Antimicrobial Prescription Patterns in Perioperative Orthopaedic Procedures at a Tertiary Care Teaching Hospital: A Cross-Sectional Study Using the WHO AWaRe Classification and Correlating Prescribing Practices with Antimicrobial Resistance Patterns

Annavarapu Sirisha; Latha Merugu; Janardhan Marupaka; I Sridhar

doi:10.51168/rx1qpd08

Autori

Annavarapu Sirisha Associate Professor, Department of Pharmacology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India
Latha Merugu Assistant Professor, Department of Pharmacology, Government Medical College, Siddipet, Telangana, India
Janardhan Marupaka Assistant Professor, Department of Pharmacology, Government Medical College, Jangaon, Telangana, India
I Sridhar Professor and Head, Department of Pharmacology, Government Medical College, Jangaon, Telangana, India

DOI:

https://doi.org/10.51168/rx1qpd08

Cuvinte cheie:

Antimicrobial resistance, antimicobial stewardship, AWaRe, orthopaedic surgery, surgical prophylaxis, surgical site infection, prescribing indicators

Rezumat

Background: Perioperative antimicrobial prescribing is essential in orthopaedic surgery, but excessive broad-spectrum use may contribute to antimicrobial resistance. WHO AWaRe classification supports stewardship assessment.

Objectives: To characterize prescribing patterns, AWaRe categories, bacterial isolates, susceptibility findings, and their descriptive relationship.

Methods: This prospective observational cross-sectional study enrolled adults receiving perioperative antimicrobials at a tertiary-care teaching hospital over two months through convenience sampling. Prescriptions, clinical characteristics, and available culture-susceptibility findings were analyzed descriptively using SPSS.

Results: Among 201 prescriptions, mean participant age was 47.94 ± 14.60 years. Open reduction and internal fixation was the commonest procedure; cefuroxime predominated perioperatively and at discharge. Watch antibiotics accounted for 70.39% perioperatively and 71.48% at discharge, Reserve for 22.02% and 25.85%, and Access for 7.58% and 2.66%, respectively. Of 20 isolates, Pseudomonas aeruginosa (30%) was most frequent, followed by Staphylococcus aureus (25%), Escherichia coli (20%), Acinetobacter baumannii (10%), Staphylococcus haemolyticus (10%), and Klebsiella species (5%). Recorded predominant susceptibility/resistance pairs were ciprofloxacin/imipenem for P. aeruginosa, linezolid/penicillin for S. aureus, amikacin/imipenem for E. coli, polymyxin B/amikacin for A. baumannii, linezolid/erythromycin for S. haemolyticus, and polymyxin B/gentamicin for Klebsiella. High Watch and Reserve use coexisted with resistance to several agents, including imipenem, but patient-level prescribing–resistance associations were not established. Mean antibiotics per encounter were 2.68; generic prescribing was 3.98%, injection use 71%, and Essential Medicines List use 58%.

Conclusion: Perioperative antimicrobial prescribing in orthopaedic procedures was characterized by a predominance of Watch and Reserve antibiotics, frequent injectable use, and limited generic prescribing. The observed bacterial resistance patterns highlight potential antimicrobial stewardship concerns. The findings underscore the need for rational antibiotic selection, adherence to surgical prophylaxis guidelines, and culture-guided antimicrobial therapy.

Recommendations: Strengthen indication-based prophylaxis, culture-guided de-escalation, Reserve restrictions, and AWaRe audits informed by local antibiograms.

Biografii autori

Annavarapu Sirisha, Associate Professor, Department of Pharmacology, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India

is an Associate Professor in the Department of Pharmacology at Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Gannavaram, Andhra Pradesh, India. Her academic and research interests include clinical pharmacology, rational use of medicines, antimicrobial stewardship, drug utilization research, pharmacovigilance, and evidence-based prescribing. She is actively involved in undergraduate medical education and research activities related to the safe and effective use of medicines.
Latha Merugu, Assistant Professor, Department of Pharmacology, Government Medical College, Siddipet, Telangana, India

is an Assistant Professor in the Department of Pharmacology at Government Medical College, Siddipet, Telangana, India. Her areas of academic interest include clinical pharmacology, antimicrobial utilization, rational prescribing, pharmacovigilance, and medication-safety research. She is involved in medical teaching and research focused on improving prescribing practices and promoting evidence-based pharmacotherapy.
Janardhan Marupaka, Assistant Professor, Department of Pharmacology, Government Medical College, Jangaon, Telangana, India

