3.3
9.9
0.5
77.3
18.8
33.5
63.3
-
567.0
1.7
30.4

Note. DDD = defined daily doses.

than of the average patient (5.4 days). Their diagnoses were
noninsulin-dependent diabetes mellitus with neurological
complication, acute peritonitis, rectal cancer, focal brain
injury, and benign neoplasm of the ovary.

This study clearly shows that the volume of prophylactic
antibiotic use is large, with more than 80% using two or
more antibiotics, and that a wide variety of different antibiotics including in most cases third generation cephalosporins
was applied in the study hospitals.
The choice of an antibiotic should be based on its antibacterial spectrum and the indication. The main bacteria causing
surgical site infections after clean procedures are the grampositive S. aureus and coagulase-negative staphylococci (eg,
Staphylococcus epidermidis) which are common species of
the skin flora. In clean-contaminated procedures, including
abdominal surgery and heart, kidney, and liver transplantations, bacteria that cause surgical site infections are similar to
those at the skin flora in a clean procedure, plus gramnegative rods, and enterococci. According to the guideline
published by IMOH7, cefazolin, a first generation cephalosporin, is applied to prevent such infections. Third generation cephalosporins such as the frequently used ceftriaxone
and cefixime in hospitals A and B are not the prophylactic
antibiotics of choice here. Cefixime was used as a ceftriaxone substitute when switching from an intravenous to an oral
antibiotic. Besides staphylococci and enterococci, ureaplasma and anaerobic bacteria are common organisms isolated from wound infections. Therefore, azithromycin or
metronidazole may be added to suppress these organisms.
Furthermore, the addition of vancomycin to cefazolin is recommended when MRSA is a frequent cause of infection.15,16
For patients allergic to beta-lactam, the recommended prophylactic antibiotics are gentamicin, fluoroquinolone,
clindamycin, or vancomycin.6
Meropenem and amikacin, both frequently applied, especially in hospital B (Table 2), are highly potent broad spectrum antibiotics used as alternatives if the bacteria are already
unsusceptible to cephalosporins and gentamicin. Ceftriaxone,
amikacin, and meropenem are not recommended for specific
gram-positive skin flora. Therefore, the use of ceftriaxone
should be limited and only be applied based on results from
an antibiotics sensitivity test showing the presence of gramnegative bacteria.
The DDD is used for benchmarking between hospitals.14
Overall, in this study, the antibiotic use was 30 DDD per
100BD meaning that on average, there were 0.3 WHO's
DDD per patient per day or 30 WHO's DDD for 100 patients
per day. This means that 30% of the patients received a DDD
of a prophylactic antibiotic per day.
The antibiotic use in hospitals A and B in 2016, with
higher preference for cephalosporins than for penicillins,
was different from the antibiotic use in two other hospitals in
Indonesia in 2005,17 where penicillins were preferred over
cephalosporins. Comparable DDD-100BD were reported for
the Isparta State Hospital in Turkey in 2013, a secondary
health care facility with 372 beds, with 49.1 DDD-100BD;
<2 DDD per patient.18 It was lower than two hospitals in
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