Antibiotic usage in primary care units in Taiwan (Chang SC et al Diag Micro Infect Dis 2001;40: 137-43)

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Antibiotic usage in primary care units in Taiwan
(Chang SC et al Diag Micro Infect Dis 200140
137-43)

• 1996 1999, collect prescriptions for 1 wk in
  March each year, sampled from 114166 health
  stations with 40891 53992 physician-visits each
  year
• Antibiotic Tx in 13.4 of total visits
• Patients lt 11 y/o highest (38.2) percentage
• Common cold most frequent (32) diagnosis for
  antibiotic prescription
• Among patients with the Dx of common cold,
  antibiotic Tx in 31, highest among lt 16 y/o
  (45.5)
• Penicillin class 35, cephalosporins 27,
  macrolides 22, others

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Six common diagnoses in which antibiotics were
prescribed Chang SC et al Diag Micro Infect Dis
200140137-43
Diagnosis No. of patients-visits with antibiotics prescribed of total antibiotic prescriptions
Common cold 13588 32.3
COPD or asthma 2408 5.7
Acute bronchitis 2127 5.1
Skin and soft tissue infections 1781 4.2
Acute tonsillitis 999 2.4
Cystitis 929 2.2
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Proportion () of patient-visits resulting in
antibiotic prescription Chang SC et al Diag
Micro Infect Dis 200140137-43
Diagnosis Age group (years) Age group (years) Age group (years) Age group (years)
Diagnosis ?15 16-64 ?65 Total
Common cold 45.5 31.5 23.1 31.3
Influenza 52.2 21.5 29.1 33.2
COPD or asthma 44.3 27.0 19.5 23.2
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Prevalence of antimicrobial resistance of common
RTI pathogens isolated from 12 major Hospital in
Taiwan, 2000

• Penicillin-nonsusceptible S. pneumoniae 6080
• Erythromycin-resistant S. pneumoniae 67100
• Ampicillin-resistant H. influenzae 4573
• Erythromycin-resistant beta-hemolytic
  streptococcus 3051 Methicillin-resistant S.
  aureus 5383
  (Hsueh PR et al Emerg Infect
  Dis 20028132-7)

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• ????????????????,??????90?2?1?????????????????????
  ,????????????????(common cold)???????,????????
• ?90?2???????????????????????49.5,90?2??????24.1?
  
• ???????????91?11?11??92?2?10?

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Guidelines for antimicrobial therapy of acute
upper respiratory tract infection in Taiwan

• Seven acute URTI chosen acute sinusitis, acute
  otitis media, acute pharyngotonsillitis, acute
  epiglotittis, acute bronchitis, common cold,
  influenza
• Principles of guidelines
• From the viewpoint of primary care physicians
• Antimicrobial agents suggested marketing in
  Taiwan
• Based on local epidemiologic data and
  antimicrobial resistant rate of pathogens
• Antimicrobial agents suggested mainly oral
  formulation

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Guidelines for antimicrobial therapy of acute URT
in Taiwan
? ? ? ? ? ?
????? (Acute sinusitis) Amoxicillin (high dose) Ampicillin Amoxicillin/clavulanate Ampicillin/sulbactam 2o or 3o cephalosporins (oral)
????? (Acute otitis media) Amoxicillin (high dose) Ampicillin Amoxicillin/clavulanate Ampicillin/sulbactam 2o or 3o cephalosporins (oral)
??????? (Acute pharyngotonsillitis) Penicillin V Benzathine penicillin (IM) Clindamycin Macrolides 1o cephalosporins
??????(Acute bronchitis) ---- ----
??(Common cold) ---- ----
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Principles of Appropriate Antibiotic Use for
Treatment of Acute Respiratory Tract Infections
in Adults Annals of Internal
Medicine. March 20, 2001

• Nonspecific Upper Respiratory Tract Infections
• Acute Rhinosinusitis
• Acute Pharyngitis
• Uncomplicated Acute Bronchitis

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Appropriate Abx Use for Tx of Nonspecific URTI
in Adults

• Recommendation 1.
• The diagnosis of URTI should be used to denote
  an acute infection that is typically viral in
  origin and in which sinus, pharyngeal, and lower
  airway symptoms, although frequently present, are
  not prominent B
• greatest concentration of virus in the nasal
  secretions sneezing, nose blowing, contamination
  with nasal secretions

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Appropriate Abx Use for Tx of Nonspecific URTI in
Adults

• Recommendation 2.
• Antibiotic treatment of adults with
  nonspecific upper respiratory tract infection
  does not
• enhance illness resolution and is not
  recommended A.

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Appropriate Abx Use for Tx of Nonspecific URTI in
Adults

• Recommendation 3.
• Purulent secretions from the nares or throat
  (commonly observed in patients with uncomplicated
  upper respiratory tract infection) predict
  neither bacterial infection nor benefit from
  antibiotic treatment A.(unless it persists for
  gt 10 to 14 days ?)

