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Antibiotic Prescribing in Upper Respiratory Tract Infections (URIs):
Patterns and Predictors of Physician Prescribing in Health Centers in Bangkok
Suttajit Sa, Tantipidoke Ra, Sitthi-amorn Ca, Wagner Ab, Ross-Degnan Db.
aChulalongkorn University, Bangkok; bHarvard Medical School, USA
Problem Statement: Unnecessary use of antibiotics leads to drug resistance and increased
health expenditures, which are important problems for low-income and high-risk communities.
Objectives: To measure patterns of and to find predictors contributing to antibiotic
prescribing for adults with URIs.
Study Population: From 2 Bangkok Metropolitan Administration health centers, all
prescriptions from 2001 written by physicians for patients over 18 years old diagnosed with
URI/cold, pharyngitis, tonsillitis, sinusitis, or otitis media were selected and reviewed.
Outcome Measures: % antibiotics prescribed, patterns of treatment for different
diagnoses, % compliance with national treatment guidelines, and factors contributing to
antibiotic use.
Results: Although 91% of the cases were likely to be viral URIs, 63% of all patients were
prescribed antibiotics: 60% for viral and 89% for bacterial cases. Amoxicillin was the most
frequently prescribed antibiotic regardless of diagnosis. Predictors of antibiotic prescribing
differed for viral and bacterial URIs. Those viral URIs cases who were young, male, and selfpaying patients were more likely to receive antibiotics; part-time physicians were more likely
to prescribe antibiotics for these patients. Among patients with, bacterial URIs, self-paying
patients were more likely to receive antibiotics. Compliance with the national treatment
guidelines was 36.4% for treatment of viral URIs and 2% for bacterial URIs.
Conclusions: There is overprescribing of antibiotics for viral URI patients. In bacterial
cases, drugs of choice were not prescribed for adequate treatment duration. Appropriate
interventions should be designed and implemented at health centers in Bangkok.
Introduction
Most upper respiratory tract infections (URIs) are
caused by viruses, and antibiotics are not recommended
in their treatment. Unnecessary antibiotic use leads to
drug resistance and increased health expenditures.
These are important problems for developing countries,
including Thailand. Problems even become more
significant in congested households of low-income and
high-risk communities with high incidence of HIV/AIDS,
multi-drug resistant TB, and drug addiction as in our
study area.
However, recent review highlights the lack of study on
factors contribute to inappropriate antibiotic use in
developing countries.
Objectives
In order to understand the problem and be able to
designing effective interventions to improve
antibiotic prescribing, the aims of this study are:
1. To measure patterns of antibiotic
prescribing for adults with URIs, and
2. To find predictors contributing to the
prescription of antibiotics for URIs.
Methods
Design
Cross-sectional study.
Setting and Study Population
Two health centers in Bangkok, Thailand that
served poor and congested communities.
All
prescriptions from 2001 written by 19 physicians
for patients over 18 years old diagnosed with
URI/cold, rhinitis, pharyngitis, tonsillitis, sinusitis,
or otitis media were reviewed.
Methods
Definition of Appropriate Treatment
We classified treatments according to the National
Standard Treatment Guideline for Respiratory
Tract Infections (MoPH, 1996).
Analysis
Data were managed and analyzed using SPSS for
Windows 12.0 and SAS 8.02.
Chi-square and Student’s t-test were applied where
appropriate. A P-value <0.05 was considered
statistically significant. We developed multilevel
models1 to adjust for clustering by provider while
examining predictors of antibiotic prescribing in
viral and bacterial URIs.
1 Guo
G & Zhao H. (2001). Multilevel modeling for binary data. Annual Review of Sociology, 26, 441-62.
Results
1
In 2001, 4,608 adult URIs patients visited the health
centers. There was no seasonal pattern of URIs. Almost all
(97.9%) patients received a prescription, resulting in 4,512
prescriptions for analysis.
Characteristics of Physicians
(n=19)
Half of the physicians were women and in middle age.
Most of them had practiced >10 years and were GPs.
Only 4 physicians worked full-time.
