INTRODUCTION:

Upper respiratory tract (URT) diseases comprise conditions that affect the nose, nasal cavity, pharynx, and larynx with the subglottic area of the trachea and it is one of the most frequently observed condition in community pharmacies¹.

Viral infections are responsible for majority of these conditions involving any part of the upper respiratory tract, and will typically resolve without the use of antibiotics². Non-severe URTI diseases symptoms last between 7 to 14 days. Pharmacists can provide over-the-counter medications and advise patients on non-pharmacologic management of URT for symptomatic management³.

The main goal of URT disease management focuses on amelioration of symptom, prevention of transmission and complication⁴. The underline cause and the patient status also affects the management strategy⁵. For viral disease like common cold symptom relief has a paramount significance. Decongestants, antihistamine, mucolytic and expectorants are the main medications that limit cough, congestion, and other symptoms in adults⁶. Moderate prophylactic dose of vitamin C may also be recommended to reduce the duration and severity of common cold⁷. Cough suppressants are also considered in patients with dry cough. However, the use of antibiotics has no evidence-based scientific support and antibiotics neither improve symptoms nor shorten the course of illness^8-10. On the other hand, if influenza infection is suspected, early antiviral treatment within 48 hours of onset of symptoms reduces the severity and duration of symptoms, decreases the length of hospital stays, and declines the risk of complications^11,12.

The management modality differs for allergic rhinitis and sinusitis. In both conditions, the community pharmacists should clearly determine the level of severity, complications and chronic symptoms. Pharmacists may recommend antihistamines and decongestants for allergic rhinitis. The use of intranasal steroid sprays better be reserved for patients with chronic symptoms¹³. For sinusitis or rhinosinusitis, the community pharmacists have to refer patients to the nearby clinic for further investigation and antibiotic prescription^14,15. However, the routine practice is a good example of sub-optimal management characterized by overuse of antibiotics^16,17.

As the most accessible and trusted professionals in the community^3,18, pharmacists manage a number of URT cases before the patients stage at clinics. Understanding how pharmacists handle URT diseases helps policy makers to devise both binding and enabling guidelines. Therefore, the aim of this study was to assess the empirical management of URT diseases in community pharmacies in Sulaymaniyah city, Iraq.

Methods:

This prospective cross-sectional study was conducted on purposively selected 51 community pharmacies in Sulaymaniyah city from March 25, 2021 to April 24, 2021. One volunteer dispenser was requested to fill the self-administer questionnaire from each pharmacy. Those working in community pharmacies without any formal training on the field of pharmacy were excluded. A semi-structured self-administered questionnaire comprised of items concentrating on the socio-demographic characteristics, academic status, ownership status, URT diseases, medications, and referral was used. Ethical clearance was obtained from the department of Pharmacy, National Institute of Technology. A written informed consent was asked from each responder. Data were collected keeping the identity of the participants’ anonymous, without revealing their names and addresses. The questionnaire was collected back 3 days after distribution. Three pharmacy technician students were employed as data collectors. The objective of the study and the questionnaire was explained by the supervisor to the data collectors before starting the data collection. With the intent to safeguard the quality of the data, the filled questionnaires were rigorously appraised for completeness and consistency. Moreover, data entry was checked for any uncertainties and any mistakes were dealt with accordingly.

Variables:

The main outcome variables were management of URT diseases in community pharmacy and antibiotic dispensing without prescription. Socio-demographic characteristics like gender, age, academic status, ownership status and years of experience were also studied to explore any association.

Data processing and analysis:

The data was entered into Microsoft excel and cleaned, checked for completeness and consistency. Then, it was imported to STATA 14 for further analysis. The data was summarized in tables and figures. Chi-square test was used to show any statistically significant association at P-value less than 0.05.

RESULTS:

Socio-demographic characteristics:

The average age of study participants was 31.3 years± 8.0 years; the age ranged from 21 to 59 years. Of the total, 30(58.8%) were male. The average years of experience was 8.6±7.8 years; it ranged from 1 to 32 years. In terms educational preparation, 25(49.0%) had a bachelor degree. Only 20(39.2%) were working in their own pharmacy and 30(58.8%) encountered up to four URTI cases per day (Table 1). The average number of URTI cases seen by a community pharmacy practitioner per day was 3.9±1.9.

