Management

1
Management Prophylaxis of Cardio-respiratory
illnesses

• DR SWATI BHAVE
• Senior consultant
• Pediatric Adolescent medicine
• Indraprastha Apollo Hospital New Delhi
• Member
• Standing committee ASPID
• ( Asian Society of Pediatric infectious disease (
  2000-03) )
• Standing committee IPA
• ( International Pediatric Association 2001-07)
• President 2000 Indian Academy of Pediatrics

2
Prophylactic antibiotics for cystic fibrosis

• Three studies, totaling 177patients aged 0-7
  years on enrollment, were suitable for inclusion
  in the review.
• A reduced prevalence of Staphylococcus aureus in
  the respiratory secretions was seen in children
  receiving anti-staphylococcal antibiotic
  prophylaxis, although no effect was seen on other
  common pathogens.
• One eligible study showed a shorter duration of
  hospital admissions in the second year ofl ife,
  in patients receiving prophylaxis. No effect on
  infant lung function has been shown after one
  year of prophylactic treatment.
• Data are not available on adverse effects of the
  interventions. There was a trend towards a lower
  cumulative isolation

• Update of Cochrane Database Syst Rev.
  2000(2)CD001912. . Smyth A, Walters S.

3
Prophylactic antibiotics for cystic fibrosis

• There was a trend towards a lower cumulative
  isolation rate of P aeruginosa in the prophylaxis
  group,after three years.
• However, as the duration of the studies reviewed
  has been oft hree years or less, conclusions
  cannot be drawn about the long term effects of
  prophylaxis on acquisition of P. aeruginosa and
  survival.
• REVIEWER'SCONCLUSIONS Anti-staphylococcal
  antibiotic prophylaxis may be of benefit when
  commenced early in infancy and continued up to
  three years of age. There is insufficient
  evidence from this review to say whether use in
  older children, or adults, or for periods of over
  three years is beneficial. 

• Update of Cochrane Database Syst Rev.
  2000(2)CD001912. . Smyth A, Walters S.

4
Prophylactic antibiotics for cystic fibrosis
objectives .

• (1) improves clinical status, lung function and
  survival
• (2) causes adverse effects (e.g. diarrhea,skin
  rash, candidiasis)
• (3) leads to fewer isolates of common pathogens
  from respiratory secretions
• (4) leads to the emergence of antibiotic
  resistance and the colonization of the
  respiratory tract with organisms, e.g.
  Pseudomonas aeruginosa.

• Smith A, Walters S . Cochrane Database Syst Rev.
  2003(3)CD001912.

5
Anti-staphylococcal antibiotic prophylaxis

• leads to fewer children having isolates of Staph.
  aureus, when commenced early in infancy and
  continued up to six years of age. The clinical
  importance of this finding is uncertain.
• Further research may establish whether the trend
  towards more children with CF with Pseudomonas
  aeruginosa, after four to six years of
  prophylaxis, is a chance finding.
• Future work should explore whether choice of
  prophylactic antibiotic or duration of treatment
  might influence infection with P aeruginosa. 

6
 Vaccine development for capsulate bacteria
causing pneumonia. 

• Hib vaccine can prevent pneumonia in developing
  countries. SP conjugate vaccine prevents X-ray
  confirmed pneumonia in low incident populations,
  but protection appears more marginal in high
  incident populations.
• Non-vaccine SP stenotypes have demonstrated
  increased carriage and mucosal disease, but not
  invasive disease following vaccination.
• GBS vaccines are in the early stages of clinical
  development as prenatal or antenatal vaccines.

Russell FM, Buttery J.  Curr Opin Pulm Med. 2003
May9(3)227-32.
7
Selective decontamination of the digestive
tract. 

