Abstract
Keywords
Introduction
Optimal utilization of drugs and judicious drug prescription, in conjunction with high-quality and accessible resources, are essential for enhancing the efficacy of healthcare services. Furthermore, the judicious use of pharmaceuticals may serve as an effective strategy to mitigate the negative impacts of drugs on health and well-being and to promote socioeconomic benefits on a global scale. 1 Given the limited financial resources allocated to healthcare in underprivileged nations, with approximately 30%–40% of this budget assigned to pharmaceuticals, it is important to ensure that medication prescriptions are made rationally to maximize potential benefits. 2 Despite these data, irrational utilization and distribution of medications remain major concerns in the healthcare systems of underprivileged countries. This problem is characterized by excessive reliance on antibiotics and injectable formulations, the practice of polypharmacy, and use of pharmaceuticals with uncertain effectiveness.3,4 Factors such as patient preferences and provider beliefs may influence prescribing quality. 5 Based on available research, it is important to acknowledge the significant issue in Iran related to the prescription of high number of pharmaceuticals per medical visit as well as the substantial use of injectable drugs and antibiotics. 6 Studies have shown that the average number of items per prescription issued by specialists and general practitioners is 3.07. In underdeveloped countries, this number varies from 1.4 to 4.8, whereas in affluent nations, it varies from 1.3 to 2.2. 7 As a medical legal document, a prescription may offer valuable insights into doctors’ prescribing practices, drug utilization trends, and patient information within a healthcare facility. Furthermore, previous research has shown that the quality of medication prescribing, including the range of available treatments and their potential benefits, has improved with enhanced prescription recording. To achieve efficient resource utilization; reduce medical errors; and improve the effectiveness, affordability, and accessibility of medical services, it is essential to systematically document patients’ medical data, conduct regular data analysis, and closely monitor doctors’ prescribing practices within hospital settings. Proper monitoring and medication analysis enable comparisons of our current status with those of other hospitals within and outside the country as well as regional benchmarks. 8
This study aimed to assess the prescribing practices at the largest women’s specialized hospital in southern Iran by creating a 1-year database of drug prescriptions. The goal was to identify issues related to drug use and improve the availability and accessibility of commonly used medications. The collected data would help monitor physicians’ practices and provide feedback to support better decision-making.
Materials and methods
Study setting and sampling
This retrospective study was conducted at the Women’s Specialized Hospital in Shiraz, a tertiary referral hospital serving a broad patient population across various specialized wards, including obstetrics, neonatal, pediatric, and adult intensive care (ICU) units. Patients were enrolled consecutively based on hospital admission records during the study period. Data for all 13,909 inpatients during the study period were collected. All patient data were fully deidentified prior to analysis to ensure patient privacy and confidentiality.
Data collection and study design
Prescription data were obtained from inpatient records collected over a 1-year period from March 2021 to March 2022. A total of 13,909 prescription records were extracted, and after excluding 42 male patients aged >1 year, 13,867 cases were included in the final analysis. Patient demographics, including age and sex, were recorded: 2429 patients were aged <1 year, including 137 females, 178 males, and 2114 patients with missing sex data; additionally, 11,438 patients were females aged >1 year.
The study analyzed the number and types of prescribed medications, routes of administration, and their distribution across hospital wards. Descriptive and comparative statistics were used to summarize drug utilization trends.
Key patient-based indicators included the proportions of patients who received at least one antimicrobial agent, one injectable medication, or one nonsteroidal anti-inflammatory drug (NSAID) during hospitalization.
This retrospective observational study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines; the official STROBE checklist and flowchart from the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network was used to guide reporting. 9
Statistical analysis
The prescription data included information on the prescriber’s ward, medication categories, and routes of administration. Patient data were analyzed using coding techniques to determine the duration of hospitalization, age range, and sex. Drugs were categorized, excluding water for injections, serums, baby formula, and medical equipment; however, these items were considered when analyzing the routes of administration. Independent sample t-test was used to examine the association between hospitalization duration and age groups. The 95% confidence intervals were calculated, and
Results
Patient demographics and hospital stay
Prescription data were collected from 13,909 patients. Among these, 42 male patients aged >1 year were excluded, leaving 13,867 cases for detailed analysis. Of these, 2429 patients were aged <1 year, including 137 females, 178 males, and 2114 patients with missing sex data. All patients aged >1 year were female, distributed as follows: 165 aged <18 years; 10,632 aged between 18 and 50 years; and 632 aged >50 years. The mean hospitalization duration for all patients was 3.12 ± 5.49 days. Additional details are presented in Table 1. Neonatal admissions included male and female newborns because obstetrics-linked neonatal care at this women’s hospital encompasses all births regardless of sex.
