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ORIGINAL ARTICLE
Are Antibiotics Needed for Common Throat Infections?
Farhan E Abdullah,1 Atif Rasool,2 Hafiz M Muazzam Ali,3 Fahad Shamsi3 and Wardah Muazzam3 ABSTRACT
Objective: Ever fuelling antibiotic use and resulting resistance is still prevalent in our society most commonly
prescribed for throat infections. However community acquired throat infections are known to be caused mostly
by viruses, therefore it was of interest to determine the incidence of bacterial species grown from infected throats
and whether the character of these isolates indicated antibiotic intervention to control ever increasing antibiotic
resistances.
Design: Prospective Study.
Place and Duration: At a private Lab and Diagnostic Centre, Karachi, Pakistan during Jan 2010 to July 2011.
Method: The isolates from 362 patients of all ages presenting with RTI were cultured and identified using
standard protocol. Antibiotic sensitivity of these isolates was checked using 23 drugs and the Kirby-Bauer disc
diffusion method at a private lab in Karachi. In addition, to know the perspective of ENT specialists regarding
the antibiotic resistance, rate of their prescriptions and the drugs they prescribe, 30 questionnaires were also
collected.
Results: Among the 362 isolates Pneumococci were most commonly seen (35.34%) followed by Staphylococcus
aureus (23.01%) and notable Klebsiella pneumoniae (14.5%). The ENT physicians interviewed commonly
prescribed any of 20 antibiotics, most often Amoxicillin, Amoxiclav or even the injectables Cefotaxime,
Ceftriaxone for pharyngitis. In our study, among others, the isolates were most sensitive to Cefotaxime (91.2%),
Ceftriaxone (91.0%) and Amoxiclav (80.4%) followed by Penicillin (71.0%). Erythromycin (43.1%) and Cefixime
(30.7%) were less effective.
Conclusion: Pneumococci and Staphylococci were most often isolated from infected throats; these were likely
part of residential flora accompanying infecting respiratory viruses, the drug therapy was hence superfluous and
essentially harmful.
Key words: Pharyngitis, Tonsillitis, Isolates, Antibiotics, Resistance.
INTRODUCTION
empirical. Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the major The rising antimicrobial resistance has become a global bacterial pathogens implicated in community acquired health concern. Respiratory tract infections are the respiratory tract infections.3-4 Among these pathogens most common of all infections occurring and being S. Pneumoniae has become resistant to various classes documented.1-2 Recurrent respiratory tract infections of antibiotics, including penicillins, macrolides, co- (RRTI) especially in children are a health concern trimoxazole and flouroquinolones.5-6 For commonly globally and most of the times these RRTI are caused prescribed antibiotics the resistance levels of 84% have by viral pathogens where multiple antibiotic courses been reported for co-trimoxazole, 52% for penicillin, are prescribed which show no effectiveness rather increase bacterial resistance to antibiotics. Availability of antibiotics over the counter at most Choice of antibiotics prescribed for usual pathogens pharmacies is another concern which has fuelled the causing throat infections by clinicians is usually misuse of antibiotics and resulted into rapid emergence of resistance during the recent decades. A recent study Department of Pathology, Sindh Medical College, Dow shows that antibiotics are dispensed without a medical University of Health Sciences, Karachi, Pakistan.
prescription in 77.6% of the pharmacies in which sore Undergraduate MBBS Student, Sndh Medical College, Dow throat and diarrhea are the chief complaints (90%) for University of Health Sciences, Karachi, Pakistan.
which the antibiotics are dispensed.9 A local study Undergraduate MBBS Student, Dow Medical College, Dow regarding antibiotic treatment of URTIs in children at University of Health Sciences, Karachi, Pakistan.
Karachi showed that most of the physicians (84%) Correspondence: Dr. Farhan E. Abdullah, Department of Pathology,
Sindh Medical College, Dow University of Health Sciences,
were aware about the antibiotic resistance from its overuse but despite this knowledge physicians were Email: drfarhanessa@essalab.com
found prescribing antibiotics presumptively due to Journal of the Dow University of Health Sciences Karachi 2012, Vol. 6 (2): 42-46 Are antibiotics needed for common throat infections? many social reasons, the rationale for such presumptive A slight inoculum of each bacterial isolate was placed antibiotic courses were mainly the following, meeting in four ml of normal saline in bijou bottles; their density parental expectations (35%), fear of losing patients was than compared with barium chloride standard (0.5 (24.7%), convenience of prescription of antibiotic as McFarland). Mueller-Hinton agar plates were evenly compared to explaining the course of the illness (33%) inoculated with standardized solutions of bacterial and avoiding the cost of a return visit (26%).
