Anais da Academia Brasileira de Cincias (2014) 86(1): 451-457

(Annals of the Brazilian Academy of Sciences)

Printed version ISSN 0001-3765 / Online version ISSN 1678-2690
http://dx.doi.org/10.1590/0001-3765201420120036
www.scielo.br/aabc

Patterns of Antimicrobial therapy in acute tonsillitis:

A cross-sectional Hospital-based study from UAE
LISHA J. JOHN1, MEENU CHERIAN2, JAYADEVAN SREEDHARAN3 and TAMBI CHERIAN2
1

Department of Pharmacology, Gulf Medical University, 4184, Ajman, United Arab Emirates
2
Department of ENT, Gulf Medical College Hospital, 4184, Ajman, United Arab Emirates
3
Statistical Support Facility, Centre for Advanced Biomedical Research and Innovation, Gulf Medical University,
4184, Ajman, United Arab Emirates
Manuscript received on December 20, 2012; accepted for publication on October 14, 2013
ABSTRACT

Background: Diseases of the ear, nose and throat (ENT) are associated with significant impairment of
the daily life and a major cause for absenteeism from work. Aim: The study determined antimicrobial
prescription pattern in patients with acute tonsillitis. Materials and Methods: A cross-sectional study was
carried out among all the patients attending the ENT department with acute tonsillitis. Data were retrieved
from the medical records using a proforma. Statistical analysis was carried out using SPSS.19. Results: Total
of 238 patients included (Males 138; females 100). About 96% of total drugs were prescribed by generic
name. Median number of drugs prescribed was four (range 1-7). Eighty eight percent of prescriptions
contained antimicrobials, (78.5%) analgesics and (57.9%) antipyretics. Amoxicillin / Clavulanic acid
(24.8%) and Ceftriaxone (12.2%) were the most commonly prescribed antimicrobials. Parenteral route
was preferred in 41.6%. About 23.7% of the patients on Amoxicillin / Clavulanic acid had received the
drug as intravenous injection. Culture and sensitivity tests were carried out in 106 (44.5%) of the cases.
Antimicrobials were changed / added after the culture and sensitivity test in 25 patients. Conclusion:
Study findings highlighted rational practices in drug prescribing. Therapeutic guidelines based on current
sensitivity pattern optimize the use of antimicrobial agents.
Key words: drug utilization, antimicrobial use, acute tonsillitis, parenteral.

INTRODUCTION

Diseases of the ear, nose and throat (ENT) affect

adults and children, with significant impairment of
the daily life (Grace and Bussmann 2006, WHO
2004). Upper Respiratory Tract Infections (URTIs)
including nasopharyngitis, pharyngitis, tonsillitis and
otitis media constitute a major proportion of the total
episodes of respiratory infections (Jain et al. 2001).
Correspondence to: Lisha Jenny John
E-mail: drlishaj@yahoo.com

This is a major cause for absenteeism from work.

The vast majority of acute URTIs are caused by
viruses (Dasaraju and Liu 1996).Inappropriate use
of drugs in the treatment of upper respiratory tract
infections has been previously reported in literature
(Gaash 2008, Brink et al. 2004). This could result
in the development of drug related problems such
as adverse drug reactions and drug resistance, in
addition to increasing the overall cost for health
care (Einarson 2008).
An Acad Bras Cienc (2014) 86 (1)

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LISHA J. JOHN, MEENU CHERIAN, JAYADEVAN SREEDHARAN and TAMBI CHERIAN

