1. Suttajit S a, Tantipidoke R a, Sitthi-amorn C a, Wagner A b, Ross-Degnan D b. a Chulalongkorn University, Bangkok; b Harvard Medical School, USA Problem Statement: Understanding where in the care process patients receive antibiotics may help in designing interventions to decrease antibiotic use and drug resistance in community. Objectives: To measure patterns of antibiotic use in adults with URIs and to identify where inappropriate use of antibiotics occurs in the community. Study Population: Interviewers visited 3,973 households in 2 congested communities in Bangkok and interviewed 779 adult patients with URIs. Methods: Interviews of adults age >18 who had URIs within 2 prior weeks in a systematic random sample of households. Outcome Measures: Patterns of care seeking, % antibiotics use, and treatment costs. Results: About 81% of URI cases were likely of viral origin. Patients with viral and bacterial URIs exhibited the same pattern of care seeking: patients first took care of themselves at home, some then went to drugstores and then to clinical settings. During their URI episode, 44% of viral URIs and 54% of bacterial URIs patients had used an antibiotic; antibiotic use was significantly higher among those who sought care outside their home. Among patients who only self-treated, 10% used antibiotics. Half of all patients sought treatment in drugstores, 65% received an antibiotic regardless of the infection type. In clinical settings, 61% of viral URIs and 71% of bacterial URIs patients received antibiotics. Self-medication with inappropriate antibiotics for viral URI cost 23 baht/patient and unnecessary visits to clinical settings for symptomatic treatment cost 89 baht/patient. Conclusions: Antibiotics are misused for viral URIs by self-medication at home but more frequently misused when patients visit drug stores and clinical settings. Interventions should be implemented to promote symptomatic self-treatment and appropriate antibiotic use by health providers as well. Care Seeking and Treatment for Adults with URIs in Congested Communities in Bangkok: Where Problems Occur

2. Introduction Most upper respiratory tract infections (URIs) are caused by viruses, and antibiotics are not recommended in their treatment. However, antibiotics are frequently used to treat URIs. Understanding where in the care process patients receive antibiotics may help in designing interventions to decrease antibiotic use and help reduce the rate of development of drug resistance in low-income and high-risk communities.

3. Objectives 1.To measure patterns of antibiotic use in adults with URIs, and 2.To identify where inappropriate use of antibiotics occurs in the community In order to understand the problem of drug use in community well and be able to design effective interventions to improve antibiotic use, the aims of this study are:

4. Methods Design Cross-sectional study Setting and Study Population In October 2002, interviewers visited 3,973 households in two congested communities in Bangkok and interviewed 779 adult patients with URIs. Methods Interviews of adults over 18 years old who had URIs within two prior weeks in a systematic random sample of households. Interviewers asked about URIs symptoms, health seeking behavior, drugs taken and cost, and self care.

5. Methods Analysis Based on patient’s reported symptoms, we adapted GAS score 1 and signs for sinusitis 2 to identify probability of Group A strep throat and sinusitis, and whether or not antibiotic should be taken in each case. Data were managed and analyzed using SPSS for Windows 12.0. Chi-square and Student’s t-test were applied where appropriate. A P-value <0.05 was considered statistically significant. 1 McIsaac WJ, White D, Tannenbaum D, Low DE. 1998. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. Canadian Medical Association Journal 158: 75-83. 2 William JW Jr, Simel DL. 1993. Does this patient have sinusitis?: Diagnosing acute sinusitis by history and physical examination. Journal of the American Medical Association 270(10):1242-1246.

6. Results 1 URI Cases in Community Total household visited was 3,973, 1,138 (28.6%) reported recently URIs within 2 weeks and 779 adult URIs cases were interviewed. About 82% were likely of viral origin. Female 81.8 % Age 18-40 44.7 % 41-60 40.1 % > 60 15.3 % Education < high school 82.8 % Income < 10000 baht 85.6 % Health insurance None 11.8 % National health plan 55.5 % Others 32.7 % Likely to be: Viral URIs 81.6 % Bacterial URIs 18.4 % Sick day, mean+SD6.21+3.97 Table1. Characteristics of Patients (n=779)

7. Results 2 Pattern of Health Seeking Behavior Viral and bacterial URIs cases usually first took care of themselves at home, but bacterial URIs were more likely have visited a clinical setting at the end of their illness. Choice of Treatment and setting 1 st choiceDuring the illness Viral (634)Bact. (145)Viral (634)Bact. (145) Non-pharmacological tx. No treatment 6.0 %4.1 % 6.0 % 4.1 % Non-drug treatment 52.7 %49.7 %53.2 %50.3 % Pharmacological tx. Self-prescribing At home 23.0 % 28.3 % 23.8 % 29.0 % At drug store 4.7 %5.5 %21.5 %21.4 % Tx. recommended by others At drug store 6.3 %7.6 %26.3 %25.5 % In clinical settings 1 6.2 %3.4 %39.7 %48.3 % Others1.1 %1.4 %3.9 %3.4 % Table 2. Choice of Treatment 1 private clinic, hospital, health center

8. Results 3 Where did URIs cases receive the antibiotics? During the illness episode, 44% of viral URIs cases and 54% of bacterial URIs cases had used an antibiotic. Antibiotic use was clearly higher among those who sought care outside their home. Table3. Antibiotics used at each setting SettingViral URIsBact. URIs Self-prescribed at home 10.6 %9.5 % at drug store 21.3 %35.5 % Recommended by others at drug store 65.5 %64.9 % at clinical settings 61.4 %71.6 % at other settings13.3 %0 %

9. Results 4 Cost of Drug Use in URIs Treatment  On average, viral URIs spent 84.6 baht ($2.2) while bacterial URIs spent 101.3 baht ($2.6).  The most frequently used pattern of care seeking costs 112.1 baht/episode ($2.9) (0.83% of average national household income).  In viral URIs, there is a lost of 59.5 baht/episode ($1.6) compared between the most appropriate and most inappropriate pattern of care seeking.  In viral URIs treatment, self-prescribing with antibiotic costs the lost of 23.3 baht/episode ($0.6) and unnecessary visiting of clinical settings costs the lost of 88.7 baht/episode ($2.3).

10. Discussions Limitations Potential misclassification of diagnoses and problem in identifying type of drug use by patients as they seldom knew their own medicines. Application of the results Researchers use the results to feedback and encourage the active citizen to take action in solving drug use problem in their community. Interventions designed together by community and research team are now implementing, such as the local URIs management guideline, Network for rational drug use, newsletters, radio broadcast, and discussion forum.

11. Conclusions What’s New? This study adds about study in developing country and in adults, and patterns of care seeking and antibiotic use in viral and bacterial URIs. Conclusions Antibiotics are misused for viral URIs by self- medication at home but more frequently misused when patients visit drug stores and clinical settings. Interventions should be implemented to promote symptomatic self-treatment of URIs. In addition, interventions should be implemented to promote appropriate antibiotic use for URIs in drug stores and clinical settings as well.

12. Acknowledgement Funding: Thailand Research Fund Applied Research on Child Health We thank Ms. Ratana Somrongthong for her continuing support coordinating the project. We also thanks staff at Duangprateep Foundation and community committees of each study communities for facilitating the data collection process. WHO Essential Drugs and Medicines Policy Department