Paediatrica Indonesiana

November 

VOLUME 51

NUMBER 6

Original Article

Qualitative evaluation of antibiotic usage in

pediatric patients
Hindra Irawan Satari, Agus Firmansyah, Theresia

Abstract
Background Antibiotics are among the most commonly
prescribed drug for pediatric patients. Inappropriate use of
antibiotics can increase morbidity, mortality, patient cost and
bacterial antibiotic resistence. Antibiotic uses can be evaluated
quantitatively and qualitatively.
Objective To qualitatively evaluate antibiotic use in patients
using Gyssens algorithm.
Methods We performed a descriptive, retrospective study of
patientmedical records of those admitted to the pediatric ward
IURP-DQXDU\-XQH
Records were screened for patient antibiotic use, followed by
qualitative evaluation using Gyssens algorithm on data from
patient who received antibiotic treatment.
Results:HIRXQGRIVXEMHFWZHUHSUHVFULEHGDQWLELRWLFV
7KHPDMRULW\RISDWLHQWVJLYHQDQWLELRWLFVZHUHDJHGPRQWK
\HDU$QWLELRWLFXVHZDVFDWHJRUL]HGE\WKHUDS\W\SH
empirical, prophylactic, or definitive. We found empirical therapy
LQ  RI FDVHV SURSK\ODFWLF LQ  DQG GHILQLWLYH LQ 
&HIRWD[LPH  ZDV WKH PRVW FRPPRQ DQWLELRWLF XVHG 
IROORZHGE\FHIWD]LGLPHDQGFRWULPR[D]ROHRI
VXEMHFWVZHUHJLYHQDQWLELRWLFVDSSURSULDWHO\ZKLOHZHUH
JLYHQLQDSSURSULDWHO\,QRISDWLHQWVDQWLELRWLFVZHUHJLYHQ
ZLWKRXWLQGLFDWLRQDQGLQWKHUHZDVLQVXIILFLHQWGDWD
Conclusions2IKRVSLWDOL]HGSDWLHQWVUHFHLYLQJDQWLELRWLFWUHDW
ment at the Departement of Child Health, Cipto Mangunkusumo
+RVSLWDOZHUHJLYHQDQWLELRWLFDSSURSULDWHO\ZKLOH
were given antibiotics inappropriately. Cefotaxime was the most
commonly used, as well as most inappropriately given antibiotic.
[Paediatr Indones. 2011;51:303-10].
Keywords: antibiotic, children, qualitative evaluation,
Gyssens algorithm.

ntibiotics are among the most frequently

prescribed drugs for pediatric patients.
They are mostly prescribed as empirical
therapy, rather than prophylactic or
definitive therapy. There have been fewer studies on
antibiotics use in children than in adultpatients.,
Inappropriate and unnecessary use of antibiotics
increases morbidity and mortality, medical expences
and microbial resistance. Inappropriate use of
antibiotics is frequently seen in developed countries
as well as developing countries.3,4
7KH:RUOG+HDOWK2UJDQLVDWLRQ:+2*OREDO
Strategy fo Containment of Antimicrobial Resistance
LQLWLDWHGDSURJUDPWRUHGXFHWKHH[SDQVLRQ
of antibiotics resistance.5 Indonesia, as one of the
WHO nations, also participated by conducting a
VWXG\LQFDOOHG$QWLPLFURELDO5HVLVWDQFH
LQ,QGRQHVLD3UHYDOHQFHDQG3UHYHQWLRQ$05,1
Soetomo Hospital Surabaya and Kariadi Hospital
Semarang. The purpose of the AMRIN study was to
FUHDWH D VWDQGDUGL]HG SURJUDP WR DFFHV DQWLELRWLFV
resistance, qualitative and quantitative use of

From the Department of Child Health, Medical School, University of

Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
Reprint requests to: Hindra Irawan Satari, Department of Child Health,
Medical School, University of Indonesia, Cipto Mangunkusumo Hospital,
-O 'LSRQHJRUR 1R  -DNDUWD  ,QGRQHVLD (PDLO hsatari54@
yahoo.com