Acute respiratory infections (ARI) accounted

for 20-40% of outpatient and 12-35% of inpatient
attendance in a general hospital (Jain et al. 2001).
In developing countries, 30% of all patients
consultations and 25% of all pediatric admissions
are due to ARI (WHO 2004). Pharyngitis and
tonsillitis account for > 10% of all visits to primary
care clinics and 50% of outpatient antibiotic use
(Linder 2008). In a study from Saudi Arabia that
analyzed the prescriptions for acute respiratory
tract infections, 65.8% of them accounted for upper
respiratory infections (El-Gilany 2000). Naghipour
et al. (2007) reported on the high frequency of
occurrence and transmissibility within the family
cohort in Iran implying the burden of these
infections on the community.
The majority of the antibiotics are prescribed
for ENT infections with a presumed viral etiology.
Acute tonsillitis, where viruses like adenovirus,
Epstein-Barr virus or influenza viruses are implicated,
is treated symptomatically with antipyretics, antiinflammatory drugs and mouth gargles, and reassu
rance to the patients. Several studies have reported
that antimicrobials are prescribed in the management
of URTI due to the drug related problems associated
with inappropriate use (Rehan 2003, Leblebicioglu
et al. 2002, McCaig et al. 2002). The limited role of
antimicrobials in acute tonsillitis of viral etiology has
been published in an overview of Cochrane reviews
by Arroll (2005). In a study published from the
Middle East, antimicrobials were rated as the fourth
most frequently prescribed drugs in primary healthcare facilities (Al Khaja et al. 2008).
In cases of secondary bacterial infection
causing purulent material to accumulate in the
tonsillar crypts, penicillin has been the drug of
choice. Recent results with amoxicillin suggest
that efficacy in acute tonsillitis, is also waning.
Cephalosporins alone or Cephalosporins with
metronidazole where anaerobes are implicated have
the highest bacteriological and clinical efficacy
(Pichichero 2006).
An Acad Bras Cienc (2014) 86 (1)

Antibiotic prescription pattern differs from

country to country, or even from region to region,
which is attributable to various factors such
as the infecting organisms and antimicrobial
susceptibility, physician preference, and costs.
Therefore, it is imperative to evaluate and
monitor the drug utilization patterns periodically,
to enable suitable modifications to be made in
prescribing patterns, in order to increase the
therapeutic benefit and decrease the adverse
effects, and thus optimize the treatment (Srishyla
et al. 1994). Drug utilization studies are designed
to systematically review the drugs prescribed
to the patients. These help provide feedback to
the clinicians, develop protocols that describe
optimal drug use, and promote appropriate drug
use through educating the patients.
Hence, the present prospective study was
aimed at determining the antimicrobial prescription
pattern in adult patients with acute tonsillitis.
MATERIALS AND METHODS

A cross-sectional, hospital-based study was carried

out to evaluate the antimicrobial prescription
pattern in patients with acute tonsillitis. All patients
attending the ENT outpatient department of a tertiary
care hospital, Ajman, UAE from January 2011 to
December 2011 and diagnosed with acute tonsillitis
were included. The approval of institutional Ethics
Committee was obtained before the start of the
study. Incomplete patient records were excluded
from the study. The drug utilization data was
retrieved from the medical records of patients using
a specially designed data collection form. The form
included the following domains: Socio demographic
characteristics (Age, gender, nationality), Clinical
data (Clinical diagnosis, Clinical manifestations,
Examination findings), Laboratory data: (Culture
and sensitivity data: Organism isolated, sensitivity
and resistance pattern), Drug data: (Antimicrobial
agents prescribed, dose and duration of treatment,

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ANTIMICROBIALS IN ACUTE TONSILLITIS

change of medication and response to treatment).

Statistical analysis was carried out using SPSS19.
RESULTS

Among the total of 238 patients, 138 (57.9%) were

males and 100 (42.1%) were females. The majority
of patients were Indians [49 (20.6%)], Emiratis
[35 (14.7%)], and Pakistanis [31 (13%)]. The highest
numbers of patients were in the age group 20-29
years and the lowest in the 60-79 years. The gender
and age distribution of patients with acute tonsillitis
is listed in Table I.
TABLE I
Age- and gender-based distribution of
patients with acute tonsillitis.
Variables
Gender

