drug utilization research is defined as research on  the marketing , distribution , prescription and use of drugs in a society , with special emphasis on the resulting medical , social and economic consequences  and has the principal aim of facilitating the rational use of drugs ( 1 ) . in developing and transitional countries ( including nepal ) , some 16 thousand million injections are administered each year  a rate of 3.4 injections per person per year ( 2 ) . reuse of injection equipment in the absence of sterilization was highest ( 75% ) in the south east asia region ( consisting of nine countries including nepal ) of the world health organization ( who ) ( 2 ) . the combination of injection overuse and unsafe practices creates a major route of transmission for human immunodeficiency virus ( hiv ) , hepatitis and other blood borne pathogenic infections ( 2 ) . in order to compare drug utilization among different countries and even among health institutions within a country , the anatomical therapeutic chemical ( atc ) classification system represents a common language for describing the drug assortment . the ddd is defined as the assumed average maintenance dose per day for a drug used for its main indication in adults ( 4 , 5 ) . a study in the intensive care unit ( icu ) from a teaching hospital in western nepal showed that 52.8% of drugs were administered by the parenteral route , and more interestingly 74% of patients were given an intravenous fluid ( ivf ) during the period of their icu stay ( 6 ) . a prospective , cross - sectional study of a tertiary care teaching hospital in eastern nepal reported that 77.7% of the in - patients were prescribed injectable drugs which constituted 40.4% of the total number of drugs ( 7 ) . these studies were either confined to a particular department or concentrated on a particular group of drugs . in view of the high prevalence of use of injectable drugs ( ids ) and intravenous fluids ( ivfs ) , there is an urgent need to study their utilization . knowledge on how ids / ivfs are being prescribed and used will be of immense help in initiating a discussion on their rational use and suggesting measures to improve prescribing . the present study was carried out to obtain baseline data on prescription of ids and ivfs to the inpatients . the objectives of the study were to : 
 obtain relevant demographic information of inpatients of manipal teaching hospital ( mth ) prescribed ids / ivfs during the study period.obtain information on the patterns of prescription of ids / ivfscalculate ddd/100 bed - days of the ten most commonly used ids and injectable antibiotics.measure ivf utilization in liters/100 bed-days.calculate the proportion of the total drug cost constituted by ids / ivfs andanalyze and compare the utilization of ids / ivfs between the mth s four major departments ( medicine , obstetrics and gynecology ( obg ) , pediatrics and surgery ) . obtain relevant demographic information of inpatients of manipal teaching hospital ( mth ) prescribed ids / ivfs during the study period . obtain information on the patterns of prescription of ids / ivfs calculate ddd/100 bed - days of the ten most commonly used ids and injectable antibiotics . calculate the proportion of the total drug cost constituted by ids / ivfs and analyze and compare the utilization of ids / ivfs between the mth s four major departments ( medicine , obstetrics and gynecology ( obg ) , pediatrics and surgery ) . the study was carried out over a six - month period ( 1st january to 30th june 2006 ) at mth , a 700 bedded tertiary care hospital , affiliated with the manipal college of medical sciences ( mcoms ) in pokhara , nepal . the middle ten days of each english month was selected to minimize the influence of income on hospital visits . the period covered five days before getting salary and five days after getting salary , since most of the nepalese people get their salary according to the nepalese month which start around the middle of the english month . to make things clearer , the nepalese month of magh 2065 started on january 14th and will end on february 11th 2009 . records of patients discharged from the various wards of mth during the study period were obtained from the medical records department ( mrd ) and analyzed . inpatients discharged after observation in the emergency department and from the ophthalmology ward were excluded . patients admitted for diagnostic procedures such as endoscopy , hemodialysis etc . and discharged after the procedure was also excluded . age , sex , address , hospital ( patient ) number , department of admission , date of admission and date of discharge of