Acute pharyngitis (AP) is a common reason for private primary care consultations, thus providing an avenue for widespread antibiotic intake among the community. However, there is limited data on the antibiotic prescription appropriateness and resistance information in the Malaysian private primary care setting, therefore, this study aimed to investigate the prevalence of isolated viruses and bacteria, antibiotic resistance patterns, antibiotic prescription patterns and appropriateness by general practitioners (GPs) and factors affecting antibiotic resistance and antibiotic prescription patterns. To investigate, a cross-sectional study was conducted among 205 patients presenting with AP symptoms at private primary care clinics in central Malaysia from 3rd January 2016 to 30th November 2016. Throat swabs were collected from 205 AP patients for two purposes: (i) the detection of four common respiratory viruses associated with AP via reverse-transcription real-time PCR (qRT-PCR); and (ii) bacterial identification using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF MS). Bacterial isolates were then subjected to antibiotic susceptibility screening and McIsaac scoring was calculated post-prescription based on GP selection of criteria. Generalized estimating equations analysis with multiple logistic regression was conducted to identify factors associated with presence of virus and antibiotic prescription. The results showed that 95.1% (195/205) of patients had at least one of the four viruses, with rhinovirus (88.5%) being the most prevalent, followed by adenovirus (74.9%), influenza A virus (4.6%) and enterovirus (2.1%). A total of 862 non-repetitive colonies were isolated from the culture of throat swabs from 205 patients who were positive for bacteria. From a total of 22 genera, Streptococcus constitutes the most prevalent bacteria genus (40.9%), followed by Neisseria (20%), Rothia (13.0%), Staphylococcus (11%) and Klebsiella (4.9%). Only 5 patients carried group A beta-hemolytic streptococci (GABHS). We also report the presence of vancomycin-resistant S. aureus or VRSA (n = 9, 10.1%) among which one isolate is a multidrug-resistant methicillin-resistant S. aureus (MDR-MRSA), while 54.1% (n = 111) were found to carry at least one antibiotic-resistant bacteria species. Application of the McIsaac scoring system indicated that 87.8% (n = 180) of patients should not be prescribed antibiotics as the majority of AP patients in this study had viral pharyngitis. The antibiotic prescription appropriateness by applying post-prescription McIsaac scoring was able to rule out GABHS pharyngitis in this sample with a GABHS culture-positive sensitivity of 40% (n = 2/5) and specificity of 90% (180/200). In conclusion, antibiotic-resistant throat isolates and over-prescription of antibiotics were observed and McIsaac scoring system is effective in guiding GPs to determine occurrences of viral pharyngitis to reduce unnecessary antibiotic prescription.

Worldwide, the ESKAPE group of pathogens - Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter species - are emerging as important pathogens which have acquired resistance towards different classes of antibiotics. Malaysia has also reported high levels of antibiotic resistance among these pathogens, based on prevalence data from hospital patients. However, the prevalence and antibiotic resistance rates of ESKAPE group members in the community are largely unknown. Therefore, this study focuses on acute pharyngitis (AP) patients from private primary care clinics in the Klang Valley, central Malaysia, as AP is the most common infection-associated reason for contact with private primary healthcare providers. Out of 205 patients, 119 were found to harbor ESKAPE group bacteria, where a total of 175 isolates were subjected to antibiotic susceptibility testing. Our results show that the most prevalent ESKAPE group member in this cohort is S. aureus, with one isolate found to be multidrug-resistant towards penicillin V, cefoxitin, erythromycin and azithromycin. We also report the first finding of community acquired resistance to cefotaxime in K. pneumoniae, imipenem in Enterobacter spp. and tetracycline, also in Enterobacter spp., in Malaysia, which were not derived from samples from a hospital setting. In conclusion, this study, which describes antibiotic resistance of community acquired ESKAPE pathogens in the Malaysian private primary healthcare setting highlights the need for a comprehensive centralized reporting system for community acquired antibiotic resistance to complement the Malaysian National Surveillance of Antibiotic Resistance.