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Principles of antibiotic therapy in paediatrics Dr. György Fekete.

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Presentation on theme: "Principles of antibiotic therapy in paediatrics Dr. György Fekete."— Presentation transcript:

1 Principles of antibiotic therapy in paediatrics Dr. György Fekete

2 Antibiotics 1.What is the reason? Indication? - local infection - empiric and targeted teatment - fever + general symptoms (CRP, WBC count and smear, etc.)

3 2. Previous microbiological investigations? - throat - urine - haemoculture - cerebrospinal fluid

4 3. What is the potential (bacterial) cause of infection? - age (newborn, infant, toddler…) - medical procedure, hospitalisation - immune deficiency - organ damage (spleen, liver, kidney)

5 Neonatal sepsis /meningitis Focal infection: pneumonia, RDS Focal infection: pneumonia, RDS Group B streptococci, E. coli, other Gram- negative rods, Listeria monocytogenes Group B streptococci, E. coli, other Gram- negative rods, Listeria monocytogenes Th: Ampicillin+ gentamicin Th: Ampicillin+ gentamicin third generation cephalosporin instead of aminoglycoside third generation cephalosporin instead of aminoglycoside

6 Bacterial meningitis in children, 2months to 12 yrs S. pneumoniae, N. meningitidis, S. pneumoniae, N. meningitidis, (H. influenzae type b) (H. influenzae type b) Therapy: - cefotaxime / ceftriaxone + vancomycine - 3. generation cephalosporines (Cefotaxime, Ceftriaxone)

7 4.Which antibiotic will be optimal? First choice? - data of bacterial resistance - site of infection – penetration? - side effects? - bactericide effect - administration: 1x / day - not expensive

8 5.Any combination is appropriate? - nosocomial infection - sepsis - abdominal and pelvic infections - endocarditis - empiric treatment - active tuberculosis

9 Active tuberculosis Treatment: INH, rifampin, pyrazinamide Treatment: INH, rifampin, pyrazinamide Ethambutol, ethionamide Ethambutol, ethionamide

10 6.Metabolism, excretion? - kidney, liver (monitoring) - renal: aminoglycosides - liver:erythromycin, clindomycin 7.Mode of administration - iv, oral - „switch”

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12 8. Dosage ? 9. Changing of antiobiotic drug? Indications? 10.How long should we treat? 10.How long should we treat? - Preterm and newborn babies need antibiotic therapy of longer duration (sepsis, bacterial meningitis, etc.) - Preterm and newborn babies need antibiotic therapy of longer duration (sepsis, bacterial meningitis, etc.)

13 Antimicrobial prophylaxis Neonatal conjunctivitis Chlamydia trachomatis Chlamydia trachomatis –0,5% erythromycin topically Neisseria gonorrhoeae Neisseria gonorrhoeae –1% silver nitrate or –0,5% erythromycin topically

14 Antimicrobial prophylaxis Splenectomy / asplenia Splenectomy / asplenia Str. pneumoniae Str. pneumoniae Penicillin Penicillin

15 Resistant clones of microorganisms Str. pneumoniae Str. pneumoniae Staph. aureus Staph. aureus Virulent Virulent Serious infections Serious infections Overuse of antibiotics Overuse of antibiotics –Viral infections –Broad spectrum antimicrobial agents

16 Antibiotic management of Staphylococcus aureus infections in US Children’s hospitals, Trends in antibiotic management for S. aureus infections, hospitalized children Trends in antibiotic management for S. aureus infections, hospitalized children The use of vancomycin, clindamycin, linezolid, trimethoprim- sulfamethoxazole, cefazolin, and oxacillin/nafcillin were examined for percentage use and days of therapy per 1000 patient- day The use of vancomycin, clindamycin, linezolid, trimethoprim- sulfamethoxazole, cefazolin, and oxacillin/nafcillin were examined for percentage use and days of therapy per 1000 patient- day patients had a discharge diagnosis for S. aureus infection patients had a discharge diagnosis for S. aureus infection The incidence of methicillin-resistant S. aureus (MRSA) infections increased 10-fold (2 to 21 cases per 1000 admissions), methicillin- susceptible infection rate remained stable The incidence of methicillin-resistant S. aureus (MRSA) infections increased 10-fold (2 to 21 cases per 1000 admissions), methicillin- susceptible infection rate remained stable Clindamycin showed the greatest increase: 21% in 1999 and 63% in 2008 Clindamycin showed the greatest increase: 21% in 1999 and 63% in 2008 Importance of continuous monitoring of local S. aureus susceptibility patterns Importance of continuous monitoring of local S. aureus susceptibility patterns Herigon J.C et al. Pediatrics 2010, 125:1267

