Original Article
Patterns of Prescription and Drug Dispensing S u n i l Karande, P u n a m S a n k h e a n d M a d h u r i K u l k a r n i
Department of Pediatrics, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
Abstract. Objective : To analyze the patterns of prescriptions and drug dispensing using World Health Organization core drug use indicators and some additional indices. Methods : Data were collected prospectively by scrutinizing the prescriptions written by pediatric resident doctors and by interviewing parents of 500 outpatient children. Results : The average number of drugs per encounter was 2.9 and 73.4% drugs were prescribed by generic name. Majority of drugs prescribed were in the form of syrups (60.8%). Use of antibiotics (39.6% of encounters) was frequent, but injection use (0.2% of encounters) was very low. A high number of drugs prescribed (90.3%) conformed to a model list of essential drugs and were dispensed (76.9%) by the hospital pharmacy. Certain drugs (5.7%) prescribed as syrups were not dispensed, although they were available in tablet form. Most parents (80.8%) knew the correct dosages, but only 18.5% of drugs were adequately labeled. No copy of an essential drugs list was available. The availability of key drugs was 85%. Conclusion : Interventions to rectify over prescription of antibiotics and syrup formulations, inadequate labeling of drugs and lack of access to an essential drugs list are necessary to further imprOve rational drug use in our facility. [Indian J Pedlatr 2005; 72 (2) : 117-121] E-mail:
[email protected] Key words : Drug utilization review; Essential drugs; Liquid drug formulations; Medical audit; Outpatients
Essential d r u g s offer a cost-effective solution to m a n y health problems in a developing country. 1They should be selected w i t h d u e r e g a r d to d i s e a s e p r e v a l e n c e , be affordable, with assured quality and be available in the a p p r o p r i a t e dosage forms. 1 Prescribers can only treat p a t i e n t s in a r a t i o n a l w a y if they h a v e access to an essential drugs list and essential drugs are available on a regular basis. 2 To assess the scope for improvement in rational drug use in outpatient practice, the World Health Organization (WHO) has formulated a set of "core drug use indicators" (Table 1). 2 The core prescribing indicators m e a s u r e the p e r f o r m a n c e of prescribers, the patient care indicators measure what patients experience at health facilities, and the facility indicators m e a s u r e w h e t h e r the h e a l t h p e r s o n n e l can f u n c t i o n effectively. 2 Based on these indicators, studies have been carried out in Bangladesh, a Burkina Faso, 4 Cambodia, s Ethiopia, 6 Ghana, 7 Lebanon, s Morocco, 9 N e p a l , 1~ Nigeria, ~ Pakistan, ~2 T a n z a n i a , ~3 Z i m b a b w e , ~4and in India. ~5-21Since no such s t u d y has been carried out selectively in a pediatric o u t p a t i e n t department, we wanted to measure these indicators in our facility to obtain data for promoting rational drug use. MATERIALS AND METHODS Ours is a major teaching tertiary-level public hospital which primarily serves the lower socioeconomic class of patients. In our outpatient department children aged from
Correspondence and Reprint requests : Dr. Sunil Karande, Fiat 24, Joothica, 5th Floor, Opposite Grant Road Post Office, 22A, Naushir Bharucha Road, Mumbai 400 007, India. Indian Journal of Pediatrics, Volume 72--February, 2005
28 days to 12 years of age avail medical consultation at a v e r y n o m i n a l cost of R u p e e s 1 0 / - , a n d d r u g s a r e dispensed free of cost. The W H O indicators are to be used to focus on the local health problems. 2 Therefore, only children w h o r e c e i v e d t r e a t m e n t for a c u t e g a s t r o e n t e r i t i s , a c u t e respiratory infections, or malaria (the three c o m m o n e s t illnesses) were prospectively enrolled. The " m i n i m u m " r e c o m m e n d e d sample size for a s t u d y carried out in a single health facility is 100 encounters. 2 We decided on a larger sample size of 500 encounters; and that both the "prescribing and patient care indicators" would be measured for the same patients, as this would give a better idea of the total service individual patients were receiving? The interviews were held discretely in the corridor just outside the pediatric outpatient department, where P.S. would record the data on predesigned W H O forms. 