Analysis of Antibiotic Use in Outpatient Pneumonia Patients at X Blitar Health Center using the Gyssens Method and the Defined Daily Dose
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Submitted
3 November 2025
Published
30 June 2026
Keywords:
-
pneumonia, Antibiotic, DDD, Gyssens, health centers
Abstract
Pneumonia is a respiratory infection that remains a public health problem and requires appropriate antibiotic therapy. However, irrational use of antibiotics has the potential to increase resistance and worsen patient clinical outcomes. This study aims to analyze antibiotic use among outpatient patients with pneumonia at the X Blitar Health Center using the Defined Daily Dose (DDD) and Gyssens methods. This study employed a cross-sectional approach, utilizing secondary data from 109 medical records and prescriptions for pneumonia patients (ICD-10 codes J12-J18) from February 2024 to May 2025. Quantitative analysis was conducted using the DDD per 1,000 patients per day method, while qualitative analysis of prescriptions was performed using the Gyssens method. The results showed that Amoxicillin (J01CA04) was the most widely used antibiotic, namely 232.42 DDD/1,000 patients per day, followed by Cefadroxil (87.04 DDD/1,000 patients per day), Ciprofoxacin (18.35 DDD/1,000 patients per day), and Azithromycin (15.29 DDD/1,000 patients per day). Gyssens' analysis revealed that most prescriptions fell into categories IIA (33.94%), IVA (29.36%), and V (27.52%). Inaccurate dosage and suboptimal antibiotic selection were the leading causes of irrational antibiotic use. Additionally, 30 pneumonia patients were identified who did not receive antibiotics despite having clinical indications for them. The results of this study emphasize the need for rationalization training in therapy, prescription audits, and strengthening the implementation of clinical guidelines in primary care facilities.
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References
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25. Degif KA, Gebrehiwot M, Tadege G, Demoze L, Yitageasu G. Spatial and temporal variation of pneumonia incidence among under-five children in central gondar zone, Northwest Ethiopia, 2013- 2022. BMC Pediatr. 2025;25(1):182. DOI: 10.1186/s12887-025-05550-7; PMID: 40069711; PMCID: PMC11895133.
26. Rodríguez-Contreras FJ, Calvo-Cebrián A, Díaz-Lázaro J, Cruz-Arnés M, León-Vázquez F, Del Carmen Lobón-Agúndez M, et al. Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study. Ann Fam Med. 2022;20(3):227-36. DOI: 10.1370/afm.2796; PMID: 35606120; PMCID: PMC9199040.
27. Htun TP, Sun Y, Chua HL, Pang J. Clinical features for diagnosis of pneumonia among adults in primary care setting : A systematic and meta-review. Sci Rep. 2019;9:7600. DOI: 10.1038/s41598-019-44145-y.
28. Mulderij-Jansen V, Bedri A, Herdeg T, Andre M, Holterman L, Boer M, et al. Contexts and concepts influencing general practitioners' and patients' decision-making on antibiotic prescriptions for upper respiratory tract infections in the Northern Dutch-German cross-border region - a qualitative study. BMC Prim Care. 2026;27(1):121. DOI: 10.1186/s12875-026-03239-z; PMID: 41772432; PMCID: PMC13063523.
29. Poutanen R, Korppi M, Csonka P, Pauniaho SL, Renko M, Palmu S. Use of antibiotics contrary to guidelines for children's lower respiratory tract infections in different health care settings. Eur J Pediatr. 2023;182(10):4369-77. DOI: 10.1007/s00431-023-05099-6; PMID: 37464182; PMCID: PMC10587298.
30. Niazi-Ali S, Bircher J. Broad spectrum antibiotic stewardship by quality improvement methods. Int J Risk Saf Med. 2022;33(S1):S35-S40. DOI: 10.3233/JRS-227021; PMID: 35871365; PMCID: PMC9844069.
