sAFIA fINAL.pdf

PRESCRIPTION PATTERN ON DRUG UTILIZATION IN
ACUTE TONSILLITIS IN PATIENTS
A Report on
PRACTICE SCHOOL
Submitted for partial fulfillment of the requirement
For the award of
BACHELOR OF PHARMACY
BY
SAFIA MWALIM HAJI
REG.NO. 2115022002
B.PHARMACY 7TH
SEMESTER (2023-2024)
UNDER THE SUPERVISION OF
MRS. RAMANDEEP KAUR SANDHU
ASSISTANT PROFESSOR, UCOP, GKU
UNIVERSITY COLLEGE OF PHARMACY
GURU KASHI UNIVERSITY
TALWANDI SABO, BATHINDA, PUNJAB
DECEMBER 2023

CERTIFICATE
This is to certify that the work embodied in project report entitled “Prescription pattern
on drug utilization in acute tonsillitis in patients at Adeshi hospital, Bathinda has
been carried out by SAFIA MWALIM HAJI under my supervision University College
of Pharmacy (Mrs. Ramandeep Kaur Sandhu), Guru Kashi University, Talwandi Sabo,
Bathinda, Punjab, India during academic session 2023-2024 and has not been submitted
for the award of any other degree
Signature
Mrs. Ramandeep Kaur Sandhu
Assistant Professor, UCOP, GKU
Guru Kashi University,
Talwandi Sabo, Bathinda, Punjab, India-151302

This is to certify that SAFIA MWALIM HAJI bearing university roll number 2115022002
has prepared report on “PRACTICE SCHOOL” in partial fulfillment of the requirement
for the degree of “Bachelor of Pharmacy” in Guru Kashi University, Talwandi Sabo,
Bathinda, Punjab, India. This work was carried out by him at the University College of
Pharmacy.
Signature:
Dean of Pharmacy Department
University College of Pharmacy
Guru Kashi University
Talwandi Sabo, Bathinda, Punjab, India-151302
CERTIFICATE BY DEAN OF PHARMACY

DECLARATION
I hereby declare that the work reported in practice school report entitled “Prescription
pattern on drug utilization in acute tonsillitis in patients at Adeshi hospital,
Bathinda has been carried out by me under the supervision of “Mrs. Ramandeep Kaur
Sandhu” at University college of Pharmacy, Guru Kashi University, Talwandi Sabo,
Punjab during the academic session 2023-2024 and has not been submitted for the award
of any other degree.
Signature
Safia Mwalim Haji
Roll no. 2115022002
B. Pharmacy
Guru Kashi University
Talwandi Sabo, Bathinda Punjab India-151302

ACKNOWLEDGEMENT
Finally I would like to give my great and lovely thanks to almighty God (S.W)
for blessing me with strong and comfortable health as well as courage for the
accomplishment of my project repot.
All the start of every major task initially difficulties seem insurmountable. But
as we begin treading on the chosen path with honesty and perseverance we find that God
is there to help us. Research is an arduous task, which despite a consistent and dedicated
mind also requires patience. Towards the completion of my thesis it is a pleasurable
aspect that I have now the break to communicate my thankfulness to all those who have
been influential in the completion of this task.
First of all, with humility, bowed head, misty eyes and folded hands, I
acknowledge my gratitude to Almighty with whose mercy it has been possible for me to
reach this so for. I express my thanks to Vice Chancellor of Guru Kashi University,
Dean of Pharmacy and my teachers for providing me all the required project facilities,
supportive assistance and for their important support throughout this project.
Finally, I wish to put on record my profound gratitude to my ever available
supervisor Mrs. Ramandeep Kaur Sandhu, University College of Pharmacy, Guru Kashi
University, Without whose guidance this study would not have been in the way it is
presented.
Date Safia Mwalim Haji
Place