Characteristics of Patients
(n=4,512)
Female
70.3 %
Bacterial URIs
Age 18-40
41-60
> 60
Self-payment
45.7 %
29.9 %
24.4 %
57.6 %
Pharyngotonsillitis
Otitis Media (OM)
Sinusitis
Viral URIs
9.0 %
6.8 %
2.0 %
0.2 %
91.0 %
Results
2
Pattern of Drug Prescribing
Nearly all patients received drug, except only 13 patients
with viral URIs. Physicians treated viral and bacterial
URIs differently.
Table 1. Drug prescribed for URIs patients
Drug prescribed
Antibiotics
Analgesics/Antipyretics
Antihistamines
Mucolytics
Cough suppressants
Vitamins
Viral URIs (n=4107)
Bact.URIs (n=405)
60.3 %
72.6 %
68.3 %
44.9 %
32.9 %
20.4 %
89.4 % *
81.0 % *
33.3 % *
48.9 % *
43.2 % *
11.4 % *
Mean no. of drugs/Rx
3.20+1.07
3.67+1.26*
Median Rx cost (baht)
with antibiotics
with no antibiotics
44
59
16
76*
78*
16
*p<0.05
Results
3
Appropriateness of Antibiotics Prescribing
Compliance with the national treatment guideline was 36.4%
for viral URIs treatment and 2.0% for bacterial URIs.
Table2. Antibiotics prescribed among antibiotic recipients
Antibiotics prescribed
Penicillin V
Erythromycin
Amoxycillin, Ampicillin,
Amoxycillin+Clavulanate K
Cotrimoxazole
Doxycyclline
Roxithromycin
Dicloxacillin/cloxacillin
Tetracycline
Chloramphenicol
1
2
URIs 2 Pharyngotonsillitis
(n=2247)
2.4 %
3.0 %
70.6 %
3.1 %
0.8 %
6.3 %
9.7 %
3.9 %
0.4 %
(n=275)
1
OM 2
(n=70)
2.9 %
1.1 %
71.3 %
4.3 %
2.9 %
44.3 %
3.3 %
0.7 %
13.5 %
5.1 %
1.8 %
0.7 %
7.1 %
5.7 %
32.9 %
35.7 %
only patients with no other diagnosis than URI
totals may sum to more than 100% because some patients received >1 antibiotic
appropriate antibiotic use
Results
4
Factors Associated with Antibiotic Prescribing
●For Viral URIs
Characteristics of
patient
Gender: Male
Female
Age: 18-40 yr.
41-60 yr.
>60 yr.
Type of payment
National health plan
Self-payment
Physician working time
Part-time
Full-time
●For bacterial URIs
Antibiotic
prescribed (%)
64.9%
58.4%
68.9%
59.4%
46.5%
Adjusted OR
(95%CI)
1.47 (1.26-1.72)
Referent
3.62 (2.92-4.50)
2.17 (1.74-2.68)
Referent
65.5%
53.5%
1.19 (1.00-1.40)
Referent
62.8%
51.0%
2.58 (0.85-7.85)
Referent
Only payment status was a significant predictor
(OR, 2.17, 95% CI, 1.15-4.09)
Discussions
What’s New?
This study adds to the research society about study
in developing country and in adults, and determinants
of antibiotic prescribing in viral and bacterial URIs.
Limitations
Potential misclassification of diagnoses, probably of
overestimate of inappropriate use of antibiotic.
However, there still a significant antibiotics overuse.
Application of the results
Results of the study were used in designing of
intervention, which is now implementing at the health
center. For examples, treatment guideline, diagnosis
rubber stamps, physician order forms, and follow up
the outcome of delaying antibiotic prescribing.
Conclusions
Physicians in the congested study communities
treated viral and bacterial URIs cases differently
and the predictors of antibiotic prescribing differed
for viral and bacterial URI treatment.
Patients with viral URIs frequently received
antibiotics and patients with bacterial URIs
frequently received inappropriate antibiotics, which
leads to economic burden on the system and patients
as well as increased drug resistance.
Interventions to promote rational use of antibiotics
in these communities are urgently needed and
evaluated their effect.
Acknowledgement
We thank Ms. Ratana Somrongthong for her
continuing support coordinating the project. We also
thanks Dr. Pricha Jarusunthornsri, Mr. Weerapong
Pinweera, physicians and the staff at the study BMA
health centers for facilitating access to their data.
Funding organizations:
Thailand Research WHO Essential Drugs and
Fund
Medicines Policy Department
Applied Research on
Child Health