Table 1: socio-demographic characteristics of study participants

Socio-demography		Frequency (%)
Gender	Female	21 (41.2)
Gender	Male	30 (58.8)
Age	≤ 31 years	33 (64.7)
Age	>31 years	18 (35.3)
Level of education	Diploma	20 (39.2)
	Bachelor of science	25 (49.0)
	Masters	6 (11.8)
Ownership status	Owners	20 (39.2)
Ownership status	Employees	31 (61.8)
Years of experience	≤ 8years	32 (62.8)
Years of experience	<8years	19 (37.2)
Number URTI cases/per day	≤4	30 (58.8)
Number URTI cases/per day	>4	21 (41.2)

URTIs and medications:

Table 2 summarizes URTIs managed in the community pharmacies. Common cold (n=21), pharyngitis (n=16), sinusitis (n=14) and rhinitis (n=13) were the top four conditions treated inside community pharmacies. However, the pharmacy professionals wrongly classified lung infection (n=7), asthma (n=4), COPD (n=2) and esophageal condition (n=2) under URTIs (Table 3).

Table 2: URT diseases managed by pharmacy professionals in community pharmacies

URTIs	Frequency (%)
Common cold	21 (23.1)
Pharyngitis	16 (17.6)
Sinusitis	14 (15.4)
Rhinitis	13 (14.3)
Laryngitis	10 (11.0)
Tonsillitis	9 (9.9)
Otitis media	3 (3.3)
Influenza	3 (3.3)
Dry cough	2 (2.2)

Table 3: conditions wrongly considered as URT diseases by professionals in community pharmacies

Wrongly classified condition	Frequency
Lung infection	7
Asthma	4
COPD	2
Esophageal infection	2

The medications commonly used by community pharmacy professionals to manage URT diseases was shown in Figure 1. Antibiotics (n=29), analgesics (n=19) and antihistamines (n=17) were the most frequently used class of medicines to manage URTIs.

Fig.1. commonly prescribed class of medicines

*Herbal products include eucalyptus oil, peppermint oil, Echinacea and chamomile tea

**Cough syrups include both antitussive and expectorants

Antibiotic use:

From the total, 29(56.9%) dispense antibiotics without physician request to manage URT diseases (Fig.2). Amoxicillin (n=20), azithromycin (n=15), levofloxacin (n=8) and cefixime (n=7) were the most commonly used antibiotics to manage URTIs without physicians’ request (Table 4).

Fig.2. Without prescription antibiotics dispensing practice by community pharmacies

Table 4: Antibiotics dispensed without prescription

Antibiotics	Frequency (%)
Amoxicillin	20 (29.9)
Azithromycin	15 (22.4)
Levofloxacin	8 (11.9)
Cefixime	7 (10.4)
Amoxicillin-clavualnic acid	6 (9.0)
Cephalexin	3 (4.5)
Ciprofloxacin	2 (3.0)
Ceftriaxone	2 (3.0)
Erythromycin	2 (3.0)
Co-trimoxazole	2 (3.0)

Factors associated with antibiotic dispensing without prescription:

Level of education and ownership status were the only factors with statistically significant association with antibiotics dispensing without prescription (Table 5).

Table 5: factors associated without prescription antibiotics dispensing by community pharmacies

		OTC antibiotic dispensing		P-Value
		Yes	No	P-Value
Gender	Female	9	12	0.091
Gender	Male	20	10	0.091
Age	≤ 31 years	22	11	0.056
Age	>31 years	7	11	0.056
Level of education	Diploma	6	14	0.003*
	Bachelor of science	20	5
	Masters	3	3
Ownership status	Owners	7	13	0.011*
Ownership status	Employees	22	9	0.011*
Years of experience	≤ 8years	21	11	0.101
Years of experience	<8years	8	11	0.101
Number URTI cases/per day	≤4	15	15	0.237
Number URTI cases/per day	>4	14	7	0.237

*Statistically significant

Referral of URT cases and reasons for referral:

Above half of the dispensers (n=28, 54.9%) said they refer URTI cases to health facilities (Fig.3). The main reasons for referral were severity of the condition, unable to identify the condition, need for further investigation and duration of illness (Fig.4.).

