final thesis


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

final thesis

  1. 1. Assessment of Prescribing Practice of Antibiotics in common cold (ARI) in children under the age of 5 years in PIMS Islamabad Submitted To: Najmuddin Bakrey Submitted By: Hadaitullah Program: Msc.IR Semester: 2 ND Registration no: 1443_311007 PRESTON UNIVERSITY, Islamabad campus 1
  2. 2. ACKNOWLEDGEMENTSAll praise and thanks to Allah all mighty, the most merciful and beneficent. He hasalways helped us out whenever we are in need.First of all, our greatest gratitude to Sir.Nujmuddin, our research supervisor, who hasbeen a source of inspiration for us. He always listened to us and guided us in a veryempathetic way. His constant guidance, criticism and encouragements have enabled us toaccomplish this task. We would like to thanks our parents for their love prayers andopportunities they provided. We would also like to thanks the chief pharmacist of thePIMS who allowed me for data collection in PIMS Islamabad.In the last I would thank specially Sir.Nujmuddin who helped me a lot and spared theirprecious time for us.Hadaitullah 2
  3. 3. Table of contentsSr. No Contents Page No 1. Title Page 01 2. Acknowledgments 05 3. Abstract 07 4. Chapter # 1 Introduction 08 5. Chapter # 2 Objectives 18 6. Chapter # 3 Methodology 20 7. Chapter # 4 Results 22 3
  4. 4. Abstract:Background: The spread of antibiotic-resistant bacteria is associated with antibiotic use.Children receive a significant proportion of the antibiotics prescribed each year andrepresent an important target group for efforts aimed at reducing unnecessary antibioticuse. The judicious prescription of antibiotics has become a central focus of professionaland public health measures to combat the spread of resistant organisms.Objective: To assess the prescribing practice of Antibiotics in common cold (ARI) inchildren under the age of 5 years in PIMS Islamabad and to compare it with standardtreatment guideline.Significance: Descriptive cross sectional study: A total of 100 prescriptions of childrenunder the age of 5 years were obtained from the hospital. Prospective method was used tocollect the prescriptions.Antibiotics were prescribed to 70% of children presenting with symptoms of commoncold in different combination. About 53% of patients were given Antiobiotic +Antipyretic + Antihistamine combination. About 30% of patients were given Antipyreticand Antihistamine combination. About 7% of patients were given Antibiotic+Antipyretic combination. About 5% of patients were given antibiotic and antihistaminescombination and about 5% of patients were using Antiobiotic +Antipyretic+Antihistamine +Multivitamins combination. There was only one class of antibiotic wasprescribed by the physicians and that was penicillin. The number of drugs prescribed perpatient varies considerably for treatment of common cold in childerns. About 55 % ofprescription contains 3 numbers of drugs. 40% of prescription contains 2 numbers ofdrugs and only 5 % of prescription contains 4 numbers of drugs.Conclusion: Antibiotics are commonly used in common cold in children under the ageof 5 years. The outcome of such irrational practices was loss of these limited resourcesand emergence of antibiotic resistance and result poor quality of health. 4
  5. 5. Chapter 1:Introduction 5
  6. 6. INTRODUCTION:- The common cold is not a single infectious disease, but rather a group of self-limitingviral upper respiratory infections (URIs) producing a similar clinical syndrome.[1] Theaverage preschool child contracts approximately 6 to 10 colds per year, and the averageadult has 2 to 4 colds annually. Roughly 23 million lost work days and 26 million missedschool days are the result of the common cold each year. Many more persons continuetheir usual activities with lower productivity and uncomfortable symptoms. Furthermoreexpenditures for products used to treat cold symptoms exceed $2.5 billion annually afteradjusting for inflation[2] The common cold is generally regarded as a mild condition thatrarely causes significant morbidity. However, serious exacerbations of underlyingdisease may occur in patients with asthma or pre-existing obstructive lung disease.Patients with the common cold are also more susceptible to acquiring otitis media andsinusitis. [3]Pediatric populations are important targets for efforts aimed at reducing unnecessaryantibiotic use. Environments unique to children, such as day care and school, enhance thetransmission and spread of drug-resistant S pneumoniae.[4] The frequency and duration ofprior antibiotic exposure are strongly associated with the spread of drug-resistant Spneumoniae, and children receive a significant proportion of the total antibioticsprescribed each year. [5]The common cold is associated with considerable costs in terms of decreasedproductivity; time lost from work or school; visits to healthcare providers; and thevolume and cost of drugs prescribed. [6] Despite the lack of effectiveness of antibiotics fortreating common cold symptoms (rhinorrhoea, stuffiness, acute cough, sore throat,pharyngitis, and laryngitis), general practitioners (GPs) frequently prescribe antibioticsfor patients with such symptoms in response to patients expectation or doctorsperceptions of these expectations.The over use of antibiotics for primarily viral respiratory tract infections has beensuggested as a contributing factor in the rise of antibiotic pathogens like Streptococcuspneumoniae because of selective pressure, particularly that exerted by broad-spectrumantibiotics. [7] 6
