JOURNAL OF DENTAL SCIENCES

Volume 2 Issue 1

PRESCRIBING ANTIBIOTICS AND ANALGESICS IN CHILDREN

Dr. Jyoti Mathur Dr. Amish Diwanji
Abstract For the purpose of having a standardized prescription practice, it is very necessary for the operators involved in dispensing treatment in a large set up, to have a quick reference system which would minimize chances of errors due to variation. We at the Department of Pedodontics, Faculty of Dental Science, Dharmsinh Desai University, have developed a quick reference chart for the ease of prescription. It contains both adult and pediatric doses of frequently prescribed antibiotics and analgesics. A separate section for contraindications and special precautions to the drugs has also been added to avoid complications. Key words- prescription, antibiotics, analgesics, orodental infections, children Introduction Sir William Osler once said, ``the desire to take medicine is perhaps the greatest feature which distinguishes man from animals.1 There exist clear cut indications for prophylactic antibiotic usage given by renowned medical bodies such as American Heart Association for endocarditis prophylaxis. Still, antibiotics are the most widely abused prescribed drugs on the basis of inappropriate indications, dosages and duration of use. Approximately half of all antibiotics used in hospitals are given to patients without signs or symptoms.2 The problem is compounded while prescribing for children. Most of the time 'random' age related prescriptions are given based on dosages for adults. The use of inappropriate antimicrobial drugs may result in ineffective therapy or contribute to the development of undesirable antibiotic resistance in the causative pathogens in the community. Without specific knowledge about correct pediatric dosage based on body weight / surface area and other factors such as gestational and postnatal age in neonates, a clinician is liable to prescribe the drugs in inappropriate suboptimal or excess dose with undesirable consequences.3 Therefore, we at the department of Pedodontics, Faculty of Dental Sciences, Dharmsinh Desai University, Nadiad have developed a quick reference chart for antibiotics and analgesics displayed on the notice board for the purpose of standardization in prescription practice by students, interns and teaching staff. The following chart is based on body weight of the child, special notes about various drugs interactions and considerations regarding preexisting hepatic and liver disorders are given subsequently in this paper.

Commonly Prescribed Drugs and Dosages (for orodental infections)1,3,4,5,7

Note: - Total pediatric dose should never exceed adult dose. Neonatal doses not included Sr. No. 1 2 Drugs Amoxicillin Amoxicillin + Clavulanic acid (coamoxi clav) Ciprofloxacin Cefixime Cefadroxil Erythromycin Azithromycin Professor & Head Lecturer Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, NADIAD-387001. GUJARAT Adult Dose 250-500mg 3Times/day 250-500mg amoxicillin +125-250mg clavulanic acid 3 times a day 250-500mg every 12 hrs 200mg 2 times a day for 7 -10 days 0.5-1g OD or Bid 250-500mg (stearate or estolate salts) or 400mg ethylsuccinate salt every 6 hrs 500mg OD Pediatric Dose 20-40mg/Kg/day in 3 doses 20-40mg/Kg/day of amoxicillin in 3 doses 25mg/Kg/day divided in 2 doses (12 hrs each). To be avoided in children below 18 yrs 8mg/Kg/day in 2 divided doses 30mg/Kg/ day in 2 doses 30 to 50 mg /Kg/ day in divided doses every 6hrs 10mg/Kg/day in a single dose Address for Correspondence : Dr. Jyoti Mathur Department of Pedodontics and Preventive Dentistry, Faculty of Dental Science, Dharmsinh Desai University, NADIAD-387001. GUJARAT E-mail : drjyotimathur74@gmail.com Ph. : 079 - 2658 9498 36

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8 9 10 11 12 13 14 15 16 17 18 Clarithromycin Doxycycline Tetracycline Ofloxacin Metronidazole Ornidazole Paracetamol Nimesulide Diclofenac sodium Ibuprofen Mefenamic acid 250-500mg every 12 hrs 200mg on day 1 (100mg every 12 hrs) then 100mg daily 250-500 mg every 6 hrs 200-400 BID 250-750mg every 8 hrs, not to exceed 4g in 24 hrs 500mg twice daily for 5 days 0.5-1 gm every 4-6 hrs Maximum dose 4g/day 100mg/dose every 12 hrs 75-150 mg/day in 2-4 divided doses, max. dose - 150mg/day 400-600mg/dose every 6-8 hrs maximum dose 2400mg/day 500 mg TID

