Rational use of antibiotic in upper respiratory tract infection (URI) and community acquired pneumonia รศ.จามร ธ รตก ลพ ศาล 23 พฤษภาคม 2550

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1 Rational use of antibiotic in upper respiratory tract infection (URI) and community acquired pneumonia รศ.จามร ธ รตก ลพ ศาล 23 พฤษภาคม 2550

2 Sinusitis

3 Upper respiratory tract infections (URI) Common cold / nasopharyngitis Pharyngitis/pharyngotonsillitis Otitis media Sinusitis

4 Antibiotic in URI Problems antibiotic overuse increasing of colonization with resistance strain of organisms and heighten the chance that subsequence invasive infection unnecessary cost

5 Thailand National ARIC Control Program of Thailand : MOPH year Objectives - to reduce mortality of pneumonia in U5 <4/100,000 morbidity of pneumonia in U5 <1.8/100.. inappropriate use of antibiotics < 20/100

6 Antibiotic Overuse in URI According to type of Health Facilities Rate % RH CH HC YEAR : Active surveillance 17 provinces 1997 : Report from 61 provinces Source : ARIC section, TB Division RH : Regional Hospital CH : Community Hospital HC : Health Center

7 Antibiotic resistance Increasing worldwide S. pneumoniae H. influenzae Thailand National surveillance 1993, 1994, 1997 and 2000

8 National surveillance of antibiotic resistance in Thailand Sample Np. Specimens from URI and pneumonia from children < 5 years Period 1993, 1994, 1997, 2000 Area study Bangkok, Pitsanuloke, Hadyai, Chonburi, Khon Kaen, Nakornratchsima

9 S.pneumoniae National surveillance of antimicrobial resistance n=1783 n=818 n= penicillin 37.4% 36.3% 55.9 % 61% - chloramphenicol 17.5% 17.9% 24.2% 21% - co-trimoxazole 60.1% 72.2% 86.4% 73% H.influenzae - ampicillin 21.3% 23.3% 26.7% 20% - chloramphenicol 14.9% 14% 7.5% 5% - co-trimoxazole 24.4% 25% 68.6% 35.7% ARIC section, MOPH

10 Antimicrobial resistance of S.pneumoniae (MIC) * penicillin chloram co-trimox Source: ARIC section, MOPH

11 Antimicrobial resistance of H.influenzae ampicillin chloram co-trimox Source : ARIC section, MOPH

12 Sinusitis

13 Common cold Acute inflammation of nasal or pharyngeal mucosa in the absence of other specifically defined respiratory infection Acute rhinitis, nasopharyngitis Recent evidence suggested that common cold usually include sinus disease : acute rhinosinusitis CDC/AAP: Pediatrics 1998; 101: 181.

14 Common cold(cont) Rhinosinusitis and mucopurulent rhinitis are almost always caused by virus : rhinovirus, coronavirus, etc. Most children will suffer between 3 and 8 colds per year 10% - 15% will have at least 12 per year particularly those attending day care centers

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16 Common cold(cont.) Physician reasons for prescribing antibiotics mucopurulent rhinitis 71% of family doctors and 53% of pediatrician prescribed antibiotic immediately for 10 month-old infant with mucopurulent nasal discharge of 1 day duration Schwartz RH 1997

17 Common cold(cont) Physician reasons for prescribing antibiotic to prevent bacterial complication such as sinusitis or lower respiratory infection patient or parents pressure on physician to prescribe antibiotic for URI?

18 Common cold(cont) Antibiotics for common cold 2,056 patients aged 6 mo - 49 years patients receiving antibiotics did not do better in term of cure or improvement than those on placebo even in purulent nasal discharge significant increase in side effects : odds ratio 2.72 ( ) Arroll B, Kenealy T. The Cochrane review 2000

19 Common cold(cont) Systematic review of the treatment of URI Children 3,626 aged 0-12 years Clinical condition worse or unchange at day 5 to 7 with AB vs placebo : RR 1.01 ( ) Complications or progression of illness : RR 0.71 ( ) Fahey T, et al. Arch Dis Child 1998

20 Common cold(cont) CDC/AAP recommendation Antibiotic should NOT be given for common cold Mucopurulent rhinitis (thick, opaque nasal dicharge) frequently accompanies common cold, it is NOT an indication for antibiotic treatment unless it persist for > 10 to 14 days without improvement Thai Guideline for Management of ARIC 2006

21 Bacterial sinusitis Prolonged nonspecific upper respiratory signs and symptoms i.e., nasal discharge and cough without improvement for > days More severe URI and symptoms i.e., fever 39 o C, facial swelling, facial pain Incidence 0.5% - 5% of viral URI S. pneumoniae, H. influenzae, M. catarrhalis are common pathogens O Brien KL. Pediatrics 1998;101:174-7

22 Bacterial sinusitis Sinusitis(cont) Initial treatment should be amoxycillin mg/kg/day oral bid or tid In high risk of DRSP such as History of previous antibiotic within 3 months Day care attendance or age < 2 years Start with high dose mg/kg/day

23 Bacterial sinusitis Sinusitis(cont) In penicillin hypersensitivity consider Erythromycin mg/kg/day or Cefuroxime 30 mg/kg/day or Cefdinir 14 mg/kg/day bid Follow up at hours