the patient were recorded . for calculating the length of stay , the name , dose , frequency , duration and route of administration of drugs prescribed during hospital stay were recorded . the patients were divided into four age groups ( 01 , 115 , 1560 and > 60 years ) . analysis of id / ivf use in the four major departments was also done separately . the department of medicine runs the medicine outpatient department , medicine wards , the semi - icu and the icu of the hospital . the mean number of drugs , ids and ivfs administered and their average cost were calculated . the proportion of total drug cost and of total drugs ( both injectable and non injectable drugs prescribed to these patients ) constituted by ids / ivfs were calculated . the cost was calculated by using health information system ( his ) , ( developed by the manipal corporate office in bangalore , india ) a computer software program used by the hospital pharmacy of mth . the cost refers only to the cost of drugs and the cost of administration and related fees was not taken into consideration . the cost was calculated in both nepalese rupees and us dollars ( one us dollar ( us$ ) = 78.5 nepalese rupees ( nrs ) on 22nd january 2009 ) . the cost was recalculated to give the latest conversion figures relative to the us dollar . the drugs were classified according to the atc system and utilization of ids was measured in ddd/100 bed - days and of ivfs in l/100 bed - days . injectable drugs ( ids ) refer to drugs which were administered by injection to the patients of the study . the ddd/100 bed - days of the ten most commonly used ids were calculated using the following formula ( 4 ) : 
 ddd/100  beddays  =  ( drug  consumption  in  the  studyperiod  ( mg )    100)/  ( assigned  ddd  ( mg )    period  ofstudy    bed  strength    average  occupancy ) the time period of study was sixty days . there were 583 beds in the wards included in the study and the average occupancy index was calculated to be 0.299 . intravenous fluid ( ivf ) utilization was calculated using the following formula : 
 ( liters/100  beddays )  =  ( consumption  of  the  particularivf  during  the  study  period  ( l )    100)/  ( period  of  study  bed  strength    average  occupancy ) for statistical analysis statistical package for social sciences ( spss ) version 10.0 for windows ( spss inc . , one way anova was applied to compare means of various parameters of the four major departments and when significant ( p<0.001 ) differences were noted , post hoc scheff test was applied . a pilot study of five days duration ( 11th to 15th december 2005 ) involving 106 patients was carried out in mth . the result of the pilot study was not included in the final analysis and was broadly similar to those reported here . the instruments used in the study were standard ones used in previous drug utilization studies . during the study period , 1131 patients were discharged , of which 938 ( 82.94% ) received one or more injection / s during their hospital stay . percentage of females receiving injections was slightly higher [ 481 ( 51.28% of the total 938 patients receiving injections ) ] than males . seventy - six patients were infants ( 01 year ) , 131 were children ( 115 years ) , 521 were adults ( 1560 years ) and 210 were elderly ( > 60years ) . five hundred and ninety - seven ( 63% ) patients were from kaski district in which mth is located . a single id / ivf was administered to 168 ( 17.91% of total 938 ) patients , while 145 ( 15.46% ) received two such drugs . the most common conditions for which an i d was prescribed were hypertension ( 10.77% ) , chronic obstructive pulmonary disease ( copd ) ( 7.78% ) , acute gastroenteritis ( 6.29% ) and ischemic heart disease ( 6.08% ) . of the 938 patients , who received ids / ivfs , 535 ( 57.04% ) received parenteral anti - microbial therapy . a single injectable anti - microbial ( iam ) was given to 252 ( 47.1% ) patients , while 161 ( 30.09% ) received two iams . tables 1 and 2 shows the atc codes and ddd/100 bed - days of the ten most commonly administered ids and iams in mth respectively . a total of 1328 ivfs were administered . median number of ivf prescribed was one . the total ivf consumption was 24.25 l/100 bed - days . median duration of stay was five days ; median cost of prescription and cost of ids / ivfs in nrs ( us$ ) were 648.5 ( $ 8.26 ) and 402 ( $ 5.12 ) . no significant gender variation in administration of ids / ivfs was observed , but significant interdepartmental variation was observed ( table 4 ) . significant differences in the median duration of stay were found between medicine and obg ( p=0.006 ) and