cultures by the help of sterile cotton swabs and were issues have led to increased difficulties in the treatment allowed to dry up. Later on, antibiotic discs with the and control of developing resistant pathogens. Studies following drug contents – amoxiclav (20/10 µg), amoxicillin (20 µg), imipenem (10 µg), amikacin (30 have shown that antibiotic resistance changes according µg), cefotaxime (30 µg), piperacillin/tazobactam to the geographical location as well as over the time.11- (100/10 µg), cefixime (5 µg), ceftazidime (30 µg), 12 It is therefore of interest to find out susceptibility ceftriaxone (30 µg), fosfomycin (200 µg), clindamycin patterns of pathogens to commonly prescribed (2 µg), ofloxacin (5 µg), enoxacin (10 µg), ciprofloxacin antibiotics at Karachi over this time to update the (5 µg), sparfloxacin (5 µg), doxycycline (30 µg), knowledge of antibiotics use for the management of cefuroxime (30 ìg), oxacillin (1 µg), Tobramycin (10 µg), erythromycin (15 ìg), gentamicin (10 ìg) and penicillin (10 IU) were placed on the appropriate plates MATERIALS AND METHODS
using standard forceps, properly spacing them to prevent any overlap. To determine susceptibility and resistance, The study was carried out at a local diagnostic lab at the diameters in plates were compared with defined Karachi, Pakistan for the period of one and a half years diameters of the control organism – Staphylococcus during January 2010 till July 2011. The patients were aureus ATCC 25923 Biosafety level (BSL) 2 after taken consent to include their data into research during incubating the plates at 350C for 24 hours.
throat swab sampling. Throat swabs were taken and tested for antibiotic susceptibilities from patients of In addition questionnaires from 30 ENT specialists all ages and both genders at a private Lab and Diagnostic were being collected to ascertain their perceptive of Centre, Karachi. Senior highly skilled nurse were given possible pathogen causing URTI and also their drug the job of taking throat swabs. A total of 362 throat preferences for empirical therapy. ENT specialists swabs were taken during this period. The samples required to fill the questionnaires were mainly practicing in two busy public sector tertiary care hospitals in taken were tested for antibiotic sensitivity patterns for Karachi namely Jinnah postgraduate medical center 23 different drugs using Kirby-Bauer disc diffusion The inclusion criterion was the presence of URTI being referred to the hospital or a doctor. The chief complaints The Frequency of isolates identified from throat swabs of the patients were sore throat and runny nose. The is given in table 1. Among 362 isolates, aside from patients who have taken any antibiotics for the past 4 irrelevant Neisseria species (17.80%), Pneumococci were most commonly seen (35.34%) followed by Staphylococcus aureus (23.01%) and notable Klebsiella For Kirby-Bauer disc diffusion method; colonies from pneumonia (14.5%). Candida albicans were grown samples were grown on different agars including from 5 throat swabs. Other isolates identified were chocolate agar, blood agar and eosin methylene blue Pseudomonas aeruginosa (4.38%), Moraxella catarrhalis agar. Some amount each of sample was inoculated into (1.09%) and E.coli (1.64%). Streptococcus pyogenes these agars and was incubated at 370C for 24-48 hours and Hemophilus influenzae were infrequently encountered.
in aerobic environment except that of chocolate agar Table:1 Frequency of Isolates identified from throat swabs
which was kept at 5-10% CO2 atmosphere. After the incubation period macroscopic and microscopic Isolates
Percentage
examination of the colonies grown on plates was done. Questionable cultures were purified by growing them in appropriate solid culture media which were stored at 40C for further analysis. Presumptive identification was done based on the cultural and morphological characteristics of pure culture on selective and differential media. To confirm the isolates, standard microbiological techniques and biochemical tests were Journal of the Dow University of Health Sciences Karachi 2012, Vol. 6 (2): 42-46 Farhan E Abdullah, Atif Rasool, Hafiz M Muazzam Ali, Fahad Shamsi and Wardah Muazzam Table:2 Antibiotic Sensitivity Patterns for the antibiotics currently available in pharmacies
Antibiotic
Sensitive
Resistant
Percentage
Table: 3 Number of Isolates in specific age group
Age Group
1-20 years 20-40 years 40 years and onwards
DISCUSSION
This study focused on prevalence of bacterial pathogens causing URTIs and their antibiotic susceptibility patterns. Noteworthy in the present study is that H. influenza and S. pyogenes which are known to be the leading causes of RTIs were not isolated.11,13-14 In another study isolation rates for Group A and B Streptococci (8%) were low and reported the use of The ENT physicians interviewed commonly prescribed any of 20 antibiotics, most often Amoxicillin, Augmentin, Sparfloxacin, Erythromycin or even the 23.01% and 14.5% were noted for S. aurues and K. injectables Cefotaxime, Ceftriaxone, and Amikacin for pneumoniae respectively which were also implicated as significant causes of URTIs in previous studies.11,14,16 Our study is thus in harmony with previously done Antibiotic sensitivity patterns tested on the isolates are studies regarding the prevalence of bacterial pathogens. given in table 2. In