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Mostafavi N Department of pediatric infectious disease Isfahan university of medical sciences 1391/09/222

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) 1391/09/223

Steps in logic antibiotic prescribe 5. 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) 1391/09/224

Steps in logical antibiotic prescribe 7. 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,..) 1391/09/225

Question 1 A 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? 1391/09/226

Diagnosis of viral URTI Fever/ clear nasal discharge/ nasal obstruction/ cough/ hoarseness/ sore throat/ pharyngitis/ GI symptomes in 1 st 1-4 days Afterward purulent nasal/postnasal discharge and cough for 5-10 days( sometimes from 1 st day) Complete improve in 14 th day 1391/09/227

Case 1 QuestionResponse DiagnosisViral upper respiratory tract infection OrganismsRhinoviruses, RSV, parainfluenza, influenza, … AntibioticNo effect 1391/09/228

Question 2 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. 1. What diagnosis? 2. Which organisms? 3. Is any antibiotic needed? 1391/09/229

Diagnosis of bacterial AOM Certain AOM: acute purulent otorrhea or all 3 criteria Recent 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 1391/09/2210

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. 1391/09/2211

What diagnosis? DiagnosisUncertain non-severe AOM in 6-24 mo old 1391/09/2212

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. 1391/09/2213

Indications for antibiotic in AOM Age< 6 mo Certain AOM in mo Severe uncertain AOM in 6-24 mo Severe certain AOM in > 24 mo No response to 2-3 days observation 1391/09/2214

Is any antibiotic needed? DiagnosisUncertain non-severe AOM in 6-24 mo old Need to antibiotic No need 1391/09/2215

Question 3 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 earach. What diagnosis? Is any antibiotic needed? If yes which antibiotic? 1391/09/2216

Is any antibiotic needed? DiagnosisUncertain severe AOM in 6-24 mo old Need to antibiotic Yes, … 1391/09/2217

Which organisms? Which sensitivities? Best antibiotic? 1391/09/2218

Bacteriology of AOM Bacteria Preval ence Spontan eous cure ChoiceAlternative Non susceptible S.pneumonia 40%15%High dose amoxicillinClindamycin, 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. Catarhalis10%80%Low dose coamoxi clav(100% amoxi- resistant) Cefixime, macrolides, ceforuxime, ceftriaxone 1391/09/2219

Treatment of AOM Type of AOMChoiceAllergy 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 1391/09/2220

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. 1391/09/2221

Best antibiotic? DiagnosisSevere uncertain AOM in 6-24 mo old ChoiceHigh dose amoxicillin for 10 days( Sus. 400 mg, 5 cc BID, 2 bottles) 1391/09/2222

Best antibiotic? The parent report than the infant had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension. 1391/09/2223

Conditions that alter the choice ConditionAllergy Type 1 hypersensitivity to penicillin azithromycine, clarithromycine Non- type 1 hypersensitivity to penicillin Cefuroxime axetile, azithromycine, clarithromycine Young ageOral solutions Refusing drugsazithromycine Inconvenient parentsazithromycine 1391/09/2224

Best antibiotic? The parent report than the infant had previously serum sickness like reaction which need admission following consumption of Amoxicllin-clavulanate suspension. 1391/09/2225

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) 1391/09/2226

Any investigation/procedure? The parent report that the child has humoral immunodeficiency and receive monthly IVIG? 1391/09/2227

Indications of myringotomy/ tympanocentesis Severe, refractory pain Hyperpyrexia Complications(facial paralysis, mastoiditis, labyrinthitis, or central nervous system infection) Immunologic compromise Third-line therapy Very young infants whose illness presumed to not be limited to middle ear. 1391/09/2228

Parent education Refrigerated Discarded after 7 days Consumption away from meals Mild diarrhea and rash need no attention 1391/09/2229

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 1391/09/2230

Logic antibiotic use 1. diagnosis? 2. organisms? 3. antibiotic? 4. investigation/proc edure? 5. Best antibiotic? 6. unusual condition? 7. Dose? Interval? Duration? 8. Supply? 9. Parent education 10. Response? 11. When return? 12. Prevention in contacts 1391/09/2231

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