Average hospitalization duration (days).
Primary prescription analysis
As a patient-based indicator of prescribing behavior, 9871 patients (70.2%) received at least one antimicrobial agent during hospitalization, and 12,116 (86.9%) were prescribed at least one injectable medication. The average number of antibiotics per patient was 5.55 across the hospital population, increasing to 13.66 in the neonatal units, reflecting a higher antimicrobial burden in this vulnerable population. Hospital-wide, the most frequently prescribed item was water for injections (30,601 units; 8.2%).
The most common medications included 5000 units/mL heparin (5.6% of all prescriptions), 10 mg oxytocin (2.8%), 1-g vial of ampicillin sodium (2.7%), 100 mg diclofenac suppository (2.7%), and hematinic pills (2.1%). Large volume parenterals (LVPs) such as 500 mL of Ringer’s solution (5.03%), 500 mL of 10% dextrose water (3.6%), and 500 mL of 1/3–2/3 serum (mixed intravenous solution of one-third normal saline and two-thirds dextrose water) (3.4%) represented significant volumes, reflecting fluid needs in critical patients.
A total of 365,025 data points on administration routes and ward prescribing were recorded. Injection use peaked in the postcaesarean section ward (23.1%), whereas injectable usage in the in vitro fertilization (IVF) ward was 84.3%. Postcaesarean wards also demonstrated the highest use of infusions (24.0%), whereas enteral administration was most common in the postnormal vaginal delivery (post-NVD) ward (26.3%) (Figure 1).
Percentage contribution of different wards of the hospital to the total number of prescriptions across the hospital. Post C/S, post-GYN, neonatal1, post-NVD, and internal wards had the highest percentage of prescriptions in the hospital, and graph 2 shows a comparison between these wards and the most commonly prescribed drug groups. Post-NVD: postnormal vaginal delivery; C/S: cesarean section; GYN: gynecology.
Prescription analysis in neonatal and pediatric wards
Across eight neonatal and pediatric wards, 79,199 items were prescribed. The most common medications included 500 cc of 10% dextrose water (12.9%; n = 10,246), water for injection (9.6%; n = 7581), 1 g ampicillin sodium (7.2%; n = 5714), 5000 units/mL heparin (5.9%; n = 4649), and amikacin sulfate (5.7%; n = 4524). Injectable formulations accounted for 92.8% of all medications (73,555 items), typical for critical care neonates requiring parenteral therapy.
Route of administration and drug-group distribution
Overall, 71.3% of all medications (264,563 of 371,056 items) were administered parenterally, including intravenous fluids (18.0%) and injections (53.3%). Oral medications accounted for 17.6%, rectal 3.6%, transdermal 0.4%, inhaled 0.6%, and ocular 0.1% of all medications (Table 2). The high injectable drug use notably exceeds the World Health Organization (WHO)-recommended levels of 13.4%–21.1%, reflecting the hospital’s specialty and patient acuity.
Percentage of drug use classified based on the route of administration in all 23 wards and clinics.
Drug groups included antimicrobials (21.8%), nutritional agents and vitamins (16.1%), cardiovascular medications (12.9%), analgesics and anti-inflammatories (12.0%), gastrointestinal drugs (8.4%), obstetric drugs (5.7%), anesthetics (4.3%), electrolytes (3.4%), and local anesthetics/muscle relaxants (2.5%) (Table 3). The distribution of the most common drug groups varied across different hospital wards, with antimicrobials and nutritional agents predominating in neonatal and critical care units, as illustrated in Figure 2.
Percentage of the most common drug group in all 23 wards and clinics.
Percentage of the most common drug groups prescribed in different wards of the Women’s Specialized Hospital, Shiraz, Iran.
