Rational antibiotic use in paediatrics

2. “When I woke up just after dawn on
September 28, 1928, I certainly didn’t plan to
revolutionize all medicine by discovering the
world’s first antibiotic, or bacteria killer. But
I suppose that was exactly what I did.”
DR GRK DSMCH 2

3. Provider and patient factors contributing to overuse of antibiotics
Contributing factor Providers Patients and public
Lack of education Suboptimal approach to diagnosis
and treatment; lack of knowledge
of the
natural course of viral disease
Insufficient knowledge of
viral v bacterial infection
Experience Diagnostic and prescribing habits
from the pre-antibiotic resistance
era
Prior antibiotic treatment
for viral infections
Expectations Belief that patients expect
antibiotics; belief that satisfaction
is related to
prescription
Belief that some conditions
require antibiotic
treatment—for example,
purulent rhinitis
Economics Time pressures; incentives linked
to satisfaction surveys; profiling
on return visits
Need to return to work or
return child to day care
DR GRK DSMCH 3

4. 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
DR GRK DSMCH 4

5. 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
DR GRK DSMCH 5

6. • The most common reasons for antibiotic
prescriptions in all ages are respiratory tract
infections (RTIs).
• The most common patients to receive antibiotics
are infants and young children, and among
these, the commonest diagnosis for which
antibiotics are prescribed is otitis media.
DR GRK DSMCH 6

7. DR GRK DSMCH 7

8. Indications of empirical antibiotic in
paediatrics
• New born post resuscitation
• Probable sepsis
• Immunocompramised
• Malnourished
• Post viral infection
• Suppurative lung disease
• Suspected meningitis
• UTI
DR GRK DSMCH 8

9. CNS INFECTION
• BACTERIAL MENINGITIS
• < 6 WEEKS -CEFOTAXIME OR AMOXACILLIN +
GENTAMYCIN
• 6WEEKS -3 MONTHS -CEFOTAXIME
• > 3 MONTHS -CEFOTAXIME+DEXAMETHASONE
DR GRK DSMCH 9

10. IMMUNOCOMPRAMISED
• PIPTAZ + GENTAMYCIN
• IF STAPHYLOCOCCUS- VANCOMYCIN
DR GRK DSMCH 10

11. SEPTICAEMIA OF UNKNOWN ORIGIN
• Neonate - Community acquired
• Early onset <72 hours of age
• IV Benzylpenicillin +
• IV Gentamicin
• Late onset >72 hours of age
• IV Cefotaxime +
• IV Amoxicillin +
• IV Gentamicin
• 1 month and above – Community acquired
• IV Cefotaxime+
• IV Gentamicin if severe
• If meningitis cannot be excluded consider adding IV Amoxicillin for
listeria cover up to 6 weeks of age.
• 1 month and above – Hospital acquired
• IV Piperacillin/Tazobactam +
• IV Gentamicin DR GRK DSMCH 11

12. LOWER RESPIRATORY TRACT
Non severe community acquired pneumonia (CAP)
Under 5 years
S.pneumoniae the likely pathogen
Oral Amoxicillin
Duration 7 days
IV amoxicillin may be used if oral route compromised
or if true penicillin allergy:
Oral Azithromycin
Duration 3 days
5yrs and above or mycoplasma or chlamydia likely pathogen
Oral Azithromycin
Duration 3 days
DR GRK DSMCH 12

13. LOWER RESPIRATORY TRACT
• Severe CAP
• IV Cefuroxime
• If septic consider adding IV Gentamicin
• If suspicious of atypical pneumonia add
Azithromycin
• Aspiration pneumonia
• IV Co-amoxiclav
• If true penicillin allergy:
• IV Clindamycin
DR GRK DSMCH 13

14. UPPER RESPIRATORY TRACT
• Otitis media
• Children with acute otitis media should not be
routinely prescribed antibiotics. Consider delayed
antibiotic treatment
• Oral Amoxicillin
• Duration 5 days
• If true penicillin allergy:
• Oral Clarithromycin**
• Duration 5 days
DR GRK DSMCH 14