ABSTRACT
Acute tonsillitis, where virus like adenovirus, Epstein-Barr virus or influenza viruses are
implicated, is treated symptomatically with antipyretics, anti-inflammatory drug and
mouth gargles, and reassurance to the patients. Several studies have reported that
antimicrobials are prescribed in the management of URTI due to the drug related
problems associated with in appropriate use. The limited role of antimicrobials in acute
tonsillitis of viral etiology has been published in an overview of Cochrane reviews by
Arroll (2005). The culture of prescriptions contained antimicrobial in the present study
and the culture and sensitivity reports on throat swab were useful tools in assisting
clinicians in selecting the most appropriate antimicrobial agent in individual patients. In a
study from Adeshi 95.9% of prescriptions contained antimicrobials in the treatment of
acute tonsillitis (Rehan 2003). In publication from Thailand, more than 80% of the
prescriptions for upper respiratory tract infections contained antimicrobials agents
(Issarachaikul and Suankraty 2013). Among the individual drugs, amoxicillinclavulanate
followed by cefriaxone were the widely utilized drugs in the present study, similar to a
previous report from India, but the common cephalosporin prescribed in the latter study
was cefopodoxime(Ain et al.2010).this finding contradicts (Senok et al.209). (Khan et
al.2011), (Daset al.2005) and (Rehan2003), were in the preferred antimicrobial agents
were amoxicilli, cefixime and ciprofloxacin respectively. Reported from Japan
documented cefcapene, a third generation cephalosporin as the most commonly
prescribed antibiotic, followed by clarithromycin (higashi 2009).
Methods:
Prescriptions for acute tonsillitis were collected outside the ENT-OPD over a period of 6
months and were analyzed.
Key words: Drug utilization, Antimicrobial use and Acute Tonsillitis.

TABLE OF CONTENTS
CHAPTER CONTENT Page No.
I INTRODUCTION 1-5
II LITRERTURE REVIEW 6-9
III SUMMARY 10-11
IV CONCLUSION 12-13
V REFERENCES 14-15

LIST OF FIGURES
Figure number Description of figure Page number
1 TOSILITIS 3
2 SIGN AND SYMPTOMS 4
3 CAUSES OF TONSILLITIS 5
4 ACTIVITY SCHEDULE 9

1
CHAPTER
I
INTRODUCTION
CHAPTER
I
INTRODUCTION

2
INTRODUCTION
Tonsillitis is inflammation of tonsils due to bacterial or viral infection causing a sore
throat, fever, and difficult in swallowing. The inflammation usually extends to the
adenoid and the lingual tonsils; therefore, the term pharyngitis may also be used. The
most common bacterium causing tonsillitis is Streptococcus pyogenes (group A
streptococcus). In the first century AD, Celsius described tonsillectomy performed with
sharp tools and followed by rinses with vinegar and other medicinal.
Since that time, physicians have been documenting administration of tonsillitis.
Tonsillitis occurs throughout the world, without racial or ethnic differences. Most
children have tonsillitis at least once during their childhood, although it rarely occur
before the age of two. It most typically occurs between the age of four and five, bacterial
infections most typically occur at later age.
Tonsillectomy is usually indicated when a patient has 6 or more acute tonsillitis attacks
during last 12 months and not recommended if a patient had less than 3 attacks.
ACUTE TONSILLITIS.
 Mostly affects children in the age group of 5-15 years, may also affect adults
 Organism: beta-hemolytic streptococci( most common), staphylococci, Pneumococci,
H.influenzae
In the normal sate, tonsils are pink in color (similar to surrounding tissues) and about the
same size.
The tonsils along with adenoids are said to form the first line of defense against infective
organism.
When the tonsils get inflamed, they become red, swollen and may develop pus pockets
that start exuding a discharge
In case of recurrent infections, the tonsils may become so swollen over a period of time
so as to almost touch each other.
Tonsillitis is very common against children
No particular gender predilection is seen in case of tonsillitis.