31. Aliabadi S, Anyanwu P, Beech E, Jauneikaite E, Wilson P, Hope R, et al. Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013-18): a quasi-experimental, ecological, data linkage study. Lancet Infect Dis. 2021;21(12):1689-700. DOI: 10.1016/S1473-3099(21)00069-4; PMID: 34363774; PMCID: PMC8612938.
32. Hasan H, Katu S, Halim R. Evaluation of the compatibility from antibiotic use with the Gyssens plot in community acruired pneumonia patients in RSUP DR Wahidin Sudirohusodo. Antimicrob Steward Healthc Epidemiol. 2025;5(Suppl 1):s17. DOI: 10.1017/ash.2025.125; PMCID: PMC12442212.
33. Kurniawan K, Puspitasari I, Nuryastuti T. Evaluasi Penggunaan Antibiotik Empirik Terhadap Outcome Klinik dan Gambaran Antibiogram Pada Pasien ISPA di Puskesmas Jetis Yogyakarta. Majalah Farmasi. 2021;17(3):256–64. DOI: 10.22146/farmaseutik.v1i1.51259.
34. Islam AFMM, Raihan MA, Ahmed KT, Islam MS, Nusrat NA, Hasan MA, et al. Prevalence of inappropriate antibiotic doses among pediatric patients of inpatient, outpatient, and emergency care units in Bangladesh: A cross-sectional study. PLOS Glob Public Health. 2024;4(9):e0003657. DOI: 10.1371/journal.pgph.0003657; PMID: 39255277; PMCID: PMC11386430.
35. Alessa M, Almangour TA, Alhassoun A, Alajaji I, Almangour A, Alsalem A, et al. Adherence to evidence-based guidelines for the management of pneumonia in a tertiary teaching hospital in Riyadh. Saudi Pharm J. 2023;31(8):101678. DOI: 10.1016/j.jsps.2023.06.011; PMID: 37448847; PMCID: PMC10336669.
36. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. DOI: 10.1164/rccm.201908-1581ST; PMID: 31573350; PMCID: PMC6812437.
37. Shapiro DJ, Hall M, Neuman MI, Hersh AL, Cotter JM, Cogen JD, et al. Outpatient Antibiotic Use and Treatment Failure Among Children With Pneumonia. JAMA Netw Open. 2024;7(10):e2441821. DOI: 10.1001/jamanetworkopen.2024.41821; PMID: 39470638; PMCID: PMC11522934.
2. Salam MA, Al-Amin MY, Salam MT, Pawar JS, Akhter N, Rabaan AA, et al. Antimicrobial Resistance: A Growing Serious Threat for Global Public Health. Healthcare. 2023;11(13):1946. DOI: 10.3390/healthcare11131946; PMID: 37444780; PMCID: PMC10340576.
3. Nazir A, Nazir A, Zuhair V, Aman S, Sadiq SUR, Hasan AH, et al. The Global Challenge of Antimicrobial Resistance: Mechanisms, Case Studies, and Mitigation Approaches. Health Sci Rep. 2025;8(7):e71077. DOI: 10.1002/hsr2.71077; PMID: 40704322; PMCID: PMC12284435.
4. Ndaki PM, Mwanga JR, Mushi MF, Konje ET, Mwita SM, Mshana SE. Drivers of inappropriate use of antibiotics among community members in low- and middle-income countries: a systematic review of qualitative studies. BMC Public Health. 2025;25(1):705. DOI: 10.1186/s12889-025-21553-6; PMID: 39979890; PMCID: PMC11841188.
5. Mulchandani R, Tiseo K, Nandi A, Klein E, Gandra S, Laxminarayan R, et al. Global trends in inappropriate use of antibiotics, 2000-2021: scoping review and prevalence estimates. BMJ Public Health. 2025;3(1):e002411. DOI: 10.1136/bmjph-2024-002411; PMID: 40444029; PMCID: PMC12121568.