  7. 7. INCIDENCE AND PREVALANCE OF COMMON COLD:-The incidence of infection peaks in the early spring (April and May) and fall, reachingthe highest incidence in the fall. The incidence of infection from coronavirus, the secondmost common viral agent, peaks in the early summer and again in the autumn to early [1]winter. Coronavirus has been detected in up to 30% of upper respiratory infections.The pattern of RSV infection is similar to that for rhinovirus; however, the peakincidence is slightly later in the spring (April through June) and fall (October through [2]November). The isolation of influenza A virus from patients with cold-like symptomsis indicative of a mild influenza illness, and the incidence is expected to follow trends ininfluenza illness within a community. Parainfluenza virus type 3 is present in summermonths and is associated with annual outbreaks or epidemics Isolation of adenovirus isfairly constant throughout the year." [2]EPIDEMIOLOGY:-Transmission of the common cold may occur by direct contact with nasopharyngealsecretions or by inhalation of small and large airborne particles. Viruses can be isolatedfrom the hands of patients with the common cold. Transmission may occur with a simple [3]touch or hand¬shake. In addition, viruses can remain viable in nasal secretions forseveral hours after being deposited on inanimate objects (e.g., door handles or faucets).The uninfected individual acquires the virus on his or her hands, and then inoculates themucosal surfaces by touching the face, nose, or eyes. IS Prevention of transmission ispossible by washing hands frequently with disinfectants, by using of virucidal tissues,and perhaps by avoiding facial and eye contact with the hands. However, these methodsare not very practical. One study suggested that aerosol transmission is the chief mode oftransmission in adults. [8]Acute respiratory infections (ARI) are among the most prevalent factors of morbidity inthe world. ARI related mortality is a major issue in children under five years of age indeveloping countries.[8] According to WHO, estimated morbidity averages bronchiolitis,and obstructive laryngitis. [9] One million deaths due to measles, 350,000 to pertussis, and 7
  8. 8. 8,000 to diphtheria are to be added. Infectious agents are first, S. pneumoniae, H.influenzae and respiratory syncytial virus, second, S. aureus, influenza, and parainfluenzae viruses, adenovirus. [8,9] Control programs of ARI are based upon adequatemedical care in primary health care centers, training of health workers, maternaleducation, and immunizations. Such programs set up in some developing countriesenabled a 20% decrease of infant mortality and a 25% decrease in children under fiveyears of age. [10]Acute respiratory infections (ARI) are a leading cause of childhood morbidity inPakistan. The National ARI Control Programme was launched in 1989 in order to reducethe morbidity attributed to ARI and rationalize the use of drugs in the management of [11]patients with ARI. WHO standard ARI case management guidelines were adopted toachieve these objectives. The medical staff at Children’s Hospital, Islamabad weretrained in such management in early 1990; further training sessions were conducted whennew staff arrived. [10,11]Among under-5-year-olds in Pakistan, acute respiratory infections (ARI) are responsiblefor more than one quarter of deaths in the community and one-third of deaths occurring [12]in hospitals. ARI is also the leading cause of morbidity in childhood. Factorscontributing to complications and mortality due to ARI include delays in talking the childto a health care provider. Misdiagnosis or delay in diagnosis by the health professionaland inappropriate use of antibiotics for treatment of ARI. [8,9]Seven countries have established national task forces for ARI control, four have prepareddocuments for implementation of the programme and six have specific budget lines forthe ARI Control Programme in the 1988-1989 biennium. [9,10]CONDITIONS AND ETIOLOGY:-The Common Cold is not a single infectious disease, but rather a group of self-limiting [1]viral upper respiratory infection (URIs) producing a similar clinical syndrome . URIsare the most common infectious diseases. They include rhinitis (common cold), sinusitis, 8
