1. health and fitness
2. disease

DRUG UTILIZATION STUDY IN UROLOGY UNIT.
By
Dr. VENKATESH M. PATIL
Dissertation Submitted to the
Rajiv Gandhi University of Health Sciences, Karnataka.
Bangalore
In partial fulfillment
of requirements for the degree of
DOCTOR OF MEDICINE
in
PHARMACOLOGY
Under the Guidance of
Dr. PATIL B.V.
M.D.,
Professor of Pharmacology
DEPARTMENT OF PHARMACOLOGY
M.R. MEDICAL COLLEGE, GULBARGA – 585 105.
2006.
i
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
DECLARATION BY THE CANDIDATE
I here by declare that this dissertation/ thesis entitled “DRUG
UTILIZATION STUDY IN UROLOGY UNIT” has been
carried out by me under the direct guidance and supervision of
Dr. Patil B.V., M.D., Professor Department of Pharmacology, M.R.
Medical College, Gulbarga in partial fulfillment of the regulations for
the
award
of
Degree
of
DOCTOR
OF
MEDICINE
in
PHARMACOLOGY as prescribed by the Rajiv Gandhi University
of Health Sciences, Karnataka – Bangalore.
I further declare that, I have not submitted this dissertation to
any other university for the award of any degree or diploma.
Date:
Place: GULBARGA
Dr. Venkatesh M. Patil
ii
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
CERTIFICATE BY THE GUIDE
This
is
to
certify
that
the
dissertation
entitled
“DRUG
UTILIZATION STUDY IN UROLOGY UNIT” has been carried out by
Dr. Venkatesh M. Patil, under my direction guidance and supervision in
partial fulfillment of the regulations for the award of Degree of DOCTOR
OF MEDICINE in PHARMACOLOGY as prescribed by the Rajiv Gandhi
University of Health Sciences, Karnataka – Bangalore.
I am satisfied regarding the authenticity of the observations noted in
the dissertation.
GUIDE
Date:
Dr. Patil B.V.
Professor
Dept. of Pharmacology,
M.R. Medical College, Gulbarga.
Place: GULBARGA
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
iii
ENDORSEMENT BY THE HOD, PRINCIPAL/
HEAD OF THE INSTITUTION
This
is
to
certify
that
the
dissertation
entitled
“DRUG
UTILIZATION STUDY IN UROLOGY UNIT”is a bonafide research
work done by Dr. VENKATESH M. PATIL under the guidance of Dr. Patil B.V.
Professor, Department of Pharmacology.
Dr. Manjunath S., MD,
Prof. & Head of the Dept.
Dept. of Pharmacology.
Dr. Mallikarjun B.
Principal
M.R. Medical College,
Gulbarga
Date:
Date:
Place: GULBARGA
Place: GULBARGA
COPYRIGHT
iv
DECLARATION BY THE CANDIDATE
I here by declare that the Rajiv Gandhi University of Health
Sciences, Karnataka shall have the rights to preserve, use and
disseminate this dissertation/thesis in print or electronic format
for academic/ research purpose.
Date:
Dr. VENKATESH M. PATIL
Place: GULBARGA
©
Rajiv Gandhi University of Health Sciences, Karnataka.
ACKNOWLEDGEMENT
v
Before embarking on this important project of dissertation, I sought the blessing
from the Almighty and my beloved teachers. Now that I have completed the work, I
would like to express my deep sense of gratitude with the same vehemence and sincerity
to all those who have made the sail smooth for me. At the very outset, I thank and pray
the invisible hand to guide me along the right path always.
I am extremely indebted to my esteemed guide, Dr. Patil B.V. M.D., Professor,
Department of Pharmacology, M.R. Medical College, Gulbarga for selecting the topic
and guiding me throughout, with proper and valuable suggestions. I am extremely
grateful to him for all this and for being a constant source of inspiration.
I am humbled by the magnanimity of my beloved teacher, Dr. S. Manjunath
M.D., Professor & H.O.D., Department of Pharmacology, M.R. Medical College,
Gulbarga for bearing with my shortcomings. My deep sense of gratitude is due for him
for keeping me along the right track in completing the work.
I take this opportunity to extend my deep sense of gratitude to my respected
teacher and co-guide Dr. R. Anil, M.S., FRCS (EDIN), FRCS (London), DURO
(London), Professor in Department of Surgery, M.R. Medical College, Gulbarga for his
valuable advises in reviewing this work from time to time.
I wish to thank my beloved teacher Dr. S. Ramabhimaiah, M.D., Professor &
Former H.O.D., Department of Pharmacology, M.R. Medical College, Gulbarga, for his
kind help and thoughtful suggestions during the study.
With deep sense of gratitude and respect, I express my indebtness to my beloved
teacher Dr. R.H. Kakkeri, MD, Professor & Former HOD, Department of Pharmacology
for providing me the necessary help, suggestions and guidance during my Post Graduate
career.
vi
I extend my heartful gratitude to the Teaching Staff, Dr. Kashinath Gumma,
M.D., Asso. Prof., Dr. S.H. Vardhamane, M.D., and Dr. G.K. Prakash, M.D., Assistant
Professors, and Dr. Ashoka Binjwadgi, M.D., Dr. Santosh Jeevangi, M.D., Lecturer,
Department of Pharmacology, for their kind help during my dissertation work.
I sincerely thank Dr. B. Mallikarjun, M.D., Dean, M.R. Medical College,
Gulbarga for his kind permission to take up this work.
I thank all my postgraduate colleagues of Pharmacology Department for their
friendly cooperation.
I am thankful to the non-teaching staff of Pharmacology Department for their
cooperation.
I am infinitely obliged to my beloved Father Late Sri. K. Mahadevappa, my
Mother Late Smt. Padmavathi, my Brother Late Sri. Basavaraj my Wife
Dr. (Mrs) Rajeshwari for their assiduousness, unwavering support without whom I
would have not been here in the first place.
Last but not in list I am extremely thankful to Mr. Shivanand B. Kalburgi &
Mrs. Sheela S. Kalburgi for their tireless and meticulous typing.
Dr. Venkatesh M. Patil
ABSTRACT
Background & Objective:
To evaluate utilization of drugs in the Urology unit, cases treated in urology unit
are mainly infections of Urinary Tract (upper and lower) and cases of Acute Renal
Failure and Chronic Renal Failure including complications during hemodialysis are dealt
vii
by Medical unit in a tertiary care hospital (Basaveshwar Teaching and General Hospital,
Gulbarga).
Methods:
A prospective cross-sectional study was conducted for 15 months in Basaveshwar
Teaching and General Hospital, Gulbarga.
WHO prescribing indicators and patient care indicators were used, prescription
pattern for each type of care in both the units were evaluated in detail.
Results:
A total of 100 patients were interviewed and their prescriptions were studied.
Established Antibiotics like:
1) Cephalosporins, were used maximally (80 to 90% including all the generation of
Cephalosporins)
2) Ciprofloxacin, Metronidiazole and Ampicillin + Cloxacillin were used in
(72.14%).
3) NSAID’s were commonly used in the Urology unit (100%).
4) One person (3.33%) received NSAID (Diclofenac) and 2 patients (6.66%)
received Amikacin in the Medical unit, which are absolutely contraindicated
drugs.
5) Diuretics – Fruesemide was used 70% in Urology unit and 100% in Medical unit.
6) Minnipress (Prazocin) and calcium were commonly used in the Medical unit in
treating Acute Renal Failure and Chronic Renal Failure.
7) 3 patients (10%) developed 1st dose effect to prazocin.
8) 30% of patients developed gastritis due to irrational use of Antibiotics.
9) 2.86% developed allergic manifestation to NSAID’s
10) 2 patients (6.66%) developed complications during hemodialysis, like
hypotension and muscle cramps.
11) Average drugs per prescription was 2 – 5.
12) Average stay per patient was between 2 – 5 days.
13) Average cost of drugs per day/patient, Urology unit = Rs. 100 – 150/-, Medical
unit = Rs. 200 – 300/- + 800 extra for patients undergoing hemodialysis.
14) Average time given for consultation per patient was 15 minutes on an average.
15) Availability of the drugs in the hospital was not satisfactory.
16) Patient compliance was satisfactory among the educated and not among the
uneducated.
17) 2 patients (6.66%) could not afford the cost of dialysis.
18) Results are statically significant.
Conclusion:
During my study in the Basaveshwar Teaching and General Hospital, Gulbarga,
the incidence of polypharmacy was high.
Many drugs were prescribed irrationally. Irrational prescription are harmful and
may lead to number of problems like:
1) Increased cost of therapy
viii
2)
3)
4)
5)
Therapeutic failure
Adverse drug reactions
Dangerous drug interactions
In appropriate treatment
To achieve health for all by 2010 AD.
We have to fight for eradication and control of disease and also to minimize the
rate of irrational prescriptions.
One way of promoting rational prescription is by
1) Conducting drug utilization studies
2) Giving education and training to doctors
3) Health education to patients
4) Patient education regarding drug use is needed to improve patient compliance.
This can be achieved by carrying out “Therapeutic Audit” on the prescription
pattern in a Tertiary Care Hospital (Basaveshwar Teaching and General Hospital,
Gulbarga).
Which can save millions of patients who are exposed to irrational prescriptions,
and there by reducing morbidity and mortality in this wide world.
LIST OF CONTENTS
1. Introduction………………………………………………………....01
2. Objectives…………………………………………………………..12
ix
3. Review of Literature………………………………………………..13
4. Methodology………………………………………………………..74
5. Results……………………………………………………………....77
6. Discussion………………………………………………………..…100
7. Conclusion……………………………………………………….....119
8. Summary …………………………………………………………...121
9. Bibliography………………………………………………………...126
10. Annexures
LIST OF TABLES
x
Sl.
No
01
02
TABLE
Case-wise Distribution of Patients
Page
No.
79
Sex-wise Distribution of the Urology and Medical Unit Cases
79
03
Age-wise Distribution of Patients in the Urology & Medical Unit cases
79
04
Diet-wise Distribution of Patients in the Urology & Medical Unit cases
83
05
History with Habits of taking Tobacco and Alcohol in the Urology &
Medical Unit cases
83
06
Average duration of stay in the Urology & Medical Unit
83
07
Discharge position in the Urology & Medical Unit
86
08
Route of During Administration
86
09
10
11
Number of Drugs used per day in the Urology & Medical Unit
Adverse Effects of Drugs
86
87
Average cost of drugs used in the treatment
LIST OF FIGURES
xi
87
Sl.
No
01
02
03
04
05
Page
No.
TABLE
Early electrocardiogram and compact electrocardiograph of today
06
First echocardiograph and 2D-Echocardiography with colour Doppler
The coronary arteries of the heart
08
12
Estimation of ejection fraction by ECG (QRS score) (51%) and
Echo (56%)
2D-
Estimation of ejection fraction by ECG (QRS score) (45%) and
Echo (45%)
2D-
xii
122
123
INTRODUCTION
“Medicines are nothing in themselves if not properly used, but the very hands of the
Gods, if employed with reason and prudence”.
Herophilus
The present study was undertaken to identify the prevailing prescription trends in
the Urology Unit and Medical unit at Basaveshwar Teaching & General Hospital
(BTGH), Gulbarga.
The study also made efforts in bridging the gap between clinical pharmacology
and rational prescribing of drugs particularly in urology case1.
Drug utilization has been defined as the marketing, distribution, prescription and
use of drugs on society with special emphasis on the resulting medical and social
consequences2 for the past few decades, more attention is being given to rational
prescribing Drug utilization studies are playing a major role in this regard. These studies
not only detect flaws in the therapy but also find out solutions to rectify the same.
The first international study on drug use was undertaken by Dr. A. Engel of
Sweden and Dr. P Siderius of Netherlands who visited six European countries on behalf
of the WHO. Ultimately formed the Drug Utilization Research Group (DURG). A novel
agency for Drug Utilization studies at international level
1
Rational drug prescribing is defined as “the use of the least number of drugs to
obtain the best possible effect in the shortest period and at a reasonable cost”3-63.
Irrational prescription of drugs is of common occurrence in clinical practice4. Important
reasons are:
1. Lack of knowledge about drugs.
2. Unethical drug promotions and
3. Irrational prescribing habit by clinicians.
Monitoring of prescription and drug utilization studies could identify the
associated problems and provide feedback to the prescriber so as to create an awareness
about the irrational use of drugs5-62.
Various factors influence the prescribing behaviour of the clinicians and it is
difficult to change the behaviour without understanding the reason behind6.
It is necessary to define the prescribing pattern and to target the irrational
prescribing habit for sending remedial message7.
Studies on drug prescribing may be hospital or practice based. They may take into
account economics of prescribing, as there is an increasing concern about cost of drugs
and several studies have documented this fact. Improved methods of examining drug
prescribing in health service are a necessary pre-requisite for the quality of medical care8.
2
Post-marketing surveillance envisages intensive monitoring of drug efficacy and
safety evaluation of a new drug. This may be carried out by the firm marketing the drug
and regulatory agencies. The resources for such studies are limited in most of the
countries9.
Hospital or community based studies aim to carry out a complete “therapeutic
audit” to see what is prescribed, what is the intention and with what benefit or ill effect
and at what cost. There is an extreme paucity of such studies in the international scene
and they are non-existent on our national scene10. Essential drugs should be accessible to
all the people.11-64
Studies were carried out to assess the prescribing trends in the out- patient
department of Nehru Hospital attached to PGI. Chandigarh. Prescriptions for 50 patients
were audited under heads of generic versus trade name prescribing the dosage form,
dosage interval and duration of treatment. The prescriptions by and large were model
ones – certain lacunae are discussed12.
“Urinary Tract Infections may be wholly asymptomatic or may make the patient
desperately ill or even kill him” (Campbell).
Urinary tract infections are extremely common disorders. They include infections
of kidney, bladder and the collecting systems. It is very important to realize that they may
be symptomatic. Even though they are not associated with significant mortality, they
3
have high mortality if complicated13. As such there are no significant reports to confirm
the incidences of morbidity caused by urinary tract infections.
Till recently not much of importance was given to identify the urinary tract
infections, and treat them promptly. Few tablets of sulpha drug and alkaline mixture used
to give relief of the symptoms, irrespective of the causative organisms. However, since
past few years, lot of work have been done in these fields and a lot of literatures are
available regarding the etiology of causative organisms and treatment aspect.
It is very important to view the urinary tract infection seriously because of the
high morbidity and emergency of antibiotic resistant organisms.
The reason for this may be improper usage of antibiotics, inadequate dosage and
insufficient duration of treatment. In recent years it has been emphasized to do culture
and sensitivity of the urine sample before starting the antibiotic, to give the drug of
choice and for sufficient number of days and frequent follow up of the patient to identify
the recurrences and relapses. The clinical features of urinary tract infections always
posses a problem to the surgeon.
In significant number of patients the classical symptoms of urinary tract infections
are absent.
4
All the above observations and profuse works that are being done by various
workers in these field, have prompted me in taking this subject for my dissertation work.
The term urinary Tract Infections include the infections of kidney, ureter, bladder,
urethra, prostate etc. Earlier the term like ‘cystitis’ for infections of bladder,
pyelonephritis for involvement of kidney were used. But now a days the term ‘Urinary
Tract Infections’ is preferred to include the infection of urine from kidney to urethra14.
HISTORICAL REVIEW
Hippocrates inferred that the urine was derived from blood and was secreted by
the kidney. He described the surgical procedure to remove the stones from pyelonephritic
kidney.
Aristotle (Great philosopher 384 – 322 B.C.) said that urine is formed in the
bladder.
Erbistratus (Alexandrian 310 – 250 B.C.) who was called the father of
Physiology. His Physiology was based on the observation that every organ is equipped
with 3 fold system, the vein, an artery and the nerve. Anatomically, he described Aorta,
renal artery, hepatic artery and azygos vein.
Galen (Greek Physician 131 – 200 A.D.) – Demonstrated the kidney function
tests. He described that they served in the separating function of urine from blood.
