An approach of clinical pharmacist in minimising length of hospital st

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 497 IJAMSCR |Volume 2 | Issue 4 | Oct - Dec - 2014 www.ijamscr.com Research article Medical research “An approach of clinical pharmacist in minimising length of hospital stay of patients and rational use of antimicrobials” Mohd Wasiullah 1 Anil Middha 1 A. Pandurangan 2 1 OPJS University Churu Rajasthan 2 Maharishi Markandeshwar University Mullana Ambala Haryana-133207 Corresponding Author: Mohd Wasiullah Email id: iqra_sid2001yahoo.co.in ABSTRACT Irrational drug therapy remains a global phenomenon. The mean number of drugs per prescription should be as low as possible since higher figure always leads to increased risk of drug interaction development o f bacterial resistance affect patient compliance and increases costs. The aim of present study is to reduce patient stay in inpatient setting. This may be studied by involving the factor like Drug interaction Percentage of amount spent on anti-microbial cost of therapy. This study will help for promoting the rational use of antimicrobials along with the reduction in hospital stay of the patient. The study was done in three wards of pediatric of MMIMSR.200 cases of anemia and 100 cases of UTI were collected during the pre intervention and post intervention studies.P1 was placed as a control while wards. P2 and P3 were placed as tests during the adherence study. The percentage of anemic patient at the time of admission in both the categories was severe 30 and mild to moderate was 70 during pre intervention but in post intervention it was found 22 and 82 respectively. 72 patient having mild to moderate anemia in pre intervention study. While it was 82.88 in post intervention studies. It is clear that the maximum percentages of the patient are those suffering from mild to moderate anemia. Patients when they were classified on the basis of associated infection it was found that 3.33 and 31.88 had infection during pre-Intervention and Post-Intervention studies. While for mild to moderate it was found 85.70 and 85.36 in pre-Intervention and Post-Intervention studies respectively. Keywords: Preintervention Postintervention Drug-interaction Rational use Hospital stay Cost of therapy Associated infection Anaemic INTRODUCTION Irrational drug therapy remains a global phenomenon. J.S. Bapna. D.G. Shewade and S.C Pradhan 1994.The mean number of drugs per prescription should be as low as possible since higher figure always leads to increased risk of drug interaction development of bacterial resistance affect patient compliance and increases costs. This study indicated general trends in prescribing. The mean drugs per prescription of hospitalized patient 6.04 was below the figure of 9.4 reported from U.S. and higher than those reported from Scotland 4.5 South Africa 4.3 Sweden 5.1 and Nepal. H.S.REHANA M.A.Nagarani and Moushumi ISSN:2347-6567 International Journal of Allied Medical Sciences and Clinical Research IJAMSCR

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 498 Rehan 1998 5.1. Community-based out-patient care in India showed 2-3 drugs per patient as per study conducted in Bangalore correlating with this study 3.29. 1-5 Main cause of over prescribing is the pressure put on the doctor to do something positive for the patient. The second factor is the apprehension of missing an underlying disease. Third reason is that the patient expects medications as some kind of a social right. 6-10 The aim of generic prescribing is to reduce consumer costs through substitution of less expensive formulation for brand name prescribed drugs. Incomes of most of the people attending the clinics are either low or medium. So there is a clear need to relieve financial burden of medical care from person with fixed income. Some patients do not like to visit the doctor on Tuesday and Fridays which they consider inauspicious. Injection culture has engulfed our society. For every injection the prescriber should strike a balance between the medical need on one hand and the risk of side effects inconvenience and cost of the other. 11-16 In fact pharmacist/doctor must advise the patient about the necessity of continuation of the antibiotic therapy even though the patient may feel better. Two out patients received chloroquine without any bacteriological investigation. Pyrexia of unknown origin and upper respiratory tract infection were treated with broad spectrum antibiotics. Several patients were found to receive antimicrobials post operatively until their discharge from the hospital or for a period of 15 days. These were against the guidelines S.C Pradhan D.G Shewade Uma Tekur D.Pachiappan A.KDey C.Adithan C.H Shashindran and J.S Bapna 1990 of antibiotic use. Indiscriminate use of cephalosporins in hospitals made the prescription costlier which in turn may lead to discontinuation of therapy by people with low income. 