24 Sinusitis(cont) Bacterial sinusitis -improve The usual duration is 10- to 14-day course of treatment or 7 days beyond the point of improvement or resolution of signs and symptoms The patients who do not demonstrate a clinical response in hr, should be changed to β-lactamase-stable agent O Brien KL. Pediatrics 1998;101:174-7 Thai guideline for management of ARIC, 2006

25 Otitis media Acute otitis media (AOM) presence of fluid in middle ear association with signs or symptoms of acute local or systemic illness such as: otalgia or otorrhea, fever Otitis media with effusion (OME) presence of fluid in middle ear absence of sign and symptom of infection

26 Acute otitis media Presence of fluid in middle ear Association with signs or symptoms of acute local or systemic illness: otalgia, otorhea or fever Etiology : common organisms S. pneumoniae H. influenzae M. catarrhalis

27 Acute otitis media (AOM) require antibiotic uncomplicated AOM may be treated with 5 to 7-day course of antibiotic 10 to 14-day course is necessary in children < 2 years membrane perforation recurrent otitis media immunocompromised host

28 Otitis media with effusion (OME) Middle ear effusion persists for weeks to months after treatment of AOM Antibiotic is not indicated for initial treatment of OME Treatment may be indicated if effusion persists for 3 months Dowell SF. Pediatrics 1998;101 suppl

29 Pharyngitis Only gr A Streptococcal pharyngitis that needed to be treated with antibiotic Gr A Streptococci were isolated from only 12% of children presented with exudative pharyngitis Children < 3 years were usually infected with virus Schwartz B. Pediatrics 1998; 101: 171.

30 Pharyngitis(cont) Viral pharyngitis usually in children < 3 years prominent extrapharyngeal signs nasal discharge, cough hoarseness conjunctivitis vesicular or ulcerative lesion generalized lymphadenopathy

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35 Pharyngitis(cont) Classic streptococcal pharyngitis acute onset of pharyngeal pain, dysphagia and fever malaise, headache, abdominal pain and vomiting commonly occur PE : pharynx is erythematous, patchy exudate on posterior pharynx and tonsils, petechiae on soft palate, enlarged and tender anterior cervical LN

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38 Pharyngitis(cont) Penicillin is the drug of choice with 10- day regimen Amoxicillin is an alternative Other alternative treatment option: cephalosporin in the condition of penicillin failure shorter course better compliance CDC/AAP Pediatrics 1998; 101: 171.

39 Pharyngitis(cont) Thai guideline 2006 Pen V 50, ,000 u/kg/day or amoxycillin mg/kg/day for 10 days Erythromycin mg/kg/day for days (if pen allergy)

40 Sinusitis

41 Community acquired pneumonia Symptoms and signs History of fever and respiratory distress Sensitive sign - fast breathing with or without chest indrawing CXR may be needed (if available)

42 Pneumonia CBC and CXR Viral pneumonia Supportive treatment O 2 box or hood hydration

43 Community acquired pneumonia Usual symptoms and signs for viral etiology History of prior cold Frequent cough except atypical pneumonia Generalized wheezing CBC is very useful

44 Pneumonia CBC and CXR Viral pneumonia Other causes that needed specific treatment Supportive treatment O 2 box or hood hydration Specific treatment empirical antibiotics Supportive treatment O 2 box or hood hydration

45 Empirical antibiotics Age < 2 months Causative organisms Gram negative e.g.., E coli, Klebsiella Gram positive - GBS - Severe case : S aureus

46 Empirical antibiotics Age < 2 months PGS 1-2 แสน U/kg/day or Ampicillin mg/kg/day IV q 6 hrs plus Gentamicin 5-7 mg/kg/day IV or IM q 12 hrs in infant age 7 days q 8 hrs in infant age > 7 days If there is any evidence of S. aureus Cloxacillin mg/kg/day IV q 6 hrs plus gentamicin

47 Empirical antibiotics Age 2 weeks - 6 months without fever Afebrile pneumonia : C trachomatis, Ureaplasma, Pertussis Erythromycin mg/kg/day divided 3-4 times/day oral for 14 days

48 Empirical antibiotics Age 2 months - 5 years NOT VERY SEVERE S pneumoniae, H influenzae Ampicillin mg/kg/day IV q 6 hrs OR PGS 1-2 แสน u/kg/day IV q 6 hrs (if CXR shows consolidation) If improve, change to amoxycillin oral for duration of 7-10 days

49 Empirical antibiotics VERY SEVERE PNEUMONIA Need to cover - S aureus or resistant strain of S pneumoniae and H influenzae Cephalosporin (2 nd /3 rd ) mg/kg/d or Amoxicillin-clavulanic acid mg/kg/d If immunocompromized, ADD gentamicin 5-7 mg/kg/day IV or IM q 8 hrs

50 Empirical antibiotics Age > 5 years For lobar consolidation : S pneumoniae PGS 50,000-1 แสน u/kg/day IV q 6 hrs If improve change to amoxycillin for 5-7 days For frequent cough, myringitis, rash M pneumoniae or C pneumoniae Erythromycin mg/kg/day oral for days

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