Age group

TOTAL

Group
Male
Female
1-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79

No.
138
100
49
17
93
56
14
6
2
1
238

%
58
42
20.6
7.1
39.1
23.5
5.9
2.5
0.8
0.4
100

The common types of tonsillitis noted were

acute parenchymatous tonsillitis, acute follicular
tonsillitis and acute pharyngotonsillitis. Of the
total, 7 (2.9%) patients had self-medicated prior to
the hospital visit. About 96% of the total number
were prescribed by generic name. The median
number of drugs prescribed was four (range 1-7).
A total of 925 medications were prescribed to
238 patients with acute tonsillitis. 209 (88%) of
the prescriptions contained antimicrobial agents.
Antimicrobials (265) were the most commonly
prescribed group of drugs followed by analgesics
(187) and antipyretics (138), as shown in Figure 1.
The prevalence and indicators of antimicrobials
used in the treatment of acute tonsillitis are shown
in Table II.

Among the antimicrobial drug classes, betalactam antimicrobials such as Cephalosporins and
Penicillins were the most frequently prescribed.
Amoxicillin/Clavulanic acid [72 (30.25%)], Ceftria
xone [40 (16.8%)] and metronidazole [35 (14.7%)]
were the most commonly prescribed antimicrobials.
Of the 264 antimicrobials prescribed, 109 (41.2%)
constituted parenteral antibiotics. The commonly
prescribed parenteral antimicrobials were Ceftriaxone
and Amoxicillin/Clavulanic acid. About 23.7%
of the patients were administered Amoxicillin/
Clavulanic acid as intravenous injection. The pattern
of monotherapy and combination therapy of anti
microbials in acute tonsillitis is listed in Table III.
The most commonly used fixed drug combination
was Amoxicillin/Clavulanic acid [72 (30.25%)].
Culture and sensitivity test of the throat swab
was carried out in 106 (44.5%) of the cases. Of the
106 throat swabs, bacterial species were isolated in
100 cases (94.3%). Alpha hemolytic streptococci
species was the most commonly isolated organisms
in 35 (33%) cases, followed by streptococcus
species 18 (17%), Neisseria species 13 (12.3%) and
a few staphylococcus species. The isolated bacteria
were most frequently sensitive to 3rd / 4th Generation
Cephalosporins and Amoxicillin/clavulanic acid.
Some organisms were multi drug resistant, being
sensitive only to piperacillin, ceftriaxone, cefotaxime
and meropenem. Antimicrobials were changed after
the culture and sensitivity test in 25 patients. Of these
patients 12 patients were on parenteral antibiotics.
No pattern was noticed with regard to the change in
antimicrobial prescription however, oral Cefuroxime
was the most frequently added antimicrobial agent
based on the sensitivity report.
DISCUSSION

The present study highlights the current trends in

antimicrobial prescriptions in the management
of acute tonsillitis at the outpatient department
of Otorhinolaryngology. A slightly higher male
preponderance was noticed, in line with previous
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LISHA J. JOHN, MEENU CHERIAN, JAYADEVAN SREEDHARAN and TAMBI CHERIAN

Figure 1 - Commonly prescribed drug classes in acute tonsillitis.

TABLE II
Prevalence and indicators of antimicrobial use.
Prevalence of Antimicrobial use
Overall drug use (n = 238)
Average number of drugs per prescription
Percentage of drugs prescribed by generic name
Percentage of prescriptions with injections
Percentage of drugs prescribed from essential drug list
Antimicrobial use
Total number of prescriptions with antimicrobials
Total number of antimicrobials prescribed
Number of antimicrobials by parenteral route
Average number of antimicrobials
Number of prescriptions with:
Antibacterial drugs
Single antibacterial agent
Multiple antibacterial agents
Two drug combination
Three drug combination

reports on the infections of the ear, nose and throat

(Ain et al. 2010, Pradhan and Jauhari 2007, Khan
et al. 2011). It was found that a majority of the patients
were in the age group of 20-29 years and the lowest
percentages were of the geriatric group. A similar
finding was reported by other studies from India
An Acad Bras Cienc (2014) 86 (1)

No. (%)
4
96%
109 (45.7%)
60%
209
264
109
1
209
165
34
10

(Khan et al. 2011) and Thailand (Issarachaikul

and Suankratay 2013). This finding could be
explained due to the studys setting being at the
ENT department, where one expects most patients
to be adults, whereas pediatric cases seen at ENT
department are referred to pediatricians.