medicine and pediatrics ( p<0.001 ) with higher duration of stay in medicine . the mean number of drugs prescribed in pediatrics was significantly ( p<0.001 ) lower than in medicine , obg and surgery . ids / ivfs constituted 40.71% of the total drugs prescribed and 72.58% of the drug cost in medicine . in surgery 63.37% of the total drugs prescribed and 74.64% total cost of drugs was due to ids / ivfs . in pediatrics and surgery , 56.71% and 66.78% of total prescribed drugs and 87.26% and 88.78% of the total cost of drugs were due to ids / ivfs the mean number of iams prescribed in medicine , obg , pediatrics and surgery were 0.71 , 1.72 , 1.09 and 1.69 , respectively . in pediatrics , medicine and surgery , types of antimicrobials prescribed in the four departments were similar except that coamoxiclav ( amoxicillin - clavulanic acid fixed dose combination ( fdc ) ) prescription was significantly higher in medicine than in the other three departments . ciprofloxacin ( 32% ) and a combination of three antimicrobials ( beta lactams , gentamicin and metronidazole ) ( 44% ) was prescribed more in obg compared to the other three departments . median number of ivfs prescribed in medicine , obg , pediatrics and surgery were one , one , one and two respectively . dextrose normal saline ( dns ) was the most frequently administered ivf in the department of medicine . in surgery , but rl and isolyte p were the most frequently administered ivf in the department of obg and pediatrics , respectively . in this study , a total of 938 ( 82.94% ) of the 1131 inpatients , discharged during the study period , received at least one injection during their hospital stay . this result is comparable to that reported from eastern nepal ( 7 ) , where 77.7% of total inpatients had received ids ( note : ivfs were not included ) . in another study from ghana , 60% of the patients received one or more injectable drugs ( 8) . this may indicate higher rate of injectable administration in mth . this maybe a matter of concern and the reasons for this should be investigated in detail . the local patients frequently visit mth for their illness , so the patients receiving injections [ 597 ( 63.65% ) ] were mostly from kaski district . district wise distribution of patients visiting mth is similar to that noted in previous studies ( 6,9 ) done at mth . nepal being a mountainous country , problems of accessibility to health care services is an important issue . the median duration of hospitalization was five days . in a previous study ( 10 ) at mth , median duration of stay was higher than that reported in the present study ( nine days ) . on comparison between departments , mean duration of stay was highest in medicine followed by surgery . in a previous study ( 6 ) in the icu of mth , the mean  sd duration of hospitalization was 3.84  3.14 days , which is lower than that reported from the medicine ward ( 7.89  6.34 ) in the present study . once a patient s condition improves , they are shifted to other wards and this may be the reason for shorter icu stay . the patients are generally unwilling to stay in the hospital after ids have been stopped ( 11 , personal observation of the authors and other healthcare providers ) . economic considerations may be partially responsible for the desire to continue further treatment at home ( 11 ) . decreased use of ids / ivfs will decrease the duration of stay and the costs associated . formulation of standard treatment guidelines and an antibiotic use policy in our hospital is in progress . the mean number of drugs administered was 8.75 . in a study from eastern nepal ( 7 ) , mean number of drugs was 5.3 and this figure would have been higher if ivfs were counted as drugs . a study by shankar pr et al ( 10 ) in mth reported the mean number of drugs to be 7.41 , which is less than this study . another study in ghana ( 8) showed an average of 3.6 drugs prescribed per patient . increased administration of ivfs may be a factor partly responsible for the increase in the mean number of drugs . the average number of drugs should be kept as low as possible to minimize the risk of drug interactions , development of bacterial resistance and hospital cost ( 12 ) . the average number of drugs was significantly higher in obg ( 10.6 ) compared to the other three departments . normal delivery and lower segment cesarean section were the most frequent clinical conditions for the admission to the obg ward . in these conditions , multiple drug prescribing was common . prescribing of more than one antimicrobial is also more frequent in obg . in medicine , the mean number of drugs was 9.56 which is less than that reported