Prescription patterns in adult ICU and neonatal intensive care unit (NICU)
In the adult ICU, 3004 prescriptions contained 2318 classified drugs. Injection was the predominant route of administration (53.7%; n = 1606), followed by the oral route (22.1%) and infusion of nonmedical fluids (17.7%). The most commonly prescribed antimicrobials were ceftazidime (13.0%) and clindamycin (11.7%). Among cardiovascular drugs, heparin (34.9%) and furosemide (12.3%) were most common, whereas ondansetron and domperidone were common gastrointestinal agents.
In the NICU, a total of 42,923 drugs were prescribed, of which 29,849 were classified drugs. Injectable administration was most prevalent (73.9%; n = 31,700), accompanied with nonmedical infusions (16.4%) and oral medications (3.6%). Ampicillin, amikacin, and vancomycin were the leading antimicrobial agents. Nutritional supplementation with vitamin B complex, vitamin C, and amino acid solutions was considerably prevalent. Heparin and furosemide were the most common cardiovascular support drugs, and dopamine likely provided inotropic support (Table 4).
Most common route of administration, drug class, and the most frequent drugs in NICUs and ICUs.
In the Adult ICU, 437 (18.9%) represents all antimicrobial prescriptions; the most frequently prescribed single antibiotic was ceftazidime 1 g (n = 57; 13.0% of antimicrobial prescriptions)
NICU: neonatal intensive care unit; ICU: intensive care unit; ASA: acetylsalicylic acid (aspirin).
Comparison of anti-Inflammatory drug prescriptions
Among the total 13,909 patients, 4009 (28.8%) received at least one NSAID. Diclofenac suppositories (100 mg) were the most commonly prescribed analgesic and antipyretic in this group, followed by paracetamol (1 g) and mefenamic acid capsules (250 mg). Injection was the predominant route for NSAID administration (37.5%), with 4.32% of patients receiving injectable forms. Overall, 30.83% of all prescriptions contained at least one NSAID, underscoring the frequent use of anti-inflammatory agents in pain and fever management across wards.
Discussion
This comprehensive retrospective study delineates inpatient prescription patterns at a major women’s tertiary hospital, focusing on overall drug utilization, routes of administration, and ward-specific profiles. As a women’s specialized tertiary hospital, almost all adult inpatients were women of reproductive age, whereas the neonatal units admitted male and female newborns. This organizational structure helps explain why obstetric and neonatal wards accounted for a large proportion of the total drug use.
In this cohort, 4009 of 13,909 patients (28.8%) received at least one NSAID, most commonly 100 mg diclofenac suppositories, 1 g paracetamol, or 250 mg mefenamic acid, with 37.5% of NSAIDs administered parenterally. Compared with Indian outpatient data, where NSAID use was 30.83% and injectable NSAIDs were prescribed far less frequently (4.32%), 10 the higher proportion of parenteral NSAID use in our study likely reflects the greater acuity of hospitalized patients and frequent postoperative pain management. Consistent with our findings, other Iranian studies have reported high NSAID utilization, emphasizing on the influence of clinical setting and disease severity on analgesic prescribing. 7
Of the 371,056 prescriptions, 67.5% were pharmaceutical products, primarily antimicrobials (21.8%), nutritional agents (16.1%), and cardiovascular drugs (14.1%). Antimicrobials were prescribed to 70.2% of patients, a proportion similar to that reported in Pakistan (68%) but considerably higher than the global point-prevalence estimate of 2.4 antibiotics per patient and the 23% reported in a study from Nepal.11–13 Ampicillin was the most commonly prescribed antibiotic, consistent with WHO recommendations for the empiric treatment of neonatal sepsis. 14 However, overall antimicrobial use exceeded the WHO recommendations (20%–26.8%), 15 raising concerns about the potential antimicrobial resistance and underscoring the need for antimicrobial stewardship and susceptibility-guided prescribing. Previous Iranian studies have suggested that high antibiotic consumption is driven by limited microbiology capacity and a high burden of neonatal infections.6,7 The frequent use of ampicillin, cefazolin, and amikacin in neonatal wards aligns with widely followed empiric therapy protocols; 16 however, the overall antibiotic load indicates a need for further evaluation and stewardship interventions.
