Rational management of community acquired infections Dr Tanu Singhal MD, MSc Consultant Pediatrics and Infectious Disease Kokilaben Dhirubhai Ambani Hospital, Mumbai
Why is rational management needed? To improve outcomes To reduce antimicrobial resistance To reduce costs To reduce adverse drug effects
Bad bugs, no new drugs! 3
General principles for antibiotic therapy Choose empirical therapy based on Likely pathogen Likely antimicrobial resistance Prior antibiotic exposure Severity of illness Host co morbidities Site of infection Modify when cultures available to most narrow spectrum and appropriate Abx (definitive therapy) Give right dose, duration and route
Upper respiratory tract infections Most are viral, some influenza Symptomatic therapy with paracetamol, nasal decongestents, home remedies and anti tussives Antibiotics don t prevent super infection Bacterial URTI: streptococcal pharyngitis, acute otitis media, sinusitis Bacterial URTI need antibiotics Amoxicillin/ coamoxiclav Cefixime/quinolones not useful and cefpodoxime/ cefdinir not needed Explain patient about complications Breathing difficulty Ear pain
Lower respiratory tract infections Most due to pneumococcus, mycoplasma, viruses OPD: coamoxiclav/ macrolide/ doxycycline WARD: ceftriaxone/coamoxiclav with macrolide OR levofloxacin monotherapy ICU: ceftriaxone and levofloxacin Caution while using quinolones since sometimes TB can present as CAP Comorbidities will need gram neg cover MRSA cover in case of necrotizing pneumonia Add oseltamivir in case of outbreak
Treatment of diarrhea In children is mostly viral and does not need antibiotics E. histolytica contributes to less than 3% Indications for antibiotics is visible blood in stool Quinolones/ cefixime/azithromycin No role of amikacin, oral colistin and fixed drug combinations
Enteric ( Typhoid/ Paratyphoid fever) Remember to send blood cultures High rates of quinolone resistance in Salmonella Outpatients Cefixime @ 20 mg/kg/day ( 1200 mg/day max) for 2 weeks Azithromycin 1 gm daily for 7-10 days Cotrimoxazole Inpatients Ceftriaxone No benefit of combo therapy, quinolones, amikacin and BL-BLI s Defervescence takes time 5-7 days In case of relapse treat with drugs with good intracellular penetration- azithromycin
Skin and soft tissue infections Common pathogens- strep and staph Rising incidence of community acquired MRSA Localized Fucidic acid, mupirocin Generalized Cephalexin, cefadroxil, coamoxiclav more broad spectrum No role of cefixime, ciprofloxacin For inpatients- IV cefazolin, cloxacillin, cefuroxime MRSA cover if sick patient/ documented MRSA
Treatment of UTI Diagnostic challenges Rising incidence of ESBL in community pathogens 1 st line therapy outpatients, stable inpatients, no history of resistance/ recurrent infections Ciprofloxacin Cotrimoxazole Amoxiclav/Cefixime/ Ceftriaxone/Cephalexin Nitrofurantoin only for cystitis 2 nd line therapy Sick patients/history of resistance/ non responders Aminoglycosides BL-BLI combinations/carbapenems
Acute bacterial meningitis S. pneumoniae, meningococcus, Hemophilus Listeria in elderly and immunocompromised Therapy of choice: Ceftriaxone 4 gm daily Current resistance status in S. pneumoniae does not warrant addition of vancomycin No benefit of adding amikacin and using BL- BLI combinations Duration of therapy 10-14 days
Bone and joint infections Staph aureus commonest pathogen ( more MSSA than MRSA) Other pathogens in extremes of age Important to send cultures ( blood/ bone/ joint fluid) prior to antibiotics IV cefazolin/ cloxacillin usually appropriate Switch to oral once clinical resolution and normalization of acute inflammatory reactants Duration 3-6 weeks
Intrabdominal infections Common organisms- E coli, anaerobes Primary peritonitis: Ceftriaxone/ BL-BLI for 5-7 days Secondary peritonitis Ceftriaxone with metronidazole BL-BLI monotherapy ( pip taz/ cef sulbactam) No need to add metronidazole if giving BL-BLI s Biliary infections: use agents with good biliary penetration ( Pip taz, quinolones) Pancreatitis: No role for prophylactic antibiotics
Malaria Vivax malaria Chloroquine is the drug of choice 10 mg/kg @ 0,24 hrs and 5 mg/kg at 48 hours Primaquine 0.3 mg/kg for 14 days for radical therapy ACT: dihydroartemisinin and piperaquine better than artemether lumefantrine Falciparum malaria Artemether lumefantrine with fatty meal Single dose of primaquine 0.25 mg/kg Severe malaria IV artesunate and then ACT
Severe sepsis/ Septic shock No clinical focus Suspicion of tropical infections (dengue/ malaria/ lepto,rickettsia Ceftriaxone and doxy and artesunate Suspect bacterial sepsis (pneumococcus/ gram neg) Ceftriaxone and amikacin Pip taz and amikacin Meropenem/ Imipenem
Dosing and Duration of antibiotics Dose Pay due attention to weight Loading dose is useful for many abx First dose is always the full dose irrespective of renal function Remember to modify doses for hepatic and renal dysfunction and upgrade when needed Duration and Route Trend to shift to oral quickly and also shorten duration No oral switchover in infective endocarditis, meningitis
Summary Decide whether antibiotics are indeed needed Remember viral infections are not benefited by antibiotics Decide empirical choices appropriately Remember to modify once culture results are available Pay due attention to drug quality, dose, route and duration