  9. 9. ear infections, acute pharyngitis or tonsillopharyngitis, epiglottitis, and laryngitis—ofwhich ear infections and pharyngitis cause the more severe complications (deafness andacute rheumatic fever, respectively) [1,2]There are many viral pathogens which can cause the symptoms of the common cold; themost common are the more than 100 serotypes of rhinoviruses.[11] The type of virusresponsible for the greatest number of colds. Other viruses that cause colds includeenteroviruses (echovirus and coxsackie viruses) and coronavirus. In most cases, aspecific virus causes a person to be ill only once, after which they are immune to that [11,12]virus . An estimated 25 million individuals seek medical care for uncomplicatedupper respiratory tract infections (URI) annually in the United States. [13]TREATMENT OPTIONS AVAILABLE FOR ARI:-There is no widely accepted specific therapy for the common cold. Use of interferonnasal spray.[14] zinc gluconate lozenges.i" high-dose vitamin C [15] and investigationalantiviral drugs[14,15] has shown limited or no benefit in shortening the duration ofsymptoms and/or reducing viral shedding. High-dose vitamin C (at least 1 gI day) mayprovide a small benefit; however, this benefit is controversial. [14] In addition, several ofthe treatments (interferon, zinc gluconate, and antiviral drugs) are associated withsignificant side effects. Zinc gluconate lozenges are unpalatable. A nasal spraycontaining soluble intercellular adhesion molecule 1 (ICAM-l) was shown to reduce coldsymptoms by almost 50% when used before or within 12 hours after experimentalrhinovirus infection. ICAM-l is responsible for binding of rhinovirus to susceptiblenasopharyngeal cells, permitting virus entry. Soluble ICAM-1 is a competitive inhibitorof this binding. It is likely that this therapy will be expensive if it becomes available.Moreover, it is not clear if treatment given beyond 12 hours after exposure to rhinoviruswould be effective. [15]CURRENT THERAPY CARRIED OUT FOR COMMON COLD:-Current therapy for the common cold focuses on symptomatic relief and includesanalgesics, systemic and topical decongestants, and antihistamines. Aspirin and 9
  10. 10. acetaminophen suppress the development of antibodies and prolong the duration of viralshedding. [16] These agents reduce fever that may be a protective response to infection.However, fever is only present in a small minority of patients. Aspirin andacetaminophen may be useful to reduce headache, malaise, and muscle aches if they arepresent. These agents should not be used routinely for the common cold. The associationof aspirin use and Reyes syndrome in children with influenza warrants further caution inthe routine use of aspirin. [16,17] This association has not been described in associationwith the common cold. However, influenza can sometimes mimic the common cold andReyes syndrome has been reported, although rarely, with adenoviruses andparainfluenza viruses. Ibuprofen and naproxen have no detrimental effect on serumantibody response and virus shedding and appear effective for relieving some coldsymptoms. [18]The use of antihistamines to relieve cold symptoms is controversial. Histamine does notappear to play a significant role in the pathogenesis of the common cold. Someantihistamines possess anticholinergic action, which may reduce nasal secretions. [19] Theuse of a sustained release formulation of brompheniramine was effective for reducing [20]sneezing, rhinorrhea, and cough after experimentally induced rhinovirus colds. Inpatients with natural colds, clemastine provided some symptomatic relief of rhinorrheaana sneezing, but the effects appeared less prominent. [21] A review of studies before1996 concluded that antihistamines do not have major effects on overall cold symptoms, [22]although some attenuation of sneezing and rhinorrhea may occur. These minorbenefits must be weighed against the potential for side effects, primarily somnolence anddry mouth and throat. Intranasal ipratropium bromide, an anticholinergic agent, isefficacious for reducing rhinorrhea and sneezing. [23]Systemic and topical decongestants have been widely used to relieve nasal congestion.Topical solutions of oxymetazoline, xylometazoline, and phenylpropanolamine are [24]rapidly effective in relieving congestion and improving nasal airflow. Withxylometazoline, this effect persists for 6 hours. These agents are only indicated for short- 10
  11. 11. term use «3 days) because rebound congestion can occur with more prolonged use.Systemic decongestants including pseudoephedrine and phenylpropanolamine also areeffective for symptomatic relief. A recent study showed that oral pseudoephedrine ismore effective than placebo for relieving nasal congestion. [25]Intranasal and inhalation formulations of sodium cromoglycate (cromolyn sodium), usedevery 2 hours for the first 2 days, then four times daily thereafter, provide symptomaticrelief of cold symptoms compared to placebo. The duration of cold symptoms wassignificantly shortened and symptoms decreased in final 3 days. [26]Cough associated with the common cold is usually related to postnasal drainage andthroat irritation and is under voluntary control. Antitussive agents such as codeine are [27]not effective for this type of cough. ,40 Codeine may be useful for chronic coughbased on a