6. Cilloniz C, Dela Cruz CS, Dy-Agra G, Pagcatipunan RS Jr; Pneumo-Strategy Group. World Pneumonia Day 2024: Fighting Pneumonia and Antimicrobial Resistance. Am J Respir Crit Care Med. 2024;210(11):1283-5. DOI: 10.1164/rccm.202408-1540ED; PMID: 39530671; PMCID: PMC11622429.
7. Obianyo CM, Muoghalu N, Adjei EM, Njoku AN, Okoro NL, Sulaiman OB, et al. Trends and Disparities in Pneumonia-Related Mortality in the U.S. Population: A Nationwide Analysis Using the CDC WONDER Data. Cureus. 2025;17(5):e83371. DOI: 10.7759/cureus.83371; PMID: 40458354; PMCID: PMC12127219.
8. Ciptaningtyas VR, Sumekar TA, Fauzia LP, Lestari ES, Farida H, Margawati A, et al. Community-acquired pneumonia in Indonesian children: insights into diagnosis, treatment compliance, and healthcare provider challenges. Arch Public Health. 2025;84(1):9. DOI: 10.1186/s13690-025-01795-x; PMID: 41339952; PMCID: PMC12794261.
9. Alharbi TAF, Rababa M, Alsuwayl H, Alsubail A, Alenizi WS. Diagnostic Challenges and Patient Safety: The Critical Role of Accuracy - A Systematic Review. J Multidiscip Healthc. 2025;18:3051-64. DOI: 10.2147/JMDH.S512254; PMID: 40470160; PMCID: PMC12134007.
10. Limato R, Lazarus G, Dernison P, Mudia M, Alamanda M, Nelwan EJ, et al. Optimizing antibiotic use in Indonesia: A systematic review and evidence synthesis to inform opportunities for intervention. Lancet Reg Health Southeast Asia. 2022;2:100013. DOI: 10.1016/j.lansea.2022.05.002; PMID: 37383293; PMCID: PMC10305907.
11. Wibowo YI, Firdhausi N, Rahmah N, Setianur N, Sunderland B, Setiadi AP. Antibiotic prescribing for children five years or younger in Indonesian primary care settings. J Infect Dev Ctries. 2025;19(3):409-17. DOI: 10.3855/jidc.19581; PMID: 40168384.
12. Saragih RH, Sihotang LE, Jaya FO, Meliala T, Keliat OK, Hasugian LS, et al. Qualitative evaluation of antimicrobial use with gyssens method in the internal medicine wards of Adam Malik General Hospital Medan. Antimicrob Steward Healthc Epidemiol. 2025;5(Suppl 1):s29–s30. DOI: 10.1017/ash.2025.163; PMCID: PMC12442193.
13. Menting SGP, Redican E, Murphy J, Bucholc M. Primary Care Antibiotic Prescribing and Infection-Related Hospitalisation. Antibiotics. 2023;12(12):1685. DOI: 10.3390/antibiotics12121685; PMID: 38136719; PMCID: PMC10740527.
14. Yau JW, Thor SM, Tsai D, Speare T, Rissel C. Antimicrobial stewardship in rural and remote primary health care: a narrative review. Antimicrob Resist Infect Control. 2021;10(1):105. DOI: 10.1186/s13756-021-00964-1; PMID: 34256853; PMCID: PMC8278763.
15. Grau S, Hernández S, Limón E, Calbo E, Horcajada JP; Catalan Infection Control and Antimicrobial Stewardship National Program (VINCat-PROA). Impact of changes in the WHO's 2019 update of DDDs on the measurement of adult hospital antibacterial consumption in Catalonia (Spain), 2008-18. JAC Antimicrob Resist. 2020;2(4):dlaa079. DOI: 10.1093/jacamr/dlaa079; PMID: 34223035; PMCID: PMC8210002.
16. Syam RA, Karuniawati H. Antibiotic Evaluation of Hospitalized Pneumonia Patients Using Gyssen or DDD 100 Bed Days or DDD 1000 Patient Days: Review. Pharmacon J Farmasi Indones. 2024;21(Special Issue 1):49–64. DOI: 10.23917/pharmacon.v21i0.23589.
