Print ISSN: 2319-2003 | Online ISSN: 2279-0780

IJBCP

International Journal of Basic & Clinical Pharmacology

DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20162459

Research Article

A study on the drug prescribing pattern in acute, recurrent and chronic

pharyngitis at a tertiary care hospital
Deepa Ranabovi1, Jyothi Ramesh1*, Jagannath Bisanna2,
Pundarikaksha Hulikallu Purushothama1

ABSTRACT
1

Department of Pharmacology,
Department of ENT,
Kempegowda Institute of
Medical Sciences, Bangalore,
Karnataka, India
2

Received: 20 May 2016

Accepted: 13 June 2016
*Correspondence to:
Dr. Jyothi Ramesh,
Email: sanjyothi03@gmail.com
Copyright: the author(s),
publisher and licensee Medip
Academy. This is an openaccess article distributed under
the terms of the Creative
Commons Attribution NonCommercial License, which
permits unrestricted noncommercial use, distribution,
and reproduction in any
medium, provided the original
work is properly cited.

Background: Pharyngitis, or sore throat, is often caused by infection. Common

respiratory viruses account for the vast majority of cases, and these are usually
self-limited. Bacteria are also important etiologic agents, and, when identified
properly, may be treated with antibacterial, resulting in decreased local
symptoms and prevention of serious sequelae. The objective of this study was to
determine the drug prescribing pattern in acute, recurrent and chronic bacterial
pharyngitis and to assess the efficacy and tolerability of AMAs.
Methods: 50 subjects of either gender were included in the study to assess the
prescribing pattern in acute, recurrent and chronic pharyngitis by purposive
sampling method.
Results: 94% subjects were between 16-45 years and mean age was
33.0613.50. 96% were from lower middle and upper lower class. Presenting
complaints were sore-throat with fever in all the subjects, Co-amoxiclav was the
most commonly used antibiotic (48%) and others were cefpodoxime+clavulanic
acid (36%), cefadroxil+clavulanic acid (8%), cefpodoxime (4%), cefuroxime
(2%) and cefixime (2%). Concomitant medications used were NSAIDs and
decongestants/mucolytic. The AMAs showed good tolerability with mild and
self-limiting adverse effects which did not require discontinuation.
Conclusions: Acute, recurrent and chronic bacterial pharyngitis can be
effectively treated by empirical use of various antimicrobials. Co-amoxiclav can
be considered as the mainstay/primary option because of the proven efficacy,
good tolerability and low cost.
Keywords: Antimicrobials, Non-steroidal anti-inflammatory drugs, Bacterial
Pharyngitis

INTRODUCTION
Pharyngitis is the inflammation of the mucus membranes
of the pharynx, presenting commonly with sore throat,
malaise, fever, cough and nasal congestion, which is
usually treated with simple therapy directed at
symptomatic relief. It can be acute, recurrent or chronic.
In majority of acute cases, infection is not the cause, and
where the infection is the cause, most of them are caused
by viral infections followed by bacterial, and rarely
fungal. Among the bacterial pathogens, group-A beta
hemolytic streptococcus (GABHS) assume a special
significance because of its suppurative and nonsuppurative complications like; retropharyngeal abscess,
peritonsillar abscess, sinusitis, cervical lymphadenitis,

www.ijbcp.com

otitis media, rheumatic fever (RF) and rheumatic heart

disease (RHD). Recurrent pharyngitis is more than 3
episodes of acute pharyngitis within 12 months of period
with positive laboratory report.1,2 Chronic pharyngitis is a
chronic inflammatory condition of the pharynx,
characterized by hypertrophy of mucosa, seromucinous
glands and subepithelial lymphoid follicles.2,3
Many antimicrobial agents (AMAs) including
antibacterial, antiviral and antifungal agents are used in
the treatment and prophylaxis of pharyngitis. The pattern
of AMA use may vary from hospital to hospital and in
different geographical areas depending on the nature of
infections, prevalent strains of pathogens, the pattern of
susceptibility/resistance
and
cost/availability
of

