Antibiotic‐prescribing patterns in outpatient departments from a tertiary care hospital in Manipur using WHO AWaRe classification

Materials & Methods

This cross-sectional study was conducted at the department of Community Medicine, Regional Institute of Medical Sciences (RIMS), a government tertiary care teaching institute located in the Imphal West district of Manipur, India from June to July 2024. Ethical approval was obtained from the Research Ethics Board of the Institute. Participation was entirely voluntary, and their right to refuse participation was reserved. A unique code number was assigned, and no personal identifiers like name and address were taken to maintain confidentiality and data is accumulatively presented.

The selected hospital is a 1,074-bed facility with 25 departments, including 16 clinical departments. It serves over 240,000 outpatients annually, attends to ⁓700 patients daily. The study was conducted among outpatients who had completed consultations and received a doctor’s prescription. Inclusion criteria were prescriptions containing at least one antibiotic, regardless of the patient’s age, gender, or diagnosis. Prescriptions for topical antibiotics and anti-tuberculosis (TB) therapy were excluded.

Results

Out of 7,629 patient prescriptions assessed; 1,339 (17.6%) contained at least one antibiotic and were included in the final analysis. The median age of patients prescribed with antibiotics was 32 yr, with an interquartile range (IQR) of 24 to 43 yr, of which 53 per cent were females. The socio-demographic characteristics of the patients are shown in table I. A total of 1451 antibiotics were prescribed, and 102 prescriptions (14.8%) contained two or more antibiotics. Route of administration is also summarized in table II. 382 (26%) were given by generic name, while 1074 (74%) were included in the EML (Table III).

According to the WHO AWaRe 2023, 552 (38%) antibiotics belonged to the Access group. The Watch group included 537 antibiotics, representing 37 per cent of the total prescriptions. Additionally, 14 antibiotics, or one per cent, were prescribed from the Reserved category. Lastly, 348 antibiotics were prescribed from the Not Recommended category, making up 24 per cent of the total antibiotics prescribed.

The most common class of antibiotics prescribed were 3rd generation cephalosporins, followed by penicillin and 2nd generation cephalosporins, with 3rd generation cephalosporins predominantly belonging to the Watch group. The most common specific type of antibiotic prescribed was amoxicillin/clavulanic acid (Access), followed by ceftriaxone (Watch). Ceftriaxone/sulbactam and cefuroxime clavulanic acid were common antibiotics prescribed in the Not Recommended group. The distribution of various antibacterials are represented in figures 1 and 2.

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Fig. 1.

Most commonly prescribed classes of antibiotics (n=1451).

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Fig. 2.

Most commonly prescribed types of antibiotics (n=1451).

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Discussion

This study reveals a notable divergence from global recommendations concerning antibiotic prescriptions, based on the WHO AWaRe 2023 classification. Only 38 per cent of antibiotics were prescribed from the Access group, which included antibiotics like amoxicillin/clavulanic acid. This figure is considerably below the WHO recommendation that at least 60 per cent of prescribed antibiotics should belong to the Access group, as these antibiotics are effective against a range of common pathogens, are cost-effective, and possess a lower potential for resistance. In contrast, 37 per cent of the antibiotics prescribed were categorized under the Watch group, primarily consisting of broad-spectrum third-generation cephalosporins such as ceftriaxone and cefuroxime, a second-generation cephalosporin. This indicates a tendency toward empirical therapy. The Not Recommended category accounted for 24 per cent of total prescriptions. This includes antibiotics such as ceftriaxone/sulbactam and cefuroxime/clavulanic acid, raising significant concerns regarding antibiotic stewardship. Reserve antibiotics, such as carbapenems and linezolid, were minimal, comprising one per cent of the total antibiotic prescriptions.

While adherence to the Access group via the frequent prescription of amoxicillin/clavulanic acid is encouraging, the high use of Watch antibiotics and the substantial presence of Not Recommended drugs are a cause of concern. Strategies such as improving diagnostic capabilities, enforcing stewardship guidelines, and prioritising Access antibiotics are essential to combat the growing burden of antimicrobial resistance (AMR). Similar prescribing patterns emerge when compared to findings from other regions in India. A study in Uttarakhand reported 43 per cent Access antibiotics and 46 per cent Watch antibiotics and flagged persistent issues like polypharmacy and the inappropriate prescribing of broader-spectrum drugs⁹. A study in Telangana also reported findings similar to ours, where 42.3 per cent were Access and 57.7 per cent were Watch antibiotics¹⁰.