17-20 Third generation cephalosporins quinolones and vancomycin should be conserved to reduce the risk of resistance. Few incidents of drug duplication were observed. It can be mainly attributed to 1 physicians ignorance about the drug components 2 Administration of drugs containing the same components in different dosage form. This can be controlled if physicians have a thorough knowledge about the drugs which they prescribe. AIM OF THE STUDY The aim of present study is to reduce patient stay in inpatient setting. This may be studied by involving the factor like Drug interaction Percentage of amount spent on anti-microbial cost of therapy. This study will help for promoting the rational use of antimicrobials along with the reduction in hospital stay of the patient. MATERIAL AND METHODS The study was done in three wards of pediatric of MMIMSR.200 cases of anemia and 100 cases of UTI were collected during the pre intervention and post intervention studies.P1 was placed as a control while wards P2 and P3 were placed as tests during the adherence study. 21-30 This was a prospective randomized controlled study and included all patients with severe and mild to moderate anemia. For urinary infections patients with all age group were included. The epidemiological data of all the diseases which are the common causes of morbidity in pediatric was collected from the admission register and the common diseases were identified. 31-35 A data collection form was designed for the required data and the data was collected from clinical case sheets. These data include name age sex and body weight in patient number date of admission date of discharge reason for admission clinical symptoms lab data provisional diagnosis and detail of therapeutic management. The pooled data analyzed after considering expert opinion of the clinicians. The prescription of anemia were analyzed to find out the percentage of patients coming under sever and mild to moderate the duration of hospital stay In days percentage patients associated with infection percentage of patients received antimicrobials average number of drugs prescribed per patient per day average cost of therapy percentage amount spent on antimicrobials were analyzed for urinary tract infection the parameter were used are percentage of the patients received antimicrobials percentage of patients received injections percentage of patients received urine culture report percentage of drug prescribed from essential drug list Haryana Government etc. The treatment pattern was compared with that given in the standard references

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 499 and also in the various standard treatment protocols which are as follow: 36-40 Delhi Society for the promotion of rational use of drug integrated management of childhood illness IMCI World Health Organization Pediatric Pharmacopoeia. The pooled information is discussed with the doctors individually and also in groups and the most acceptable treatment is selected to develop a standard treatment protocol. Assessment of prescriptions in-patient 41- 50 100 in-patients cases were collected 50 each from each of the two wards of medicine. The qualifications of all the prescribers were MD/MS or above. Follow up of the drug therapy of clinical cases were made from the day of admission to the day of discharge. Patient’s case records were examined for details of prescription to fill the Performa. For any clarification required patient and the doctor on duty was interviewed. Assessment of prescriptions out-patient The consumption of drugs has steeply increased all over the world though differences exist between countries and within the same country. Keeping in view all these concept ad as well as the socio- economic condition of the outpatient who are from nearby area of mullana i.e. Yamunanagar Jagadari Shahranpur etc. Seventy 70 outpatients prescription were collected from two general practioners from the OPD of MMIMSR. At the time of collection of the data in the form of prescription the prescription was collected from outpatient ward while the doctors were also present with the patient. The patients as well as the prescriber both were also interviewed and later on data were collected in prepared Performa. MANAGEMENT OF POSSIBLE DRUG INTERACTIONS 51-53 DJ Quinin and R.O Day. Clinically important drug interactions 1997 Lvan. H. Stockley Drug Interactions 2nd edition 1991 Philip. D. Hansten: Drsginteractions. 4th edition 1979 Arshia Shariff and Sarasija Suresh. Antibiotic incompatibility 1996. Frusemide –digoxin When these drugs are administered together Hypokalemia may result. Hypokalemia can be managed properly with the administration of potassium supplements Else monitor the therapy or use a potassium-sparing diuretic such as spironolactone or triamterene. Amikacin –frusemide Both the drugs are associated with ototoxicity and nephrotoxicity. If concurrent use is inevitable monitor for any evidence of change in serum levels of amikacin and ear or kidney damage. Enlapril –frusemide Although ACE inhibitors can maintain body potassium their concurrent use can result in hypokalemia. Potassium supplements can be given. Regular monitoring of serum K + level is essential if congestive heart failure is treated with ACE inhibitor and K + loosing diuretics. Alprazolam –digoxin A high risk of toxicity is observed with increased plasma digoxin concentration in the elderly. If possible avoid this combination by using alternative benzodiazepines. If