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 » Introduction
 »  Materials and Me...
 » Observations
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 Table of Contents    
Year : 2022  |  Volume : 54  |  Issue : 1  |  Page : 13-18

Evaluation and optimization of antibiotic usage in upper respiratory tract infections in children at a tertiary care outpatient department: A clinical audit

Department of Pediatrics, Tata Main Hospital, Jamshedpur, Jharkhand, India

Date of Submission10-May-2021
Date of Decision20-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication18-Mar-2022

Correspondence Address:
Dr. Preeti Srivastava
Department of Pediatrics, Tata Main Hospital, Jamshedpur, C Road, Northern Town, Jamshedpur - 831 001, Jharkhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijp.ijp_373_21

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 » Abstract 

INTRODUCTION: Inappropriate antibiotic (ab)use contributes to antimicrobial resistance. Upper respiratory tract infection (URTI) is the most common reason for antibiotic prescription in an outpatient department (OPD). Several factors influence the high and unjustified antibiotic use in a common ailment.
MATERIALS AND METHODS: A clinical audit was performed to assess antibiotic prescription rate (APR) for URTI in the pediatric OPD against the available benchmark. The prescription pattern was assessed, and interventions were formulated to improve prescription behavior. Data of all children attending OPD and fulfilling the criteria for URTI group were collected from the online hospital management system and analyzed. Interventions, in the form of discussions, presentations, posters, and guidelines (Indian Ministry of Health Guidelines for URTI) regarding etiology of URTI, and indications for antibiotic prescription were implemented. Data were monitored and feedback to consultants was given.
RESULTS: The baseline APR was 14.7%. There was wide variation in APR (4.1%–53.1%) among consultants. Three consultants had a rate of 53.1%, 29.7%, and 28.6%, which was very high. Postintervention, the average APR decreased to 8.7%, a reduction of 40.8%. There was a reduction in APR among consultants with high APR as well. There was reduction in the use of azithromycin, a drug recommended for patients with penicillin allergy, from 21.2% to 14.4% (32.1% reduction). Amoxycillin plus clavulanic acid combination and amoxicillin alone continued to be the most prescribed antibiotics.
CONCLUSION: Interventions through clinical audit were useful in reducing APR. The APR of 8.7% achieved in this study postintervention can be used as a benchmark by other institutions to assess APR in children with URTI.

Keywords: Antibiotics, children, clinical audit, upper respiratory tract infection

How to cite this article:
Mishra S, Srivastava P, Sunder S, Mishra AK, Tanti SK. Evaluation and optimization of antibiotic usage in upper respiratory tract infections in children at a tertiary care outpatient department: A clinical audit. Indian J Pharmacol 2022;54:13-8

How to cite this URL:
Mishra S, Srivastava P, Sunder S, Mishra AK, Tanti SK. Evaluation and optimization of antibiotic usage in upper respiratory tract infections in children at a tertiary care outpatient department: A clinical audit. Indian J Pharmacol [serial online] 2022 [cited 2022 Dec 1];54:13-8. Available from: https://www.ijp-online.com/text.asp?2022/54/1/13/339907

 » Introduction Top

Self-medication is rampant.[1],[2] Indian society is no exception. One of the risks of self-medication is unsupervised and inappropriate antibiotic (ab)use, which may contribute to antimicrobial resistance.[3] Continuing medication on an old prescription for an acute illness without medical practitioner's advice has emerged as a common form of self-medication and is used for adults as well as for children. Since the original prescription was meant for a single episode of illness, repeat administration of the same medication for similar symptoms may seem justified. However, similar symptoms do not mean the same disease. In such situation, it may be dangerous to self-medicate on the same prescription as it may lead to delay in diagnosis and appropriate treatment. At the same time, it may be responsible for the use of antibiotics where none was necessary. Antibiotic use is associated with increased risk of isolation of antibiotic-resistant organisms.[4] Prescription behavior of general practitioners and over-the-counter dispensing of medicines by pharmacists often mimic that of the specialists.[5] Therefore, it becomes necessary that prime institutions lead the way in prescription behavior.

