| Can J App Sci 2012; 1(3):176-179

Javed & Zahra, 2012

Canadian Journal of Applied Sciences; 2012; 2(1): 176-179, January, 2012 Intellectual Consortium of Drug Discovery & Technology Development Inc. ISSN 1925-7430 Available online http://www.canajas.com Case Report TREATMENT OF UPPER RESPIRATORY TRACT INFECTION: A CASE REPORT. Sumreen Javed, Zahra S.S Riphah Institute of Pharmaceutical Sciences, Riphah International University, G-7/4, 7th Avenue, Islamabad, Pakistan. ABSTRACT Respiratory tract infections are the most common infections in the developing countries. Its mode of spread is also very fast as compared to any other infection. Therefore; we have based this study on the comparison of two different drugs, Ciprox (Ciprofloxacin) and Augmentin (amoxicillin/clavulanate potassium), for the treatment of upper respiratory tract infection. A 25 years old female came in the local hospital of Rawalpindi (Pakistan) with the chief complaints of high grade fever of 103F for 3 days with rigors and chills, flu and productive cough for 3 days, body rash and red spots for 1 day. The first doctor prescribed her tablet Ciprox (ciprofloxacin) 750 mg BID (twice a day), tablet Avil (pheniramine) 250 mg TID (three times a day), Paracetamol 500 mg TID and advised her to take healthy diet. Doctor also prescribed her blood C.P (complete picture) test and dengue virus test. Patients health condition became worse and then they sought another medical practitioner. The second physician prescribed her tablet Augmentin (amoxicillin/clavulanate potassium) 625 mg BID, syrup Cosome E (ammonium chloride/diphenhydramine) 1 table-spoon TID, tablet Paracetamol 500 mg and tablet Neo-Intestopan (Attapulgite) 630 mg TID. He also prescribed her herbal tea (Joshanda), honey in luke-warm water, noodles with soup and Chicken soup. Patient recovered from second treatment. Augmentin is more effective in upper respiratory tract infection and Ciprofloxacin can only be used as a 2nd line therapy only when resistance or hypersensitivity occurs from 1st line therapy. Thus; irrational drug usage and specious prescription are a serious challenge in Pakistan. The clinical services and pharmaceutical care can work together to rationalize the pharmacotherapy. Thus; there is a dire need to induct qualified pharmacists in existing health care system to save precious lives. Key words; Upper respiratory tract infection, Augmentin, ciprofloxacin, pharmacist. Corresponding Author; Syeda Saniya Zahra, Riphah Institute of Pharmaceutical Sciences, Riphah International University, G-7/4, Islamabad, Pakistan. Email: saniya166@gmail.com

INTRODUCTION Upper respiratory tract infections (URTIs) include rhinitis (common cold), sinusitis, ear infections, acute pharyngitis or tonsillo-pharyngitis, epiglottitis, and laryngitis, of which ear infections and pharyngitis cause the most severe complications (deafness and acute rheumatic fever, respectively) [1]. 176

