High Rate of Antibiotic Prescriptions for Outpatients with Influenza-Like Illness in Southern Sri Lanka
Acute respiratory illnesses, including influenza, account for a large proportion of ambulatory care visits worldwide. In the developed world, these encounters commonly result in unwarranted antibiotic prescriptions; data from more resource-limited settings are lacking.
Consecutive patients presenting to the Outpatient Department in the largest tertiary care hospital in southern Sri Lanka were surveyed for influenza-like illness (ILI). Patients meeting World Health Organization criteria for ILI-- acute onset of fever ≥38.0°C and cough in prior 7 days—were enrolled. Consenting patients were administered a structured questionnaire, physical examination, and nasal/nasopharyngeal sampling for rapid influenza A/B testing (Veritor, Becton Dickinson). Results were released to clinicians only in aggregate, as the test had not been formally approved for clinical use in Sri Lanka.
We enrolled 311 patients with ILI from March- November 2013, with 54.7% (170) children ≤18 years and 55% (172) males. Approximately half (147, 47.2%) tested positive for influenza: 94 (30.2%) for influenza A and 53 (17.0%) for influenza B. On bivariable analysis, clinical features associated with influenza included pleuritic chest pain (26.5% vs 8.8%, p<0.001), decreased appetite (83.0% vs 72.3%, p=0.026), fatigue (87.8% vs 76.7%, p=0.012), headache (85.0% vs 73.6%, p=0.014), arthralgias (81.6% vs 62.9%, p<0.001), and myalgias (81.6% vs 66.0%, p=0.002). Most patients (253, 81.4%) were prescribed antibiotics, with no difference with regards to influenza status (p=0.320). Commonly prescribed antibiotics included penicillins (164, 52.7%), first generation cephalosporins (64, 20.6%), and erythromycin (12, 3.9%). Patients prescribed antibiotics were more likely to be clinically diagnosed with a respiratory tract infection versus unspecified viral fever (p<0.001), and to receive additional diagnostic tests (22.9% vs 10.3%, p=0.033).
Approximately 50% of outpatients with ILI had confirmed influenza, but most were prescribed antibiotics. Improving access to low-cost, rapid diagnostic tests may decrease excessive antibiotic use, drug-related adverse effects, and healthcare costs. Rational prescribing of antibiotics in all settings is imperative given the rising global threat of antimicrobial resistance.
L. G. Tillekeratne,
A. Nagahawatte, None
D. Vidanagama, None
V. Devasiri, None
W. Kodikara Arachchi, None
R. Kurukulasooriya, None
D. De Silva, None
T. Ostbye, None
M. E. Reller, None
C. W. Woods, Becton Dickinson: Investigator and Scientific Advisor, Consulting fee and Research support