Pharmacology & Pharmacy, 2012, 3, 458-461
http://dx.doi.org/10.4236/pp.2012.34062 Published Online October 2012 (http://www.SciRP.org/journal/pp) 1
The Impact of Clinical Pharmacist Interventions on Drug
and Antibiotic Prescribing in a Teaching Hospital in Cairo
Osama H. Mohamed Ibrahim1,2, Suleiman El-Sharif3
1Department of Pharmacy Practice, College of Pharmacy, University of Sharjah, Sharjah, UAE; 2 Department of Clinical Pharmacy,
College of Pharmacy , Cairo University , Cairo, Egypt; 3Department of Pharmaceutics and Pharmacology, College of Pharmacy, Uni-
versity of Sharjah, Sharjah, UAE.
Received July 4th, 2012; revised August 13th, 2012; accepted September 7th, 2012
ABSTRACT
Background: The present study was undertaken to investigate the patterns of drug and antibiotics prescribing in a
teaching hospital in Cairo, Egypt. Aim: To determine the impact of interventions on such trends in an attempt to ration-
alize drug use. Method: 1200 prescriptions and patients’ records covering the months of January to December, 2011.
Prescribing patterns were analyzed using WHO guidelines with regard to prescribing, patient care and health facility
indicators. The same parameters were again assessed after distributing antibiotic guidelines and holding workshops ac-
tivities directed towards rational drug use. Results: The number of hospital visits resulting in a prescription was sig-
nificantly reduced from 94% to 86% (P-value < 0.05) and in both cases none of the encounters contained a generic drug.
The average number of drugs per encounter was 2.7 and did not decrease significantly after intervention. A significant
reduction was achieved in the number of prescriptions with antib iotics whereas reduction in enco unters with injectable
drugs was not statistically significan t. Penicillins was the most commonly prescribed class of antib iotics and amoxicillin
was the most frequently prescribed antibiotic. A significant reduction was observed in both encounters with penicillin
and the total of thos e with antib iotics. An alysis of prescriptions with antibiotics rev ealed that pen icillin s, cepha lospo rins
and erythromycin comprised 94% and 97% of all antibiotics prescribed before and after interventions respectively.
Conclusion: The present results clearly indicated that interventions including distribution of antibiotic guidelines and
running workshops and seminars on rational drug use to prescribers can lead to significant improvement in prescribing
behavior.
Keywords: Intervention; Clinical Pharmacist; Teaching Hospital; Antibiotics; Cairo
1. Introduction
A plethora of drug utilization studies focused on assess-
ing patterns of drug prescribing [1-5] as a mean of pin-
pointing areas for improvement with the aim to rational-
ize drug use. The health threats that can be caused by
improper prescribing cannot be overlooked. Improper
prescribing can cause toxicity for patients and will be a
waste of money and time. It can also cause therapeutic
failure that results in progress of disease conditions and
worsening of the patient health condition. The improper
prescribing and excessive use of antibiotics can lead to
loss of the effectiveness of currently used antibiotics
[1-5]. The World Health Organization (WHO) has re-
peatedly emphasized the importance of drug utilization
studies and developed indicators examine trends of pre-
scribing and the health facilities [6 ]. Once irrational drug
use in its various forms is determined, feasible means of
intervention are tried with the hope to improve drug use
[7]. The use of antibiotics has been the subject of several
studies [8-10], because of the globally confirmed trends
of under treatment, wrong antibiotic selection and the
risk of consequent emergence of bacterial resistant [1,11].
Guidelines for rational prescribing have been developed
[12] but unfortunately, they have neither been always
available nor effectively implemented in many develop-
ing countries. However, drug utilization studies in Egypt
are scarce and misuse of particularly antibiotics has not
been extensively explored [13]. In the present study, we
applied the WHO indicators to analyze the pattern of
drug prescribing in a teaching hospital in Cairo, and
studied patient care and health facility indicators. These
indicators are summarized with their measured parame-
ters before and after the study intervention in Table 1.
