Asian Biomedicine Vol. 7 No. 1 February 2013; 15-20 DOI: 10.5372/1905-7415.0701.146 Original article

Antibiotic prescription for adults with upper and at King Chulalongkorn Memorial Hospital, Thailand

Ratima Issarachaikul, Chusana Suankratay Division of Infectious Diseases, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand

Background: Inappropriate use of for upper respiratory tract infection (URI) and frequently observed among patients in the outpatient department (OPD) can lead to increased rates of - resistant bacteria and an unnecessary increase in cost of treatment. At the OPD of the King Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand, the majority of antibiotics are prescribed by general practitioners and residents for patients with URI and acute bronchitis. Objective: To determine physician practices in prescribing antibiotics for adult patients with URI and acute bronchitis attending a major urban OPD. Material and Methods: This is a descriptive study of 379 cases involving adult patients with URI and acute bronchitis attending the OPD of KCMH from 1 October to 31 December 2010. Results: Of the 379 study patients, 126 (33.2%) were males and 253 (66.8%) females; the mean age was 42.5±16.1 years. There were 339 (89.4%) and 40 (10.6%) patients with URI and acute bronchitis, respectively. Of 339 patients with URI, there were 171 (50.4%) URI of multiple and unspecified sites, 91 (26.8%) with , 32 (9.4%) with nasopharyngitis, 19 (5.6%) with , 14 (4.13%) tonsillitis, and 12 (3.5%) patients with . One hundred and sixty-seven (44.1%) patients were treated by residents and 212 (55.9%) by faculty staff. Antibiotics were prescribed for 81.3% of cases; the rates were 73.7% by residents and 87.7% by faculty staff. The most commonly prescribed antibiotic was (127 patients, 41.2%), followed by amoxicillin/clavulanic acid (86 patients, 27.9%), and roxithromycin (60 patients, 19.5%). According to the multivariate analysis, the factors contributing to antibiotic prescription included the presence of sore , abnormal lung signs, and examination and treatment by non-Medicine residents and staffs. Conclusions: There is a very high rate of overuse of antibiotics for URI and acute bronchitis in our institute. Interventions to reduce the overuse of antibiotics are urgently needed.

Keywords: Acute respiratory tract infection, acute bronchitis, antibiotic, antibiotic prescription, Thailand

Most acute upper respiratory tract are can result in marked differences in the prevalence of caused by viruses including , adenovirus, antibiotic-resistant strains among various countries virus, and corona virus [1-3]. However, worldwide [7-9]. With this documented correlation inappropriate use of antibiotics for such infections is in mind, documenting the rates of unnecessary frequently observed among patients at the outpatient prescription for antibiotics is a useful indicator of rates department (OPD) [4-6] and can lead to increased of antibiotic resistant bacteria. rates of antibiotic-resistant bacteria with unnecessary The majority of antibiotics are prescribed by increases in the cost of treatment. The consumption general practitioners and residents for patients with of antibiotics is directly correlated with the frequency URI and acute bronchitis at the OPD of the King of resistant strains. The difference in consumption Chulalongkorn Memorial Hospital (KCMH), Bangkok, Thailand. The objective of the present study was to Correspondence to: Chusana Suankratay MD, PhD, Division of determine the rate of and factors contributing to Infectious Diseases, Department of Medicine Chulalongkorn University Hospital Bangkok, 10330 Thailand. antibiotic prescription for adult patients with URI and E-mail: [email protected] acute bronchitis attending at the OPD. 16 R. Issarachaikul, C. Suankratay