International Journal of Basic & Clinical Pharmacology | July-August 2016 | Vol 5 | Issue 4

Page 1494

Ranabovi D et al. Int J Basic Clin Pharmacol. 2016 Aug;5(4):1494-1498

antimicrobial agents. The assessment of drug utilization

is
important
for
clinical,
educational
and
pharmacoeconomic purposes. Though there have been
several studies and reports in the literature, there are
limited and inconsistent data from the Indian population.
Hence, there is a need for more systematic studies to
generate valid data to formulate effective guidelines for
improved quality of care and therefore the present study
was taken up, to describe the pattern of drugs used in
acute, recurrent and chronic pharyngitis and to assess the
efficacy and tolerability of the antimicrobials used in the
present study.
METHODS
This observational study was done to assess the pattern of
drugs used in acute, recurrent and chronic bacterial
pharyngitis. After approval and clearance from the
institutional ethics committee, 50 subjects with
pharyngitis visiting the outpatient department of ENT at
Kempegowda institute of medical sciences, hospital and
research centre, Bangalore were included into the study
by the investigator after coordinating and confirming the
diagnosis with ENT specialist. Study subjects were
recruited by purposive sampling method from January
2012-January 2013. Written informed consent was
obtained from all the study subjects after fully explaining
the study procedure to their satisfaction, in both English
and vernacular language. Subjects fulfilling the inclusion
criteria were included into the study; Patients of all age
groups above 3 years, from either gender attending the
OPD of ENT department with bacterial pharyngitis and
willingness of the patients/parents or legal representatives
to give the written informed consent and available for
follow up. Patients with the following conditions were
excluded from the study; Patients already receiving
antimicrobial therapy, pharyngitis due to viral or fungal
infections and immunocompromised patients.
Patients were subjected to a detailed history taking
including personal history, family history, present and
past medical history and drug history. Details of drug
therapy, i.e., the intended purpose of use i.e. prophylaxis
or cure, the therapeutic class of AMA used, dose, route,
frequency and duration of administration, tolerability and
drug interactions were recorded. After the completion of
AMA therapy, the efficacy and outcome of the
antimicrobial therapy was assessed by clinical
examination by the ENT specialist was also documented
by the investigator. Only the reported adverse drug
reactions were documented after the completion of the
AMA therapy. The data collected was analysed by using
descriptive statistics, namely mean, standard deviation.
The results were also depicted in the form of tables and
Figures. Microsoft word and excel are used to generate
Figures and tables.
RESULTS
Out of 50 study subjects, 26 were male and 24 were
female. The mean age was 33.0613.50. Majority of the