5
Marcello Malphigi (1624 – 1694) was the first to describe the glomerulii of
kidney.
Brelini (1662) was the first to recognize the tubular structure of kidney.
Bowmann (1842), Physiologist, described clear morphological structure of
glomerulii is which secretes water, which flushes the tubules, which secretes solutes.
Lerdwid – According to him the glomeruli formed protein free filtrate and tubules
reabsorbed most of the filtrate resulting in urine formation and he totally refused the role
of secretion by the tubules.
Roberts (1881), first introduced the term bacteriuria.
Marshal and Vicker (1923) gave evidence for the role of renal tubular secretion
by using phenol red.
Richards (1936) showed the way to calculate Glomerular Filtration Rate by using
inulin.
Verney (1947) showed the role of ADH in concentration of urine.
6
Marple (1941) studied urine sample obtained by catheterization of 100 female
patients and was first to apply the principle quantitative bacteriology (bacterial count and
colony count) to culture of urine.
Kass (1956) brought out the qualitative analysis of organism in relation to urinary
tract infection. He showed that if sample is collected properly, the bacterial number in
urine will be more than 105/ml in urinary tract infection.
Ludwing Ischoff, the famous physician was first to give description of the
syndrome of pyelonephritis in 1893.
In 1897 Ryer first described urinary infection by the term pyelitis and
distinguished between infection of the pelvis and infection of parenchyma.
In 1896 Escherich diverted the attention to urinary tract infections in childhood
and specially in girls.
ANATOMY OF URINARY TRACT
The urinary tract includes a pair of kidneys which forms the urine, a pair of
ureters, each attached to one kidney through which the urine is diverted to the bladder.
The urethra forms the outlet for the passage of urine from the bladder15, 16.
7
The kidneys are paired organs; each is situated on either side of the vertebral
column.
Each kidney weighs about 150 gms. They are placed in retroperitoneal space.
Each pyramid opens to major and minor calyces which in turn open into renal
pelvis.
The kidneys are enclosed in fibrous capsule is easily stepped off from the kidney
surface.
The large spherical nuclei are situated towards the base of the cells whose free
border is a straightened cone (a brush border).
URETER
These are two in number, one on each side and they pass from the kidneys on the
posterior abdominal wall to the bladder in the true pelvis. Each is 25-30 cms long and 0.5
cms in diameter. There is an upper dilated portion called pelvis of uteter. At its lower
extremity the ureter ends by penetrating the wall of the bladder. It is retroperitoneal
throughout its course.
8
URINARY BLADDER:
This is normally, a pelvic organ. But when distended, it becomes an abdominal
organ.
URETHRA:
The urethra is the final drainage passage of the urine. In male it nearly measures
18-20 cms extending from the internal sphincter of the bladder to urethral orifice over the
glans penis.
FEMALE URETHRA:
It is about 4 cms in length. Near the bladder the lining epithelium is transitional. It
is lined by stratified squamous epithelium.
In females the bladder is in close proximity of the uterus and vagina and it is not
unusual to find uterovesical and vesico-vaginal fistulae commonly.
ACUTE RENAL FAILURE
Definition:
Acute renal failure (ARF) is defined as the deterioration of renal function
occurring over a period of hours to days. Unfortunately, there is no uniformly accepted
description of ARF, and this has to be considered when evaluating articles and clinical
trials. Some use an increase of serum creatinine concentration by more than 50% or
greater than 0.5 mg/dl above baseline, whereas others define it as a need for dialysis. In
9
addition, terms such as acute tubular necrosis may be used to define ARF even when
there is no pathologic diagnosis of tubular necrosis17.
The serious clinical problems associated with an acute loss of kidney function
arise from the patient’s limited capacity to achieve a balance between the intake and
excretion of water and minerals and the accumulation of metabolic byproducts (chiefly
from protein) leading to the symptoms of uremia.
Scope of the problem:
Some degree of ARF can be found in 2 to 5% of hospitalized patients, usually as a
complication of other illnesses, surgery, or both; the incidence rises to 4 to 15% after
cardiopulmonary bypass. How serious is ARF? It is associated with 35 to 65% mortality,
but this mainly depends on the presence of other diseases causing or associated with ARF
and the complications of these diseases. Kidney failure has a lower impact because
dialysis can substitute for kidney function. Undoubtedly, the serious illnesses associated
with ARF (e.g., sepsis) and especially the degree of hypercatabolism occurring in ARF
patients are important factors; mortality rates are higher in older patients and in those
with more severe renal damage or serious underlying disorders17.
10
CHRONIC RENAL FAILURE
Definition and Epidemiology:
Chronic renal failure (CRF) is associated with a falling glomerular filtration rate
(GFR) and is a progressive disease characterized by an increasing inability of the kidney
to maintain normal low levels of the products of protein metabolism (e.g., urea), normal
blood pressure and hematocrit, and sodium, water, potassium, and acid-base balance18.
Scope of the problem:
In the United States, about 270,000 patients are presently undergoing dialysis and
an additional 100,00 are living with a functioning renal transplant. In addition, it is
estimated that about 11 million people have an elevated serum creatinine. Furthermore,
such patients and those with proteinuria or microalbuminuria* have a markedly enhanced
risk of adverse cardiovascular events18, 36.
HEMODIALYSIS
Dialysis substitutes two major renal functions: Solute removal and fluid removal.
In hemodialysis, solute removal occurs predominantly by diffusion, which is the
movement of solutes from the blood compartment to the dialysate compartment across a
semipermeable membrane19, 51.
Solute removal can also occur by the process of convention, the movement of
solutes by bulk flow in association with fluid removal (solvent drag)19.
11
AIMS OF THE STUDY
1) To study the drug utilization pattern in urology unit.
2) To analyze the prescription pattern of drugs in acute and chronic renal failure.
3) To study the complications occurring during haemodialysis and its management.
4) Hospital based studies aim to carry out a complete “Therapeutic audit” and to
see what is prescribed, what is the intention and to analyze the cost effect benefit.
5) To study the adverse drug reaction and
6) To study the cost benefit ratio.
12
REVIEW OF LITERATURE
Pharmacoepidemiology, relatively a newer discipline means “defining both
beneficial as well as adverse effects and studying the response of the population to the
effect”.20
The drug utilization studies provide data on prescribing pattern and may help to
improve the prescribing habits of general medical practitioners. The WHO has defined
drug utilization studies as “the study of marketing, distribution, prescription and use of a
drug in a society with a special emphasis on the resulting medical, social and economical
consequences”. Prescribing habits differ from doctor and several factors influence drug
prescribing. It has been proposed that there are national differences in prescribing due to
difference in therapeutic approach among the doctors in different countries e.g.,
hypertension, diabetes and mental disorders.21
However, there are reasons to believe that there may be even inter-individual
differences in prescribing in a country probably due to variation in individual attitude.
In 79% of prescriptions analyzed, there was at least one error in prescription
writing. Many errors were trivial, but many could have resulted in overdose, serious
interaction or under-treatment. So the studies on the utilization pattern of the drugs are
very much essential. These studies improve the prescribing habits of the doctors and
provide a data on prescribing pattern.
13
In contrast to this, pharmacoepidemiology is the study of effect of the drugs in a
population. According to the recent definition, it is the study of distribution and
determinants of drug related events in a population and application of this for the safe and
efficacious drug use.
Pharmacoepidemiological studies can be used in many cases where other models
cannot be used, for example groups such as elderly, pregnant or paediatric patient and
those having concomitant diseases or using other drugs. This field offers the best
approach in monitoring the use of new drugs, particularly in identifying possible new and
rare adverse drug reactions through post-marketing surveillance programmes.
Pharmacoepidemiological studies, thus would provide valuable support to clinicians,
regulatory authorities and the pharmaceutical industry.22
Focus of Pharmacoepidemiology and Related Areas of Study:
Discipline
Clinical
Pharmacology
Drug utilization
Pharmacoepidemiological
Focus
Individual patients
Groups
Population defined
Indication of drug
exposure
Clinical effect
Adverse
reaction
Utilization
pattern
Appropriateness
of use
Correlation
with outcome
-
Exposureoutcome
relationship
Comparative
effectiveness
Comparative
toxicity
14
Result studies
-
Drug
effectiveness
Drug toxicity
Excessive or
inadequate use
Quality of care
Drug safety
Possible
relationships
Casulty
Qualification
of benefit
Qualification
of risk
Thus,
the
drug
utilization
studies
are
to
some
Pharmacoepidemiological studies. Most of the drug utilization
extent
studies
related
mainly
to
lay
emphasis on two important aspects i.e.
1) Prescription of drugs and
2) Its use in society
They fail to highlight other aspects of prescription due to problems such as lack of
manpower, lack of information about marketing and distribution pattern and lack of time
or money. Thus, the drug prescribed by the doctors are an integrated part of these studies.
According to Lesar et al,23 the prescribing error is said to exit if a prescription
contains any one of the following:
1) A wrong drug
2) Inappropriate dose
3) Inappropriate frequency
4) Improper route
5) Inappropriate indication
6) Unnecessary duplicate therapy
7) Contraindicated drugs
8) Medication to which the patient is allergic
9) Order for wrong patient
10) Drug having inadequate information
15
WHO draft, 1985 describes the criteria for the irritational drug prescription when the
medication prescribed happens to be:
1) Incorrect
2) Unnecessary
3) Inadequate
4) Inappropriate
5) Excessive
Incorrect Prescribing:
Incorrect prescribing is that when patient receives drugs from doctor inspite of:
a) Inadequate knowledge of the drug
b) Inadequate history of disease
c) Wrong diagnosis
d) Lack of laboratory or other diagnostic facilities
e) Administration of drug by an improper route
Over Prescribing:
Over prescribing is that when:
a) Drugs are given in more frequencies then required
b) In excessive dosage
c) For too long a period of time
16
Inadequate Prescription:
A prescription is said to be inadequate when:
a) Drug prescribed is in inadequate dose
b) Too short duration of action
c) Lesser frequency of administration than needed
d) Conserving medication for only very sick patients etc.
Reasons for Irritational Prescribing:
1) Inadequate knowledge of clinical Pharmacology
2) Disposal of too many patients within a short time
3) Reliance on personal liking towards a particular drug regardless of its scientific
merits, etc.
4) Fancy for costlier drugs
5) Lack of continuing education about new drugs
6) Pressure by patients to prescribe certain drugs
7) Promotional activities by the manufacture
Irrational drug prescriptions are harmful because they may lead to:
1) Increased cost of therapy
2) Therapeutic failure
3) Adverse drug reaction
4) Dangerous drug interaction etc.
17
Multiple Prescribing:
It is the use of unnecessary number of drugs when fewer drug can produce
equivalent beneficial effects e.g. Two or more drugs or multidrug combination products,
when only one or two drugs are needed.
1) Use of a drug to counteract adverse effect produced by the primary drug when
selection of an alternative primary drug can reduce or eliminate such side effect
e.g., ampicillin produce diarrhoea for which anti-diarrhoeal are used, while
ciprofloxacin can be used as a safe alternative to amplicillin.
2) Failure to adequately treat the primary medical condition that is responsible for
the secondary condition for which the drug(s) is (are) being prescribed.
Under Prescribing:
It involves giving inadequate amount of medication or failure to prescribe a
needed drug e.g., withholding medications like morphine, in terminally ill patients
because of an inreasonable fear of producing opioid dependence.23, 64
Prescribing inadequate dosage or using medication for insufficient period of time
to treat the patient e.g. sub-therapeutic dosage of antibiotics promote the development of
bacterial resistance.
Under prescribing is often employed in an attempt to conserve medication for
very sick patients or using lower doses to treat more people.24
18
Report of chloramphenicol causing aplastic anemia was widely published since
1952 even though use of the drug was negligible. A chloramphenicol audit which was
conducted from December, 1962 to Feburary 1964 in Northern Ireland led to the warning
attention to physicians in prescribing chloramphemicol.
Two second generation piperidine H1-antagonist, Terfenadine and Astemizole,
which are metabolized by CPY4503A system can cause a potentially fatal arrhythmia,
torsades-de-pointes, when their metabolism is impaired by liver disease or drugs that
inhibit the 2A family of P450 enzymes (e.g. erythromycin).25
“Urinary Tract Infections may be wholly asymptomatic or may make the patient
desperately ill or even kill him” (Campbell).
It is very important to view the urinary tract infection seriously because of the
high morbidity and emergency of antibiotic resistant organisms.
AEITOLOGY, PATHOGENESIS AND PATHOLOGY
The normal bladder urine is bacteriologically sterile. Even though the urine is a
good media for bacterial growth experimental introduction of bacteria into the bladder
failed to establish infection. This may be because the bladder mucosa has got lot of
defence mechanism. The bladder and urethral mucosa secretes many immunoglobulins
specially Ig A and Ig G which club up the bacteria, the flushing of organism during
micturition etc. All of these provide immunity against infection in normal individuals.
19
AETIOLOGY
Urinary tract infections are seen in all age groups. But generally it is common in
old age, children and also women of child bearing age.
Causes of Urinary Tract Infection in Neonate and Children:
The most common cause in Neonate is congenital abnormality of urinary system.
This also continues in the age group upto 4-5 years.
In the older children it is the vesico-ureteric reflex that plays a dominant role.
AGE AND SEX
Urinary tract infection is commonly seen in children below the age of 2-4 years
and as the age advances the incidence become less and equal in male and female. Again
in females the incidences increases during the child bearing age and incidence remains
high in old age group both in males and females.
PREGNANCY:
The frequency of urinary tract infection in pregnancy is high. This is attributed to:
i)
Stasis of urine in renal system because of compressive effect of gravid uterus
over urethra.
ii)
Decreased bladder tone.
iii)
Decreased urethral peristalsis.
iv)
Dilatation of ureters and renal pelvis.
20
OLD AGE
The condition which favour urinary tract infection in old aged men are:
a) Benign prostatic hyperplasia
b) Tumour specially bladder and prostate
c) Stones
d) Foreign bodies in urinary tract
e) Trauma and fistulas of urinary tract
f) Diabetes mellitus
In females:
Prolapse of uterus.
CAUSES OF URINARY TRACT INFECTION:
The causes of urinary tract infection can be classified into:
1) Invasion by micro – organisms
The route of invasion may be
a) Direct
i)
From abnormal openings
e.g., Fistulas, Ectopic orifices
ii)
Ascending from below
iii)
Direct extension from the neighbouring structures
iv)
Instrumentation
b)
Heamatogenous route
21
-
from any of the systemic infection
2) Lowered resistance
-
as in general debility
-
as seen in lowered resistance like
- Trauma
- Stones
- Tumour
- Malformation
3) Stasis
- Obstruction in urinary tract
- Atonia of urinary tract
- Neuromuscular causes if stasis of urine
The obstruction to urinary flow may be due to various reasons, either congenital
or acquired.
Among congenital – it can be congenital valves in the urethra, congenital
narrowing of ureter etc.
Catheterization either by rubber catheter or by metal catheters – cause urinary
tract infection either by directly carrying the organisms along with them and/ or by
causing local trauma.
22
VESICO URETERIC REFLEX:
When the detrusor muscle contracts, the urine tends to regurgitate along the
ureters in a backward direction. This tendency varies with the persons. Some show
increased tendency who are susceptible for urinary tract infection. It is the commonest
cause of urinary tract infection in children.26
Rosenheim (1963) lists various causes for vesicoureteric reflex. They are:
1) Abnormalities of urinary tract including ureteric orifices
a) Congenital
b) Acquired
2) Infection
3) Obstruction of lower urinary tract
4) Neurogenic bladder –
a) Congenital
b) Acquired
5) Megacystitis – Mega ureter syndrome
6) Unexplained – Association with chronic atropic pyelonephritis.
TOXEMIA AND TRAUMA:
Toxic injury of the renal tissue reduce their resistance to infection, just as
congestion dose (Campbell) and make the organ more vulnerable to the invading
organism.
e.g.: Scarlet fever, Measles, Tuberculosis, Diphtheria etc.
23
The trauma by external violence, renal stones, or by instrumentation induces
variable congestion and comparable local debility in the renal parenchyma.