2 The data for the "prescribing indicators" was r e c o r d e d b y s c r u t i n i z i n g the p r e s c r i p t i o n i m m e d i a t e l y after the patient-prescriber encounter. P.S. would then instruct the parent to collect the prescribed drugs from the hospital pharmacy, and to meet her again to record data for the "patient care indicators". Which drugs were dispensed was determined by examining the drug packages/bottles the parent had actually received. It was noted whether they had been adequately labeled, viz. whether the name of the patient, the generic name of the drug and when the drug should be taken was written on them. 2 Lastly, the parent's knowledge of when and in what quantity each drug that was actually dispensed should be taken was evaluated. Failure to know either of these two points would result in p a r e n t ' s k n o w l e d g e being scored as inadequate. 2Data 117
Sunil Karande et al
was collected on Mondays and Thursdays, from 10 a.m. to 12 noon, the middle time of the outpatient day, to ensure that the results were not overly influenced by the rush to see patients at the beginning or end of a clinic session, or by freshness or fatigue of the health workers. 2 It took P.S. a period of nine months (April to December 2001) to collect the data. In our outpatient department, c h i l d r e n are seen b y m a n y r e s i d e n t s in a single consultation room and parents often queue within the consultation room itself. Also at the hospital pharmacy c o u n t e r situated on a n o t h e r floor, p a t i e n t s from all outpatient departments queue to collect their medicines. Thus it was impossible to collect data to calculate the average consultation and dispensing times. Penicillins, other antibacterial agents (including sulfa drugs), anti-infective dermatological drugs, anti-infective ophthalmological agents and antidiarrheal drugs with streptomycin, neomycin, nifuroxazide or combinations w e r e r e g a r d e d as antibiotics; w h i l e a n t i a m o e b i c , antigiardiasis, antihelminthic, and antimalarial drugs were not regarded as antibiotics. 2 Immunizations were not counted as drugs dispensed. 2 The 1998 WHO model list of essential drugs (tenth list) was used to define the drug names that were counted as "generic". 22 Data p e r t a i n i n g to the "facility indicators" w e r e gathered at the end of the present study. The staff nurse r e s p o n s i b l e for m a i n t a i n i n g e q u i p m e n t was asked whether any essential drugs list existed in the outpatient department during the study period. 2 Fifteen essential drugs formed the checklist to measure the availability of "key drugs", viz. drugs that should always be available for the treatment of common health problems, during the study period (Table 2). 2 This information was obtained from the records of the hospital pharmacy and medical stores. Even if one bottle or a few tablets were available the drug was recorded as being in stock. 2 Additional indices viz. "specific treatment practices" were calculated: (i) the types of drugs (injections, tablets, syrups, etc.) b e i n g prescribed, (ii) the p e r c e n t a g e of antibiotics of total number of drugs prescribed, (iii) the commonest antibiotics prescribed, (iv) the n u m b e r of antibiotics p e r p r e s c r i p t i o n , (v) the p e r c e n t a g e of prescriptions w h e r e i n all the prescribed drugs were dispensed, (vi) the percentage of drugs not dispensed in the same strength as prescribed, (vii) the drugs that were prescribed, yet not dispensed, and (viii) the errors in dispensing, if any.2 RESULTS
The m e a n age of the patients was 3.5 years (range 3 months-12 years, s.d. _+3.3 years). Males were 299 and females 201 (59.8% vs. 40.2%). A total of 1432 individual drugs were prescribed for 500 drug encounters, giving an average of 2.9 (s.d. _ 0.98); and the range of drugs per encounter varied from 1 to 8 (Table 3). There was not a single prescription wherein no d r u g was prescribed. 118