Method underlying illnesses including cardiovascular diseases Study design (57 patients; 15.04%), pulmonary diseases (19; 5.01%), A descriptive study was carried out in all adults and endocrinologic disorders (18; 4.8%). Among these with the diagnosis of URI and/or acute bronchitis 379 patients, there were 82 (21.6%) who were self- made in the OPD of KCMH from 1 October to 31 paying and 297 (78.4%) patients supported by the December 2010. This study was approved by the Social Security Office, the Nation Health Security Ethics Committee of the King Chulalongkorn Memorial Office, or the Comptroller General’s Department, Hospital, Faculty of Medicine, Chulalongkorn respectively. University. Clinical characteristics Patients Of 339 patients with URI, there were 171 (50.4%) The inclusion criteria included all adults older URI of multiple and unspecified sites, 91 (26.8%) with than 15 years with a diagnosis of URI and/or acute pharyngitis, 32 (9.4%) with nasopharyngitis, 19 (5.6%) bronchitis. All patients were treated on an ambulatory with sinusitis, 14 (4.13%) tonsillitis, and 12 (3.5%) basis. All medical records of these patients were patients with rhinitis. Of 379 patients, the most common identified by searching KCMH Outpatient Hospital symptom was cough (294, 77.9%), followed by sore Records for the disease codes based on International throat (289, 76.3%), serous nasal discharge (193, Classification of Diseases-10 (ICD-10) which include 50.9%), (188, 49.6%), (174, J00 acute nasopharyngitis (), J01 acute 45.9%), myalgia (121, 31.9%), non-purulent sputum sinusitis, J02 acute pharyngitis, J03 acute tonsillitis, (96, 25.3%), purulent sputum (77, 20.3%), purulent J06 acute upper respiratory tract infections of multiple nasal discharge (29, 7.7%), hoarseness of voice and unspecified sites, J31 acute rhinitis, and J40 acute (18, 4.8%), diarrhea (5; 1.3%), and conjunctivitis bronchitis. All data including epidemiology, clinical (4, 1.1%). The most common sign was pharyngeal features, and treatment were analyzed. injection (126 of 168 patients, 74.6%), followed by nasal turbinate swelling (255 of 378 patients, 67.5%), Statistic analysis body temperature of >37.9°C (255 of 378 patients, The study was designed to determine the antibiotic 67.5%), tonsillar injection (37 of 378 patients, 9.8%), prescription rate in adults with URI and/or acute abnormal lung signs (wheezing, rhonchi, or crackles) bronchitis. Assuming the prescription rate was 56% (22 of 369 patients, 5.96%), cervical in the KCMH institute (unpublished data from a recent (14 of 80 patients, 17.5%), on (8 of pilot study), a sample size of 379 patients was required. 378 patients, 2.1%). This calculation was based on the assumption that alpha and beta errors were 0.05 and 0.20, respectively. Antibiotic prescription rate The Pearson Chi-square test or Fisher’s exact test Of 379 patients, 167 (44.1%) were treated by was used to compare categorical variables. The residents and 212 (55.9%) patients were treated by variables, which were significantly different between faculty staff. There were no staff members from the the two groups in the univariate analysis, were then Medicine Faculty in the present study. However, in tested by the binary logistic regression model for the comparing their prescription practices with Medicine multivariate analysis. All P values were two-tailed with residents, they were found to be more likely to those of less than 0.05 considered statistically prescribe antibiotics. Three hundred and eight patients significant. The SPSS software version 17 was used had received antibiotics, accounting for 81.3% for the analyses. prescription rate, 73.7% residents and 87.7% of 212 faculty staff prescribed antibiotics. The highest rate Results of antibiotic prescription was noted in non-Medicine Patient demography residents (91 of 101 patients, 90.01%), followed by During the study period, there were 379 patients non-Medicine staff (186 of 212 patients, 87.7%) and (126 (33.2 %) males and 253 (66.8 %) females) with Medicine residents (32 of 66 patients, 48.5%) as shown the mean age of 42.5±16.1 years (Table 1). One in Table 1. hundred and twenty-one patients (31.9 %) had Vol. 7 No. 1 Antibiotic prescription for adults with upper respiratory tract infection 17 February 2013 and acute bronchitis

Table 1. Baseline characteristics of 379 patients with upper respiratory tract infection and acute bronchitis

Factors Number (%) Antibiotic prescription Number (%)

Age group (years) 15-44 223 (58.8) Yes 186 (83.4) No 37 (16.6) 45-65 116 (30.6) Yes 93 (80.2) No 23 (19.8) >65 40 (10.6) Yes 30 (75) No 10 (25) Sex Male 126 (33.2) Yes 104 (82.5) No 22 (18.5) Female 253 (66.8) Yes 205 (81.03) No 48 (18.97) Underlying CVS1 57 (15.04) Yes 43 (75.4) condition No 14 (24.7) Lung2 19 (5.01) Yes 17 (89.5) No 2 (10.5) Endocrine3 18 (4.8) Yes 14 (77.8) No 4 (22.2) CNS4 10 (2.6) Yes 6 (60) No 4 (40) HIV infection 5 (1.3) Yes 5 (100) No 0 (0) Malignancy5 5 (1.3) Yes 4 (80) No 1 (20) Immunocompromised6 2 (0.5) Yes 2 (100) No 0 (0) Others7 8 (2.11) Yes 5 (62.5) No 3 (37.5) Health insurance Supported payment8 297 (78.4) Yes 254 (85.5) No 43 (14.5) Self payment 82 (21.6) Yes 55 (67.07) No 27 (32.9) Physician Non-Medicine staff 212 (55.9) Yes 186 (87.7) No 26 (12.3) Non-Medicine residents 101 (26.7) Yes 91 (90.01) No 10 (9.99) Medicine residents 66 (17.4) Yes 32 (48.5) No 34 (51.5)