reflex mechanism that occurs in some patients after resolution of the cold.Antihistamines and decongestants may be effective in relieving cough associated withacute upper respiratory infection. [28]Considerable interest in the effectiveness of echinacea for prevention and treatment ofthe common cold has evolved in recent years. A double-blind placebo-controlled studyshowed no benefit of using echinacea for preventing the common cold or respiratoryinfection. [29] The relative risk of acquiring an URI was 0.88 (95% confidence interval[CI] of 0.60 to 1.22) with treatment. Once a cold occurred, the median duration ofsymptoms was 4.5 days in the echinacea group and 6.5 days in the placebo group (notsignificant). It remains possible that a very small effect would be detected in a largertrial; however, the clinical significance remains questionable. Variations in the sourceand chemical makeup of various echinacea products could explain why other sourcesclaim efficacy with echinacea for the treatment of the common cold. There is no role forthe use of antibacterial drugs in the treatment of the common cold. [30] Antibiotics maybe required only to manage complications such as acute otitis media or acuterhinosinusitis. [31] 11
  12. 12. IRRATIONAL PRESCRIBING PRACTICES IN COMMON COLDTREATMENT:-Although a cold is a viral illness, antibiotics often are inappropriately prescribed topatients, even when bacterial complications (e.g., pneumonia, bacterial sinusitis) are notpresent. Studies of antibiotics for the treatment of the common cold focus on cure rate,symptom persistence, prevention of secondary bacterial complications, and adverseeffects. [32]Over prescription and abuse of antibiotics in the treatment of acute respiratory infectionsand is a worldwide problem, potentially leading to widespread antibiotic resistance. [33]The use of antimicrobials is especially prevalent in the very young and the elderly. In onestudy, 37 and 70 percent of children, by three and six months of age respectively, hadreceived at least one antibiotic prescription. [34]Most antibiotic prescriptions in the ambulatory setting are for respiratory infections.Studies evaluating physicians prescribing patterns have found that almost 50 percent ofoffice visits for colds and upper respiratory tract infections (URIs), and 80 percent ofvisits for acute bronchitis are treated with antibacterial agents. [35]The majority of antibiotics prescribed to adults in ambulatory practice in the UnitedStates are for acute sinusitis, acute pharyngitis, acute bronchitis, and nonspecific upperrespiratory tract infections (including the common cold). For each of these conditionsespecially colds, nonspecific upper respiratory tract infections, and acute bronchitis (forwhich routine antibiotic treatment is not recommended) [36] 12
  13. 13. IRRATIONAL TREATMENT PRACTICES OF COMMON COLD INPAKISTAN:-A knowledge, attitude and practices (K.A.P.) survey was conducted among doctorsworking as general practitioners (GP) in Multan, for diagnosis and management of acuterespiratory infections (ARI) in children under five years of age. GPs in Multan were notfamiliar with national ARI control Program and rational drug use guidelines. They rarelyasked about symptoms describing severity of disease while taking patient histories anddid not look for signs of severe pneumonia during physical examinations. Most patientsdiagnosed as URTI (upper respiratory tract infection) received oral antibiotics and thosewith pneumonia received inject able antibiotics. Other drugs prescribed included coughsyrups, antihistamines and antipyretics. The average number of drugs prescribed perpatient was 3.4. The doctors were deficient in providing home care advice for sickchildren to the caretakers. Average time spent by doctors on each patient was twominutes and twenty-three seconds. A combination of biomedical and social factors helpto perpetuate this irrational prescribing behavior of the GPs. Continuing educationprograms for doctors in general practice about ARI management in children and rationaluse of drugs and health education of the public may improve the current prescribingpractices. The resolution adopted at the SEARC conference on South East Asian childrenin October 1986 provided endorsement to the policy of ARI control at the highest officiallevel. [9]SITUATION ANALYSIS IN CHILDREN UNDER 5:-The highest rates of antibiotic prescribing in primary care are to children with respiratoryillness but surprisingly there have been few prospective controlled studies of the impactof such prescribing on resistance in a community setting In the 1980s Brook reported [37]isolation of lactam producing bacteria in 46% of children one week after antibiotictreatment of otitis media or pharyngitis and 27% after three months compared with aconstant 11% in controls.21 A paper from Malawi in 2000 reported recovery of co-trimoxazole resistant pneumococci in 52% of children one week after malaria treatmentwith co-trimoxazole compared with 34% in controls but with no difference after four 13
