Prevalence survey of antibiotic usage in a secondary care hospital in east Trinidad and Tobago

Rajeev P. Nagassar¹, Gabriella Dhanraj-Singh², Steven Gajadhar², Dmitri Maharaj², Faith Mac Donald², Khashvir Persad², Alyssa Phillips², Steffan Poonwassie², Shaundell Solomon², Darren K. Dookeeram³

¹ The Department of Microbiology, The Sangre Grande Hospital, The Eastern Regional Health Authority, Trinidad and Tobago

² The Department of Public Health, The Faculty of Medical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago

³ The Department of Emergency Medicine, The Sangre Grande Hospital, The Eastern Regional Health Authority, Trinidad and Tobago

Corresponding Author:
Dr. Rajeev P. Nagassar
Email: [email protected]

DOAJ: 04038dc1ea8449bc96e73b8b886ed0b8
DOI: https://doi.org/10.48107/CMJ.2025.06.004
Published Online: July 13, 2025

Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.

©2025 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association

ABSTRACT
Background: Empirical utilisation of antimicrobials has become standard practice in healthcare, but ultimately it may be associated with drug resistance. This study serves to determine the prevalence of antibiotic use at a secondary care hospital in east Trinidad and Tobago.

Methods: A cross-sectional study was conducted at the Sangre Grande Hospital. The World Health Organization’s Methodology for Point Prevalence Survey on Antibiotic Use in Hospitals and the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance were adapted for a simple prevalence study involving inpatient and outpatient accident and emergency settings. Researchers reviewed medical records of all patients present at the hospital for the preceding 24 hours for inpatients and 4 hours for patient records reviewed in the accident and emergency department. Information collected included antibiotic class, dosages, frequency, course duration, indication and microbiology data. Data was stored in an Excel spreadsheet. It was analysed using IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp, as descriptive statistics. Clinical and Laboratory Standards Institute M100, Version 33, was used to interpret susceptibility data.

Results: There were 543 total patients sampled with 218 (40.1%) prescribed antibiotics. The most frequently prescribed classes included cephalosporins (31.4%), penicillins (31.1%) and nitroimidazoles (17.1%). Among the cephalosporins, 56 (54%) were third generation. The most common route of administration was parenteral. Antibiotics were most frequently administered as medical prophylaxis (63.9%). The surgical department was the service with the highest use of antibiotics (31.19%) followed by the emergency medicine department (27.52%). The most frequent systemic indications for antibiotic use were skin and soft tissue infections (32%), obstetric and gynaecological conditions (18%) and sepsis (13%). Out of 218 patients receiving antibiotics, only 9 (4%) cultures were identified as taken. Four species of bacteria were identified and treated based on susceptibility reports.

Conclusion: There was greater utilisation of broad-spectrum antibiotics. Microbiology culture reports were not utilised by most services. This report provides an opportunity for improvement of antibiotic stewardship.

INTRODUCTION
Antibiotic therapy has long been recognised as an effective tool in the fight against infection in healthcare settings globally. Recently however, the impending catastrophe of antimicrobial resistance (AMR) has been a growing phenomenon. Flasche S et al. highlights the conundrum of balancing the need for this life saving modality against the emerging burden of multi-drug-resistant infections. Their article further underscores the need for evidence-based solutions and an understanding of the root cause of poor antibiotic selection in healthcare.¹ This inherent challenge is rooted at the level of providers who, in the provision of their service, overutilise antibiotics within the healthcare industry; this inadvertently precipitates the development of AMR and is recognized by the World Health Organisation (WHO) as an emerging challenge.²

Antimicrobial resistance is a global health threat with control of antibiotic use being a major component of the fight against antibiotic resistance.³ According to a 2022 systematic analysis on the Global Burden of Antimicrobial Resistance, it was estimated that there were 1.27 million deaths directly due to bacterial antimicrobial resistance.⁴ A pivotal aspect of preventing AMR is the need for antimicrobial stewardship programs.

