TITLE:

Frequency of usage of different antibiotics for Upper Respiratory Tract Infections in

Children in a tertiary care hospital.

INTRODUCTION:

Respiratory tract infection (RTI) is defined as any infectious disease of the

upper or lower respiratory tract. Upper respiratory tract infections (URTIs)
include the common cold, laryngitis, pharyngitis/tonsillitis, acute rhinitis, acute
rhinosinusitis and acute otitis media(1). Respiratory disease is the major cause
of mortality and morbidity worldwide, with infants and young children
especially susceptible(2).Upper respiratory tract infections (URTI) are very
common throughout infancy and childhood, with many children getting multiple
infections throughout their lives(3). Respiratory infections are the most frequent
health problem in childhood(4). Although acute respiratory infections (ARIs)
are the global leading cause of pediatric morbidity and mortality, the relative
impact of viral pathogens on pediatric ARIs is still poorly understood, especially
in equatorial settings(5). The majority of cold and flulike illnesses are caused by
human rhinoviruses (HRVs)(6). Human Metapneumovirus (HMPV) is one of
the commonest causes of viral ARI especially among pediatric patients(7).
Parainfluenza virus (PIV) is a common pathogen in childhood among the
respiratory viruses(8).
Upper respiratory tract infections are the most common source of antibiotic
prescriptions(9). Although the majority of such infections are viral in etiology,
they account for three-quarters of all antibiotic consumption(10). Excessive and
inappropriate use of antibiotics is considered to be the most important reason for
development of bacterial resistance to antibiotics. As antibiotic resistance may
spread across borders, high prevalence countries may serve as a source of

bacterial resistance for countries with a low prevalence(11). Therefore, bacterial

resistance is an important issue with a potential serious impact on all countries.
Epidemiologic context and the number of cases of FRI that a physician had
recently seen were associated with his or her likelihood to prescribe
antimicrobials for FRI(12). Parental misconceptions and even "demand" for
unnecessary antibiotics were previously viewed as contributors to overuse of
these agents(13).
A scientific study of the inappropriate use of antibiotics in local settings, which
can lead to antibiotic resistance, and emergence of resistant organism is
important. It will also bring about awareness about antibiotic stewardship,
which can be used to improve guidelines for rational antibiotic prescription
national level.

OBJECTIVES:
To determine the frequency of usage of different antibiotic classes ( Penicillins,
Cephalosporins, Quinolones and Macrolides ) for Upper Respiratory Tract Infections among
children between 2 months and 60 months of age in the Pediatric Emergency Department and
Consulting Clinics at The Aga Khan University Hospital, Karachi.

OPERATIONAL DEFINITIONS:
Upper Respiratory Tract Infection:
Any child between 2 months to 60 months who presents to clinic/emergency department with
fever, cough, runny nose and ear discharge of any duration without clinical signs of
Pneumonia (as per IMNCI). See annex II attached.

Antibiotics:

All per oral antibiotics (Penicillins, Cephalosporins, Quinolones and Macrolides) irrespective
of class of antibiotic prescribed in mg/kg of standard dosing.

MATERIAL AND METHODS:

STUDY DESIGN:
Cross Sectional Study

SETTING:
Pediatric Emergency department and Consulting Clinics at The Aga Khan University
Hospital, Karachi.

DURATION OF STUDY:
The study will be carried out over a six month period after the approval of synopsis.

SAMPLING TECHNIQUE:

Non probability purposive sampling.

SAMPLE SIZE:
Assuming the prevalence 12%, a sample size of 163 children will be needed to have an
estimate that falls within 5% of the true proportion with 95% confidence. For the sample size
WHO "Sample Size Determination in Health Studies" software will be used. (Annex 1).

INCLUSION CRITERIA:
Any child between 2 months to 60 months who presents to clinic/emergency department
with fever, cough, runny nose and ear discharge of any duration without clinical signs of

Pneumonia. (as per IMNCI). Annex II

EXCLUSION CRITERIA:

1)

Children diagnosed with chronic diseases like Tuberculosis, Cystic Fibrosis,

Malignancy and Heart Disease
2) Clinical or radiological evidence of Lower Respiratory Tract Infections including

Pneumonia such as fast breathing and chest indrawing.

3) Children having Severe Malnutrition with body weight <60% of the expected
weight for age.

DATA COLLECTION:
After taking informed consent the childs demographic characteristics including age, gender,
weight and clinical parameters will be documented on Performa. Children having signs and
symptoms of upper respiratory tract infection diagnosed by the Pediatric Emergency
Medicine Consultants and Pediatricians in Consulting clinics will be included and the type of
antibiotic(s) prescribed will be recorded on a pre-designed questionnaire. All data will be
collected by the primary researcher.