15. UPPER RESPIRATORY TRACT
• Tonsillitis (if antibiotic required)
• Oral Penicillin V
• (IV Benzylpenicillin if unable to swallow)
• Duration 10 days
• If true penicillin allergy:
• IV or oral Clarithromycin**
• Duration 5 days
DR GRK DSMCH 15

16. GASTROENTERITIS
• No antibiotic usually required
DR GRK DSMCH 16

17. UPPER TRACT UTI/ PYELONEPHRITIS
• Fever above 38°c and significant systemic upset
or if patient below 6 months age
• I.V. ceftriaxone* +/- gentamicin
• Fever above 38°c and mild systemic upset in
patients above 6 months of age
• Oral co-amoxiclav
• If true penicillin allergy: ciprofloxacinDuration 7
days
DR GRK DSMCH 17

18. LOWER TRACT UTI/ CYSTITIS
• If nitrite positive or significant
symptoms/concerns re lower UTI and no
fever
• Oral co-amoxiclav
DR GRK DSMCH 18

19. As we are celebrating the Rational Antibiotic Day on
28th September and a week thereafter, here is a
mnemonic
RATIONALE to fit in some aspects of rational
prescribing practices:
R- Reasoning for prescription, Right dose, route,
duration;
A- Academically updated decisions;
T-Training of mind, residents, parents, pharmacists;
I - Instructions to parents;
O-Organism search;
N- Noting down the diagnosis;
A- Antibiotic Policy;
L- Local sensitivity pattern; and
E- Ethical considerations, Economic condition of the
patient DR GRK DSMCH 19

20. ANTIBIOTIC PARADIGM
Excessive / inappropriate
antibiotic use
Failure of antibiotic treatment
Antibiotic resista
DR GRK DSMCH 20

21. 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
DR GRK DSMCH 21

22. 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?
DR GRK DSMCH 22

23. • Clinically diagnosed : Viral URI – seasonal
(pharyngotonsillitis)
 Management:
 General & Symptomatic Therapy
 Antibiotics : Not needed
DR GRK DSMCH 23

24. 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
DR GRK DSMCH 24

25. 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?......DR GRK DSMCH 25

26. 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
DR GRK DSMCH 26

27. 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
DR GRK DSMCH 27

28. 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
DR GRK DSMCH 28

29. 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 ?
DR GRK DSMCH 29

30. AZHAR HAS ACUTE OTITIS MEDIA
RIGHT EAR
On examination of Rt ear:
 Erythema
 Fluid
 Impaired mobility
 Acute symptoms
MANAGEMENT ?
DR GRK DSMCH 30

31. 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
DR GRK DSMCH 31

32. 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
DR GRK DSMCH 32

33. Jignesh....
 Ill look
 Depressed AF
 Dry skin and mucous membrane
 Sunken eyeballs
 Rapid, low volume pulse
How will you manage?
DR GRK DSMCH 33

34. 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?
DR GRK DSMCH 34

35. No antibiotics
DR GRK DSMCH 35

36. 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?
DR GRK DSMCH 36

37. CLINICAL PATHWAY FOR ANTIBIOTIC USE
1. Does the patient need an antibiotic?
2. Document the site of infection and possible
microorganism.
3. Send appropriate cultures
4. Choose the antibiotic from the antibiotic policy after
checking for allergy risks.
5. Some antibiotics should be prescribed after getting an
nfectious disease consult. These include carbapenems,
colistin, linezolid, teicoplanin, vancomycin, voriconazole,
amphotericin B
6. Follow the clinical response and de-escalate
antibiotics.
7. Infection control team should fill antibiotic audit
form and conduct regular department-wise audits.DR GRK DSMCH 37

38. 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
DR GRK DSMCH 38

39. 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
DR GRK DSMCH 39

40. 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
DR GRK DSMCH 40

41. 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
DR GRK DSMCH 41

42. 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
DR GRK DSMCH 42

43. 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
DR GRK DSMCH 43

44. Review Antibiotic Therapy DAILY: Stop?
Simplify? Switch?
DR GRK DSMCH 44

45. 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
DR GRK DSMCH 45

46. DR GRK DSMCH 46