Improper prescriptions, treatment duration and lack of innovation in drug development also contribute to AMR.^2,3 The WHO report on surveillance of antimicrobial consumption in 2016 proposed a global approach to monitor antibiotic use using patient documentation and medical records. This report indicated that “there is a clear link between inappropriate antibiotic use and resistance in microorganisms”.⁵ The data from this WHO study showed wide regional differences in consumption and types of antibiotics consumed, with some countries having very high antimicrobial consumption rates and others having lower rates.⁵ Multidrug-resistant organisms like methicillin resistant Staphylococcus aureus (MRSA) are increasingly causing community infections, leading to more antibiotic usage. Increased antibiotic usage also results in bacterial mutations that reduce antibiotic effectiveness. Okoth C et al., in Kenya, found that 67.7% of patients were on antibiotics, with the obstetrics and gynaecology department having the highest rates of hospital-associated infections.⁶

The use of broad-spectrum antibiotics without proper review or stop orders contributes to recurrent infections with highly resistant bacteria. A study in Tanzania found that these antibiotics were most commonly prescribed without microbiological examination results.⁷ Diagnostic facilities are needed to guide antibiotic prescription practises and basic infection prevention measures must be implemented to avoid prolonged surgical prophylaxis.

Mohan S et al. found that in Trinidad and Tobago, antibiotics were overprescribed for paediatric upper respiratory tract infections (URTI) due to concerns of secondary bacterial infections and parent demands.⁸ Physicians often do not request laboratory investigations, further contributing to the problem. Gao J et al. found that even though blood cultures are the gold standard for diagnosing bloodstream infections, it is often disregarded by physicians when prescribing antibiotics, thereby increasing the cost of patient maintenance and decreasing the efficacy of the antibiotics available for prescription.⁹

Proper antimicrobial stewardship is necessary to address these issues. Ankrah D et al., in Ghana, revealed a high prevalence of antimicrobial use (53.3%), with 41% of antibiotics prescribed for community-acquired infections and prophylaxis.¹⁰ Compliance with antimicrobial guidelines was relatively high (80-90%), but surgical prescriptions did not follow current guidelines.

Akhloufi H et al. found that 29.3% of the prescribed antibiotics were fallaciously prescribed, with unjustified use, while Thu TA et al. found that one third of the patients in their study sample had an inappropriate indication for prescription, particularly in the obstetrics and gynaecology department and surgical wards.^11,12 These findings highlight the scarcity of targeted treatment and support for doctors choosing to use broad-spectrum antibiotics in developing nations. Notably, Nagassar RP et al. also highlights the improper use of antibiotics.¹³

In Trinidad and Tobago, there is a limitation in the availability of national antibiotic guidelines coupled with greater utilisation of empirical broad-spectrum antibiotics which create the ideal backdrop for AMR and its downstream burdens. The promotion of elements of antimicrobial stewardship, such as measurement of consumption and antibiotic utilisation patterns, can potentially reduce the development and spread of resistant strains of bacteria, which is a pillar of public health.^14,15 This has significant benefits for the socio-economic and health sectors of populations. This study sought to look at the prevalence of antibiotic use at a secondary care hospital in east Trinidad and Tobago, in both inpatient and outpatient settings.

METHODS
Study Setting
The study was conducted at Sangre Grande Hospital from January 2023 to March 2023. This hospital had a capacity of 120 beds for admitted patients and an emergency department that saw approximately 200 patients per day. Sangre Grande Hospital is a secondary care health facility   in the Eastern Regional Health Authority (ERHA) of Trinidad and Tobago. Their services include internal medicine, critical care, general surgery, orthopaedics, paediatrics, obstetrics and gynaecology and emergency medicine. Sampling of patients from the outpatient clinics of the hospital were excluded from this study. Patients seen at the accident and emergency department from 8 am to 12 noon on the day of data collection were included as outlined below. The hospital was fully equipped with a microbiology service that performed microscopy, cultures and sensitivity on all forms of body samples. The microbiology laboratory utilised the BD Phoenix Automated Bacterial Identification and Susceptibility Testing System (BD Diagnostic Systems, Sparks, MD). All software was updated to the latest Clinical and Laboratory Standards Institute (CLSI) standards. The hospital had a Specialist Medical Officer (SMO) in microbiology attached to the laboratory and for clinical consultations.

