Rational use of antibiotic in upper respiratory tract infection (URI) and community acquired

pneumonia

Rational use of antibiotic in upper respiratory tract infection (URI) and community acquired

pneumonia

รศ.จามรี ธีรตกุลพิศาล23 พฤษภาคม 2550

Sinusitis

Upper respiratory tract infections (URI)

• Common cold / nasopharyngitis• Pharyngitis/pharyngotonsillitis• Otitis media• Sinusitis

Antibiotic in URI

Problems• antibiotic overuse• increasing of colonization with

resistance strain of organisms and heighten the chance that subsequence invasive infection

• unnecessary cost

Thailand

National ARIC Control Program of Thailand : MOPH year 2002-2006Objectives - to reduce• mortality of pneumonia in U5 <4/100,000• morbidity of pneumonia in U5 <1.8/100•………………………………………………..• inappropriate use of antibiotics < 20/100

58.2 56.347.4 47.7

36.1

63 62.1

0

10

20

30

40

50

60

70

1991 1992 1993 1994 1995 1997

RH

CH

HC

Antibiotic Overuse in URI According to type of Health Facilities

Rate %

YEAR

1990-1995 : Active surveillance 17 provinces1997 : Report from 61 provincesSource : ARIC section, TB Division

RH : Regional Hospital

CH : Community Hospital

HC : Health Center

Antibiotic resistance

• Increasing worldwide– S. pneumoniae– H. influenzae

• Thailand– National surveillance – 1993, 1994, 1997 and 2000

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

National surveillance of antimicrobial resistance

1993 1994 1997 2000n=1783 n=818 n=1197

S.pneumoniae- 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

37.4

17.5

60.1

36.3

17.9

72.2

55.9

24.2

86.4

61

21

73

0102030405060708090

1993 1994 1997 2000*

penicillinchloramco-trimox

Source: ARIC section, MOPH

Antimicrobial resistance of S.pneumoniae (MIC)

Antimicrobial resistance of H.influenzae

21.314.9

24.4 23.3

14

25 26.7

7.5

68.6

20

5

35.7

0

10

20

30

40

50

60

70

1993 1994 1997 2000

ampicillin

chloram

co-trimox

Source : ARIC section, MOPH

Sinusitis

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.

Common cold(cont)

• Rhinosinusitis and mucopurulentrhinitis are almost always caused by virus : rhinovirus, coronavirus, etc.

• Most children will suffer between 3and 8 colds per year

• 10% - 15% will have at least 12 per year particularly those attending day care centers

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

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 ?

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 (1.02-7.27)

Arroll B, Kenealy T. The Cochrane review 2000

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 (0.9-1.13)

– Complications or progression of illness : RR 0.71 (0.54-1.21)

Fahey T, et al. Arch Dis Child 1998

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

Bacterial sinusitis

• Prolonged nonspecific upper respiratory signs and symptoms i.e.,nasal discharge and cough without improvement for > 10-14 days

• More severe URI and symptoms i.e.,fever≥ 39oC, facial swelling, facial pain

• Incidence 0.5% - 5% of viral URI• S. pneumoniae, H. influenzae, M. catarrhalis

are common pathogensO’Brien KL. Pediatrics 1998;101:174-7

Sinusitis(cont)

Bacterial sinusitis• Initial treatment should be amoxycillin

40-50 mg/kg/day oral bid or tid• In high risk of DRSP such as

– History of previous antibiotic within 3months

– Day care attendance or age < 2 yearsStart with high dose 80-90 mg/kg/day

Sinusitis(cont)

Bacterial sinusitis• In penicillin hypersensitivity consider

Erythromycin 30-40 mg/kg/day or Cefuroxime 30 mg/kg/day or Cefdinir 14 mg/kg/day bid

• Follow up at 48-72 hours

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 48-72 hr, should be changed to β-lactamase-stable agent

O’Brien KL. Pediatrics 1998;101:174-7Thai guideline for management of ARIC, 2006

Otitis media

• Acute otitis media (AOM)

• Otitis media with effusion (OME)– presence of fluid in middle ear– absence of sign and symptom of

infection

– presence of fluid in middle ear– association with signs or symptoms of

acute local or systemic illness such as:otalgia or otorrhea, fever

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

• 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

Acute otitis media (AOM)

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

Pharyngitis

• Only gr A Streptococcal pharyngitisthat 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.

Pharyngitis(cont)

Viral pharyngitis• usually in children < 3 years• prominent extrapharyngeal signs

– nasal discharge, cough– hoarseness– conjunctivitis– vesicular or ulcerative lesion– generalized lymphadenopathy

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

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.

Pharyngitis(cont)

Thai guideline 2006• Pen V 50,000-100,000 u/kg/day or

amoxycillin 40-50 mg/kg/day for 10days

• Erythromycin 30-40 mg/kg/day for 10-14 days (if pen allergy)

Sinusitis

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)

Pneumonia

CBC and CXR

Viral pneumonia

Supportive treatment

• O2 box or hood

• hydration

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

Pneumonia

CBC and CXR

Viral pneumonia

Supportive treatment

• O2 box or hood

• hydration

Other causes that needed specific treatment

Specific treatment

• empirical antibiotics

Supportive treatment

• O2 box or hood

• hydration

Empirical antibiotics

Age < 2 monthsCausative organisms• Gram negative e.g.., E coli, Klebsiella• Gram positive - GBS

- Severe case : S aureus

Empirical antibiotics

Age < 2 months• PGS 1-2 แสน U/kg/day or

Ampicillin 100-200 mg/kg/day IV q 6 hrs plus• Gentamicin 5-7 mg/kg/day IV or IM

q 12 hrs in infant age ≤ 7 daysq 8 hrs in infant age > 7 days

• If there is any evidence of S. aureusCloxacillin 100-150 mg/kg/day IV q 6 hrsplus gentamicin

Empirical antibiotics

Age 2 weeks - 6 months without fever“ Afebrile pneumonia”: C trachomatis, Ureaplasma, Pertussis

• Erythromycin 30-40 mg/kg/day divided 3-4times/day oral for 14 days

Empirical antibiotics

Age 2 months - 5 years NOT VERY SEVERES pneumoniae, H influenzae

• Ampicillin 100-200 mg/kg/day IV q 6 hrsOR

• 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

Empirical antibiotics

VERY SEVERE PNEUMONIANeed to cover - S aureus or resistant strain of S pneumoniae and H influenzae

• Cephalosporin (2nd/3 rd)100-150 mg/kg/d or• Amoxicillin-clavulanic acid 40-50 mg/kg/d• If immunocompromized, ADD gentamicin

5-7 mg/kg/day IV or IM q 8 hrs

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, rashM pneumoniae or C pneumoniaeErythromycin 30-40 mg/kg/day oral for 10-14days

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