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This infection is the leading cause of morbidity and mortality in critically ill patients in developing countries [2]. Upper respiratory tract infections (URTIs) involve direct invasion of the mucosa lining of the upper airway. It is a global problem accounting for over 50 million deaths each year and occurs in both community and health care settings [3]. The vast majority of URTIs have a viral aetiology. Rhinoviruses account for 25 to 30 percent of URTIs; respiratory syncytial viruses (RSVs), Para influenza and influenza viruses, Human Meta pneumo virus and adeno viruses for 25 to 35 percent; corona viruses for 10 percent; and unidentified viruses for the remainder [4]. Because most URTIs are self-limiting, their complications are more important than the infections. Acute viral infections predispose children to bacterial infections of the sinuses and middle ear [5]. The upper respiratory tract infection is caused by Streptococcus pyogenes which contributes to almost (22.4%) of the total infections. Others contributing less to this disease are Streptococcus pneumoniae (21.6%), Staphylococcus aureus (19.0%), Klebsiella pneumoniae (11.2%), and Haemophilus influenza (10.3%), Proteus mirabilis (8.6%) and Pseudomonas aeruginosa (6.9%) in order of ranking [6]. Acute respiratory tract infections comprised a total of 8954 (32%) of all the infections in 27,963 patients in Khyber Pakhtun Kha during the period of 4 months in 2009. Its highest prevalence was observed in children less than five years of age [7]. CASE PRESENTATION A 25 years old female came in the local hospital of Rawalpindi with the chief complaints of high grade fever of 103F for 3 days with rigors and chills, flu and productive cough for 3 days, body rash and red spots for 1 day. Patient has a drug history of taking Basoquin (Amodiaquin) as a self-medication because she thought that she is suffering from malaria and could not seek the medical practitioner on account of Eid holidays. The patient belonged to a middle class social stratum. She had a family history of diabetes. The patient was diagnosed as an upper respiratory tract infection on the basis of her physical examination. The doctor prescribed her tablet Ciprox (ciprofloxacin) 750 mg B.I.D (twice a day), Avil (pheniramine) 250 mg T.I.D (three times a day) and Paracetamol 500 mg TID. She was advised to take healthy diet. Doctor prescribed her blood C.P (complete picture) test and Dengue Virus test due to its extreme prevalence in the population at the time of case presentation. On 2nd day of her treatment, she was suffering from the fever of 102F in morning. She looked pale and lethargic. Her B.P was 110/70. In evening, her body temperature was 101F and developed stomach cramps and diarrhoea. She also started having sedation and drowsiness. Her cough and flu also worsened. On 3rd day of her therapy, she started taking yogurt to stabilize the stomach. She also added milk and different juices in her diet. Her stomach cramps were relieved but the physicians could not treat her infection. Her temperature was 101F in the morning and 102F at the night. Cough and flu were worsened. Sedation was also there and she also had muscle weakness and pain in her joints. Her blood C.P test values were more or less in the range and did not predict any major complication. Same therapy continued for 4th day, she did not have stomach cramps but she was still experiencing sedation and fever. The skin rash was decreased in intensity. She was not finding relief against flu and fever. Patient used healthy diet such as chicken, eggs, milk and yogurt. Dengue test from ELISA (Enzyme-linked immunosorbent assay) method came out to be negative and that ruled out any chances of dengue fever to the patient.

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Therapy continued for the 5th day, there was not much recovery from the fever; however the skin rashes were much in control. Patient was having sedation and muscle weakness. The flu and cough were still present. The patients attendants decided to change the prescriber. The new physician prescribed her tablet Augmentin (amoxicillin/clavulanate potassium) 625mg BID, syrup CosomeE (ammonium chloride and diphenhydramine) 1 table spoon TID, Paracetamol 500 mg and Neo Intestopan (attapulgite) 630 mg TID. He told the patient to exclude yogurt and milk from her diet during the course of therapy and also prescribed her a herbal tea (Joshanda), honey in luke-warm water and noodles and chicken soup for quick recovery. He was also more concerned about the patients health. On 2nd day of her new therapy, she started to feel better. Her morning fever was 100F which remained the same in the evening. She also started to recover from her respiratory tract infection. Therapy continued for full five days and patient recovered from upper respiratory infection, fever, sedation, muscle weakness and diarrhoea. DISCUSSION This case depicts a difference in the prescribing trends by different prescribers in the same hospital in Rawalpindi, Pakistan. All the doses were according to the specifications except the dose of Avil which should have been given BID instead of TID. The patient used basoquin as a self-medication which is associated with the side effect of skin allergy. Adjei et al., [8] reported that Basoquin causes skin rash which could be very dangerous if not taken under the supervision of a qualified medical practitioner. While, Timothy [10] recommended the usage of ciprofloxacin in urinary tract infections. Roland et al., 1994 reported that unresponsive behaviour of Ciprox has been observed in cases of URTIs and amoxicillin should be preferred. Amoxicillin and beta-lactamase inhibitors are used in empirical therapy while, fluoroquinolones are not recommended as first line therapy in upper respiratory tract infections. According to Javier Garau [12], Augmentin is preferred over ciprofloxacin in upper respiratory tract infection and also causes less severe side effects. The sedation of the patient was due to 1st generation anti-histamine that has a prominent side effect of marked sedation and drowsiness which has worsened the condition of patient. This was due to the increased dose of Avil. The fever did not subside in the 1st therapy due to the use of milk and yogurt in diet that led to diminished therapeutic effect. Papai et al., [13] suggested that calcium in milk and dairy products decrease the effectiveness of ciprofloxacin by complexation. In the 2nd therapy, the drug Neo Intestopan relieved stomach cramps and diarrhoea. Patient already had high grade fever and lethargy while use of ciprofloxacin led to marked muscle weakness and pain in joints (side effect of ciprofloxacin). De Sarro et al., [14] also reported that ciprofloxacin causes extreme muscle lethargy and should be used with caution. Therapy prescribed by 2nd prescriber was a combination of both pharmacological and nonpharmacological approaches which is a better treatment plan as compared to the treatment with drugs alone. CONCLUSION Irrational drug usage and specious prescription are a serious challenge in Pakistan. The clinical services and pharmaceutical care can work together to rationalize the pharmacotherapy. Thus; there is a dire need to induct qualified pharmacists in existing health care system of Pakistan to save precious lives. .

