Pediatric Upper Respiratory Tract Infection. Prescribing Pattern and Health Economics
©2017
Textbook
51 Pages
Summary
It is necessary to ascertain current prescribing of antibiotics for upper respiratory tract infections (URTIs) to address potential overuse. Hence, the objective of this study is to analyse the current prescription patterns and the economics of drugs used in the treatment of URTI. For this, a prospective observational study was carried out in the out-patient department of paediatrics. Children of 1 month to 18 years, diagnosed with URTI by the physician, were included in the study. The demographic details, drugs prescribed, dose, duration of therapy, cost of drug therapy were all noted from the out-patient record. The cost of individual drugs was analysed and the health economic analysis of drugs was performed.
Excerpt
Table Of Contents
1
I. ABSTRACT
Background: It is necessary to ascertain current prescribing of antibiotics for
upper respiratory tract infections (URTIs) to address potential overuse.
Objective: To analyse the current prescription patterns and the economics of
drugs used in the treatment of URTI.
Methods: A prospective observational study was carried out in the out-patient
department of paediatrics. Children of 1 month to 18 years, diagnosed with
URTI by the physician were included in the study. The demographic details,
drugs prescribed, dose, duration of therapy, cost of drug therapy were all noted
from the outpatient record. The cost of individual drug was analysed and the
health economic analysis of drugs were performed.
Results: The maximum number of children was in the age group of 1-5 years.
The average number of drugs per encounter was found to be 2.01.
Antihistamines were commonly prescribed and hence it cost more to the
patients, followed by cough syrups.
Conclusion: Medical audit is effective in improvising the prescribing pattern.
Long-term interventional studies are needed to enhance the rational prescribing.
KEY WORDS: Paediatrics, economics, URTI.
2
II. INTRODUCTION
Upper respiratory tract infection (URTI) non-specifically describes acute
infections involving nose, paranasal sinuses, pharynx, larynx, trachea and
bronchi caused by many viruses, mainly rhinovirus.
1,2
A small percentage of
cases (0.510%) are sometimes accompanied by bacterial infections.
3
Prescribing antibiotics routinely for URTIs is not justified as they have limited
clinical efficacy. However, they are more commonly prescribed in situations
where they are not indicated such as in infections with bacterial uncertainty or
uncertain viral etiology.
4-7
The evolving public health threat of antimicrobial resistance (AMR) is driven
by both appropriate and inappropriate use of anti-infective medicines for human
and animal health and food production, together with inadequate measures to
control the spread of infections. Recognizing the public health crisis due to
AMR, several nations, international agencies, and many other organizations
worldwide have taken action to counteract it through strategies applied in the
relevant sectors. Several World Health Assembly resolutions have called for
action on specific health aspects related to AMR, and the World Health
Organization published its global strategy to contain AMR in 2001.
8
3
On World Health Day (WHD) 2011, in a six-point policy package, countries
were called upon to:
(1) Commit to a comprehensive, financed national plan with accountability and
civil society engagement
(2) Strengthen surveillance and laboratory capacity
(3) Ensure uninterrupted access to essential medicines of assured quality
(4) Regulate and promote rational use of medicines in animal husbandry and to
ensure proper patient care
(5) Enhance infection prevention and control
(6) Foster innovations and research and development of new tools.
9
Paediatric respiratory tract infections are one of the most common reasons for
physician visits and hospitalisation, and are associated with significant
morbidity and mortality. Respiratory infections are common and frequent
diseases and present one of the major complaints in children and adolescents.
The role of physicians and other healthcare providers has expanded from merely
treating disease to implementing measures aimed at health maintenance and
disease prevention.
10
Respiratory infections (RI), mainly involving the upper airways, are common in
children and their recurrence constitutes a demanding challenge for the
paediatricians. There are many children suffering from so-called recurrent
4
respiratory infections (RRI). The child with recurrent respiratory infections
presents a difficult diagnostic challenge. It is necessary to discriminate between
those with simply-managed cause for their symptoms such as recurrent viral
infections or asthma, from the children with more serious underlying pathology
such as bronchiectasis or immune dysfunction. Many different disorders present
this way, including cystic fibrosis, various immunodeficiency syndromes,
congenital anomalies of respiratory tract, but in some children lung damage
could follow a single severe pneumonia or can be the consequence of the
inhalation of food or foreign body.