Generic prescribing dominated (Table 4). Drugs were prescribed in eight different dosage forms. Syrups were most commonly prescribed (60.8%), followed by tablets (20.5%), oral rehydration salts (11.1%), e y e / e a r / n o s e d r o p s (3.2%), nebulizations (2.1%), capsules (1.8%), lotions (0.4%), and injections (0.1%). Use of antibiotics was f r e q u e n t (Table 4). The n u m b e r of e n c o u n t e r s w i t h antibiotics was 198. Antibiotics constituted 14% of the total number of drugs prescribed. A single antibiotic was prescribed in 195 prescriptions, and two antibiotics were prescribed in the remaining three prescriptions. Thirtyfour (24.6%) out of 138 children with acute gastroenteritis, 162 (52.8%) out of 307 children with acute respiratory infections, and 2 (3.6%) out of 55 children with malaria were prescribed antibiotics. Ampicillin, cotrimoxazole, amoxicillin, and erythromycin constituted 87.6% (176/ 201) of the total number of antibiotics prescribed. Every child with acute gastroenteritis was prescribed oral r e h y d r a t i o n salts. No a n t i d i a r r h e a l d r u g s w i t h streptomycin or neomycin were prescribed. Injection use was very low. Only one patient, a three-year-old boy with acute gastroenteritis received an injection of hyoscine butylbromide for his abdominal colic. Most of the drugs prescribed (1293/1432) c o n f o r m e d to the W H O tenth revised model list of essential drugs. Three-fourths (1102/1432) of prescribed drugs were TABLE1. World Health Organization Core Drug Use Indicators to Investigate Drug Use in Health Facilities Prescribing indicators
1 2 3 4 5
Average number of drugs per encounter Percentage of drugs prescribed by generic name Percentage of encounters with an antibiotic prescribed Percentage of encounters with an injection prescribed Percentage of drugs prescribed from essential drugs list or formulary
Patient care indicators
6 Average consultation time + 7 Average dispensing time * 8 Percentage of drugs actually dispensed 9 Percentage of drugs adequately labeled 10 Patient's knowledge of correct dosage Facility indicators 11 Availabilityof copy of essential drugs list or formulary 12 Availabilityof key drugs +
Not recorded in current study
actually dispensed b y the hospital pharmacy. In 50% (250/500) of encounters the fuU quota, and in 3% (15/500) none of the prescribed drugs were dispensed. Only 2.2% (31/1432) of d i s p e n s e d d r u g s w e r e not in the same strength as prescribed. Certain drugs prescribed as syrups (for e x a m p l e , calcium s u p p l e m e n t s , iron-folic acid supplements, mebendazole, metronidazole, multivitamins, pheniramine maleate, and salbutamol) were not dispensed although they were available in tablet form. They constituted 5.7% (82/1432) of the total number of drugs prescribed. No patient received a wrong drug or Indian Journal of Pediatrics, Volume 72--February, 2005
Patterns of Prescription and Drug Dispensing TABLE2. World Health Organization Recommended List of Key Drugs for Testing Drug Availability
N o essential d r u g s list w a s available. O n l y t w o key drugs, procaine penicillin injection a n d tetracycline eye ointment were not available.
Common health problem Key drug
Diarrhea Acute respiratory tract infections Malaria Anemia Worm infestations Conjunctivitis Skin disinfection Fungal skin infection Pain Prophylactic drugs
Oral rehydration salts, cotrimoxazole tablets Cotrimoxazole tablets, procaine penicillin injection, pediatric paracetamol tablets, Chloroquine tablets, Ferrous salt + folic acid tablets Mebendazole tablets Tetracycline eye ointment Iodine, gentian violet or local alternative Benzoic acid + salicylic acid ointment Acetylsalicylic acid or paracetamol tablets Retinol (vitamin A), ferrous salt + folic acid tablets
DISCUSSION
TASTE3. Number of Drugs Prescribed Per Prescription
Prescription containing number of drugs One Two Three Four Five Six Seven Eight Total
Number of prescriptions (%) 24 164 204 81 22 3 1 1 500
(4.8) (32.8) (40.8) (16.2) (4.4) (0.6) (0.2) (0.2) (100)
an i n c o r r e c t d o s a g e . M o s t d r u g s ( 8 9 8 / 1 1 0 2 ) w e r e inadequately labeled as the n a m e of the patient and the generic name of the d r u g were not written. H o w e v e r , all d r u g p a c k a g e s / b o t t l e s h a d a pictogram d r a w n on them indicating h o w the d r u g should be taken. For example, if a tablet was to be taken three times a day; the pictogram d r a w n was O O O. Four-fifths (392/485) of parents knew the correct dosage schedule for all the drugs prescribed.