Paediatr Indones, Vol. 51, No. 6, November 2011 303

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients

antibiotics, as well as control of nosocomial infection,

with the expectation that the finding would be applied
in all hospitals in Indonesia.
Evaluation of antibiotics use may be conducted
WRREWDLQWKHDPRXQWRIDQWLELRWLFVXVHGTXDQWLWDWLYH
and antibiotics appropriateness based on the choice
of antibiotics, dosage, and duration of administration
TXDOLWDWLYH4XDQWLWDWLYHHYDOXDWLRQRIDQWLELRWLFXVH
LVH[SUHVVHGE\GHILQHGGDLO\GRVH'''SDWLHQWV
GD\V4XDOLWDWLYHHYDOXDWLRQE\*\VVHQVDOJRULWKP
has been widely used in many countries to evaluate the
use of antibiotics.56LQFH&LSWR0DQJXQNXVXPR
+RVSLWDO &0+ KDV KDG DQ DQWLELRWLF UHVLVWDQFH
UHVWUDLQSURJUDP335$WHDPDQGDPDSRIPLFURELDO
patterns and antibiotic sensitivities.6 However, the use
of antibiotics in the inpatient unit of Child Health of
CMH has never been evaluated in accordance with
WKH335$VWDQGDUGOHDGLQJXVWRTXHVWLRQLWVOHYHO
of appropriate antibiotic use. The purpose of this
study was to evaluate the use of antibiotics in the
patients ward of Childs Health Departement of CMH
TXDOLWDWLYHO\XWLOL]LQJWKH*\VVHQVDOJRULWKP

Methods
We conducted a descriptive, retrospective study using
the medical record of patients treated in the pediatric
ward of Child Health Departement to evaluate the
appropriateness of antibiotic use. This study was
approved by the Research Ethics Committee at the
University of Indonesia Medical School.
6XEMHFWVZHUHSDWLHQWVDJHGPRQWKWR<
years who received antibiotics therapy and were
KRVSLWDOL]HG LQ &ODVV ,, RU &ODVV ,,, LQSDWLHQWV XQLWV
RIWKHSHGLDWULFZDUGIURP-DQXDU\WR-XQH
  :H H[FOXGHG WKRVH WUHDWHG  IRU OHVV WKDQ
 KRXUV WKRVH UHFHLYLQJ WRSLFDO DQWLELRWLFV VXFK
as eye drops or ointment, those receiving only
antituberculosis agents, and those treated in the ICU
and neonatal ward.
We completed the research forms, which included
demographic characteristics (health insurance,
DJH JHQGHU LQSDWLHQW XQLW GXUDWLRQ RI WUHDWPHQW
working diagnosis, antibiotic data including type of
antibiotics, route of administration, dosage, frequency,
duration of administration, culture results and
microbial resistance. Culture results refers to cultures

304Paediatr Indones, Vol. 51, No. 6, November 2011

conducted prior to antibiotic use. Repeated cultures

ZHUH QRW LQFOXGHG LQ WKLV VWXG\ :H FDWHJRUL]HG
VXEMHFWVLQWRVXUJLFDODQGQRQVXUJLFDOFDVHV6XUJLFDO
FDVHVZHUHFDWHJRUL]HGLQWRFOHDQFRQWDPLQDWHGFOHDQ
contaminated, and unclean. Antibiotics usage was
FDWHJRUL]HG LQWR HPSLULFDO SURSK\ODFWLF GHILQLWLYH
or undefined. We used previous, published studies to
asses rational antibiotic usage in addition to Gyssens
algorithm (Figure 1
We evaluated antibiotic usage based on the
amount administered during treatment, not the
number of patients. We assumed diagnosis in the
medical records were correct. Based on Gyssens
algorithm, antibiotic use was classified into six
categories. I for appropriate use, II a, b, c for
inappropriate dosing, interval, route of administration,
III a, b for inappropriate treatment duration too long
or too short, respectively, IV a, b, c, d for availability
of safer, cheaper, more effective, or more spectrum
specific antibiotics campared to the ones used in
the cases, respectively, V no indication and VI for
incomplete medical records. We compared the results
first and second assessor (previosily briefed by head
RI335$ZLWKFRQFOXVLRQVPDGHE\WKHLQIHFWLRXV
GLVHDVHFRQVXOWDQWDQGKHDGRI335$
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YHUVLRQ$JUHHPHQWEHWZHHQWKHILUVWDQGVHFRQG
DVVHVVRUZDVDQDO\]HGXVLQJNDSSDFRHIILFLHQW

