Management Of Acute Respiratory Infections Research Articles

Factors Determining Correct Case Management of Acute Respiratory Infections in Children by Primary Health care in Ibadan

Background: Inappropriate case management of Acute Respiratory Infections (ARIs) is one of the factors responsible for the high ARI mortality in developing countries. Identification of factors which influence ARI case management by health workers is key for interventions to improve Quality of case management. Objective: To identify factors which determine correct case management of Acute Respiratory Infections (ARIs) in children by primary health care workers in Ibadan. Design: A descriptive cross sectional study was carried out from June to December 1999 in Ibadan South East LGA and Lagelu LGA. Study materials included observation checklists, validation checklist, and health worker interview questionnaires. Results: Twenty-five health workers and 20 health workers were observed managing 390 children and 386 children in Ibadan South East and Lagelu LGA respectively. More than half of Pneumonia cases were correctly treated in the two LGAs (62.3% and 66.1% respectively). Sex and category of health workers was significantly associated with correct treatment of mild ARI with female workers and Nursing staff doing better (Odds ratio 4.57, 95% CI 2.15, 9.95 and 4.61, 95% CI 2.57, 8.31 respectively). Health workers who had been trained performed better in the management of Pneumonia though it was not statistically significant. Conclusions: There is a need for targeted research to identify the relative contribution of the myriad of factors influencing health worker performance in specific localities in order to improve the quality of care in child health programmes. Keywords: Factors, Case Management, ARI, Health workers.NQJHM Vol. 16 (1) 2005: pp. 14-19

An Evidence-Based Approach to the Diagnosis and Management of Acute Respiratory Infections

Acute respiratory infections (ARIs) are commonly experienced in primary care. Although most ARIs are viral in nature and resolve without treatment, nurse practitioners and other clinicians prescribe antibiotics for them 40% to 50% of the time. Thus, the purpose of this article is to review current evidence-based recommendations about the diagnosis and management of ARIs in adults.

There’s a lot of it about: acute infections in primary careThere’s a lot of it about: acute infections in primary care Worrall Graham 1st Radcliffe Publishing 160 £21.95 1-84619-084-3 1846190843

This book claims to provide all primary health care professionals with a fascinating and useful aid to the diagnosis and management of acute respiratory infections. If it did what it promises to do this would be an invaluable aid for primary care. Acute respiratory infections account for a large proportion of the consultations in primary care and there is good evidence of idiosyncrasies in care.

La formation des agents de santé communautaire instruits : une stratégie pour améliorer l'accès des enfants au traitement des infections respiratoires aiguës au Sénégal

Background Acute respiratory infections (ARI) are the leading cause of death in childhood. Most of children's deaths happen at home without health level first cares. However in Senegal only health workers are allowed to prescribe antibiotics. A competency-based training was developed to improve and assess the management of acute respiratory infections in young children aged 2 to 59 months by low level educated community health workers (CHWs) in 4 districts of Senegal. The first findings showed the CHWs capable of acquiring the skills needed to effectively manage ARI cases in accordance with the World Health Organization's ARI case management strategy. The aim of this study was to assess the quality of their management after a 1 year follow-up. Methods We provided to CHWs 3 days course in ARI management. After the 3-day course, a 4-month follow-up was performed. We organized a 1-day refresher course every month and in every district. In order to assess the quality of management of CHWs we analyzed the management process and compared the CHWs classification to the classification of the first level health facilities. Results Twenty-three percent (3727/15,965) of IRA cases of district were managed by CHWs. Ninety percent (2738/3042) among them were well classified, well managed and well followed-up. But 28% of severe pneumonia cases were misclassified as pneumonia. About treatment, 22.5% of « cough or cold » got wrong treatment with cotrimoxazole and 10.3% of severe pneumonia got cotrimoxazole without referral. Less than half of severe pneumonia benefited of the first follow-up and only 18% of the second. Conclusions The results highlight that a CHWs low-level educated in French, trained and followed-up could apply the WHO algorithm of IRA management. They could help to give proximal care related to children ARI, to the community. But it seems useful of emphasizing the recognition of danger signs and the follow-up of severe cases.