During the period of the present study (2009), a clinical
pharmacist, a clinical pharmacologist and a microbiolo-
gist formed the antibiotics control group of Kasr El Aini
teaching hospital in Cairo. The group prepared guidelines
for antibiotic use in the hospital that were circulated to

The Impact of Clinical Pharmacist Interventions on Drug and Antibiotic Prescribing in a Teaching Hospital in Cairo 459
Table 1. Results of drug-use indicators (according to WHO
guidelines) before and after intervention.
Drug-use indicator BeforeAfter
Prescribing indicators
Average number of drugs per encounter 2.7 2.5
% of drugs prescribed by generic name 0 0
% of encounters with an antibiotics prescribed 47 34*
% of encounters with an injection 18 16
% of drugs prescribed from PHC drug formulary 100 100
% of visits resulting in a prescription 94 86*
Patient care indicators
Average consulting time (minute s ) 11.6 12.1
Average dispensing time (seconds) 85 87
Percentage of drugs actually dispensed 100 100
Percentage of drugs adequately labeled 97 98
Health facility indicators
Availability of key drugs (%) 93 94
Availability of a copy of an essential drugs
list or formu l ary (%) 100 100
*Statistically significant, P-Value < 0.05.
all practicing physicians within the hospital. Moreover,
workshops were held concentrating on rational drug use.
In the present study, we evaluated the impact of such
interventions on th e drug use particularly of antibiotics.
2. Methods
Twelve core indicators were applied as described by the
WHO [6] and Internatio nal Network for the Ration al Use
of Drugs (INRUD). These include prescribing indicators
namely; average number of drugs per encounter, and
percentage of visits resu lting in a prescription, pr escribed
generics, encounters with antibiotics, injection and drugs
prescribed from hospital drug formulary. An additional
indicator, the percentage share of each antibiotic, i.e. the
proportionate distribution of antibiotics prescribed, was
included to identify the frequency of individual antibiot-
ics prescribed. We also studied patient care indicators
such as average consu lting time, average dispensing time,
and percentage of drugs actually dispensed and those
adequately labeled. For the health facility indicators, we
assessed the availability of dru gs and a copy of an essen-
tial drug list or formulary.
The present study was carried out during the months
January to December, 2010. For prescribing indicators
we used data from patient’s records and prescriptions.
The total number of patients studied was 1200. The av-
erage consultation time expressed in minutes was calcu-
lated by dividing the total time for a series of consulta-
tions by their number and the average dispensing time
expressed in seconds was determined by dividing the
total time for dispensing medications to patients by the
total number of those patients. Interventions applied in-
clude distribution of generic antibiotic guidelines to phy-
sicians and running workshops and seminar activities
aimed at increasing awareness to rational drug use. These
interventions were implemented in June, 2012 thus in-
formation collected for the period of January to May
covered data before interventions. The study was ap-
proved by the hospital ethical committee before the
commencement of study.
For statistical analysis, SPSS (version 18) was used.
Frequency distribution was obtained and the Mann-
Whitney test was used for nonparametric data analysis to
ascertain the significance of differences between pre-and
post-intervention data. P-value of <0.05 was considered
significant.
3. Results
Results of the study of prescribing indicators are shown
in Table 1.
The number of hospital visits resulting in a prescrip-
tion was significantly reduced from 94% to 86% and in
both cases none of the encounters contained a generic
drug. The reduction in the average number of drugs per
encounter was not significant (2.7 to 2.5). A significant
reduction was achieved in the number of prescriptions
with antibiotics whereas reduction in encounters with
injectable drugs was not statistically significan t. Th e time
of both consultation and medication dispensing remained
the same before and after intervention and so the per-
centage of adequately labeled drugs. Penicillin was the
most commonly prescribed class of antibiotics and
amoxicillin was the most frequently prescribed drug. A
significant reduction was observed in both encounters
with penicillin and the total of those with antibiotics.
Analysis of prescriptions with antibiotics revealed that
penicillins, cephalosporins and erythromycin comprised
94% and 97% of all antibiotics prescribed before and
after interventions respectively (Table 2). However, after
interventions, the non-significant reduction in penicillin
use was compensated for by double increase in cepha-
losporin prescribing and slight increase in erythromycin
use.