There are many studies that show high antibiotic prescription rate (APR) in upper respiratory tract infection (URTI) and wide variation in antibiotic use by clinicians.[5],[6],[7] There is also wide variation in the choice of antimicrobials prescribed.[7] Various reasons are attributed to such behavior, and they range from commercial interests to lack of knowledge, time, and parental pressure.[7],[8]

 » Materials and Methods Top

The primary objective of the current study was to assess the APR in pediatric outpatient department (OPD) for URTI patients with respect to available benchmark and to decide on interventions required to improve the prescription behavior.

The secondary objective was to assess the antibiotic prescription pattern for URTI in our hospital.

The study, a clinical audit, was conducted in the pediatric OPD of our hospital, between June 1, 2019, and March 31, 2020. Our hospital is a 983-bedded tertiary care hospital, owned by a steel giant, and provides free treatment to its employees and their family members and, on a payment basis, to the community at large. Paying patients form approximately 25% of the OPD attendance in the pediatric OPD.

The hospital management system (HMS) has an OPD module which is used to generate on-line prescriptions for patients entitled for free treatment which are dispensed at the in-house pharmacy counters. For paying patients, hard copy of prescription is given, and they buy medicines from outside the hospital. This prescription is not entered in HMS to avoid duplication of work. The diagnosis in online OPD form is not coded as per the ICD and is written as free text by the doctors. This project was registered as a self-initiated project on total quality management website of our organization, with due ethical clearance.

Literature search for benchmark on APR for URTI did not reveal clear-cut guidelines. Individual reports suggested that 60%–75% infections were viral.[9] A Cochrane review suggested that antibiotics were used in delayed antibiotic group in 27%–38% of patients based on the method of prescription filling, i.e., handing over delayed prescription versus keeping prescription ready at the primary care center.[10] Based on this, an acceptable level of antibiotic use was defined as <25% of total URTI treated. Guidelines on antibiotic use suggested that amoxicillin, co-amoxiclav, and azithromycin, in case of penicillin allergy, were appropriate first-line antibiotics.[11],[12] Thus, these two antibiotics were considered appropriate antibiotics for the treatment of URTI. Azithromycin was considered appropriate if penicillin allergy was documented.

The following data for the full financial year 2018–2019 (FY-19) were generated through HMS: number of patients seen in pediatric OPD, diagnosis of these patients, medicines prescribed, name of the prescribing doctor, and tests ordered. The data were segregated doctor-wise. The doctor's name was coded, and the coded data were given to other authors involved in the study. The person who coded the data (SS) was involved in analysis, but not in the assessment process. Analysis of baseline data was completed in July 2019. August and September 2019 were used to decide and implement the interventions. Postintervention data were collected from October 2019 to March 2020. The same method was repeated while analyzing data in the postintervention period each month.

For analysis, the following conditions that have overlap of symptoms were included in the URTI group: upper respiratory infection, URTI, common cold, cold, rhinitis, acute rhinitis, sinusitis, rhinosinusitis, pharyngitis, acute otitis media, acute respiratory infections, acute respiratory tract infections, and viral fever. The diagnoses entered as wheeze-associated lower respiratory infections, reactive airway disease, asthma, bronchitis, and lower respiratory infections were not included in the study.

Master sheet for baseline data was created in Excel with the following noted against the patient name: presence of URTI (Y for yes), antimicrobial prescription given (Y for yes), and name of antibiotic. Numbers of URTI group patients, those receiving antimicrobials, and type of antimicrobials were thus counted. This was the baseline data.

After analyzing baseline data, interventions for improvement were planned through brainstorming session involving all doctors in the department of pediatrics. Variations in antibiotic use and overall data were shared with all the doctors. However, prescription rate of an individual doctor was not shared with doctors at this stage. Initially, a recapitulation session on URTI was organized for doctors alone, where doctors with the highest prescription rate for antibiotics were invited to speak on etiology of URTI, diagnosis of bacterial URTI with indications for antibiotic therapy, and choice of antibiotics. Ministry of Health and Family Welfare guidelines was also reviewed with respect to respiratory infections.[11],[12]

Next, posters stating that URTI is viral and does not need antibiotics were displayed in OPD consultation chambers. This served as a public education tool as well as a reminder to consultants.