Community trials on case management of acute respiratory infections (ARI) in rural villages

A community trial was conducted in two rural subdistricts in Subang, West Java, Indonesia, i.e., Cisalak as the intervention area and Sagalaherang as reference area. The study aimed to evaluate the usefulness new version of case management on acute respiratory tract infections (ARI). All babies born between January and December 1994 were enrolled in the study, and followed for 6 to 12 months. The field workers visited the babies every 2 weeks. They examined the babies and interviewed mothers about ARI symptoms, by using a pretested questionnaire. During that period 969 babies were born, 53.3% in Cisalak and 46.7% in Sagalaherang; 548 of them were followed for 12 months; however, only 263 among them had complete data. The morbidity of ARI increased with increasing age; there was no difference between those two study areas. The prevalence of ARI at the age of less than 3 months was 35.1% and 32.7%; between 4 to 6 months 49.9% and 45.3%; between 7 to 9 months 47.0% and 45.9% ; and between 10 to 12 months 53.7% and 50%, for Cisalak and Sagalaherang, respectively. Nevertheless, the mortality in Sagalaherang was higher than in Cisalak (118 per 1000 and 78 per 1000, respectively), and the pneumonia-related deaths were 64.8% and 52.5%, respectively. The age specific death rate for pneumonia was high among babies of less than 3 months of age, i.e., 68.5% and 57.2%, respectively. We conclude that mothers and primary health care workers in rural areas should be taught and encouraged to use case management of ARI, and monitoring and evaluation of the application is needed.

Failure of standard antimicrobial therapy in children aged 3-5 months with mild or asymptomatic HIV infection and sever pneumonia

To determine whether children aged 3-59 months with mild or non-symptomatic human immunodeficiency virus (HIV) infection and WHO-defined severe pneumonia have a higher failure rate than do HIV-uninfected children when treated with the standard WHO treatment of parenteral penicillin or oral amoxicillin. This study was a planned sub-analysis of a randomized trial of 3-59-month-old children presenting with WHO-defined severe pneumonia (the APPIS study). We included two sites with high HIV prevalence in Durban, South Africa and Ndola, Zambia. Primary outcome measures were clinical treatment failure at day 2 and day 14. CLINICALTRIALS.GOV IDENTIFIER: CT00227331http://www.clinicaltrialsgov/show/NCT00227331). Of the 523 children enrolled, HIV status was known for 464 participants; 106 (23%) of these were infected with HIV. By day 2, 57 (12.3%) children had failed treatment and 110 (23.7%) failed by day 14. Twenty (18.9%) HIV-infected children failed by day 2 compared with 37 (10.3%) uninfected children (adjusted odds ratio (OR) 2.07; 95% confidence interval (CI): 1.07-4.00). Thirty-four (32.1%) HIV-infected children failed treatment by day 14 compared with 76 (21.2%) uninfected children (adjusted OR 1.88; 95% CI: 1.11-3.17). Analysis stratified by age showed that the greatest differential in treatment failure at day 2 and day 14 occurred in the children aged 3-5 months. HIV-infected children with severe pneumonia fail WHO-standard treatment with parenteral penicillin or amoxicillin at day 2 and day 14 more often than do HIV-uninfected children, especially young infants. Standard case management of acute respiratory infection (ARI) using WHO treatment guidelines is inadequate in areas of high HIV prevalence and reappraisal of empiric antimicrobial therapy is urgently needed for severe pneumonia associated with HIV-1.

Home and community management of acute respiratory infections in children in eight Ugandan districts

Acute respiratory infections (ARI), especially pneumonia, are the second largest child killer in sub-Saharan Africa. Symptoms, including cough and difficult/rapid breathing, frequently overlap those of malaria. In Uganda, the Home-Based Management (HBM) strategy treats all childhood fevers as malaria in the community, ignoring the pneumonia symptom overlap. To determine the extent of overlap of fever and ARI symptoms at community level, the timeliness of care-seeking and the treatments sought for ARI with or without fever. From eight districts, 3223 households with 3249 children aged <2 years were randomly selected through two-stage cluster sampling and their primary caretakers were interviewed regarding the child's most recent illness episode using 2-week recall. Of the 1682 children <2 years who had been sick, 19% reported overlapping symptoms of fever, cough and "difficult/rapid breathing". Of these, 45% were given antimalarials alone. Use of health facilities was low and 42% of antibiotics used were obtained from drug shops or home-stocks. Given the large overlap of fever and ARI symptoms and the reported practice of using primarily antimalarials, the implications of HBM might be the continued or increased mismanagement of pneumonia. Community drug distributors' ability to identify rapid breathing and make a presumptive diagnosis of pneumonia based on respiratory rate should be tested.