our study, the isolates were most sensitive to Imepenem (96.7%), Pipericillin+ Present study showed high isolation rates for S. aureus Tazobactam (93.3%), Cefotaxime (91.2%), Ceftriaxone and K. pneumoniae in younger age group of 1 to 20 (91.0%), Fosfomycin (81.0%), Cefuroxime (80.5%) years, 31.8% and 10.3% respectively as compared to and Augmentin (80.4%), followed by Penicillin adult age group of 20 to 40 years in which the isolations (71.0%), Amoxicillin (66.6%), and Ciprofloxacin rates were 19.6% and 8.6% respectively as shown in (65.1%). Erythromycin (43.1%), Cefixime (30.7%), table 3. A study in the Gambia also showed a higher Cotrimoxazole (16.3%) and Doxycycline (13.0%) were prevalence of URTI pathogens in young children as compared to that in adults.17 Sazawal S and Black RE, Journal of the Dow University of Health Sciences Karachi 2012, Vol. 6 (2): 42-46 Are antibiotics needed for common throat infections? 2003 are of view that young children are the most a correlation between the antibiotic usage and the extent susceptible to cold therefore URTI spreads rapidly of drug resistance encountered in this study in among youngsters.2 Our study showed the same pattern accordance with a previous study.12 Rapid diagnostic of prevalence of pathogens as was highlighted in method for sore throats such as polymerase chain previous studies, therefore high risk young age group reaction (PCR) assays targeted for 13 URTI viruses is more vulnerable to URTIs because of the predisposing may reduce antibiotic prescription rates at the initial factors such as under nourishment, less sleep and humid visit in an outpatient setting23 which can prove to be weather which may easily give way to viruses to cause a good tool to reduce antibiotic prescription rates infection and can lead to secondary bacterial infection especially in our society where it has been the main by pathogens already present with normal flora. driving force for fuelling emergence of antibiotics resistance. In Spain a study showed that physicians However in this study Pneumococci (35.34%) and prescribed antibiotics to only 27.9% of patients with Neisseria (17.80%) were also frequently isolated from signs RTI, the criterion most associated with this infected throats; these were likely part of residential prescription was the presence of tonsillar exudate flora accompanying infecting respiratory viruses, and followed by ear discharge and purulence of sputum, that drug therapy in such cases was hence superfluous conversely cough was considered as protective factor.24 and essentially harmful. It’s a widespread agreement The present study indicates the need of a similar pre- that viral pathogens are the initiators of the RTI and defined criterion for the prescription of antibiotics.
secondary bacterial infection is a sequel to the viral initiation.18 Thus prescribing antibiotic courses to all CONCLUSION
the patients would cause more harm by increasing antibiotic resistance. Rather the antibiotics should be In conclusion routine request for PCR assays or prescribed only to high risk groups in which secondary Culture/Sensitivity check is preferred to ascertain bacterial infections are likely. The major microbial whether a significant bacterial species is indeed the pathogens isolated in secondary bacterial infections irritant, and its drug profile. Pneumococci and Neisseria after severe influenza virus infection include were most often isolated from infected throats; these Streptococcus Pneumoniae, Haemophilus influenzae, were likely part of residential flora accompanying Staphylococcus aureus, Klebsiella pneumoniae, and infecting respiratory viruses, and that drug therapy was hence superfluous and essentially harmful. This study as Pseudomonas aeruginosa and few species of the provides a baseline data for further studies on susceptibility patterns considering the fact that very Enterobacteriaceae may also be islolated.19-20 A study
few data is available on susceptibility patterns of showed a 9.7% carrier rate for Group A Streptococci pathogens causing URTIs in this locality despite of the (GAS) in healthy screened children and 3.2% and 2.2% fact that a very high rate of antibiotic overuse and carrier rates for Group G and Group C streptococci misuse is reported. This study is therefore of clinical respectively21 which indicates rational use of antibiotics be implemented to minimize resistance against GAS, consistent with theme of this study. Acknowledgements: I am thankful to Dr. Essa Abdulla
for his guidance, support and permission to work at
The major reason facilitating the emergence of antibiotic Dr.Essa’s Laboratory and Diagnostic Center for our resistance is their extensive use.12 It is notable that research work. Additionally I acknowledge the help Cefotaxime (91.25%), Ceftriaxone (91.04%), and of Uzma Rasool Mahar (Peoples Medical College), Amikacin (90.9%) are less abused than other antibiotics Ali Raza Bhutto (Dow Medical College) and Faiz because of their mode of administration which is by pasha (Sindh Medical College) for their help and injection and their high prices. It may be because of support in data collection and literature search. these factors that low rate of resistance is recorded for such antibiotics. In contrast, because of high use, Conflict of Interest: None declared.
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