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 More of these, better the predictability No single sign is definitive Age less than 3 years more chance of viral

Suggest Viral Pharyngotonsillitis

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 -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) Penicillin V (Oral) (10d) Amoxycillin (Oral) (10d) Children (< 30kg) 250 mg BID 40mg/kg/day (Max 250 mg tid) Children ( > 30kg) 500 mg BID 250 mg TID 1.2 Million Units.

Benzathine penicillin G (IM) (single 6 lakh Units dose)

In children with Penicillin allergy (Non type 1) Antibiotic ( route ) ( days) Erythromycin ethylsuccinate (oral) (10ds) Azithromycin (oral ) ( 5days) Children ( < 27 kg) 40-50 mg/kg/day TID 12 mg/kg OD

I generation Cephalosporin (oral) (10ds)

Cephalexin/Cephadroxyl 25 to 30 mg/kg / 2nd gen cephalosporins* in usual doses.

10-20 mg / kg.
*early second generation

IInd Line: Clindamycin (oral) (10days)

HERPANGINA

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

Choice - first line Amoxycillin / Co-amoxyclav Second line Second generation cephalosporins e.g. Cefaclor, cefuroxime.

Antibiotics in divided doses for 10 days

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

Pallor, Purpura, Oliguria

Hosptalise

Watery Diarrhea without blood in stool

Diarrhea with macroscopic blood in stool in stool

Diarrhea with Systemic infection

Assess dehydration

Severe dehydration

Mild to moderate dehydration

IV fluids ORS(10) Zinc (11) Continued frequent feeding including BF

ORS (10) Zinc (11) Continued frequent feeding including BF

No antibiotics

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 2 4 2 2 2 2 Duration in days 5 5 5 5 5 5

Child with Acute Diarrhea

Pallor, Purpura, Oliguria

Hospitalise

Watery Diarrhea without blood in stool

Diarrhea with macroscopic blood in stool in stool Rule out risk factors & noninfectious conditions
Treat with 3 Gen Oral Cephalosporins ORS to treat & prevent dehydration Zinc continued frequent feeding including BF
rd

Diarrhea with Systemic infection

Antibiotics for infection ORS Zinc Continued frequent feeding including BF

Better in 2 days?*

No 2nd line drugs: ciprofloxacin /ceftriaxone

Yes

Complete 3 days treatment

Response in 2 days ? **

No

Yes

Look for trophoziotes of E. histolytica in stools

Complete 5 days treatment

Absent

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 Second line
Pharyngotonsillitis Penicillin/1st gen ceph 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