Prescribing-Antibiotics-in-Pediatric-Office-Practi.ppt

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,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,Prescribing Antibiotics in Pediatric Office Practice,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,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,?,Perhaps it matters more than we think it does,Versatile Genetic Engineers,Equalitarian and Social,Horizontal Transmission of Resistance Genes among Species,Gene Transfer in the Environment.Levy&Miller,1989,ANTIBIOTIC PARADIGM,Excessive/inappropriate,antibiotic use,Failure of antibiotic treatment,Antibiotic resistance,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,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?.,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,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,4 months later,Mehul is back with fever,cough and coryza.See his throat,Treating pediatrician considers him to have viral pharyngitis,DO YOU AGREE?,HERPANGINA,Pharyngeal Erythema but not bacterial,Some more non-bacterial Pharyngeal Inflammation,Case 3:Azhar,Azhar,a 15 month otherwise healthy boy had rhinorrhea,cough and fever of 102,0,F 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,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,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?,Jignesh.,Hosptalise,No antibiotics,Hospitalise,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/1,st,gen ceph Amoxycillin,/Macrolides,Otitis/Sinusitis,Amoxycillin Co-amoxyclav/,2nd gen ceph/Macrolides,Pneumonia(CA),High dose Amoxy/2,nd,/3,rd,gen Inj ceph,Co-amoxyclav/Clox,/Vanco,Enteric fever,3rd gen oral ceph 3,rd,gen inj ceph/,Fluoroquinolones,Dysentery,Norflox 2,nd,gen quinolones,/3,rd,gen oral ceph /Ceftriaxone,UTI,Sulpha/Trimetho/Co-amoy Fluoroquinolones,/3,rd,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,