subjects (94%) were between 16-45 years, and only 6% of

subjects below 16 years (Table 1). All the subjects
presented with sore throat, 50% of the subjects with fever,
and 12% with headache, 10% running nose, 18% with
nasal obstruction, 6% with cough, and majority of the
subjects (70%) had more than one symptom (Figure 1).
Most of the subjects (96%) had the duration of symptoms
of less than 10 days (among them 58% of subjects for less
than 5 days) and only 4% subjects had symptoms more
than 10 days. Majority of the patients (72%) had 1-2
episodes, 18% with 3-4episodes, and only 6% with >4
episodes. Co-amoxiclav was used in 24% of the subjects
and cefadroxil+clavulanic acid in 4%, in the past one
year. None of the subjects had history of allergic reactions
to the commonly used AMAs like beta-lactams,
fluroquinolones or macrolides. Most of the subjects had
acute bacterial pharyngitis (90%), only 2 subjects with
chronic bacterial pharyngitis and 3 subjects with recurrent
pharyngitis (Figure 2). Throat swab culture was done in
only in 1 subject with chronic pharyngitis to confirm the
causative organism and sensitivity pattern, which showed
the growth of co-amoxiclav resistant S. pyogenes. Coamoxiclav which is a fixed dose combination of
amoxicillin and clavulanic acid, was the most commonly
used antibiotic (48%) and other AMAs used were
cefpodoxime+clavulanic
acid
(36%),
cefadroxil+clavulanic acid (8%), cefpodoxime (4%),
cefuroxime (2%) and cefixime (2%) (Table 2). In one
subject with reported co-amoxiclav resistant S. pyogenes,
cefpodoxime+clavulanic acid was used. The concomitant
medications used in the present study mainly included
NSAIDs and decongestants/mucolytics. All the subjects
received NSAIDs; 66% as fixed dose combinations which
included
aceclofenac+paracetamol
and
diclofenac+paracetamol (20%), and monotherapy with
diclofenac (20%), nimesulide (10%) and paracetamol
(4%) (Table 3). The outcome of therapy with various
AMAs was assessed clinically after completing the course
of AMA therapy. Complete cure, both subjective and
objective, was seen in 13 subjects. Significant clinical
improvement was observed in the other 37 subjects (Table
4). None of the subjects reported lack of improvement or
worsening. Among the 13 subjects with complete cure, 8
had received co-amoxiclav and the other 4
cefpodoxime+clavulanic
acid
and
1
subject
cefadroxil+clavulanic acid. As observed in the present
study, the cure rate was 26% and clinical improvement
was 74% with 5 day course of beta-lactams and the rate of
resolution of infection was almost comparable with coamoxiclav and the cephalosporins. The AMAs showed
good tolerability with mild and self-limiting adverse
effects which did not require discontinuation. The adverse
effects were mainly gastrointestinal like abdominal
discomfort with distension and mild diarrhoea (Table 5).
No allergic reactions were observed. Change of AMA was
required in only one subject. Because of inadequate
clinical improvement with 5 day course of co-amoxiclav,
the therapy was changed to cefpodoxime+clavulanic acid
which was continued for 5 days which resulted in
complete cure. Patient compliance to the prescribed

International Journal of Basic & Clinical Pharmacology | July-August 2016 | Vol 5 | Issue 4

Page 1495

Ranabovi D et al. Int J Basic Clin Pharmacol. 2016 Aug;5(4):1494-1498

medications was assessed by pill count method/recovering

empty packets. All the patients had complied very well to
the prescribers instructions.
Table 1: Age and socio-economic status* (n= 50).
Age group
(in years)

n (%)

3-15

3 (6.00)

16-25

13 (26.00)

26-35

13 (26.00)

36-45

11 (22.00)

>45

10 (20.00)

Socioeconomic
status
Upper
Upper
middle
Lower
middle
Upper
lower
Lower

n (%)
0 (0)
2 (4.00)
28 (56.00)
20 (40.00)
0 (0)

Mean ageSD = 33.0613.50; *Based on Kuppuswamy

socio-economic status scale modified up to 1998.

Table 2: Antimicrobial agents used.

AMAs*
Coamoxiclav
Cefpodoximeclavulanic acid
Cefadroxilclavulanic acid
Cefpodoxime
proxetil
Cefuroxime
axetil
Cefixime

Dose
Frequency Duration n (%)
625 mg
BID
5 days 24 (48.00)
325 mg
625 mg
100 mg
200 mg

250 mg

160mg

BID

5 days

18 (36.00)

BID

5 days

4 (8.00)

BID
BID

5 days
5 days

1 (2.00)
1(2.00)

BID

5 days

1 (2.00)

BID

5 days

1 (2.00)

Table 4: Outcome of therapy.

Outcome*
Cured
Improved
No change

n (%)
13 (26.00)
37 (74.00)
0 (00)

*Assessed clinically after 5 days of AMA therapy; 8 had

received co-amoxiclave; All the subjects had acute
pharyngitis; 3 subjects with recurrent pharyngitis, 2 with
chronic pharyngitis and all others had acute pharyngitis.