  14. 14. weeks[38]. An Australian study in 2002 reported a twofold increase in the odds of recoveryof resistant pneumococci in children who had used lactam antibiotics in the two monthsbefore swab collection.[39] We report a prospective study in children from UK generalpractice with new methods for identifying a highly mobile integrative and conjugativeelement (ICE) that encodes lactamase and circulates among nasopharyngealHaemophilus species.[40]Studies showed that irrational prescribing practices of common cold is one of the mostcritical issue that need to be global considerations. In Pakistan a small efforts is put onthis issue. Lot is to be done in this area therefore this study will have focus on todocument current treatment practices of ARI in selected facilities and try to find theprevalence of ARI and reason of ARI and reason for prescribing antibiotics in ARI andidentify the problems that need to be sorted out. This work will add to existing literaturein will give you bases will be helpful in research. 14
  15. 15. Chapter 2:Objectives 15
  16. 16. GENERAL OBJECTIVE:- Assessment of prescribing practice of antibiotics in common cold under the age offive years in PIMS Islamabad.SPECIFIC OBJECTIVES;- • To document the current treatment practices of (ARI) in selected hospital of Islamabad Pakistan • To identify the most common prescribing combination of drug in ARI . • To determine the %age of patients receiving antibiotics in children under 5 • To determine the average number of drugs per patient • To determine the %age of patients receiving different dosage forms • To determine the %age of patients receiving drugs other than antibiotics 16
  17. 17. Chapter 3:Methodology 17
  18. 18. Methodology: A descriptive cross sectional study was conducted in Pakistan Institute of MedicalSciences during the period of September to October. Standard Treatment Guideline wasused as a reference point to describe that antibiotics should not be prescribed in childrenunder the age of 5 years having common cold. These standard treatment guidelines weredeveloped from Davidson’s Principles and Practice of Medicine 20th Edition by NicholasA. Boon, Nicki R. Colledge, Brian R. Walker, John Hunter.The data was collected by using data collection tools. In order to collect data fromPakistan Institute of Medical Sciences an application was written to Director HamdardInstitute of Pharmaceutical Sciences in order to issue a letter to hospital givepermission to carried out study easily in Pakistan Institute of Medical sciences . Thenthis letter was submitted to the Hospital Administration .the letter was processed inthe hospital within three weeks .The permission letter was granted by hospital and alsoissue a letter to the Children hospital for permission. After this the field visit for datacollection was planned. The data was collected from Out Patient department of ChildrenHospital Pakistan Institute of Medical Sciences .We travel by our own car to reachHospital for data collection. We collected data between 10 am to 1pm because at thistime the sufficient patients visit to OPD hospital. In order to collect quantities data, a data collection form was design by consultingwith teacher and WHO manual How to Investigate Drug use in Health Facility,after designing the form was pilot tested to check its utility, after the success fullpilot testing the form was used for data collection. Then the permission letter wasshown to the chief pharmacist in Pakistan institute of medical sciences forissuance of permission for the prescription observation on children OPD. Aftercollecting the required data, we thank a lot to dispenser for his cooperation. At theend of the day, we move by car towards home and entered the collected data indata collection form. . After the completion of data in data collection form, the datawas entered in Statistical Package for Social Sciences(SPSS 17) by creatingvariables. Then the data was analyzed by applying different statistical test .andthen results were presented in graphical and tabular form. 18
  19. 19. Chapter 4: Results 19
  20. 20. Results: Out of the 100 prescriptions from Pakistan Institute of Medical Sciences to checkamong the most commonly prescribe combination of drugs in ARI under 5. theprescribed drug was antipyretic, antihistamine and antibiotic. From antipyreticparacitamol, from antihistamine chlorpheneramine and from antibiotic Amoxil. Thepercentages of these combinations were shown in Fig-1. Drug combination used Antiobiotic+Antipyr etic+Antihistamine 60 53 Antiobiotic+Antihist 50 amine 40 Antibiotic+Antipyret 30 ic 30 %age 20 Antihistamine+Anti pyretic 10 5 7 5 Antiobiotic+Antipyr 0 etic+Antihistamine+ Multivitamin 1 Fig-1 20
  21. 21. The presence of antibiotic in overall prescription was shown in Fig-2. Fig-2The no. of drugs per patient was shown in Fig-3. Fig-3 21
  22. 22. The class of antibiotic prescribed was shown in Fig-4. Fig-4The age of patient was shown in Fig-5. Fig-5 22
  23. 23. The number of antibiotic per prescribtion was shown in Fig-6. Fig-6 23
  24. 24. 24