1CVS: cardiovascular disease: hypertension, ischemic heart disease 2Lung (respiratory tract and pulmonary disease): , chronic obstructive pulmonary disease, 3Endocrine (endocrinologic disorders): diabetes mellitus, dyslipidemia, Graves disease 4CNS (central nervous system): stroke, myasthenia gravis 5Malignancy: hematologic and nonhematologic malignancy 6Immunocompromised: those receiving immunosuppressive drugs including steroid, cyclophosphamide 7Others: idiopathic thrombocytopenia, rheumatoid arthritis, mixed connective tissue disease 8Payment supported by the Social Security Office, the Nation Health Security Office, or the Comptroller General’s Department 18 R. Issarachaikul, C. Suankratay

The most commonly prescribed antibiotic was diseases with an overwhelmingly viral etiology (>85% amoxicillin (127 patients, 41.2%), followed by in some studies). A study in 2001 at Siriraj Hospital amoxicillin/clavulanic acid (86, 27.9%), roxithromycin [10] showed that the antibiotic prescription for adults (60, 19.5%), cefdinir (13, 4.2%), /sulbactam with URI before and after implementation of clinical (7, 2.3%), cefuroxime (3, 0.97%), clarithromycin practice guidelines of antibiotic treatment for adults (3, 0.97%), cefuroxime and ciprofloxacin (2, 0.7% with URI was 86.0% and 31.1%, respectively. A each), and levofloxacin (1, 0.3% each) recent study in India also showed the antibiotic (Table 2). prescription rate for common outpatient illnesses was An estimate of antibiotic cost per visit was 81.8% [11]. In Japan, the prescription rate was 60% approximately THB 113.2 (USD 3.68) per case, for URI [12]. The prescription of antibiotics especially accounting for 53.98% of a total cost of treatment. in the OPD varies among different countries in Europe. According to univariate analysis, ten factors The rates are very low in Scandinavian countries, significantly contributed to antibiotic prescription compared with South Europe. In Norway, the antibiotic (p <0.05): patients with self payment; those diagnosed prescription rates were 18% and 64% for URI and as acute nasopharyngitis (common cold), acute acute bronchitis, respectively [13]. In Denmark, the sinusitis, and acute pharyngitis, those with , prescription rates were 57%, 38%, and 42% for acute pharyngeal injection, tonsillar injection, and abnormal sinusitis, tonsillitis, and bronchitis, respectively [14]. lung signs, and those treated by non-Medicine In contrast, in Spain the antibiotics were prescribed in residents. 65%, 62%, and 60% of the patients with acute sinusitis, According to the multivariate analysis, the factors tonsillitis, and bronchitis, respectively [14]. In the contributing to antibiotic prescription included the United States, the antibiotic prescription rates varied presence of sore throat, the presence of abnormal depending on the institute and the year studied. A study lung signs, and being treated by non-Medicine by the National Ambulatory Medical Care Survey in residents. 1992 described the antibiotic prescription rate varied from 3% to 12% for different kinds of URI, and was Discussion 11% for acute bronchitis [15]. A chart review from In the present study, an overall antibiotic 2003 to 2004 in the United States showed the rates prescription rate for adult patients with URI and acute were 38% and 72% for URI and acute bronchitis, bronchitis was 81.3%, which is very high for treating respectively [16]. A recent study by the National

Table 2. Rate and type of antibiotic prescription

Antibiotics Number (%)

Beta-lactams Total 238 (77.3) Amoxicillin 127 (41.2) Beta-lactam/beta-lactamase inhibitor 93 (30.2) Amoxicillin/clavulanic acid 86 Ampicillin/sulbactam 7 Oral 18 (5.8) Cefdinir 13 Cefuroxime 3 Cefditoren 2 Total 64 (20.8) Roxithromycin 60 Clarithromycin 3 1 Total 3 (0.97) Fluoroquinolones Total 3 (0.97) Ciprofloxacin 2 Levofloxacin 1 Total 308 (81.3) Vol. 7 No. 1 Antibiotic prescription for adults with upper respiratory tract infection 19 February 2013 and acute bronchitis

