PRESCRIPTION PATTERN ANALYSIS USING WHO AWARE GUIDELINE OF ANTIBIOTICS USED AMONG IN-PATIENTS IN DIFFERENT DEPARTMENTS OF A TERTIARY CARE HOSPITAL IN UPPER ASSAM – A CROSS-SECTIONAL STUDY

PRESCRIPTION PATTERN ANALYSIS USING WHO AWARE GUIDELINE OF ANTIBIOTICS USED AMONG IN-PATIENTS IN DIFFERENT DEPARTMENTS OF A TERTIARY CARE HOSPITAL IN UPPER ASSAM - A CROSS-SECTIONAL STUDY

F. I. Khan *, G. Sarma, S. Barua, P. K. Dutta and S. K. Dutta

Department of Pharmacology, Assam Medical College & Hospital, Dibrugarh, Assam, India.

ABSTRACT: Background: Antimicrobial resistance (AMR) is largely caused by the irrational and inappropriate use of antibiotics. To encourage sensible antibiotic prescription and enhance antimicrobial stewardship, the WHO established the AWaRe (Access, Watch, Reserve) categorization and also to uncover irrational prescribing practices. Objectives: To assess antibiotic prescribing patterns and compliance with WHO AWaRe standards in several tertiary care hospital departments. Material & Methods: A cross-sectional observational study was conducted with in-patients admitted to the medical, dermatological, and psychiatric departments of the ‘Assam Medical College and Hospital in Dibrugarh’. Using purposive sampling, 230 prescriptions that contained at least one antibiotic. Case record form was used to document demographic information, diagnosis, recommended antibiotics, mode of administration, length of therapy, and generic prescriptions. Antibiotics were categorized using the WHO AWaRe classification, and Microsoft Excel's descriptive statistics were used to examine prescription indicators. Results: Antibiotics were given more frequently from the Watch group (56%) compared to the Access group (36%). Ceftriaxone (36.54%) as most commonly prescribed and other broad-spectrum antibiotics accounted for the majority of prescriptions and there was male (55.3%) preponderance in antibiotic consumption.Generic prescriptions revealed high adherence (91.35%) to WHO guideline, and the majority of antibiotics were administered parenterally (92.1%) and Department of Medicine (47.1%) with the highest prescription of antibiotics followed by Dermatology (43.4%) and Psychiatry (10.6%). The results showed indications of irrational antibiotic use together with a partial adherence to WHO AWaRe recommendations. Conclusion: Various departments had inconsistent adherence to WHO AWaRe standards and a preponderance of Watch group antibiotics. To lower antimicrobial resistance and enhance patient care, routine prescription audits, antimicrobial stewardship initiatives, and the encouragement of sensible antibiotic prescribing are essential.

Keywords: Antibiotics, AWaRe classification, Antimicrobial resistance, Prescription pattern, Rational drug use, Antimicrobial stewardship

INTRODUCTION: In healthcare antibiotics are commonly prescribed and have dramatically decreased the morbidity and mortality linked to infectious diseases.

However, the irrational and inappropriate application of antibiotics has led to the emergence of AMR, which is presently recognized as a major global public health concern.

Irrational antibiotic use includes over prescription, unnecessary use of antibiotics with broad spectrum, incorrect dosage and time frame, self-medication, including irrational fixed-dose combinations. Treatment failure, higher healthcare expenses, longer hospital stays, and higher mortality are all consequences of these procedures ^{1, 2, 3, 4}. AWaRe (Access, Watch, Reserve) classification was established by World Health Organization (WHO) in 2017 to encourage sensible antibiotic usage and combat anti-microbial resistance. Based on their recommended usage, resistance potential, and spectrum of activity, categorization of antibiotics is done by AWaRe framework. While the Watch group of antibiotics has a broader range of action and a higher potential for resistance, the Reserve group of antibiotics are considered last-resort drugs to treat illnesses that are resistant to numerous treatments, and the Access group of antibiotics are recommended as first-line treatment for common diseases. According to WHO recommendations, the Access group should account for at least 60% of all antibiotic consumption ^{5, 6, 7, 8}.

