Antimicrobial Prescription Pattern in ENT Outpatient Department in a Tertiary Care Teaching Hospital, Telangana, India

Introduction

Diseases of ENT are common in general population. ENT diseases affect all age groups ranging from children to adults with significant disability-adjusted life-year (DALY) of patient.^[1] Most common ENT infections that can be managed with medications are acute rhinitis, sinusitis, adenoiditis, tonsillitis, pharyngitis, acute and chronic suppurative otitis media (CSOM), otitis externa, laryngitis and epiglottitis. If these conditions are not treated properly some serious consequences can occur like stridor, hoarseness of voice, permanent hearing problems and emotional disturbances which lowers the patient's quality of life.^[2]

Upper respiratory tract infections (URTI)s such as tonsillitis, pharyngitis, nasopharyngitis, and otitis media contribute to 20 to 40% of infections among patients who are attending outpatient departments (OPD).^[3] For some ENT and respiratory infections such as rhinopharyngitis and acute bronchitis, though the etiology is viral antibiotics were prescribed commonly.

Antimicrobial prescription pattern differs from place to place, depending on the antimicrobial susceptibility, infecting organisms, physician preference, and costs.^[4] Irrational antimicrobial usage such as antibiotics in nonbacterial infections, inadequate dosage, and improper route has led to ineffective treatment, prolongation of illness, increased frequency of adverse drug reactions, suboptimal therapy, therapeutic failure, polypharmacy, which ultimately causes increased burden of medical cost as well as the emergence of antibiotic resistance.^[5,6] The International Network for the Rational Use of Drugs (INRUD) was established in 1989 and developed various guidelines to promote the rational use of drugs in developing countries.^[7]

Regarding the rationale use of antibiotics, sufficient literature is available in India and abroad.^[8–10] As increased antibiotic resistance is having impact on economy of developing countries such as India, we thought this type of study will also help physicians to prescribe appropriate antibiotics. This observational study was designed to evaluate the antimicrobial usage in otolaryngology outpatient department. Based on the present study results, we can plan proper interventions and modifications at the level of the physician and the institution to promote rational antibiotic usage.

Materials and Methods

An observational study was planned over a period of 8 months from July 2019 to February 2020 in ENT outpatient department (OPD) at Mamata General Hospital, Khammam in Telangana after obtaining approval from the Institutional Ethics Committee (IEC/IRB: 97/19).

Results

A total of 562 prescriptions collected from the ENT OPD were classified according to the site of origin, which included 210 ear, 178 throat, and 136 nasal infections. The total number of drugs prescribed was 1,789, of which 703 were antibiotics. Based on the age group classification, 44.83% of the prescriptions belonged to patients of 21 to 40 years, followed by 1 to 20 years (29.53%) [Table 1]. Of total 562 prescriptions, 56.9% were males and remaining 43.1% were females. Most common infections observed were CSOM followed by sinusitis and tonsillitis [Table 2].

Analysis of antibiotic prescriptions

In total, 66.01% of the patients received a single antibiotic, 27.58% of the patients received two antibiotics, and remaining 6.40% of patients did not receive any antibiotic. The average number of antibiotics prescribed per encounter was 1.25 [Figure 1]. Next, 52.9% of dosage forms were tablets, followed by 31.8% of capsules and 9.10% of syrups [Figure 2]. Also, 93.9% of antibiotics were prescribed by oral route, followed by 6.11% of topical application, whereas injectables were not prescribed.

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Figure 1

Numberof antimicrobial agents used per prescription.

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Figure 2

Distribution of various dosage formulations of antibiotics prescribed.

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In our study, penicillins (34.7%), cephalosporins (25%), and fluroquinolones (23.3%) were commonly prescribed antibiotics [Table 3]. Amoxicillin with clavulanic acid was observed to be the most common FDC, followed by cefpodoxime with clavulanic acid [Table 4]. Also, 70.3% antibiotics were prescribed for 3 to 5 days and 27.6% were prescribed for 6 to 10 days and 2.13% were for more than 10 days [Figure 3]. Most antibiotics prescribed were generic (65.57%) [Table 5].

Table 3 Different classes of antibiotics prescribed.

Class of drugs	Frequency (N = 703)	% Consumption
Penicillins	244	34.7
Cephalosporins	176	25
Fluoroquinolones	164	23.3
Macrolides	28	3.98
Antifungal drugs	27	3.84
Miscellaneous*	64	9.1

*Metronidazole, cotrimoxazole, bacitracin, linezolid, doxycycline, and mupirocin.

Table 4 Types and frequency of antibiotics prescribed.

Class of antimicrobials	Antimicrobial agents prescribed	Frequency of prescribed antibiotics (N = 703)	% of antibiotic consumption
Penicillins (244)	Amoxicillin	4	0.56
	Amoxicillin + clavulanic acid	184	26.17
	Ampicillin + cloxacillin	56	7.96
Cephalosporins (176)	Cefpodoxime + clavulanic acid	154	21.9
	Cefuroxime	12	1.70
	Cefixime	10	1.42
Fluoroquinolones (164)	Ciprofloxacin	134	19.06
	Ofloxacin	22	3.13
	Levofloxacin	8	1.13
Macrolides (28)	Azithromycin	18	2.56
	Clarithromycin	10	1.92
Antifungal drugs (27)	Clotrimazole	18	2.56
	Nystatin	9	1.28
	Metronidazole	14	1.99
Others (64)	Cotrimoxazole	14	1.99
	Bacitracin	13	1.84
	Linezolid	12	1.70
	Doxycycline	08	1.13
	Mupirocin	03	0.42

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Figure 3

Duration of antibiotics prescribed.

