World Health Organization defines drug utilization research as “the study of marketing, distribution, prescription, and use of drugs in a society, with special emphasis on the resulting medical, social, and economic consequences”.1 Drug utilization studies are a type of pharmacoepidemiologic research that estimates the extent of rational drug use and compliance with established guidelines.2,3 Drug utilization research plays a vital role in evaluating prescribing trends, medication safety, quantification of suboptimal medication use (underutilization or overutilization), and treatment optimization. The primary objective was to promote rational pharmacotherapy at the population level. At an individual patient level, it is important to ensure prescription of a right drug at right dosage which is also cost-effective.4 Such studies also guides for improving the prescribing skills of junior residents in a tertiary care setting by understanding the essential medicines list (EML), the importance of prescribing with generic names and right prescribing practices. In a surgical setting, pre-and postoperative use of multiple classes of drugs and combinations, including antibiotics, parenteral analgesics, and IV fluids, is quite common.4 Hence, polypharmacy is a frequent concern in surgical patients, particularly in managing comorbidities and preventing complications. Excessive medication use can increase the risk of drug-drug interactions and adverse effects.5 A tertiary care setting poses several challenges to rational prescribing, such as patient load, variations due to a greater number of prescribers, and drug availability. Prescribing trends in a tertiary setting, where patient inflow is huge, can serve as an important tool to review and modify prescribing practices to ensure rational drug use.6 There are only a few studies that have considered drug utilization patterns in surgical inpatient wards. This study was therefore conducted to analyze the patterns of drug utilization in the inpatient wards of the Department of Surgery in a tertiary care teaching hospital in Tamil Nadu.

Study design - A prospective observational study Study centre – Department of Surgery, Government Tiruppur Medical College, Tiruppur Study population - Inpatients admitted in surgery department Study duration - June to August 2023 This study was conducted on 304 prescriptions, ensuring compliance with ethical guidelines and institutional regulatory standards. The drug utilization patterns were analyzed using the following parameters: 1. Different classes of drugs used and percentage of prescriptions with each class of drug used 2. Average number of drugs per prescription (Total number of drugs prescribed / Total number of prescriptions) 3. Antimicrobial drug utilization - percentage of prescriptions with antimicrobials, frequency of prescribing each antimicrobial drug 4. Percentage of prescriptions with drugs used for supportive management 5. Percentage of prescriptions with drugs used for co-morbidities 6. Percentage of prescriptions with Fixed dose combinations 7. Percentage of prescriptions with generic names 8. Percentage of prescriptions with at least one injection Descriptive and inferential statistical analyses were performed using JAMOVI 2.4.11.

A total of 304 prescriptions were analyzed in this study. Among the prescriptions analyzed, 36% of the study population were males and 64% were females [Figure 1]. The drug utilization pattern revealed that antibiotics (96.7%), proton pump inhibitors (PPIs) (98.4%), and analgesics (98.4%) were the most prescribed drug classes [Figure 2]. Other frequently used medications included antiemetics (17.7%), antidiabetics (23.9%), antihypertensives (13.1%), hypolipidemic drugs (6.9%), and antiplatelets (6.2%). 99% of patients received at least one injection. The average number of drugs per prescription was calculated dividing the total number of drugs prescribed by total number of prescriptions. In this study, the average number of drugs per prescription was 6. Majority of the prescriptions showed use of five drugs [27.3 % (n = 83)], followed by four drugs per prescription [21.3 % (n = 65)], indicating a high prevalence of polypharmacy [Figure 3]. This trend indicates the need for periodic prescription audits for enforcing rational drug use and minimizing potential drug interactions. The utilization of antibiotics in surgical inpatients was analyzed to find out the frequently used antibiotic class and commonly used individual antibiotics. The most prescribed antibiotics were Metronidazole (73%) and Ceftriaxone (59.2%), followed by Cefotaxime (23.4%), Amikacin (9.5%), and Piperacillin-Tazobactam (7.2%) [Figure 4], indicating a high consumption of broad-spectrum antibiotics for infection control in surgical settings. Beta lactam antibiotics were the most frequently used group of antibiotics. The data was also analyzed to enumerate the commonly prescribed drugs for comorbidities and supportive care. Routine first line antihypertensive drugs were commonly used. Amlodipine was the most prescribed antihypertensive medication (57.5%), followed by Atenolol (27.5%), Enalapril (25%), and Metoprolol (17.5%). Among antidiabetic drugs, oral drugs like Metformin (45.3%) were the most frequently prescribed, followed by Glimepiride (25.7%); while Sitagliptin (5.6%) and Voglibose (3.3%) were comparatively prescribed less. Insulin was used among 20.1% of prescriptions. Drugs used for cardiac care included hypolipidemic drugs and antiplatelets. Of which, Atorvastatin was used in 6.9%; Aspirin in 3.9% and Clopidogrel in 2.3% of the prescriptions [Table 1]. Prescribing pattern among drugs for supportive care included proton pump inhibitors, antiemetics and analgesics. Among them Ranitidine (76 %) was the preferred antiulcer agent, Ondansetron (63%) and Domperidone (27%) were frequently administered antiemetics. Paracetamol (62.2%) followed by Diclofenac (52.6%) were the most commonly used analgesics. Use of these supportive drugs reflect their essential role in perioperative care of surgical patients. Additionally, Normal Saline (96.1%) and Ringer Lactate (87.8%) were the most used intravenous fluids. Use of multivitamins was found in significant number (27.3%) of prescriptions [Table 1]. Fixed-dose combinations (FDCs) were used in 10.5% of prescriptions [Figure 5]. Only 37.8% of drugs were prescribed by generic names [Figure 6], reflecting the need of sensitization to prescribe using generic names in prescriptions. TABLE 1: PRESCRIBING PATTERNS OF DIFFERENT CLASS OF DRUGS FOR COMORBID CONDITIONS AND SUPPORTIVE CARE Drug classes Number of prescriptions (n) Percentage (%) Antihypertensive drugs Amlodipine 175 57.5 Metoprolol 53 17.5 Enalapril 76 25 Atenolol 84 27.5 Propranolol 8 2.5 Cilnidipine 15 5 Antidiabetic drugs Metformin 138 45.3 Glimepiride 78 25.7 Insulin 61 20.1 Sitagliptin 17 5.6 Voglibose 10 3.3 Hypolipidemics Atorvastatin 21 6.9 Antiplatelets Aspirin 12 3.9 Clopidogrel 7 2.3 Antiulcer agents Omeprazole 73 24 Ranitidine 231 76 Antiemetics Domperidone 82 27 Ondansetron 192 63 Analgesics Diclofenac 160 52.6 Paracetamol 189 62.2 Tramadol 62 20.5 Miscellaneous Drugs Normal Saline 292 96.1 Dextrose 23 7.6 Ringer Lactate 267 87.8 Multivitamins 83 27.3 Anti rabies 5 1.6 Human Rabies Immune Globulin 4 1.3 Diphtheria and Tetanus vaccine 16 5.3