Average n u m b e r of drugs/injections per encounter is an important index of the scope for educational intervention in p r e s c r i b i n g practices. 2 O u r f i g u r e of 2.9 d r u g s p e r encounter is higher than the r e c o m m e n d e d limit of 2.0. 2 Similar f i n d i n g s h a v e b e e n r e p o r t e d in o t h e r I n d i a n studies (Table 4); and f r o m Burkina Faso, 4 C a m b o d i a , s Ethiopia, 6 G h a n a J Morocco, 9 Nepal, 1~Nigeria, u Pakistan, 12 T a n z a n i a , 13 a n d Z i m b a b w e '4 (2.2 to 4.8 d r u g s p e r encounter). Even in USA 23children receive 2.7 drugs p e r encounter. However, studies from Bangladesh 3 and L e b a n o n 8 have r e p o r t e d rational figures of 1.4 a n d 1.6, respectively. In the p r e s e n t s t u d y three or m o r e d r u g s were prescribed in 62.4% of prescriptions which increase the risk of d r u g interactions, of dispensing errors and of the parent not k n o w i n g the dosage schedules. 2 Increasing generic prescribing w o u l d rationalize the use and reduce the c o s t of d r u g s . 1 O u r f i g u r e of 73.4% d r u g s b e i n g prescribed by generic n a m e is higher than those reported in all o t h e r I n d i a n s t u d i e s (Table 4); a n d t h o s e f r o m Ghana, 7 Lebanon, ~ Nepal, ~~and Pakistan 12(2.9% to 65.0%). H o w e v e r h i g h e r f i g u r e s (75% to 99.8%) of g e n e r i c prescribing has been reported from Bangladesh, 3 Cambodia, 5 Ethiopia, 6 and Tanzania23 Appropriate use of antibiotics is necessary to prevent emergence of d r u g resistant bacteria. O u r figure of 39.6% p r e s c r i p t i o n s h a v i n g an antibiotic is l o w e r than those reported in most other Indian studies (Table 4); and those from Cambodia, s Ethiopia, 6 Ghana, 7 Morocco, ~ and N i g e r i a 1~ (47.5% to 100%). H o w e v e r lesser f i g u r e s of a n t i b i o t i c p r e s c r i b i n g (17.5 % to 35.4%) h a v e b e e n r e p o r t e d f r o m B a n g l a d e s h , 3 L e b a n o n , 8 N e p a l , ~~ a n d Tanzania. ~3Most acute gastroenteritis cases are viral and n e e d o n l y oral r e h y d r a t i o n t h e r a p y . 24 A l t h o u g h in the
TABLE4. Comparison of Core Drug Use Indicators Obtained in Current Study with Other Indian Studies
Core drug use indicator
Current study
Average number of drugs prescribed % of drugs prescribed by generic names % of encounters with an antibiotic prescribed % of encounters with an injection prescribed % of drugs prescribed from essential drug list Average consultation time (rain) Average dispensing time (rain) % of drugs actually dispensed % of drugs adequately labeled % patients with correct knowledge of dosage Essential Drugs List / formulary available % availability of key drugs
Biswas
Hazra
et al
et al
(20oo)
(2000)
2.9 73.4 39.6 0.2 90.3
1.4-4.1 6.3 - 25.1 14.4 - 22.3 0.0-4.4 74.1 - 95.8
76.9 18.5 80.8 No 85.0
10.5 - 15.6
3.2 46.2 72.8 3.9 45.7 3.7 3.1 11.6 56.2 64.5 No
Biswas et al
(2001) 3.0 35.0
Rehan
Maini
Rehan
et al
et al
et al
et al
(2002)
(2002)
(2003)
2.6 6.9 46.9 6.8 23.O
2.5 49.5 72.7 0.9 84.2
3.6 51.0 77.2 7.0
(2001) 2.4 1.5 78.8 0.0 18.5
Rishi
64.6 0.0 71.5
Ref Reference, % percentage, - not recorded/mentioned
Indian Journal of Pediatrics, Volume 72--February, 2005
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Sunil Karande et al present study 24.6% of children with acute gastroenteritis were prescribed an antibiotic, this is lower than figures reported in other Indian studies (64 and 83%) 25,26;and those f r o m Nigeria, 27 Indonesia, 2s B a n g l a d e s h , 29 and Pakistan 3~(58% to 96%). Similarly most acute respiratory i n f e c t i o n s are v i r a l a n d a n t i b i o t i c s n e e d not be prescribed. 31In the present study 52.8% of children with acute respiratory infections were prescribed an antibiotic, but this is l o w e r than figures reported f r o m Mexico 32 (77%); and from developed countries such as USA a3 (43%) and Canada 3*(74%). An u r g e n t n e e d arises to r e d u c e injection use in developing countries to p r e v e n t healthcare associated infections with H W and other blood borne pathogens. 