not monitor plasma digoxin concentrations and the patients clinical status. Carbamazipine-haloperidol Serum level of haloperiodol can be reduced to about 50 by concurrent use of carbamazepine. Neutrotoxicity during concurrent use is also found. Carbamazepine induces the metabolism of haloperidol. So concurrent use should be well monitored for any signs of reduced haloperidol effects and be alert for any signs of neurotoxicity. Heparin-aspirin Aspirin in doses of 500 mg/day increases the bleeding 3-5 times in those taking anticoagulants. Aspirin has a direct irritant effect on the stomach and can cause gastrointestinal bleeding. Low dose aspirin 75 mg daily does not cause much problem. Safer analgesics have to be substituted. Aspirin – insulin Aspirin lowers blood sugar level. The blood sugar lowering effect of this combination is additive. So readjustment in the dose of

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 500 hypoglycemic agent may be appropriate if large doses of salicylates are used. Ciprofloxacin – theophylline Serum levels of theophylline can be increased two-three fold by concurrent use of ciprofloxacin. Ciprofloxacin inhibits the metabolism of theophylline. Avoid concurrent use or monitor the serum levels of theophylline Lomefloxacin appears not to interact with theophylline. Ampicillin – chloramphenicol Chloramphenicol is bacteriostatic and ampicillin is bactericidal. ampicillin will act only on dividing cells. Chloramphenicol will render the ampicillin action ineffective. Paracetamol – chloramphenicol Half-life of chloramphenicol is prolonged by paracetamol by decreased elimination of the former. But this is a common combination for enteric fever. Monitor serum chloramphenicol levels closely for agranulocytosis. Carbamazepine – glibenclamide The diuretic effect of glibenclamide is opposed by carbamazepine. It is better to avoid the concurrent use of these drugs with antagonistic action. Antacids – ciprofloxacin Serum ciprofloxacin levels can be reduced below therapeutic concentrations by the concurrent use of aluminium and magnesium antacids. Antibotics form insoluble chelates with aluminium and magnesium ions in the gut which reduces the absorption. Both these drugs should be administered with an interval of atleast 4 hours. Plan of work This study was carried out in three wards of pediatric department of MMIMSR a tertiary care multi specialty teaching hospital in Mullana. The work plan was made in consultation with clinician of the pediatric department to fulfill the objective criteria. For the present study anaemia UTI was selected in pediatric along with the study of polypharmacy drug interaction and rational use of antimicrobials for out patients and inpatients setting. The work plan included  Collection of epidemiological data of the common diseases in pediatric and outpatient as well as in patient setting.  Designing a data collection form.  Collection of data from clinical data sheets.  Analysis of treatment given by the clinician for each disease.  The enquiry of the individual clinician in treating each disease condition.  Comparision of treatment plan with reference standard clinical guideline.  Dissemination of pooled information with doctors individually and in group for developing and acceptable treatment protocol.  A study was conducted to monitor the clinician adherence to standard treatment guideline in promoting rational prescribing.  For the purpose of outpatient prescription study was conducted at different health care facilities in the same period to avoid seasonal variations. Only drugs or modern medicine were included in the study H.S.REHANA M.A.Nagarani and Moushumi Rehan 1998. Intravenous fluids and transfusions were not counted as drugs. Each drug was counted once per patient irrespective of change in dose route of administration and combination drug were counted as one in evaluation of drug use indicators. H.S.REHANA M.A.Nagarani and Moushumi Rehan 1998 Proformas collected were subjected to analysis and compared under the following headings:-  In-patient and outpatient prescriptions from MMIMSR Mullana.  The parameters for evaluation: DRUG USE INDICATORS 54-57 Prescribing indicators Incidence of polypharmacy Utilization of essential drugs list Incidence of antimicrobial agent use Distribution of AMA among different chemical class. Health facility indicators In order to find out health facility indicators following questions were asked at each health facility under study. 1. Does the facility have its own essential drugs list or formulary