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REFERENCES: 1. Eric A. F. Simoes, Thomas Cherian, Jeffrey Chow, Sonbol ShahidSalles, Ramanan Laxminarayan, and T. Jacob John. Acute Respiratory Infections in Children available at: http://files.dcp2.org/pdf/DCP/DCP25.pdf 2. Jafari N J, Ranjbar R, Haghi-Ashtiani MT, Abedini M, Izadi M. The study of prevalence and antimicrobial susceptibility of tracheal bacterial strains isolated from paediatric patients. Pak. J. Biol. Sci., 2009. 3. Imani R, Rouhi H, Ganji F. Prevalence of antibiotic resistance among bacteria isolates of lower respiratory tract infections in COPD Shahrekord, Iran. Pakistan. J. Med. Sci., 2007. 4. Denny, F. W. Jr. The Clinical Impact of Human Respiratory Virus Infections. American Journal of Respiratory and Critical Care Medicine 1995 5. Berman S. Otitis Media in Children. New England Journal of Medicine 1995 6. A. M. El-Mahmood, H. Isa1, A. Mohammed and A. B. Tirmidhi. Antimicrobial susceptibility of some respiratory tract pathogens to commonly used antibiotics at the Specialist Hospital, Journal of Clinical Medicine and Research Vol. 2(8), pp. 135142, August 2010. 7. Weekly Morbidity and Mortality Report Week 04 (17-23 Jan), 2009 NWFP/FATA, Pakistan available at: http://reliefweb.int/sites/reliefweb.int/files/resources/10B1369815679907C125755A0 04EAE20-full_report.pdf 8. G. o. Adjei, B. q. Goka, et al., Amodiaquine-Associated Adverse Effects After Inadvertent Overdose And After A Standard Therapeutic Dose Ghana Medical Journal, Sep 2009. 9. Ruiz, Maria E. Current drug safety. Bentham Science Publishers Volume 5, Number 4, October 2010, pp. 315-323(9). 10. Timothy Jancel and Vicky Dudas, Management of uncomplicated urinary tract infections, West J Med. 2002. 11. Roland.J.korner et al., Dangers of Oral Floroquinolones Treatment in Acquired Upper Respiratory Tract Infections BMJ 1994 PMC2542530. 12. Javier Garau et al., Upper Respiratory Tract Infections: Etiology, Current Treatment, and Experience with Fluoroquinolones Clic Microbiology and Infections 1998. 13. Papai K In vitro food-drug interaction study: Which milk component has a decreasing effect on the bioavailability of ciprofloxacin? J Pharm Biomed Anal. 2010. 14. De Sarro A, De Sarro G Adverse reactions to fluoroquinolones. An overview on mechanistic aspects. Curr Med Chem. 2001.

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