Quality of child health services in primary health care facilities in south‐east Nigeria

To assess the quality of child health services in primary health care (PHC) facilities in Calabar, south-east Nigeria. Cross-sectional, descriptive design. Key informant interviews, structured observation, self-administered questionnaire and focus group discussion. Calabar, south-east Nigeria. Participants All 10 PHC facilities in Calabar, 252 PHC workers serving in the facilities, and 76 mothers whose children received care in the facilities. Adequacy of structure (equipment and personnel); process (diagnosis, training and knowledge, use of national case-management algorithm, and supervision), and output (clients' satisfaction). PHC facilities were adequately equipped to the extent of providing immunization services and management of diarrhoea but not for other aspects of care expected of a PHC centre, including management of acute respiratory infections (ARI), a common problem in children in the region. Supply of essential drugs was inadequate in all centres and facilities for emergency care were lacking. Many of the health care workers (68.3%) had adequate training in immunization, and their knowledge scores on immunization issues (62%) was higher than in other aspect of PHC. Use of the national case management algorithm was low among PHC workers. Results of the focus group discussions with mothers showed that a few perceived quality of care to be poor. The main concerns were long waiting time, lack of essential drugs, and attitude of the health workers. Inadequacy in the quality of child health services in PHC facilities is a product of failures in a range of quality measures -- structural (lack of equipment and essential drugs), process failings (non-use of the national case management algorithm and lack of a protocol of systematic supervision of health workers). Efforts to improve the quality of child health services provided by PHC workers in the study setting and similar locales in less developed countries should focus not only on resource-intensive structural improvements, but also on cheap, cost-effective measures that address actual delivery of services (process), especially the proper use of national guidelines for case management, and meaningful supervision.

Assessment of the Case Implementation of the Case Management of Acute Respiratory Infections in Children by Primary Health Workers in Ibadan

Assessment of the Case Implementation of the Case Management of Acute Respiratory Infections in Children by Primary Health Workers in Ibadan

Serious bacterial infections in newborn infants in developing countries.

The overwhelming majority of the world's annual 4 million neonatal deaths occur in developing countries. This review therefore briefly addresses the burden, aetiology, prevention and management of serious neonatal bacterial infections in low-income settings. Bacterial infection is the biggest cause of neonatal admissions to hospitals, and probably the biggest cause of morbidity in the community, but its burden is unclear. The commonest serious infections involve bacteraemia, meningitis and respiratory infection, and case fatality rates may be as high as 45%. Key pathogens are Escherichia coli, Klebsiella species, Staphylococcus aureus and Streptococcus pyogenes. The incidence of neonatal infections with group B streptococcus is highly variable, as is the spectrum of antimicrobial resistance. Current areas of research include the rectification of micronutrient deficiencies, neonatal skin care, appropriate breastfeeding recommendations, cleansing of the birth canal, and simplified methods of diagnosis of infection. Operational activities include the control of neonatal tetanus, the diagnosis and treatment of sexually transmitted infections, integrated strategies for improving pregnancy, childbirth and neonatal survival, community-based management of acute respiratory infections, and community-based management of neonatal sepsis.

Formation d’agents de santé communautaire à la prise en charge des infections respiratoires aiguës de l’enfant: Assessment of management training for low-level community health workers providing care for children with acute respiratory infections in four districts of Senegal

Acute respiratory infections are the leading cause of death in childhood and most child deaths in Senegal occur at home without qualified health care. Despite this situation, only qualified healthcare workers are authorized to prescribe antibiotics. A competency-based training program was developed to improve and assess management of acute respiratory infections in young children aged between 2 and 59 months by low-level educated community health workers (CHWs) in four districts of Senegal. In accordance with the strategy developed by the World Health Organisation, educated low-level community health workers in four district of Senegal were given a three-day course on the management of acute respiratory failure. We assessed the effects of the course by comparing pre-training and post-training skills with the Students t test. The results showed that the educated low-level community health workers were capable of acquiring the skills needed to effectively manage children with acute respiratory failure. Further evaluation is needed to determine the mid- and long-term effects of the course and supervised post-training activities.