Etiology of Recurrent Urinary Tract Infection:
Recurrent urinary tract infections may be due to
a) Re-infection
b) Or due to relapse
The re-infection is due to infection by different or same organisms. This
commonly involves lower tracts. Usually seen in adult female.26
The relapse is seen in urinary infections associated with diabetes mellitus, S.L.E.,
and obstructive uropathy plays major role in this. Eighty percent relapses occur in urinary
tract infections.
Urinary Tract Infections and Renal Transplant:
Urinary infection is frequent complications of renal transplant in adults.
Infection was considerably more in female children. In nearly 50% the infection
developed within a month after transplantation.27
Classification of Urinary Tract Infection:
It can be classified as:
24
a) Bacterial or infective
b) Non-bacterial
The causes of non bacterial infection in urinary infection are:
i)
Analgesic abuse
ii)
Drug hypersensitivity
iii)
Radiation nephritis
The bacterial infection can be classified into:
i)
Non-tubercular
ii)
Tubercular
iii)
Unusual – like due to parasitic infestation, mycotic syphilis etc.
The tubercular infection can be divided into acute and chronic.
Acute predominantly manifested by constitutional symptoms with urinary
abnormalities.
In chronic infection the patients may not have significant symptoms referable to
urinary tract. The significant bacteriuria may be found out when urine is examined in
suspection.
25
The Routes of Urinary Infections:
The urinary infection mainly comes from four routes 27, 72
a) Haematogenous route
b) Urogenous
c) Lymphogenous
d) Direct
SYMPTOMS:
Acute Pyelonephritis: The development of symptoms in acute pyelonephritis is
quite rapid, usually starts with acute onset of fever of either remittent or intermittent
nature, mostly of high degree, usually accompanied by chills and rigors. Other symptoms
like nausea, vomiting diarrhoea etc., are associated with the above symptoms.
The symptoms like frequency of micturition, dysuria, burning micturition may all
be present due to involvement of lower tract. Majority of the patients complain of loin
pain. On physical examination, patient will be usually febrile. There may be generilised
tenderness of abdominal muscles, on palpation renal tenderness in angels may be tender.
On bimanual palpation also the renal angle tenderness be elicited angles.
The patient may show remission spontaneously after 4-5 days when the secondary
causes are not there like vesicle calculi, enlarged prostate, ureteric calculi etc. The
symptoms may completely subside and the patient may go into a state of chronic
pyelonephritis, where the symptoms almost subside.
26
Chronic Pyelonephritis: Generally the patients who suffer from chronic
pyelonephritis are asymptomatic. When it leads to renal failure, or if the hypertension is
too much, then they manifest with symptoms of renal failure or hypertensive
complications. The children with chronic pyelonephritis may present with retarded
growth, with skeletal abnormalities or symptoms of renal failure.
When the patient is examined, only hypertension and secondary anemia, may be
the signs.
Cystitis: The symptoms of cystitis are most of the time characteristic increased
frequency, urgency and dysuria. Patient may have fever, on examination the only positive
sign may be the supra pubic tenderness.
Urethritis: If the urethritis is due to gonococcal infection, it may manifest like
any other acute infections. Patients may manifest with dysuria, frequency of micturition.
In female it may be associated with vaginitis also.
DIAGNOSIS OF URINARY TRACT INFECTION
A carefully taken history is very important, in some cases to come to proper
diagnosis, of the site of involvement and to know whether the infection is acute or
chronic.
27
The diagnosis of acute urinary tract infection is relatively simple depending on the
history and the examination. The diagnosis of chronic infection becomes sometimes very
difficult, because most of the patients are asympomatic, and the examination findings are
very minimal. It requires many investigations to diagnosis.
The following investigations are employed to diagnose urinary tract infections.
URINE:
Method of collection of urine is the most important part of examination of urine,
because an improperly collected urine sample may given rise to false and erroneous
results.
Microscopic examination – measurement of total urinary output of 24 hours has to
be done. This depends on several factors, it may vary from 1000-2500 ml/day. A
significant increase in the urine output may be the early feature of the chronic renal
failure. If the day and night output are measured separately, then equal amount of urine
output in the night hours compared to the output during daytime is suggestive of chronic
pyelonephritis.
COLOUR:
A pale coloured urine in person in whom chronic urinary tract infection is
suspected suggests chronic pyelonephritis.
28
CLARITY:
The urine sample will be turbid if there is pyuria.
Bloody urine or macroscopic haematuria may be an indication of sever urinary
tract infection, haemorrhagic cystitis, vesiculus calculus, renal tuberculosis or urinary
malignancies.
SPECIFIC GRAVITY:
Fixed specific gravity in response to over hydration or fluid deprivation – should
suggest the serious damage to the renal parenchyma.
REACTION:
The reaction of urine depends on its pH, some bacteria thrive well in acidic pH,
some in alkaline pH. Testing the reaction of urine is helpful also in the therapeutic part,
as some drugs act better in acidic media than in alkaline media and vice-versa.
CHEMICAL EXAMINATION:
If the urine examination is done for protein, a mild protein-uria suggests severe
renal damage.
Sugar in the urine suggests diabetes mellitus, which is commonly complicated
with urinary infections.
29
MICROSCOPIC EXAMINATION:
In majority of the urinary infections pyuria is seen. According to Ascher (1977)
symptomatic urinary infection almost never occurs in the absence of pyuria. Microscopy
of uncentrifuged specimen is more informative than centrifuged one, as the latter lacks
the quantitative precision. The amount of urine examined per high power field (55x) in
the microscope is 1/30,000th ml. Hence the presence of 2-3 pus cells in high power field
suggests a count of 60,000-90,000 cells/ ml which is abnormal count.
R.B.C’s may be seen in simple urinary infection or in those complicating vesical
calculus etc.
Pus cell casts indicate, that the infection is likely to be in the kidneys.
Demonstration of non-cellular sediment may either be normal or indicate urinary
content.
BACTERIA:
For the microscopic examination of urine, the method of obtaining urine samples
is very important. Because improperly collected sample may give wrong count of
bacteria.
30
Methods of Collection of Urine Samples:
1)
Voided midstream specimen.
2)
Specimen obtained by catheterization: In persons who are on indwelling
catheters, specimen must be obtained by aseptic needle aspiration of urine
through catheter wall, not by disconnecting the closed system.
3)
Specimen obtained by suprapublic aspiration: Once the sample is obtained
by any one of the above methods, the urine should be examined immediately
(not more than 1-2 hours) or it should be kept in refrigeration, at 40C for not
more than 18 hours.
Examination of Urine Bacteria and Other Micro-organisms:
When micro-organisms are demonstrated in a freshly collected urine (midstream
urine), it is almost always abnormal.
Finding 2-3 bacteria per high power field, in an uncentrifuged sample of urine
correlates well with significant bacteriuria.
Simple gram staining of noncentrifuged urine specimen and finding of more than
2 organisms per high power field correlates well with culture results.
Pyuria defined as more than 10 W.B.C’s per high power field in a centrifuged
urine specimen. It correlates well with gram staining and culture reports.
31
Bacteriuria without pyuria suggests colonization, rather than infection and to a
much less extent asymptomatic bacteriuria.
Sterile pyuria may be suggestive of renal interstitial disease, brucellosis,
leptosprirosis, enteroviral infection, diphtheria, tuberculosis etc. Hence pyuria is
significant when associated with bacteriuira.
It is generally accepted that demonstration of 105 bacterial count or more per ml,
should be considered as diagnostic of urinary infection, even in the absence of clinical
manifestations.
Urine Culture and Sensitivity:
This is the most important of all the investigations in establishing the diagnostics
and it aids in the management and follow up. This procedure helps to know the
organisms, its number and to its bacterial sensitivity pattern. The draw-back is that it is
time consuming requiring 18-48 hours.
There are various methods available for culture of urine.
1) Loop streak method.
2) Dipslide method (Capital)
3) Pomplate method
4) Filter paper method
32
CLINICAL TESTS FOR SIGNIFICANT BACTERIURIA
I.
Triphenyl Tetrazolium Chloride Test (Simens & Williams 1962): This test
depends on the ability of the actively respiring bacteria to reduce the colourless
chemical 2, 3, 5 triphenyl tetrazonlium chloride (TTC) to red insoluble triphenyl
formanzan. The result will be ready by 4 hours. In this study triphenyl tetrazolium
chloride was positive in 94.6% of cases where the bacterial count was more than
100,000/ ml and in 7% of cases where bacterial count was less than 100,000/ml
organisms/ml. The percentage of false negative results are upto 6%.
II.
Nitrite Test (Slien, 1965): This depends in the urinary pathogens to reduce
nitrates to nitrites. 1 ml of solution of mixture of sulphanilic acid and alpha
naphthyloxidde is added to 1 ml of urine containing 0.02 ml of 5% potassium
nitrate and incubated.
BLOOD EXAMINATION:
A differential count of W.B.C’s is done in chronic pyelonepheritis or recurrent
urinary infection. Sedimentation rate is also useful.
Blood urea estimation is not very essential in a isolated attack of urinary infection.
However it is useful in recurrent infections and chronic pyelonphritis.
RADIOLOGICAL INVESTIGATIONS:
Radiological examination is very essential for the first attack of urinary infections.
Blood and urine examination is enough to make a diagnosis. However Ascher 1977
33
opines that men and children should be screened for obstructive uropathy after one attack
urinary infection.
a) Plain X-ray of KUB region
b) Intravenous pyelography
c) Cystogram and voiding cystogram
CYSTOSCOPY:
This will be of help in the diagnosis of chronic cystitis, to rule out bladder growth
and to identify the diseased site in an unilateral septic renal disease.
Other tests which are not routinely done:
A) Culture of swabbings from the introitus of female:
O’ Grady et al (1970) demonstrated the colonization of introitus by enterobacteria
which was followed by over urinary infection in a significant number of persons studied.
So such a study may be useful in the prophylaxis of urinary tract infection in pregnancy
and diabetes.
B) Determination of site of infection:
Determination of site of infection is very important in planning the treatment and
assessing the prognosis.
There are four groups of tests to localize the site:
i) Direct methods: This is considered to be more reliable. It includes culture of urine
34
obtained by stamey ureteric catheterization procedure, culture of urine after the bladder
has been sterilized with antimicrobial solution, and kidney biopsy.
The bladder wash test was described by Fairly et al 1967.
Fairly Test: Here the bladder is washed out with antibiotic lotion rinsed and drained
though catheter. Continuing bacteriuria one hour after this test indicates kidney
involvement.
ii) Indirect methods: (Jones, Smith and Sanfold 1974)
a)
Antibody coated bacteria test (ABC test): This depends on the fact that bacteria in
intimate contact with the epithelium of upper urinary tract elicits an antibody
reaction that can be detected in the urine by immuno-flourescent techniques. A
negative test implies a lower urinary tract infection. False positive ACB test may
occur with faecal contamination or prostatitis.
b)
Single dose antibiotic: Here the patient is given a large (3 gms) oral dose of
Amoxicillin. If this eliminates bacteriuria in urinary tract infection, the infection
is of lower tract involvement. A single dose of any antibiotic would not be
expected to clear an upper urinary infection. The single dose test has got the
diagnostic and the therapeutic values.
ACB test correlates well with single dose test.
35
Despite all the above investigations, the urinary tract infection may remain
undiagnosed, specially chronic ones when patient does not manifest with clinical
features.
THERAPEUTICS:
The treatment of urinary infections has changed dramatically for the past few
years. It starts from traditional administration of sulpha drug for all urinary tract
infections, to a single high dose of appropriate antibiotic.
Management of infections of urinary tract depends on a close integration of the
physician and bacteriologist. Choice of antibiotic is influenced not only by the sensitivity
of the organisms involved, but also by the level of renal functions present, the pH of
urine, and osmolality of urine.
The effective management aims at:
a) Prevention of urinary tract infection in susceptible individuals.
b) Treatment of overt infection
c) Management of recurrent infection relapses.
36
PREVENTION OF URINARY TRACT INFECTION IN
SUSCEPTIBLE POPULATION
Asymptomatic bacteriuria is frequently seen in pregnant women. Which is often
followed in due course by symptomatic infection. The diabetes also increased frequency
of asymptomatic bacteriuria. Those patients who are catheterized for bladder drainage
either due to neurological cause or some other, are also at high risk of contracting urinary
infection.
All these groups of persons are to be treated aggressively in the absence of
symptoms.
When a person requires catheterization for retention of urine, it could be done
under strict a septic precautions and they have reported high incidence of urinary tract
infection following catheterization. These patients will be benefited by administration of
antibiotics symptomatically for the first 3-4 days. After 4 days of drainage, the incidence
of urinary tract infection is equal in both the groups. Alternative method is to use an
irrigating solution containing bactericidal concentration of polymixins and neomycin are
administered per catheter and a bladder wash in performed periodically.
Treatment of Overt Infection:
Once the diagnosis is made as urinary tract infection, the organism should be
isolated and its sensitivity to antibiotic determined. The next steps of management are:
i)
The urinary output should be increased by encouraging the patient to take
plenty oral fluids. This acts as mechanical flushing.
37
ii)
The pH of urine should be suitably maintained. This is necessary to provide an
optimal pH for the drug to act maximally, and to inhibit the bacterial growth.
The pH should be maintained towards the alkaline side during treatment with
sulphonamides to prevent crystalluria. The alkaline pH also enhance the
action of tetracyclines, penicillin, erythromycin and aminoglycosides.
Nitrofurantoin and Mandelamine act in acidic medium, pH below 5.5,
suppress greatly the growth of bacteria.
iii)
The drug should be given in adequate dosage and duration.
iv)
The last dose of drug should be given immediately before retiring, having
emptied the bladder completely, this is important because the diminished
urinary flow and frequency at night encourages bacterial growth.
The acidification of urine can be done by administration of ammonium
chloride, 2 – 6 gms/ day/ Ascorbic acid 1 – 2 gms/ day. For chloromycetin, the
pH adjustment is not required as it has a wide range of pH.
v)
Chemotherapeutic agents: These can be broadly classified into
a) Bactericidal
–
Ampicillin,
Cycloserine,
Kenamycin,
Sterptomycin,
Gentamycin, Trimethoprim-Sulfamethoxazole combination.28
b) Those drugs for e.g., Nitrofurantoin, Nalidixic acid, oxalinic acid and
Mefanaminc which acts as antibacterial agents only in the urinary tract are
sometimes called ‘Urinary Antiseptics’.28
A brief account of the drugs commonly employed in the treatment of urinary
tract infection, is given below:
38
MANAGEMENT OF ACUTE INFECTION
Once the diagnosis of acute urinary tract infection is made, depending on the
clinical features, the urine culture and sensitively test should be done. Meanwhile a broad
spectrum antibiotic can be started, the duration of which depends on whether the upper
urinary tract is involved or lower urinary tract is involved. The antibiotics can be changed
according to the drug sensitivity patterns.
In an uncomplicated lower urinary tract infection, treatment with antibiotic 3-5
days is enough to cure. In an uncomplicated upper urinary tract infection the duration
should extend to 7-10 days. For complicated urinary infection of lower tract, the duration
may have to be extended upto 10 days and 4-6 weeks in case of upper urinary tract
involvement.
Short Course or Single Dose Therapy29
For the past few years short course therapy is employed in the treatment of
urinary infections, it is useful in only lower urinary tract infections.
Drugs which are employed in single dose therapy are:
1) Amoxycillin – 3 gms orally in a single dose (30 mgs/kg/day for 4 days in short
course therapy).
2) Co-Trimoxazole – 0.75 to 1.44 gm by mouth or 2 double strength tablets as a
single dose.
3) Sulphadiazine – 200 mgs/kg as single dose.
39
4) Nitrofurantion – 5-7 mgs/kg as a single dose.
5) Ampicillin – 1 gm in two divided doses.
Even though acute prostatitis in lower urinary tract infection, it does not respond to
single dose or short course therapy. Therapy has to be continued for 7-10 days.
