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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