35In the present study injection use was very low as compared to other I n d i a n studies (Table 4). I n a p p r o p r i a t e high injection prescribing (17.1% to 80%) has been reported from Ethiopia, 6 Ghana, / Morocco, 9 Pakistan, 12Tanzania, 13 and Zimbabwe. 14Although our pediatric residents had no e s s e n t i a l d r u g s list to r e f e r to, 90.3% of the d r u g s prescribed w e r e essential drugs, which is higher than figures reported in most other Indian studies (Table 4); and those f r o m Bangladesh, 3 Burkina Faso, 4 Lebanon, s M o r o c c o , 9 N e p a l , 1~ a n d P a k i s t a n 12 (2.9% to 88%). H o w e v e r , higher figures of 99.7% and 97% h a v e been reported from C a m b o d i a s and Ghana, 7 respectively. A locally a d a p t e d essential drugs list will help p r o m o t e rational drug use in our outpatient depa~-tment. 1,2 In o u r facility 76.9% of p r e s c r i b e d d r u g s w e r e dispensed, which is higher than figures reported in other I n d i a n s t u d i e s (Table 4); b u t l o w e r t h a n those f r o m Burkina Faso,* Cambodia, s and Ethiopia 6 (82% to 100%). The cost of e q u i v a l e n t dose of d r u g in s y r u p form is a l m o s t twice that of the d r u g in tablet form. 36 Hence o v e r d e p e n d e n c e on s y r u p f o r m u l a t i o n s n e e d s to be rectified. Also, if a d r u g p r e s c r i b e d as s y r u p is not available; its tablet form should be dispensed. The parent can be explained each time to crush the prescribed tablet and prepare a palatable syrup dose, otherwise the parents would have to use private resources to obtain the syrup formulation, which they often cannot, resulting in noncompliance with the treatment. The level of appropriate labeling (18.5%) needs to be i m p r o v e d . A l t h o u g h not a single d i s p e n s e d d r u g was adequately labeled in an Indian, 2~and Cambodian s study; much higher figures of 56.2% and 87%, respectively, have been reported in another Indian, 16and Tanzanian ~3study. At the end of the study, when the dispensers were asked about the inadequate labeling, they stated that given their typical w o r k l o a d t h e y h a r d l y got a few m i n u t e s to interact with the parents, which they preferred to utilize to draw the pictogram and explain h o w the individual drugs should be taken. The use of pictograms has been shown to improve recall of medical information in people with low literacy skiUsY However, writing the patient's n a m e a n d g e n e r i c n a m e of the d r u g on the label is necessary. This w o u l d also help in reducing the risk of 120
dispensing errors. 3~Although only 80.8% of parents knew the correct dosage schedule, our figure is higher than those reported in other Indian studies (Table 4); and those from Bangladesh, 3 Burkina Faso 4 and Cambodia 5 (55% to 68.3%). The d i s p e n s e r s after h a v i n g e x p l a i n e d once should request the parents to repeat the drug dosages. This w o u l d help i d e n t i f y p a r e n t s w h o r e q u i r e to be explained again. The availability of all key drugs should be ensured. A similar figure of 86.6% availability of key drugs has been reported from Cambodia 5, a lower figure of 54% from Bangladesh, 3 and an optimal figure of 100% from Ethiopia. 6 A n y d r u g utilization s t u d y based on the W H O core d r u g use indicators has l i m i t a t i o n s ? D e t e r m i n i n g the quality of diagnosis and evaluating the adequacy of drug choices is beyond the scope of the prescribing indicators? Also, the patient care indicators do not capture m a n y fundamental issues related to the quality of examination and treatment. 2 H o w e v e r , the present s t u d y p r o v i d e s i m p o r t a n t useful baseline data which will be useful for comparison when in future any pediatric drug utilization study is carried out. Acknowledgement
We thank our Dean, Dr. M. E. Yeolekar, for granting us permission to publish this study.