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Appropriate Abx Use for Tx of Nonspecific URTI in
Pediatrics

• Controlled trials of antimicrobial treatment
  failed to change the course or outcome
• No evidence of a protective effect for
  antimicrobial treatment to prevent LRTIs
  (Gadomski AM et al PIDJ 199312115-20)
• Chemoprophylaxis can help prevent AOM in some
  high-risk child
  
  (Rosenstein N et al Pediatrics
  1998101181-4)

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Appropriate Abx Use for Tx of Acute
Rhinosinusitis in Adults

• Most cases of acute rhinosinusitis diagnosed in
  ambulatory care are caused by uncomplicated viral
  URTI A.
• Sinus radiography is not recommended for
• diagnosis in routine cases B.

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Appropriate Abx Use for Tx of Acute
Rhinosinusitis in Adults

• Bacterial and viral rhinosinusitis are difficult
  to differentiate on clinical grounds B.
• Acute Bacterial Sinusitis
• Symptoms lasting 7 days or more,
• unilateral maxillary pain,
• maxillary toothache,
• unilateral tenderness of the maxillary
  sinus
• mucopurulent nasal discharge
• Gold standard Sinus aspiration , grow at least
  105 organisms/ml

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Appropriate Abx Use for Tx of Acute
Rhinosinusitis in Adults

• Sinusitis in radiography
• complete opacification and air-fluid level
• ? Sensitivity 80 (71-87), specificity
  85(76-91)
• various degrees of mucosa thickening
• Specificity 4050
• Absence of all three findings
• ? Sensitivity 90

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Appropriate Abx Use for Tx of Acute
Rhinosinusitis in Adults

• Who should not be treated
• Acute bacterial sinusitis (mild or moderate)
• Who should be treated
• severe or persistent (more than 7 days)
  moderate symptoms specific findings of
  bacterial sinusitis

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Appropriate Abx Use for Tx of Acute
Rhinosinusitis in Adults

• For initial treatment,the most narrow-spectrum
  agent active against the likely
  pathogens,Streptococcus pneumoniae and
  Haemophilus influenza should be used
• High dose Amoxicillin (most favored)
• Augmentin, Fluroquinolones, Telithromycin
• X Erythromycin

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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults

• An inflammatory illness of mucous membranes and
  underlying structures of throat
• Frequently involve nasopharynx, uvula, soft
  palate
• Erythema, exudate, ulceration
• Usually acute, sore throat
• Common causes of pharyngotonsillitis
• Group A beta-hemolytic streptococci ,Epstein-Barr
  virus ,Adenovirus ,Influenza viruses ,
  Enteroviruses , Parainfluenza viruses

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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults
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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults

• The large majority of adults with acute
  pharyngitis have a self-limited illness, for
  which supportive care only is needed.
• Antibiotic treatment of adult pharyngitis
  benefits only those patients with GABHS
  infection.
• Complications Acute Rheumatic Fever, Acute
  Glomerulonephitis, Peritonsillar abscess, Disease
  contagion

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Diagnosis of Strep. pharyngitis

• Throat culture
• Rapid antigen test
• Centor criteria
• history of fever, tonsillar exudates, no
  cough , and tender anterior cervical
  lymphadenopathy (lymphadenitis)
• Centor RM, Witherspoon JM, Dalton HP, Brody CE,
  Link K.
• The diagnosisof strep throat in adults in the
  emergency room. Med Decis Making.19811239-46.

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Throat cultures

• Does not always correlate with antistreptolysin
  titers
• Produces results that vary depending on technique
• Throat cultures also fail to distinguish acute
  infection from the carrier state.
• ? Not recommended for the routine primary
  evaluation of adults with pharyngitis or for
  confirmation of negative results on rapid antigen
  tests

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Indications of Throat Cultures

• Investigations of outbreaks of GABHS disease
• Monitoring the development
• and spread of antibiotic resistance
• When such pathogens as gonococcus are being
  considered.

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Rapid Antigen Tests

• Approximately the same sensitivity and greater
  specificity for predicting results of throat
  culture
• Medicalize pharyngitis because
• patients would need to see a physician for the
  test to be performed.

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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults

• Principle 1. Clinically screen all adult patients
  with pharyngitis for the presence of the four
  Centor criteria
• Principle 2. Do not test or treat patients with
  none or only one of these criteria. These
  patients are unlikely to have GABHS infections
  A.

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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults

• Principle 3. For patients with two or more
  criteria, the following strategies are
  appropriate
• a) Test these patients by using a rapid
  antigen test,
• and limit Abx to patients with positive
  results
• b) Abx for patients with four criteria, and
  patients with 23 criteria plus rapid test ()
• c) Limit Abx to those with 34 criteria only
• Principle 4. Administer appropriate analgesics,
  antipyretics, and supportive care to all patients
  with pharyngitis A.