Study Design
Sample Size Calculation
The following software was used for sample size calculation: http://www.raosoft.com/samplesize.html.

Using the Raosoft^© software, values were inputted through the following series of equations:

x=Z(c/100) ²r(100-r)

n= N x/((N-1) E² + x)

E=Sqrt [(N – n) x/n(N-1)]

where: Z = 1.96, c = 95, r = 40 (population proportion), N = 120,000 (population size), E = 5% (margin of error). Therefore, the calculated sample size was equal to 384 patients.

A cross-sectional study was carried out and data collection was performed in a cross-sectional manner until the sample size was achieved. Data was collected from patients in a non-random manner and based on convenience sampling. In each of the patient care areas, data was collected, and records were kept. All patients who were available at the times of the study were sampled for both inpatients and accident and emergency, outpatient settings. Patients who stopped antimicrobials the day prior to data collection were excluded from the study as per the adaptation of the protocol. Microbiological culture specimens that were sent to the hospital’s laboratory were recorded. The WHO Point Prevalence Survey (PPS) methodology was adapted throughout data collection. This WHO tool was designed to collect data at a specific point in time over one to two days. It was meant for inpatient settings and for getting a snapshot of the antibiotic use at the inpatient setting which could be tracked over time. This type of data collection does not need a sample size, however, we modified this to a simple prevalence study and further modified it for outpatient accident and emergency department patients. The sample size calculation was needed as we deviated from a simple point prevalence to a prevalence study. The WHO methodology is an adaptation of the European Centres for Disease Control protocol for point prevalence surveys of healthcare-associated infections and antimicrobial use, complemented by methodologies from the Global PPS project from University of Antwerp, the United States Centres for Disease Control and Prevention and the Medicines Utilisation Research in Africa (MURIA).¹⁶ We adapted this methodology to conduct a prevalence study of antibiotic use. The adaptations included changing the study from a point prevalence study to prevalence study by non-random sampling on consecutive days, utilising the “Hospital, Ward, Indication, Antibiotic and Microbiology” forms and adapting the methodology of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (2023 GLOBAL-PPS) for the outpatient setting in accident and emergency. The sampling time for accident and emergency patients was adapted to be between 8 am and 12 noon while that for inpatients was in the preceding 24 hours.¹⁷

Study Population
The sample included all inpatients for the preceding 24-hour period. Data for outpatients in the accident and emergency department was also collected from 8 am to 12 noon on the day of data collection. The data included patients in both inpatient and outpatient settings as outlined in the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance which included a protocol for collecting outpatient data. There was no duplication of patients. If the investigators returned during the following collection period and the same patient was on the ward, that patient was excluded unless they were prescribed different antibiotics. Several investigators reviewed the data collection sheets to reduce the chance of duplication.

Inclusion and Exclusion Criteria
The sample included the acute care outpatient unit of the accident and emergency department in addition to hospitalised patients (inpatients). This included all age groups present at the time of data collection inclusive of pregnant patients. The sample excluded non acute outpatient wards such as the renal dialysis ward, day surgery/treatment patients and patients in whom antibiotics were stopped before the days of data collection. Patients at the outpatient clinics were also excluded from the study. All day/ambulatory units were excluded except for the accident and emergency department.

Data Collection
The medical record for each patient on the day of data collection was reviewed by the researchers. Data collected included demographics, diagnoses and antibiotics prescribed. Records were made of any samples which had been sent to the laboratory for testing and codes generated for follow-up of results after one week. Clinical and Laboratory Standards Institute (CLSI) M100, Version 33 was used to interpret susceptibility data. The European Committee on Antimicrobial Susceptibility Testing was used for gram positive bacilli.

