Advances in Biomedicine and Pharmacy (An International Journal of Biomedicine, Natural Products and Pharmacy)

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1 ISSN: Adv. Biomed. Pharma. 2:6 (2015) Advances in Biomedicine and Pharmacy (An International Journal of Biomedicine, Natural Products and Pharmacy) Case Study Upper respiratory tract infections in UAE: Prescription of antimicrobials and physician s behaviour- A case study. Abduelmula R Abduelkarem* 1 and Eman Abu-Gharbieh 2 1 Pharmacy Practice and Pharmacotherapeutics Department, College of Pharmacy, University of Sharjah, UAE. 2 Department of Pharmacology and Toxicology, Dubai Pharmacy College, Dubai , UAE. *Corresponding Author: Abduelmula R Abduelkarem Pharmacy Practice and Pharmacotherapeutics Department, College of Pharmacy, University of Sharjah, UAE. address: aabdelkarim@sharjah.ac.ae; Tel., Running Title: Upper Respiratory Tract Infections in UAE Received: 12 August, 2015; Revised: 08 December, 2015 Accepted: 17 December, 2015 Available online at Abstract Upper respiratory tract infections are considered among the most frequent causes for visiting physician s office. The aim of present study was to investigate the physicians behavior in prescribing antibiotics for the management of URTI in UAE. Cross sectional survey was conducted over four months on 45 physicians from different specialties. The Physician's first drug of choice for acute tonsillitis and otitis media was amoxicillin-clavulinate, and amoxicillin was first choice for acute sinusitis. Though, amoxicillin, cefixime and amoxicillin-clavulinate were the second frequently prescribed antibiotics for acute tonsillitis, otitis media and acute sinusitis respectively. The least prescribed drug for acute tonsillitis were neomycin and azythromycin for otitis media and ciprofloxacin for acute sinusitis. Factors affecting physician s prescribing pattern were found to be related with the convenient dosing. Similar agreement response was observed with cost-effectiveness, safety and tolerability factors. Amoxicillin and amoxicillin-clavulinate were the preferred agent for the UAE physicians for all URTIs. Absence of local or regional guidelines and hospital formulary may attribute to the irrational use of antibiotics in UAE. Therefore policy of antibiotic prescribing should be applied strictly and pharmacy role at dispensing and prescribing stages should be regulated in a strict manner. Keywords: Upper Respiratory Tract Infection; amoxicillin-clavulinate; cost effectiveness. Introduction Respiratory tract infections are considered among the most commonly encountered illnesses and in particular, upper respiratory tract infections (URTIs) are one of the most common reasons for patient counseling in primary health care [1,2]. This is mainly due to the presence of over 200 pathogens that can cause URTI, these types of pathogens are extremely contagious and are spread by direct contact, such as shaking hands, sharing food or drink, and kissing [3]. URTIs usually affect daily activities and make an individual to spend more time in bed. Definitely, URTIs alone will not cause permanent sequelae or death, but still they may serve as a gateway for adjacent organs infection, resulting in otitis media, bronchitis, bronchiolitis, pneumonia, sepsis, meningitis, intracranial abscess, and other infections. Serious complications may result in clinically significant morbidity and rare deaths [3]. Most people have a minimum of two colds per year and URTIs affect 3% of children every year [4]. In UAE, upper respiratory tract infections are in the top list of the most common cases at hospitals and clinics, however it could be attributed to the changes in the environmental conditions like high temperature and humidity that affect the natural defense system [5]. 260