Single dose therapy has been found to be effective upto 85 – 90% in
uncomplicated cystitis in women. The recurrence rate is upto 0 – 15%.
The single dose therapy is preferred in lower urinary tract infections for some
advantages like:
a) Lesser cost for the patients
b) Short duration of therapy
c) Lesser side effects
d) Inpatients
who
have
re-infection
immediately
related
to
intercourse,
administration single dose immediately following intercourse, sometimes prevents
infection.30
There are some disadvantages like
a) It is useful only in lower urinary tract infection
b) Appreciable recurrence rate
c) Less effective in as they usually have urological abnormalities and enlarged
prostate.
d) Difficulty in the fallow up of the patient after administration of the drug.
40
All the patients who receive single dose therapy should be advised for urine
culture after 48 – 72 hrs. If significant bacteriuria persists they should be treated for 7 –
10 days
Management of the Recurrent Infection31
From the various etiological factors responsible for recurrent urinary infections,
the following guidelines can be drawn regarding the management.
1)
All the suspected cased of urinary tract infection must be submitted for culture
studies and antibiotic sensitivity pattern and the suitable antibiotics to be
given for the full course. After the course of antibiotic the cure should be
confirmed by repeated culture studies.
2)
The children and men should be submitted for investigation to rule out
obstructive uropathy even after one attack of proved urinary tract infection.
However all the females who get single attack of urinary tract infection need
not be submitted for all these laboratory investigations.
3)
In case of recurrent non-tubercular urinary infection, the possibility of
tubercular pyelinephitis should be considered.
4)
Whenever the organisms show resistance to the commonly used antibiotics.
The :any –drugslike cephalaxine. nalidixic acid. Etc., should be used.
5)
When L-forms are responsible for recurrent infection. Certain antibiotics
witch act on organisms with weakened bacterial cell wall. Like Erythromycin
may be employed. Proper hydration of the patient by oral fluids may produce
41
an alteration in the medullary osmolality and thus make it unfavourable for Lforms to thrive.
6)
Obstructive uropathy must be corrected surgically.
7)
Those with vesico-ureteric reflex can undergo a reconstructive surgery.
8)
Administration of small doses of nitrofurantoin (100 mg)in the night
continuously over weeks or methenamine mandelate l gm QID with vit. C l
gm QID as the urine acidifying agent or co-trimaxazole (Trimethoprim 40
mgs, and sulphamethoxazole 200 mgs) daily.
Relapse, Reinfection and Prognosis31
Recurrent bacteriuria or infection can be divided into two groups:
a) Reinfection
b) Relapse
a) Reinfection:
Reinfection indicates infection due to different organisms. It commonly affects
lower urinary tract, commonly seen in adult females.
b) Relapse:
Relapse indicates the recurrent infection due to same organisms. It usually affect
upper tract.
The most trouble some aspect of urinary tract infection is the increased frequently
of recurrences. It is often difficult to differentiates between relapse and reinfection.
42
However, many workers in this field believes the when infection reappears within
a month after stopping the treatment, it is often a relapse and indicate failure of therapy.
Otherwise such recurrence is considered as reinfection suggesting impairment of defence
mechanism of the host.
The patient is often relieved of his distressing complaints within 24 – 48 hrs after
starting the therapy in acute urinary tract infection. This apparent cure may prompt him to
discontinue the drug and may contribute to relapse of the infection.
However in the case of reinfection a number of factors other than patient’s
compliance have been identified.
1) Wrong choice of Drug:
While awaiting the culture and sensitivity from the laboratory, the physician is
compelled to put the patient on a broad spectrum antibiotic which may later turn out to be
an improper choice.
2) Emergence of Resistant Strains:
The organisms do not acquire resistance to the antibiotics during the therapy as it
may sometimes appear. The resistant strain would have been present from the beginning
though inconspicuous in their number. Once the sensitivity organisms are destroyed by
the antibiotic these organisms are destroyed by the antibiotic these organisms multiply
unchecked and cause recurrence of infection.
43
3) Inadequate Duration of Treatment:
The inadequate duration of therapy, often is due to patient’s non-compliance, as
already stated. The prolonged therapy has no beneficial effect in protecting the individual
from getting the recurrence of the infection. This fact has been clearly borne out by a
study of cure rate of bacteria in pregnant women treated for 8, 21, 30 days.
4) Inadequate concentrations of the Antibacterial agents:
It is important to have an optimum concentration of urinary antiseptics in the
urine to be effective against the pathogens. Most of the urinary antibiotics fulfill this
requirement. However, they fail to concentrate adequately in the urine in impaired renal
function. In a given case of urinary tract infection it is often difficult to judge the extent
to which the kidneys are damaged.
5) L-Forms:
The combined effects of host defence mechanisms and the antibiotics such as
penicillin may alter the bacterial wall synthesis, thereby producing osmotically flagile
bacteria. Such bacteria or organisms are treated L-forms, normally perish in due course
and do not harm. However, they thrive well in the hypertonic media of the renal medulla
and revert back to parent strain once the antibiotic is stopped. Some reports suggests that
the L-forms are not responsible for recurrences atleast in 20% of cases.
6) Urolithiasis:
Urolithiasis is well known cause for recurrent urinary tact infection.
44
7) Structural Abnormalities in the Urinary Tract:
Either congenital or acquired abnormalities in the structure of the urinary tract
contributes significantly to recurrence of infection. In a study of re-infection 22% had
abnormal urogram, 15% had calictasis, 3% had hydronephtosis, in 2% abnormally small
kidney and 23% of the cases vesi-ureteric reflex was present.
8) Idiopathic:
In a few instances there was no apparent cause for recurrence.
45
ACUTE RENAL FAILURE
Definition:
Acute renal failure (ARF) is defined as the deterioration of renal function
occurring over a period of hours to days. Unfortunately, there is no uniformly accepted
description of ARF, and this has to be considered when evaluating articles and clinical
trials. Some use an increase of serum creatinine concentration by more than 50% or
greater than 0.5 mg/dl above baseline, whereas others define it as a need for dialysis. In
addition, terms such as acute tubular necrosis may be used to define ARF even when
there is no pathologic diagnosis of tubular necrosis.17
The serious clinical problems associated with an acute loss of kidney function
arise from the patient’s limited capacity to achieve a balance between the intake and
excretion of water and minerals and the accumulation of metabolic byproducts (chiefly
from protein) leading to the symptoms of uremia.17
46
CAUSES OF ACUTE RENAL FAILURE
PRIMARY DISORDER
Prerenal Hypovolemia
Ineffective arterial volume
Arterial occlusion
Postrenal Ureteral obstruction
Urethral obstruction
Venous occlusion
Intrarenal/intrinsic vascular
Glomerulars
Tubular injury Ischemia
Endogenous proteins
Intratubular crystals
Tubulointerstitial inflammation
Nephrotoxins
CLINICAL EXAMPLES
Hemorrhage, skin losses (burns, sweating),
gastrointestinal losses (diarrhoea, vomiting), renal
losses (diuretics, glycosuria), extravascular polling
(peritonitis, burns)
Congestive heart failure, cardiac arrhythmias, sepsis,
anaphylaxis, liver failure
Bilateral arterial thromboembolism,
thromboembolism of a solitary kidney, aortic or
renal artery aneurysm
Bilateral or in a solitary kidney (calculi, neoplasm,
clot, retroperitoneal fibrosis, iatrogenic)
Prostatitis, clot, calculus, neoplasm, foreign object
Bilateral or a solitary kidney (renal vein thrombosis,
neoplasm, iatrogenic)
Vasculitis, microangiopathy, malignant
hypertension, vasopressor, eclampsia, hyperviscosity
states, hypercalcemia, iodinated radiocontrast agents.
Acute glomerulonephritis
Profound hypotension, postrenal transplant,
vasopressors, microvascular constriction, sepsis.
Hemoglobinuria, myoglobinuria, light chain
myeloma
Uric acid, oxalate, sulfonamides, phenazopyridine
Interstitial nephritis caused by drugs, infection
radiation
Antibiotics (aminoglycosides, cephaloridine,
amphotericin B); metals (mercury, bismuth,
uranium, arsenic, silver, cadmium, iron, antimony);
solvents (carbon tetrachloride, ethylene glycol,
tetrachloroethylene); iodinated contrast agents,
antineoplastic agents (bleomycin, cisplatin)
47
SYSTEMATIC APPROACH TO DIAGNOSING THE CAUSE OF ACUTE
RENAL FAILURE17
1) Medical history: clinical setting, medications
2) Physical examination: postural changes in blood pressure and evaluation of
hemodynamic status, skin rash, signs of systemic diseases.
3) Urinalysis with evaluation of sediment.
4) Chemical analysis of blood and urine: serum biacarbonate, potassium, uric acid,
calcium, phosphorus, urine osmolality, urine and serum urea, creatinine,
sodium.
5) Bladder catheterization
6) Fluid-diuretic challenge
7) Radiologic studies to exclude obstruction: ultrasonography, CT scan, or
retrograde pyelography
8) Renal biopsy
In addition, bilateral renal artery occlusion from emboli originating in the heart or
from atheromas in the aorta can cause prerenal ARF, and if these lesions decrease blood
flow to the kidneys sufficiently, sudden histologic damage to the kidney can occur
because of ischemia.
There are other tip-offs to the presence of prerenal ARF: One is the ratio of the
blood urea nitrogen to serum creatinine; the ratio in normal adults or in patients with
48
uncomplicated CRF is approximately 10:1. When this ratio exceeds 10 to 1, there may be
prerenal ARF.
URINARY INDICATERS IN ACUTE RENAL FAILURE
Laboratory test
Urinary osmolality (mOsm/kg H2O)
Prerenal
Acute Tubular Injury
>500
<350
Urinary sodium (mEq/L)
<20
>40
Urinary/plasma creatinine ratio
>40
<20
<1
>1
Fractional sodium excretion*
_______________
Urine [Na]/serum [Na]
*
x 100
Urine [creatinine]/serum [creatinine]
49
DIAGNOSTIC CLUES TO THE CAUSE OF ACUTE RENAL FAILURE
Primary Disorder
Prerenal
Hypovolemia
Inflective arterial
Volume
Arterial occlusion
Urinalysis
Clinical Findings
Hyaline casts, on RBC,
Or WBC, low FENa
Hyaline casts, no RBC
low FeNa
Hyaline casts, rare to
Many RBCs
Rapid weight loss,
Postural hypotension
Weight gain, edema, normal
or low blood pressure
Occasional flank or low
back pain
Postrenal
Ureteral obstruction WBCs if infected, crystals Flank pain radiating into
Or RBCs
the groin
Urethral
WBCs & RBCs
Urethral pain
Venous occlusion
Proteinuria, hematuria
Occasional flank pain
Renal
Vascular
Granular casts, proteinuria Systemic illness suggesting
RBCs and WBCs
vasculitis hypertension
Glomerular
RBC casts, granular casts,
Systemic illness, hypertension
RBCs, WBCs proteinuria
Tubular
Granular casts, tubular
Hypotension, sepsis
Cells, RBCs, WBCs.
_______________
FENa = fractional sodium excretion; RBC = red blood cell; WBC = white blood cell.
GUIDELINES FOR TREATING ACUTE RENAL FAILURE
General
Prerenal
Postrenal
Intrinsic
Avoid drugs that reduce renal blood flow (e.g., NSAID’s) and/or
are nephrotoxic (e.g., radiocontrast agent, certain antibiotics)
Restore blood pressure and intravascular volume
Urologic evaluation
Prevent hypotension and try to convert oliguria to nonoliguria; if
edematous, try 80-100 mg furosemide, but if nonedematous, try
250-500 mL saline intravenously.
_______________
NSAIDs = nonsteroidal anti-inflammatory drug.
50
TREATMENT
Treatment of ARF includes correction of reversible causes, prevention of addition
injury, use of metabolic support during the maintenance and recovery phases of the
syndrome, and attempts to convert oliguric to nonoliguric renal failure.17
Correction of Reversible Causes: In all ARF patients, administration of drugs that
interfere with renal perfusion or function or potential nephrotoxins should be stopped
(e.g., radioconstast agents should be avoided). Since the kidney is involved in the
clearance of so many drugs, the dosage of all drugs should be adjusted according to
guidelines, for the degree of renal insufficiency.
For hypovolemic, hypotensive patients in the prerenal classification, blood
pressure should be restored by discontinuing the use of antihypertensive drugs and
administering blood (if bleeding or anemia is present) or isotonic saline to expand the
extracellular volume (unless the patient has edema or ascites). In edematous patients,
blood transfusions are the preferred means of increasing blood pressure. Finally,
appropriate blood pressure guidelines should be used. Obstructed patients require
urologic consultation plus careful attention to maintenance of zero fluid balance.
A challenge with 500 mL of saline combined with 40 to 80 mg of intravenous
furosemide may reverse an oliguric to a nonoliguric state and, in some cases, even
prevent progressive tubular damage. Alternatively, a trail of 80 to 100 mg of furosemide
51
can be used in edematous patients to attempt conversion of oliguric to nonoliguric renal
failure.
General support: Indwelling urinary catheters should be avoided in
uncomplicated cases; intermittent catheterization using sterile technique usually suffices
even in oliguric, obtunded patients and reduces the risk of infection. In all patients,
maintaining fluid balance is crucial. The simplest and most accurate estimate of fluid
balance is a compulsively measured daily weight; fluid intake and output records are
more cumbersome and generally less accurate. Initially, the required fluid intake can be
approximated by giving the patient fluids (e.g., water, tea) equal to 500 mL plus the
amount of urine excreted in the preceding 24 hours.
Extra sodium, potassium and chloride besides that in food should not be given to
patients with ARF.
Unfortunately, strategies based on intensive hemodialysis regimens have not
improved the prognosis of patients with ARF and catabolic conditions.32 However,
hemodialysis is critical for treating some of the complications of ARF. Peritoneal dialysis
may be the most suitable method of treatment for patients with severe heart failure
because it avoids the rapid shifts in blood volume and blood components that occur with
hemodialysis33. The other benefit to peritoneal dialysis is that anticoagulants are not
needed.
52
Recovery of Renal Function: ARF secondary to prerenal causes is potentially
reversible if the underlying disease in treated. Glomerulonephritis and vasculitis may
respond to immunosuppressive therapy with complete recovery of renal function.34 Renal
tubular injury from ischemia or toxins is usually reversible; recovery to nearly normal
renal function seems to be more likely in nonoliguric than in oliguric patients.
Prevention
Every effort should be made to prevent ARF. Patients should be given
intravenous saline to improve hemodynamic function and urine flow before receiving
iodinated radiocontrast material and or other toxins (to prevent hyperconcentration of any
toxin in the kidney) and before surgical procedures, especially patients with poor kidney
function or those in whom renal blood flow will be interrupted (e.g., repair of abdominal
aortic aneurysm).Pretreatment with allopurinol can decrease uric acid production when
leukemia or massive tumors are being treated. Patients with renal disease should not be
given NSAIDs, and nephrotoxic antibiotics should be avoided or carefully monitored in
patients with ARF.35
53
CHRONIC RENAL FAILURE
Definition and Epidemiology:
Chronic renal failure (CRF) is associated with a falling glomerular filtration rate
(GFR) and is a progressive disease characterized by an increasing inability of the kidney
to maintain normal low levels of the products of protein metabolism (e.g., urea), normal
blood pressure and hematocrit, and sodium, water, potassium, and acid-base balance.18
Etiology:
Causes of Chronic Renal Failure18
Diabetic glomerulosclerosis*
Hypertensive nephrosclerosis
Glomerular disease
Glomerulonephritis
Amyloidosis, light chain disease*
SLE, Wegener’s granulomatosis*
Tubulointerstitial disease
Reflux nephropathy (chronic pyelonephritis)
Analgesic nephropathy
Obstructive nephropathy (stones, BPH)
Myeloma kidney*
Vascular disease
Scleroderma*
Vasculitis*
Renovascular renal failure (ischeamic nephropathy)
Anteroembolic renal disease*
Cystic diseases
Autosomal dominant polycystic kidney disease
Medullary cystic kidney disease
_____________
*Systemic disease involving the kidney
BPH = benign prostatic hypertrophy; SLE = systemic lupus erythematosus.