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Table 5 Prescriptions of total drugs and antibiotics as per brand/generic names.

Parameter	Number of drugs (N = 1789)	Percentage (%)	Number of antibiotics (n = 703)	Percentage
Drugs prescribed by brand name	464	25.9	242	34.42
Drugs prescribed by generic name	1,325	74.06	461	65.57

Analysis of Adjuvant Drug Prescriptions

Of 562 prescriptions, 256 (45.5%) had three drugs per prescription, followed by two drugs (21%) with an average of 3.18 [Figure 4]. In the adjuvant group, nasal decongestants were commonly prescribed (52%), followed by antihistamines (18%) and non-steroidal anti-inflammatory drugs (13%) [Figure 5].

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Figure 4

Number of drugs prescribed per prescription.

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Figure 5

Distribution of prescriptions based on the adjuvants prescribed.

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Discussion

In practice, while covering the most likely pathogens in the treatment of ENT infections is empirical, culture-sensitive antibiotics are prescribed for some times on need basis. The present observational study describes prescription pattern of antibiotics in the OPD of ENT department. These type of studies guide the rational use of drugs and also useful in making treatment cost-effective and beneficial to patients and reduce the medical burden in developing countries such as India.^[12]

More number of antibiotic prescriptions were observed in the 21 to 40 years age group patients and the least were observed in the geriatric age group, similar to Ain et al (66.3% between 6 and 35 years age group and 2.17% in 66 to 85 years group).^[13] In our study, 56.9% of prescriptions were male and 43.1% were female patients similar to studies by Ain et al (62.68% males) and Suman et al (62% males).^[13,14] Higher ambulatory working adult male population and higher exposure to environmental pollutants and pathogens might be the cause of increased prevalence in males. In contrast to our study, more number of female patients (53.12%) were enrolled in a study by Harish et al.^[15]

In this study, prescriptions with single antimicrobial agent were 66.01% and with two AMA were 27.58% which was similar to the study by Padwal et al (92.98% of prescriptions with one AMA and 2.10% with two AMA).^[16] The average number of antibiotics per prescription was 1.25, which was lower than in the studies done by Suman et al (2015) (1.69),^[14] Ain et al (2010) (1.58),^[13] Pallavi et al (2016) (2.42),^[4] and higher than Padwal et al (2015) (0.98).^[16] Penicillins (34.7%), cephalosporins (25%), and fluoroquinolones (23.3%) were commonly prescribed antibiotics and in the FDC, amoxicillin with clavulanic acid was the commonest followed by cefpodoxime with clavulanic acid. Studies conducted by Suman et al (85%), Khan et al (75.68%), Bhat et al (77%), and Anandhasayanam et al (61%) have reported that β-lactam antibiotics were given the highest priority.^[14,17–19] The change in the prescription pattern from a narrow spectrum to extended-spectrum penicillins could overcome the problem of antibiotic resistance. Lisha et al^[20] observed an almost similar pattern of antibiotic prescription but in contrast to our study, 41% of injectables were prescribed. In our study, CSOM was the most common infection, followed by sinusitis and tonsillitis. Kumar et al (2005) also reported that CSOM was the commonest infection (60%) in their study.^[5] The commonest route of administration was oral, followed by topical. No injectable antibiotics were prescribed. Similar findings such as zero injections were given out of 855 prescriptions in a study done by Padwal et al.^[16] This absolute lack of use of injections indicate physicians' awareness regarding side effects related to the over use of injections.

The WHO recommendation for average number of drugs per prescription is 2 to2.5. However, in this study, it was 3.18 which is also reported by Khan et al (2.70),^[17] indicating a trend of polypharmacy.^[21] As the over prescribing of drugs has higher chances of drug–drug interactions, increased risk of adverse drug reactions, increase in unnecessary cost of treatment and most importantly antibiotic resistance average number of drugs per prescription should be reduced.^[22,23] Analysis of prescription of adjuvants showed predominant prescription of nasal decongestants (52%) followed by antihistamines (18%), which are similar to those of Srinivasa et al's study with 60% of nasal decongestants.^[24]

About 74.06% of drugs prescribed were generic, which is in contrast with other studies reporting a higher use of brand names.^[13,25,26] In the present study, 96% of drugs prescribed were from the hospital formulary list, meaning that physicians are adhering to the list. Also, 95% of the drugs prescribed were from the National List of Essential Medicines, India. The WHO recommendation is 100% prescription of drugs from the essential drug list (EDL).^[27] This study clearly showed the prescription pattern of antibiotics, increased prescriptions of generic drugs, and importance of rationale use of antibiotics, which would be useful for all practitioners to reduce the antibiotic resistance and unnecessary medical burden of people of India.

Limitations

The study was performed for a period of 8 months only. Seasonal variations in ENT infections and their prescribing patterns were not counted. Though the sample size was high, this study was conducted in one hospital only. In this study, antimicrobial therapy was based on empirical and clinical diagnosis as laboratory investigations were not done.

Conclusion

The pattern of prescribing a drug and its utilization plays a major role in advising a physician and hospital administration to prescribe antibiotics rationally and analyze its cost beneficiality. The present study though prescription pattern of antibiotics and adherence to the hospital formulary by the physicians in the hospital is encouraging, still there is a chance in reducing the number of drugs prescribed per patient. Extensive studies on the restricted use of antibiotics and updation of development to formulate guidelines for the treatment of common diseases through continuing medical education (CME) is needed. So that the patient and health care system on the whole will be benefitted.