Emergency department management of acute respiratory infections.

Respiratory tract infections are one of the most common problems prompting visits to the emergency department. Although many are the result of self-limited viral illnesses, these infections may result in substantial morbidity and, rarely, mortality. Prompt recognition and appropriate treatment can reduce morbidity and largely prevent mortality. Careful selection of antimicrobial agents is essential to maximize benefit and prevent overuse, which contributes to the emergence of antibiotic resistance.

Integrated Management of Childhood Illness (IMCI): a robust strategy.

Integrated Management of Childhood Illness (IMCI), a strategy fostering holistic approach to child health and development, is built upon successful experiences gained from effective child health interventions like immunization, oral rehydration therapy, management of acute respiratory infections and improved infant feeding. The core intervention of IMCI is integrated management of the five most important causes of childhood deaths-acute respiratory infections, diarrheal diseases, measles, malaria and malnutrition. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death as well as the frequency and severity of illness and disability, thus contributing to improved growth and development. In health facilities, the IMCI strategy promotes the accurate identification of childhood illness (es) in the outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers and the provision of preventive services, and speeds up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. It also creates a scientifically sound link between the management guidelines at the community level and the management approach in a referral centre. The strategy also envisages actual situations when referral is not possible and offers the best possible options in such circumstances. In the home setting, it promotes appropriate early home care and care-seeking, improved nutrition and prevention, and the correct implementation of prescribed care. In addition to its focus on treatment of illness in the health facility as well as at home, it also provides an opportunity for important preventive interventions such as immunization and improved infant and child nutrition including breastfeeding. The IMCI strategy reduces wastage of resources and avoids duplication of efforts that may occur in a series of separate disease control programs. The essential pillars include improvement in the case management skills of health personnel, improvement in health systems, and improvement in family and community practices. IMCI has been introduced in more than 80 countries and 19 of them have already scaled up IMCI implementation Even though it is too early to relate the decrease in childhood mortality with the introduction of IMCI in these countries, there are several indirect indicators which endorse its validity as a comprehensive and effective strategy. IMCI has helped countries to revise and update their child health policies, streamline the essential drug lists for children, increase service utilization, improve quality of care and nutritional counselling, improve health systems and improved family and community practices.

The quality of private and public primary health care management of children with diarrhoea and acute respiratory infections in Tlaxcala, Mexico.

In Tlaxcala, Mexico, 80% of the children who died from diarrhoea or acute respiratory infections (ARI) in 1992-1993 received medical care; in more than 70% of cases it was provided by a private general practitioner (GP). The present study evaluated the quality of case management by private and public GPs to children under five years of age with diarrhoea and ARI. During the clinical observation, the treatment and counselling given to the mother were assessed with the WHO guidelines as reference standard. A total of 41 private and 40 public GPs were evaluated for the management of diarrhoea, and 59 private and 40 public GPs for the management of ARI. For diarrhoea, half of the private GPs gave inadequate rehydration therapy, 63% gave incorrect advice on diet, 66% and 49% made an incorrect correct decision in the prescription of antimicrobial and symptomatic drugs, respectively. Public GPs generally performed better in diarrhoea management: 7% gave inadequate rehydration therapy, 13% gave wrong advice on diet, 3% made a wrong decision in the prescription of symptomatic drugs and 28% gave a wrong decision in antimicrobial prescription. In the management of ARI, 66% and 58% of private GPs made a wrong decision in the prescription of antimicrobial and symptomatic drugs, respectively, compared to 30% and 20% of public GPs, respectively. Counselling to the mother given by both private and public GPs was considered inadequate in most cases of diarrhoea and ARI. These results clearly show that private doctors, as important providers of medical care, need to be included in the strategies to improve the quality of care of children with diarrhoea and ARI. Future research needs to address the determinants of the clinical practice of private doctors in countries like Mexico.