*Microalbuminuria is not detected by the “stix” tests used for routine analysis and
is defined as an albumin of 30-300 mg/24 hrs.
54
Clinical Manifestations
FEATURES OF CHRONIC RENAL FAILURE18
Early
Hypertension
Proteinuria; elevated BUN or SCr
Nephrotic syndrome
Recurrent nephritic syndrome
Gross hematuria
Late (GFR < 15mL/min, BUN > 60 mg/dL) (“uremia”)
Cardiac failure
Anemia
Serositis
Confusion, coma
Anorexia
Vomiting
Peripheral neuropathy
Hyperkalemia
Metabolic acidosis
_______________
BUN = blood urea nitrogen; GFR = glomerural filtration rate; SCr = serum
creatinine.
55
POTENTIALLY REVERSIBLE FACTORS IN CHRONIC RENAL FAILURE
Prerenal failure
ECF volume depletion
Cardiac failure
Hemodynamic prerenal
NSAIDs, ACE inhibitors, cyclosporine
Postrenal failure
Obstructive uropathy
Intrinsic renal failure
Severe hypertension
Acute pyelonephritis
Drug nephrotoxicity (ATN, AIN, vasculitis)
Acute interstitial nephritis
Radiocontrast agents (ATN)
Hypercalcemia
Vascular
Renovascular
Renal vein thrombosis*
Atheroembolism
Miscellaneous
Hypoadrenalism
Hypothyroidism
_____________
* In nephritic syndrome.
ACE = angiotensin-converting enzyme; AIN = acute interstitial nephritis; ANT =
acute tubular necrosis; ECF = extracellular fluid; NSAIDs = nonsteroidal antiinflammatory drugs.
DIAGNOSIS
A history of nephritic syndrome suggests previous glomerular disease as a cause
of the CRF. Recurrent gross hematuria may accompany IgA nephropathy or
membranoproliferative glomerulonephritis. A careful personal and family history for
hypertension and diabetes mellitus should be obtained, including information on any
family members in whome ESRD developed. The family history is also very helpful in
the diagnosis of autosomal dominant polycystic kidney disease – although in about 30% a
56
spontaneous mutation occurs; familial glomerulonephritis (Alport’s syndrome). IgA
nephropathy and medullary cystic kidney disease.
On physical examination, signs of hypertensive diabetic disease are important,
Knobby, bilaterally enlarged kidneys support a diagnosis of polycystic kidney disease,
and a palpable bladder or large prostate suggests obstructive uropathy and is an indication
for measurement of residual urinary volume after voiding. Gouty tophi and a history of
gout may be relevant. Signs and symptoms of polyarteritis nodosa, systemic lupus
erythematosus,
Wegener’s
granulomatosis,
scleroderma,
and
essential
mixed
cryoglobulinemia should be sought because these systemic disease often involve the
kidney. Hepatosplenomegaly and macroglossia suggests renal amyloidosis.
Laboratory studies should include measurement of serum electrolytes, calcium,
phosphorus, alkaline phosphates, and albumin. Careful urinalysis and urinary microscopy
should be performed, as well as measurement of 24 hours urine protein excretion or of
urine protein/creatinine ratio in a “spot” urine sample. Marked proteinuria with a
abundance of red blood cells, white blood cells, and granular casts suggests a
proliferative type of glomerulonephritis, whereas membranous glomerulopathy and local
glomerulosclerosis are associated with less active findings on urinary microscopy.
Predominant pyuria occurs in analgesic abuse nephropathy, polycystic kidney disease,
and renal tuberculosis, even without superimposed bacterial urinary tract infection.
57
Urinary protein excretion of more than 3 g/24 hr suggests primary glomerular
disease. Serologic screens for hepatitis B and C virus infection are important because of
their
respective
associations
with
membranous
and
membranoproliferative
glomerulonephritis. Human immunodeficiency virus-associated glomerulopathy is an
important cause of local glomerulosclerosis. Antineutrophil cytoplasmic antibodies are
often positive in Wegener’s granulomatosis.
Renal ultrasonagraphy is a useful noninvasive test that can demonstrate cortical
scarring renal stones, hydronephrosis, ureteric obstruction, or polycystic kidney disease.
Computed tomography without contrast may show papillary necrosis or papillary
calcifications suggestive of analgesic abuse nephropathy. A more severe degree of
anemia than would be anticipated for the degree of renal failure suggests myeloma
kidney; serum and urine immunoelectrophoresis should be performed to detect,
respectively, monoclonal antibodies, and/or lambda or kappa light chains.
If the diagnosis remains obscure and kidney size is normal or only slightly
reduced, renal biopsy should be considered for diagnosis after control of blood pressure
and, if necessary, dialysis.
58
Antimicrobial dosages in renal failure.
No
Change
Aminoglycoside Amikacin
Gentamicin
Netilmicin
Tobramycin
Amphotericin B
Azithromycin
Cephalosporins
First-generation:
Cefadroxil
Cephradine
Cephalexin
Cephalothin
Cephapirin
Cefazolin
Second-generation:
Cefaclor
Cefonicid
Cefotetan
Cefoxitin
Cefuroxime
Third generation:
Cefoperazone
Cefotaxime
Ceftazidime
Ceftizoxime
Ceftriaxone
Chloramphenicol
Clatrithromycin
Clindamycin
Erythromycin
Monobactams (aztreonam)
Nitrofurantoin
Penicillins
Amoxicillin
Ampicillin
Azlocillin
Carbenicillin
Dicloxacillin
Methicillin
Mezlocillin
Nafcillin
Moderate
Reduction
Marked
Reduction
√
√
√
√
√
Avoid
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
59
No
Change
Penicillin G
Piperacillin
Ticracillin
Quinolones
Ciprofloxacin
Norfloxacin
Trimethoprim-sulfamethoxazole
Tetracyclines
Doxycycline
Tetracycline
Vancomycin
Moderate
Reduction
√
Marked
Reduction
Avoid
√
√
√
√
√
√
√
√
GFR = < 10 mL/ min
TREATMENT
Chronic Renal Failure develops in about 30% of type 1 and type 2 diabetics with
a peak incidence at about 15 years after the development of diabetes mellitus and the
drug of choice for diabetic patients with hypertension/ microalbuminuria or fixed protein
uria, is Angiotensin-converting enzyme or angiotensin II receptor blocker (ARB).36, 37
60
Presentation/detection of CRF/CRI
Reversible
factors
Sudden
fall
Specific
diagnosis
Treatable
Cure/
Improvement
Monitor
declining GFR
Follow-up to
Slow rate of fall
BP
Proteinuria
Lipids
Diet
Prevent/detect
Complication
CVS
Bone
Anemia
K↑, HCO3↓
Nutrition
GFR 10 – 20 mL/min
Earlier
in
Diabetes,
CHF,
BP↑
Prepare for renal
replacement
therapy
Education
Available donor?
Establish access
Maintain nutrition
ESRD
Renal
Replacement therapy
Outline of management of patients in the various stages of chronic
renal failure.
Treatment of hypertension is the most important measure to slow the progression
of Chronic Renal Failure and to reduce cardiovascular morbidity and mortality.38, 39
61
ACE inhibitors and ARB are the initial drugs of choice, long acting calcium
channel blockers are usually the next antihypertensive to be added, and they have
synergistic effects with ACE inhibitors and loop diuretics.40, 43, 70
Measure urinary protein/creatinine ratio
On morning urine at each visit
Treat specific disease, e.g., SLE or MG
Control mean BP to ≤ 92 mm Hg
(ACE inhibitor or ARB* preferred ± loop
diuretic for BP control)
Increase dose of ACE inhibitor or ARB* as
BP allows, and even if BP control good
41, 71
If needed to control BP or to reduce
proteinuria further, use both ACE inhibitor and ARB*
2 g sodium, 0.8 g/kg protein diet;
HMG-CoA reductase inhibitor to reduce
LDL to < 100 mg/dL
Add non-DHP CCB
Add spironolactone 25-50 mg daily
*Monitor serum potassium and renal function
Downtitration of proteinuria in a patient with chronic renal failure.
62
Patients with Chronic Renal Failure are at increased risk for atherosclerosis. Low
density lipoproteins with statins is useful for secondary prevention of coronary
events.42,43
Once it is determined that a patient has CRF; careful and regular follow-up is
mandatory. It is best in the primary care physician and the nephrologists cooperate
closely in the management of such patients, especially while dealing with hypertension
associated with Chronic Renal Failure.43, 71
TREATMENT OF IRREVERSIBLE RENAL FAILURE
Unlike other forms of end-stage organ failure, renal failure is unique in having
three modalities of therapy:
1) Hemodialysis
2) Peritoneal dialysis
3) Renal transplantation
Each form of renal replacement therapy (RRT) has its unique risks and benefits.
The key is to identity patients with progressive renal failure early so as to enabe
them to make an educated choice that fits their lifestyle and medical situation. Planning
and establishing access early decrease emergency hospitalizations and complications and
significantly reduce cost. Early evaluation also enables identification of potential living
donors so that preemptive transplantation can be performed.
63
HEMODIALYSIS
Dialysis substitutes two major renal functions: Solute removal and fluid removal.
In hemodialysis, solute removal occurs predominantly by diffusion, which is the
movement of solutes from the blood compartment to the dialysate compartment across a
semipermeable membrane.19
1. Molecular size – clearance is size dependent and is higher for smaller
molecules.
2. The concentration gradient between the blood and the dialysis solution of
a particular substance – the greater the concentration gradient, the more
rapidly diffusion occurs.
3. Membrane surface area – the net transfer of solute increases as membrane
surface area increases.
4. Membrane permeability – this is determined by the specific characteristics
of the membrane such as pore size, charge, and quaternary conformation.
5. Blood and dialysate flow rates – higher flow rates allow greater solute
removal, especially if the flow of dialysate is counter-current to blood
flow, which permits maximum gradient across the membrane.
Solute removal can also occur by the process of convention, the movement of
solutes by bulk flow in association with fluid removal (solvent drag).
Fluid removal in hemodialysis occurs by the process of ultrafiltration. The
ultrafiltration increases when positive pressure is applied to the blood compartment or if
64
negative pressure is applied to the dialysate side of the dialysis membrane. During
dialysis the ultrafiltration rate is adjusted to obtain the desired fluid loss.
The hemodialysis machine has three main components:
1. The dialyzer (i.e., the dialysis membrane)
2. A pump that regulates blood flow
3. A dialysate solution delivery system.
In addition, the machine has many safety devices to monitor arterial and venous
pressures, concentration of ions and temperature in the dialysate, as well as air and blood
leaks.
HEMODIALYZERS
The hollow-fiber dialyzer is composed of thousands of parallel capillary tubes.
Blood flows through the capillary tubes and dialysate flows through the canister, bathing
the outside of the capillary tubes.
The dialysis membrane is an essential component of the dialyzer. The initial
membranes were made of cuprophane, a derivative of cellulose, which has excellent
clearance of small molecules but very poor clearance of middle-sized molecules. The
contact of blood with these membranes leads to activation of inflammatory and clotting
cascades. The alternative pathway of complement is also activated by contact with the
65
dialysis membrane, leading to activation of granulocytes. Platelet-activating factor
production is also increased in complement-activating membranes.
The activation of inflammatory and coagulation pathways leads to significant
clinical events. Acutely, patients may develop chest pain, back pain, and shortness of
breath, especially with cellulosic membranes. Chronic activation of inflammation may
also lead to accumulation of β2 – microglobin and a form of amyloidosis described only
in long-term hemodialysis patients44. Dialysis related amyloidosis is associated with
carpal tunnel syndrome, diffuse arthropathy, lytic bone lesions, and pathologic fractures.
The synthetic membranes made of polycarbonate, polysulfones, polyacrylonitrile, or
polymethylmethacrylate are less proinflammatory and also have higher diffusive
clearance for larger molecules and higher ultrafiltration rates.
The survival of patients with acute renal failure appears to be impacted by the
type of membrane employed. Studies comparing cuprophane with synthetic membranes
showed not only improved patient survival and more rapid recovery of kidney function
after acute renal failure but a decrease in the incidence of death from sepsis in the patients
dialyzed with a synthetic membrane.45
ACCESS
To perform hemodialysis on a repetitive basis, access to the circulation is
essential. The arteriovenous fistula is the “gold standard” hemodialysis access and
involves the anastomosis of the radial artery to the cephalic vein, with subsequent
66
“arterialization” of the superficial forearm problem associated with AVFs is failure to
mature, particularly in patients with peripheral vascular disease and diabetes. Thus, it is
important to spare the nondominant arm in all patients with chronic kidney disease
(CKD) from venipuncture and to plan the placement of AVFs long in advance of the
patients approach to hemodialysis because the fistula generally takes 6 to 8 weeks to
mature. Elective placement of a permanent access before dialysis initiation reduces
morbidity, mortality, and cost. The National Kidney Foundation/Disease Outcomes
Quality Initiative (NKF/DOQI) guidelines recommend placement of an AVF when the
serum creatinine exceeds 4 mg/dL, creatinine clearance falls below 25 mL/min, or
hemodialysis initiation is anticipated within 1 year.46
Synthetic arteriovenous grafts (AVGs) can be used when a native AVF cannot be
placed. The AVG carries a higher rate of thrombosis and infection than a fistula. The
third option is percutaneous dulalumen catheters, which are placed preferentially in the
internal jugular vein and a segment of the line is tunneled under the skin.
Vascular Access Infections:
Although tunneled lines proved immediate and convenient access to the
circulation, they have a high rate of infection and clotting. The skin and the catheter hubs
are the primary source of bacteria. Infectious complications of the vascular access are a
major source of morbidity and mortality among hemodialysis patients, accounting for up
to 73% of all cases of bacteremia in this population.
67
Overtime the inner surface of indwelling catheters becomes covered by biofilm, a
complex of proteoglycans, which can act as a nidus for microbial growth. Any approach
that aims to limit biofilm formation may help decrease catheter-related infection.
Thrombus within the catheter is another significant nidus for pathogens. Therefore, the
use of anticoagulants to prevent catheter obstruction may have a beneficial impact on the
prevention of catheter-associated infections.
If the patient has any evidence of systemic sepsis with hemodynamic instability,
the line should be pulled promptly and reinserted only after blood cultures are negative
on antibiotics for at least 48 hours and after the patient has defervesced.
If the patient with probable catheter-related infection fails to improve after the
first 24 hours of antibiotics, it is prudent to remove the catheter and replace it once the
patient becomes afebrile and the cultures are negative for 48 hours. Vancomycin is
generally employed in institutions with an increased incidence of methicillin-resistant
staphylococci.47, 48, 44
In patient with a prompt response to antibiotic therapy, antimicrobials should be
administered for at least 2 to 3 weeks. A prolonged course of antibiotic therapy (4 to 8
weeks) should be employed if there is evidence of endocarditis, septic arthritis,
osteomyelitis, epidural abscess, or other metastatic infection.
68
Anticoagulation
The contact of patient’s blood with the dialysis membrane and the tubing leads to
activation of the coagulation cascade. Heparin is generally required to prevent clotting of
the hemodialysis circuit. Several complications may occur as a result of heparin use,
including bleeding or the development of heparin-induced thrombocytopenia.47, 69
In patients at high risk of bleeding, hemodialysis can be performed without
anticoagulation. Heparin-free dialysis requires a high blood flow rate and frequent
flushing of the system with normal saline.
Dialysate Solution
Dialysate is a balanced solution of sodium, potassium, calcium, magnesium,
chloride and dextrose using bicarbonate as buffer. During dialysis the sodium
concentration can be increased during part of the hemodialysis session to counterbalance
the intracellular hyperosmolarity caused by the rapid fall in urea concentration – defined
as sodium modeling. Because urea is cleared at a faster rate from the extracellular space,
the intracellular space becomes relatively hyperosmolar, causing fluid to shift from the
extracellular space into the intracellular space, which may lead to hypotension and central
nervous system manifestations (dialysis disequilibrium syndrome) during hemodialysis.