is an Assistant Professor in the Department of Pharmacology at Government Medical College, Jangaon, Telangana, India. His academic interests include antimicrobial stewardship, drug utilization studies, clinical pharmacology, pharmacovigilance, and rational therapeutics. He is engaged in undergraduate medical education and research addressing appropriate medication use and contemporary issues in antimicrobial prescribing.
I Sridhar, Professor and Head, Department of Pharmacology, Government Medical College, Jangaon, Telangana, India

is Professor and Head of the Department of Pharmacology at Government Medical College, Jangaon, Telangana, India. He is actively involved in undergraduate medical education, academic administration, and pharmacology research. His areas of interest include clinical pharmacology, rational use of medicines, antimicrobial stewardship, pharmacovigilance, drug utilization research, and evidence-based therapeutics. He has contributed to the academic development of medical students and research activities aimed at promoting safe, appropriate, and scientifically grounded prescribing practices.

Referințe

1. Sharland M, Pulcini C, Harbarth S, Zeng M, Gandra S, Mathur S, et al. Classifying antibiotics in the WHO Essential Medicines List for optimal use-be AWaRe. Lancet Infect Dis. 2018;18(1):18-20. https://doi.org/10.1016/S1473-3099(17)30724-7

2. Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, et al. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect. 2024;30 Suppl 2:S1-S51. https://doi.org/10.1016/j.cmi.2024.02.003

3. Panditrao AM, Shafiq N, Chatterjee S, Pathak A, Trivedi N, Sadasivam B, et al. A multicentre point prevalence survey (PPS) of antimicrobial use amongst admitted patients in tertiary care centres in India. J Antimicrob Chemother. 2021;76(4):1094-1101. https://doi.org/10.1093/jac/dkaa533

4. Bhattacharjee S, Mothsara C, Shafiq N, Panda PK, Rohilla R, Kaore SN, et al. Antimicrobial prescription patterns in tertiary care centres in India: a multicentric point prevalence survey. EClinicalMedicine. 2025;82:103175. https://doi.org/10.1016/j.eclinm.2025.103175

5. Skender K, Singh V, Stalsby-Lundborg C, Sharma M. Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: a 10-year observational study. PLoS One. 2021;16(1):e0245902. https://doi.org/10.1371/journal.pone.0245902

6. Skender K, Machowska A, Singh V, Goel V, Marothi Y, Lundborg CS, Sharma M. Antibiotic use, incidence and risk factors for orthopedic surgical site infections in a teaching hospital in Madhya Pradesh, India. Antibiotics (Basel). 2022;11(6):748. https://doi.org/10.3390/antibiotics11060748

7. Saxena S, Priyadarshi M, Saxena A, Singh R. Antimicrobial consumption and bacterial resistance pattern in patients admitted in I.C.U at a tertiary care center. J Infect Public Health. 2019;12(5):695-699. https://doi.org/10.1016/j.jiph.2019.03.014

8. Nsojo A, George L, Mwasomola D, Tawete J, Mbotwa CH, Mweya CN, et al. Prescribing patterns of antimicrobials according to the WHO AWaRe classification at a tertiary referral hospital in the southern highlands of Tanzania. Infect Prev Pract. 2024;6(2):100347.

https://doi.org/10.1016/j.infpip.2024.100347

9. Bansal A, Sharma R, Prakash R. Adoption of the World Health Organization access, watch reserve index to evaluate and monitor the use of antibiotics at a tertiary care hospital in India. Perspect Clin Res. 2022;13(2):90-93. https://doi.org/10.4103/picr.PICR_202_19

10. Mathur P, Mittal S, Trikha V, Srivastav S, Pandey RM, Katyal S, et al. Surveillance for surgical site infections in orthopedic trauma surgeries at an Indian hospital. Indian J Med Microbiol. 2022;40(2):268-273. https://doi.org/10.1016/j.ijmmb.2021.12.016

11. Ahmed MN, Tluanpuii V, Trikha V, Sharma V, Farooque K, Mathur P, et al. Unraveling antibiotic susceptibility and bacterial landscapes in orthopedic infections at India's apex trauma facility. J Clin Orthop Trauma. 2024;57:102552. https://doi.org/10.1016/j.jcot.2024.102552

12. Eisner R, Lippmann N, Josten C, Rodloff AC, Behrendt D. Development of the bacterial spectrum and antimicrobial resistance in surgical site infections of trauma patients. Surg Infect (Larchmt). 2020;21(8):684-693. https://doi.org/10.1089/sur.2019.158

13. Berrios-Torres SI, Umscheid CA, Bratzler DW, Leas B, Stone EC, Kelz RR, et al. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017. JAMA Surg. 2017;152(8):784-791. https://doi.org/10.1001/jamasurg.2017.0904

14. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. https://doi.org/10.2146/ajhp120568