Results
We obtained data from 774 patients, with 415
antibiotic courses used. The algorithm shown in
Figure 2.
The mean age of patients was four years, ranging
from 1 month to 17 years old. The group receiving
the most antibiotics was aged 1 month to 1 year.
'XUDWLRQRIWUHDWPHQWUDQJHGIURPGD\VZLWK
mean of 11 days.
:H DQDO\]HG EDFWHULDO FXOWXUH UHVXOWV WDNHQ
prior to administration of antibiotics. The total of
DQDO\]HGDQWLELRWLFFRXUVHVZDVRQO\EXWRI
due to incomplete data. One hundred sixty antibiotic
FRXUVHVZHUHJLYHQWRSDWLHQWDIWHUFXOWXUH
UHVXOWVZHUHREWDLQHG6L[W\HLJKWLOOQHVVFDVHV
were reffered to the Infectious Disease Division
IRU DQWLELRWLFV DGPLQLVWUDWLRQ  RI SDWLHQWV

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients

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TH E A N TIBIOTIC USE DEFIN ETELY

Figure 1. Gyssens algorithm7

Paediatr Indones, Vol. 51, No. 6, November 2011 305

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients

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Table 1. Case based illness distribution (n=224)
Case
Surgery
Neurology
Respirology
Cardiology
Gastroenterology
Nephrology
Tropical Infection
Hematology-oncology
Dermatology

n
18
13
39
5
27
24
42
75
1

%
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5.3
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9.8
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Total

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according to chemical structure. The most frequently
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9,ZHUHDQGUHVSHFWLYHO\
Table 2 shows the distribution of the ten most
frequently used antibiotics according to Gyssens
algorithm. Cefotaxim was the most frequently used
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Table 2. Distribution of the ten most frequently administrated antibiotics according to Gyssens categories
Antibiotics
Cefotaxime
Ceftazidime
Cotrimoxazole
Metronidazole
Chloramphenicol
Ampisilin
Amikacin
Ceftriaxone
Meropenem
Amoxicillin

I
28
24
27
22
17
17
5
3
9
5

II
16
12
10
7
5
2
10
6
3
0

306Paediatr Indones, Vol. 51, No. 6, November 2011

Gyssens categories
III
IV
16
34
5
11
9
1
5
1
9
2
9
1
2
4
1
3
0
2
4
0

V
7
5
0
1
0
0
0
1
0
1

VI
13
7
3
3
2
0
2
2
1
2

Total
114
64
50
39
35
29
23
16
15
12

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients


Empirical



Empirical

West
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definitive



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3URSK\OD[LV

definitive


Empirical

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definitive

Figure 3. Distribution of antibiotics administration based on indication and Gyssens category.

used antibiotic for all six Gyssens categories.

Total number of antibiotics administered as em
SLULFDOWKHUDS\ZDVZKLOHWKHRQHVDGPLQ
LVWHUHGDVSURSK\ODFWLFWKHUDS\ZDVDQGDV
GHILQLWLYHWKHUDS\7KHPRVWIUHTXHQWO\
administered antibiotic was cefotaxime for empirical
WKHUDS\ FRWULPR[D]ROH IRU SURSK\ODFWLF WKHUDS\ DQG
meropenem for definitive therapy. Distribution of an
tibiotic administration based on indication and Gyssens
category is shown in Figure 3.
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IRXQGFXOWXUHVUHVXOWVLQWKHPHGLFDO
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results. Overall, the most frequent culture results
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FXOWXUHVUHVXOWFRQVLVWLQJRI
  LVRODWHV  RI Staphylococcus epidermidis  
 LVRODWHV RI $FLQHWREDFWHU VS  
isolates of Escherichia coliDQGLVRODWHV
of Klebsiella pneumonia.
Based on cultures results , we found there
Staphylococcus epidermidisEscherichia
coliDQGQRQSDWKRJHQLFEscherichia
coli   ZHUH WKH PRVW IUHTXHQWO\
isolated microorganisms in blood, urine and faeces,
respectively.