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 501 2. Whether the facility is using any WHO or National essential drug list 3. Whether all the key drugs are available at the health facility EVALUATION OF RATIONALITY 58-61 Drug-drug interaction Whether any clinically significant drug-drug interactions were present among the prescribed drugs Analyses of prescriptions were manually performed. Data from the proforma were further analysed using various analysis sheets appendix 2 to 6. Following references were utilized for the evaluation of rationality of prescription. Hospital Formulary. Medical College Hospital Trivandrum 1997 Indian drug review IDR March /April 1999 DJ Quinin and R.O Day. Clinically important drug interactions 1997 Lvan. H. Stockley Drug Interactions 2nd edition 1991 Philip. D. Hansten: Drsginteractions. 4th edition 1979 Daniel A Hussar. METHODOLOGY Setting The study was done in three wards of pediatric of MMIMSR. 200 cases of anemia and 100 cases of UTI were collected during the pre intervention and post intervention studies. P1 was placed as a control while wards P2 and P3 were placed as tests during the adherence study. Design This was a prospective randomized controlled study and included all patients with severe and mild to moderate anemia. For urinary infections patients with all age group were included. Collection of epidemiological data The epidemiological data of all the diseases which are the common causes of morbidity in pediatric was collected from the admission register and the common diseases were identified. Designing a data collection form A data collection form was designed for the required data and the data was collected from clinical case sheets. These data include name age sex body weight in patient number date of admission date of discharge reason for admission clinical symptoms lab data provisional diagnosis and detail of therapeutic management. Analysis of pooled data The pooled data analyzed after considering expert opinion of the clinicians. The prescription of anemia were analyzed to find out the percentage of patients coming under sever and mild to moderate the duration of hospital stay In days percentage patients associated with infection percentage of patients received antimicrobials average number of drugs prescribed per patient per day average cost of therapy percentage amount spent on antimicrobials were analyzed for urinary tract infection the parameter were used are percentage of the patients received antimicrobials percentage of patients received injections percentage of patients received urine culture report percentage of drug prescribed from essential drug list Haryana Government etc. Comparison of treatment pattern with standard references The treatment pattern was compared with that given in the standard references and also in the various standard treatment protocols which are as follow: Delhi Society for the promotion of rational use of drug integrated management of childhood illness IMCI World Health Organization Pediatric Pharmacopoeia. Intervention The pooled information is discussed with the doctors individually and also in groups and the most acceptable treatment is selected to develop a standard treament protocol. Adherence study A study is conducted to monitor the clinicians adherence to standard treatment guidelines by making use of all the parameters used earlier. The study for the rationality of outpatient prescription and rationality study for two main complication i.e. anemia and urinary tract infection in pediatric in inpatients setting was carried out from May 2014 to September 2015 by collecting details of prescriptions to fill the proforma.

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 502 Proforma contain following format Patients details Social history Family history of illness Previous history of drug interaction allergies or severe ADR Past medical history Signs and symptoms or complaints for which consultation saught Investigatons Diagnosis Medication therapy As entered in prescription Instruction for diet Average cost of prescription drugs/day Discharge advice and Any other remarks.Study was devided into two following parts Assessment of prescriptions in-patient 100 in-patients cases were collected 50 each from each of the two wards of medicine. The qualifications of all the prescribers were MD/MS or above. Follow up of the drug therapy of clinical cases were made from the day of admission to the day of discharge. Patients case records were examined for details of prescription to fill the proforma. For any clarification required patient and the doctor on duty was interviewed. Assessment of prescriptions out-patient The consumption of drugs has steeply increased all over the world though differences exist between countries and within the same country. Keeping in view all these concept ad as well as the socio- economic condition of the outpatient who are from nearby area of mullana i.e. yamunanagar jagadari shahranpur etc. 70 out patients prescription were collected from two general practioners from the OPD of MMIMSR. At the time of collection of the data in the form of prescription the prescription were collected from outpatient ward while the doctor were also present with the patient.the patient as well as the prescriber both were also interviewed and later on data were collected in prepared performa. Table – 1 Percentage of anemic patient at the time of admission Category Pre Intervention Post Intervention Severe 30 22 Mild to Moderate 70 82 The percentage of anemic patient at the time of admission in both the categories was severe 30 and mild to moderate was 70 during pre intervention but in post intervention it was found 22 and 82 respectively. 72 patient having mild to moderate anemia in pre intervention study. While it was 82.88 in post intervention studies. It is clear that the maximum percentages of the patient are those suffering from mild to moderate anemia. Fig-1- Percentage of anemic patient at the time of admission 0 20 40 60 80 100 120 Pre Intervention Pre Intervention mild to moderate severe