17 Broad - spectrum antimicrobial agents Drastic changes in bowel flora Drastic changes in bowel flora Bleeding disorders Bleeding disorders Emergence of resistant organisms Emergence of resistant organisms Superinfections: yeasts, enterococci Superinfections: yeasts, enterococci

18 Local (hospital) microbiological laboratory Knowing the prevalence of antibiotic – resistant organisms in a particular community (nursery) is helpful in choosing the first-line antibiotic regimens Knowing the prevalence of antibiotic – resistant organisms in a particular community (nursery) is helpful in choosing the first-line antibiotic regimens

19 Specific therapeutic values Vancomycin : methicillin-resistant staphylococci Vancomycin : methicillin-resistant staphylococci Metronidazole : anaerobic infections Metronidazole : anaerobic infections Ceftazidine : Pseudomonas aeruginosa Ceftazidine : Pseudomonas aeruginosa Trimethoprime+ sulfamethoxazole: shigellosis, salmonellosis, Pneumocysis carinii ( pentamidine ) Trimethoprime+ sulfamethoxazole: shigellosis, salmonellosis, Pneumocysis carinii ( pentamidine )

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24 Test of efficacy= patient’s response No respond to seemingly appropriate therapy: reassessment is needed! No respond to seemingly appropriate therapy: reassessment is needed! In some infections additional supportive treatment ( surgical) is necessary In some infections additional supportive treatment ( surgical) is necessary

25 Tonsillitis, tonsillopharyngitis Streptococcus pyogenes : Penicillin for 10 days Streptococcus pyogenes : Penicillin for 10 days Penicillin allergy: macrolid antibiotics Penicillin allergy: macrolid antibiotics Non- Streptococcus origin: amoxicillin, amoxicillin+ clavulanic acid, macrolids, cephalosporin antibiotics Non- Streptococcus origin: amoxicillin, amoxicillin+ clavulanic acid, macrolids, cephalosporin antibiotics

26 Anaerobic infections Oropharynx, gastrointestinal tract, vagina, skin Oropharynx, gastrointestinal tract, vagina, skin Gram- negative nonsporulating rods: Bacteroides, Fusobacterium Gram- negative nonsporulating rods: Bacteroides, Fusobacterium Gram-positive nosporulating rods: Eubacterium, Propionibacterium Gram-positive nosporulating rods: Eubacterium, Propionibacterium

27 Anaerobic infections Neonates: prolonged rupture of membranes, amnionitis, obstetric difficulties Neonates: prolonged rupture of membranes, amnionitis, obstetric difficulties Peritonitis, appendicitis Peritonitis, appendicitis Aspiration pneumonia with lung abscess Aspiration pneumonia with lung abscess Orofacial infections Orofacial infections Brain abscess Brain abscess

28 Periodontal infection („trench mouth”) Acute Necrotizing Ulcerative Gingivitis ( ANUG) Periapical abscesses Periapical abscesses Anaerobic osteomyelitis of the mandible /maxilla Anaerobic osteomyelitis of the mandible /maxilla

29 Vincent stomatitits Ulcers covered by brown/grey, foul- smelling exudate Ulcers covered by brown/grey, foul- smelling exudate

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31 Ludwig angina Acute cellulitis of the sublingual and submandibular spaces Acute cellulitis of the sublingual and submandibular spaces Rapid spread Rapid spread Edema of the tongue and airway Edema of the tongue and airway

32 Anaerobic infections/ treatment Cefoxitin, amoxicillin/ clavulanate, clindamycin Cefoxitin, amoxicillin/ clavulanate, clindamycin Metronidazole Metronidazole Cefotetan Cefotetan Imipenem, merapenem Imipenem, merapenem Piperacillin, tazobactam Piperacillin, tazobactam

