30131

Report
Prescribing Antibiotics in
Pediatric Office Practice
Dr. Raju C. Shah
M.D., D.Ped., F.I.A.P.
National President, IAP(2005)
President, Pediatric Association of SAARC
Ankur Institute of Child Health
B/h. City Gold Cinema, Ashram Road,
Ahmedabad - 9
Antibiotic Prescription
Antibiotic prescription should ideally
comprise of the following phases:




Perception of need - is an antibiotic
necessary?
Choice of antibiotic – which is the most
appropriate antibiotic?
Choice of regimen : What dose, route,
frequency and duration are needed?
Monitoring efficacy : is the antibiotic
effective?
What is our current practice?
Commonest reasons for antimicrobial drug use
among children in office practice are:

Nonspecific upper respiratory tract infections
including Pharyngotonsillitis,

Otitis media,

Diarrhea

Fever without focus
Most of the time these antimicrobials are often
unwarranted
Why do we err?

Erroneous trust in our ability to treat all
infections (equated fever) with antibiotic
prescription



Many fevers are not due to infections
Majority of infections seen in general practice are of
viral origin
Antibiotics often prescribed in the belief that this
will prevent secondary bacterial infections

No evidence except where chemoprophylaxis is
advocated
Errors galore

Using the “best” cover with the latest, potent,
broad spectrum higher generation antibiotic




But it may not be the best and also not the safest too
Injectables are used often than needed
The duration of use is often not regulated
Often upgrade or change the antibiotics for a
patient who continues to have fever despite
antibiotic use

Causes are many like incorrect diagnosis, incorrect dose
and/or route of administration or incorrect choice of drug,
phlebitis, antibiotic itself and not always due to antibiotic
resistance
Bacterial Resistance
• Drug Resistance is a result of
exposure to drug
• It can be Genetic in origin

Prevent Access to Site


Decrease Influx
Increase Efflux

Inactivate Drug

Change Site of Action
Does it matter?
http://www.sciam.com/1998/0398issue/0398levybox2.html
Perhaps it matters more than we
think it does
Horizontal Transmission of
Resistance Genes among Species
•
•
Versatile Genetic Engineers
Equalitarian and Social
http://www.sciam.com/1998/0398issue/0398levybox3.html
Gene Transfer in the Environment. Levy & Miller, 1989
ANTIBIOTIC PARADIGM
Excessive / inappropriate
antibiotic use
Failure of antibiotic treatment
Antibiotic resistance
Choice of Antibiotics
The choice of antibiotics should largely
be determined by:

source or focus of infection

patient's age and immunologic status

whether the infection is viral or bacterial

is it community acquired or nosocomial
In office practice usual infections are
community acquired
Case 1:
Apurva
Apurva, 1 yr 6 months old male,







Brought with history of fever and cough with
rhinorrhoea of two days
red eyes,
diarrhea,
No exanthema,
cough ++
H/o Similar case
in family
O/E Throat congested
How will you manage?
Your thoughts……………
Clinically diagnosed : Viral URI - seasonal
(pharyngotonsillitis)

Management:


General & Symptomatic Therapy
Antibiotics : Not needed
2nd Case: Mehul
41/2 year old Mehul - brought to your clinic with 2
days history of high spiking fever and mild cough
From history and examination:
 Has no red eyes or rhinorrhea
 No exanthema
 Difficulty in swallowing,
 No history of similar case in the family
 He looks sick even when afebrile
Mehul on examination……






RR 28, HR 110
perfusion and B.P normal
Rt tonsil showed a purulent
discharge with inflammation of
both tonsils
Bilateral tender cervical LN++
Ear and Nose – Normal
Other system examination –
normal
How will you manage?......
Apurva and Mehul – what difference?
Apurva
 Acute onset, Red eyes,
rhinorrhea, cough++,
diarrhea
 No rashes
 Pharyngeal congestion but no
or scanty exudates and no
cervical lymphadenopathy
 Age less than 3 years
Most probably viral
Mehul
 Acute onset, throat pain,
rapid progression, very little
cough/cold
 Pharyngeal congestion more,
thick exudates or follicles,
purulent patchy lesions on
tonsils with tender enlarged
LN
 Toxicity ++
 Age more than 3 years
Most probably bacterial
Viral vs Bacterial
Signs with good predictive values







Presence of watery nasal discharge
Absence of pharyngeal erythema
Absence of tonsillar exudate or follicles
Absence of tender lymphadenopathy
Involvement of multiple systems
Generalized maculopapular rashes
H/o similar illness in family or community
Suggest Viral Pharyngotonsillitis