Table 5: Adverse effects*.

Adverse effects AMAs
Co-amoxiclav
Cefpodoxime+clavulanic
GI discomfort
acid
Cefpodoxime
Cefpodoxime+clavulanic
Mild diarrhoea
acid
Decreased
Cefpodoxime+clavulanic
appetite
acid

n (%)
6 (12.00)
2 (4.00)
1 (2.00)
1 (2.00)
1 (2.00)

*Possibly related to AMA therapy, which were mild and selflimiting not requiring discontinuation. None of the patients
had any serious adverse reactions.

*All medications given as oral formulations for 5 days irrespective of

the duration of symptoms, Oral suspension for pediatric age group;
all other formulations were used as tablets.

Table 3: Concomitant medications (n=50).

Drugs used
NSAIDs*
Aceclofenac+paracetamol
Diclofenac+paracetamol
Diclofenac
Nimesulide
Paracetamol
Decongestants/mucolytics*
Cetirizine+pseudoephedrine
Phenylephrine+chlorpheniramine
Ambroxol+terbutaline+guaiphe
nesin
Levocetirizine+pseudoephedrine
Other drugs
Rabeprazole+domperidone
Omeprazole
Multivitamins

Number of patients
23 (46)
10 (20)
10 (20)
5 (10)
2 (4)

Figure 1: Presenting complaints/symptoms.

3 (6)
3 (6)
1 (2)
1 (2)
2 (4)
1 (2)
1 (2)

* Used as adjuvants for symptomatic relief; For associated

gastritis and nausea; As nutritional supplements.

Figure 2: Diagnosis/provisional diagnosis.

International Journal of Basic & Clinical Pharmacology | July-August 2016 | Vol 5 | Issue 4

Page 1496

Ranabovi D et al. Int J Basic Clin Pharmacol. 2016 Aug;5(4):1494-1498

DISCUSSION
In the present study, the pattern of prescribing in bacterial
pharyngitis, the criteria for their selection, their safety,
tolerability and clinical outcome, was assessed in patients
attending the ENT outpatient department in KIMS
hospital and research centre, a tertiary care teaching
hospital. All the study subjects fulfilled the inclusion and
exclusion criteria and were fully compliant with the
prescribed medications.
Majority of the subjects (94%) were between16-45 years,
and only 6% of subjects below 16 years. In other studies
higher prevalence was observed in children and
adolescents.4,5 This may indicate a possible geographic
variation and also the fact that most of the subjects in the
pediatric age group were treated by pediatricians.
Majority of the subjects were from lower middle and
upper lower class indicating a greater predisposition of
this group for pharyngitis because of overcrowded
housing and inadequate personal hygiene as reported in
other studies.6,7 All the subjects presented with sore
throat, 50% of the subjects with fever, similar pattern of
symptoms were reported in other studies indicating that
pharyngitis usually coexists with other complaints.8,9
Majority of the subjects had the duration of symptoms
less than 10 days and this was consistent to the fact that
most of the subjects in the present study had suffered
from acute pharyngitis. Hence the duration of symptoms
may correspond to the pattern of infection, acute,
recurrent or chronic. Other studies have also reported a
higher prevalence of acute pharyngitis compared to
chronic or recurrent.10,11 None of the subjects had history
of allergic reactions to the commonly used AMAs like
beta-lactams, flouroquinolones or macrolides. Recording
and scrutinizing the data about the previous medications
may help to analyse the pattern of exposure to AMAs, to
elicit any history of allergy or intolerance and also to
consider any possibility of resistance to the previous
AMA therapy.
Most of the subjects had acute bacterial pharyngitis, by
this observation it may be presumed that the availability
of effective chemotherapy has considerably reduced the
chronicity and recurrence of the bacterial pharyngitis.
Other studies have also reported prevalence of acute
bacterial pharyngitis ranging from 52% to 89%.12 All the
AMAs used were beta-lactams including extended
spectrum penicillins, first generation, second generation
and third generation cephalosporins. The AMAs were
chosen empirically at the discretion of the prescribers, and
in only one subject based on the throat culture report. All
the AMAs were used by oral route for 5 days, irrespective
of duration of symptoms. Co-amoxiclav which is a fixed
dose combination of amoxicillin and clavulanic acid, was
the most commonly used antibiotic. Amoxicillin is
extended spectrum penicillin with good activity against
most of the bacterial pathogens responsible for
pharyngitis; the addition of clavulanic acid further widens
the spectrum by protecting the antibiotic against bacterial

