Open Journal of Stomatology, 2013, 3, 492-496 OJST
http://dx.doi.org/10.4236/ojst.2013.39080 Published Online December 2013 (http://www.scirp.org/journal/ojst/)
The antibiotic utilization at the university dentistry clinical
center of Kosovo
Fehim Haliti1, Naim Haliti2, Ferit Koçani3, Agim Begzati1, Fatmir Dragidella4, Luljeta Ferizi1,
Lumnije Krasniqi1, Dafina Doberdoli1, Shqiprim Bajrami1, Shaip Krasniqi5
1Pediatric Dentistry, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
2Institute of Forensic Pathology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”, Prishtina, Kosovo
3Restorative Dentistry and Endodontology, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan
Prishtina”, Prishtina, Kosovo
4Peridontology and Oral Medicine, Department of Stomatology, Faculty of Medicine, University of Prishtina “Hasan Prishtina”,
Prishtina, Kosovo
5Institute of Pharmacology and Toxicology and Clinical Pharmacology, Faculty of Medicine, University of Prishtina “Hasan
Prishtina”, Prishtina, Kosovo
Received 11 October 2013; revised 16 November 2013; accepted 1 December 2013
Copyright © 2013 Fehim Haliti et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Antibiotic drugs are a very important drug group
considering their frequent use, safety profile and their
impact on bacterial resistance induction. Aim: To
investigate the utilization of antibiotic drugs at the
University Dentistry Clinical Center of Kosovo
(UDCCK). Methodology: Retrospective and descrip-
tive study. Patient records were used as a data source
collected for a period of 3 months. The total number
of registered outpatients in the UDCCK was 1117
patients. The data analysis was performed using the
WHO methodology and results were expressed in
DDD per 1000 inhabitants per day. Results: The total
prescription of antibiotics at UDCCK was 7.18 DDD/
1000 inhabitants/day. Antibiotics were prescribed for
86 or 7.70% of patients. The most commonly pre-
scribed antibiotic was Amoxicillin with clavulonic
acid 3.12 (43.45%) DDD, followed by Metronidazole
2.31 DDD and Amoxicillin 1.25 DDD. Erythromycin
and Cefalexin were prescribed evidently less com-
pared to other antibiotics (0.38 and 0.12 DDD/1000
inhabitant/day, respectively). Conclusions: The quan-
titative analysis showed no rationality of prescription
of antibiotics in UDCCK. Generally, the use of anti-
biotics in both departments of UDCCK is higher
compared to other countries. We recommend the im-
plementation of restrictive prescription standards for
antibiotics.
Keywords: Antibiotic; Utilization; ATC/DDD
1. INTRODUCTION
In pharmaco-therapeutic clinical practice, antimicrobials
are considered to be a group of drugs of essential value,
due to their common prescription, therapeuticall success,
and their impact on the development of bacterial resis-
tance [1,2]. Their magnitude of prescription is significant
not only for in-patients but also fo r outpatients. Scien tific
evidence reports that antibiotics are the most commonly
prescribed medications in the USA, and they contribute
approximately 20% - 50% of the total medications used
[3]. Antibiotics are an essential group in oral health care
as well. The use of these medications requires restrictive
prescription by respecting all standards for rational use in
order to achieve the highest rate of treatment, less side
effects and not to induce the bacterial resistance [4]. The
clinical evidence reports that antibiotic prescriptions by
dental and medical practitioners are asso ciated with con-
siderable percentage of medication errors and abuse [5,
6]. To achieve the standards for rational prescription of
antibiotics by dentists requires knowledge of the bacte-
riological profile of infections in oral-facial region,
choosing of an antibiotic with adequate spectrum of ac-
tivity and selecting the safest an tibiotic possible [7,8]. To
achieve the standards for rational prescription set in a
national drug policy of various countries, there are con-
tinuing professional education programs on clinical
therapy for medical personnel including strategies for
systematic surveys on antibiotic prescribing. All these
activities provide feedback information and evaluation of
drug prescribing for implementing adequate measures
aimed at raising standards for rational prescribing prac-

F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496 493
tices [9,10].
In daily dentist’s services, antibiotic prescription is a
frequent practice and a conclusion is drawn that a pre-
scription survey will enable us to have at our disposal
information for qualitative critical analysis of antibiotic
prescrib ing [11-13]. Therefore, the purpose of this survey
was to perform a pharmacotherapeutical analysis of an-
timicrobial us e in University Den tistry Clinical Center of
Kosovo. Simultaneously, we analyzed the structure of
diagnoses in order to reveal the quality of the antimicro-
bial prescription.
2. MATERIAL AND METHOD
The survey was a pharmaco-epidemiological, retrospec-
tive study performed in the two departments of UDCCK.