Excessive usage of Watch group antibiotics and unreasonable hospital prescribing practices have been documented in a number of research carried out in India and other nations. In order to reduce antimicrobial resistance, these researches highlighted the necessity of conducting routine prescription audits, setting antimicrobial stewardship programs into place, and following AWaRe and WHO prescribing indicators ^{1, 2, 5, 6, 9, 10, 11}.

Due to high volume of critically ill and infectious patients, tertiary care facilities are important hubs for the use of antibiotics. Depending on the disease profile and prescribing methods, different clinical departments may exhibit different patterns of antibiotic prescription. To identify illogical prescribing trends and assist antimicrobial stewardship efforts, it is crucial to evaluate department-wise antibiotic consumption utilizing the WHO AWaRe categorization. Thus, applying the WHO AWaRe classification, the current study was carried out to evaluate the pattern of antibiotic consumption in several departments at a tertiary care.

MATERIAL & METHODS: This cross-sectional investigation was conducted in the ‘In-Patient Departments (IPDs) of Medicine, Dermatology and Psychiatry at Assam Medical College and Hospital in Dibrugarh, Assam’ for a period of three months. Before the study started, the ‘Institutional Ethics Committee (H) of the Assam Medical College and Hospital in Dibrugarh granted ethical permission vide no. AMC/EC/2025/23’. Written infomed consent was taken from patients and patient data was kept confidential throughout the study.

The study population comprised all in-patients admitted for the designated departments and were prescribed antibiotics at least once during their hospital stay. Patients of all ages and genders were included in the study. The study excluded women who were pregnant or nursing, prescriptions that did not contain antibiotics, repeat prescriptions, ICU patients and incomplete case records. As the study was limited to selected departments and did not employ probability sampling, the findings are intended to reflect antibiotic utilization patterns within the sampled population and should not be generalized to the entire inpatient population.

Assuming total antibiotic use among all drug classes as 17.5% (6) with 5% margin of error and 95% conficence interval, the sample size was calculated using the formula:

N = Z²(pq)/d²

After putting the values result comes to be 221 which was rounded to 230. The study participants were chosen using the purposive sampling technique. Following the participants' informed consent, data were gathered prospectively using a standardized case record form. The demographic parameter of patients, diagnosis, prescribed antibiotics, dose, frequency, mode of management, duration of treatment, as well as brand-name as well as generic prescriptions were each recorded.

Prescription trends were examined using WHO AWaRe (Access, Watch, Reserve) categorization and WHO prescribing indicators. The duration of antimicrobial treatment, the average quantity of antibiotics provided per hospital stay, the proportion of medicines prescribed under generic name, adherence to hospital formulary and WHO guidelines, and prescribing trends were all examined after classifying antibiotics using the AWaRe classification.

Antibiotic use was assessed using the ‘Anatomical Therapeutic Chemical (ATC) and Defined Daily Dose (DDD)’ classification systems. Descriptive statistics were used to assess the gathered data once it was imported into Microsoft Excel. Tables and percentages were used to display the results. The formula for DDD/1000/DAY used was:

(Total no. of dosage units prescribed × Dose strength × 1000) / (DDD × Duration of study × Total sample size) ⁶

RESULTS AND DISCUSSION: 230 prescriptions from the departments of Medicine, Dermatology, and Psychiatry at ‘Assam Medical College and Hospital in Dibrugarh’ that contained at least one antibiotic were examined.

The majority of patients who used antibiotics were adults (45-63 years, 40.7%, Table 1), and Females (45.2%) were less likely than males (55.3%) to take antibiotics (Table 2). Similar Studies in Pakistan and India revealed same demographic results ^{12, 13}.