3
Figure 1, Tonsiliitis
Recurrent tonsillitis
Recurrent tonsillitis is defined as repeated attacks of acute tonsillitis with periods with
only very few, or without any symptoms recurrent tonsillitis has some sequalae and
complications including: severe lower tract infections and the need for surgery with
high impact on families' daily life and healthcare costs. Owing to the high morbidity,
mortality and healthcare costs, effective prevention and treatment are needed
Tonsillectomy is associated with significant risk of primary and secondary hemorrhage;
in addition, it is painful procedure. Also, tonsillectomy may affect patient's immune
system through the significant decrease of interleukin and immunoglobulin’s levels
postoperatively
Recent studies recommend more randomized controlled trials with adequate long-term
follow-up to clarify the benefits of tonsillectomy versus non-surgical treatment in patients
with recurrent tonsillitis. Drugs such as penicillin and Azithromycin (AZT) are widely
used to control recurrent tonsillitis. Sire manna et al. Reported the usefulness of long-
acting penicillin in recurrent tonsillitis prevention. However; long-term use of penicillin
may result in hypersensitivity reactions, irrelative responses, anaphylaxis, severe local
pain and gluteal abscesses. AZT is an azalide, a subclass of macrolide antibiotics. It is
rapidly absorbed and widely distributed throughout the body; with higher concentrations

4
in infected tissues and its therapeutic levels in tonsil tissue occurs during weekly
medication with minimal side effects. Gopal et al. reported that use of 500 mg once
weekly oral AZT was effective in prevention of streptococcal throat infection compared
to oral penicillin therapy.
Signs
 Sore throat
 Difficulty in swallowing
 General body ache
 Fever
 Enlarged lymph nodes in neck region
 Earache and thick speech
Figure 2, sign and symptoms
Symptoms
 Soreness of throat
 Difficult in swallowing or painful swallowing of food or drink
 Change of voice
 Difficulty in taking feeds in babies- this may be the sole indicator in some cases of
tonsillitis in infant
 Pain or discomfort while swallowing saliva
 Malaise, tiredness
 Headache
 Pain in the ears ( due to common nerve supply of the back of the throat and ears ).

5
Causes
 Most cases of tonsillitis are caused by infection with a common virus, but bacterial
infections also may cause tonsillitis.
 Because appropriate treatment for tonsillitis depends on the cause, it's important to get a
prompt and accurate diagnosis. Surgery to remove tonsils, once a common procedure to
treat tonsillitis, is usually performed only when tonsillitis occurs frequently, doesn't
respond to other treatments or causes serious complications.
Figure 3, causes of tonsillitis
OBJECTIVES
PRIMARY OBJECTIVE
1. To evaluate the pattern of drug utilization associated with acute tonsillitis at adeshi
hospital
SECONDARY OBJECTIVE
1. To study and analysis the drug prescription and antibiotic for acute tonsillitis
2. To find out the base line data on prescribing pattern of drugs in acute tonsillitis.

6
CHAPTER
II
REVIEW OF
LITERATURE

7
REVIEW OF LITERATURE
Specified that tonsillectomy raises the hazard of deep neck contaminations. Using a
health insurance research database search, the investigators found patients to be at greater
risk of deep neck infection after experiencing tonsillectomy. A retrospective cohort study
of 61,430 patients who experienced tonsillectomy specifies that the use of intravenous
steroids on the day of surgery increases the frequency of post tonsillectomy bleeding in
children, but not in adults. In the study, Suzuki et al found that the rate of reoperation for
bleeding was 1.2% for children aged 15 years or younger who received intravenous
steroids, versus 0.5% for patients in the same age group who did not. Between patients
older than 15 years, nevertheless, the reoperation rate was not expressively higher in the
steroid patients than in the controls (1.7% vs. 1.4%).1
Showed that respiratory compromise is the most frequent complication happening in
children (9.4%) following adenotonsillectomy, with secondary haemorrhage being the
second most frequent (2.6%). The authors similarly found that in children who experience
adenotonsillectomy, the hazard of respiratory complications is 4.9 times higher in those
who have obstructive sleep apnoea than in children who do not, but the hazard of
postoperative bleeding is lesser.II
Specified that the hazard of postoperative bleeding in children experiencing tonsillectomy
is expanded when the surgery is accomplished on a child with recurrent tonsillitis (4.5
times expanded hazard), on a child with responsiveness deficit hyperactivity disorder (8.7
times expanded hazard), or on an older child (twice the bleeding hazard in children aged
11 years or above).III
Found a strong association of tonsillitis with age, unhygienic living condition, balanced
diet, stressful environment and the use of sour/spicy foods. The disease was more prevalent
in males compared to females and children aged <5 years were more vulnerable to the
disease which is in line with an earlier study. In younger age, the tonsils can easily
become overwhelmed with infection. According to a study, in children aged up to 6 years
the tonsils are larger in size than the adults, which make them an easy target to tonsillitis.
Stressful environment also played a significant role in causing tonsillitis because stress
may increase the possibility of acute respiratory infection in children and this increases
with the level of stress. IV