Ambulatory Network Study from 1998 to 2003 residents and still indicated a higher rate of antibiotic showed the rates of antibiotic prescription were 65% prescription among non-Medicine care-givers. This and 78% for URI and acute bronchitis, respectively observation is consistent with the previous studies in [17]. A recent study from 2003 to 2004 at Pittsburgh the United States [18] and Norway [13] which showed showed that the prescription rates were 16% and 78% that a well-trained physician prescribed antibiotics less for URI and acute bronchitis, respectively [18]. In frequently than a general practitioner. In addition, the conclusion, the antibiotic prescription rates for URI very high rate of antibiotic prescription in the present and acute bronchitis are very high in our institute and study may be due to the high proportion of patients both developing and developed countries in Asia as treated by non-Medicine doctors. However, some well as in South Europe, compared with low rates in studies have shown that being a specialist was the Scandinavian countries and most hospitals in the strong predictor for prescription of a broad-spectrum United States. However, the prescription rates are antibiotic, compared with a general practitioner [13, still very high for acute bronchitis in most countries 19, 20] worldwide. In the present study, there was a higher antibiotic Amoxicillin was the most commonly prescribed prescription rate in the patients with supported payment antibiotic in the present study, followed by amoxicillin/ than self-payment. This observation is interesting and clavulanic acid and roxithromycin. A study in India could be due to either the practice of the care-giving showed that the most commonly prescribed antibiotic doctor and/or the demand from the patient. was a (28.6%), followed by a sulfa (21.9%) The present study has some limitations. Some and a fluoroquinolone (19.5%) [11]. In Japan, a third- important data including pertinent symptoms and generation was the most commonly physical signs, the attitude and knowledge of caring prescribed antibiotic (46%), followed by a physicians regarding management of URI and acute (27%) and a quinolone (16%) [12]. In Norway, 37% bronchitis, and the request for antibiotics by patients of the patients treated for URI and acute bronchitis were not available. In addition, there were too small were prescribed penicillin V and 28% a macrolide number of patients who were treated by Medicine [13]. In Denmark, a narrow-spectrum penicillin was residents and no patients treated by Medicine faculty the most commonly prescribed drug (58%), followed staff. Hence, our results should be interpreted with by a macrolide (29.0%) and a broad-spectrum caution regarding both physician- and patient-related penicillin [14]. In Spain, the most commonly prescribed factors influencing the rate of antibiotic prescription. antibiotic was a broad-spectrum penicillin (62.3%), In conclusion, there is a very high rate of overuse followed by a macrolide (22.3%) and a quinolone of antibiotics in our institute. Interventions to reduce 96.7% [14]. A study in the United States from 1998 the overuse of antibiotics is urgently needed. In addition, to 2003 showed that broad-spectrum antibiotics studies regarding the reasons for prescribing antibiotic (cephalosporins, new generation macrolides, and should be carried out in the future, along with a respiratory quinolones) were the most frequently program to educate all doctors regarding the indications prescribed (56%) [17]. In conclusion, a narrow- for antibiotic use in all cases of upper respiratory spectrum penicillin is the most frequently prescribed infection and acute bronchitis. antibiotic in our institute, India, and Scandinavian countries, compared with a broad-spectrum penicillin/ Acknowledgements cephalosporin commonly prescribed in Japan, South The authors are thankful to all health personnel of Europe, and the United States. The difference in the the OPD of King Chulalongkorn Memorial Hospital type of antibiotic prescribed among different countries who assisted in obtaining all medical records of the may be due to several factors including knowledge of patients. The authors have no conflict of interests to the care provider, local data regarding etiologic agent declare. and susceptibility pattern, and the cost of the antibiotic. In the present study, non-Medicine doctors both References staff and residents were more likely to inappropriately 1. Makela MJ, Puhakka T, Ruuskanen O, Leinonen M, prescribe antibiotics for URI and acute bronchitis. As Saikku P, Kimpim ki M, et al. Viruses and bacteria in stated above, since there were no Medicine faculty the etiology of the common cold. J Clin Microbiol. staff in the study, the prescribing practices of non- 1998; 36:539-42. Medicine faculty were compared with medicine 20 R. Issarachaikul, C. Suankratay

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