Dr. Arun S. Desai M.D., Neonatal Fellow Aus

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Improving Antibiotic Outcome in Paediatric
Practice

• Dr. Arun S. Desai M.D., Neonatal Fellow (Aus)
• Prof. H.O.D., of Pediatrics,
• Belgaum Institute Of Medical Sciences
• Senior Consultant,
• Belgaum Childrens Hospital

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ARTI Challenge

• It is evident that one of the greatest challenge
  faced by healthcare providers is the treatment of
  respiratory tract infections in an age of
  increasing antimicrobial resistance

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ARTI Gravidity

• Acute Respiratory Infections are the single
  greatest cause of death among children
• Represent 21.3 of all deaths lt5yrs of age
• Acute lower RTI including Pneumonia,
  Bronchiolitis Bronchitis are major causes of
  deaths in developing areas.
• Each year cause 2million deaths in lt5yrs old
  children

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ARTI Gravidity Contd..

• Approximately 10-20 of all children lt5yrs, in
  developing countries develop Pneumonia
• About 1 Pneumonia cases result in sequele,
  which increases risk of recurrent infection
• 75 of Pneumonia deaths occur among infants under
  1yr
• Early recognition treatment of Pneumonia are
  most effective action to reduce mortality

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ARTI Risk factors In Children

• Boys more frequently affected than Girls.
• Overall incidence stable until 5yrs, but
  mortality concentrated in infancy
• Throughout world no of ARI episodes is same
  (5/child/yr) but incidence of Pneumonia is
• 3-4 in industrialized countries
• 10-20 in developing countries
• Lower educational levels in mothers associated
  with increased hospitalization mortality

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ARTI Risk factors In Infants lt2yrs

• Infants under 2yrs are more susceptible due to
• Malnutrition micronutrient deficiency
• Maternal factors
• High-risk environmental factors
• Premature birth
• Delay of intrauterine growth
• Immunological immaturity
• Other factors

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ARTI Classification

• Acute Upper RTI
• Common Cold
• Bacterial Pharyngitis / Tonsillitis
• Otitis Media
• Sinusitis
• Diphtheria

• Acute Lower RTI
• Viral Croup
• Bacterial tracheitis
• Epiglottitis
• Bronchiolitis
• Pneumonia

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ARTI WHO RecommendationsEvaluationClassificatio
nTreatment -For Infants
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ARTI WHO RecommendationsEvaluationClassificatio
nTreatment -For Infants
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ARTI WHO RecommendationsEvaluationClassificatio
nTreatment -For Infants
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ARTI Causative Pathogens

• Major causative pathogens are
• Streptococcus pneumoniae
• Hemophilus influenzae
• Moraxella catarrhalis

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ARTI Streptococcus pneumoniae

• Remains a challenging organism to treat
  successfully even in 21st century
• Important cause of community acquired infections,
  especially in young children
• Also capable of causing variety of infectious
  syndromes like meningitis, peritonitis sepsis

Prevention of infection is the key to combat
spread of antibiotic-resistant strains.
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ARTI Hemophilus influenzae

• Another major causative pathogen for RTI
• Children between 6mts to 4yrs most vulnerable
• 50 children acquire Hemophilus infection before
  reaching 1 year of age
• Almost all children would develop Hemophilus
  infection before age of 3 years

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ARTI Hemophilus influenzae Contd..

• Also causes Bacterial sepsis in Newborn,
  Epiglottitis, Meningitis
• Second most commen cause of Middle ear infection
  and Sinusitis
• May also develop Infectious Arthritis

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ARTI Empiric Antibiotic selection

• When extended spectrum antibiotic is appropriate
  for empiric therapy of RTI, selection should be
  based on
• Efficacy
• Adverse event profile
• Compliance-enhancing features
• Dosing with meals
• Once or twice administration
• Good palatability in suspension
• Shortened course of therapy
• Affordability

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ARTI Antibiotic Usage

• Majority of antibiotic prescriptions are for
  Otitis media and Pharyngitis followed by URTI,
  sinusitis, bronchitis.
• Many prescriptions are for infections unlikely to
  have bacterial origin
• This excessive antibiotic use increases risk that
  a patient will become colonized or infected with
  a resistant organism

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ARTI Antimicrobial Resistance -Common cause
of Treatment Failure

• Unnecessary antibiotic use
• Poor patient compliance
• Prescription for antibiotics not taken correctly
• Not taken to completion
• Exposure to antimicrobial soaps, solutions etc
• Socio-economic considerations
• Misuse of antibiotics
• Poor quality drugs
• Poor surveillance and compliance
• Poverty and poor hygiene

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ARTI Antimicrobial Resistance
-Mechanisms

• Reduction in the intracellular concentration of
  the drug within the bacteria
• Ability of the bacteria to inactivate drugs
• Modification of antibiotic target site
• Elimination of the target site for the antibiotic
  agents

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ARTI Antimicrobial Resistance
-Mechanisms
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ARTI Selecting Antibiotic

• Depends on
• Antibiotic Efficacy
• One with most studies powered for equivalence
• Safety of agent
• Patient compliance
• Once a day
• 5day course
• Oral easy less expensive

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ARTI Shorter Antibiotic Courses

• Accumulating evidence from large number of
  prospective clinical studies suggests that
  shortened courses may be as effective or more
  effective than conventional regimens.
• Equivalent or enhanced efficacy
• Improved patient compliance
• Reduced rate of clinical bacteriological failure

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ARTI Shorter Antibiotic Courses Contd..