11
According to the epidemiological studies it was estimated that around 6% of the
children younger than 6 years of age present RRI. In developed countries, up to
25% of children aged < 1 year and 18% of children aged 1-4 years, experience
RRI.
10
Moreover, ENT infections represent the most frequent pathologies in
children aged from 6 months to 6 years. Although the etiologic agents
responsible for RRI are not always readily identifiable, viral agents are typically
the main cause.
The real task for the paediatricians is to discriminate the normal children with
high respiratory infections frequency related to an augmented exposure to
environmental risk factors from the children affected by other underlying
pathological conditions (immunological or not), predisposing to infectious
5
respiratory diseases.
12
Usually, the children with RRI are not affected by severe
alterations and RRI represent essentially the consequence of an increased
exposure to infectious agents due to environmental factors during the first years
of life.
13
In the clinical practice, most of the children suffer from the recurrent infections
of the upper airways, but in approximately 10-30%, the lower tract is also
affected. There are two peaks of the incidence of RRI:
11
x 6-12 months of age - after consumption of the maternal passively transferred
immunoglobulins with concomitant postponed synthesis of own antibodies
x the involvement of the child in to the group of children at nursery or school.
Upper respiratory infections are common but are unlikely to indicate an
underlying medical condition when they occur in isolation. When evaluating the
patients with recurrent infections, it is reasonable to use acronym SPUR (severe,
persistent, unusual, recurrent) to prompt appropriate investigations for
underlying causes. Children with RRI have the course of the airway infections
(feature, severity and duration) similar to those presented by children with
"normal" incidence of respiratory infections. The frequency of RI in children
with RRI shows typical seasonality with the highest rate during autumn and
winter.
13
Typically, these children are not affected by the recurrent infections of
the other systems (gastrointestinal tract, central nervous system, uro-genital
6
tract or skin). While most children with recurrent infection have a normal
immunity, it is important to recognize the child with an underlying primary
immunodeficiency and investigate and treat appropriately and not over-
investigate normal children.
14
RRI are a common problem mainly in preschool age, usually due to the
presence of unfavourable environmental conditions, including early
socialization, as well as the immaturity and inexperience of the immune
system.
15
In infancy and early childhood, the immune system encounters
antigens for the first time, mounting immune responses and acquiring memory.
Young children mix with other children in families or nursery and are exposed
to many pathogens and therefore there are more vulnerable to infection and
recurrent infections are common.
14
Many of the children are simply having the
repeated viral upper respiratory tract infections that are a normal part of
growing up. In others, the symptoms are the first manifestations of asthma.
If there is a history of persistent or recurrent pneumonia with or without chronic
sputum production, it is indicating more severe pathology.
11
RRI initially occur
as a viral respiratory tract infection, but bacterial growth is demonstrated in
60% of patients with symptoms of an upper respiratory tract infection of at least
10 days duration.
16,17
The children with prolonged or recurrent respiratory
illnesses most often have a series of infections rather than persistent infection
7
with one virus strain.
18
Some children experience considerable morbidity as a
result of RRI and receive repeated courses of antibacterials that are not effective
against viral infectious agents and can increase bacterial resistance.
19
Hence,
URTIs is a major burden to the healthcare systems, especially when
inappropriate antibiotic treatment leads to increased antibiotic resistance.
20
Infections of the Upper Respiratory Tract (URT) are the most commonly
encountered illness of childhood
21
and one of the main reasons for pediatric
consultations.
22,23
More than 200 viruses can cause upper respiratory tract
infections (URTIs). Acute respiratory infection accounts for 20-40% of
outpatient in Pediatrics.
24
The emergence of bacterial resistance to
antimicrobials is a growing concern all over the world.
25
The relationship
between the use of antibiotics and the development of resistance is confirmed
by various studies.