The third intervention was to monitor data on a monthly basis and provide feedback to consultants.

Further intervention planned was documenting reason for antibiotic use in the OPD prescriptions and software modification in the HMS where the prescribing doctor would need to link the prescription to an indication; these were not found practical due to the cost of modification and the time required in a busy OPD.

Statistical analysis

Statistical analysis was done on Microsoft Excel sheet. APR for URTI was defined as number of patients receiving antibiotics/100 patients of URTI group. SPSS 23 software was used to calculate Pearson's correlation coefficient and P value.

 » Observations Top

Baseline data showed that 38,135 patients registered for consultation, of which 20,552 patients had adequate information and were included in study. Of these, 7912 (38.5%) patients belonged to URTI group. During the postintervention period of 6 months from October 2019 to March 2020, 21,458 patients registered. Among these, adequate data were available for 12,143 patients and 5817 (48%) patients belonged to URTI group [Table 1] and [Table 2]. This difference is highly significant (P < 0.0001)
Table 1: Baseline data for the year 2018-2019 (financial year-2019) showing method of coding, audit and results

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Table 2: Trend in use of antibiotics over study period

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Baseline data showed that average antimicrobial prescription rate in FY-19 (2018–2019) was 14.7% in URTI [Table 1]. Based on our target of <25% prescription rate of antibiotics, it was well within the acceptable limits and did not require further intervention. However, doctor-wise analysis showed a variation from 4.1% to 53.1% [Table 1]. This wide variation required to be addressed. Three doctors had an APR rate of 53.1%, 29.7%, and 28.6%. Subsequent monitoring of trends focused on total prescription rate and prescription rates of these doctors. Trend for total prescription is shown in [Figure 1]. Postintervention, the average APR was 8.7% which showed a reduction in APR by 40.8%. The antibiotic prescription trends for three doctors are shown in [Figure 2]. Both figures show a postintervention downward trend in the prescription rate of antibiotics.
Figure 1: Overall trend of antibiotic prescription for upper respiratory tract infection patients

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Figure 2: Trend of Antibiotic prescription for “high prescribers”

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Type of antibiotics prescribed [Table 1] were co-amoxiclav (52.6%), amoxicillin (13%), azithromycin (21.2%), cephalexin (8.6%), and others (4.6%). Other drugs were ofloxacin and cefuroxime used occasionally in children suffering from diarrhea along with respiratory infection. In subsequent months, a gradual reduction in the use of azithromycin (recommended for children with penicillin allergy) was seen [Table 2]. Since azithromycin is not being used specifically for penicillin allergy, appropriate APR for first-line antibiotics is 65.6% considering amoxicillin and co-amoxiclav as the first-line antibiotics for URTI. Postintervention, prescription of appropriate first-line antibiotics (amoxicillin and co-amoxiclav) increased to 73.1% which showed a marginal improvement by 11.4%. Azithromycin use decreased significantly from 21.2% to 14.4%, showing a decline by 32% [Table 2].

Data collection was discontinued from April 2020 to October 2020 as our hospital was designated a COVID hospital and the routine OPD was suspended. Therefore, data from April 2020 to October 2020 were not analyzed. As normal OPD restarted in November 2020, we analyzed data for November 2020 and December 2020 to see if the effect of interventions persisted. APR in November and December showed a value of 36 (11.6%) out of 311 and 26 (10.9%) out of 239 cases of URTI, respectively.