2 Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 Abduelkarem and Abu-Gharbieh. Antibiotics are usually prescribed for treatment of bacterial upper respiratory tract infections to speedup recovery of URTI. About two-thirds of antibiotic prescriptions in general practice are for respiratory tract infections (RTIs) [6]. Over the last decade, general practitioners (GPs) have been encouraged to prescribe more rationally and to follow evidence-based guidelines while prescribing antibiotics [6]. Despite the fact that many studies around the world have extensively looked at this point in particular, there is a lack of research targeting the factors influencing the antibiotic prescribing by physicians in our target areas of the UAE. Thus the aim of this study was to investigate the physicians behavior in prescribing antimicrobial agents for the management of URTI in UAE. Materials and Methods Setting and sample size Over the period of four months (December 2009 to March 2010) a cross sectional survey study was carried out using a pre-tested questionnaire. To assess the factors which influence physician antibiotic selection for URTI, a total of 45 physicians from different specialties (pediatricians, general practitioners, ENT) who were practicing in different in medical centers and private clinics were approached directly by the researcher and invited to take part in this study. Data collection Data was obtained from different medical centers and private clinics over a period of four months and was retrospectively analyzed. The study is based on random samples of visits to non federally employed office-based physicians who are primarily engaged in direct patient care. Physicians were provided with survey materials and instructions, and each physician recorded the data depending on the appropriate antibiotic for each case. The survey also provides statistics on the demographic characteristics of physicians including information about their name, specialty, last medical certificate and the number of years in practice. Questionnaire development The Questionnaire focused on the factors that influence physician antibiotic selection for URTI. It consists of three questions as: current prescribing habits, prescribing criteria and the period suggested for each case to be prescribed in form of tables, ranks and numeration. The selection of factors within the questionnaire was based on the aim of the study. Statistical Analysis Statistical analyses were performed using statistical software IBM SPSS v20.0. Prescribing antibiotics was the basic dependent variable. Adjusted odd ratios and 95% confidence intervals for the probability of prescribing antibiotics were calculated for each predictor. The stepwise selection procedure was used for entering independent variables into the model, and only those variables that met the 0.05 significance entry level were reported. Results A total of 45 physicians agreed to participate in the study from Dubai, Sharjah and Ajman were interviewed over the six months of the study period (from October to April). More than three fourths of the respondents (n=36, 76%) practice in Sharjah or Ajman area. More than half of the physician (n=25, 56%) included in the study described their current clinical practice as Ear, Nose and Throat (ENT). Bachelor of Medicine and Surgery MB BCh as a medical degree was the main ultimate degree for the twenty six (60%) of the physician under the study. More than half (n=23, 51%) of the pooled sample had been in practice for more than 15 year, but less than 30 years. Complete frequency and percentages for the participants area of practice, specialty, degree, number of year in practice are summarized in Table 1. Physician's first drug of choice for acute tonsillitis and otitis media was Augmentin in 73% and 53% of them respectively, while Amoxil was first choice for acute sinusitis in about one third of the respondents as shown in Table 2. Though, Amoxil (71%), Suprax (36%) and Augmentin (40%) were the second frequently prescribed antibiotics for acute tonsillitis, otitis media and acute sinusitis respectively. While the least prescribed drug for acute tonsillitis was Neomycin (29%), Zithromax (40%) for otitis media and Ciprobay (56%) for acute sinusitis. Percentages and frequencies of prescribed antibiotics for acute tonsillitis, acute sinusitis and otitis media infections are shown in Table

3 Least Prescribed Second Frequent Prescribed Most Frequently Prescribed Number of years In practice Last Medical Certificate City Specialty Upper Respiratory Tract Infections in UAE Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 Table 1: Demographic characteristics of the physicians. Variables N (%) General Practitioners (GP) 10 (22.2) ENT 25(55.6) Pediatricians 10 (22.2) Dubai 11 (24.4) Sharjah 25(55.6) Ajman 9 (20.0) MBBCH 27 (60.0) MSC/diploma 14 (8.9) MD 4 (31.1) year 23 (51.1) > 30 years 3.0 (6.7) < 30 years 19 (42.2) Table 2: Percentages and frequencies of prescribed antibiotics for acute tonsillitis, acute sinusitis and otitis media infections. Variables Brand Name Generic name N (%) Acute tonsillitis Augmentin Amoxicillin and clavulanic acid 33 (73.3) Acute sinusitis Amoxil Amoxicillin 14 (31.1) Otitis media Augmentin Amoxicillin and clavulanic acid 24 (53.3) Acute tonsillitis Amoxil Amoxicillin 32 (71.1) Acute Sinusitis Augmentin Amoxicillin and clavulanic acid 18 (40) Otitis Media Suprax Cefixime 19 (35.6) Acute tonsillitis Neomycin Neomycin 13 (28.9) Acute sinusitis Ciprobay Ciprofloxacin 18 (55.6) Otitis Media Zithromax Azythromycin 25 (40.0) 262