from tribhuvan university teaching hospital ( 13 ) but higher than that reported from harare ( 14 ) . elderly patients and patients with multiple conditions comprised the majority of patients being treated in the medicine wards . this might be the reason for the greater average number of drugs in medicine . in this study , it has been found that significantly lower number of drugs were used in pediatrics ( 5.43 ) compared to other departments . even though mean number of drugs prescribed in pediatrics was less , the value is higher than the mean of 3.45 reported in a previous zimbabwean study ( 15 ) . but the result is comparable to the previous studies ( 9 , 16 ) done in nepal . of the total drugs this is very similar to that observed in a previous study ( 6 ) in mth but higher than that reported from a study from eastern nepal ( 7 ) . in the present study , 17.91% patients were administered a single injection , while 15.46% were administered two injections . the average number of injectable drugs should be kept as low as possible , to reduce poly - pharmacy , cost and hazards associated with the practice of injectables ( 17,18 ) . but mean number of ids used is higher than that observed previously ( 1.68 ) ( 16 ) . the percentage of patients receiving ivfs was 69.96% in medicine ( lower than that reported earlier ) ( 13 ) . among the four departments , the median number of ivfs used was higher in surgery   compared to the other three departments . this is less than the median number of ivf prescribed   in a study from spain ( 19 ) . the utilization of ivf was 24.25 l/100 bed - days which is similar to the utilization in the icu ( 6 ) . although dns was the most commonly prescribed ivf in the mth and in medicine department , rl was the most frequently administered ivf in surgery and obg . in obg this is different from that reported in other studies ( 20,21 ) . the first study ( 20 ) was carried out among post - operative surgical patients while the second studied various fluid maintenance therapy regimens in adult inpatients admitted to the general surgery ward over a one - year period . in a hospital in serbia , europe utilization of ivfs varied from 89 to 94 ddd/100 beddays ( 22 ) . an old study had looked at use of ivf among medical inpatients in hospitals in the united states , scotland , new zealand , israel and canada ( 23 ) . the study ( 23 ) was published in 1977 and the passage of time makes it difficult to draw conclusions . median cost of drugs and ids / ivfs per patient was 8.26us$ and 5.12us$. however , the cost was higher than the mean cost of drugs observed previously ( 9 ) among pediatric inpatients who are less likely to suffer from multiple diseases . the cost of the prescription ( and treatment ) is an important variable in determining accessibility and concordance to treatment especially in nepal where the per capita income is 260us$ per year ( 24 ) . mth is a private sector health care provider where most of the patients have to pay for their treatment and medicines . but , to make the treatment accessible to patients belonging to low socioeconomic groups , the poor patient fund ( ppf ) has been created and mth organizes free treatment service  camps outside the hospital . . these could either be within pokhara city , within the valley or outside iams were prescribed in 57% of the patients . in a study from western nepal ( 12 ) , 51% of the patients were prescribed injectable antibiotics . in an indian study ( 25 ) , 42.5% of patients were prescribed antibiotics parenterally . similarly , in an israeli study ( 26 ) , 64% of patients were prescribed antibiotics parenterally . an implementation program promoting early switch over from intravenous to oral quinolones ensured a total hospital saving of 41420us$ during the time period considered ( 27 ) . similar programs could be implemented in mth for cost effective use of ids / ivfs . ampicillin and cloxacillin fdc was defined to be irrational by the drug and therapeutics committee of mth and was not available in the mth pharmacy . furthermore , it was found that a combination of three anti - microbials ( betalactam , aminoglycoside and metronidazole ) was often prescribed to patients . educational interventions to reduce the prescription of coamoxiclav are underway and departmental comparison showed the average number of iams prescribed was highest in obg followed by surgery , pediatrics and medicine . the lower mean does not signify that prescription of antimicrobials is lowest in medicine because antimicrobials might have been used orally . generally , prophylactic antibiotics were given parenterally in obg and surgery and that