Volume 2 Issue 1 7.5mg/Kg twice daily (upto 500mg twice daily) (age 8 yrs or older) : 4.4 mg/Kg in 2 divided doses on day 1 than 2.2 mg/Kg/day (age 8yrs or older)25-50 mg/kg/day divided into 6hrly doses 10-15 mg/kg/day divided in 2 doses (every 12 hrs), max. dose 800 mg per day 30-50 mg/Kg/day in 3 divided doses for 5-10 day 10mg/ Kg every 12 hrs 10-15mg/Kg/ doses every 4-6 hrs maximum 5 doses in 1 day 5mg/Kg/day divided every 8-12 hrs 2-3mg/Kg/day in 2-4 divided doses 5-10mg/Kg/dose every 6-8hrs max. dose 40 mg/kg daily Analgesic dose10-25/mg/Kg/day (divided into 6 hrly doses) Antipyretic dose3mg/Kg/dose every 6hrs Precaution avoid in children with seizures

Antifungals 1. Nystatin Use Oral candidiasis Neonate: 100,000 units to each side of mouth X QID Infant : 200,000 units to each side of the mouth X QID Children and Adults: 400,000-600,000 units to each side of the mouth X QID 1 Nystatin tablet (500,000) units dissolved in 5 ml glycerin provides 100,000 units/ml 2. Fluconazole Neonate >14 days, infants and children a. Oropharangeal or oesophageal candidiasis Day 1: 6mg/kg (max200mg) PO/IV (OD) Then 3mg /kg/day (max100mg) PO/IV (OD) X 14-21 days Other Topical Antifungal Hamycin: Better water solubility than nystatin For Oral thrush: 2 lac units /ml suspension to be applied to the affected area with sterile cotton 2-3 times daily for 7-10 days. Available as 10 ml suspension which gives 200,000 units /ml. Contraindications for all antifungals- hypersensitivity, pregnancy, lactations

Antibiotic dosing Virtually all resistance occurs by transposable element gene transfer promoted by the use of antibiotics, particularly at low doses and for long duration.8,9,10 Antibiotics should be used aggressively and for as short a time as is compatible with patient's remission of the disease.10,11 Many clinicians follow the pattern of continuing antibiotics for a minimum of 48 hours after disappearance of symptoms. That would mean reevaluating the patient 1-2 days after initiation of antibiotics.11 The dosage and duration of the therapy depend upon the nature of the infection and the severity of the infection. A simple urinary tract infection in an adult female may only require 3 days of oral therapy, but deep seated infections like osteomyelitis or endocarditis will require prolonged parenteral therapy for six weeks or more.13 Contraindications and special precautions: In patients with blood disorders, active CNS diseases, hypersensitivity, sever hepatic failure, pregnancy, lactation, neonates, active peptic ulcers, asthma etc, it is advisable to seek opinion from the concerned physician before prescribing these drugs. Interesting fact Fluorides, Ibuprofen, Iron Salts, Iodine drugs, tetracycline ingestion may discolor stools black Greenish grey or white/speckling is seen with many oral antibiotics.

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Important Interactions between Antibiotics and other drugs5,6,11, Ciprofloxacin (and most other quinolones) Interacting drug Antacids, iron, sucralfate theophyline, cyclosporin, warfarin Effect

Volume 2 Issue 1

Decrease absoption of quinolones (ciprofloxacin)

Clindamycin Erythromycin Metronidazole Tetracyclines

Increase effect of theophyline, cyclosporine, warfarin NSAID Increase risk of CNS stimulation seizures erythromycin Mutual antagonism carbamazepine Inceases serum levels of carbamazepine causes nystagmus, ataxia, vomitting, (avoid this combination) Anticoagulants increases anticoagulant effect Phenobarbitones, hydantoins Decreases effect of metronidazol antacids, iron, Decreases tetracycline effect sucralfate,digoxin Increases toxicity of digoxin (may persist for several months in 10% patients)

