DR SANDIP GUPTA

PGT,PEDIATRICS

B.S.M.C.H.

RATIONAL ANTIBIOTIC THERAPYRATIONAL ANTIBIOTIC THERAPY

Why Rational Antibiotic Therapy ?

• Better care of patients.

• Combating antimicrobial resistance.

• Prevent misuse of antibiotics.

• Reduce cost of treatment.

Misuse of antibiotics

• Lack of awareness & evidence based practice.

• Fear of secondary infection.

• False sense of security.

• Fear of losing patients.

• Parental anxiety & pressure.

• Is an antibiotic really necessary?

• Must have a provisional diagnosis.

• Predict the organisms.

• Consider stensitivity pattern.

• Narrowest spectrum, least toxic, less costly.

• Host factors.

• Co existing medical problem.

HOW TO CHOOSE ANTIBIOTICS

• Skin & soft tissue infections

• ENT infections

• LRTI

• GI infections

• UTI

• CNS infections

• CVS infections

• Osteoarticular infections

Common bacterial infections

• This includes impetigo, pyoderma, abscesses, lymphadenitis, pyomyositis & bites.

• Common organism responsible : GrAstreptococcus,staphylococcus.

• 1st generation cephalosporins(cephalexin,cefadroxil) amoxyclav, cloxacillin.

• Duration of therapy is 5-10 days.

Skin & soft tissue infection

ENT INFECTIONS

Otitis media & sinusitis:

cover pseudomonas, H influenze & moraxella.

(a) 1st line: Amoxycillin for 5 to 10 days.

(b) 2nd line: coamoxyclav/injceftriaxone/macrolide.

(c) for sinusitis complete at least 14-21 days of therapy

LOWER RESPIRATORY TRACT INFECTIONS

Community acquired:

Cover for Gp A streptococcus, pneumococcus, & staph aureus in infants& toddlers . Atypical agents in school age & adolescent.

(a) Outpatient– consider in less severe illness.

(i) Amoxycillin. (ii)coamoxyclav/cefpodoxime/cefuroxime axetil.

(iii) Add macrolide if atypical pneumonia suspected.

Cont.

(b) Hospitalized:

1st line:inj cetriaxone/inj cefotaxime/inj cefuroxime for 10 to 14 days

if staph is suspected (rapid evolution,empyema,pneumatocele)

initial antibiotic should include vancomycin or clindamycin.

Add macrolides if atypical pneumonia is suspected.

Respiratory floroquinolones are alternative in adolescence

Reassess choice of antibiotic after 48 -96 hrs if no response/modify as

per results of cultures, look for other factors.

GASTROINTESTINAL INFECTIONS

1.Cholera: Doxycycline 4mg/kg/day bid for 3d cotrimoxazole,

erythromycin, furazolidone.

2. Enteric fever:

3rd gen cephalosporin (14 days), azithromycin.

3. Acute dysentery: ciprofloxacin 30mg /kg for 5d.

4. Peritonitis:

(a) SBP– inj cetriaxone/inj cefotaxime.

(b) Secondary to bowel pathology– inj meropenem/inj

imipenem/inj ampicillin+inj gentamycin+inj clindamycin

URINARY TRACT INFECTIONS

1. Uncomplicated UTI:

oral:cefixime,amoxyclav,cephalexin,floroquinolonesfor 7-10 days.

2. Complicated UTI:

inj ceftriaxone,amikacin,amoxyclav for 10-14 days.

3. Prophylaxis:

Nitrofurantoin/cotrimoxazole,cephalexin,cefadroxil.

CNS INFECTIONSMeningitis:Empirical– inj vancomycin + inj ceftriaxone/injcefotaxime .

H influenza-ceftriaxone/cefotaxime for 7-10 dPneumococcus– If penicillin susceptible inj penicillin G

or 3rd gen cephalosporin . If resistant continue on inj ceftriaxone+ inj vancomycin for 10-14 days.

N.Meningitidis-inj penicillinG 4lacU/kg/d for 5-7 d.Gm –ve organism t/t for 3 wks with 3rd gen

cephalosporin (ceftazidime for pseudomonas).Brain abcess t/t for 4-6 wks with 3rd gen cephalosporin

+ inj vancomycin + metronidazole.2nd Line: meropenem+ vancomycin

CARDIOVASCULAR INFECTIONSEndocarditis:

inj vancomycin & inj gentamycin to start with. Modify as per c/s report.

(a) inj penicillin G / inj ceftriaxone & inj gentamycin/ injvancomycin in case of S Viridans.

(b) Enterococcus– Ampicillin/vancomycin & inj gentamycin.

(c)S aureus/ Epidermidis– inj vancomycin/ inj cloxacillin & injgentamycin for 6wks.

(d) Pneumococcus/ Gonococcus/ Gp A streptococcus– injpenicillin G/ inj ceftriaxone/ inj vancomycin.

HACEKorganisms: inj ceftriaxone & inj gentamycin for 6wks

Gm-veorganisms:piperacillin/ceftazidime+gentamycin 6wks

OSTEOARTICULAR INFECTIONS

1. Bacterial arthritis/ osteomyelitis:Cover S aureus & Gp A streptococcus;

Pneumococcus & H influenze in infancy. Modify therpy according to c/s reports.(a) 1st line: inj cloxacillin iv for 21 days followed by oral therapy for a total of 4-6 weeks+ceftriaxone.(b) 2nd line: inj vancomycin or inj clindamycin for 21 days followed by oral therapy for a total period of 4-6 weeks. Use as first line if MRSA is suspected.

.

Antibiotic prophylaxis

• UTI: in infants waiting imaging, VUR,

Frequent febrile UTI(30 or more/yr).

• Rheumatic fever

• Tuberculosis

• IE prophylaxis

• Pertussis contacts

Stratergies to prevent antibiotic resistance

• Optimal use of antimicrobials.

• National protocol .

• Restriction policy.

• Antibiotic cycling.

• Combination therapy.

• Surveillance for resistant bacterial pathogen.

Non antimicrobial prevention stratergies

Primary prevention programme for specific infections

a. Adoption of WHO stratergies, e.g.DOTS.b. Vaccines & immunoglobins.c. Reducing length of hospital admission.d. Avoiding invasive procedures.Prevention of horizonital transmissiona. Hand washing b. Gloves & gownsHealth education