8
In our study unhygienic/polluted environment was also found to have vital role in
causing tonsillitis which agrees with earlier findings children who consumed sore/spicy
foods were at high risk of tonsillitis which also confirmed earlier findings in this regard. In
the current study, the urban-rural divide had no significant role in causing tonsillitis,
which is in contrast with the findings of an earlier study.V
Methodology
Setting: This is hospital-based study and data will be collected from OPD of ENT
department.
Duration: 6 months.
Type of study: This is a prospective, observational study
Details of subjects to be used: All patients suffering Tonsillitis and Recurrent of tonsillitis
will be enrolled into the study.
Sample size:
Based on Duration of Study
Place of work: This Study will be conducting in Adesh hospital, Bathinda.
Inclusion criteria:
1. Individual who suffering from any type of tonsillitis
Exclusion Criteria:
1. Patients Suffering from any other chronic illness
Source of Data
 Informed Consent Form
 Questionnaire
Statistical analysis
Data collected and analyzed by using Microsoft Excel
Ethical Consideration: The research conducted after approval from AIPBS- Departmental
Research Committee and informed to Ethics Committee, Adesh hospital, Bathinda and
informed consent will be obtained from the Patients.

9
Annexure III Activity Schedule
Figure 4, activity schedule
Activity Sep Oct Nov Dec Jan Feb
1.Review of literature
2.Design Study Protocol
3.Ethics Committee Approval
4.Data Collection
5.Analysis of data
6.Thesis Writing
7.Submission of project report
8.Pre-report submission
seminar(second seminar)
9.Submission of project report
10.Seminar to examiner and
viva voce(Third Seminar)

10
CHAPTER
IV
SUMMARY

11
SUMMARY
Patient with tonsillitis often present with a sore throat, a common symptom with a myriad
of possible diagnoses. A thorough history and physical examination performed by the
healthcare team is paramount to hone in on a diagnosis.
When diagnosing tonsillitis and implementing treatment. It is important for healthcare
provider to discuss treatment options and choices with the patient, especially when
considering the administration of antibiotics.
Risk and adverse reactions should be disclosed to the patient when prescribing any drug.
In cases where other diagnoses are possible, it can be helpful to recruit specialist,
including otolaryngology, internal medicine, and nephrology, depending on the patient
clinical picture and test results. Additionally, when ordering imaging , it is important to
provide the radiologist with physical examination finding to hone in on areas of interest
when reading films. Evidence of treatment effectiveness includes multiple large
randomized controlled trials included in several Cochrane review articles. The decision to
treat model, Centor criteria, has also be evaluated in several extensive studieds.
The evidence of this topic consist of a broad range of evidence and overall study quality
through level 1 evidence is available in regarding to the use of antibiotics in GABHS,
causing tonsillitis and the use of Centor criteria in risk stratification.
Tonsillitis diagnosis and treatment requires an interprofessional team approach, including
physicians, specialist, specialty –trained nurses, and pharmacist, all collaborating across
disciplines to achieve optimal patient results.
Primary care providers evaluate and order treatments. Ambulatory and otolaryngologic
nurses educate patients and their families, updating the team as needed.
Pharmacists assess doses, interaction and compliance.