Home management of acute respiratory infections: a challenge to the family and the community

Reports on a survey conducted to investigate acute respiratory infections (ARI) in children in developing countries, looking particularly at the Philippines. Explores the role of the National Committee for Acute Respiratory Infections and states its objectives and responsibilities. Asserts that state of health is associated with community structure, environmental factors, and social and psychological conditions. Finds also that maternal factors are important determinants in the incidence of ARI episodes, for example, the mother’s characteristics, level of health knowledge, her illness control activities, age, level of education, number of children, smoking behaviour, and the extent to which she has to fulfil other tasks. Explains the methodology used in the survey, the sampling procedure and research instruments used. Indicates that poor housing and living conditions should become the focal point of developmental efforts, and that better nipping in the bud health management should be encouraged through health education programmes.

Parents' management of ARI in the Region of Marrakech.

Diarrhea and acute respiratory infections (ARI) cause child morbidity and mortality in most developing countries. ARI can often develop rapidly from a mild cold to severe pneumonia if the illness is poorly managed at the outset and if decisions and actions to seek medical care are delayed. This potential lends importance to parents decision-making process and the mothers role concerning disease diagnosis treatment and management. 100 mothers and 23 health care providers in 3 rural communities near Marrakech were interviewed in 1993 in their homes and at medical facilities to investigate their management of ARI in infants and children up to age 5 years with the goal of decreasing childrens mortality through policy messages. Parents in this study region use both traditional and Western health systems depending upon their socioeconomic condition. They make ARI treatment-related decisions based upon their financial means constraints knowledge and understanding of medical concepts and health systems.

The Management of Acute Respiratory Infections: Saudi National Protocol for Diagnosis and Treatment

The Management of Acute Respiratory Infections: Saudi National Protocol for Diagnosis and Treatment

Patterns and determinants of use of antibiotics for acute respiratory tract infection in children in China.

Use of antibiotics for acute respiratory infection (ARI) of presumed viral etiology is a worldwide problem. The World Health Organization (WHO) has provided guidelines for diagnosis and treatment of ARI for developing countries. Specially trained observers applied the WHO criteria to study the diagnosis and treatment of ARI given by 100 randomly selected health care workers (HCWs) in a rural county in China. A total of 750 cases of ARI were evaluated. Before the parents sought medical care, 47% of children in the county hospitals, 25% of those in the townships and 18% of those in the villages had already received antibiotics, available without prescription. Among the HCWs antibiotic abuse (antibiotics for presumably viral disease) was detected in the treatment of 97% of cases, and severe abuse (such as prescription of two incompatible antibiotics) was detected in 37%. Most (197 of 200) patients with bacterial disease received antibiotics, but inappropriate antibiotic treatment (dose or type) was observed in 63% of these cases. HCWs with university training and those with higher test scores on knowledge and attitude prescribed antibiotics more judiciously than those lacking those attributes. Abuse of antibiotics for ARI is a serious and costly problem in rural China, potentially leading to widespread antibiotic resistance. Educating HCWs in the management of ARI and proper use of antibiotics has high priority in China.

The Management of Acute Respiratory Infections in Children: Practical Guidelines for Outpatient CareThe Management of Acute Respiratory Infections in Children: Practical Guidelines for Outpatient CareWorld Health Organization, 1995. ISBN: 92-4-154477-5