4 amount of sample given inviting you to conference s and seminars regular rep visit no drugdrug interaction. rapid onset of action Safe and tolerable Cost Effective Simple & convenient drug doses Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 Abduelkarem and Abu-Gharbieh. Table 3 summarizes the physicians prescribing criteria and factors affecting prescribing habits. The interviewed physicians were also asked about prescribing criteria, more than 50% reported that it's important to give a drug in simple and convenient doses, around 46.7 % agreed that it is important to consider antibiotic cost-effectiveness while prescribing, about half of them said that it is very important to give a drug that is safe and tolerable with low incidence of side effects. About half of the physicians (53.3 %) stated that sometimes they consider the onset of action of drug while prescribing. More than half of physicians (58%) approved that it's important to give a drug with no significant drug-drug interaction. Moreover, they were asked regarding the factors affecting prescribing habits, 62.5% stated that it is to some extent important to have regular medical representative visits for a particular drug. About 67% see it is sometimes important to be invited to conferences and seminars held by drug companies and 62% said it s sometimes important for the amount of sample given. Table 3: Physicians prescribing criteria and factors affecting prescribing habits Variables N (%) Very important 10 (22.2) Important 25 (55.6) Sometimes 5 (11.1) Least Important 5 (11.1) Very important 12 (26.7) Important 21 (46.7) Sometimes 7 (15.6) Least Important 5 (11.1) Very important 23 (51.1) Important 12 (26.7) Sometimes 7 (15.6) Least Important 3 (6.7) Very important 4 (8.9) Important 7 (15.6) Sometimes 24 (53.3) Least Important 10 (22.2) Very important 11 (24.4) Important 26 (57.8) Sometimes 5 (11.1) Least Important 3 (6.7) Very important 28 (62.5) Important 13 (30.1) Sometimes 3 (5.0) Least Important 1 (2.4) Very important 30 (67.0) Important 6 (13.3) Sometimes 3 (6.6) Least Important 6 (13.3) Very important 28 (62.0) Important 8 (18.0) Sometimes 5 (11.0) Least Important 4(9.0). 263

5 Upper Respiratory Tract Infections in UAE Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 Discussion This investigation provided insights of physician s decision-making about antibiotic prescribing in United Arab Emirates. Since most of the URTI are viral infections in origin, the treatment is usually symptomatic and directed to relief the most prominent symptoms [7]. There are several guidelines for the judicious use of antibiotics for upper respiratory illness because overuse of antibiotics for these indications is implicated in the development of antibiotic resistance [8-13]. Of greater importance, a substantial proportion of individuals obtained antibiotics through a method other than a physician prescription for the condition; subjects not only used their own leftover medication, but they also used from friends and family members leftover pills. Usually, most of the cases of uncomplicated URTI in adults resolve spontaneously without medications, while small proportion becomes complicated by bacterial rhinosinusitis or pneumonia particularly in high-risk patients like infants, elderly and chronically ill patients [14]. Our findings showed that Augmentin and Amoxil were the most two frequent antibiotics prescribed for URTIs. It also showed that prescribing pattern was highly influenced by regular medical representative visits and seminars they were invited to. Prescribing pattern was rarely to be influenced by considering the efficacy of the drug. The results ranked amoxicillin as the most frequently prescribed antibiotic, followed by third-generation cephalosporins for the general management of URTI. Indeed, safety and tolerability of the prescribed antibiotic was one of the major factors affecting the drug selection. Amoxicillin is a well-known beta-lactam antibiotic and apart of hypersensitivity reaction, it is safe and tolerable that makes it preferred by many physicians. On the other hand, third generation cephalosporins (e.g. cefixime) are effective but more expensive comparing to amoxicillin with almost similar side-effect and drug interaction profiles. This brought cephalosporines to the second rank although the second generation drugs are also active and relatively cheaper but they are not commonly prescribed by our physicians. This could be related to weak advertisement and promotion from the pharmaceutical company since the regular visit of the medical rep. was very important factor for drug selection. On the other hand, floroquinolons ranked at the bottom of the list and it could be attributed mainly to their high cost and their side effects profile. Our results are in concordance with the findings of Bahraini [15], New Zealander [16] and Thai [17] s where amoxicillin and amoxicillin-clavulanate were most frequently to treat URTIs. Overall, we can summarize our recommendations as following: First, the stakeholders and decision makers in UAE need to consider the results of this study and other similar studies to open discussion about the problem of irrational prescribing and to encourage a multidisciplinary team concept in disease management. Second, continuous education and campaign that target all of the healthcare providers could be one good answer to tackle the problem in the future. Last, increase in the awareness of healthcare providers about antibiotics prescribing and to avoid misuse of antibiotics and to avoid antibiotics side effects, which is both preventable and manageable. Limitations Small sample size and the responses were dependent on the doctors' honesty and fidelity and their time availability. Additionally, not all emirates in UAE were covered in this study. Conclusion Physicians in UAE preferentially prescribe antimicrobials for URTI, tonsillitis, sinusitis and otitis media. Amoxicillin and amoxicillin-clavulinate were the preferred agent for all URTIs. The absence of local or regional guidelines and hospital formulary may attribute to the inappropriate and irrational use of antibiotics reported in the current study. Therefore policy of antibiotic prescribing should be applied strictly and pharmacy role at dispensing and prescribing stages is an obvious issue and must be regulated. Financial Assistance None declared Conflict of Interest The authors declare that there is no conflict of interest to reveal 264

