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TRANSCRIPT
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Dr. Raju C. ShahM.D., D.Ped., F.I.A.P.
National President, IAP(2005)President, Pediatric Association of SAARC
Ankur Institute of Child HealthB/h. City Gold Cinema, Ashram Road,
Ahmedabad - 9
Prescribing Antibiotics inPediatric Office Practice
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Antibiotic Prescription
Antibiotic prescription should ideallycomprise of the following phases:
Perception of need - is an antibioticnecessary?
Choice of antibiotic which is the most
appropriate antibiotic?
Choice of regimen : What dose, route,frequency and duration are needed?
Monitoring efficacy : is the antibioticeffective?
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What is our current practice?
Commonest reasons for antimicrobial drug useamong 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 oftenunwarranted
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Why do we err?
Erroneous trust in our ability to treat allinfections (equated fever) with antibioticprescription
Many fevers are not due to infections
Majority of infections seen in general practice are ofviral origin
Antibiotics often prescribed in the belief that thiswill prevent secondary bacterial infections
No evidence except where chemoprophylaxis is
advocated
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Errors galore
Using the bestcover 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 despiteantibiotic 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 antibioticresistance
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Bacterial Resistance
Drug Resistance is a result ofexposure 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
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Perhaps it matters more than we
think it does
Versatile Genetic Engineers
Equalitarian and Social
Horizontal Transmission ofResistance Genes among Species
http://www.sciam.com/1998/0398issue/0398levybox3.htmlGene Transfer in the Environment. Levy & Miller, 1989
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ANTIBIOTIC PARADIGM
Excessive / inappropriateantibiotic use
Failure of antibiotic treatment Antibiotic resistance
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The choice of antibiotics should largelybe 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
Choice of Antibiotics
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Case 1:
Apurva
Apurva, 1 yr 6 months old male,
Brought with history of fever and cough withrhinorrhoea of two days
red eyes,
diarrhea,
No exanthema, cough ++
H/o Similar casein family
O/E Throat congested
How will you manage?
Your thoughts
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Clinically diagnosed :Viral URI - seasonal(pharyngotonsillitis)
Management:
General & Symptomatic Therapy Antibiotics : Not needed
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41/2 year old Mehul - brought to your clinic with 2days history of high spiking fever and mild cough
From history and examination:
Has no red eyes or rhinorrheaNo exanthema
Difficulty in swallowing,
No history of similar case in the family
He looks sick even when afebrile
2ndCase: Mehul
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Mehul on examination
RR 28, HR 110 perfusion and B.P normal
Rt tonsil showed a purulentdischarge with inflammation ofboth tonsils
Bilateral tender cervical LN++ Ear and Nose Normal
Other system examination
normal
How will you manage?......
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Apurva and Mehul what difference?
Apurva
Acute onset, Red eyes,rhinorrhea, cough++,diarrhea
No rashes
Pharyngeal congestion but noor scanty exudates and nocervical lymphadenopathy
Age less than 3 years
Most probably viral
Mehul
Acute onset, throat pain,rapid progression, very littlecough/cold
Pharyngeal congestion more
thick exudates or follicles,purulent patchy lesions ontonsils with tender enlargedLN
Toxicity ++
Age more than 3 yearsMost probably bacterial
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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
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Etiology
Viral cause : Rhino virus (common cold) (60%),
Enterovirus, Influenza virus, Para-influenza virus Adenovirus
Special : HIV, Cytomegalovirus, Coxsackievirus, Herpessimplex,Ebstein-barr virus, Bird flu?
Bacterial cause : Common - Group A -hemolytic streptococci(15-30% of ag
>3 years,
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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
dose)6 lakh Units 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 3
mg/kg / 2nd gen cephalosporins* i
usual doses.
IInd Line: Clindamycin (oral) (10days) 10-20 mg / kg.
*early second generation
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4 months later, Mehulis back with fever,cough and coryza. Seehis throat
Treating pediatricianconsiders him to haveviral pharyngitis
DO YOU AGREE?
HERPANGINA
Pharyngeal Erythema but not bacterial
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Some more non-bacterial Pharyngeal
Inflammation
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Case 3: Azhar
Azhar, a 15 month otherwise healthy boyhad rhinorrhea, cough and fever of 1020Ffor two days
On day 3, he became fussy and woke upcrying multiple times at night
WHAT COULD BE WRONG?HOW DOES ONE EVALUATE THIS CHILD ?
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AZHAR HAS ACUTE OTITIS MEDIA
RIGHT EAR
On examination of Rt ear:
Erythema
Fluid
Impaired mobility Acute symptoms
MANAGEMENT ?
