1391/09/221. Mostafavi N Department of pediatric infectious disease Isfahan university of medical...
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Transcript of 1391/09/221. Mostafavi N Department of pediatric infectious disease Isfahan university of medical...
Mostafavi NDepartment of pediatric infectious disease
Isfahan university of medical sciences
1391/09/22 2
Steps in logic antibiotic prescribe
1. What diagnosis?2. Which organisms?3. Is any antibiotic needed?4. Is any investigation/procedure
needed? ( drainage, culture, lab exam)
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Steps in logic antibiotic prescribe5. Best antibiotic?( maximum coverage,
narrowest spectrum, oldest, cheapest, available, tolerable, diffusible, least interval, best rout)
6. Is any unusual condition?( drug interactions, allergy, low age, low economy, G6PD deficiency; underlying renal, neurological, hepatic disorders)
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Steps in logical antibiotic prescribe7. Which dose? interval? duration? supply?8. Parent education.( measuring amounts of
drug, refrigeration)9. How parents assess response? When
return?( intolerance, no adequate response, adverse reactions, lab results, monitoring safety and efficacy)
10.Prevention in contacts.( isolation, antibiotic) and patient( prophylactic Abs, IVIG, INF, ..)
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Question 1A 2 years old girl brought with
history of 3 days fever, coryza and cough, on examination she has purulent post nasal discharge.
1.What diagnosis?2.Which organisms?3.Is any antibiotic needed?
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Diagnosis of viral URTIFever/ clear nasal discharge/ nasal
obstruction/ cough/ hoarseness/ sore throat/ pharyngitis/ GI symptomes in 1st 1-4 days
Afterward purulent nasal/postnasal discharge and cough for 5-10 days( sometimes from 1st day)
Complete improve in 14th day
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Case 1 Question Response
DiagnosisViral upper respiratory tract infection
OrganismsRhinoviruses, RSV, parainfluenza, influenza, …
AntibioticNo effect
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Question 2A 16 months old girl brought with history of 3
days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis.
1.What diagnosis?2.Which organisms?3.Is any antibiotic needed?
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Diagnosis of bacterial AOMCertain AOM: acute purulent otorrhea or
all 3 criteriaRecent onset( < 3-7 days)Inflammation
• Marked redness • Significant ear pain
Effusion Bulging Bubbles/air-fluid level ↓mobility
• Uncertain AOM: < 3 criteria• Severe AOM( certain/uncertain): severe otalgia,
T> 39⁰С
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What diagnosis?A 16 months old girl brought with history of 3
days fever and coryza and cough, on examination
she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis.
1391/09/22 11
Is any antibiotic needed?A 16 months old girl brought with history of 3 days
fever and coryza and cough, on examination she
has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis.
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Indications for antibiotic in AOMAge< 6 moCertain AOM in 6- 24 moSevere uncertain AOM in 6-24 moSevere certain AOM in > 24 moNo response to 2-3 days observation
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Is any antibiotic needed?Diagnosis
Uncertain non-severe AOM in 6-24 mo old
Need to antibiotic
No need
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Question 3A 16 months old girl brought with history of 3 days
fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis. No antibiotic were prescribed.
The child returned one day later with severe earach. What diagnosis? Is any antibiotic needed? If yes which antibiotic?
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Is any antibiotic needed?Diagnosis
Uncertain severe AOM in 6-24 mo old
Need to antibiotic
Yes, …
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Bacteriology of AOMBacteriaPreva
lence Spontaneous
cureChoice Alternative
Non susceptible S.pneumonia
40%
15%
High dose amoxicillin Clindamycin, ceforuxime , ceftriaxone
Nontypeable H. flu
30%
50%
Low dose coamoxi clav( 40% amoxi-resistant)
Cefixime, macrolides, ceforuxime, ceftriaxone
Sucseptible S.pneumonia
20%
15%
Low dose amoxicillinMacrolides, ceforuxime, ceftriaxone
M. Catarhalis
10%
80%
Low dose coamoxi clav(100% amoxi-resistant)
Cefixime, macrolides, ceforuxime, ceftriaxone1391/09/22 19
Treatment of AOMType of AOMChoice Allergy to
penicillin
Non-severeHigh dose amoxicillin
Ceforuxime, azithromycine, clarythromycine
SevereHigh dose coamoxiclav
ceftriaxone
Treatment failure with amoxi, non severe
High dose coamoxiclav
Ceftriaxone, clindamycine
Treatment failure + severe, Failure with coamoxiclav
CeftriaxoneTympanocentesis, clindamycine
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Best antibiotic?A 16 months old girl brought with history of 3
days fever and coryza and cough, on examination she has purulent post nasal discharge. No antibiotic were prescribed. Three days later the patient returned with recurrence of fever( 38⁰С) and earache. On examination she has mild erythema of the right tympanic membrane and no significant purulent rhinitis. No antibiotic were
prescribed. The child returned one day later with severe earache. BW= 10 Kg.
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Best antibiotic?Diagnosis
Severe uncertain AOM in 6-24 mo old
Choice High dose amoxicillin for 10 days( Sus. 400 mg, 5 cc BID, 2 bottles)
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Best antibiotic?The parent report than the infant
had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension.
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Conditions that alter the choiceCondition Allergy
Type 1 hypersensitivity to penicillin
azithromycine, clarithromycine
Non- type 1 hypersensitivity to penicillin
Cefuroxime axetile, azithromycine, clarithromycine
Young ageOral solutions
Refusing drugsazithromycine
Inconvenient parentsazithromycine
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Best antibiotic?The parent report than the infant
had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension.
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Best antibiotic?Specific condition
Alternative
Non- type 1 hypersensitivity to penicillin, young age
Azithromycine( sus 100/5cc, 5cc first day the 2.5 cc for 4 days, 1 bottle) Clarithromycine( sus 125/5cc, 3 cc bid for 10 days)1391/09/22 26
Any investigation/procedure?The parent report that the child has humoral immunodeficiency and receive monthly IVIG?
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Indications of myringotomy/ tympanocentesisSevere, refractory painHyperpyrexiaComplications(facial paralysis,
mastoiditis, labyrinthitis, or central nervous system infection)
Immunologic compromise Third-line therapyVery young infants whose illness
presumed to not be limited to middle ear.
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Parent educationRefrigeratedDiscarded after 7 daysConsumption away from mealsMild diarrhea and rash need no attention
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How parents assess response? When return?Good response:
Improve of pain and fever within 1- 3 days
When return? 2 weeks for frequent recurrences:
Improve in tympanic membrane exam 1-3 mo for all cases: Improve in
middle ear effusion Non-copmpliance Adveres reactions: diarrhea, rash
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Logic antibiotic use1. diagnosis?2. organisms?3. antibiotic?4. investigation/
procedure?5. Best antibiotic?6. unusual
condition?
7. Dose? Interval? Duration?
8. Supply?9. Parent
education10.Response? 11.When return?12.Prevention in
contacts1391/09/22 31