Book ReviewsThe Management of Acute Respiratory Infections in Children: Practical Guidelines for Outpatient Care Husn FrayhaMD Husn Frayha Head, Section of Infectious Diseases, Department of Pediatrics, MBC 58, King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia Search for more papers by this author Published Online:24 Apr 2019https://doi.org/10.5144/0256-4947.1997.264aSectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutIntroductionAcute respiratory tract infections are frequent in children, and are associated with high morbidity and mortality, particularly in underdeveloped and developing countries. Children with acute respiratory infections account for a significant proportion of patients seen at primary health facilities. It is estimated that pneumonia is responsible for 25% of deaths in children under five years of age in developing countries.This WHO book is intended for health staff working in outpatient first-level health care facilities. It provides guidelines for initial assessment and management of children with acute respiratory infections, and identification of children whose condition is sufficiently serious to warrant referral to hospital. The aim is to improve the outcome of children with acute respiratory infections, particularly young infants who are at the highest risk of complications and death from pneumonia.The approach to case management is summarized in two fold-out charts. One deals with the “Management of the Child with Cough or Difficult Breathing,” and the other with the “Management of the Child with an Ear Problem or Sore Throat.” These charts are reasonably sized and suitable for posting on an office wall and/or carrying around in a folder. They serve as quick and practical references to the management of children presenting with acute respiratory problems.Each chapter ends with a list of the essential skills and knowledge required by health workers for the management of acute respiratory infections. The book uses simple and clear terminology that makes it easy to read. The instructions are easy to follow. Technical words are defined at the end of the book.The first chapter includes a description of how to select the appropriate case management chart for assessment, classification and treatment of acute respiratory infections. Chapters 2, 3 and 4 focus on the assessment of a child presenting with cough or breathing difficulty. They provide instructions on how to obtain the necessary information about the child's illness by asking the appropriate questions, and looking for physical signs and symptoms that would identify those with severe disease that require referral to a hospital for treatment. These chapters contain many well-designed illustrative diagrams and case examples that reinforce their educational objective. Chapter 5 describes treatment guidelines for children who do not require hospitalization. These include detailed instructions on the dosages and administration of a select number of antibiotics, home care instructions to prevent dehydration and malnutrition, monitoring of fever and use of antipyretics and bronchodilators whenever indicated. While many of the acute lower respiratory tract infections may be due to a viral etiology and thus may not require antibiotics, the lack of viral diagnostic testing and close follow-up, and the possibility of superimposed bacterial infections may justify the empirical use of antibiotics in many of these patients. Such practices, on the other hand, may contribute to the global problem of increasing bacterial resistance.Chapter 6 deals with the assessment, classification and management of a child presenting with an ear problem. The instructions for the management of chronic ear infection are particularly well designed.Chapter 7 describes the management of a child with sore throat. The criteria for use of antibiotics in these health facilities where cultures are not available are pertinent.The annexes complement the material described in the main chapters. Of particular usefulness are the recommendations for use of rapid-acting bronchodilators. The failure to mention erythromycin for treatment of pertussis (Annex 2) is a shortcoming.This book will be useful for its stated purpose, i.e., health workers in primary health care centers in underdeveloped and developing countries with limited health facilities. While the recommendation for widespread use of antibiotics in young children with pneumonia is largely understandable, this practice will undoubtedly contribute to the ever-increasing problem of bacterial resistance. The choice of antibiotics, particularly for treatment of lower respiratory infections, is influenced by cost considerations. The applicability of the antibiotic treatment guidelines to other health care settings is limited. Previous article Next article FiguresReferencesRelatedDetailsCited byKhoja D (2019) The Management of Acute Respiratory Infections: Saudi National Protocol for Diagnosis and Treatment, Annals of Saudi Medicine , 18:1, (86-86), Online publication date: 1-Jan-1998. Volume 17, Issue 2March 1997 Metrics History Published online24 April 2019 InformationCopyright © 1997, Annals of Saudi MedicinePDF download

Recognition and management of ARI--a KAP study on private medical practitioners.

We interviewed 113 private medical practitioners (PMPs) of all system of medicine in Ambedkar Nagar area of South Delhi to determine as to how they recognise and treat Acute Respiratory tract Infections (ARI) in children, in particular, pneumonia. Allopathic PMPs reported viruses and bacteria as causes of ARI as compared to PMPs of other system of medicine who often reported exposure to cold, change in weather and dietary habits as a cause of ARI. Sixty-eight PMPs out of 113 did not count the respiratory rate (RR) in children with ARI and among those who counted, only 19.5% PMPs could correctly tell the normal RR in children aged less than two months. In children aged 2-12 months, the percentage of PMPs responding correctly was 15.0%. Relatively greater proportion of PMPs (31.8%) could correctly tell the normal respiratory rate in children aged 1-5 years. X-ray to diagnose pneumonia was suggested by 102 (90.3%) PMPs. Majority of PMPs prescribed some form of medication including antibiotics for the treatment of cough and cold. Eighty-seven (77%) PMPs prescribed antibiotics, 53 (46.9%) antihistaminics and 49 (43.4%) prescribed allopathic cough syrups to treat cough and cold. For pneumonia, 108 (96.4%) PMPs prescribed antibiotics and 31 (27.7%) PMPs prescribed steroids among other things.