Parenteral administration predominated in the hospital, with 71.3% of prescriptions and 86.9% of patients receiving injectable therapy. These figures exceeded those reported from Ethiopia (54%), WHO recommendations of 13.4%–21.1%, and previous Iranian outpatient studies.7,17–19 Neonatal wards showed particularly high use of parenteral medications (88.5%–92.8%), in contrast a study from Nepal reported a lower prevalence of 48.9%. 13 These differences likely reflect variations in case mix, illness severity, and local practice patterns. Commonly used injectables included heparin, oxytocin, and ampicillin, administered for thromboembolism prevention, labor management, and treatment of severe infections. In Iranian gynecological settings, frequent use of metronidazole, clotrimazole, and folic acid has also been reported, further highlighting the central role of antimicrobials and nutritional agents in this patient population.7,10
The postcesarean section ward had the highest prescription volume (23.8%) and the largest proportion of injectable medications (23.1%), consistent with the intensive postoperative needs of these patients. Neonatal wards accounted for 50% of all ampicillin and 24.3% of all antimicrobial prescriptions, consistent with a Brazilian NICU study in which 75% of neonates received antibiotics, and 88.5%–92.8% of medications were administered parenterally due to the inability of critically ill newborns to take oral drugs. 8 In contrast, the post-NVD ward favored enteral administration (26.3%) in clinically stable patients, illustrating how patient condition and care setting shape prescribing practices.
In NICUs, high drug use is likely related to prolonged hospitalization (up to 124 days) and the complexity of neonatal cases, with ampicillin, amikacin, and vancomycin most frequently used for the empiric treatment of neonatal sepsis. 16 In adult ICUs, antimicrobials (ceftazidime and clindamycin) were most commonly prescribed, followed by cardiovascular drugs (heparin and furosemide) and gastrointestinal agents such as ondansetron, consistent with previous studies highlighting the intensive use of sedatives and antiulcer medications in critically ill patients.20,21 Most medications in these units were administered via injection (73.9% in the NICU and 66% in the adult ICU), reflecting the high acuity of the patient population. Heparin use in both units emphasizes the importance of thromboembolism prevention in immobilized patients. 10 In one study, the mean number of drugs per patient was 8.0, notably lower than that observed in the current study.13,20
From an international perspective, our findings align with and differ from prescribing patterns reported in other settings. The proportion of injectable drugs in this study (71.3%) and the high rate of antimicrobial prescriptions (70.2%) substantially exceed WHO recommendations (13.4%–21.1%) 17 and are comparable to figures reported from Pakistan (68%) and Ethiopia (54%).10,14 However, these rates remain higher than those reported in Nepal (23%) and most European countries, where robust antibiotic stewardship programs are more firmly established.11,12 Similarly, the observed NSAID prescription rate (28.8%) is consistent with reports from India (30%–35%) 9 but exceeds those reported in the United Kingdom and United States, where inpatient NSAID prescribing is generally <20% because of stricter safety and pain-management protocols. Together, these cross-country differences reflect variations in healthcare infrastructure, prescriber behavior, and policy enforcement around rational drug use and highlight the value of our data for global comparison.
This study has several limitations. First, the prescription data were not linked to clinical outcomes, which limits the ability to draw conclusions about the effectiveness and safety of specific prescribing patterns. Second, missing sex data for 2114 infants and other documentation gaps may have introduced bias. Finally, the high number of medications per patient, particularly in neonates, exceeds the WHO benchmark of 1.6–1.8 drugs per prescription and suggests possible overprescribing, potentially driven by the severity of illness and prematurity.14,18 Finally, the extensive use of antimicrobials and injectable formulations also raises concerns regarding antimicrobial resistance and adherence to WHO guidelines. Future work should incorporate clinical outcomes, antimicrobial resistance surveillance, and structured prescriber feedback. Strengthening feedback mechanisms and implementing institutional standards may help reduce irrational prescribing and promote more rational use of medicines, as recommended in systematic reviews of prescription-pattern monitoring studies. 22
Conclusions
Our study indicates a high prevalence of antimicrobial, NSAID, and injectable drug use among hospitalized patients in a tertiary women’s hospital, likely reflecting the clinical complexity and intensity of care in such settings. These findings emphasize the need for continuous prescription audits, antimicrobial stewardship initiatives, and institutional policies aimed at promoting rational drug use, reducing unnecessary polypharmacy, and improving patient safety.
Footnotes
Acknowledgments
Author contributions
Data availability statement
Declaration of conflicting interests
Ethics approval
Funding
ORCID iD