The current study’s findings align with global trends in low- and middle-income countries (LMICs), where a significant portion of antibiotic prescriptions belong to Watch antibiotics. A study conducted in Zambia found that Watch antibiotics, such as ceftriaxone, were the most frequently prescribed, accounting for 20.3 per cent of prescriptions. This occurred despite the dominance of Access antibiotics, which made up 55 per cent of prescriptions¹¹. Similarly, another study in the Democratic Republic of Congo reported antibiotic utilization rates of 36.5 per cent for Access antibiotics¹², 43.2 per cent for Watch antibiotics, and 20.3 per cent for Not Recommended antibiotics. A study conducted at Faisalabad, Pakistan, also reported similar findings aligning to our study, where 25.4 per cent were from the Access group, 72.9 per cent from the Watch group, and 1.8 per cent from the Reserve group of antibiotics¹³. These findings highlight a widespread reliance on broad-spectrum antibiotics, representing a significant challenge for healthcare systems globally.

High-income countries demonstrate better adherence to WHO guidelines. Oceania achieved an antibiotic usage rate of 57.7 per cent for Access, compared to only 28.4 per cent in West and Central Asia. This difference reflects the positive impact of rigorous antimicrobial stewardship programmes and improved diagnostic support¹⁴. These regional and global comparisons underscore the need for context-specific interventions in low- and middle-income countries (LMICs) like India, where challenges such as limited access to diagnostics, reliance on empirical treatment methods, and varying prescriber perceptions hinder rational antibiotic use.

Our study observed that 74 per cent of prescribed antibiotics were listed in the WHO Essential Medicines List (EML). While this figure is encouraging, the remaining 26 per cent reflects inappropriate prescribing that may further exacerbate AMR. Comparatively, studies in Ethiopia reported adherence to the EML at 67.5 per cent¹⁵. A study¹⁶ from South India showed similar patterns with an adherence of 62.5 per cent. In a survey conducted¹⁰ in Telangana, 77.8 per cent of the antibiotics were prescribed from EML. Stricter adherence to the EML is critical to ensure rational antibiotic prescribing, particularly in resource-limited settings.

Use of injectable antibiotics, which accounted for 37 per cent of all antibiotic prescriptions, exceeds the WHO recommended range of 13 per cent to 24 per cent for parenteral antibiotic administration. In contrast, in the outpatient tertiary care hospital in the hilly State of Uttarakhand, only 1.1 per cent of prescribed antibiotics were in injectable form⁹. Study from South India indicated a better adherence to WHO standards¹⁶. This tendency and discrepancy, particularly in outpatient care settings where oral formulations are often sufficient, warrant prescriber education and stewardship measures to promote safer, cost-effective practices.

Studies in South India and Uttarakhand consistently reported amoxicillin, ceftriaxone, and cefixime as the most prescribed antibiotics^16,9, similar to our results. The study also revealed a critical gap in generic drug prescribing, with only 26.3 per cent of antibiotics prescribed by their generic names, far below the WHO recommendation of 100 per cent. Comparative studies from South India and Uttarakhand reported significantly higher rates of generic prescribing at 87.5 per cent, and 67.4 per cent, respectively^9,10. Barriers such as pharmaceutical marketing, prescriber habits, and patient preferences for branded medications persist, contribute to irrational prescribing practices.

A limitation of the study is that it may not have captured seasonal variation, and data collected during specific periods may not fully represent year-round prescribing patterns. Further findings from a single tertiary care hospital may not be generalizable to other healthcare settings. The study revealed deviations from WHO recommendations, highlighting underuse of access antibiotics, over-reliance on the Watch and Not Recommended categories, excessive use of parenteral antibiotics, and low adherence to generic prescribing.

To address these gaps, it is essential to strengthen prescriber education to promote the rational use of antibiotics, ensure adherence to the WHO Essential Medicines List (EML) to improve prescribing practices, minimize the use of injectable antibiotics when oral formulations are suitable, implement regular prescription audits and provide feedback to ensure sustained compliance and encourage generic prescribing through prescriber training and regulatory policies to enhance cost-effectiveness and accessibility.

This study underscores the need for targeted interventions to optimize antibiotic prescribing patterns in Manipur. By addressing these gaps, healthcare providers can contribute to combating antimicrobial resistance, improving patient outcomes, and safeguarding the efficacy of essential antibiotics for the future.