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ANTIMICROBIALS IN ACUTE TONSILLITIS

TABLE III
Pattern of monotherapy and combination therapy in acute tonsillitis.
Antimicrobial drug class
Penicillin
Cephalosporins

Macrolides

Fluroquinolones
Nitroimidazoles

Individual antimicrobial
Amoxicillin/Clavulanic acid
Cefpodoxime
Cefidinir
Ceftriaxone
Cefuroxime
Cefexime
Azithromycin
Clarithromycin
Clindamycin
Ciprofloxacin
Levofloxacin
Metronidazole
Tinidazole

The most commonly prescribed categories

of anti-bacterials were found to be from -lactam
antimicrobials (Penicillin and Cephalosporins).
This finding was in par with several other studies
conducted by Ain et al. (2010), Khan et al.
(2011), Senok et al. (2009), Higashi (2009) and
Issarachaikul and Suankratay (2013).
Among the individual drugs, amoxicillinclavulanate followed by ceftriazone 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. (2009), Khan et al. (2011), Das et al. (2005) and
Rehan (2003), wherein the preferred antimicrobial
agents were amoxicillin, cefixime and ciprofloxacin
respectively. Reports from Japan documented
cefcapene, a third generation cephalosporin as the
most commonly prescribed antibiotic, followed
by clarithromycin (Higashi 2009). The reason
for prescribing amoxicillin/clavulanate and third
generation Cephalosporins could be due to the
preponderant mixed group of infections and increase
in antibiotic resistance, which encourages physicians
to choose a broader spectrum antibiotic.
The median number of drugs per prescription
was one, whereas Ain et al. (2010), Das et al. (2005)

Monotherapy
60
19
18
13
13
1
22
4
5
4
1
1
-

Combination therapy
12
6
5
27
5
5
6
1
34
3

Overall utilization
72
25
23
40
18
1
27
10
5
4
2
35
3

and Rehan (2003) documented that the average

number of drugs per prescription was as high as
three drugs. The average number of drugs is an
important indicator to assess rational practice in
drug prescribing. The mean number of drugs per
prescription should be as low as possible to avoid
increased risk of drug interactions, adverse drug
effects, development of bacterial resistance, poor
patient compliance and increased treatment related
costs. This finding in the present study indicates the
practice of rationalization in prescribing drugs, to
minimize the total number of drugs prescribed.
The culture of prescriptions contained antimicrobials
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 agents in individual patients. In a
study from Nepal 95.9% of prescriptions contained
antimicrobials in the treatment of acute tonsillitis
(Rehan 2003). In a publication from Thailand,
more than 80% of the prescriptions for upper
respiratory tract infections contained antimicrobials
(Issarachaikul and Suankratay 2013).
About 96% of the drugs in this study were
prescribed using generic names indicating a
rational practice of drug prescribing. Prescribing
by generic names reduce overall expenditure
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LISHA J. JOHN, MEENU CHERIAN, JAYADEVAN SREEDHARAN and TAMBI CHERIAN