[Table 3] depicts month-on-month comparison between the pre- and post-intervention month showing a consistent decline in APR.
Table 3: Comparison of antibiotic prescription in same months in 2 study years

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Our analysis also revealed that there is no statistically significant correlation between the number of patients seen and rate of antibiotic prescription as shown by a Pearson's correlation coefficient of 0.395 and P = 0.116. [Figure 3] depicts the relationship between number of patients seen by a consultant and APR.
Figure 3: Relationship of total patients seen and antibiotic usage. Statistical analysis shows a Pearson's correlation coefficient 0.395 and P = 0.116, suggesting absence of correlation between number of patients seen and antibiotics prescribed

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 » Discussion Top

Antimicrobial resistance is an emerging epidemic that calls for action to reduce the development of antibiotic resistance. Antibiotic (ab)use is the prime reason for developing antibiotic resistance.[13],[14] URTI is the most common reason for OPD prescriptions of antibiotics.[15],[16] Therefore, URTI was chosen as a subject for this study. Our baseline data for 1 year (2018–2019 or FY-19) suggested that we were within the acceptable range of overall APR (14.7%). However, doctor-wise analysis suggested over-prescription of antibiotics by three doctors that needed correction. The intervention showed that with proper training, reminders, and regular feedback on the APR, the prescription rates of these doctors came down. COVID-19 pandemic interrupted this study as our hospital was designated a COVID hospital, and routine work was scaled down. As regular OPDs resumed in November 2020, we saw a little uptrend in APR (11.6%), which was still lower than the APR of baseline year. This came down further in December 2020 (10.9%) with reinforcement of the feedback, suggesting that regular feedback leads to improvement in appropriateness of prescription.

Postintervention data suggested that the number of patients within URTI group increased significantly from 38.5% to 48%. This appeared to be the result of awareness about monitoring and consequent improved documentation of respiratory problems. This was an unexpected gain from the study.

Another gain from the interventions was reduced use of azithromycin. It is good to reduce the use of this drug so that the development of resistance is delayed or prevented. Azithromycin is particularly important as it is a drug, useful for the treatment of multidrug-resistant typhoid fever.

During the postintervention period, January 2020, data showed a spike in APR [Table 3]. This led us to compare APR month on month. This comparison showed that APR was highest (20.4%) in January 2019, in the FY-19, and there was a reduction in APR in January 2020 as well. Possible reasons for higher APR may be seasonality associated increased URTI rates, higher incidence of bacterial infections due to peak winters, increased travel as schools reopen after winter vacations, and possible parental anxiety to send children to school, leading to increased demand for “quick relief.”[17] Bacteriological studies are required to confirm or refute this hypothesis. A study in Bengaluru on airborne viable bacterial pollution showed that Corynebacterium and Streptococcus were the most common bacterial pollutants in winters, although the highest concentration of bacterial pathogens, including Streptococcus pneumoniae was seen in premonsoon season.[18]

During the study, it was suggested that the doctors who have larger number of patients may be using antibiotics more frequently due to time pressure in busy OPDs. However, [Figure 3] clearly shows that there is no correlation between number of patients seen by a doctor and APR. It helps in emphasizing the fact that busier doctors do not prescribe more antibiotics and should be a lesson for the younger trainees in pediatrics.

Limitations of this study include our inability to include paper prescriptions in the analysis. It may be argued that consultants may have a different prescription pattern for people who purchase medicines, and it may influence overall APR. However, considering that such patients account for 25% of OPD attendance, conclusions drawn from our data seem reliable. Another limitation is our inability to link the prescription to clinical signs observed and microbiological investigations. However, this is the reality of OPDs in resource-limited settings, and our study contributes to better understanding of the prescription patterns and ways to reduce APRs.

 » Conclusion Top

The present study achieved an APR of 8.7% for URTI. Clinical audit methodology helped us to reduce APR by 40.8% and use of azithromycin by 32% in URTI in children. Based on the observation and analysis of data from this study, we infer that the APR and appropriateness of choice of antibiotics can be enhanced through clinical audit. Monitoring and feedback at regular interval seem the most effective intervention to achieve the goal of appropriate antibiotic prescription for URTI in children. APR of 8.7% can be used as a benchmark by other institutions in resource-limited settings to compare their data and optimize antibiotic use in pediatric OPD in children suffering from URTI as defined in the present study.