Discussion
,QWKLVVWXG\RQO\RISDWLHQWPHGLFDOUHFRUGV
were available. This number was smaller than the
number of medical records discovered in Husnis

study. in the Childs Health Departement, CMH

LQ   7KLV ORZ SHUFHQWDJH UHIOHFWV KRZ
medical record filing in Childs Health Deparement,
CMH still needs improvement. The same problem
was encountered in the AMRIN study in the Kariadi
and Soetomo Hospitals, which both stated problems
regarding medical record filing.5
$QWLELRWLFVZHUHJLYHQWRRIVXEMHFWVLQ
this study similar to that Husnis study. 
However, our finding was much lower than that of
WKH $05,1 VWXG\ ZKHUH  RI SDWLHQWV LQ WKH
pediatric ward were given antibiotics during their
stay.5 A study in developing and low economic income
FRXQWULHV UHSRUWHG WKDW  RI LQSDWLHQW DUH
given antibiotics. This may depend on policy of each
hospital and may be influenced by the distribution of
patient morbidity, which is dominated by infectious
diseases in developing countries.
There were more boys than girl in this study. The
age distribution ranged from 1 month to 17 year, with
PHDQDJHRIIRXU\HDUV6LPLODUO\3RWRFNLHWDOIRXQG
the mean age to 5.1 years old.11 The age group which
received the most antibiotics was 1 month to 1 year,
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Duration of hospital stay of the patients ranged
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stay campare to the study of Shankar et al, who
reported a median of 4 days. This was probably due to
differences in morbidity distribution in each study. The
most frequent antibiotic administrated illness cases
LQWKLVVWXG\ZHUHKHPDWRORJ\RQFRORJ\FDVHVZLWK
febrile neutropenia as the most frequent. However,

Paediatr Indones, Vol. 51, No. 6, November 2011 307

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients

Shankar et al found that the most frequent cases

WREHDFXWHJDVWURHQWHULWLV$QWLELRWLFVZHUH
administered after culture results were obtained in
RIDQWLELRWLFFRXUFHV7KLVREVHUYDWLRQPD\EH
GRWRILQDQFLDOFRQVWUDLQWVDVPRVWVXEMHFWVSDLGIRU
PHGLFDO FDUH RXWRISRFNHW  )XUWKHUPRUH
cultures were not performed in every case, example
in pneumonia cases when diagnosis could be made
based on clinical findings.
Consultation by an infectious disease expert
RQ DQWLELRWLF FKRLFH ZDV GRQH LQ  FDVHV
Consultation can increase the rate of proper
antibiotics use.
The most frequent use antibiotics in our
VWXG\ ZDV IRU WKH  KHPDWRORJ\RQFRORJ\ FDVHV
 LQFOXGLQJ IRU IHEULOH QHXWURSHQLD 
RIKHPDWRORJ\RQFRORJ\FDVHVDQGDVSURSK\ODFWLF
FRWULPR[D]ROHWKHUDS\IRUFDQFHUSDWLHQWVXQGHUJRLQJ
chemotherapy.
$OWKRXJKWKHIUHTXHQF\RISUHVFULELQJDQWLELR
WLFVIRUFKLOGUHQGHFUHDVHGLQWKHXVHRIEURDG
spectrum antibiotics increased. Consistent with
these finding, we observed that of 455 antibiotics
FRXUVHVSUHVFULEHGEURDGVSHFWUXPDQWLELRWLFVZHUH
PRVW IUHTXHQWO\ XVHG FHIRWD[LPH DQG  FHIWD]LGLPH