The present study provides a comprehensive analysis of drug utilization patterns in surgical inpatients, shedding light on prescribing trends, antibiotic stewardship, and rational drug use. Compared to previously published studies in top-tier journals, the findings highlight both areas of conformity with global prescribing trends and opportunities for improvement in rational drug use. The study revealed a high prevalence of polypharmacy. 72% of prescriptions contained five or more drugs per prescription. [27.3 % (n = 83), receiving five drugs per prescription followed by four drugs per prescription 21.3 % (n = 65)]. The average number of drugs per prescription in our study was 6. In a similar study conducted in western part of India, the average number of drugs per prescription was 8.94, which indicated high incidence of polypharmacy in surgical wards.7 While polypharmacy is sometimes justified in complex surgical cases, it also increases the risk of drug-drug interactions and adverse effects.8 In another study conducted in ICU settings, patients received an average of 15.8 drugs per encounter, highlighting concerns regarding medication overload and inappropriate prescribing practices.9 A systematic audit of prescriptions is necessary to ensure rational and evidence-based drug use. One of the most striking findings of this study is the extensive use of antibiotics (96.7%), particularly Metronidazole (73%) and Ceftriaxone (59.2%). This is consistent with studies conducted in other tertiary care hospitals, where Ceftriaxone was also among the most frequently prescribed antibiotics due to its broad-spectrum activity.10,11 However, overprescription and prolonged use of antibiotics have been linked to the rise in antimicrobial resistance, as demonstrated in a study where 98% of patients who underwent minor or major surgeries received antibiotics, despite a lack of definitive infection indicators.11 This underscores the urgent need for antimicrobial stewardship programs, which have been shown to reduce unnecessary antibiotic use and improve patient outcomes.12 Pain management is a critical aspect of postoperative care, reflected in the high prescription rates of analgesics (98.4%), with Paracetamol (62.2%) and Diclofenac (52.6%) being the most commonly used drugs. These findings align with global trends where NSAIDs are frequently preferred over opioids to minimize dependence and adverse effects.13 Additionally, antiulcer and antiemetic drugs were prescribed in majority of the prescriptions, consistent with studies where antiulcer drugs were among the top three prescribed drug classes.14 While gastroprotective agents are essential in preventing NSAID-induced ulcers, overprescription without clear indications should be carefully reviewed. The study identified that 10.5% of prescriptions contained fixed-dose combinations (FDCs). Only 37.8% of prescriptions used generic names, a trend observed in other studies, where generic prescribing was as low as 21.8%.15 Prescribing using generic names is one the core indicators of rational prescribing as per the WHO guidelines and national health policies. Sensitizing prescribers to use generic names is hence crucial. The findings of this study emphasize the need for regular prescription audits, strict adherence to antimicrobial stewardship, and institutional policies and guidelines. Institutions that have implemented stewardship programs, prescription monitoring and training sessions for junior doctors on rational prescription writing according to WHO guidelines and rational drug use have shown improvements in prescription quality, adherence to essential drug lists and a significant reduction in antibiotic overuse and healthcare costs.

The present study aligns with global trends in drug utilization among surgical inpatients which highlights several areas of concern, including high antibiotic usage, polypharmacy, and the need for better prescribing practices. These challenges can be addressed by conducting regular prescription audits, mandatory clinical training on prescribing skills for undergraduates and postgraduates and antimicrobial stewardship programs. Targeted sensitization programs for residents and junior doctors can help to reduce unnecessary medications by adopting rational prescribing policies to improve overall healthcare.

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