Suttajit Sa, Tantipidoke Ra, Sitthi-amorn Ca, Wagner Ab, Ross-Degnan Db.

aChulalongkorn University, Bangkok; bHarvard Medical School, USA

Problem Statement: Understanding where in the care process patients receive antibiotics may help in designing interventions to decrease antibiotic use and drug resistance in

community.

Objectives: To measure patterns of antibiotic use in adults with URIs and to identify where inappropriate use of antibiotics occurs in the community.

Study Population: Interviewers visited 3,973 households in 2 congested communities in Bangkok and interviewed 779 adult patients with URIs.

Methods: Interviews of adults age >18 who had URIs within 2 prior weeks in a systematic random sample of households.

Outcome Measures: Patterns of care seeking, % antibiotics use, and treatment costs.

Results: About 81% of URI cases were likely of viral origin. Patients with viral and bacterial URIs exhibited the same pattern of care seeking: patients first took care of themselves at

home, some then went to drugstores and then to clinical settings. During their URI episode, 44% of viral URIs and 54% of bacterial URIs patients had used an antibiotic; antibiotic use was significantly higher among those who sought care outside their home. Among patients who only self-treated, 10% used antibiotics. Half of all patients sought treatment in drugstores, 65% received an antibiotic regardless of the infection type. In clinical settings, 61% of viral

URIs and 71% of bacterial URIs patients received antibiotics. Self-medication with inappropriate antibiotics for viral URI cost 23 baht/patient and unnecessary visits to clinical

settings for symptomatic treatment cost 89 baht/patient.

Conclusions: Antibiotics are misused for viral URIs by self-medication at home but more frequently misused when patients visit drug stores and clinical settings. Interventions should be implemented to promote symptomatic self-treatment and appropriate antibiotic use by health

providers as well.

Care Seeking and Treatment for Adults with URIs Care Seeking and Treatment for Adults with URIs in Congested Communities in Bangkok: Where Problems Occurin Congested Communities in Bangkok: Where Problems Occur

Introduction

Most upper respiratory tract infections (URIs) are caused by viruses, and antibiotics are not

recommended in their treatment. However, antibiotics are frequently used to treat URIs.

Understanding where in the care process patients receive antibiotics may help in designing

interventions to decrease antibiotic use and help reduce the rate of development of drug resistance

in low-income and high-risk communities.

Objectives

1. To measure patterns of antibiotic use in adults with URIs, and

2. To identify where inappropriate use of antibiotics occurs in the community

In order to understand the problem of drug use in community well and be able to design effective interventions to improve antibiotic use, the aims

of this study are:

Methods

Design

Cross-sectional study

Setting and Study Population

In October 2002, interviewers visited 3,973 households in two congested communities in Bangkok and interviewed 779 adult patients

with URIs.

Methods

Interviews of adults over 18 years old who had URIs within two prior weeks in a systematic random sample of households. Interviewers asked about URIs symptoms, health seeking

behavior, drugs taken and cost, and self care.

Methods

Analysis

Based on patient’s reported symptoms, we adapted GAS score1 and signs for sinusitis2 to

identify probability of Group A strep throat and sinusitis, and whether or not antibiotic should

be taken in each case.

Data were managed and analyzed using SPSS for Windows 12.0. Chi-square and Student’s t-

test were applied where appropriate. A P-value <0.05 was considered statistically

significant.

1 McIsaac WJ, White D, Tannenbaum D, Low DE. 1998. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Canadian Medical Association Journal 158: 75-83.

2 William JW Jr, Simel DL. 1993. Does this patient have sinusitis?: Diagnosing acute sinusitis by history and physical examination. Journal of the American Medical Association 270(10):1242-1246.

Results 1

URI Cases in Community

Total household visited was 3,973, 1,138 (28.6%) reported recently URIs within 2 weeks and 779 adult URIs cases were interviewed. About 82% were likely

of viral origin.

Female 81.8 %Age 18-40 44.7 % 41-60 40.1 % > 60 15.3 %Education < high school

82.8 %

Income < 10000 baht

85.6 %

Health insurance

None 11.8 % National health plan 55.5 % Others 32.7 %Likely to be:

Viral URIs 81.6 % Bacterial URIs 18.4 %Sick day, mean+SD 6.21+3.

97

Table1. Characteristics of Patients (n=779)

Results 2

Pattern of Health Seeking Behavior

Viral and bacterial URIs cases usually first took care of themselves at home, but bacterial URIs were more likely have visited a clinical setting at the end of their

illness.

Choice of Treatment and setting

1st choice During the illness

Viral (634)

Bact. (145)

Viral (634)

Bact. (145)

Non-pharmacological tx. No treatment 6.0 % 4.1 % 6.0 % 4.1 % Non-drug treatment 52.7 % 49.7 % 53.2 % 50.3 %Pharmacological tx.

Self-prescribing

At home 23.0 % 28.3 % 23.8 % 29.0 % At drug store 4.7 % 5.5 % 21.5 % 21.4 % Tx. recommended by others At drug store 6.3 % 7.6 % 26.3 % 25.5 % In clinical settings1 6.2 % 3.4 % 39.7 % 48.3 % Others 1.1 % 1.4 % 3.9 % 3.4 %

Table 2. Choice of Treatment

1 private clinic, hospital, health center

Results 3

Where did URIs cases receive the antibiotics?

During the illness episode, 44% of viral URIs cases and 54% of bacterial URIs cases had used an

antibiotic. Antibiotic use was clearly higher among those who sought care outside their home.

Table3. Antibiotics used at each setting

Setting Viral URIs Bact. URIsSelf-prescribed

at home 10.6 % 9.5 % at drug store 21.3 % 35.5 %Recommended by others at drug store 65.5 % 64.9 % at clinical settings 61.4 % 71.6 % at other settings 13.3 % 0 %

Results 4

Cost of Drug Use in URIs Treatment

On average, viral URIs spent 84.6 baht ($2.2) while bacterial URIs spent 101.3 baht ($2.6).

The most frequently used pattern of care seeking costs 112.1 baht/episode ($2.9) (0.83%

of average national household income).

In viral URIs, there is a lost of 59.5 baht/episode ($1.6) compared between the most

appropriate and most inappropriate pattern of care seeking.

In viral URIs treatment, self-prescribing with antibiotic costs the lost of 23.3 baht/episode

($0.6) and unnecessary visiting of clinical settings costs the lost of 88.7 baht/episode

($2.3).

Discussions

Limitations

Potential misclassification of diagnoses and problem in identifying type of drug use by patients as they seldom knew their own

medicines.

Application of the results

Researchers use the results to feedback and encourage the active citizen to take action in

solving drug use problem in their community.

Interventions designed together by community and research team are now implementing, such

as the local URIs management guideline, Network for rational drug use, newsletters,

radio broadcast, and discussion forum.

Conclusions

What’s New?

This study adds about study in developing country and in adults, and patterns of care

seeking and antibiotic use in viral and bacterial URIs.

Conclusions

Antibiotics are misused for viral URIs by self-medication at home but more frequently

misused when patients visit drug stores and clinical settings.

Interventions should be implemented to promote symptomatic self-treatment of URIs.

In addition, interventions should be implemented to promote appropriate antibiotic use for URIs in drug stores and clinical settings

as well.

Acknowledgement

Funding:

Thailand Research Fund

Applied Research on Child Health

We thank Ms. Ratana Somrongthong for her continuing support coordinating the project. We

also thanks staff at Duangprateep Foundation and community committees of each study communities

for facilitating the data collection process.

WHO Essential Drugs and Medicines Policy

Department