17. Wijaya D, Alifah NN, Rahmadanita FF, Indrawijaya YYA, Susantin AM. Evaluation of Antibiotic Use in Pneumonia Patients with Gyssens Method. Pharm J Farmasi Indones. 2025;22(1):12-5. DOI: 10.30595/pharmacy.v22i1.17565.
18. Gyssens IC, van den Broek PJ, Kullberg BJ, Hekster Y, van der Meer JW. Optimizing antimicrobial therapy. A method for antimicrobial drug use evaluation. J Antimicrob Chemother. 1992;30(5):724-7. DOI: 10.1093/jac/30.5.724; PMID: 1493990.
19. Yulistiani Y, Barkah HH, Utomo FN, Andrianto L, Jathi AP, Yudistira NGPR. Analysis of Defined Daily Dose (DDD) and antibiotic problems in Intensive Care Unit (ICU) patients. Explor Res Clin Soc Pharm. 2025;21:100688. DOI: 10.1016/j.rcsop.2025.100688; PMID: 41492401; PMCID: PMC12765335.
20. GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect Dis. 2018;18(11):1191-210. DOI: 10.1016/S1473-3099(18)30310-4; PMID: 30243584; PMCID: PMC6202443.
21. Cheong D, Song JY. Pneumococcal disease burden in high-risk older adults: Exploring impact of comorbidities, long-term care facilities, antibiotic resistance, and immunization policies through a narrative literature review. Hum Vaccin Immunother. 2024;20(1):2429235. DOI: 10.1080/21645515.2024.2429235; PMID: 39631047; PMCID: PMC11622649.
22. Sarfo JO, Amoadu M, Gyan TB, Osman AG, Kordorwu PY, Adams AK, et al. Acute lower respiratory infections among children under five in Sub-Saharan Africa: a scoping review of prevalence and risk factors. BMC Pediatr. 2023;23(1):225. DOI: 10.1186/s12887-023-04033-x; PMID: 37149597; PMCID: PMC10163812.
23. Pecoraro L, Lanzilotti AG, De Musso M, Di Muri E, Tramacere F, Altavilla E, et al. The Role of Environmental Exposures in Pediatric Asthma Pathogenesis: A Contemporary Narrative Review. Children. 2025;12(10):1327. DOI: 10.3390/children12101327; PMID: 41153509; PMCID: PMC12564774.
24. Guma SP, Godman B, Campbell SM, Mahomed O. Determinants of the Empiric Use of Antibiotics by General Practitioners in South Africa: Observational, Analytic, Cross-Sectional Study. Antibiotics. 2022;11(10):1423. DOI: 10.3390/antibiotics11101423; PMID: 36290081; PMCID: PMC9598257.
25. Degif KA, Gebrehiwot M, Tadege G, Demoze L, Yitageasu G. Spatial and temporal variation of pneumonia incidence among under-five children in central gondar zone, Northwest Ethiopia, 2013- 2022. BMC Pediatr. 2025;25(1):182. DOI: 10.1186/s12887-025-05550-7; PMID: 40069711; PMCID: PMC11895133.
26. Rodríguez-Contreras FJ, Calvo-Cebrián A, Díaz-Lázaro J, Cruz-Arnés M, León-Vázquez F, Del Carmen Lobón-Agúndez M, et al. Lung Ultrasound Performed by Primary Care Physicians for Clinically Suspected Community-Acquired Pneumonia: A Multicenter Prospective Study. Ann Fam Med. 2022;20(3):227-36. DOI: 10.1370/afm.2796; PMID: 35606120; PMCID: PMC9199040.
27. Htun TP, Sun Y, Chua HL, Pang J. Clinical features for diagnosis of pneumonia among adults in primary care setting : A systematic and meta-review. Sci Rep. 2019;9:7600. DOI: 10.1038/s41598-019-44145-y.