Sodium modeling helps prevent hypotension, muscle cramps, nausea, vomiting,
headaches, and seizures during hemodialysis44,47. The sodium concentration os
programmed to return to normal range by the end of hemodialysis. Mannitol can also be
used to prevent dialysis disequilibrium syndrome.
69
Water Quality
Since patients are exposed to large volumes of water during each hemodialysis
treatment, the purity of the water is essential to avoid exposure to aluminum,
chloramines, endotoxin, and bacteria. The use of a charcoal filter removes organic toxins
such as chloramines, which can cause acute hemolysis.
Aluminum is frequently added to the water supply to precipitate suspended
colloidal material. Chronic exposure to aluminum can lead to dialysis dementia. Sever
bone disease and erythropoietin-resistant anemia are also associated with aluminum
intoxication. Therefore, removal of aluminum from the water used to prepare dialysis is
essential. Reverse osmosis or deionization of the water effectively removes aluminum,
fluoride, and copper.
Complications
Complications During Hemodialysis
Hypotension, muscle cramps, nausea, vomiting, headache, and chest pain.
Although excessive fluid removal is the most frequent cause of hypotension, it is critical
to rule out other potential etiologies if the hypotension persists after fluid replacement.
Antihypertensive agents may need to be withheld prior to dialysis to avoid hypotension.
Air embolus is the most dreaded technical complication of the hemodialysis
procedure44. Despite the presence of air detectors in the dialysis machine, there remains
the risk of an air embolus with repeated disconnections of catheters. The patients may
70
develop agitation, cough, dyspnea, and chest pain. As soon as the diagnosis is suspected,
the patient should be positioned with the left side down in an attempt to trap air in the
right ventricle and 100% oxygen should be administered.
ANEMIA
The development of anemia parallels the progression of CKD. CKD – related
anemia is usually normochromic and normocytic. Nearly two thirds of patients starting
dialysis have hematocrit levels below 30%. The target hemoglobin range established by
the NKF/DOQI is between 11 to 12g/dL. Untreated anemia contributes to cardiovascular
morbidity and mortality and has been associated with impaired cognition, exercise
capacity, and ability to perform simple tasks.
Anemia Therapy.
The administration of erythropoietin together with repletion of iron stores, folic
acid supplementation, and treatment of concomitant infection, is effective in correcting
the anemia of chronic renal disease49, 68. The best way to replenish the iron stores is the
administration of iron intravenously. Some iron preparations have been associated with
severe allergic reactions, including anaphylaxis, due to the presence of dextran. The
newer iron preparations, containing sucrose instead of dextran, appear to be associated
with fewer side effects. A transferrin saturation level (serum iron/total iron- binding
capacity x100%) below 20% is considered the point to imitate intravenous iron therapy.
71
MALNUTRITION.
Hypoalbuminemia is associated with an increased morality on dialysis An
albumin level below 3.0g /dL has a 2-year mortality arte up to 40% in comparison with
the expected mortality rate 20%. Marked catabolism, anorexia, and severe diet limitations
during the predialysis period lead to loss of lean weight. After the initiation of dialysis,
patients generally have an improved appetite and the protein intake recommended should
be at least 1.2g/kg per day with a total caloric intake of 35 cal/ kg. Water-soluble
vitamins, including folic acid, need to be replaced because they are depleted during
dialysis.44, 19
CHRONIC KIDNEY DISEASE AND CARDIOVASCULAR DISEASE.
Cardiovascular disease is the most important cause of death among patients with
CKD. CKD accounts for approximately 50% of the mortality among patients on dialysis
and recipients of renal allografts. Two thirds of patients with CKD have diabetes mellitus
or hypertension. But the rates of CVD and mortality are also elevated among patients
with primary renal diseases such as glomerulonephritis. The relative hazard is greatest
among patients younger than 45 years of age. In this age group, cardiac mortality is 100
times greater than in the general population.44, 73
In patients imitating dialysis, the main cardiac abnormality left ventricular
hypertrophy. Atherosclerosis with prominent calcification often accompany left
ventricular hypertrophy.
72
Dialysis Dose
The prescription of hemodialysis is tailored to the patients size and protein intake.
Urea is used as surrogate marker for clearance50. Because it reflects the efficiency of
removal of small uremic toxins various methods have been proposed to quantity
hemodiaysis adequacy. The most frequently used methods are the urea reduction ratio
(URR) and urea kinetic modeling (Kt/V). The URR (100 x 11 – postdialysis BUN/
predialysis BUN]) has the advantage of simplicity but it does not account for the fact that
urea is removed ultrafiltration and that urea cannot be used to assess nutritional status.
The Kt/V takes into account both of these variables and is the preferred method for
determining adequacy for stable chronic dialysis patients.
The NKF/DOQI recommends a Kt/V greater than 1.2 and URR greater than 65%
to minimize uremic complication and hospitalization.51, 67
73
MATERIALS AND METHODS
The H.K.E. Society’s Basaveshwar Teaching and General Hospital, attached to
M.R. Medical College has a capacity of 700 beds.
The Urology unit and Medical ward which deals with the cases of Acute Renal
Failure and Chronic Renal Failure is supplied by 12 beds and 30 beds respectively.
Dialysis Unit of the hospital is well equipped with all the facilities to handle the
Acute Renal Failure and Chronic Renal Failure patients and has the ability to counter act
all the emergency needs during hemodialysis.
METHODS OF DATA COLLECTION:
The study was conducted after obtaining the permission of the ethical committee
of our institution. The present study included patients who were admitted to the Urology
unit and the Medical unit which deals with Urinary Tract Infection and Acute Renal
Failure and Chronic Renal Failure cases respectively.
Detailed history, chief complaints, physical signs, and investigations were
recorded. The prescriptions were noted down for a period of 3 days the patients were
followed for adverse effect and prognosis until discharge or death. Total duration of study
was over a period of 15 months i.e., from August 2004 to Oct. 2005. During this period
74
100 prescriptions i.e., 70 form Urology unit and 30 from Medical unit, with a special
audit on hemodialysis and its complications.
DATA ANALYSIS
As mentioned above 100 prescriptions were taken, out of which 70 prescriptions
were taken form Urology unit and 30 prescriptions from Medical unit. The data collected
was condensed and a master chart was prepared by giving proper code words to ease the
analysis. The data was subjected to statistical analysis.
The overall information generated was presented in the following headings:
01) Case wise distribution of patients in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
02) Sex wise distribution of patients in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
03) Age wise distribution of patients in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
04) Diet wise distribution of patients in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
05) History with habit of taking Tobacco and Alcohol in Urology unit and Medical
unit (Acute Renal Failure and Chronic Renal Failure cases).
06) Diagnosis wise distribution of patients in Urology unit and Medical unit (Acute
Renal Failure and Chronic Renal Failure cases).
75
07) Etiology wise distribution of patients in Urology unit and Medical unit (Acute
Renal Failure and Chronic Renal Failure cases).
08) Average duration of stay in the hospital in Urology unit and Medical unit (Acute
Renal Failure and Chronic Renal Failure cases).
09) Discharge position in both the units (Acute Renal Failure and Chronic Renal
Failure cases).
10) Route of drug administration in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
11) Average number of drugs used per day in treating the Urological cases and Acute
Renal Failure and Chronic Renal Failure cases in Urology unit and Medical unit
(Acute Renal Failure and Chronic Renal Failure cases).
12) Adverse effects of drugs in both the units (Acute Renal Failure and Chronic Renal
Failure cases).
13) Average cost of drugs in Urology unit and Medical unit (Acute Renal Failure and
Chronic Renal Failure cases).
14) Analysis of drugs in the Medical unit concerned with Acute Renal Failure and
Chronic Renal Failure.
15) Analysis of drugs in the Urology unit.
16) Analysis of complication during dialysis if any.
17) Irrational prescriptions of drugs in Urology unit and Medical unit (Acute Renal
Failure and Chronic Renal Failure cases).
76
RESULTS
Analysis of 70 cases of Urinary Tract Infection:
These 70 cases who were admitted to Basaveshwar Teaching and General
Hospital, Gulbarga from August 2004 to Oct. 2005 with symptoms of Urinary Tract
Infection were analyzed.
40% were proved to have significant bacteriuria by culture, 13% of cases showed
no significant growth and remaining were sterile.
Among these 70 cases who presented with Urinary symptoms 38 were females
and 32 were males.
Out of 38 females 20 were culture positive and out of 32 males 10 were culture
positive. The dominance of females with Urinary Tract Infection is maintained. The
increased incidence of Urinary Tract Infection was seen in the age group of 18 to 35
years, after 50 the increased incidence of males is maintained.
Majority of the infections occurred in the age group of 21 to 30 years. Pyuria was
found in more than 45% of cases, massive pyuria was present in 20 cases.
The incidence of infection due E-coli were in clear majority.
77
E-coli was found in all the age groups in higher frequency when compared to
other organisms.
Analysis of 30 cases of Acute Renal Failure and Chronic Renal Failure cases in the
Medical unit:
These 30 cases who were admitted to Basaveshwar Teaching and General
Hospital, Gulbarga form August 2004 to Oct. 2005 with symptoms of Acute Renal
Failure and Chronic Renal Failure were analyzed with a special audit on complications
during hemodialysis.
Among the 30 patients 11 patients were suffering from Acute Renal Failure and
19 patients were suffering from Chronic Renal Failure, among these cases 19 were male
patients and 11 were female patients.
The dominance of male patients with Renal Failure is maintained.
The increased incidence of Renal Failure was seen in the age group of 51 to 75
(53.33%) and in the age group of 25 to 50 (36.66%) and in the age group of 1 to 25
(10%).
Majority of cases occurred in age group of 51 to 75 and majority of cases
presented with disorders of BUN (Blood Urea Nitrogen).
Normal ratio is 10:1 and if the ratio exceeds 10 to 1 and more, renal failure starts.
78
OBSERVATIONS
Table – 1: Case-wise Distribution of Patients
Case
No. of Patients
Percentage
Urology Unit
70
70%
Medical Unit
30
30%
Total
100
100%
Table – 2: Sex-wise Distribution of the Urology and Medical Unit Cases
Sex
Cases
Male
No. of Patients
Percentage
Female
No. of Patients
Percentage
Urology unit
32
45.71%
38
54.29%
Medical unit
19
63.33%
11
36.66%
Table – 3: Age-wise Distribution of Patients in the Urology & Medical Unit cases
Cases
Cases
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
1 to 25
12
17.14%
3
10%
26 to 50
30
42.85%
11
36.66%
51 to 75
25
35.71%
16
53.33%
> 75
3
4.28%
0
0%
79
Case-wise Distribution of Patients
100
100
80
70
60
40
Urology Unit
Medical Unit
30
Total
20
0
No. of Patients
80
Sex-wise Distribution of the Urology and
Medical Unit Cases
38
40
35
32
30
25
19
20
15
11
10
5
0
Urology unit
Medical unit
Sex Male No. of Patients
Sex Female No. of Patients
81
Age-wise Distribution of Patients in the Urology
& Medical Unit cases
30
30
25
25
20
15
10
16
12
5
0
11
3
3
0
1 - 25.
26 - 50
51 - 75
Cases Urology Cases No. of Patients
82
> 75
Cases Medical Cases No. of Patients
Table – 4: Diet-wise Distribution of Patients in the Urology & Medical Unit cases
Diet
Cases
Vegetarian
No. of Patients
Percentage
Non-vegetarian
No. of Patients
Percentage
Urology unit
39
55.71%
31
44.28%
Medical unit
20
66.66%
10
33.33%
Table – 5: History with Habits of taking Tobacco and Alcohol in the Urology &
Medical Unit cases
Cases
Habits
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
Smokers
15
21.42%
8
26.66%
Alcoholics
30
42.85%
15
50%
Tobacco
chewers
25
35.71%
7
23.33%
Table – 6: Average duration of stay in the Urology & Medical Unit
Cases
Duration of
Stay (days)
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
1 to 7
25
35.71%
11
36.66%
2 to 5
35
50%
8
26.66%
1 to 2
10
14.28%
0
0%
> 10
0
0%
11
36.66%
83
Diet-wise Distribution of Patients in
the Urology & Medical Unit cases
39
40
35
31
30
25
20
20
15
10
10
5
0
Ur ology unit
Diet Vegetarian No. of Patients
Me dic a l unit
Diet Non-vegetarian No. of Patients
84
History with Habits of taking Tobacco and
Alcohol in the Urology & Medical Unit cases
35
30
30
25
25
Cases Urology Cases
No. of Patients
20
15
10
15
15
Cases Medical Cases
No. of Patients
8
7
5
0
Smokers
Alcoholics
Tobacco
chewers
85
Table – 7: Discharge position in the Urology & Medical Unit
Cases
Discharge
Position
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
On advise
50
71.42%
12
40%
Against advise
8
11.42%
3
10%
Expired
9
12.85%
8
26.66%
Absconding
3
4.28%
0
0%
Referred to
higher center
0
0%
7
23.33%
Table – 8: Route of During Administration
Cases
Route
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
Oral route
50
71.42%
20
66.66%
Intramuscular
70
100%
30
100%
Intravenous
70
100%
30
100%
Table – 9: Number of Drugs used per day in the Urology & Medical Unit
Cases
Number of
Drugs
Urology Cases
No. of Patients
Percentage
Medical Cases
No. of Patients
Percentage
1 to 5
35
50%
11
36.66%
6 to 9
25
35.71%
18
60%
> 10
10
14.28%
1
3.33%
86
Table – 10: Adverse Effects of Drugs
Cases
Adverse Effects
No. of Patients
Percentage
Urology Unit
Gastritis
20
28.57%
Super infection
2
2.85%
Allergic reaction
2
2.85%
Vomiting
6
8.57%
Gastritis
11
36.66%
First dose effect
4
13.33%
Vomiting
2
6.66%
Medical Unit
Table – 11: Average cost of drugs used in the treatment
Cases
Urology Unit
Medical Unit
Dialysis
Average cost per day per
patient (Rs.)
Days
Amount (Rs.)
One
100 to 150
Two
200 to 300
Three
300 to 400
One
200 to 300
Two
300 to 400
Three
400 to 500
Per setting
800/-
87
Table 1: Case wise distribution of patients.
70% of patients in the Urology unit and 30% in the Medical unit.
Table 2: Sex wise distribution
In the Urology unit 38 were female and 32 were males, in the Medical unit 19
were males and 11 were females.
Table 3: Age wise distribution of patients
In the Urology unit 17.14% were in the age group of 1 to 25 years, 42.85% were
in the age group of 26 to 50 and 35.71% were in the age group of 51 to 75, 4.28% were in
the age group of above 75 years.
In the Medical unit 10% of the patients were in the age group of 1 to 25, 36.66%
were in the age group of 26 to 50, 53.33% were in the age group of 51 to 75.
Table 4: Diet wise distribution of patients
In the Urology unit 55.71% of cases were vegetarians, 44.29% were nonvegetarians.
In the Medical unit 66.66% of cases were vegetarians, 33.33% were nonvegetarians.
88
Table 5: Habit of taking Tobacco and Alcohol
In the Urology unit 21.42% of cases were smokers, 42.85% of cases were
alcoholics, 35.71% of cases were tobacco chewers.
In the Medical unit 26.66% of cases were smokers, 50% of cases were alcoholics,
23.33% of cases were tobacco chewers.
Table 6: Diagnosis
In the Urology unit 71.42% of patients were diagnosed to be suffering from
Urinary Tract Infection, 14.28% of patients were diagnosed to have hematuria, 17.14% of
patients were diagnosed to have urethritis, 20% of patients were diagnosed to have
cystitis, 20% of patients were diagnosed to have prostatitis.
Complicated – calculi 14.28%, Vesico-ureteric reflux 7.14%, Indwelling –
catheter 7.14% .
In the Medical unit 36.66% of patients were diagnosed to have Acute Renal
Failure, and 63.33% of patients were diagnosed to have Chronic Renal Failure.