Authors are grateful to GMMS Tata Steel Ltd for granting us permission to publish this article. Authors thank Dr Sujata Mitra, Director, MTM Cancer Hospital, and HOD, Nuclear Medicine Department, and Head, Total Quality Management, Tata Main Hospital, for peer review and critical appraisal of the article which helped us improve the write-up.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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Vidyawati SD, Sneha A, Kamarudin J, Katti SM. Self-medication: Reasons, risk and benefits. Int J Healthc Biomed Res 2016;4:21-4.  Back to cited text no. 2
Bennadi D. Self-medication: A current challenge. J Basic Clin Pharm 2014;5:19-23.  Back to cited text no. 3
Hay AD, Thomas M, Montgomery A, Wetherell M, Lovering A, McNulty C, et al. The relationship between primary care antibiotic prescribing and bacterial resistance in adults in the community: A controlled observational study using individual patient data. J Antimicrob Chemother 2005;56:146-53.  Back to cited text no. 4
Kotwani A, Holloway K. Antibiotic prescribing practice for acute, uncomplicated respiratory tract infections in primary care settings in New Delhi, India. Trop Med Int Health 2014;19:761-8.  Back to cited text no. 5
Aravamuthan A, Arputhavanan M, Subramaniam K, Udaya Chander JS. Assessment of current prescribing practices using World Health Organization core drug use and complimentary indicators in selected rural community pharmacies in southern India. J Pharm Policy Pract 2017;10:1-6.  Back to cited text no. 6
Jadhav S, Khanwelkar C. Prescribing patterns of drugs in acute respiratory tract infections in children aged 1-5 years at tertiary care teaching hospital. Biomed Pharmacol J 2018;11:1903-11.  Back to cited text no. 7
O'Connor R, O'Doherty J, O'Regan A, Dunne C. Antibiotic use for acute respiratory tract infections (ARTI) in primary care; what factors affect prescribing and why is it important? A narrative review. Ir J Med Sci 2018;187:969-86.  Back to cited text no. 8
Simoes EA, Cherian T, Chow J, Shahid Salles SA, Laxminarayan R, Jacob John T. Acute respiratory infections in children. In: Jamison DT, Breman JG, Measham AR. editors. Disease Control Priorities in Developing Countries. New York: Oxford University Press; 2006. p. 483-97.  Back to cited text no. 9
Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev 2017;9:CD004417.  Back to cited text no. 10
National Treatment Guidelines for Antimicrobial Use in Infectious Diseases. Version 1.0. National Centre for Disease Control, MoHFW, Govt. of India; 2016. Available from: http://pbhealth.gov.in/AMR_guideline7001495889.pdf. [Last accessed on 2020 Dec 24].  Back to cited text no. 11
MoHFW. Standard Treatment Guidelines: Management of Common Respiratory Infections in Children in India. Available from: http://clinicalestablishments.gov.in/WriteReadData/4671.pdf. [Last accessed on 2021 Jan 04].  Back to cited text no. 12
Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient antibiotic use and the need for increased antibiotic stewardship efforts. Pediatrics 2018;141:e20174124.  Back to cited text no. 13
Majhi B, Panda A, Barma SK. Antibiotic prescribing pattern in pediatrics outpatient in a tertiary care hospital. J Evid Based Med Healthc 2017;04:3048-51.  Back to cited text no. 14
Malpani AK, Waggi M, Rajbhandari A, Kumar GA, Reddy N, Chakravarthy AK. Study on prescribing pattern of antibiotics in a pediatric outpatient department in a tertiary care teaching and non teaching hospital. Indian J Pharm Pract 2016;9:253-9.  Back to cited text no. 15
Messina F, Clavenna A, Cartabia M, Piovani D, Bortolotti A, Fortino I, et al. Antibiotic prescription in the outpatient paediatric population attending emergency departments in Lombardy, Italy: A retrospective database review. BMJ Paediatr Open 2019;3:e000546.  Back to cited text no. 16
Eccles R. An explanation for the seasonality of acute upper respiratory tract viral infections. Acta Otolaryngol 2002;122:183-91.  Back to cited text no. 17
Sivasakthivel S, Nandini N. Seasonal variation in airborne bacterial pollution in Bengaluru urban, Karnataka, India. Environ Sci Indian J 2017;13:145.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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