28. Mulderij-Jansen V, Bedri A, Herdeg T, Andre M, Holterman L, Boer M, et al. Contexts and concepts influencing general practitioners' and patients' decision-making on antibiotic prescriptions for upper respiratory tract infections in the Northern Dutch-German cross-border region - a qualitative study. BMC Prim Care. 2026;27(1):121. DOI: 10.1186/s12875-026-03239-z; PMID: 41772432; PMCID: PMC13063523.
29. Poutanen R, Korppi M, Csonka P, Pauniaho SL, Renko M, Palmu S. Use of antibiotics contrary to guidelines for children's lower respiratory tract infections in different health care settings. Eur J Pediatr. 2023;182(10):4369-77. DOI: 10.1007/s00431-023-05099-6; PMID: 37464182; PMCID: PMC10587298.
30. Niazi-Ali S, Bircher J. Broad spectrum antibiotic stewardship by quality improvement methods. Int J Risk Saf Med. 2022;33(S1):S35-S40. DOI: 10.3233/JRS-227021; PMID: 35871365; PMCID: PMC9844069.
31. Aliabadi S, Anyanwu P, Beech E, Jauneikaite E, Wilson P, Hope R, et al. Effect of antibiotic stewardship interventions in primary care on antimicrobial resistance of Escherichia coli bacteraemia in England (2013-18): a quasi-experimental, ecological, data linkage study. Lancet Infect Dis. 2021;21(12):1689-700. DOI: 10.1016/S1473-3099(21)00069-4; PMID: 34363774; PMCID: PMC8612938.
32. Hasan H, Katu S, Halim R. Evaluation of the compatibility from antibiotic use with the Gyssens plot in community acruired pneumonia patients in RSUP DR Wahidin Sudirohusodo. Antimicrob Steward Healthc Epidemiol. 2025;5(Suppl 1):s17. DOI: 10.1017/ash.2025.125; PMCID: PMC12442212.
33. Kurniawan K, Puspitasari I, Nuryastuti T. Evaluasi Penggunaan Antibiotik Empirik Terhadap Outcome Klinik dan Gambaran Antibiogram Pada Pasien ISPA di Puskesmas Jetis Yogyakarta. Majalah Farmasi. 2021;17(3):256–64. DOI: 10.22146/farmaseutik.v1i1.51259.
34. Islam AFMM, Raihan MA, Ahmed KT, Islam MS, Nusrat NA, Hasan MA, et al. Prevalence of inappropriate antibiotic doses among pediatric patients of inpatient, outpatient, and emergency care units in Bangladesh: A cross-sectional study. PLOS Glob Public Health. 2024;4(9):e0003657. DOI: 10.1371/journal.pgph.0003657; PMID: 39255277; PMCID: PMC11386430.
35. Alessa M, Almangour TA, Alhassoun A, Alajaji I, Almangour A, Alsalem A, et al. Adherence to evidence-based guidelines for the management of pneumonia in a tertiary teaching hospital in Riyadh. Saudi Pharm J. 2023;31(8):101678. DOI: 10.1016/j.jsps.2023.06.011; PMID: 37448847; PMCID: PMC10336669.
36. Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, et al. Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019;200(7):e45-e67. DOI: 10.1164/rccm.201908-1581ST; PMID: 31573350; PMCID: PMC6812437.
37. Shapiro DJ, Hall M, Neuman MI, Hersh AL, Cotter JM, Cogen JD, et al. Outpatient Antibiotic Use and Treatment Failure Among Children With Pneumonia. JAMA Netw Open. 2024;7(10):e2441821. DOI: 10.1001/jamanetworkopen.2024.41821; PMID: 39470638; PMCID: PMC11522934.
Authors
1.
Hariyani HR, Widiyawati R, Herawati F, Chusna N. Analysis of Antibiotic Use in Outpatient Pneumonia Patients at X Blitar Health Center using the Gyssens Method and the Defined Daily Dose. Borneo J Pharm [Internet]. 2026Jun.30 [cited 2026Sep.29];9(2):225-34. Available from: https://journal.umpr.ac.id/index.php/bjop/article/view/11327
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