TABLE 1: ANTIBIOTIC DISTRIBUTION BY AGE

TABLE 2: ANTIBIOTIC DISTRIBUTION AMONG PATIENTS BY GENDER

Among the most commonly recommended antibiotics in the current study were cephalosporins (38.46%), particularly third-generation cephalosporins like Ceftriaxoneand Cefixime followed by Piperacillin-tazobactam, Meropenem, Linezolid, Cefotaxim, Azithromycin, Amoxicillin-clavulanic acid, Metronidazole, , and Doxycycline (Table 1), were among the other frequently recommended antibiotics. Studies from Northern India, Pakistan, tertiary care facilities, ENT inpatient studies, New Delhi, and respiratory infection investigations from India where Watch group antibiotics were predominant, all revealed similar results ^{6, 12, 13, 14, 15, 16, 17}.

The bulk of prescriptions were for Watch group antibiotics (Table 5), followed by Access group antibiotics, while Reserve antibiotics were administered very infrequently, according to the WHO AWaRe categorization. This implies that the usage of broad-spectrum antibiotics, which have a greater potential for resistance, is increasing. Studies from Pakistan, Northern India, Tanzania, Zambia, and the United Kingdom all showed similar results ^{2, 5, 9, 12, 13}.

Most of the antibiotics in this trial were given intravenously. The Essential Medicines List (EML) did not include all prescribed antibiotics and generic prescriptions were very uncommon. Previous ENT inpatient and tertiary care hospital investigations reported similar findings ^{14, 15}.

TABLE 3: DDD OF EACH ANTIBIOTIC WITH THE ATC CODE

‘ATC: Anatomic, Therapeutic, Chemical. DDD: Defined Daily Dose’

The DDD analysis showed a rise in the usage of antibiotics with a broad spectrum such as Ceftriaxone (27.49 DDD/1000/Day) followed by Doxycycline (8.5 DDD/1000/Day) and Piperacillin (5.42 DDD/1000/Day). The overall antibiotic consumption in this study was 59.25 DDD/1000/day. Direct comparision with many published studies is difficult because different denominators (DDD/100 bed -days, DDD/1000 patient days, or DDD/1000/inhabitants/days) have been used. However the result provides a standard estimate of antibiotic utilization within the study population. Overall Ceftriaxone was most commonly prescribed antibiotic. In Dermatology its use was highest among patients with erythroderma and pemphigus vulgaris, while in psychiatry it was frequently prescribed in patients admitted with alcohol dependence with delirium or schizophrenia who had concurrent infectious condition. In the Medicine Department, Ceftriaxone was used across a broad spectrum of infectious conditions without a single predominant diagnosis.

TABLE 4: DEPARTMENT WISE DISTRIBUTION OF ANTIBIOTICS

The departments of Medicine, Dermatology, and Psychiatry all showed differences in antibiotic prescribing practices with Department of Medicine showing highest antibiotic prescribing (47.1%, Table  4) followed by Dermatology (43.4%) and Psychiatry (10.6%).

TABLE 5: CATEGORIZATION OF ANTIBIOTICS USING THE AWARE SYSTEM

Access group: 36%, Watch group: 56%, Reserve group: 8%.

The current study evaluated antibiotic prescribing behaviors in multiple departments in a tertiary care hospital using the WHO AWaRe classification. The study showed that Watch group drugs were more common (56%, Table 5) than Access group medicines, suggesting a partial disregard for WHO guidelines as well as an increase in the use of broad-spectrum antibiotics. Watch group antibiotics used were 14 followed by Access group that were 9 and Reserve group were 2 in number. To reduce antimicrobial resistance, According to WHO recommendations, the Access group should account for at least 60% of antibiotic use. Nonetheless, the current study revealed a rise in the use of Watch group antibiotics, which is similar to research done in Pakistan, Zambia, Tanzania, the UK, Northern India, and urban outpatient settings in India ^{2, 5, 9, 12, 13, 17}.