6 Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 Abduelkarem and Abu-Gharbieh. References [1] Teng CL, Shajahan Y, Khoo EM, et al., The management of upper respiratory tract infections. Med. J. Malaysia, 2001; 56: [2] Mlynarczyk G, Mlynarczyk A and Jeljaszewicz J., Epidemiological aspects of antibiotic resistance in respiratory pathogens. Int. J. Antimicrob. Agents, 2001; 18: [3] Meneghetti A, Mosenifar Z., Upper Respiratory Tract Infection, Available at: [4] American Urological Association., Pediatrics Urinary Tract Infections, Available at: [5] Fares A., Factors influencing the seasonal patterns of infectious diseases, Int. J. Prev. Med., 4: , [6] Akkerman AE, van der Wouden JC, Kuyvenhoven MM, Dieleman JP and Verheij TJ., Antibiotic prescribing for respiratory tract infections in Dutch primary care in relation to patient age and clinical entities, J. Antimicrob. Chemother., 54: , [7] Kistler A, Avila PC, Rouskin S, et al., Pan-viral screening of respiratory tract infections in adults with and without asthma reveals unexpected human coronavirus and human rhinovirus diversity, J. Infect. Dis., 196: , [8] American Academy of Pediatrics., Diagnosis and management of acute otitis media, Pediatrics, 113: , [9] Burrows HL, R. Blackwood A, Cooke JM, et al., Guidelines for clinical care Ambulatory: Otitis media, UMHS Otitis Media Guideline, [10] Snellman L, Adams W, Anderson G, et al., Institute for Clinical Systems Improvement. Diagnosis and Treatment of Respiratory Illness in Children and Adults. Inst. Clin. Syst. Improv., [11] Bisno AL, Gerber MA, Gwaltney JM, et al., Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America, Clin. Infect. Dis. 35: , [12] Bisno AL., Acute pharyngitis, N. Engl. J. Med., 344: , [13] Zoorob R, Sidani MA, Fremont RD and Kihlberg C., Antibiotic use in acute upper respiratory tract infections, Am. Fam. Physician, 86: , [14] Sung L, Arroll J, Arroll B, et al., Antibiotic use for upper respiratory tract infections before and after an education campaign as reported by general practitioners in New Zealand, N. Z. Med. J., 119: U1956, [15] Senok AC, Ismaeel AY, Al-Qashar FA, et al., Pattern of upper respiratory tract infections and physicians' antibiotic prescribing practices in Bahrain, Med. Princ. Pract., 18: , [16] Dowell SF, Schwartz B and Phillips WR., Appropriate use of antibiotics for URIs in children: Part II. Cough, pharyngitis and the common cold. The Pediatric URI Consensus Team, Am. Fam. Physician, 58: ,

7 Upper Respiratory Tract Infections in UAE Advances in Biomedicine and Pharmacy Vol. 2 (6) 2015 [17] Mohan S, Dharamraj K, Dindial R, et al., Physician behaviour for antimicrobial prescribing for paediatric upper respiratory tract infections: a survey in general practice in Trinidad, West Indies, Ann. Clin. Microbiol. Antimicrob., 3: 11, ABP 2015 Reproduction is free for scientific studies This work is licensed under a Creative Commons Attribution 4.0 International License. ADVANCES IN BIOMEDICINE AND PHARMACY is indexed in Google scholar, Index Copernicus International (ICV: 66.16), Eurasian Scientific Journal Index, CiteFactor, Open Academic Journals Index, International Scientific Indexing, InfoBase Index (IBI Factor: 3.1), Advanced Science Index, Universal Impact Factor, International Society of Universal Research in Sciences, Scientific Indexing Services. 266