REFERENCES 1 Quick JD, Hogerzeil HV, Velasquez G, Rago L. Twenty-five years of essential medicines. Bull WHO 2002; 80 : 913-914. 2 International Network for Rational Use of Drugs and World Health Organization. How to investigate drug use in health facilities: Selected drug use indicators. EDM Research Series No. 7 [WHO/DAP/93.1]. Geneva: World Health Organization, 1993. 3. Guyon AB, Barman A, Ahrned JU, Ahmed AU, Alam MS. A baseline survey on use of drugs at the primary health care level in Bangladesh. Bull WHO 1994; 72: 265-271. 4. Krause G, Borchert M, Benzler Jet al. Rationality of drug prescriptions in rural health centres in Burkina Faso. Health Policy Plan 1999; 14 : 291-298. 5. Chareonkul C, Khun VL, Boonshuyar C. Rational drug use in Cambodia: study of three pilot health centers in Kampong Thorn Province. Southeast Asian J Trop Med Public Health 2002; 33: 418-424. 6. Desta Z, Abula T, Beyene L, Fantahun M, Yohannes AG, Ayalew S. Assessment of rational drug use and prescribing in primary health care facilities in north west Ethiopia. East Afr Med J 1997; 74 : 758-763. 7. Bosu WK, Ofori-Adjei D. An audit of prescribing practices in health care facilities of the Wassa West district of Ghana. West Afr J Med 2000; 19: 298-303. 8. Hamadeh GN, Dickerson LM, Saab BR, Major SC. Common prescriptions in ambulatory care in Lebanon. Ann Pharmacother 2001; 35 : 636-640. 9. Simon N, Hakkou F, Minani M, Jasson M, Diquet B. Drug prescription and utilization in Morocco. Therapie 1998; 53 : 113120. 10. Ravi Shankar P, Partha P, Nagesh S. Prescribing patterns in medical outpatients. Int J Clin Pract 2002, 56 : 549-551. 11. Chukwuani CM, Onifade M, Sumonu K. Survey of drug use Indian Journal of Pediatrics, Volume 72--February, 2005
Patterns of Prescription and Drug Dispensing
12.
13.
14.
15.
16.
17.
18.
19
20.
21.
22.
23.
24. 25.
26.
27.
practices and antibiotic prescribing pattern at a general hospital in Nigeria. Pharm World Sci 2002; 24:188-195. Najmi MH, Hafiz RA, Khan I, Fazli FR. Prescribing practices: an overview of three teaching hospitals in Pakistan. J Pak Med Assoc 1998; 48 : 73-77. Massele AY, Nsimba SE, Rimoy G. Prescribing habits in church-owned primary health care facilities in Dar Es Salaam and other Tanzanian coast regions. East Afr Med J 2001; 78: 510514. Trap B, Hansen EH, Hogerzeil HV. Prescription habits of dispensing and non-dispensing doctors in Zimbabwe. Health Policy Plan 2002; 17: 288-295. Biswas NR, Biswas RS, Pal PS et al. Patterns of prescriptions and drug use in two tertiary hospitals in Delhi. Indian J Physiol Pharmaco12000; 44 : 109-112. Hazra A, Tripathi SK, Alam MS. Prescribing and dispensing activities at the health facilities of a non-governmental organization. Natl Med J India 2000; 13 : 177-182. Biswas NR, Jindal S, Siddiquei MM, Maini R. Patterns of prescription and drug use in ophthalmology in a tertiary hospital in Delhi. Br J Clin Pharmaco12001; 51 : 267-269. Rehan HS, Singh C, Tripathi CD, Kela AK. Study of drug utilization pattern in dental OPD at tertiary care teaching hospital. Indian J Dent Res 2001; 12 : 51-56. Maini R, Verma KK, Biswas NR, Agrawal SS. Drug utilization study in dermatology in a tertiary hospital in Delhi. Indian J Physiol Pharmacol'2002; 46 : 107-110. Rehan HS, Lal P. Drug prescribing pattern of interns at a government healthcare centre in northern India. Trop Doct 2002; 32: 4-7. Rishi RK, Sangeeta S, Surendra K, Tailang M. Prescription audit: experience in Garhwal (Uttaranchal), India. Trop Doct 2003; 33 : 76-79. World