Evaluation of Antibiotic Prescription for Upper Respiratory Tract Infections in the Community Pharmacy Setting

Objectives: To empirically classify the etiology of URTI; to study the prescription pattern for antibiotics in URTI; and to analyze the necessity and adequacy of prescribed therapy. Study design: Observational non analytical cross-sectional study. Study sites: Two community pharmacies located in Almada and in Elvas. Study population: Patients with an antibiotic prescription for a URTI (self use) and age greater than or equal to 18 years. Methods: Clinical and therapeutic data were collected during patient observation performed by a training pharmacist, and complemented with information collected through a questionnaire administered face-to-face to patients meeting the inclusion criteria and agreeing to participate. Empirical classifications were developed, one to ascertain the probability of URTI, based on Centor criteria, and another, to judge the need for antibiotic therapy, based on additional criteria considering subpopulations known to be at higher risk. Data was analyzed using the software SPSS, version 20.0. Results: The sample included 22 patients (27.3% recruited in Almada and 72.7% in Elvas). The most frequently prescribed antibiotic class was macrolides (54.5%), followed by penicillins (36.4%). In the first group, clarithromycin prevailed (66.7%) and in the second group, the more common was the association amoxicillin/clavulanic acid (75%). Considering the empirical classification developed, it was estimated that only one patient (4.5%) presented signs and symptoms suggestive of URTI with probable bacterial aetiology, and only three patients (13.6%) had an indication for antimicrobial therapy. Conclusion: The majority of patients observed were classified as having infections with apparently non-bacterial aetiology, for which the prescription of antibiotic would have been probably needless. This alerts to the overuse of antibiotics in the community setting, particularly for URTI, and its contribution to resistance. *Corresponding author: Filipa Alves da Costa, Pharm D, PhD, CiiEM (Interdisciplinary Research Centre Egas Moniz) Assistant Professor, Instituto Superior de Ciências da Saúde Egas Moniz (ISCSEM), Portugal, Email: [email protected] Citation: da Costa, F.A., et al. Evaluation of Antibiotic Prescription for Upper Respiratory Tract Infections in the Community Pharmacy Setting. (2015) J Pharm Pharmaceutics 2(1): 29-34. Evaluation of Antibiotic Prescription for Upper Respiratory Tract Infections in the Community Pharmacy Setting Telma Mangerico, Filipa Alves da Costa*, Patrícia Cavaco Silva Received date: September 18, 2015 Accepted date: December 14, 2015 Published date: December 18, 2015 DOI: 10.15436/2377-1313.15.009 da Costa, F.A., et al. J Pharm Pharmaceutics | volume 2: issue 1 Although it is relatively difficult to establish a differential diagnosis in pharyngitis, the Centor criteria are highly recognized and commonly used during patient observation. These criteria consider the signs and symptoms most commonly involved in pharyngitis, which can be summarised by: presence of pharyngeal exudates, anterior cervical adenopathy, fever and the absence of cough. Consequently, in the presence of at least three of these features, it is possible to predict that the infection is probably of bacterial origin[6]. Rhinosinusitis can be classified as acute sinusitis, when the duration of the symptoms is less than one month; subacute, when the symptoms persist for twelve weeks, and chronic when exceeding twelve weeks. Sinusitis may also be classified as recurrent when the individual presents four or more episodes per year[7]. Antibiotic treatment instituted in these URTI is essentially empirical since the microbiological diagnosis is rarely made, due to the time limitations, difficulty in obtaining clinical samples (sinusitis) and costs of rapid tests (e.g. rapid antigen detection test for group A streptococcus)[8,9]. Taking into account that URTI are frequently caused by respiratory viruses, antibiotic therapy proves to be unnecessary in most of the cases. Nevertheless, antimicrobials are used mainly to prevent potential complications that may arise from non-antibiotic indication. In Portugal, primary care prescription focuses mainly on beta-lactamic antibiotics, especially the association amoxicillin/clavulanic acid[10]. Antibacterial therapy may be beneficial to avoid the development of suppurative complications such as tonsillitis, sinusitis, otitis media and cellulite, however delayed antibiotic therapy can be similarly effective in preventing complications when compared to immediate and empirical prescription[6,11,12] . Furthermore, antimicrobials are indicated in certain circumstances, such as patients who have complications (e.g. pneumonia and mastoiditis), who have a higher risk of developing complications (e.g. renal impairment) and elderly over 65 with cough and presenting two or more Centor criteria, or elderly over 80 with diabetes mellitus, hospital admission in the preceding year, history of heart failure, or under oral glucocorticoid treatment[13]. This study has focused on pharyngitis and sinusitis because these are the leading causes of acute morbidity in adults in primary care and, the majority of cases for which antimicrobials are prescribed[2]. Also, URTI are differently expressed in children due to their susceptibility to bacterial otitis media, associated with Eustachian tube dysfunction and immaturity of the immune system[2-4]. Thereby, the main objective of this study was to evaluate the need for antibiotic treatment, considering the presence of symptoms and previously known risk factors. Two research questions were formulated: “Is the aetiology of the infection, in case of antibiotic prescription, probably of bacterial origin?” and, “Is the prescribed antibiotic therapy for the treatment of URTI, necessary?”