The method of data collection utilised forms (adapted from the WHO methodology), consisting of multiple variables for analysis as well as general demographic data including gender, age, weight, date of admission and microbiology data collection tools. Trained data collectors were used, in which, training consisted of lectures provided to the data collectors. Training was conducted by the lead investigators and provided information on the data collection tools and the modification of the methodology for this study. Each data collector was responsible for de-identification and safe storage of obtained information. Data was collected on non-consecutive Thursdays during the study period. Regrading inpatients, this was for the preceding 24 hours and for outpatients in the accident and emergency department, this was from 8 am to 12 noon.

Data Analysis
Variables were analysed using the IBM SPSS Statistics for Windows, Version 29.0.2.0 Armonk, NY: IBM Corp. Descriptive statistics were generated and presented in the form of bar charts and graphs.

Ethical Considerations
Ethical approval was obtained from The University of the West Indies (CREC SA.1880/11/2022) and the Eastern Regional Heath Authority (ERHA.REC.063/12/2022).

Privacy and Confidentiality
No patients were interviewed. The data was collected in a private room and then inputted into SPSS on a password protected computer. No hard copies of the data were maintained for any period of time. If the investigators had hard copies, they were stored in a locked cabinet.

RESULTS
Data was collected over a period of five days, in a non-random method, until the sample size was attained. Data collection personnel visited the hospital on non-random Thursdays, with the days being chosen based on convenience. A total of 543 patients were enrolled in the study, of which, 218 had been prescribed antibiotics. There was an overall prevalence of antibiotic usage of 40.1%. The highest utilisation was present in the surgical wards (31.19%), the emergency medicine department (27.52%) and the internal medicine wards (19.27%). The maternity ward accounted for 13.3%, paediatrics for 3.67%, neonatal intensive care unit for 2.75% and adult intensive care unit for 2.29%.

When disaggregated by systemic indication for antibiotic use, the three most common categories of diagnosis found included skin and soft tissue, bone and joint infections (SSTBJ) (69, 28.16%), obstetrics and gynaecology (40, 16.33%), and no indication (38, 15.51%). Other indications included urinary tract infection (UTI) (28 cases), respiratory tract infection (15 cases), gastrointestinal infection (20 cases), cardiovascular infection (6 cases) and sepsis (17 cases). Common reasons for the administration of antibiotics for SSTBJ infections included soft tissue injuries (20.17%), wounds (7.98%), infections including cellulitis, erysipelas etc. (7.04%) and other soft issue issues (1.88%). Joint/bone injuries accounted for 7.99%, fractures/amputations for 6.57%, bone infections for 0.47% and explicit soft tissue injuries for 0.94%.

Medical prophylaxis (MP) was the leading indication for the prescription of antibiotics within the hospital. Twenty cases were due to UTI (13.25%) and 16 cases were due to sepsis (10.6%). Diabetes mellitus and surgery for cellulitis of the “right foot” secondary to diabetes accounted for 3 occurrences (3.26%). Community acquired infections were the least recorded indication for prescription of antibiotics. The percentage and number (%, n) of antibiotic used for community acquired infections (1.0%, 3/288), healthcare associated infections (2.1%, 6/288), medical prophylaxis (63.9%, 184/288), medical prophylaxis and surgical prophylaxis (2.4%, 7/288), surgical prophylaxis (29.5%, 85/288) and other indications (1.0%, 3/288) are outlined here.

Inappropriately used antibiotics were mainly prescribed for candidiasis, chronic obstructive pulmonary disease, premature birth, post-delivery pain, post inguinal hernia repair, per vaginal bleed and other respiratory conditions not requiring antibiotics. The overall percentage of inappropriately prescribed antibiotics was 28.16%

There were 334 antibiotics prescribed to the patients of the hospital in this study. These were separated into eleven groupings by class of antibiotic. Penicillins (31.1%, 104 patients) and cephalosporins (31.4%, 105 patients) accounted for the majority of antibiotics prescribed. Among the cephalosporins, 54% were third generation. Nitroimidazoles (17.12%), fluoroquinolones (5.11%), carbapenems (5.71%), aminoglycosides (5.11%), glycopeptides (0.6%), macrolides (0.3%), tetracyclines (0.9%), oxazolidinones (1.5%) and others (0.9%) were rarely administered.

