A pharmacoepidemiological study of prescription pattern for upper respiratory infections in a tertiary health care center.

pper respiratory tract infections (URTIs) constitute one of the most common causes of seeking medical advice, both in primary health care and in the hospital environment.1,2 Most of these infections are caused by viruses, and usually do not require treatment with antibacterial agents. Symptomatic treatment to reduce patient suffering may be all what is required.1,2 Irrational prescribing of antibacterial agents for URTIs, especially those caused by viruses such as common cold and viral pharyngitis, is a worldwide problem.3 The excessive and irrational use of antibacterial agents has been implicated as one of the main causes of the emergence of bacterial resistance to antibiotics.4 Several current clinical practice guidelines for the use of antibiotics in URTIs are available.1 This work was designed to collect information on the pattern of prescriptions for URTIs in a tertiary health care setting located within the Southwestern part of Saudi Arabia. The purpose of the work was to identify deficiencies and provide suggestions for a more rational prescription behavior for URTIs. All outpatient prescriptions from within the hospital, irrespective of the clinic of origin, received by and kept in the pharmacy were the target of the study. One-year prescriptions during the period 8th April 2000 until 7th April 2001 were analyzed retrospectively. This period was divided into 4 seasons: spring, summer, fall and winter. One week (5 working days) of each season was sampled randomly and systemically as every other prescription. Of these, all prescriptions with a diagnosis of URTI, common cold, influenza, rhinitis, otitis media, sinusitis, tonsillitis, pharyngitis or cough were analyzed for the type and number of drugs prescribed. When a combination product was prescribed, its components are counted as separate entities. The local "Ethics Committee" at Aseer Central Hospital approved the study. The data generated were fed to the SPSS program and simple descriptive statistics were used to analyze the results. A total of 3796 prescriptions were reviewed, 905 (23.8%) of which carried a diagnosis of either an unspecified URTI, common cold, influenza, rhinitis, pharyngitis, otitis media, sinusitis, tonsillitis or cough. The majority of prescriptions (75.6%) carried the diagnosis URTI without specifying the type, while 15.3% carried the diagnoses otitis media, sinusitis and tonsillitis. The age group distribution of the prescription included 35% for the pediatric age group and 19.2% for adults, while such information was missing in 45.7% of prescriptions. The most frequently prescribed drug groups were in descending order: paracetamol was present in 77.9% of prscriptions, antibacterial agents in 67.5%, histamine H1-receptor antagonists in 59.8%, and decongestants (α1-adrenoceptor agonists) in 33.1% of prescriptions. Prescriptions of antipyretics for patients with URTI are considered appropriate to alleviate fever and are a reasonable symptomatic treatment. The most frequently prescribed antibacterial agents were penicillins (50.5% of all prescriptions), especially amoxicillin, and in few cases, ampicillin , penicillin V or penicillin G, followed by macrolides (5.3%), cephalosporins (first generation and cefuroxime) (5%), and cotrimoxazole (2.3%). Other antibacterials and various other combinations of antibiotics appeared in 4.4% of all prescriptions. Antibiotics prescribed according to the type of URTI are presented in Table 1. Our finding of 65.2% of prescriptions for unspecified URTI containing antibacterial agents is close to the 52% figure reported by Gonzales et al.3 Prescribing of antibacterial drugs for unspecified URTI, although difficult to assess, does not seem to be appropriate as the site of URTIs can be identified in many cases on clinical ground alone, and it seems that many physicians are not keen on being more specific. Our finding that 17.5% of prescriptions labeled with common cold and other viral causes of URTI as a diagnosis received antibacterial agents is less than percentages of 51% and 40-60% which have been reported by Gonzales et al3 and Mainous et al,5 respectively. It is not acceptable to prescribe antibacterial drugs for viral causes of URTI. Although some prescribers believe that their use could prevent secondary bacterial infections, it has been shown that amoxicillin/clavulanic acid is ineffective in preventing otitis media in children with viral URTI, even in susceptible patients.6 Although pharyngitis is mainly caused by viruses, 88.5% of prescriptions labeled with pharyngitis as a diagnosis contained antibacterial agents with amoxicillin (and in few cases ampicillin) being the most frequently prescribed (65.4%). Such antibiotics will be justified for bacterial causes of pharyngitis such as Streptococcus pyogens. Our finding that 95.1% of prescriptions labeled with otitis media and sinusitis and 97.4% of prescriptions labeled with tonsillitis receiving antibacterial agents is reasonable since these infections are mainly caused by bacteria. In both situations, amoxicillin was the most frequently