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37 CEPHALOSPORIN ANTIBIOTICS 1.generation drugs Cefazolin(Kefzol) does not cross the blood- brain barrier. No use for initial th. of sepsis / meningitis Cefalexin(Keflex. Ospexin) Cefadoxil(Duracef)

38 2. generation drugs Cefamandol(Mandokef) Cefuroxim(Zinnat, Zinacef) Cefoxitin(Mefoxin) Cefaclor(Ceclor)

39 3. generation drugs Cefotaxime(Claforan) Ceftriaxone(Rocephin) Cefoperazon(Cefobid) Ceftazidim((Fortum) Cefixim(Suprax) Ceftibuten(Cedax)

40 4.generation drug Cefepim(Maxipime)

41 Presentation 7-year-old boy 7-year-old boy 3 weeks of headache refractory to acetaminophen, 1 day of altered mental status, diplopia, photophobia 3 weeks of headache refractory to acetaminophen, 1 day of altered mental status, diplopia, photophobia Physical examination: he is difficult to arouse and is confused. He vomits once in the ED. Physical examination: he is difficult to arouse and is confused. He vomits once in the ED. No skin lesions, signs of meningeal irritation, or joint swelling. Bilateral papilledema and photophobia No skin lesions, signs of meningeal irritation, or joint swelling. Bilateral papilledema and photophobia WBC 15.8x10 9 /L, 85% segmented neutrophils. Lumbar puncture, CSF sent for Lyme titers, serum antibodies: positive for IgG and negative for IgM WBC 15.8x10 9 /L, 85% segmented neutrophils. Lumbar puncture, CSF sent for Lyme titers, serum antibodies: positive for IgG and negative for IgM Th: 28 days IV ceftriaxone (100 mg/kg per day) Th: 28 days IV ceftriaxone (100 mg/kg per day) Additional questioning:2 months prior he had erythema migrans, was diagnosed as having Lyme disease, and was treated with 21 days of cefuroxime Additional questioning:2 months prior he had erythema migrans, was diagnosed as having Lyme disease, and was treated with 21 days of cefuroxime

42 PENICILLIN Penicillin G VStreptococcus procain-penicillinStr. pneumoniae

43 METHICILLINOxacillin Staphylococcus aureus Nafcillin

44 AMINOPENICILLIN (ampicillin, amoxicillin) Streptococcus B (ampicillin, amoxicillin) Streptococcus B Str. pneumoniae Listeria

45 AMINOPENICILLIN beta+-lactamaserespiratory, inhibitor urinary tract infections (ampicillin+sulfactam, amoxicillin+clavulanic acid)

46 UREIDOPENICILLIN mezlocillin, piperacillin (+beta-lactamase inhibitor as well) piperacillin/tazobactam Severe systemic infections

47 Tetracyclines Good effect: Good effect: Chlamydia, Mycoplasma, Actinomyces, Lyme disease, pelvic infections, urethritis, brucellosis Chlamydia, Mycoplasma, Actinomyces, Lyme disease, pelvic infections, urethritis, brucellosis Contraindicated before the age of 10 yrs! Contraindicated before the age of 10 yrs!

48 ANTIBIOTIC DRUGS Active ingredientProduct AmoxicillinAktil, Augmentin + clavulanic acid AmpicillinOspamox,Penstabil, Pentrexyl

49 Active ingredientProduct AmpicillinUnasyn +Sulbactam AzithromycinSumamed AzlocillinSecuropen

50 Active ingredientProduct CefadroxilDuracef CeftazidimeFortum CeftriaxonRocephin CefiximSuprax

51 Active ingredientProduct CefepimeMaxipime CeftibutenCedax CefoperazonCefobid CefotaximClaforan

52 Active ingredientProduct CefuroximZinacef, Zinnat ClarithromycinKlacid ClindamycinDalacin C CiprofloxacinCiprobay, Cifran, Supplin

53 Active ingredientProduct ImipenemTienam + cilostatin JosamycinWilprafen MeropenemMeronem MetronidazolKlion

54 Active ingredientProduct MezlocillinBaypen NetilmicinNetromycine PenicillinMaripen, Ospen, Vegacillin

55 Active ingredientProduct Sulfamethoxazol Sumetrolim, +trimethoprim Bactrim, Cotrimel Teicoplanin Targocid Tobramycin Brulamycin Vancomycin Vancocyn


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