In contrast to our study, Shankar et al found
WKDW KRVSLWDOL]HG  FKLOGUHQ ZHUH PRVW IUHTXHQWO\
prescribed the antibiotics ampicilin, cefotaxime,
and gentamycin. This may be due to the differences
in microbial patterns and antibiotic sensitivities in
different hospitals and countries.13
We found the appropriate use of antibiotics
FDWHJRU\,,RIDQWLELRWLFFRXUFHV7KLVQXPEHU
ZDV KLJKHU WKDQ WKDW RI WKH $05,1 VWXG\ 
We found that the most frequently used antibiotics
ZDV FHIRWD[LPH  DQG LW ZDV DOVR WKH PRVW
frequently inappropriately used. Inappropriate use
may be attributed to wrong antibiotics choice ( there
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GXUDWLRQRIDGPLQLVWUDWLRQPDLQO\WRRORQJ7RRORQJ
of a duration, may be caused by failing to evaluate the
response to the antibiotic and halting its use. Response
towards antibiotics should be evaluated after
administration, generally after three days (depending
RQWKHGLDJQRVLV,IWKHDQWLELRWLFVJLYHQGLGQRWHOLFLW
a response, then the possibility of complication, other
sources of infection, microbial resistance to the drug,

308Paediatr Indones, Vol. 51, No. 6, November 2011

or misdiagnosis should be evaluated.14

Rapid use of cefotaxime in the Childs Health
Dept. should be reassessed given its low sensitivity
DFFRUGLQJWR3HWDEDNWHUL&0+&0+
0DSRI0LFURELDO3DWWHUQV6 Data from the Clinical
3DWKRORJ\'HSDUWHPHQWLQ-DQXDU\-XQLVKRZHG
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LVRODWHG EDFWHULD ZHUH     
 IRU Escherichia coli, Staphylococcus epidermidis,
Acinetobacter sp, Enterobacter aerogenes, Pseudomonas
sp, and Klebsiella pneumoniae, respectively. With these
low sensitivities and the absence of a comprehensive
guideline on antibiotic use or periodic evaluations,
cefotaxime resistance may further increase.
Two studies which evaluated antibiotics
qualitatively in a teaching hospital in Thailand
reporteds that the percenrage of inappropriate
DQWLELRWLFSUHVFULSWLRQZDVLQEXWGHFUHDVHG
WRLQ15,16 These studies shows that with
periodic antibiotic evaluation, appropriate use of
antibiotics can be promoted.
Antibiotics were most frequently prescribed for
HPSLULFDOWKHUDS\7KLVILQGLQJZDVFRQVLVWHQW
with study of Van Houten et al. which stated that
KRVSLWDOL]HG SDWLHQWV PRVW  IUHTXHQWO\  UHFHLYHG
empirical therapy without evidence of bacterial
infection. In our study, this finding was probably
due to financial constraints and the fact that culture
results takes three to seven days, whereas medications
may needs to be administered as soon as possible.
3UHVFULSWLRQ  RI DQWLELRWLFV DV SURSK\ODFWLF
WKHUDS\LQWKLVVWXG\ZDV7KLVUHVXOWZDVORZHU
WKDQWKDWRIWKH$05,1VWXG\7KLVILQGLQJ
ZDVSRVVLEO\GXHWRGLIIHUHQWGLVWULEXWLRQLQVXEMHFWV
morbidity in the two studies. However, prophylactic
use in our study was consistent with the study of
Shankar et al. in which HIV patients received
prophylaxis to prevent opportunistic infections and
for cancer patients getting chemotherapy.
Antibiotic prescription as definitive therapy in
WKLVVWXG\ZDVREVHUYHGLQRQO\RIDQWLELRWLF
courses, similar to that observed in developed
countries. An American study reported the use
RI DQWLELRWLFV DV GHILQLWLYH WKHUDS\ LQ  RI
SDWLHQWVZKLOHLQ+ROODQGLWZDVUHSRUWHGVLQ
of patients. This may be caused by the timeneeded
to wait for culture results, while medication needs to
be administered as soon as possible. In addition even