Table 7: Etiology wise distribution
In the Urology unit
89
Acquired Disorders:
1) Obstructions of Urinary Tract
71.42%
2) Infection of Urinary Tract
3) Hypercalcaemia
17.14%
4) Hyperoxaluria
Inherited Disorders:
1) Cystinuria
2) Zanthinuria
3) Gout
11.42%
In the Medical unit
Acute Renal Failure:
1) Dehydration leading to hypovolemia
13.33%
2) Diarrhea/ Vomiting leading to gastrointestinal fluid loss
3)
4)
5)
6)
Diabetes Mellitus
Pulmonary Hypertension
Ischemia
Renal Artery Obstruction
23.33%
Chronic Renal Failure:
1) Diabetic kidney disease
leading to protein urea and metabolic acidosis. 26.66%
2) Hypertension
3) Cystic kidney disease
4) Fluid electrolyte and acid base disorders 36.66%
Table 8: Duration of stay
In the Urology unit 35.71% of patients remained in Urology unit for 1 to 7 days,
50% were there for 2 to 5 days and 14.28% there for 1 to 2 days.
90
In the Medical unit 36.66% of patients remained in Medical unit for 1 to 5 days,
26.6% were there for 2 to 3 days and 36.66% remained for more than 10 days.
Table 9: Discharge position
In the Urology unit 71.42% were discharged on advise, 11.42% of patients got
discharged against advise, 12.85% of patients expired during treatment, 4.28% of patients
absconded.
In the Medical unit 40% were discharged on advise with weakly interval of
dialysis, 26.66% of patients expired during treatment, 23.33% were referred to higher
centers, 10% of patients got discharged against advise.
Table 10: Routes of drug administration
In the Urology unit 71.42% of patients received drugs by oral route, 100% by
intramuscular route and 100% by intravenous route.
In the Medical unit 23.33% of patients received drugs by oral route, 100% by
intramuscular route and 100% by intravenous route.
Table 11: Average number of drugs used per day
In the Urology unit 50% of patients received 1 to 5 drugs per day, 25% of patients
received 6 to 7 drugs per day, 4.28% of patients received more than 10 drugs per day.
91
In the Medical unit 60% of patients received 1 to 5 drugs per day, 36.66% of
patients received 6 to 9 drugs per day, 3.33% of patients received more than 10 drugs per
day.
Table 12: Adverse effects of drugs
In the Urology unit 28.57% of patients on treatment reported gastritis, 2.85%
reported super infection (diarrhoea), 2.63% of patients reported allergic reactions, 8.57%
developed vomiting with Ceftazidine, 2.82% developed allergic reaction to NSAIDS.
In the Medical unit 36.66% developed gastritis, 13.33% of patients developed first
dose effect to prazocin as adverse effect, 1 patient received NSAID, which is a contra
indicated drug 6.66% developed vomiting.
Table 13: Average cost of drugs used
Average cost of drugs in the Urology unit was 100 to 150 per day per patient,
while the cost of drugs in Medical unit to treat Acute Renal Failure and Chronic Renal
Failure was 500 to 1500 if the patient undergoes dialysis.
Table 14: Analysis of drugs in the Urology unit
Intramuscular route:
100% of patients received drugs by intramuscular route, out of this
100% of patients received diclofenac.
100% of patients received Paracetomol
92
14.28% of patients received Vitamin K.
54.54% of patients received dicyclomine hydrochloride.
4.54% of patients received diazepam
Intravenous route:
100% of patients received drugs by intravenous route, out this
62.27% of patients received Normal Saline
54.54% of patients received Ringerlactate
29.09% of patients received 5% Dextrose
5.62% of patients received 25% Dextrose
4.54% of patients received Isolyte – P (type 1 USP)
10% of patients received Vitamin C
26.45% of patients received Multi Vitamin Infusion
1.81% of patients received amino acids
Oral route:
Anti ulcer drug:
67.27% of patients received Ranitidine
26.66% of patients received Pantoprazole
17.14% of patients received Rebaprazole
35.71% of patients received Omeprazole
4.54% of patients received Antacids
93
Anti emetic drug:
28.57% of patients received Metaclopramide and Domstall
Antibiotics:
28.57% of patients received Cefuroxime
15.45% of patients received Cefoperazone
36.66% of patients received Cefpirone
17.27% of patients received Sulpactum + Cefoperazone
16.36% of patients received Cefotaxime
17.27% of patients received Cefixime
1.81% of patients received Lincomycin
7.27% of patients received Cefdinir
28.57% of patients received Gentamycin
72.14% of patients received Ciprofloxacin & Metronidazole
Oral route:
72.14% of patients received Ciprofloxacin, Norfloxacin, Ampicillin-Cloxacillin
28.57% of patients received Erythromycine
17.27% of patients received Ofloxacin
NSAIDS:
85.71% of patients received Diclofenac
28.57% of patients received Paracetamol
94
14.28% of patients received Nimesulide + Paracetamol
28.57% of patients received Tramadol
17.42% of patients received Brufen + Paracetamol
28.57% of patients received Dicyclomine Hydrochloride
Diuretics:
54.54% of patients received Furosemide
Miscellaneous drugs:
5.45% of patients received Aminophylline
3.63% of patients received Dopomine
1.81% of patients received Atropine
35.45% of patients received Multi Vitamin Infusion
2.89% of patients received Calcium
3.63% of patients received Vitcoferal
Topical route:
10% of patients received Ciprofloxocin 0.3%
Transdermal route:
2.72% of patients received Diclofenac
95
Inhalational route:
12.85% of patients received Oxygen
Analysis of Drugs used in Medical Unit during the treatment of Acute Renal Failure &
Chronic Renal Failure and complications during dialysis if any:
Intravenous fluids:
2.89% of patients received 5% Dextrose
17.14% of patients received DNS
13.63% of patients received Normal saline
Blood Transfusion:
11.14% of patients received Blood Transfusion
1.81% of patients received Aminoacids
Antibiotics:
18% of patients received Crystalline Penicillin
62% of patients received Ampicillin & Cloxocillin
62% of patients received Cefixime
62% of patients received Sulbactum + Cefoperazone
62% of patients received Metronidazole, Ciprofloxocillin, Ampicillin
3.66% of patients received Vancomycin
11% of patients received Amikacin
4% of patients received Lincomycin
96
Anti-Ulcer Drugs:
12% of patients received Pentoprazole
22.66% of patients received Ranitidine
Oral route:
11.74% of patients received Pentoprazole
25% of patients received Ranitidine
NSAIDS:
3.33% of patients received Diclofaenic
6.66% of patients received Tramadol
10% of patients received Hydrocortisone
10% of patients received Dexamethasone
Oral route:
4.12% of patients received Paracetamol
Diuretics:
76.14% of patients received Frusemide
25.86% of patients received Torusemide
Anti-Emetic:
6.66% of patients received Metaclopramide
97
Miscellaneous drugs:
22% of patients received Dopomine
11% of patients received Dobutamine
11.41% of patients received Atropine
18% of patients received Calcium Glauconate
6.66% of patients received Vitamin C.
10% of patients received B-complex Vitamins
Oral route:
40% of patients received Phostate (calcium)
50% of patients received Minipress (prazocin)
33.33% of patients received Livogen
40% of patients received Alprozolom
30% of patients received Calcium (shelcal)
Inhalational route:
46.66% of patients received Oxygen
Irrational prescription of drugs in Urology unit:
4.28% of patients received Cefotaxime in excessive amount and longer duration
2.85% of patients received Ceforoxime for excessive amount and longer duration
4.28% of patients received Ciprofloxocin, Metronidazole, Ampicillin for
excessive duration.
98
Medical Unit:
6.66% of patients received Normal saline in excessive dose.
1.31% of patients received NSAID, which is a contra indicated drug
36.66% of patients received Cefotaxime in excessive amount and longer duration
99
DISCUSSION
In the Urology unit & Medical unit patients hanging on to the thread of life is a
real challenge to the surgeon and physician. Considering the conditions of the patients
and the number of drugs to be prescribed, the surgeon and physician has to weigh the
pros and cons of every drug before using it.
Keeping this in mind, the present study of drug utilization pattern in the Urology
unit and Medical unit has been taken up.
The present study was plan to identify the prevailing prescription trends in the
Urology unit and Medical unit of Basaveshwar Teaching and General Hospital, Gulbarga.
The main aims of the study were:
•
To through light on the prescription pattern of surgeons and physicians in the
Urology unit and Medical unit.
•
To study the complications during haemodialysis and its management.
•
To analyze the rationality of prescriptions.
•
To make a comparison between the defined daily and prescribed daily dose of
drugs used in the Urology and Medical unit.
•
To study the adverse drug reactions and drug interactions.
•
To calculate the cost benefit ratio.
100
The present study included patients who were admitted to Urology and Medical
unit were randomly selected for study.
Detailed history, chief complaints, physical signs and investigations were
recorded. The prescriptions were noted down for a period of three days. Then the patients
were followed for adverse effects and prognosis until discharge or death.
The total duration of the study was over a period of 15 months from August 2004
to Oct. 2005.
During this period 70 prescriptions from the Urology units and 30 prescriptions
from the Medical unit were taken. Total 100 prescriptions were collected and analysed.
The prescription were collected from the day admission to the day of discharge or death.
Drugs prescribed at the time of discharge were also noted.
In the present study in the Urology unit it may be observed that 54.28% were
females, 45.71% were males. In the Medical unit 36.66% were females and 63.33% were
males. Earlier study shows that the incidence of Urinary Tract Infection is common in
females than males and the incidence of Acute Renal Failure and Chronic Renal Failure
is more in males than females because of increased percentage of acquired diseases like
diabetes mellitus and hypertension.
101
It was observed in over study that maximum number of patients in the Urology
unit were in the age group of 25 to 50 percentage is 42.82%, 50 to 75 years is 35.71%, 1
to 25 years is 17.14% and 4.28% above 75 years.
This correlates with many number of studies that increased risk of Urinary Tract
Infection is seen females of age 20 to 30 and increased incidence in males is seen
between the age group of more than 75 years.
In the Medical unit patients were maximum in the age group of 51 to 75 years
(53.33%) and 36.66% in the age group of 25 to 50 and 10% in the age group of 1 to 25
years. This correlates with many studies that the incidence of Acute Renal Failure and
Chronic Renal Failure is in the age group of 50 to 75 years.52
Diet wise distribution in the Urology unit showed that 55.71% were vegetarian
and 44.28% were non-vegetarian. In the Medical unit 66.66% were vegetarian and
33.33% were non-vegetarian.
In the Urology unit 21.42% of patients were in the habit of smoking tobacco and
42.82% of patients were in the habit of consuming alcohol, 35.71% were in the habit of
chewing tobacco.
In the Medical unit 26.66% were smokers, 50% were alcoholics, 23.33% were
tobacco chewers.
102
This correlates with many studies that increased consumption of alcohol and
tobacco can lead to severe grades of Acute Renal Failure and Chronic Renal Failure.
For example: Hepatorenal syndrome is more commonly seen in Acute Renal
Failure and Chronic Renal Failure.53, 66
Increased amount of alcohol also leads to hypovolemia, renal fluid loss, uremic
syndrome and electrolyte imbalance.53, 58
Increased amount of tobacco input also leads to atherosclerotic plaque,
thrombosis, embolism, hypertension and renal artery obstruction.
In the Urology unit patients 35.71% had an average stay of 1 to 7 days, 50% of
the patients stayed for 2 to 5 days, 14.28% stayed for 1 to 2 days.
50% of patients were discharged within 2 to 5 days encouraging early ambulation,
20% of them underwent surgeries for various grades of obstructive Urology. 5.45% of
patients stayed for more than 7 days because of complications like indwelling catheter
and vasico ureteric reflux.
In the Medical unit 36.66% of patients had an average stay of 1 to 5 days, 26.66%
patients stayed for 2 to 3 days, 36.66% stayed for more than 10 days.
103
26.66% of patients were discharged within 2 to 3 days asking them to undergo
emergency dialysis who had complications with uremic syndrome, 36.66% of patients
were discharged within 1 to 5 days. Time taken was to correct the electrolyte imbalance,
hypertension which like to more rapid loss of renal function and development of
cardiovascular diseases. Hypotension was corrected by intravenous lebetolol and fenol
dopam, salt restriction was advised on discharge.
Blood pressure was controlled to at least the level established in the guidelines of
the Sixth Joint National Commission on Hypertension Detection Education and Followup programme. (i.e., 130/80 – 85 mm/Hg) It was seen that in our study according to the
above said guidelines blood pressure was brought down to 125/75 mm/Hg in few patients
who had protein urea more than 1gram/24 hours.53
36.66% of patients were discharged after 10 days, this was to get treatment of
complication in Acute Renal Failure and Chronic Renal Failure like
BUN – Abnormal reading
GFR – less than 60ml/min.
Metabolic acidosis
Hyperkalemia
Hyponatremia
Hyperphosphatemia
104
In the Urology unit 71.42% of patients were discharged on advise, 11.42% of
patients got discharged against medical advise, 4.28% were of absconding, 12.85% of
patients expired during treatment, most of them expired due to Septicemia and Renal
failure.
In the Medical unit 40% were discharged on advise with weekly interval dialysis,
26.66% expired during treatment, 23.33% were referred to higher centers, 10% got
discharged against advise. Most of them died within two days of treatment due to uremic
complication leading to renal failure. Two of them died because of non-affordability to
meet the expenses for dialysis.
In the Urology unit 100% of patients received drugs through parentral route
(IM/IV) 71.42% of patients received drugs by oral route.
Oral drugs were given to prevent extra burden on patients financially and to
maintain cost benefit ratio.
In the Medical unit 23.33% of patients received drugs by oral route, 100% of
patients received drugs parentrally (IM/IV).
In the Urology unit 35.71% of patients received more than 6 to 9 drugs, 50% of
them were received 1 to 5 drugs, 14.28% of patients received more then 10 drugs.
105
This proves that modern medicine seems to believe that MOST IS THE BEST.
In the Medical unit 36.66% of patients received 1 to 5 drugs, 60% of patients
received 6 to 9 drugs because of multiple disorders associated with renal failure like
diabetes mellitus, hypertension, hypocalcaemia and electrolyte imbalance.
In the study of drug utilization in Urology unit NSAIDS were most commonly
used. 85.71% of patients received Diclofenac, which was given parenterally and followed
by oral route, 28.57% of patients received Paracetamol, 14.28% of patients received
Nimuslide + Paracetamol, 28.57% of patients received Tramadol, 17.42% of patients
received Brufen + Paracetamol combination.
These drugs were used to reduce pain, swelling and edema, which either acted as
analgesic or anti-inflammatory agents. 2.82% of patients developed allergic
manifestations and were treated accordingly, 28.57% of patients reported gastritis this
was due to over prescriptions of NSAIDS. 28.57% of patients received dicyclomine
which correlates with the earlier studies the use of anti-spasmostic helped in reliving
obstructive urology.54
Among the patient admitted in the Urology unit
67.27% of patients received Normal Saline
54.54% of patients received Ringerlactate
29.09% of patients received 5% Dextrose
106
5.62% of patients received 25% Dextrose
4.54% of patients received Isolyte – P (type 1 USP)
10% of patients received Vitamin C
26.45% of patients received Multi Vitamin Infusion
1.81% of patients received amino acids
Most of the Intravenous fluids were used to correct dehydration and maintain
electrolyte balance, because 10% of patients were suffering from Urinary Tract Infection
with diarrhoea. Intravenous fluids were used to induce forced diuresis to remove or
relieve obstructive urology.
In the Medical unit among the patients who received intravenous fluids:
2.89% of patients received 5% Dextrose
17.14% of patients received DNS
13.63% of patients received Normal saline
Blood Transfusion:
11.14% of patients received Blood Transfusion
1.81% of patients received Aminoacids
Although fluids are restricted in the treatment of Acute Renal Failure and Chronic
Renal Failure. Fluids were used to correct hypovolemia in Acute Renal Failure and to
maintain acid-base balance in cases like Acute Renal Failure associated with shock,
Gastroenteritis and septicemia.55
107
Blood transfusion was done in patients who suffering from anemia and
hypotension.