• Reduced emergence of resistant strains
• Fewer adverse effects
• Improved patient satisfaction
• Lowered treatment costs.

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ARTI Ways to combat over-prescribing of
Antibiotics

• Prescribing antibiotic therapy only when needed
• Using appropriate agent for the organism
• Prescribing the appropriate dose and duration of
  therapy

Antibiotic use drives antibiotic resistance!
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ARTI Appropriate Antibiotic in Children

• Center for Disease Control / AAP / American
  Academy of Family Physicians guidelines for
  appropriate use of antibiotics in children
• Cough illness / Bronchitis rarely warrants
  Antibiotics
• Prolonged cough (gt10days) may need Antibiotics
• Pertussis to be treated as per recommendations
• Mycoplasma pneumoniae infection ?Macrolide
• Underlying chronic pulmonary disease may benefit
  with Antibiotics, during acute illnesses

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ARTI Macrolides

• Well established and extensively used in
  infections caused by gram-positive organisms
• Advantages of newer Macrolides Azithromycin
• Once-daily dosing
• Resistance to degradation in stomach
• Improved absorption
• Reduced GI adverse effects
• Excellent tissue intracellular penetration
• Expanded enhanced antimicrobial spectrum

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ARTI Macrolides Pharmacokinetics

• Penetrate well into Respiratory, Genitourinary,
  GI tracts as well into Skin, Soft tissues
  Sinuses.
• Moderately protein bound (40-50)
• Azithromycin
• Excreted unchanged in bile
• Half life 32 hrs in children
• Slowly released Prolonged elimination
• Pharmacokinetics similar in younger older than
  5yrs

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ARTI Azithromycin Dosages

• 10mg/kg once daily for 3days
• OR
• 10mg/kg on first day followed by 5mg/kg for 4days

Macrolides have low incidence of toxic effects
reported during last 40yrs of their use.
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ARTI Azithromycin Efficacy

• Equivalent to
• Amoxycillin, Clavulanate, Cefaclor,
  Cefuroxime-axetil, Erythromycin Penicillin-V
• In
• Otitis media, Bronchitis, Community-acquired
  pneumonia, Streptococcal pharyngitis
  Tonsillitis
• Also in Skin soft tissue infections
• Possible alternative in management of Trachoma

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ARTI Azithromycin Efficacy Contd..

• Community acquired pneumonia, bronchitis other
  RTI respond as well to Azithromycin as to
  Amoxycillin-Clavulanate, Cefaclor or Erythromycin
• Symptoms of LRTI resolve more rapidly with
  Azithromycin than Erythromycin or Cefaclor
• Once weekly 10mg/kg, provides same efficacy as
  continuous Amoxycillin for prevention of
  Recurrent Acute Otitis media

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ARTI Cephalosporins

• Cephalosporins have specific advantages over
  Penicillins in terms of
• Allergic reactions
• Fewer immediate and delayed hypersensitivity
• Tolerance and Compliance
• Better taste
• Antimicrobial Spectrum
• Broader spectrum

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ARTI Cephalosporins Cefdinir

• Broad spectrum cephalosporin against many
  Gram-negetive Gram-positive aerobic organisms
• Streptococcus pneumoniae
• Staphylococcus aureus
• Streptococcus pyogenes
• Haemophilus influenzae
• Moraxella catarrhalis

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ARTI Cefdinir

• Stable to hydrolysis, rapidly absorbed from GI
  tract
• Efficacy demonstrated in numerous clinical trials
  with
• Pharyngitis
• Sinusitis
• Acute Otitis media
• Acute Bronchitis
• Acute exacerbation of chronic bronchitis
• Community acquired pneumonia
• Skin infections

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ARTI Cefdinir

• Cefdinir with a broad spectrum of activity
  against many Gram-negative and Gram-positive
  aerobic organisms is a valuable option and can be
  dosed once or twice daily for the treatment of
  upper and lower respiratory tract infections

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ARTI Summery

• Primary care physicians need to be aware of local
  antibiotic susceptibility patterns of respiratory
  pathogens, especially as the initial therapy is
  empirical
• The more swiftly antibiotics are given in RTI,
  the better the clinical outcome.
• The more judiciously that these antibiotics can
  be prescribed, the lower the antibacterial
  resistance, and increase in clinical longevity of
  these drugs

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THANK YOU