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 503 Table – 2 Classification of patient on the basis of associated infection Pre Intervention Post Intervention Severe 33.33 31.88 Mild to Moderate 85.7 85.36 Patients when they were classified on the basis of associated infection it was found that 3.33 and 31.88 had infection during pre-Intervention and Post-Intervention studies. While for mild to moderate it was found 85.70 and 85.36 in pre- Intervention and Post-Intervention studies respectively. Fig-2- Percentage of patients on the basis of associated infection Table – 3 Duration of hospital stay Category Pre Intervention Post Intervention Severe 14 16 Mild to Moderate 8 6 The duration of Hospital stay was found short in case of mild to moderate anemic patients during pre-intervention and Post-Intervention studies. But in case of severely anemic patients the length of hospital stay has increased by two days during pre- intervention and Post-intervention studies. 0 20 40 60 80 100 120 Pre Intervention Post Intervention mild to moderate severe

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 504 Fig-3- Comparision of average length of hospital stay based on infection during pre-intervention and post- interventions studies Table – 4 Percentage amount spent on antimicrobials Category Pre Intervention Post Intervention Severe 44 42 Mild to Moderate 52 49 In the study of cost of therapy it was found that the most portion of the cost of therapy is the amount is spent on antimicrobials but in post- intervention study it was reduced in the patients associated with infection. Fig-4- Comparision of the percentage amount spent on antimicrobials during the preintervention and post intervention studies 0 2 4 6 8 10 12 14 16 Pre Intervention Post Intervention Severe Mild to Moderate

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 505 Table – 5 Cost of therapy Category Pre Intervention Post Intervention Severe 686 784 Mild to Moderate 256 192 In case of severely anemic patient the cost of therapy was found more than to mild to moderate category after intervention the cost of the therapy for the mild to moderate category has decreased because of decrease in duration of hospital stay. Fig-5- Comparison of cost of therapy is based on condition of anemia during pre-intervention and post- intervention studies Possible drug interactions The possibility of potentially serious drug interactions were evaluated in hospitalized patients as well as out-patients. Interactions which were relatively well documented and potentially harmful to the patients were studied. Incidences of possible drug interactions are presented in Table 13. 20 potentially harmful drug interactions were possible among the prescribed drugs. The study reveals that there was a chance of drug interaction among 6.5 of total study population. Digoxin-Frusemide drug interactions were more common 25. In outpatient incidence of drug interaction was less. In ward 2 chances of drug interactions was more. 0 100 200 300 400 500 600 700 800 Pre Intervention Post Intervention 686 784 256 192 Severe Mild to Moderate

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 506 Table -6 Distribution of incidence of possible clinically significant No. Interacting Drugs Incidence Total In-patient Out-patient ward 1 ward 2 1. Digoxin-Frusemide 4 416 2. Amikacin-Frusemide 1 15 3. Enalapril-Frusemide 1 15 4. Alprazolam-Digoxin 1 15 5. Carbamazepine-Haloperidol 1 15 6. Aspirin -Heparin 1 15 7. Aspirin-Insulin 1 1 210 8. Ciprofloxacin-Theophylline 1 210 9. Ampicillin-Chloramphenicol 15 10. Paracetamol-Chloramphenicol 1 15 11. Carbamazepine-Glibenclamide 15 12. Antacid-Ciprofloxacin 1 15 13. Sodiumvalproate-Phenobarbitone- 1 15 Total 3 11 1 18 Injection must be administered to patients only in such situations like when immediate response is required When drug is not available in any other dosage form When drug cannot be administered by other safe routes due to patient related factors. Consultants of outpatient in many cases have not included the dispensed drugs in prescription. But documentation of dispensed as well as prescribed drugs is essential to prevent irrationality. The quality of drug is of prime importance to its biological activity. In outpatient dispensing of loose tablets and capsules prevails and quality of such drugs will be affected because of improper storage. RESULT AND CONCLUSION The percentage of anemic patient at the time of admission in both the categories was severe 30 and mild to moderate was 70 during pre intervention but in post intervention it was found 22 and 82 respectively. 