beta-lactamases. The AMAs used in other studies were

amoxicillin (29.7%), macrolides (24.3%), cephalosporins
(17.2%) and co-amoxiclav (7.2%) which were chosen
empirically and continued for 7-10 days.13 As there are no
fixed and stringent guidelines, the pattern of AMA use
may vary from centre to centre depending upon the
pattern and prevalence of infections and the prescribing
trend of the clinicians. Considering the good tolerability
and cost-effectiveness, co-amoxiclav can be considered as
the primary option for the initial empirical therapy of the
bacterial
pharyngitis,
and
other
AMAs
like
cephalosporins and macrolides can be considered as a
reserve options.
Concomitant medications used as adjuvants for
symptomatic
relief
were
NSAIDs
and
decongestants/mucolytics. Since the predominant
symptom of pharyngitis is sore throat, the NSAIDs may
help to relieve pain, congestion and soreness. However
using the FDCs of NSAIDs can be considered irrational
and only paracetamol would be suitable as adjuvant for
symptomatic relief as it is free from gastric irritation and
does not enhance the gastric distress likely with some of
the AMAs, unlike other NSAIDs.5,6 The concomitant
medications used in the present study do not seem to have
any adverse interactions with AMAs other than gastric
distress.
The outcome of therapy with various AMAs was assessed
clinically after completing the course of AMA therapy.
As observed in the present study, the cure rate was 26%
and clinical improvement was 74% with 5 day course of
beta-lactams and the rate of resolution of infection was
almost comparable with co-amoxiclav and the
cephalosporins. Other studies have reported a cure rate of
more than 90% with 7-10 days course of penicillins and
cephalosporins.14,15 Some studies have reported 90%
clinical improvement with 5 days of cephalosporins
which was comparable to a 10 days course of oral
penicillins.15 Thus it can presumed that, the minimum
duration of therapy for adequate clinical improvement
should be 5 days and the cure rate will be higher with
more than 7 day course of therapy. The AMAs showed
good tolerability (as assessed by the reported adverse
events) with mild and self-limiting adverse effects which
did not require discontinuation. Other studies have
reported an overall incidence of adverse effects up to
2.1% which mainly included gastrointestinal (65%) and
allergic skin rashes (23%) with no significant difference
between penicillins and cephalosporins.15 Thus it appears
that a short course of AMA therapy of 5-7 days is
generally safe with only mild and self-limiting
gastrointestinal adverse effects, unless the person is
allergic to beta-lactams. There are some limitations to this
study. The sample size was less and the treatment was
mainly empirical.
CONCLUSION
Acute, recurrent and chronic bacterial pharyngitis can be
effectively treated by empirical use of various AMAs. Co-

International Journal of Basic & Clinical Pharmacology | July-August 2016 | Vol 5 | Issue 4

Page 1497

Ranabovi D et al. Int J Basic Clin Pharmacol. 2016 Aug;5(4):1494-1498

amoxiclav can be considered as the mainstay or primary

option because of the proven efficacy, good tolerability
and low cost. Other AMAs like cefpodoxime+clavulanic
acid,
cefadroxil+clavulanic
acid,
cefuroxime,
cefixime+clavulanic acid and levofloxacin can be
considered as alternatives. Though a 5-day course of
AMA therapy can produce a significant clinical
improvement, the cure rate may be increased by
continuing the AMA therapy for 7-10 days. All the AMAs
showed good tolerability and patient compliance.