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Appropriate Abx Use for Tx of Acute Pharyngitis
in Adults

• Drug of Choice
• Single dose of intramuscular penicillin
• ( 1.2 MU for adults)
• Penicillin VK 500mg orally 23 times per day
  for 10 days
• Alternative 1o generation cephalosporins,
  macrolides, clindamycin
• Neither repeat bacterial test of patients or
  testing of asymptomatic household contacts
  recommended
• A small percentage have a recurrence
• Bisno AL et al Clin Infect Dis 200235113-25)

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The above guildlines do not apply to

• Patients of rheumatic fever, valvular heart
  disease, immunosuppression,
• recurrent or chronic pharyngitis
  (symptoms7days), or to patients whose sore
  throats have a cause other than acute infectious
  pharyngitis.
• A known epidemic of acute rheumatic fever or
  streptococcal pharyngitis or in nonindustrialized
  countries in which the endemic rate of acute
  rheumatic fever is much higher

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Appropriate Abx Use for Tx of Acute bronchitis in
Adults

• The evaluation of adults with an acute cough
  illness (lt 3 weeks) should focus on ruling out
  serious illness, particularly pneumonia.
• Pneumonia abnormalities in vital signs (HR 100
  beats/min, RR 24 breaths/min, or temp 38 C),
  CXR(eg. Focal consolidation), rales, egophony,
  and fremitus

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Appropriate Abx Use for Tx of Acute bronchitis in
Adults

• Technically definition inflammation of bronchial
  respiratory mucosa, resulting in productive cough
  
• Clinical definition not well established,
  usually cough with or without fever or sputum
  production
• Lack of a standardized case definition
  (Obrien KL et al
  Pediatrics 1998101178-81)

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Pathogens of Acute bronchitis

• Viral pathogens account for the majority of
  agents
• Parainfluenza viruses, RSV, influenza viruses
• 20 adults with rhinovirus colds continue to
  cough gt 14 days
• (Gwaltney JM et al JAMA 1967202494-500)
• Mycoplasma pneumoniae, Chlamydia pneumoniae,
  recognized pathogens in children gt5y/o
• Neither production of sputum nor character of
  sputum predictive of a bacterial etiology for
  cough
• Nasopharyngeal culture poor predictors of true
  bacterial pathogens
• Fever not indicate cough related to a bacterial
  infection
  
• (Obrien KL et al Pediatrics 1998101178-81)

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Pathogens of Acute bronchitis

• The majority of prolonged cough illness are
  allergic, postinfectious, or viral in nature
• Reactive airway disease one of the most common
  causes, respond to bronchodilators
• Pertussis, particularly among older children and
  adults
• Mycoplasma Pneumoniae , in school children
• No specific or pathognomonic signs of cough
• A macrolide small effect on shortening the
  duration of cough
• (Obrien KL et al Pediatrics 1998101178-81)

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Appropriate Abx Use for Tx of Acute bronchitis in
Adults

• Routine antibiotic treatment of uncomplicated
  acute bronchitis is not recommended, regardless
  of duration of cough.
• Antimicrobial treatment for prolonged cough (gt10
  days) may be indicated occasionally
• Pertussis
• Mycoplasma pneumoniae, usually in children gt 5
  y/o, a macrolide agent
• Underlying chronic pulmonary disease with acute
  exacerbation

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Diagnosis of Acute Otitis Media in Children
Pediatrics. 113(5)1451-65, 2004 May.

• A history of acute onset,
• Identify signs of middle-ear effusion (MEE),
• Evaluate for the presence of signs and symptoms
  of middle-ear inflammation.

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Managements of AOM in Children
Pediatrics. 113(5)1451-65, 2004 May

• Assessment of pain If pain is present, the
  clinician should recommend treatment to reduce
  pain. (strong recommendation)
• Observation in a child with uncomplicated AOM is
  an option for selected children

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Managements of AOM in Children
Pediatrics. 113(5)1451-65, 2004 May

• Observation is an appropriate option only when
  follow-up can be ensured and antibacterial agents
  started if symptoms persist or worsen.
• Nonsevere illness is mild otalgia and fever lt39oC
  in the past 24 hours.
• Severe illness is moderate to severe otalgia or
  fever 39oC.
• A certain diagnosis of AOM meets all 3 criteria
• (rapid onset, signs of MEE, signs and
  symptoms of middle-ear inflammation)

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Managements of AOM in Children
Pediatrics. 113(5)1451-65, 2004 May

• If a decision is made to treat with an
  antibacterial agent, the clinician should
  prescribe amoxicillin 80 to 90 mg/kg/day for most
  children
• Treatment course
• 10 days younger children, children with severe
  disease
• 57 days children 6 years of age and older with
  mild to moderate disease
• If the patient fails to respond to the initial
  management within 48 to 72 hours ? Reassessment

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Recommended Antibacterial Agents
Pediatrics. 113(5)1451-65, 2004 May
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Managements of AOM in Children
Pediatrics. 113(5)1451-65, 2004 May

• Clinicians should encourage the prevention of AOM
  through reduction of risk factors (strong
  recommandation)
• Ex genetic predisposition, premature birth, male
  gender, presence of siblings in the household,
  and low socioeconomic status, supine
  bottle-feeding (bottle propping), pacifier use
  in the second 6 months of life, exposure to
  passive tobacco smoke

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