72 patient having mild to moderate anemia in pre intervention study. While it was 82.88 in post intervention studies. It is clear that the maximum percentages of the patient are those suffering from mild to moderate anemia. Patients when they were classified on the basis of associated infection it was found that 3.33 and 31.88 had infection during pre- Intervention and Post-Intervention studies. While for mild to moderate it was found 85.70 and 85.36 in pre-Intervention and Post-Intervention studies respectively. The duration of Hospital stay was found short in case of mild to moderate anemic patients during pre-intervention and Post-Intervention studies. But in case of severely anemic patients the length of hospital stay has increased by two days during pre- intervention and Post-intervention studies. In the study of cost of therapy it was found that the most portion of the cost of therapy is the amount is spent on antimicrobials but in post- intervention study it was reduced in the patients associated with infection. In case of severely anemic patient the cost of therapy was found more than to mild to moderate category after intervention the cost of the therapy for the mild to moderate category has decreased because of decrease in duration of hospital stay. The possibility of potentially serious drug interactions were evaluated in hospitalized patients as well as out-patients. Interactions which were relatively well documented and potentially harmful to the patients were studied. Incidences of possible drug interactions are presented in Table 13. 20 potentially harmful drug interactions were possible among the prescribed drugs. The study reveals that there was a chance of drug interaction among 6.5 of total study population. Digoxin-Frusemide drug interactions were more common 25. In outpatient incidence of drug interaction was less. In ward 2 chances of

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 507 drug interactions was more. Injection must be administered to patients only in such situations like 1. When immediate response is required 2. When drug is not available in any other dosage form 3. When drug cannot be administered by other safe routes due to patient related factors. Consultants of outpatient in many cases have not included the dispensed drugs in prescription. But documentation of dispensed as well as prescribed drugs is essential to prevent irrationality. The quality of drug is of prime importance to its biological activity. In outpatient dispensing of loose tablets and capsules prevails and quality of such drugs will be affected because of improper storage. REFERENCES 1. Alexpoulou A Dourakis SY Mantzoukis D Pitsariotis T Kandyli A Deutsch M et al.Adverse drug reactions as a cause of hospital admissions: a 6-month experience in a single center in Greece. Eur J Int Med 19 2008 505–10. 2. American Academy of Pediatrics Clinical practice Guideline: Treatment of the School Aged child with Attention - Deficit / Hyperactivity Disorder" 1084 2002 1033. 3. B. Benoist E. McLean I. Egli and M. Cogswell Worldwide Prevalence of Anaemia 1993–2005. WHO Global Database of Anaemia World Health Organization Geneva Switzerland 4. B. Glader ―Diseases of the blood section 2—anemias of inadequate protection: iron deficiency anemia‖ in Nelson Textbook of Pediatrics R. M. Kliegman R. E. Behrman H. B. 5. B.S. Balakrishna. Rational use of drugs. Proceedings of National Seminar on Hospital and Clinical Pharmacy J.S.S College Mysore. 1999 24. 6. Calvin.M. Kunin T.Tupasi W.A Craig. Use of antibiotics. Annals of Internal Medicine J 973:79: 555-560. 7. Camargo AL Cardoso Ferreira MB Heineck I. Adverse drug reactions: a cohort study in internal medicine units at a university hospital. Eur J Clin Pharmacol 62 2006 143–9. 8. Conway PH Cnaan A Zaoutis T Henry BV Grundmeier RWKeren R. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA. 9. Corsonello A Pedone C Corica F Antonelli Incalzi R on behalf of the Gruppo Italiano di Farmacovigilanza GIFA investigators. Polypharmacy in the elderly patients at discharge from the acute care hospital. Ther Clin Risk Manage 3 2007 197–203. 10. D.Sharma K.H Reeta D.K Badyal S.K Garg and V.K Bhargava. Antimicrobial. Prescribing pattern in an Indian Tertiary Hospital. Indian J PhysiolpharmacoI A24 1998 533-537. 11. Death and adverse clinical events in elderly patients according to disease clustering: the REPOSI study. Rejuvenation Res 13 2010 469–77. 12. Delhi Society for promotion of rational use of Drugs Standard Treatment Guidelines 2002. 13. Delhi Society for promotion. Of Rational use of Drugs The Medicines Scenario India: Perceptions and Perspectives 1996. 14. Dept of Health Family Welfare Govt. of Himachal Pradesh Standard Treatment Guidelines 2000. 15. DJ Quinin and R.O Day. Clinically important drug interactions. Chapter 7 and Appendix B.Avery’s Drug treatment 4 1997. Aids international limited. 16. Drugs and Therapeutic Committee-A practical guide WHO in ColIabration with Management Science for Health 2003 100. 17. G.Tomson and I.Angunawela. Patients doctors and their drugs. EurJ ClinPharmacol 39 1990 463-467. 18. Gallagher PF O’Connor MN O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria. Clin Pharmacol Ther 89 2011 845– 54. 19. Garfinkel D Mangin D. Feasibility study of a systematic approach for discontinuation 20. Ghai OP Essential Pediatrics 4 1998 193-203. 21. Gnjidic D Le Couteur DG Abernethy DR et al. A pilot randomized clinical trial utilizing the drug burden index to reduce exposure to anticholinergic and sedative medications in older people. Ann Pharmacother 44 2010 1725–32.