Out of the 218 patients, 9 patients or 4.13% of those who had been prescribed antibiotics had culture samples sent to the laboratory. Of those nine samples, four bacteria were identified: Klebsiella pneumoniae, Staphylococcus haemolyticus, Escherichia coli and gram-positive bacilli. These patients were treated based on susceptibility reports.

DISCUSSION
This study helps to highlight that the monitoring of antibiotic use is pivotal to preventing antimicrobial resistance. It is the first study to report on antibiotic use in an accident and emergency setting in Trinidad and Tobago and the Caribbean. Necessary improvements include the need for antimicrobial stewardship programs, as well as a greater utilisation of directed treatment using antibiotics that target specific microbes detected via cultures instead of relying on broad spectrum antibiotics alone.⁴ Garraghan FM. also used the 2023 Global-PPS and found that antibiotic prescribing was adequate with a high percentage of intravenous antibiotics being used.¹⁷

Cephalosporins (31.4%) and penicillins (30.77%) were the most commonly prescribed antibiotic classes. Among the cephalosporins, 54% were third generation. This is similar to findings by Thu TA et al. where they found a high utilisation of broad-spectrum antibiotics.¹² According to Gashe F et al., 56.5% of bacterial isolates showed resistance, unlike our study, as this was hard to determine as only nine bacterial cultures were sent to the laboratory.¹⁸ While this study showed a decrease in cephalosporin prescriptions compared to Yimenu DK et al., the overall prevalence of antibiotic use and the lack of cultures obtained (4%) remains a concern.¹⁹ It is important to monitor the selection of culture directed antibiotic classes to ensure appropriate choices and minimise the risk of emergence of antibiotic resistance. Similarly, Horumpende PG et al also found that there was improper utilisation of microbiology services in their study.⁷

Skin and soft tissue and bone and joint infection infections were the most common indications for treatment. Conversely, cardiovascular-related issues had the lowest antibiotic prescription rate. Surgical and emergency services utilised antibiotics the most. These findings differ from that of Veerapa-Mangroo LP et al., who found that most antibiotics were used for the management of cellulitis, wound and deep soft tissue infections not involving bone and were surgery unrelated issues.²⁰ These differences indicate that healthcare workers may be prescribing antibiotics with care for certain conditions, while potentially overusing them in others. Further investigations would be needed to understand the factors that influence prescribing decisions for specific indications and to develop targeted interventions that encourage appropriate antibiotic use across different clinical scenarios. Malik OA et al. indicated that patients in the accident and emergency department developed infections despite surgical prophylaxis being given and thus, the use of broad-spectrum antibiotics should be re-examined in the context of this study.²¹

Further examination of indications for antibiotic prescriptions showed that 15.51% of antibiotics were prescribed without any indication, unlike the findings of Ray MJ et al., which showed that 2.39% of antibiotics were prescribed without any indication.²² This shows a lack of adherence to proper prescribing guidelines and warrants stricter enforcement of prescribing policies and guidelines to ensure proper documentation and justification for antibiotic prescriptions.

Finally, the variation in antibiotic use across different hospital wards is noteworthy. The surgical (31.19%) and accident and emergency (27.5%) departments had high rates of antibiotic use, while oncology had the lowest (0.5%). In contrast, Kakolwa MA et al. reported high antibiotic use in caesarean section wards among different hospitals.^12,23 These variations likely reflect the differences in patient populations and clinical practises across different healthcare settings. Furthermore, the excessive utilisation of antibiotics within the surgical and emergency departments, coupled with the prescription of broad-spectrum antibiotics and lack of bacterial cultures, collectively foster the emergence of antibiotic-resistant bacteria.^24-29 It is important to adhere to prescribing guidelines in order to mitigate this issue. This emphasises the importance of interventions such as educational campaigns targeting healthcare providers, promoting adherence to antibiotic prescribing guidelines and implementing antibiotic stewardship programs which could help optimise antibiotic selection and limit the use of broad-spectrum antibiotics when narrower options are available.^29-32