• Ventilator-associated pneumonia usually
  originates patient's oropharyngeal microflora.
• In selective digestive decontamination, topical
  antibiotics applied to the oropharynx and
  stomach for prevention of pneumonia and other
  infections,
• Also used for the prevention of gut-derived
  infections in acute necrotizing pancreatitis and
  liver transplantation

• Krueger WA, Unertl KE.  Curr Opin Crit Care. 2002
  Apr8(2)139-44.

8
Remains controversial
Selective decontamination of the digestive
tract. 

• Reduction of the incidence of pneumonias
  accepted, but the extent of reduction is debated.
  
• Mortality was not reduced in most individual
  trials.increased resistance shift to
  Gram-positive
• selection of appropriate groups of patients for
  underlying diseases and severity of illness,
  and selection of ICUs, based on the endemic
  resistance patterns

• Krueger WA, Unertl KE.  Curr Opin Crit Care. 2002
  Apr8(2)139-44.

9
Prospects for the prevention and control of
pseudomonal infection in children with cystic
fibrosis.

• by eliminating cross-infection and by early
  aggressive antibiotic treatment of the first
  positive sputum culture and of subsequent
  intermittent colonisation. By using chronic
  suppressive antibiotic maintenance therapy and
  anti-inflammatory drugs it is however, possible
  to maintain the lung function of these patients
  for a number of years.

Hoiby N Paediatr Drugs. 2000 Nov-Dec2(6)451-63.
10
Antibiotics for preventing pneumonia in children
with measles.

• The quality of the trials reviewed was poor, and
  they provide very weak evidence for giving
  antibiotics to all children with measles.
  Available evidence suggests that antibiotics
  should be given only if a child has clinical
  signs of pneumonia or other evidence of sepsis.

 
Shann F, D'Souza RM, D'Souza R., Cochrane
Database Syst Rev. 2000(2)CD001477.
11
 Vaccine development for capsulate bacteria
causing pneumonia. 

• Hib vaccine can prevent pneumonia in developing
  countries. SP conjugate vaccine prevents X-ray
  confirmed pneumonia in low incident populations,
  but protection appears more marginal in high
  incident populations.
• Non-vaccine SP stenotypes have demonstrated
  increased carriage and mucosal disease, but not
  invasive disease following vaccination.
• GBS vaccines are in the early stages of clinical
  development as prenatal or antenatal vaccines.

Russell FM, Buttery J.  Curr Opin Pulm Med. 2003
May9(3)227-32.
12
Pulmonary fungal infections in immuno-compromised
children.

• Treatment is usually successful if initiate
  dearly, although pulmonary aspergillosis and
  zygomycosis are portentous ailments unless
  surgical resection or prompt immunologic recovery
  ensue. 

• Shenep JL, Flynn PM. Curr Opin Pediatr. 1997
  Jun9(3)213-8.

13
Use of prophylactic antibiotics in cancer
patients .

• Severe neutropenia lt 100/mm3) forgt 2 weeks should
  receive oral antibiotic prophylaxis.
• At present, trimethoprim sulfamethoxazole in
  combination with either nystatin or amphotericin
  B is the best regimen for reducing the incidence
  of serious infections.

• Wolff LJ. Am J Pediatr Hematol Oncol. 1984
  Fall6(3)267-76.

14
THERAPY HAS IMPORTANT ROLE

• Management of valvular heart dis-ease
• stabilization of patients until the time of
  surgery, treatment of the underlying
• cause,and prevention of bacterial endocarditis
  and rheumatic fever
• it is still not proven to alter the course of
  valvular heart disease or the time of surgery
  when a serious structural abnormality is

Cleveland clinic journal of medicine volume 68
number 10 october 2001881rug
15
ANTIBIOTICPROPHYLAXIS in Rheumatic disease

• Prophylaxis is indicated if
• echocardiography shows evidence of a rheumatic
  etiology of valve disease

16
Summary

• Prophylactic antibiotics should be judiciously
  used
• There are recommendations based on good research
  studies
• A protocol should be standardized for each setup
  that should be strictly followed by all the
  concerned personalle