Blood transfusion is the preferred means of increasing blood pressure.
Anti-ulcer drugs:
67.27% of patients received Ranitidine
26.66% of patients received Pantoprazole
17.14% of patients received Rebaprazole
35.71% of patients received Omeprazole
4.54% of patients received Antacids
Medical Unit:
Anti-Ulcer Drugs:
12% of patients received Pentoprazole
22.66% of patients received Ranitidine
Oral route:
11.74% of patients received Pentoprazole
25% of patients received Ranitidine
All the anti-ulcer drugs mentioned above were used with the idea of preventing
gastritis induced by NSAID’s and antibiotics and also to prevent stress induced ulcers.
108
All the patients admitted in the Urology unit received prophylactic anti-microbials
by parentral as well as oral route. Among them:
Antibiotics:
28.57% of patients received Cefuroxime
15.45% of patients received Cefoperazone
36.66% of patients received Cefpirone
17.27% of patients received Sulpactum + Cefoperazone
16.36% of patients received Cefotaxime
17.27% of patients received Cefixime
1.81% of patients received Lincomycin
7.27% of patients received Cefdinir
28.57% of patients received Gentamycin
72.14% of patients received Ciprofloxacin & Metronidazole
Oral route:
72.14% of patients received Ciprofloxacin, Norfloxacin, Ampicillin-Cloxacillin
28.57% of patients received Erythromycine
17.27% of patients received Ofloxacin
Thus our study correlates with earlier studies, that use of prophylactic antibiotics
in Urinary Tract Infections.
109
In the Urology unit 28.57% of patients on treatment reported gastritis, 2.85%
reported super infection (diarrhoea), 2.63% of patients reported allergic reactions, 8.57%
developed vomiting with Ceftazidine, 2.82% developed allergic reaction to NSAIDS.
Allergic manifestations were noted in the present study was due to over
prescription of NSAID’s and antibiotics as mentioned above.
Topic agents in the Urology unit 10% received Ciprofloxocin 0.3%. This was
used as a result of hospital acquired infection.
Transdermal route:
2.72% of patients received Diclofenac, this route was used to prevent severe
gastritis.
Inhalational route:
12.85% of patients received Oxygen, this was used as an emergency measure to
keep up the normal respiratory rate.
Among other drugs used
Miscellaneous drugs:
3.63% of patients received Dopomine
1.81% of patients received Atropine
35.45% of patients received Multi Vitamin Infusion
2.89% of patients received Calcium
3.63% of patients received Vitcoferal
110
This correlates with the earlier studies that use of B-complex and nutritional
supplements helps in healing and general nourishment of the patients.
Among the 70 patients of Urinary Tract Infections diuretics like furosemide and
torusemide was used as a measure of forced diuresis at a percentage of 54.54%, this
correlates with the earlier studies that the use of diuretics helps in preventing obstructive
urology and cardiac manifestations.56, 65
In the Medical unit, intravenous fluids were used for the correction of dehydration
and electrolyte imbalance especially in Acute Renal Failure cases, which were associated
with hypovolemia and gastroenteritis.
Even though intravenous fluids are absolutely contra indicated in the Chronic
Renal Failure cases, intravenous fluids were used to correct associated complication with
Chronic Renal Failure like Chronic Renal Failure with septicemia and Chronic Renal
Failure with diarrhoea. Intravenous fluids were used in the percentage of the following.
Intravenous fluids:
2.89% of patients received 5% Dextrose
17.14% of patients received DNS
13.63% of patients received Normal saline
This was also a step to correct hypotension.
111
Blood Transfusion:
11.14% of patients received Blood Transfusion
1.81% of patients received Aminoacids
Blood transfusion was done to maintain the hematocrit value and at the same time
to maintain blood pressure, which is an absolute indication in the treatment of two
important disorders.57
1) Anemia
2) Hypotension
Regarding the use of anti-microbials in the treatment of Acute Renal Failure and
Chronic Renal Failure were as follows:
Antibiotics:
18% of patients received Crystalline Penicillin
62% of patients received Ampicillin & Cloxocillin
62% of patients received Cefixime
62% of patients received Sulbactum + Cefoperazone
62% of patients received Metronidazole, Ciprofloxocillin, Ampicillin
3.66% of patients received Vancomycin
11% of patients received Amikacin
4% of patients received Lincomycin
112
Antibiotics were used as prophylaxis, as for as systemic antibiotics are concerned
in the treatment of Acute Renal Failure and Chronic Renal Failure, antibiotics were used
to reduce the risk of bacterial infection especially when Acute Renal Failure and Chronic
Renal Failure cases were associated with septicemia, gastroenteritis and use of catheters
during the course of treatment.
Penicillin is administered however, to eradicate the vegetative forms of the
bacteria that may persist.
As for as the use of analgesics is concerned these NSAID’s are absolutely
contraindicated in the treatment of Acute Renal Failure and Chronic Renal Failure, even
than 1.81% of patients received diclofaenic were in the chances of renal failure were
more.
NSAIDS:
3.33% of patients received Diclofaenic
6.66% of patients received Tramadol
10% of patients received Hydrocortisone
10% of patients received Dexamethasone
113
Corticosteroids are of value in the redaction or prevention of cerebral edema and
edema associated with parasites and with neoplasms. 20% of the patients received
Corticosteroids – controlled clinical trials don’t support their use in these settings.
Among the patients who received inotropic drugs, 22% of patients received
Dopomine, 11% of patients received Dobutamine. These positive inotropic agents are
often used for the short term support of circulation and are used for prevention cardiac
failure.59
Among the patients who received diuretics, 76.14% of patients received
Furosemide, 25.86% of patients received Torusemide.
Diuretics were used maximally in order to maintain
1) Reduced cardiac preload
2) Mobilization of edema fluid
3) To reduce pulmonary congestion
4) To remove peripheral edema
5) To induce forced diuresis
Anti-Emetic:
6.66% of patients received Metaclopramide
This was to treat vomiting induced by over prescription of antibiotics.
114
7.27% of patients complained of diarrhoea and vomiting (super infection), this
was due to prolonged use of antibiotics like cefotaxime and cefuroxime.
18% of the patients received calcium intravenously and 11.24% received orally.
The use of calcium was done to increase impulse generation in heart and in
regulating the coagulation of blood which correlates with many studies.
Prazocin was received in 12.64% of patients.
Prozocin which is a vital drug in the treatment of benign prostatic hypertrophy,
severe hypertension and a known drug in the treatment of scorpion bite.60
Few cases 13.33% were seen with the first dose effect leading to postural
hypotension and fluid retention.
Dialysis: its complication if any and its management
1) 6.66% had hypotension has a complication
2) 3.33% had muscle cramps as complication
115
Management of Hypotension during hemodialysis was as follows:
1) Discontinuation of ultra filtration was done
2) Administration of 100 to 250 ml of isotonic saline was done
3) One person was instructed to avoid heavy meals before coming to get dialysis as a
prophylactic measure
Management of Muscle cramps during dialysis:
1) Muscle cramps were managed by reducing volume removal during dialysis.
2) By using higher concentration of sodium in the dialysate.
3) This person was asked to take quinine sulfate (260mg two hours before treatment)
for the next dialysis.
No anaphylactoid reactions to the dialyzer was noticed.
In the Urology unit the average cost of drugs was as follows:
For 1 day = 100 to 150 Rs./day/patient
For 3 days = 400 to 450 Rs./day/patient
For 7 days = 1300 to 1400 Rs./day/patient
116
In the Medical unit the average cost of drugs to treat Acute Renal Failure and
Chronic Renal Failure was as follows:
For 1 day = 400 to 500 Rs./day/patient
For 3 days = 1200 to 1500 Rs./day/patient
For 7 days = 2500 to 3000 Rs./day/patient
If the person under goes dialysis then an extra amount of Rs. 800/- per setting will
be charged.
The present study reviles the following irrationalities in prescribing
In the Urology unit:
5 patients were given Cefotaxime and Cefuroxime against the standard
prescription i.e., duration resulting in super infection (diarrhoea)
6 patients developed gastritis because of over prescription of NSAID’s
2 patients developed allergic manifestation to NSAID’s
6 Patients developed vomiting with ceftazidine
In the Medical unit:
4 patients developed first dose effect to prazocin (minipress) when the dose was
used irrationally.
117
2 patients received amikacin (aminoglycoside) which is absolutely a contra
indicated drug while treating Acute Renal Failure and Chronic Renal Failure cases.
2 patients received intravenous fluids irrationally to counter act septicemia.
118
CONCLUSION
In the present study some of the prescriptions were irrational.
WHO Draft, 1983 describes the criteria for irrational drug prescription. According
to WHO, a prescription is defined as irrational, if it is incorrect, unnecessary, inadequate,
inappropriate or excessive.
In our study cefuroxime, cefotaxime, ampicillin and cloxicillin, metronidazole
and ciprofloxocin, and prazocin, NSAID’s were used irrationally. Irrational prescriptions
are harmful and may lead to a number of problems such as:
1) Increased cost of therapy
2) Therapeutic failure
3) Adverse drug reactions
4) Dangerous drug interactions
5) In appropriate treatment
To achieve health for all by 2010 AD.
We have to fight for eradication and control of disease and also to minimize the
rate of irrational prescriptions.
One way of promotion of rational prescription is by
1) Conducting drug utilization studies.
2) Giving education and training to Doctors.
119
3) Health Education.
4) Patient Education regarding drug use is needed to improve patient compliance.
This can be achieved by carrying out therapeutic audit on the prescribing pattern in the
Basaveshwar Teaching & General Hospital, Gulbarga, as a regular preventive measure.
Which can save millions of patients who are exposed to irrational prescription and there
by reducing morbidity and mortality in this wide
120
SUMMARY
The present study was under taken to identify the prevailing prescription trends in
the Urology care and Medical care units at the Basaveshwar Teaching & General
Hospital, Gulbarga.
Urinary Tract Infections are extremely common disorders. Even though they are
not associated with significant mortality, they have high mortality if complicated. It is
very important to view the Urinary Tract Infections seriously because of the high
morbidity and emergence of antibiotic resistant organism. On the other hand Acute Renal
Failure and Chronic Renal Failure are the major causes of morbidity and mortality world
wide.
Total duration of the study was 15 months, during this period 100 prescriptions
were collected and analysed. (70 form the Urology care unit and 30 from the Medical
care unit).
In our observation 70% of patients were from Urology unit and 30% were from
the Medical unit.
In the Urology unit 45.71% were males and 54.29% were females. In the Medical
unit 63.33% were males and 36.33 were females.
121
In the Urology care unit 17.14% of patients were of the age group of 1 to 25
years, 42.82% of patients were of the age group of 26 to 50 years, 35.71% of patients
were of the age group of 51 to 75 years. In the Medical care unit 10% of patients were of
the age group of 1 to 25 years, 36.66% of patients were of the age group of 26 to 50
years, 63.66% of patients were of the age group of 51 to 75 years.
In the Urology unit 55.71% of patients were vegetarians and 44.29% of patients
were non-vegetarians. In the Medical unit 66.66% of patients were vegetarians and
33.33% of patients were non-vegetarians.
In the Urology unit 21.42% of patients were smokers, 42.82% of patients were
alcoholics and 37.72% were tobacco chewers. In the Medical unite 26.66% of patients
were smokers, 50% of patients were alcoholics and 23.33% of patients were tobacco
chewers.
In the Urology unit 71.42% of patients were diagnosed as
ACQUIRED : Obstruction of Urinary Tract
Infection of Urinary Tract
13.14% hypercalciuria and hyperoxaluria
INHERITED: Cystinuria, Xanthuria, Gout = 11.42%
In the Medical unit in Acute Renal Failure 13.33% of patients were diagnosed as
122
Dehydration, diarrhoea and vomiting leading to hypovolemia and gastrointestinal fluid
loss.
23.33% of patients were diagnosed as Acute Renal Failure associated with
diabetes mellitus, pulmonary hypertension, ischemia and renal artery obstruction.
In Chronic Renal Failure 36.66% of patients were diagnosed as fluid-electrolyte
and acid-base disorders, 26.66% of patients were diagnosed as Chronic Renal Failure
associated with diabetic kidney disease, hypertension, and cystic kidney disease.
In the Urology unit maximum number of patients stayed for a duration of 2 to 5
days (50%). In the Medical unit maximum number of patients stayed for a duration of 2
to 5 days (36.66%).
In the Urology unit 12.85% of patients expired during treatment. In the Medical
unit 26.66% of patients expired during treatment.
In the Urology unit 100% of patients received drugs by parenteral route and
71.42% of patients received drugs by oral route. In the Medical unit 100% of patients
received drugs by parenteral route and 66.66% of patients received drugs by oral route.
In the Urology unit 14.82% of patients received more than 10 drugs. In the
Medical unit 60% of patients received more than 9 drugs.
123
In the Urology unit 28.57% of patients on treatment reported gastritis, 2.85%
reported super infection (diarrhoea), 2.63% of patients reported allergic reactions, 8.57%
developed vomiting with Ceftazidine, 2.82% developed allergic reaction to NSAIDS.
In the Medical unit 36.66% developed gastritis, 13.33% of patients developed first
dose effect to prazocin as adverse effect, 1 patient received NSAID, which is a contra
indicated drug 6.66% developed vomiting due to irrational prescription of antibiotics.
In the Urology unit the average cost of drugs per day was Rs. 100 to Rs. 150.
In the Medical unit the average cost of drugs per day was Rs. 300 to Rs. 400.
In the Urology unit the commonest NSAID used was diclofenac sodium. The
commonest antibiotic used was cefpirone.
In the Medical unit the commonest antibiotic used was Cefotaxime and
Ampicillin and Cloxicillin combination.
In the Urology unit the commonest Intravenous fluid used was dextrose normal
saline.
In the Medical unit the commonest Intravenous fluid used was 5% dextrose.
124
In the Medical unit mannitol, dexamethasone was used in patients as anti-edema
measure.
In the Urology unit the commonest anti-ulcer drug used was ranitidine.
In the Medical unit the commonest anti-ulcer drug used was pantoprazole.
When prescribed doses and duration was compared with standard doses in the
present study, it was noted in the Urology unit that ceprofloxacin, metronidazole and
cefpirone and ceforoxime were used for prolonged duration in 5 patients.
3 patients suffered from 1st dose effect because of prazocin.
In the Medical unit 1 patient received NSAID and 2 patients received amikacin,
both of these drugs were absolutely contraindicated during the treatment of Acute Renal
Failure and Chronic Renal Failure.
In the Medical unit 2 patients received irrational doses of antibiotic.
HEMODIALYSIS: 2 patients developed hypotension during hemodialysis and 1 patient
developed muscle cramps during hemodialysis and they were treated accordingly.
125
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132
PROFORMA
DRUG UTILIZATION IN UROLOGY UNIT AND MEDICAL UNIT AT
BASAVESHWAR TEACHING & GENERAL HOSPITAL, GULBARGA.
Name
I.P. Reg. No.
Age
DOA
Sex
DOD
Caste
Food habits: Veg/ Non-veg.
Address
Risk factors: Smoker/ Non-smoker
Income
Occupation
History of presenting illness:
Alcoholic/ Non-alcoholic
Any other
Diagnosis:
History of past illness:
Family & social history:
Physiology Signs:
Investigations:
133
Drug Prescribed with Dose and Route of Administration
Sl. No.
Sl. No.
Sl. No.
Generic Name of
Drug
FIRST DAY
Trade Name of
Route of
Drug
Administration
Generic Name of
Drug
SECOND DAY
Trade Name of
Route of
Drug
Administration
Generic Name of
Drug
THIRD DAY
Trade Name of
Route of
Drug
Administration
Adverse drug reactions:
Any reason to stop drugs during study:
Complications of dialysis:
1) Before Dialysis
2) During Dialysis
3) After Dialysis
Prognosis:
Advise on discharge:
134
Cost
Cost
Cost