4. Discussion
In the present study, the average number of drugs per
encounter was 2.7 and was not significantly reduc ed after
intervention. Such a number is larger than the optimal
WHO figure of 2 drugs per encounter, less than those
reported in Indonesia and Nigeria (3.3 and 3.8 respec-
tively) [14] and far in excess of those described for
United Arab Emirates, Bangladesh and Lebanon [1,15,
16]. It is rather intriguing that although all the drugs

The Impact of Clinical Pharmacist Interventions on Drug and Antibiotic Prescribing in a Teaching Hospital in Cairo
460
Table 2. Antibiotics prescribed as a percentage of the total
drugs prescribed and as the percentage share of antibiotics
prescribed before and after intervention.
Percentage
of total Percentage share of antibiotics
Antibiotics
Before After Before After
Penicillins 37.5 26.8 78 70
Cephalosporins 4.5 5 8 16
Erythromycin 5.3 5.2 8 11
Tetracyclines 1 0 1.5 0.2
Sulfonamides 0.7 0.55 1.7 1.3
Aminoglycosides 0 0.15 1.3 0.8
Chloramphenicol 0.4 0.2 0.5 0.2
Other antibiotics 0.4 0.5 0.5 0.3
Anti-tuberculosis 0.1 0.1 0.5 0.2
Total 50.5 39.5 100 100
prescribed were from the hospital available formulary
that listed only generic drugs, all drugs were prescribed
by their proprietary names. This may be attributed to the
very effective drug promotional activities that target
physicians. It seems important to include in the curricu-
lum of medical schools and also in continuing medical
educational programs material emphasizing the general
aspects of essential drug list and generic prescribing.
Slightly less than 50% of all encounters were for an an ti-
biotic and such a prescribing trend was significantly re-
duced in prescription issued following the intervention.
The high percentage of visits resulting in prescription
was similarly influenced by the intervention. Such posi-
tive changes were not observed in the number of en-
counters with injectable drugs. Both th e consultation and
dispensing times were not significantly altered after the
intervention. Howev er, although the average co nsultation
time (11.6 minutes) seems reasonable and comparable to
figures reported for UAE [8] but it is longer than figures
reported for Bangladesh, Indonesia and Nigeria [14]. On
the other hand the dispensing time of 85 seconds seems
rather short to explain to patients the various aspects on
the safe use and storage of the prescribed medications.
The obviously short dispensing time may be attributed to
lack of a pharmacy technician and the high patients-
pharmacist ratio. All the prescribed drugs were actually
dispensed and 97 of the drugs were adequately labeled
before and intervention. The percentage availability of
key drugs was 93 before and 94 after intervention and a
copy of the formulary of drugs was always available
during the period of the study.
A significant reduction in the percentage of total anti-
biotics prescribing from 50% to 39.5%, and the most
commonly prescribed antibiotics were penicillin with
amoxicillin being on top of list as the most commonly
prescribed of all penicillins. In the present study pre-
scribing antibiotics was almost double that in UAE [1],
comparable to that in Norway [17] and lower than that
reported for Sud an, Iran and England [18-20]. Penicillins,
cephalosporins and erythromycin comprised 94% and
97% of all antibiotics prescribed before and after inter-
ventions resp ectively ( Table 2). Howev er, after interven-
tions, the non-significant reduction in penicillin use was
compensated for by double increase in cephalosporin
prescribing and slight increase in erythromycin use.
5. Conclusion
In conclusion, the present study clearly indicated that
interventions including distribution of antibiotic guide-
lines and running workshops and seminars on rational
drug use to prescribers can lead to significant improve-
ment in prescribing of antibiotics. However, educational
circulars and programmes on prescribing generic drugs
are needed. This can be enforced through introducing
such concepts and those of rational prescribing in cur-
riculum of medical schools.
6. Acknowledgements
The author is very grateful for Dr. Amal Hussein and Dr.
Ghada Mans our from Kasr El Aini hospital ph armacy for
their help in data collection and prescriptions checking.
The author is also grateful for Dr. Hanzada Mahboub for
her help in reviewing the data analysis.
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