For Patients with Liver Disorders 6 In the presence of hepatic diseases, dosage adjustment may be indicated for several drugs which are metabolised in the liver (1) Antimicrobials clindamycin, metronidazole, doxycycline etc. (2) Other drugs Lidocaine -Prednisone is less effective in hepatic disease as it needs hepatic metabolism for activation Drugs in Renal Failure 6 In broad terms potentially nephrotoxic drugs need careful modification in dosing pattern in patients with renal insufficiency so as to prevent toxicity while maintaining their adequate therapeutic levels. This is done based on the patients GFR (glomerular filtration rate) in ml/min. The correct dosage is achieved by either (i) Extension of interval between dosages or (ii) Reduction of dosage keeping the interval between doses normal, (iii) In some case both reduced dosage along with extension in interval is required. For further details, reference of the topic from the concerned text book is must as most of the commonly prescribed antimicrobials like Cephalosporins, Penicillins, Metronidazole along with NSAIDs like acetaminophen require specific dose and interval adjustment for renal failure patients. Maternal drugs to be avoided or used with great caution during breastfeeding 6 Possible effect on infant Aspirin: Avoid high dose as there is risk of bleeding, Reye's syndrome Estrogens: Gynaecomastia in male infants Metronidazole : Suspend breast feeding for 12hrs after single dose as it is secreted in large amounts in breast milk.

Phenobarbitone(&OtherSedatives) Sedation Tetracycline: Teeth pigmentation, enamel hypoplasia, cataract, skeletal growth retardation Streptomycin: deafness Alcohol Congenital cardiac, CNS, limb anomalies, Developmental delay, attention Deficit, autism Vitamin D analogues (alfacalcidol, calcitriol): Aortic stenosis (supraclavicular), hypercalcemia (avoid high doses) Conclusion: For the conclusion, it would be prudent to refresh the topic of 'selection of appropriate antibiotic therapy' .The selection of antibiotic therapy for an infection requires a knowledge of 1) the infecting organism including the pathogen most likely to be present in given clinical or geographical circumstances, 2) the local patterns of antimicrobial resistance in common pathogens, 3) an understanding of pharmacokinetics of the antimicrobials selected. 4) The physiology of the patients, metabolic upsets, renal or hepatic dysfunction, age and available routes of administration.13 References: 1. Yagiella, Dowd and Neidle. Pharmacology & Therapeutics for Dentistry, 5th edition, Delhi, Elsevier, 2004, pg xvi, introduction. 2. Yagiella, Dowd and Neidle. Pharmacology & Therapeutics for Dentistry, 5th edition, Delhi, Elsevier, 2004, pg 596. 3. R.K Suneja. Handbook of Pediatric Drug Therapy and Immunization, 2nd edition, Delhi, Elsevier 2004, pg: Preface to the first edition. 4. Advanced Drug Review, issue-4,Aug-Nov 2006, Lucknow, The Arora Medical Book publishers Pvt. Ltd. 5. Lange, Basic& Clinical Pharmacology, Editor -Bertram G Katzung, 9th edition (international edition) Singapore, McGraw Hill, 2004, pg 1121.

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R.K Suneja. Handbook of Pediatric Drug Therapy and Immunization, 2nd edition, Delhi, Elsevier 2004, pg: Preface to the first edition. Pg 247-299. 7. IDR(Indian drug review) triple i ,vol XIII' no.6, Nov 07Jan 08, Bangalore,CMP Medica India Pvt Ltd 8. Levy SB: The antibiotics paradox, New York 1992, Plenum press. 9. Pallasch TJ: Global antibiotics resistance and its impact on the dental community, J calif Dent. Assoc 28:215233, 2000 10. Pallasch TJ: How to use antibiotics effectively,J calif Dent. Assoc 21:46-50, 1993. 6.

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11. Yagiella, Dowd and Neidle. Pharmacology & Therapeutics for Dentistry, 5th edition, Delhi, Elsevier, 2004, pg 609. 12. Yagiella, Dowd and Neidle. Pharmacology & Therapeutics for Dentistry, 5th edition, Delhi, Elsevier, 2004, pg 620-657, pg 663.. 13. Davidson's principles &practice of medicine, international editor-John A.A. Hunter, 20th edition, Philadelphia USA,Elsevier,2006,pg 145

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