26,27
Antibiotics are commonly used for treating of upper
respiratory tract infections, although viruses cause most of URTIs.
28
Anti Microbial Agents (AMAs) are the most frequently used drug and it is
misused more commonly compared to all other drugs. The inevitable
consequence of the common use of AMAs has been the emergence of antibiotic
resistant pathogens, fuelling an ever increasing need for new drugs. Decreasing
inappropriate antibiotic use is the best way to reduce or control resistance.
Eventhough there are increased awareness about the harmful effects of
8
antibiotic misuse, over prescribing remains widespread. It mainly occurs by
patient demand, time pressure on clinicians and diagnostic uncertainty.
Appropriate selection of AMAs for treating infectious diseases requires clinical
judgment of disease and the drugs. The bacterial infection should be identified
before treatment and should be initiated whenever possible. To initiate right
choice of empirical antibiotic therapy, knowledge on the most likely infecting
microorganism and their susceptibilities to antimicrobial drugs is essential.
29
The bacterial agents that are resistant to antibiotics are of greatest concern.
These resistance are mainly due to common and inappropriate antibiotic therapy
for children with upper respiratory tract illnesses. Approximately three fourths
of all outpatient antibiotic prescriptions given to children are for upper
respiratory tract conditions mainly viral infections, bronchitis, pharyngitis,
sinusitis, and otitis media. To reduce and look into this problem, the Centers for
Disease Control and Prevention (CDC) and the American Academy of
Pediatrics published "The Principles of Judicious Use of Antimicrobial Agents
for Pediatric Upper Respiratory Tract Infections".
5
This document focuses on
reducing the antibiotic usage for such conditions that do not respond to them
and promoting the use of narrow- rather than broad-spectrum antibiotics.
Respiratory infections are the major reason for prescribing antibiotics in
paediatrics. According to the 1992 National Ambulatory Medical Care Survey
9
(NAMCS) in the United States, acute otitis media was the most common
diagnosis for which antibiotics were prescribed (30%), followed by upper
respiratory tract infection (URTI), pharyngitis and bronchitis (12%, 10% and
9%, respectively).
30
Inappropriate prescription of antibiotics can lead to the
emergence of bacterial resistance, an increase in adverse drug effects and high
pressure on financial burden.
In November 2013, The American Academy of Pediatrics released a set of three
basic principles for the effective use of antibiotics to treat pediatric URIs,
including acute otitis media, acute bacterial sinusitis, and streptococcal
pharyngitis.
31,32
The principles are as follows:
·
Accurate diagnosis of a bacterial infection;
·
Consideration of the risks vs benefits of antibiotic treatment; and
·
Implementation of judicious prescribing strategies, including selection of
the most effective antibiotic, prescription of an appropriate dose, and treating
for the shortest possible duration.
These principles will help healthcare providers distinguish bacterial infections
from viral infections.
Medical audit looks into the standards of medical treatment at all levels of the
healthcare delivery system.
32
Prescribing pattern study is a part of the medical
10
audit and it monitors, evaluates and suggest modifications in prescribing
practices to make medical care rational and cost-effective.
The CDC in collaboration with the American Academy of Paediatrics (AAP)
recommends stringent diagnostic criteria for URTIs to avoid misdiagnosis and
inappropriate antibiotic prescriptions. Antibiotic treatment is helpful to children
only if symptoms persist for 10-14 days without any improvement.
33
New drugs and new modes of treatment are constantly being introduced. The
medical care's quality should be judicially implemented, appropriate, safe,
effective and economic. "Good" prescribing is a complex balance between
various conflicting factors.
34
Details
- Pages
- Type of Edition
- Erstausgabe
- Year
- 2017
- ISBN (PDF)
- 9783960676379
- ISBN (Softcover)
- 9783960671374
- File size
- 314 KB
- Language
- English
- Publication date
- 2017 (March)
- Grade
- 1
- Keywords
- Paediatrics Economics URTI Antibiotics Audit study Medical audit Prospective observational study Pediatrics Prescription pattern Drug prescription