The data were extracted from electronic patient database
and individual hard copy records for each individual pa-
tient at the Dept. of Oral Surgery and Dept. of Perio-
dontology, respectively, for a period of (March 3rd, 2012
and June 30th, 2012) three months. During this period of
study a total of 1117 patients were officially recorded
(806 at Dept. of Oral Surgery and 311 at Dept. of Perio-
dontology). Patients were identified by their patient re-
cord number. For each individual patient we collected
information about their gender, diagnosis, daily dose of
used antimicrobial and the ATC Antimicrobial Classifi-
cation [14,15]. Parametric testing of the data was per-
formed with the statistics module of Excel® Microsoft®
Office® program. The quantitative analysis was per-
formed based on DDD/1000 inhabitants/day (daily de-
fined doses/1000 inhabitants per day) and ATC classifi-
cation according to WHO, methodologies [16].
3. RESULTS
In total, antibiotics were prescribed in 86 patients
(7.70%). There were significant differences in antibiotic
prescribing between the departments including differ-
ences in diagnoses for witch antimicrobials were pre-
scribed and other parameters as presented below (Table
1). There were no significant differences of the mean for
the age of patients between the two departments, how-
ever there were reported differences for the gender
structure with predominantly female patients in both de-
partments. In the group of patients treated with antibiot-
ics there were significant differences between the de-
partments; 18% of patients in Dept, of Periodontology vs
3.72% in the Dept. of Oral Surgery. Brand names were
mostly prescribed in both departments (93.33% in the
Oral Surgery compared to 98.21% in the Periodontology
Department). 1.61% of patients in the Oral Surgery De-
partment and 3.22% in Periodontology Department were
identified with proven hypersensitivity to penicillin.
Figures 1 and 2 show the ICD10 coded diagnoses for
Table 1. Demographic data and indicators of antibiotic pre-
scription between oral surgery and periodontology departments.
Department of Oral Surgery Department of Periodontology
Subject no = 806 Subject no = 311
Age
Mean 36.90 Mean 37.16
StDev 17.42 StDev 16.54
Median 33 Median 34
Max 80 Max 80
Min 33 Min 34
Gender
F 448 (55.58%)F 197 (63.34%)
M 358 (44.42%)M 114 (36.66%)
Therapy with antibiotics
Yes 30 (3.72%) Yes 56 (18%)
No 776 (96.28%)No 255 (82%)
Brand name vs Generic name of antibiotics
Brand name 28 (93.33%) Brand name 55 (98.21%)
Generic name2 (6.67%) Generic name 1 (1.79%)
Hypersensitivity against penicillin
13/806 (1.61%) 10/311 (3.22%)
2
80
4
223
139
14 4
309
117 423121
0
50
100
150
200
250
300
350
The structu re of patients by ICD10 in the Ora l
S urg e ry De part ment (n = 80 7)
Frequency
Figure 1. The structure of diagnoses of ICD10 in oral surgery
department.
214
277
1177632
0
50
100
150
200
250
300
350
B37K02 K04K05K06K07 K12K13K14L43Q38
The structu re of patien ts by ICD10 in the
P er i odontol o gyD epar tme n t (n= 31 1)
Frequency
Figure 2. The structure of diagnoses of ICD10 in periodontol-
ogy department.

F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496 494
level of antibiotic prescription in Oral Surgery Depart-
ment in particular. A total of four antibiotics were mainly
prescribed in both departments of UDCCK. The Dept. of
Oral Surgery in line with Amoxicillin and Clavulonic
acid and Metronidazole also prescribed Cefalexin. Dept.
of Periodontology on the other hand did not prescribe the
latter at all, however, they prescribed Erythromycin.
Roda R, et al, presented that in Service of Dentistry, Va-
lencia University General Hospital, 8 antibiotics were
described i n g eneral [1 7].
registered patients in both departments. In Oral Surgery
department the most frequent diagnoses were K08 (309),
K04 (223) and K05 (139) while in the Periodontology
Department the majority of diagnoses belonged to K05
category of disease.
The latter diagnosis structure has also influenced the
prescription rate of antibiotics and has reflected the dif-
ferences in total prescription of antibio tics ( Table 2). The
most prescribed antibiotic was Amoxicillin with Clavu-
lonic acid 3.12 DDD (43.45%), followed by Metronida-
zole 2.31 DDD and Amoxicillin 1.25 DDD. Erythromy-
cin and Cefalexin were prescribed evidently less com-
pared to other antibiotics (0.38 or 0.12 DDD/1000 in-
habitant/day) (Tab le 2 and Figure 3). Between the two
departments there are significant differences regarding
the type and the amount of use of antibiotics.
Although in the Oral Surgery Department, cases of
hypersensitivity to penicillin were identified, and there
are no recorded cases of antibiotic usage from macrolide
group, which are considered the first choice of treatment
for patients hypersensitive to penicillin. This aspect of
antibiotherapy remains to be verified; perhaps the state-
ment of hypersensitive patient needs to be further veri-
fied with adequate diag nostic methods.
In the Oral Surgery Department, the utilization of an-
tibiotics is approximately 5 times higher, compared to
Periodontology Department (5.97 versus 1.23 DDD/100
inhabitant/day). The prescription rate of Amoxicilin and
Clavulonic acid and Metronidazol is significantly higher
in Oral Surgery compared to Periodontology Dep artment.