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Management AOM Under 2 Yrs
Analgesia
Paracetamol in adequate doses as good as Ibuprofen
Antibiotics in divided doses for 10 days
Choice - first lineAmoxycillin / Co-amoxyclav
Second line Second generation cephalosporins e.g.
Cefaclor, cefuroxime.
Co amoxyclav if not used earlier
Decongestants no role
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10 month old jignesh, brought on 2ndDecember, 2006
Illness 2 days Started with vomiting 6-7/day
Fever Frequency of stool 12-15/day, watery,
large quantity On BF + Weaning diet
Case 4: Jignesh
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Ill look
Depressed AF
Dry skin and mucous membrane
Sunken eyeballs
Rapid, low volume pulse
How will you manage?
Jignesh....
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Winter season
Infant
Started with vomiting, mild fever andthen watery stool
Think of Viral (Rota Virus) diarrhea
Ask, Is he bottle fed?
What next?
Jignesh...
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Child with Acute Diarrhea
Watery Diarrheawithout blood in stool Diarrhea withmacroscopic blood in stool Diarrhea withSystemic infection
Assess
dehydration
Severedehydration
Mild tomoderate
dehydration
IV fluids
ORS(10)
Zinc (11)
Continuedfrequent
feeding -
including BF
ORS (10)
Zinc (11)
Continued
frequentfeeding -
including BF
Pallor, Purpura,
Oliguria Hosptalise
No antibiotics
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Only when frequency of stool with macroscopicblood 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
Dysentery
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Antimicrobial agents in acute dysentery
Drug Mg/kg/day Divided doses
Duration in
daysCo-trimoxazole (TMP + SM)
(Resistance very high)TMP 5SM 25
2 5
Nalidaxic Acid 55 4 5
Norfloxacin 20 2 5
Ciprofloxacin 10-15 2 5
Cefixime 8 2 5Ceftriaxone 80-100 2 5
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Child with Acute Diarrhea
Watery Diarrhea
without blood in stool
Diarrhea with
macroscopic blood in stool
Diarrhea with
Systemic infection
Rule out risk factors &
noninfectious conditions
Treat with 3r
GenOral CephalosporinsORS to treat &prevent dehydrationZinccontinued frequentfeeding including BF
Better in 2 days?*
No Yes
2n
line drugs:ciprofloxacin
/ceftriaxone
Complete3 days
treatment
Res onse in 2 da s ? **
No Yes
Look fortrophoziotes of
E. histolyticainstools
Complete5 days
treatment
Absent Present
Treat withMetronidazole
Antibiotics forinfection
ORS
Zinc
Continued
frequent feeding
including BF
Pallor, Purpura,
Oliguria
** Disappearance of fever,
less blood in stools - fewer
in no, improved appetite,
decreased abdominal
pain, return to normal
activity indicate good
response.
Hospitalise
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Salmonella Typhi:
Suspect only when fever of more than 4 days,without focus and primary reports suggestive
MDR Strains still rampant
Sensitivity to - 3rdgen 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
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Golden rules for Judicious use of
antimicrobials
Golden rule 1Acute infection always presents with fever;
in acute illness, absence of fever does not justify antibioti
Golden rule 2Infection 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
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Golden rule 3
Clinical differentiation is possible betweenbacterial 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 orchest signs)
- Fever is generally moderate at the onset and peaks by D3-4
CBC does not differentiate between acute bacterial and
viral infection
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Golden rule 4Chronic 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
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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
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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 butshould 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
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Recommendations for Antibiotic selection
Conditions First line drugs Second linePharyngotonsillitisPenicillin/1stgen ceph Amoxycillin
/Macrolides
Otitis/Sinusitis Amoxycillin Co-amoxyclav/
2nd gen ceph /Macrolides
Pneumonia (CA) High dose Amoxy/ 2nd/3rdgen Inj cephCo-amoxyclav/Clox /Vanco
Enteric fever 3rd gen oral ceph 3rdgen inj ceph/
Fluoroquinolones
Dysentery Norflox 2ndgen quinolones
/3rdgen oral ceph /CeftriaxoneUTI Sulpha/Trimetho / Co-amoy Fluoroquinolones
/3rdgen oral ceph /Aminoglycosides
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Key Messages:
Resistance in community acquired infections very - more perceived than real
Irrational & Overuse of antibiotics great concern
Start antibiotic only if indicated
Always use first line drugsUse Microbiology Lab more often
Develop culture of culture
Spend more time with parents
Select proper empirical antibiotics
Do not use antibiotics in nonbacterial conditions
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hank You