More of these, better the predictability
No single sign is definitive
Age less than 3 years – more chance of viral
Etiology
Viral cause :

Rhino virus (common cold) (60%),

Enterovirus, Influenza virus, Para-influenza virus


Adenovirus
Special : HIV, Cytomegalovirus, Coxsackievirus, Herpes
simplex, Ebstein-barr virus, Bird flu?
Bacterial cause :



Common - Group A ß-hemolytic streptococci (15-30% of age
>3 years, <5% in age <3 yrs )
Rare - C. diptheriae, Hemophilus influenzae, N. meningitides
Special : Gonococcus,, Mycoplasma pneumoniae
In children with no Penicillin allergy
Antibiotic (route) (days)
Children (< 30kg)
Children ( > 30kg)
Penicillin V (Oral) (10d)
250 mg BID
500 mg BID
Amoxycillin (Oral) (10d)
40mg/kg/day
(Max 250 mg tid)
250 mg TID
Benzathine penicillin G (IM) (single 6 lakh Units
dose)
1.2 Million Units.
In children with Penicillin allergy (Non type 1)
Antibiotic ( route ) ( days)
Children ( < 27 kg)
Erythromycin ethylsuccinate (oral) (10ds)
40-50 mg/kg/day TID
Azithromycin (oral ) ( 5days)
12 mg/kg OD
I generation Cephalosporin (oral) (10ds)
Cephalexin/Cephadroxyl 25 to 30
mg/kg / 2nd gen cephalosporins* in
usual doses.
IInd Line: Clindamycin (oral) (10days)
10-20 mg / kg.
*early second generation

HERPANGINA
4
months later, Mehul
is back with fever,
cough and coryza. See
his throat
 Treating pediatrician
considers him to have
viral pharyngitis
Pharyngeal Erythema but not bacterial
DO YOU AGREE?
Some more non-bacterial Pharyngeal
Inflammation
Case 3: Azhar


Azhar, a 15 month otherwise healthy boy
had rhinorrhea, cough and fever of 1020F
for two days
On day 3, he became fussy and woke up
crying multiple times at night
WHAT COULD BE WRONG?
HOW DOES ONE EVALUATE THIS CHILD ?
AZHAR HAS ACUTE OTITIS MEDIA
RIGHT EAR
On examination of Rt ear:
 Erythema
 Fluid
 Impaired mobility
 Acute symptoms
MANAGEMENT ?
Management AOM – Under 2 Yrs

Analgesia


Paracetamol in adequate doses as good as Ibuprofen
Antibiotics in divided doses for 10 days


Choice - first line Amoxycillin / Co-amoxyclav
Second line
 Second generation cephalosporins e.g.
Cefaclor, cefuroxime.


Co amoxyclav – if not used earlier
Decongestants no role
Case 4: Jignesh






10 month old jignesh, brought on 2nd
December, 2006
Illness 2 days
Started with vomiting 6-7/day
Fever
Frequency of stool 12-15/day, watery,
large quantity
On BF + Weaning diet
Jignesh....





Ill look
Depressed AF
Dry skin and mucous membrane
Sunken eyeballs
Rapid, low volume pulse
How will you manage?
Jignesh...

Winter season
Infant
Started with vomiting, mild fever and
then watery stool
Think of Viral (Rota Virus) diarrhea

Ask, Is he bottle fed?



What next?
Child with Acute Diarrhea
Watery Diarrhea
without blood in stool
Diarrhea with
macroscopic blood in stool
in stool
Assess
dehydration
Severe
dehydration
IV fluids
ORS(10)
Zinc (11)
Continued
frequent
feeding including BF
Pallor, Purpura,
Oliguria
Mild to
moderate
dehydration
ORS (10)
Zinc (11)
Continued
frequent
feeding including BF
No antibiotics
Diarrhea with
Systemic infection
Hosptalise
Dysentery