However, the difference of Amoxicillin use between the
two departments is evidently smaller (remains higher in
the Oral Surgery Department).
Based on the results of antibiotic u se, we can conclude
that we found a higher difference between departments
and we assume that this is a result of differences in the
structure of clinical diagnosis of patients treated in the
Tab le 2 . The antibiotic utilization (DDD/1000 inhabitant/day)
at university dentistry clinical center of Kosovo.
The use of Erythromycin in Periodontology Depart-
ment is 0.38 DDD/100 inhabitants/day whereas in Oral
Surgery is not prescribed at all. In the Department of
Oral Surgery we have noted low rate of prescription of
Cefalexin while this antibiotic is not prescribed in the
Periodontology Department (Figure 4).
ATC Code Antibiotic DDD/1000
inhabitant/day
J01CR02 Amoxicillin + ac. Clavulonic 3.12
J01CA04 Amoxicillin 1.25
J01XD01 Metronidazol 2.31
J01DB01 Cefalexin 0.12
J01FA01 Erythromycin 0.38
Total 7.18
4. DISCUSION
The structure of antibiotic use in UDCCK shows a higher
43.45
17.41
32.17
1.68 5.29
0
5
10
15
20
25
30
35
40
45
50
Amoxicillin+ac.
Clavulonic Amoxicillin MetronidazolCefalexinErythromycin
J01CR02J01CA04J01XD01J01DB01 J01FA01
Antibiotic with ATC code
50
45
40
35
30
25
20
15
10
5
0
Structu re
Figure 3. Antibiotic utilization at university dentistry clinical center of Kosovo.

F. Haliti et al. / Open Journal of Stomatology 3 (2013) 492-496 495
3.02
0.76
2.07
0.12
0
0.11
0.5
0.24
0
0.38
0
5
Amoxicillin+ac.
ClavulonicAmoxicillin MetronidazolCefalexinErythromycin
Structure
Ora l Surgery
Periodontolog
y
Figure 4. Antibiotic utilization DDD/1000 inhibitants/day by departments of
university dentistry clinical center of Kosovo.
two depart ments.
In both departments of UDCCK, there are still no ap-
proved official antimicrobial protocols in the treatment
of oral-dental infections. Therefore, we couldn’t conduct
a qualitative analysis of antibiotic prescribing practices,
or the differences in treatment protocols. Furthermore, in
the patient records, there are no request notes for micro-
biology cultures, which is essential in the process of an-
tibiotic selection using sensitivity testing.
The absence of treatment and guidelines for antibiotic
prescription also reflects another negative effect, i.e. pre-
scription of the antibiotics by brand name. According to
the presented results in both departments, the prescrip-
tion of antibiotics by their brand names is noted in over
90% of ca s e s .
The prescription of only four antibiotics in each de-
partment shows an irrationality of antibiotics selection.
Indeed, the present number of antibiotics in pharmaceu-
tical market gives us a higher opportunity for selection of
antibiotics and enabling a higher efficiency and a thera-
peutic safety.
The antibiotics expenditure in UDCCK is obviously
higher, compared to similar medical centers’ in other
countries. In a survey conducted in different dental cen-
ters’ of Norway, the rate of DDD/1000 inhabitants units
per day in 2004 was 0.5189 DDD, while in 2005 it was
0.60 DDD, which is obviously lower than the antibiotic
use in UDCCK. Also in this survey it was reported that
11 different antibiotics were used, phenoxymethylpeni-
cillin being most commonly used narrow spectrum peni-
cillin, then metronidazol, followed by erythromycin,
whilst in our survey the most prescribed antibiotics were
the broad spectrum penicillin’s (Amoxicillin and Clavu-
lonic acid, and amoxicillin) and metronidazol. Although
a higher rate of prescription of broad spectrum penicil-
lin compared with the narrow spectrum penicillin is ob-
served also in other countries of Europe like England
where the prescription of Amoxicillin was 55 .8% of pre-
scriptions, whereas phenoxymethilpencillin was only
8.2% [18]. The higher prescription of metronidazole is
consistent with the prescription rate of dental practice in
other countries, considering that metronidazole is an ef-
ficient antibiotic for the treatment of anaerobic oral-den-
tal infections.
In all dental centers of Norway involved in the survey,
the metronidazole was prescribed between 6.3% to 6.9%
of all prescriptions, however, in Great Britain the pre-
scription of metronidazole is significantly higher.
While considering the above presented facts, we con-
clude that the exp enditure of antibiotics generally in bo th
departments of UDCCK is higher especially in Oral Sur-
gery Department [19].
The prescription of antibiotics is not preceded by mi-
crobiological testing of samples and in the UDCCK the
antibiotic protocols are not in use.
Generally, we recommend performing surveys for de-
termination of microbial sensitivity and bacterial resis-
tance of organisms causing oral-facial infections. More-
over, we recommend the approval of treatment protocols
for oral-dental infections, and organization of trainings
for antibiotic use in dental practice in the framework of
continuing medical education.
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