Results and discussion

In total, 790 adult prescriptions were included. The average age of patients in the study was 35.27 years (range, 18–90). The median length of stay was 9 days (range, 1–95). Minor surgical interventions were performed in 93 patients (11.7%) and 448 patients (56.7%) underwent major surgical interventions: orthopedic surgeries (n = 238); abdominal surgery (n = 40); spinal surgery (n = 70); thoracic surgery (n = 8); and polytrauma or grafting surgeries (n = 33). Among these patients, 241 (30.5%) underwent conservative management.

In total, 667 prescriptions (84.4%) were for antibiotics. Among the patients who received them, appropriate microbiological specimens were obtained in 523 cases (67.3%), and a specific pathogen was identified in 214 cases (28.80%). The most commonly identified organisms were Acinetobacter baumannii (n = 44, 8.3%), Pseudomonas aeruginosa (30, 5.6%), Escherichia coli (n = 27, 5.08%), Klebsiella pneumoniae (n = 16, 3%), and Staphylococcus aureus (n = 26, 4.9%). Other organisms, such as Citrobacter spp, Proteus spp, Providentia spp, Enterococcus spp, and Streptococcal spp, were also identified. The antimicrobial susceptibility profiles of the most commonly isolated organisms are provided in Table 1. Moreover, 162 patients were diagnosed with infections during their hospitalization. Among them, 72 (10.7%) developed skin and soft-tissue infections, 45 (6.16%) developed respiratory infections, 28 (4.08%) developed bloodstream infections, and 17 (2.41%) developed urinary tract infections. For the patients who received the remaining 123 discharge prescriptions (32.7%), microbiological cultures were not sent to guide the antibiotic therapy. Directed therapy based on susceptibility testing was provided in 74 cases (18%), and 82 patients on antibiotics (12.3%) were culture negative at any time during their hospital stay.

Table 1. Antimicrobial Susceptibility Profiles of the Most Commonly Isolated Organisms

^a Other entrobacteriaceae like citrobacter specise, serratia specise, salmonella specise and proteus specise.

Commonly prescribed antibiotics are shown in Figure 1. Overall, 74 prescriptions at discharge (18%) did not mention the exact duration of antibiotics. Also, 29 prescriptions (4.6%) exceeded the recommended duration of antibiotics prescribed. In 43 prescriptions (6.8%), the antibiotic prescribed at discharge was not targeted to organisms isolated in culture. In total, antibiotics with broad gram-negative activity (ie, a fluoroquinolone or amoxicillin-clavulanic acid) were prescribed in 241 cases (38.3%).

Fig. 1. Antimicrobials prescribed on discharge.

*Miscellaneous antimicrobials such as clindamycin, metronidazole, azithromycin, doxycycline, netilmicin, rifampicin, amikacin, and ceftriaxone-sulbactam.

Most of the antibiotics were prescribed in the orthopedics department (28%), followed by trauma surgery and critical care units (18.4%), neurosurgery department (13%), and general surgery department (6.6%). However, the rates of culture ordering in these departments were 7%, 9%, 8.3%, and 3% respectively. Most of the restricted antibiotics and combinations of >2 antibiotics were used in the orthopedic department. The median total antibiotic duration was 7 days (IQR, 3–14).

Controlling antibiotic prescription at discharge is increasingly recognized as a potential tool for AMS. Overall, >80% of the patients were discharged with broad-spectrum antibiotics, but culture positivity was only 28% in our study. This overprescribing may be due to fear of developing MDR infections because most patients (66%) had undergone a major surgery. Prescriber behavioral factors, such as fear of treatment failure or readmission, as well as habit may also contribute. Doctors may not account for the intravenous and oral antimicrobial therapy already received by the patient during the hospital stay and thus may simply prescribe a standard 5- or 7-day course of antibiotics upon discharge. AMS programs and repeated training will strengthen the confidence of surgeons in limiting antimicrobial prescriptions.

The overuse of antibiotics is associated with increasing antimicrobial resistance and increased risk of C. difficile infection, as well as unnecessary healthcare costs. ^{Reference Yogo, Haas and Knepper5}

Our results contribute to understanding the prescribing pattern of antibiotics at hospital transition and the common errors present at this time, so well-structured strategies can be applied to reduce the overuse of antibiotics. Because most patients in our hospital are trauma patients and their chief complaints are not related to infection, the appropriateness of discharge prescription needs to be further prioritized as an area for AMS interventions.

According to the Scoping Report on Antimicrobial Resistance in India (2017), under the aegis of the government of India, among the gram-negative bacteria, >70% of isolates of E. coli, K. pneumoniae, and A. baumannii and nearly half of all P. aeruginosa were resistant to fluoroquinolones and third-generation cephalosporins drugs. ^{Reference Gandra, Joshi, Trett, Lamkang and Laxminarayan6} These important findings suggest that follow-up cultures and adherence to antibiotic policy regarding the recommendations of antibiotics at discharge should be followed in each hospital. The use of fluoroquinolones in hospitalized patients and upon discharge needs to be monitored and assessed for appropriateness. Few studies have highlighted the impact of fluoroquinolone restriction on the overall reduction of its use and CDI rates. ^{Reference Shea, Hobbs and Jaso7,Reference Sarma, Marshall, Cleeve, Tate, Oswald and Woolfrey8} The treatment guidelines issued by the ICMR, which are based on its AMR surveillance data, should be followed when prescribing antibiotics.

Because antimicrobials are so commonly prescribed upon hospital discharge, it is important to identify the patients, indications, and antimicrobials at highest risk of harm from inappropriate therapy. Novel interventions are also needed to reduce the overuse of the antibiotics. Published studies have indicated that improved prescribing can be achieved in many ways: education, involvement of AMS team, electronic prescribing and flagging, generation of alert, culture-based follow-up at discharge, follow-up of patients with inconclusive or pending culture reports, and more.

The findings of this study, along with the paucity of previous studies in India that have addressed this topic, suggest that oral antibiotic prescribing at the transition from inpatient to outpatient care is an important and underrecognized opportunity to reduce the overuse of antibiotics.