DATA ANALYSIS:
The data will be analyzed at SPSS Version 17. The descriptive frequencies and percentages
will be computed for qualitative variables (gender, diagnosis,type of antibiotics etc.). Mean
and standard deviation will be computed for quantitative variables (age, weight, etc).
Stratification will be done with regard toage and weight to look for confounding plus effect
modification. P value <0.05 will be taken as significant. No of subjects receiving antibiotics

divided by the total no of subjects diagnosed to have upper respiratory tract infection to
calculate frequency of antibiotic use will be reported as a percentage.

ANNEX I

ANNEX II

ANNEX III
PROFORMA:

Medical Record Number__________

Serial Number___________

Age__________________________

Gender M/F_____________

Address_______________________

Contact Number__________

Weight_______________________

Clinical Examination:

Symptoms:

Fever yes/no

Cough yes/no

Headache yes/noOthers

__________________________________________________________________
Antibiotic(s) Prescribed:

Dosage (mg/kg):

Amoxycillin yes/no

_____________

Amoxycillin+Clavulanic acid yes/no

______________

Azithromycin yes/no

______________

Clarithromycin yes/no

______________

Cefixime yes/no

______________

Ciprofloxacin yes/no

_______________

1.
Respiratory Tract Infections - Antibiotic Prescribing: Prescribing of
Antibiotics for Self-Limiting Respiratory Tract Infections in Adults and Children in
Primary Care. National Institute for Health and Clinical Excellence: Guidance.
London2008.
2.
Papenburg J, Boivin G. The distinguishing features of human
metapneumovirus and respiratory syncytial virus. Reviews in medical virology.
2010 Jul;20(4):245-60. PubMed PMID: 20586081.
3.
Purssell E. Upper respiratory tract infection in infants from a nutritional
perspective. The journal of family health care. 2009;19(5):164-8. PubMed PMID:
19911732.
4.
Gruber C, Keil T, Kulig M, Roll S, Wahn U, Wahn V, et al. History of
respiratory infections in the first 12 yr among children from a birth cohort.
Pediatric allergy and immunology : official publication of the European Society of
Pediatric Allergy and Immunology. 2008 Sep;19(6):505-12. PubMed PMID:
18167154.
5.
Alonso WJ, Laranjeira BJ, Pereira SA, Florencio CM, Moreno EC, Miller MA, et
al. Comparative dynamics, morbidity and mortality burden of pediatric viral
respiratory infections in an equatorial city. The Pediatric infectious disease
journal. 2012 Jan;31(1):e9-14. PubMed PMID: 22001966. Pubmed Central PMCID:
3414195.
6.
Mak RK, Tse LY, Lam WY, Wong GW, Chan PK, Leung TF. Clinical spectrum
of human rhinovirus infections in hospitalized Hong Kong children. The Pediatric
infectious disease journal. 2011 Sep;30(9):749-53. PubMed PMID: 21494174.
7.
Ljubin-Sternak S, Mlinaric-Galinovic G, Buntic AM, Tabain I, Vilibic-Cavlek T,
Cepin-Bogovic J, et al. Seasonal occurrence of human metapneumovirus
infections in Croatia. The Pediatric infectious disease journal. 2014
Feb;33(2):165-7. PubMed PMID: 23989108.
8.
Maeng SH, Yoo HS, Choi SH, Yoo KH, Kim YJ, Sung KW, et al. Impact of
parainfluenza virus infection in pediatric cancer patients. Pediatric blood &
cancer. 2012 Oct;59(4):708-10. PubMed PMID: 22095941.
9.
Lopardo G, Calmaggi A, Clara L, Levy Hara G, Mykietiuk A, Pryluka D, et al.
[Consensus guidelines for the management of upper respiratory tract infections].
Medicina (B Aires). 2012;72(6):484-94. PubMed PMID: 23241293. Consenso sobre
diagnostico y tratamiento de infecciones de vias respiratorias altas.
10.
Low D. Reducing antibiotic use in influenza: challenges and rewards.
Clinical microbiology and infection : the official publication of the European
Society of Clinical Microbiology and Infectious Diseases. 2008 Apr;14(4):298-306.
PubMed PMID: 18093237.
11.
Kho BP, Ong CM, Tan FT, Wee CY. Antibiotic prescribing for upper
respiratory tract infections in sarawak district hospitals. The Medical journal of
Malaysia. 2013 Apr;68(2):136-40. PubMed PMID: 23629559.
12.
Gonzalez de Dios J, Ochoa Sangrador C, Alvarez Calatayud G. [Rational
management of antibiotherapy in ORL infections in children: critical review of the
best scientific evidences]. Acta otorrinolaringologica espanola. 2006
Feb;57(2):66-81. PubMed PMID: 16550859. Manejo racional de la antibioterapia
en las infecciones otorrinolaringologicas en la infancia: revision critica de las
mejores pruebas cientificas.

13.
Finkelstein JA, Dutta-Linn M, Meyer R, Goldman R. Childhood infections,
antibiotics, and resistance: what are parents saying now? Clinical pediatrics.
2014 Feb;53(2):145-50. PubMed PMID: 24137024.