Health Organization Expert Committee. The use of essential drugs. Eighth report of the WHO Expert Committee (including the revised Model List of Essential Drugs). World Health Organ Tech Rep Ser 1998; 882 : 1-77. Hong SH, Shepherd MD. Outpatient prescription drug use by children enrolled in five drug benefit plans. Clin Ther 1996; 18: 528-545. Phavichitr N, Catto-Smith A. Acute gastroenteritis in children: what role for antibacterials? Pediatr Drugs 2003; 5 : 279-290. Singh J, Bora D, S a c h d e v a V, Sharma RS, Verghese T. Prescribing pattern by doctors for acute diarrhoea in children in Delhi, India. J Diarrhoeal Dis Res 1995; 13 : 229-231. Raghu MB, Balasubramanian S, Balasubrahmanyam G, Indumathy, Ramnath A. Drug therapy of acute diarrhoea in children- actual practice and recommendations. Indian J Pediatr 1995; 62:433-437. Okeke TA, Okafor HU, Amah AC, Onwuasigwe CN, Ndu AC.
Indian Journal of Pediatrics, Volume 72--February, 2005
28.
29.
30.
31.
32.
33
34.
35.
36.
37.
38.
Knowledge, attitude, practice, and prescribing pattern of oral rehydration therapy among private practitioners in Nigeria. J Diarrhoeal Dis Res 1996; 14: 33-36. Gani L, Arif H, Widjaja SK et al. Physicians' prescribing practice for treatment of acute diarrhoea in young children in Jakarta. J Diarrhoeal Dis Res 1991; 9 : 194-199. Chowdhury AK, Matiaa MA, Islam MA, Khan OF. Prescribing pattern in acute diarrhoea in three districts in Bangladesh. Trop Doct 1993; 23 : 165-166. Mahmud A, Jalil F, Karlberg J, Lindblad BS. Early child health in Lahore, Pakistan: VII. Diarrhoea. Acta Pediatr Suppl 1993; 82 (Supp1390): 79-85. Pichichero ME, Green JL, Francis AB, Marsocci SM, Murphy ML. Outcomes after judicious antibiotic use for respiratory tract infections seen in a private pediatric practice. Pediatrics 2000; 105: 753-759. Pelaez-Ballestas I, Hemandez-Garduno A, Arredondo-Garcia JL, Viramontes-Madrid JL, Aguilar-Chiu A. Use of antibiotics in upper respiratory infections on patients under 16 years old in private ambulatory medicine. Salud Publica Mex 2003; 45: 159-164. Watson RL, Dowell SF, Jayaraman M, Keyserling H, Kolczak M, Schwartz B. Antimicrobial use for pediatric u p p e r respiratory infections: reported practice, actual practice, and parent beliefs. Pediatrics 1999; 104: 1251-1257. Wang EE, Einarson TR, Kellner JD, Conly JM. Antibiotic prescribing for Canadian preschool children: evidence of overprescribing for viral respiratory infections. Clin Infect Dis 1999; 29: 155-160. Hutin YJF, Hauri AM, Armstrong GL. Use of injections in healthcare setting worldwide, 2000: literature review and regional estimates. BM] 2003; 327 : 1075-1079. Singhania RU, Bansal A, Sharma JN, Chana RS. Should we continue with use of syrups and suspensions. Indian ] Pediatr 1987; 54 : 126-127. Dowse R, Ehlers MS. The evaluation of pharmaceutical pictograms in a low-literate South African population. Patient Educ Couns 2001; 45 : 87-99. Peterson GM, Wu MS, Bergin JK. Pharmacist's attitudes towards dispensing errors: their causes and prevention. J Clin Pharm Ther 1999; 24: 57-71.
Contributors : SK was the postgraduate guide, and was responsible for concept, design, interpretation of data, review of literature, drafting the article and will act as guarantor for the article; PS for collecting and analysis of data, discussing core ideas and review of literature; MK for design, discussing core ideas and critical review of the article. Funding: None. Competing interests: None.
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