on drugs, especially on newer antibiotics, and

promote rational use of drugs. Prescribing by
trade name benefits drug promotional activities of
pharmaceutical companies, and undermines the
objectives of the essential drug concept.
One of the noteworthy findings was that a
significant proportion (41%) of the antimicrobial
were prescribed by parenteral route unlike earlier
studies where parenteral route was used only in
16% of the patients (Ain et al. 2010). The probable
reason for this finding was due to the acute
presentation of the symptoms in a majority of the
patients necessitating parenteral antibiotics.
The most commonly used antimicrobial fixed
dose drug combination (FDC) was Amoxicillin/
Clavulanic acid about 30%. Amoxicillin/Clavulanic
acid prescribed in this study is among the rational
FDC recommended by World Health Organization
(WHO 2013) in the management of upper
respiratory tract infections. Rehan (2003) reported
only 16.5% utilization of antimicrobial fixed drug
combination and the most common being Ampicillin
with cloxacillin. Khan et al. (2011) documented the
frequently used FDC in their study as Cefixime+
Clavulanic acid (9.7%) followed by Amoxicillin/
Clavulanic acid (9.5%).
Culture and sensitivity test of the throat swab was
carried out in 44.5% of the patients as other patients
were already on antimicrobials. Alpha hemolytic
streptococci species was the most commonly isolated
bacterial organisms in 33% of the cases which is one
of the commensal in the throat. This finding needs
to be further investigated to elucidate the role of
commensals in the pathogenesis of acute tonsillitis.
However, most of the isolated bacterial organisms
were sensitive to 3rd /4th Generation Cephalosporins
and Amoxicillin/clavulanic acid. A trend towards
multi drug resistance was also noted which needs to
be further explored.
The strength of the study is that it highlighted
several rational prescribing practices and newer
trends in the administration of antimicrobial
An Acad Bras Cienc (2014) 86 (1)

agents. The limitation of the study included nongeneralizability of the study findings as the study was
carried out at a single center; hence the results cannot
be generalized to the whole region. Considering the
findings of this study, treatment guidelines based
on the current sensitivity pattern for tonsillitis may
be developed to optimize the use of antimicrobial
agents and provide cost effective treatment.
Pharmacoeconomic studies can be undertaken to
establish cost effective treatment strategies
CONCLUSION

Beta lactam antimicrobials were the most commonly

prescribed antimicrobials. Injection was a widely
used route of administration of antimicrobials.
The majority of the patients received a single
antimicrobial. The majority of the medications were
prescribed in generic names encouraging rational
use of drugs. The culture and sensitivity tests
were performed in most of the cases to identify
the organism and to prescribe the appropriate
antimicrobials indicating a rational practice.
RESUMO

Fundamento: As doenas do ouvido, nariz e garganta

(ENT) esto associadas a comprometimento significativo
da vida diria e uma das principais causas de afastamento
do trabalho. Objetivo: O estudo teve como objetivo deter
minar o padro de prescrio de antimicrobianos em
pacientes com amigdalite aguda. Materiais e Mtodos:
Foi realizado um estudo transversal com todos os
pacientes atendidos no Setor de Otorrinolaringologia e que
apresentavam amigdalite aguda. Os dados foram extrados
dos pronturios mdicos, utilizando uma pr-forma.
A anlise estatstica foi realizada utilizando SPSS.19.
Resultados: Total de 238 pacientes includos (homens 138;
mulheres 100). Cerca de 96 % do total de medicamentos
foram prescritos pelo nome genrico. O nmero mdio
de medicamentos prescritos foi de quatro (intervalo 1-7).
Oitenta e oito por cento das prescries continham
antimicrobianos, (78,5%), analgsicos e (57,9%) antipi
rticos (57,9%). Amoxicilina / cido clavulnico (24,8%)

ANTIMICROBIALS IN ACUTE TONSILLITIS

e ceftriaxona (12,2%) foram os antimicrobianos mais

comumente prescritos. A via parenteral foi preferida
em 41,6 %. Cerca de 23,7% dos pacientes tratados com
Amoxicilina / Clavulanato receberam a droga por via
intravenosa. Testes de cultura e de sensibilidade foram
realizados em 106 (44,5%) dos casos. Os antimicrobianos
foram alterados / adicionados aps a cultura e teste de
sensibilidade realizados em 25 pacientes. Concluso:
Os achados destacam as prticas racionais na prescrio
de medicamentos. Diretrizes teraputicas com base no
padro de sensibilidade atual otimizam o uso de agentes
antimicrobianos.
Palavras-chave: utilizao de drogas, utilizao antimi
crobiana, amidalite aguda, parenteral.
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