Fig.3. Pharmacists’ patient referral to health facilities

Fig.4. Reasons for referral

DISCUSSION:

In this study, we assessed the URT diseases empirical management practice in community pharmacies and antibiotic use without prescription for treatment of URTIs in Sulaymaniyah city. All of the community pharmacy practitioners on average saw 4 URTI cases per day. Around a fourth URT cases seen by community pharmacy practitioners were common cold (23.1%) followed by pharyngitis (17.6%), sinusitis (15.4%) and rhinitis (14.3%). More than a quarter of the medicines used to manage URT diseases were antibiotics (26.9%) followed by analgesics (17.6%), antihistamines (15.7%) and herbal products and honey (14.8%). However, the pharmacy professionals wrongly classified lung infection (n=7), asthma (n=4), COPD (n=2) and esophageal condition (n=2) under URT conditions.

Upper airways related complaints are among the most prevalent reasons to community pharmacy visits, absence from work and school, and productivity loses^1,3,
19. The common cold caused by over 200 different virus strains takes the lion-share of upper respiratory tract infections²⁰. Sore throats (pharyngitis) manifest during an infection with the common cold or influenza due to an increase in inflammation in the throat. Although viral infection causes up to 90% sore throats, bacterial infection is also involved in some of the cases^21,22.

More than half of the community pharmacy practitioners (56.9%) dispense antibiotics without physician request to manage URTIs. Amoxicillin (29.9%), azithromycin (22.4%), levofloxacin (11.9%)) and cefixime (10.4%) were the most commonly used antibiotics to manage URTIs without physicians’ request. Level of education (P=0.003) and ownership status (P=0.011) were the only factors with statistically significant association with antibiotics dispensing without prescription.

Over-prescribing of antibiotics for upper respiratory tract infections (URTIs) is an intrusive practice. A study reported 47% of patients diagnosed with an acute URTI were prescribed an antibiotic despite guidelines indicating an acceptable range of 0% to 20%¹². An observational study in the Netherlands found that 46% of antibiotic prescriptions by general practitioners for respiratory tract infection were not indicated by the guidelines²³. In a UK primary care study, the top 10% of highest prescribing general practices prescribed antibiotics for 72% of colds/URTIs, 67% of coughs/bronchitis, 90% of patients with otitis media, 78% of sore throats and 100% of cases of rhinosinusitis ²⁴. Similarly, a study in Ethiopia also reported amoxicillin, amoxicillin-clavulanic acid and azithromycin as commonly dispensed antibiotics without prescription²⁵. Although antibiotics do not directly affect pain, discomfort, or length of recovery in viral URTIs, antibiotic prescribing remains a predictor of patient satisfaction. Thus, providers need strategies to improve patient satisfaction with care when antibiotics are not appropriate²⁶. Complementary medicines maybe often sought by consumers in upper respiratory tract infections to either reduce symptom severity or decrease the duration of symptoms. Preparations may commonly include ingredients such as vitamin C (ascorbic acid), zinc, garlic, propolis, Echinacea, ivy leaf (Hedera helix), and creat (Andrographis paniculata)^12,21,27.

Above half of the dispensers (54.9%) said they refer URT cases to health facilities. The main reasons for referral were severity of the condition, unable to identify the condition, need for further investigation and duration of illness. Pharmacists have the basic know how on the diagnosis and management of a common cold and allergic rhinitis. Pharmacists need to be vigilant about upper airways signs and symptoms that seek referral to physicians for further assessment²⁸. Referral is also a reasonable decision when it is difficult to ascertain the condition and a mix of upper and lower respiratory conditions co-exist^1,3.

Generally, community pharmacies are the most accessible health care centers for people with upper respiratory tract infection. This makes pharmacists key stakeholders in antimicrobial stewardship for the prevention of antimicrobial resistance^21,29-31. Pharmacists better be instrumental in patient education, provision of rational symptom based treatment in conditions of the upper airways and avoid irrational use of antibiotics.

CONCLUSION:

On average at least four URT cases visit a community pharmacy and, common cold and pharyngitis were the most common types. The use of antibiotics without prescription for the treatment of URT diseases was rampant. Amoxicillin, Azithromycin and levofloxacin were the top three antibiotics. We recommend training on URTIs diagnosis and management, and antimicrobial stewardship to prevent antimicrobial resistance and improve the quality of care to the society. We also recommend a larger survey on skill of community pharmacy practitioners on the management of URTIs.

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Received on 15.11.2021 Modified on 03.02.2022

Research J. Pharm. and Tech. 2022; 15(8):3407-3411.

DOI: 10.52711/0974-360X.2022.00570