Hindra I. Satari et al: Qualitative evaluation of antibiotic usage in pediatric patients

when there was a culture result, empirical therapy was

not always reevaluated. After the microbe is identified
and the sensitivity test obtained, definitive therapy
should follow.17. The use of antibiotics in this study
IRUXQNQRZQLQGLFDWLRQVZDVDWORZHUWKDQWKDW
RIWKH$05,1VWXG\5
Inappropriate empirical and inappropriate
definitive therapy antibiotic prescription was
more frequent than appropriate empirical and
appropriate definitive prescription, respectively.
Inappropriateness was mostly due to wrong antibiotic
choice, mistakes in dosing, and duration of antibiotics
administration that was too long. The absence of an
antibiotic response reevaluation and the absence of
uniformity in dosing guidelines for each disease, may
lead to errors of these types, making the creation
of uniform antibiotic administration guidelines
important. In prophylaxis therapy case, there was
more appropriate use of antibiotics compared to
inappropriate use. However, this may not be the
actual data, given that surgery cases were not further
DQDO\]HGGXHWRLQFRPSOHWHGDWD
:H IRXQG WKDW WKH PDMRULW\ RI *UDP SRVLWLYH
bacteria isolated from culture was Staphylococcus
epidermidis. This bacteria is normal flora of human
skin and mucosae. Therefore, the possibility of
contamination must be considered. To reduce the risk
of contamination, it is important to practice aseptic
techniques and wash hands properly prior to collecting
of culture specimens.
In conclusion, inappropriate use of antibiotics
remains a problem encountered by practitioners.
It is hoped that health workers will be carefull in
choosing antibiotics, including determining the
dose, route of administration, and interval, as well
as in evaluating clinical response. Cephalosporin
use should be considered carefully, especially
cefotaxime, since microbial sensitivity is very
ORZ  3HULRGLF HYDOXWLRQLV QHGG WR LQFUHDVH
appropriate antibiotic use.

3.

4.

5.

6.

7.







11.



13.

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14.
1.

Van Houten MA, Luinge K, Laseur M, Kimpenn JLL. An

WLELRWLF XWLOL]DWLRQ IRU KRVSLWDOL]HG SHGLDWULF SDVLHQWV ,QW -
$QWLPLFURE$JHQWV
 Ceyhan M, Yildirim I, Ecevit C, Aydogan A, Ornek A, Salman
Na et al. Inappropriate antimicrobial use in Turkish pediatric

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KRVSLWDOVDPXOWLFHQWHUSRLQWSUHYDOHQFHVXUYH\,QW-,QIHFW
'LV
Sorensen TL, Monnet D, Control of antibiotic use in the
FRPPXQLW\WKH'DQQLVKH[SHULHQFH,QIHFW&RQWURO+RVS
(SLGHPLRO
5DG\RZLMDWL$+DDN+,PSURYLQJDQWLELRWLFXVHLQORZLQ
FRPHFRXQWULHVDQRYHUYLHZRIHYLGHQFHRQGHWHUPLQDQWV
6RF6FL0HG
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XVDJHDQGLQIHFWLRQFRQWURODVHOIDVVHVVHPHQWSURJUDPIRU
,QGRQHVLDQKRVSLWDOV-DNDUWD'LUHNWRUDW-HQGUDO3HOD\DQDQ
0HGLVS
/RKR7$VWUDZLQDWD'$:3HWDEDNWHULGDQNHSHNDDQWHUK
DGDSDQWLELRWLF56831&LSWR0DQJXQNXVXPR-DQXDUL-XQL
 -DNDUWD 'HSDUWHPHQ 3DWRORJL .OLQLN &0+).8,
S
*\VVHQV,&9DQGHQ%URHN3-.XOOEHUJ%-+HNVWHU<9DQ
GHU0HHU-:02SWLPL]LQJDQWLPLFURELDOWKHUDS\$PHWKRG
for microbial drug use evaluation. J Antimicrob Chemother.

7ULKRQR33$ODWDV+7DPEXQDQ73DUGHGH62.RQVHQVXV
WDWDODNVDQDVLQGURPQHIURWLNSDGDDQDN(GLVLNHGXD-DNDUWD
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Paediatr Indones, Vol. 51, No. 6, November 2011 309

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