TABLE 6: HOSPITAL PRESCRIBING FACTORS FOR THE USE OF ANTIBIOTICS

TABLE 7: USAGE OF ANTIBIOTICS ACCORDING TO ROUTE OF ADMINISTRATION

In this study, generic prescriptions were satisfactory (91.35%, Table 6). In order to lower treatment costs and encourage sensible drug usage, WHO strongly advises generic prescribing. Current study is consistent with studies from New Delhi and ENT departments which showed improved adherence to generic prescribing procedures ^{15, 16}.

Parenteral (92.1%) usage of antibiotics were much more than oral (6.5%), that exceeds the WHO guidelines which states to keep parenteral usage under 10%, followed by topical (1.3%). The current study evaluated the pattern of antibiotic use in multiple departments in a tertiary care hospital utilizing the WHO AWaRe classification. The study showed that Watch group drugs were more common than Access group medicines, suggesting a partial disregard advocating an increase in the utilization of broad-spectrum antibiotics and WHO recommendations.

Injectable versions of third-generation cephalosporins were widely utilized, and they were among the most commonly prescribed antibiotics. Antibiotic prescribing trends varied among departments, and generic prescribing was quite low.

TABLE 8: COMMON DEPARTMENT WISE INDICATIONS FOR ANTIBIOTIC USE

The results indicates the existence of somewhat less logical antibiotic prescribing patterns, which could be a factor in the development and dissemination of antimicrobial resistance. Regular prescription audits, adherence to WHO AWaRe guidelines, promotion of generic prescription, implementing antimicrobial stewardship initiatives is essential to enhancing sensible antibiotic use and optimize patient care in tertiary care hospitals.

Department wise assessment of antibiotic prescribing trends using AWaRe classification was one of the study’s main strengths. Prescribing indicators evaluation and trends in antibiotic use added valuable information about antibiotic use.

This study employed purposive sampling and included only selected inpatient departments over a period of three months. Therefore, the findings may not represent overall inpatient antibiotic utilization across the entire hospital. Small sample size and short length of the study in a single tertiary care institution limits how far results may be applied. Microbiological culture and sensitivity reports were not taken into account and long term clinical effects of antibiotic therapy could not be assessed. However despite these limitations, the study provides baseline information about antibiotic use trends and proposes the necessity of ongoing surveillance and sensible prescription practices.

CONCLUSION: This study reveals how antimicrobial drugs are prescribed and used in different departments, and underlined significance of rational prescribing in promoting safe, efficient, and cost-effective therapy which helps to minimize antimicrobial resistance, adverse drug reactions and treatment costs. Shortcomings in prescription methods, such as frequent application of broad-spectrum antibiotics and limited adherence to normal prescribing recommendations underscore the need for regular prescription audits and antibiotic stewardship initiatives in clinical practice. The results may help physicians and policymakers in developing plans for encouraging rational medicine usage and improving antimicrobial prescription practices. Bigger population, multi-centric, long term studies are needed to improve evidence based medical practice.

ACKNOWLEDGEMENTS: Nil

CONFLICTS OF INTEREST: Nil

REFERENCES:

1. Sindhuja C, Mithila S, Chowdary R and Devanandan P: Assessment of Antibiotics Prescribing Using WHO/INRUD Indicators and AWaRe Classification in an Indian Regional Hospital. Arch Pharm Pract 2025; 16(3): 1-9.
2. Priyadharsini RP, Ramasamy K and Amarendar S: Antibiotic-prescribing pattern in the outpatient departments using the WHO prescribing indicators and AWaRe assessment tool in a tertiary-care hospital in South India. J Family Med Prim Care 2022; 11: 74-78.
3. Jain S, Upadhyaya P and Goyal J: A systematic review of prescription pattern monitoring studies and their effectiveness in promoting rational use of medicines. Perspect Clin Res 2015; 6(2): 86-90.
4. Mudenda S, Nsofu E and Chisha P: Prescribing Patterns of Antibiotics According to the WHO AWaRe Classification during the COVID-19 Pandemic at a Teaching Hospital in Lusaka, Zambia. Pharmacoepidemiology 2023; 2: 42-53.
5. Nsojo A, George L and Mwasomola D: 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: 100347.
6. Mugada V, Mahato V, Andhavaram D and Vajhala SM: Evaluation of Prescribing Patterns of Antibiotics Using Selected Indicators for Antimicrobial Use in Hospitals and the Access, Watch, Reserve (AWaRe) Classification by the World Health Organization. Turk J Pharm Sci 2021; 18(3): 282-288.
7. Medicines, Technologies, and Pharmaceutical Services (MTaPS) Program. A technical guide to implementing the World Health Organization's AWaRe antibiotic classification in MTaPS program countries. Arlington (VA): Management Sciences for Health 2020
8. World Health Organization. WHO AWaRe (Access, Watch, Reserve) classification of antibiotics for evaluation and monitoring of use 2023.
9. Abdelsalam Elshenawy R, Umaru N and Aslanpour Z: WHO AWaRe classification for antibiotic stewardship: tackling antimicrobial resistance – a descriptive study from an English NHS Foundation Trust prior to and during the COVID-19 pandemic. Front Microbiol 2023.
10. Syafhan NF, Fitriani SW and Sutantoputri DB: Antibiotic Use Evaluation Based on AWaRe Classification in Hospitalized Patients at Universitas Indonesia Hospital. J Sains Farm Klin 2024.
11. Christina S, Nandeibam R and Pearson RL: Antibiotic-prescribing patterns in outpatient departments from a tertiary care hospital in Manipur using WHO AWaRe classification. Indian J of Medical Res 2025; 162: 220-225.
12. Kumar S, Siwach P, Mehta K and Mathur A: Assessment of Antibiotic Prescribing Pattern using WHO Access, Watch, and Reserve Classification (AWaRe) at a Tertiary Care Centre of Northern India: A Cross-sectional Study. J Clin Diagn Res 2025; 19(3): 12-16.
13. Zafar U, Iqbal A and Basit A: Antibiotic Prescribing Practices in a Tertiary Care Teaching Hospital: A Retrospective Cross-Sectional Analysis. Cureus 2024; 16(11): e73092.
14. Remesh A, Salim S, Gayathri AM, Nair U and Retnavally KG: Antibiotics Prescribing Pattern in the In-patient Departments of a Tertiary Care Hospital. Arch Pharm Pract 2013; 4(2): 71-77.
15. Satheesh Kumar KG, Bharathi U, Meenakshi L and Asha Latha M: Antimicrobial prescription practices among the inpatients of ENT Department using WHO AWaRe Classification: A Cross-sectional Study. Int J Curr Pharm Res 2026; 18(2): 77-81.
16. Nabi N, Rehman S and Khan M: Antibiotic Prescribing Practices at a Tertiary Care Hospital in New Delhi: From Awareness to Action. Int J Med Pharm Res 2026; 7(1): 542-548.
17. Ramaraj A, Sanjana SN and Kapoor N: Antibiotic prescription patterns for respiratory infections in urban outpatient settings in India: a multicenter, retrospective, EMR-Based Study Using WHO AWaRe Classification. J Epidemiol Found India 2025; 3(2): 137-14
    

    ---

    How to cite this article:

    Khan FI, Sarma G, Barua S, Dutta PK and Dutta SK: ‘Prescription pattern analysis using who aware guideline of antibiotics used among in-patients in different departments of a tertiary care hospital in upper Assam - a cross-sectional study’. Int J Pharm Sci & Res 2026; 17(10): 3146-53. doi: 10.13040/IJPSR.0975-8232.17(10).3146-53.

    ---

    All © 2026 are reserved by International Journal of Pharmaceutical Sciences and Research. This Journal licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.