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 508 22. Gnjidic D Le Couteur DG Abernethy DR et al. Reducing drugs in older adults is more.Arch Intern Med 171 2011 868–9. 23. Guru Prasad Mohanta and S.M Baranidharan. National essential drugs list an overview. Indian Journal of Hospital Pharmacy November-December 1997 223-224. 24. H.S.REHANA M.A.Nagarani and Moushumi Rehan. A study on the drug prescribing pattern and use of antimicrobial agents at a tertiary care teaching hospital in Eastern Nepal. Indian Journal of Pharmacology. 30 1998 175-180 25. Hajjar ER Cafiero AC Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother 5 2007 345–51. 26. Hayes O. W. "Clinical Practice Guidelines: A review Journal of the American Osteopathic Association 649 1994 732. 27. Indian drug review IDR March /April 2 1999. 28. J.S. Bapna. D.G. Shewade and S.C Pradhan. Training medical professional on the concepts of• essential Drugs and rational drug Use 13r.JC/inFharmac. 37 1994 399-400. 29. J.S. Bapna. U.Tekur B.Gitanjali C.H Shashindran S.C Pradhan M.ThuJasimani and G.Tomson. Drug utilization at primary health care level in Southern India. EurJ ClinPharmacal 43 1992 413 -415. 30. John O. Forfar and Gavin C. Arneil "Acute dysuria can be treated potassium citrate mixture in older children. Text book of pediatric Churchill living store 4th edition 1992 1026-1041. 31. Jonathan D Quick et al "Managing Drug Supply" Management Sciences for Health in Collaboration with WHO 2nd Edition Kumarian Press 2001 124-135. 32. Jonathan H. Ross and Robert Kay "Pediatric urinary tract infection and reflun" American family physician March 596 1999 1485 33. K.K.Kafle S.M. • Rajbhandarai ISrivastava and S.Regmi. Drug prescribing in out-patient departments in teaching hospital in Nepal. IndianJournal of Pharmacology. 3 1991 219-221. 34. Koh Y Kutty FBM Li SC. Drug-related problems in hospitalized patients on polypharmacy:the influence of age and gender. Ther Clin Risk Manag 1 2005 39–48. 35. Kuruvilla K.George and K.R John. Prescription patterns and cost analysis of drugs in a base hospital in South India. The National Medical Journal of India. 74 1994 167-168. 36. L. Jaber S. Rigler A. Taya et al. ―Iron polymaltose versus ferrous gluconate in the prevention of iron deficiency anemia of infancy‖ Journal of Pediatric Hematology/Oncology 328 585–588 2010 37. National Institute for Health and Clinical Excellence. Urinary tract infection in children: diagnosis treatment and long-term management. Available at: www.nice.org.uk/cg054. Accessed 2008 38. P. Geisser and S. Burckhardt ―The pharmacokinetics and pharmacodynamics of iron preparations‖ Pharmaceutics 31 2011 12–33. 39. P. L. Geltman L. K. Hironaka S. D. Mehta et al. ―Iron supplementation of low-income infants: a randomized clinical trial of adherence with ferrous fumarate sprinkles versus ferrous sulfate drops‖ Journal of Pediatrics 1545 2009 738 40. Paediatric pharmacopoeia Royal Childrens Hospital Melbourne 13. 41. Passarelli MCG Jacob-Filno W Figueiras A. Adverse drug reactions in an elderly hospitalized population. Inappropriate prescription is a leading cause. Drug Aging 229 2005 767–77. 42. Pennesi M Travan L Peratoner L et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars A randomized controlled trial. Pediatrics. 1216 2008. Available at: www.pediatrics.org/cgi/content/full/121/6/e1489 43. Pharmacists Drug Handbook American Society of health system pharmacists spring House Corporation 2001. 44. Pope G Wall N Peters CM et al. Specialist medication review does not benefit short-term outcomes and net costs in continuing-care patients. Age Ageing 40 2011 307–12. 45. Richard Grol Jah.annes Dalhuijsen Seip Thomas Cees in" t veld. Guy Rutten Henk Mokkink. "Attributes of Clinical Guidelines that inflience use of guidelines in general practice: Observational Study: BMJ 817 1998 858 - 6l.