Interestingly medical prophylaxis was the leading indication for antibiotic use in the hospital. This was primarily for UTIs and sepsis. This is quite interesting as urinary tract infections are one of the most common infections, second only to respiratory tract infections.^33,34 A study from Europe using a Bayesian Weighted Incidence Syndromic Antibiogram approach concluded that multiple antibiotic use over single antibiotic use was beneficial in healthcare associated urinary tract infections. It also concluded that hospitals with working infection prevention and control (IPC) programs had more antibiotic choices.³⁵ This highlights the role of IPC in antimicrobial stewardship. According to one literature review, urosepsis may represent up to 31% of sepsis cases.³⁶ This requires further investigation at the study site.

The results show less than 29% inappropriate antibiotic use. Milani RV et al. has shown that up to 50 % of antibiotics can be inappropriately prescribed in one setting in the United States of America.³⁷ This contrasts with our study. The study by Mohan S et al. also shows inappropriate antibiotic prescribing. Unlike Milani’s and Mohan’s studies which focused on respiratory tract infections, our study examined prescribing practises for a wide variety of infection types.

Limitations
Limitations of clinical practise included medical practitioners making insufficient requests for microbiology cultures, preventing thorough consideration and analysis of the contribution of microbiological data. This however can also be used to recommend that physicians use more approaches to antibiotic treatment involving the use of microbiology cultures. This should be utilised in the public hospitals as it is at no cost to the patient in the public system. Several demographic data and variables had no up-to-date patient information available. There was an absence of information on how antibiotics were given and administered at the patient level. Notably, Schechner V at al. highlighted the lack of studies linking inappropriate antibiotic use with resistance.²⁹ We therefore cannot conclude that inappropriate antibiotic use leads to resistance.

CONCLUSION
There was greater utilisation of broad-spectrum antibiotics. Antibiotic stewardship programs aimed at ensuring evidence based, directed treatment to target causative agents detected via cultures, rather than prescribing broad spectrum antibiotics is necessary. Lastly, microbiology results improve the understanding of antibiotic use in hospitals and should be better utilised at public hospitals.

Acknowledgements: [Tahoma; 10pt; Black; 1.15 Spacing; 6pt Paragraph Spacing]
Ethical approval statement: Ethical approval was obtained from The University of the West Indies (CREC-SA.1880/11/2022) and the Eastern Regional Heath Authority (ERHA.REC.063/12/2022).
Financial disclosure or funding: Not applicable.
Conflict of interest: None. Artificial intelligence was not used. However, it may have been inadvertently incorporated.
Informed consent: Informed consent was obtained, where necessary.
Author contributions: Rajeev P. Nagassar, Gabriella Dhanraj-Singh, Steven Gajadhar, Dmitri Maharaj, Faith Mac Donald, Khashvir Persad, Alyssa Phillips, Steffan Poonwassie, Shaundell Solomon and Darren K. Dookeeram have made a substantial contribution to the conception and design of the study, data acquisition, analysis and interpretation of the study. Rajeev P. Nagassar, Gabriella Dhanraj-Singh, Steven Gajadhar, Dmitri Maharaj, Faith Mac Donald, Khashvir Persad, Alyssa Phillips, Steffan Poonwassie, Shaundell Solomon and Darren K. Dookeeram were involved in drafting the manuscript or revising it critically for intellectual content. Rajeev P. Nagassar, Gabriella Dhanraj-Singh, Steven Gajadhar, Dmitri Maharaj, Faith Mac Donald, Khashvir Persad, Alyssa Phillips, Steffan Poonwassie, Shaundell Solomon and Darren K. Dookeeram gave final approval for submission of the manuscript.

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