Skip to main content

Knowledge and Practices of Physicians regarding prescription of Antibiotics in the treatment of Upper Respiratory Tract Infection, Riyadh, 2006

Upper respiratory tract infection (URTI) is a nonspecific term used to describe acute infections involving the nose, ear, nasal sinuses and throat. Although 90-95% of URTI are viral in origin, antibiotics are often used for treatment. This study was conducted to assess knowledge, and reported practices of physicians toward prescribing antibiotics in treatment of URTI.
A cross-sectional study was conducted covering both governmental hospitals and PHCCs in Riyadh city. Stratified random cluster sampling was used to obtain 2 hospitals and 10 PHCC that were sampled randomly. The study involved 267 physicians, 144 (53.9%) from hospitals and 123 (46.1%) from PHCCs. Their mean age was 40.3 years (SD ± 8.3), 93 (34.8%) were males and 174 (65.2%) were females. Saudi nationality constituted 53 (19.9%). Most of the physicians were general practitioners 119 (44.6%), specialists 83 (31.3%) and residents 65 (24.3%).
Over half (62.1%) reported being able to differentiate between bacterial and viral infection by physical examination, 56.6% by history of the patient, 52.1% by general appearance of the patient, 43.1% by nasal and throat swab, 39.0% by blood investigation, 3.7% did not try to differentiate and 1.9% thought that none of these investigations could differentiate between bacterial and viral infection.
Out of the total physicians, 86.5% reported prescribing antibiotics for URTI patients and 13.5% never did. Reasons stated by those who prescribed antibiotics for URTI cases are documented in Table 1. The most common antibiotics prescribed were Amoxicillin 57.3%, Augmentin 22.5%, Erythromycin 14.3%, Azithromycin 7.8%, Ampicillin 6.9%, Penicillin 5.6%, Cephalosporin 4.8%, and Ampicillin + cloxacillin 3.9%.
Different factors thought to limit the prescription of antibiotics in URTI treatment were: availability of evidence of no benefit 61.5%, and an official policy of no antibiotic use 22.1%
All the physicians who did not prescribe antibiotics stated that most URTIs are of viral etiology. Out of 36 physicians who did not prescribe antibiotics for URTIs, 58.3% stated that URTIs were self-limiting, 19.4% stated that antibiotics were of no benefit, and 13.9% were fearful of their side effects
The major causes stated for starting antibiotic therapy on the first examination of an URTI case were: severely ill-looking appearance of patient 82.8%, if patient had high grade fever 58.8% and the patient€™s favorable response to antibiotics in previous URTI 15.0%
Most physicians (88.8%) agreed that there was a risk associated with prescribing unnecessary antibiotics, 10.2% did not agree, and 1.0% did not know. Among physicians who believed that there was a risk, stated risks were bacterial resistance 91.0%, diarrhea and vomiting 69.9%, fungal and commensal growth 69.4%, unnecessary cost 58.0%, allergy 55.8%, decreased immunity 45.1%, and renal and hepatic complications 42.1%.
Of the total, 76.4% agreed that there was a general over-prescription of antibiotics, 11.6% thought there over-prescription, and 12.0% were not sure. Reasons given for over-prescription were: uncertainty of diagnosis 53.6%, patient having combined conditions.
30.3%, patient demand 28.8%, physician belief in efficacy of antibiotics 26.2%, patient appearance of severe illness 19.5%, and patient leaving the city and requesting antibiotics 9.7%.

Editorial note:

Antibiotic over-prescription is a major health problem worldwide. It is one of the contributing factors to antibiotic-resistant bacteria. Antibiotics are frequently prescribed for the management of URTI, in spite of the fact that the majority of these infections are viral in origin.
In this study, the majority of physicians at both PHCCs and hospitals (86.5%) prescribed antibiotics for URTI patients. A study in northern in Saudi Arabia showed similar results.[1] This is different from other parts of the world, such as the USA where the proportion of antibiotic prescription previously reported was 48.0%.[2,3]
While most of physician's practices were satisfactory, some practices deviated from the correct. Some physicians inappropriately prescribed antibiotics although they recognized that most of the infections are viral
The main reason behind prescribing antibiotics for URTI could be related to diagnostic uncertainty. A second very important factor is pressure from patients and their relatives.4A third issue is loss of a trusting relationship between the patient and the physician. These factors combined may encourage a defensive treatment approach, which includes excessive antibiotic use. A fourth issue relates to the patients expectation of antibiotic therapy when seeking treatment, which may be the purpose of their office visit.
Most physicians stated prescribing antibiotics to prevent secondary bacterial infection. However, antibiotic administration do not reduce the incidence of these infections.[4] Also, physicians agreed that overuse of antibiotics was a major factor contributing to development of antibiotic resistance. This has been documented in several surveys.2,3 Diarrhea and vomiting increase growth of fungi and commensals, decrease immunity, allergy, unnecessary cost and serious renal and hepatic complications were risks that could occur due to antibiotic over-prescription. The immediate hazards, however, are their side effects and additional cost of therapy.[2,3]
In this study, Amoxicillin, Augmentin and other broad-spectrum antibiotics were found to be the most significantly prescribed antibiotics. Increasing use of broad-spectrum antibiotics has important implications for bacterial resistance, and they provide little clinical advantage over narrow-spectrum antibiotics or no antibiotic therapy at all.[2,3] It seems that physicians have increased their reliance on newer, largely broad-spectrum antibiotics, which may breed a new crisis in antibiotic resistance. By prescribing antibiotics for URTI a substantial proportion of resources are used for non-indicated and ineffective treatments. [5]
Physicians who had received short training courses or had read guideline or protocol had better practices compared to others.
Antibiotic prescription for URTI patients remains a common problem. The study reinforces the need for training courses for physicians and the need to implement forthwith the Saudi national program for diagnosis and treatment of RTI. The high rates of antibiotic prescription, the wide variations in practice patterns, and the strong association of non-clinical factors with antibiotic choice suggest opportunities to improve prescription patterns.
  1. El-Gilany AH. Acute respiratory infection in primary health care centers in Northern Saudi Arabia. East Med Hlth J 2000; 6(5): 955.
  2. Dosh SA, Hickner JM, Mainous AG, Ebell MH. Predictors of antibiotic prescribing for non-specific upper respiratory tract infections, acute bronchitis, and acute sinusitis. J Fam Pract 2000; 49(5): 407.
  3. Nyquist AC. Antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. JAMA, 1998; 279: 875.
  4. Moxaham J, Costello JF, Souhami RL. Upper respiratory tract infection. In: Edwin CH, Chilvers JA, & Hunter NA (Eds). Davidson's principles and practice of medicine. Edinburgh, London. 1999. pp. 471-542.
  5. Maternal and child health trainee manual for general practitioners, 1st ed. Riyadh, Ministry of Health, 1988:156.
Table 1: Reasons for prescribing antibiotics for URTI patients (N= 240)
Type of virus
Prevention of secondary bacterial infection
Relief of symptoms and signs of infection
Shortening the duration of illness
Inability to differentiate between bacterial and viral infection
Demand / pressure from patient or relatives
Suspicion of bacterial infection
Reading relevant articles including treatment with antibiotics
Advice from more experienced physicians