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Mohd W et al / Int. J. of Allied Med. Sci. and Clin. Research Vol-24 2014 497-509 509 46. S.C Pradhan D.G Shewade Uma Tekur D.Pachiappan A.K Dey C.Adithan C.H Shashindran and J.S Bapna. Changing pattern of antimicrobial utilization in an Indian teaching hospital. International Journal of clinical pharmacology Therapy and Toxicology. 288 1990 339-343. 47. S.L. NASA and Poonam Gulati. Prescription errors prevention by pharmacists. TheIndian Journal of Hospital Pharmacy. 1990 129-130. 48. Srijayam M. and jhansi Rani P. Energy balance in selected anemia adoleseant girl. The Indian journal of nutrition and dieteties 2001 S4-S9. 49. Steinman MA Landefeld CS Rosenthal GE Berthenthal D Sen S Kaboli JP. Polypharmacy and prescribing quality in older people. J Am Geriatr Soc 54 2006 1516–23. 50. To reduce polypharmacy and falls in an ambulatory rural elderly population. J Gen Intern Med 23 2008 399–404. 51. Tooth L Hockey R Byles J Dobson A. Weighted multimorbidity indexes predicted mortality health service use and health-related quality of life in older women.J Clin Epidemiol 61 2008 151–9. 52. Trade names and generic names in drug prescriptions. Bulletin. Hospital and Clinical Pharmacy Services MCH Trivandrum. 53. Tulner LR Frankfort SV Gijsen GJPT van Campen JP Koks CH Beijnen JH. Dug–drug interactions in a geriatric outpatient cohort. Prevalence and relevance. Drugs Aging 254 2008 343–55. 54. Using a large health insurance database. Pharmacoepidemiol Drug Saf 2009doi:10.1002/pds.1841. 55. Van der Hooft CS Sturkenboom CJM van Groothest K Kingma HJ Stricker HC. Adverse drug reactions - related hospitalizations. A nationwide study in The Netherlands. Drug Saf 292 2006 161–8. 56. WHO and ECHO International Health Services Essential drugs and Medicines. Practical Pharmacy The U.K. Department for International Development 5 1997. 57. Wilson N Gnjidic D March L et al. Use of PPIs are not associated with mortality in institutionalized older people. Arch Intern Med 171 2011 866. 58. Wilson NM Hilmer SN March LM et al. Associations between Drug Burden Index and falls in older people in residential aged care. J Am Geriatr Soc 59 2011 875–80. 59. World Health Organization Guidelines for WHO Guidelines EIP / G PT / EQC /2003.1. 60. World Health Organization the rational use of Drugs in the management of acute Diarrhoea in Children 1990. 61. World Health Organization World Health Report 2002: Reducing Risks Promoting Healthy Life World Health Organization Geneva Switzerland 2002. How to cite this article: Mohd Wasiullah Anil Middha A. Pandurangan. ―An approach of clinical pharmacist in minimising lenth of hospital stay of patients and rational use of antimicrobials‖. Int J of Allied Med Sci and Clin Res 2014 24: 497-509. Source of Support: Nil. Conflict of Interest: None declared.

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