Only when frequency of stool with macroscopic
blood and pus
Common pathogens are shigella,
enteroinvasive E.coli, salmonella,
campylobacter jejuni, yersenia enterocolitis etc
Shigella is the most common in age < 5 years
Never a mixed etiology (amoebiasis)
Peak in summer
More severe in malnourished and non breast
fed infants
Antimicrobial agents in acute dysentery
Drug
Co-trimoxazole (TMP + SM)
(Resistance very high)
Nalidaxic Acid
Norfloxacin
Ciprofloxacin
Cefixime
Ceftriaxone
Mg/kg/day
TMP 5
SM 25
55
20
10-15
8
80-100
Divided doses
Duration in
days
2
5
4
2
2
2
2
5
5
5
5
5
Pallor, Purpura,
Oliguria
Child with Acute Diarrhea
Watery Diarrhea
without blood in stool
Diarrhea with
macroscopic blood in stool
in stool
Hospitalise
Diarrhea with
Systemic infection
Rule out risk factors &
noninfectious conditions
Antibiotics for
infection
ORS
Zinc
Continued
frequent feeding
including BF
rd
Treat with 3 Gen
Oral Cephalosporins
ORS to treat &
prevent dehydration
Zinc
continued frequent
feeding including BF
Better in 2 days?*
No
Yes
nd
2
line drugs:
ciprofloxacin
/ceftriaxone
Complete
3 days
treatment
Response in 2 days ? **
No
Yes
Look for
trophoziotes of
E. histolytica in
stools
Absent
Complete
5 days
treatment
Present
Treat with
Metronidazole
** Disappearance of fever,
less blood in stools - fewer
in no, improved appetite,
decreased abdominal
pain, return to normal
activity indicate good
response.
Salmonella Typhi:
Suspect only when fever of more than 4 days,
without focus and primary reports suggestive
•MDR Strains still rampant
•Sensitivity to - 3rd gen cephalosporin – 98%
- Quinolones* – 90-95%
Always send Blood culture before starting antibiotics
*Recently some centers from apex institutes less sensitivity
Golden rules for Judicious use of
antimicrobials
Golden rule 1
Acute infection always presents with fever;
in acute illness, absence of fever does not justify antibiotic
Golden rule 2
Infection is the most common cause of fever in office
practice, though not always bacterial infection
- Viral infection in majority RTI
- Viral infection should not be treated with antibiotic
Golden rule 3
Clinical differentiation is possible between
bacterial and viral infection most of the times
• Viral infection is disseminated throughout the system
(URTI / LRTI)
- May affect multiple systems
- Fever is usually high at onset, settles by D3-4
- Child is comfortable and not sick during inter febrile state
• Bacterial infection is localized to one part of the system
(acute tonsillitis does not present with running nose or
chest signs)
- Fever is generally moderate at the onset and peaks by D3-4
• CBC does not differentiate between acute bacterial and
viral infection
Golden rule 4
Chronic infection may not be associated with
fever and diagnosis can be difficult
- Relevant laboratory tests are necessary
- Antibiotic is considered only after observing progress
- There is no need to hurry through antibiotic
prescription
Golden rule 5
Choose single oral antibiotic, either covering
suspected gram positive or negative organism,
as per site of infection and age of patient
• Combination of two antibiotics is justified
only in serious bacterial infection without proof
of specific organism and can be
administered intravenously
Golden rule 6
At first visit (within 48 hrs of fever) antibiotic is justified only
if bacterial infection is clinically certain
and that does not call for any tests prior to starting the drug
(Acute tonsillitis / acute otitis media / bacillary dysentery
/ acute suppurative lymphadenitis)
• If bacterial infection is clinically strongly suspected but
should have confirmative tests prior to starting drug,
then order relevant tests and start appropriate antibiotic
(Acute UTI)
• In absence of clinical clue but not suspected to be serious
disease, observe without antibiotic and follow the progress
Recommendations for Antibiotic selection
Conditions
First line drugs
Pharyngotonsillitis Penicillin/1st gen ceph
Second line
Amoxycillin
/Macrolides
Otitis/Sinusitis
Amoxycillin
Co-amoxyclav/
2nd gen ceph /Macrolides
Pneumonia (CA) High dose Amoxy/
2nd/3rd gen Inj ceph
Co-amoxyclav/Clox
/Vanco
Enteric fever
3rd gen oral ceph
3rd gen inj ceph/
Fluoroquinolones
Dysentery
Norflox
2nd gen quinolones
/3rd gen oral ceph
/Ceftriaxone
UTI
Sulpha/Trimetho / Co-amoy Fluoroquinolones
/3rd gen oral ceph
/Aminoglycosides
Key Messages:
• Resistance in community acquired infections very low
- more perceived than real
• Irrational & Overuse of antibiotics – great concern
• Start antibiotic only if indicated
• Always use first line drugs
• Use Microbiology Lab more often
• Develop culture of culture
• Spend more time with parents
• Select proper empirical antibiotics
• Do not use antibiotics in nonbacterial conditions
Thank You

similar documents