6.

7.

8.
ACKNOWLEDGEMENTS
We are grateful to all the patients and ENT staff from
KIMS hospital who contributed to this study.
9.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee

10.

REFERENCES
11.
1.

2.

3.

4.

5.

Gerber MA. Group A streptococcus. In: Kliegman

RM, Jenson HB, Behrman RE, Stanton BF, editors.
Nelson Textbook of Pediatrics. 18th edition, New
Delhi: Elsevier; 2008;2:1135-45.
Diagnosis and treatment of respiratory illness in
children and adults. Institute for Clinical Systems
Improvement.
2011;3:1-81.
Available
at
https://www.icsi.org/_asset/1wp8x2/RespIllness.pdf.
Dhingra PL, Dhingra S. Acute and chronic
pharyngitis. In: diseases of ear, nose and throat. 5th
edition. New Delhi: Elsevier; 2010:268-270.
Somro A, Akram M, Khan MI, Asif HM, Sami A, Ali
Shah SM, et al. Pharyngitis and sore throat: A
review. African Journal of Biotechnology.
2011;10(33):6190-7.
Shulman ST, Bisno AL, Clegg HW, Gerber MA,
Kaplan EL, Lee G, et al. Clinical practice guideline
for the diagnosis and management of group A
streptococcal pharyngitis: Update by the infectious

12.

13.

14.

15.

diseases society of America. Clinical infectious

diseases. 2012;55(10):86-102.
Struble K, Bronze MS, Halsey ES. Bacterial
pharyngitis. Medscape reference; Available at
http://emedicine.medscape.com/article/225243overview. Accessed on 27 July 2013.
Ananthanarayan R, Paniker CKJ. Streptococcus. In:
Textbook of Microbiology. 8th edition. Hyderabad:
Universities Press (India) Private Limited; 2009:204216.
Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL,
Schwartz RH. Practice guidelines for the diagnosis
and management of group A streptococcal
pharyngitis.
Clinical
Infectious
Diseases.
2002;35(2):113-25.
Choby BA. Diagnosis and treatment of streptococcal
pharyngitis.
American
Family
Physician.
2009;79(5):383-90.
Regoli M, Chiappini E, Bonsignori F, Galli L, de
Martino M. Update on the management of acute
pharyngitis in children. Italian Journal of Pediatrics.
2011;37:10.
Renner B, Mueller CA, Shephard A. Environmental
and non-infectious factors in the aetiology of
pharyngitis (sore throat). Inflammation Research.
2012;61(10):1041-52.
Cohen R. Clinical efficacy of cefpodoxime in
respiratory tract infection. Journal of Antimicrobial
Chemotherapy. 2002;50:23-7.
Hong SY, Taur Y, Jordan MR, Wanke C.
Antimicrobial prescribing in the U.S. for adult acute
pharyngitis in relation to treatment guidelines. J Eval
Clin Pract Dec. 2011;17(6):1176-83.
Bisno AL. Are cephalosporins superior to penicillin
for treatment of acute streptococcal pharyngitis?
Clinical Infectious Diseases. 2004;38:1535-37.
Adam D, Scholz H, Helmerking M. Short-course
antibiotic treatment of 4782 culture-proven cases of
group A streptococcal tonsillopharyngitis and
incidence of poststreptococcal sequelae. The Journal
of Infectious Diseases. 2000;182:509-16.
Cite this article as: Ranabovi D, Ramesh J,
Bisanna J, Purushothama PH. A study on the drug
prescribing pattern in acute, recurrent and chronic
pharyngitis at a tertiary care hospital. Int J Basic
Clin Pharmacol 2016;5:1494-8.

International Journal of Basic & Clinical Pharmacology | July-August 2016 | Vol 5 | Issue 4

Page 1498