might be one of the reasons for the higher mean number of iams in these departments . to prevent injection - associated infections , injection use needs to decrease and injection safety must be achieved ( 28 ) . several interventions were conducted world wide to decrease injection overuse and/or to achieve safer practice ( 28,29 ) . better communication between prescriber and patients and managerial approaches ( i.e. restricting access to selected unnecessary and dangerous injectable drugs ) can reduce overuse ( 28 ) . the authors of a study conducted among private sector injection providers ( pharmacies / medical shops and other venues ) in the central region of nepal ( 30 ) found unnecessary and unsafe use of injections to be common . adverse effects like abscesses were common , unsafe handling and disposal of injection equipment and sharps is common and reuse of non - sterile injection equipment with the same patient was commonly observed . providers failed to wash their hands or take other precautions while injecting and recycling waste was a problem ( 30 ) . certain of the problems mentioned may also be applicable to the hospital setting . in the west , patients managed with other agents are treated as outpatients saving money for the healthcare system . in nepal , patient demand for injections , and the inappropriate use of injections are a common health problem ( 31 ) . parenteral therapy is often started and maintained for the satisfaction of the patient , because of the patients expectations of quicker recovery and for satisfying patient demand ( personal observation of the authors ) . so the issue of parenteral drug treatment in nepalese hospitals should be studied in more detail . the study describes the pattern of injectable utilization , but did not investigate the reasons why . the study was carried out over a six month period ( during the winter and summer months ) and seasonal variations in disease pattern and drug utilization were not considered . drugs used for induction and maintenance of anesthesia , which are generally more expensive than drugs for many other uses , were also not considered but this was due to lack of proper documentation . only the drug costs were considered and other costs were not taken into consideration . follow - up of the patients and their opinion regarding the injectable use was not done and the rationality of drug use in different conditions was not assessed . the study provides an overview about utilization of ids / ivfs among inpatients in mth and could serve as a basis for further research , which will help prescribers to improve patient management by rationalizing injection practices . the high rate of prescription of ids / ivfs is a matter of concern . decreasing the prescription and early switch over to oral preparations will significantly reduce both the drug and non - drug cost ( cost of injection , surgical items and hospital & nursing charges ) .
unnecessary , excessive and poor injection practices in the south east asia region ( including nepal ) have been observed previously . 
 the authors aim to study prescription of injectable drugs to inpatients in a teaching hospital in western nepal . 
 prescription of injectable drugs ( ids ) and intravenous fluids ( ivfs ) to inpatients discharged from the wards of the manipal teaching hospital during 1st january to 30th june 2006 was studied . 
 the mean number of drugs , ids and ivfs administered , median cost of drugs and of ids / ivfs per prescription calculated . 
 comparison of id / ivf use in the four major hospital departments ( medicine , obstetrics and gynecology , pediatrics and surgery ) was done . 
 the administration of ids / ivfs and injectable antimicrobials were measured in defined daily dose ( ddd)/100 bed - days and of intravenous fluid in liters ( l)/100 bed - days . of 
 the 1131 patients discharged , 938 ( 82.94% ) patients received one or more ids / ivfs . the mean number of drugs , ids and ivfs prescribed were 8.75 , 4.72 and 1.42 . 
 median cost of drugs and ids / ivfs per prescription were 8.26us$ and 5.12us$ respectively . 
 ids / ivfs accounted for 81.37% of total drug cost . 
 the most commonly used i d , injectable antimicrobial and ivf were diclofenac ( 19.3 ddd/100 bed - days ) , metronidazole ( 7.68 ddd/100 bed - days ) and dextrose normal saline ( 8.56 l/100 bed - days ) , respectively . 
 the total ivf consumption was 24.25 l/100 bed - days . 
 significant differences between departments were observed ( p<0.05 ) . in conclusion , 
 the use of ids / ivfs was higher compared to other studies . 
 interventions to improve ids / ivfs prescribing practices may be required .