12
CHAPTER
IV
CONCLUSION

13
CONCLUSION
A prospective study was under taken to find out base line data on the prescribing Patten
of drugs in acute tonsillitis at Adesh hospital in Bathinda was carried out. Prescriptions
for acute tonsillitis were collected outside the ENT-OPD over a period of 6 months and
were analyzed. The average number of drugs per prescription was 3.24. Ninety five
percent of the Prescriptions contained antimicrobial agents (with an average of 1.04
AMAs per Prescription). Antimicrobial agent was the most commonly prescribed
(31.81%) group of drug followed by analgesics and antipyretics (20.70%). Amoxicillin
(38.80%) and Azithromycine (20.63%) were the most common Prescribed AMAs.
Erythromycin was prescribed in 11(6.73) patients while penicillin was not at all
prescribed. Culture and sensitivity test was advice only in 14.75% of cases. Cough
expectorants were the most common used fixed dose combination. Of total drugs used,
96.9% were prescribed by brand names. The duration of therapy was not motioned for
35.60% of the drugs prescribed. The iatyprtyriate and over use of antimicrobial agents
make treatment east effective.

14
CHAPTER
V
REFERENCES

15
REFERENCES
1. Wang, H., Fu, Y., Fang, Y., Guan, J., & Yin, S. (2015). Tonsillectomy versus
tonsillectomy for sleep-disordered breathing in children: a meta-analysis. Plops
one, 10(3), e0121500.
2. Canto, G. D. L., Pacheco-Pereira, C., Aydinoz, S., Bhattacharjee, R., Tan, H. L.,
Kheirandish-Gozal, L & Gozal, D. (2015). Aden tonsillectomy complications: a meta-
analysis. Paediatrics, 136(4), 702-718.
3. Spektor, Z., Saint-Victor, S., Kay, D. J., & Mandell, D. L. (2016). Risk factors for
paediatric post-tonsillectomy haemorrhage. International journal of paediatric
otorhinolaryngology, 84, 151-155.
4. Khan, D. M., Hamraz, M., Khattak, A. Z., Ali, I., Khalil, U., & Khan, Z. (2020). The
analysis of risk factors associated with tonsillitis in district Mardan, Pakistan. JPMA. The
Journal of the Pakistan Medical Association, 70(7), 1169-1172.
5. Brahmadathan, K. N., Anitha, P., & Gladstone, P. (2005). Increasing erythromycin
resistance among group A streptococci causing tonsillitis in a tertiary care hospital in
southern India. Clinical microbiology and infection, 11(4), 335-337.
6. Binotto M, Guilherme L, Tanaka A. Rheumatic Fever. Images Paediatr Cardiol. 2022
Apr, 4(2); 12-31.
7. ESCMID Sore Throat Guideline Group. Pelucchi C, Esposito S, Huovinen P , Little P,
Verheij T. Guideline for treatment of acute sore throat.
8. Hamlyn E, Marriott D, Gallagher RM. Secondary syphilis presenting as tonsillitis in three
patients. J Laryngol Otol.2006 Jul,120(7)
9. Meegalla N, Downs BW. StatPearls (internate). StatPearls, Publishing , Treasure Island
(FL), Jun 11,2022. Anatomy, Head and Neck, Palatine Tonsil.
10. Bartlett A, Bola S, Williams R. Nav Med Serv.2015, 101(1):69-73
11. Georgalas CC, Tolley NS, Narula A. Tonsilittis . BMJ Clin Evid. 2009 Oct 26,2009
12. Johannesen KM, Bodtger U. Lemierres syndrome : current perspective on diagnosis and
management. Infect Drug Resist.2016,221-227.(PMC free article ) (PubMed)
13. Walker MJ, Barnett TC, McArthur JD, Cole JN, Gillen CM, Henningham A, Sriprakash
KS, Sanderson-Smith ML. Nizet V. Disease manifestations and pathogenic mechanisms
of Group A Streptococcus. Clin Microbiol Rev.2014 Apr,27(2):2643

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