1. Antibiotics therapy in pediatrics
Dr .Ebtihal Elameen Eltyeb
Assistant professor Jazan university

2. objectives To know the types of antibiotics for pediatrics.
To know what is the indication for it.
The choice of antibiotics.
How do antibiotics act.
To know the term antibiotics resistance.
To know the combination antibiotics therapy

3. The choice of antibiotics should largely be determined by:
source or focus of infection
patient's age and immunologic status
whether the infection is viral or bacterial
is it community acquired or nosocomial

4. Factors should be considered to choose antibiotic
Any history of allergy, toxicity?
Is it appropriate for the spectrum I want to cover?
What route of admin: oral or i.v?
Any factors affecting absorption ?
Is it going to reach the site of infection?
Any drug interactions?
Any serious toxicity eg, hepatic, renal?
Does it need monitoring eg aminoglycosides, vancomycin, streptomycin?

5. What is our current practice?

6. Prescribing Pattern of Antibiotics in Pediatric Patients in the Jazan Region, Kingdom of Saudi Arabia
The mean age of patient on antibiotic was 3.71 ± antibiotics were prescribed to the patients and the average number of antibiotics per prescription was 1.45 ± Fever (12.5%) and pneumonia (9.7%) were most frequently found diseases in infants, while other diseases constitute 47.9%. Cephalosporin group of antibiotics were most frequently (52%) prescribed antibiotics, followed by aminoglycoside group (17.3%), penicillins (12.5%), macrolides (8.3%) and quinolones (0.69%). Most of the antibiotics were administered parenterally for inpatients.
Khaled M Alakhali, et al . RGUHS J Pharm Sci | Vol 4 | Issue 3 | Jul–Sep, 2014

7. Misuse of antibiotic: A systemic review of Saudi published studies.
a high prevalence of antibiotic misuse among Saudi population ranging from 41%-92%, especially among the children. The reasons of this high prevalence are complex, and several contributing factors including cultural factors, behavioral characteristics, socio-economic status, and level of education.
Abdul Rahman Alnemri et al .Curr Pediatr Res 2016; 20 (1&2):

8. How does antibiotic act?
Penicillin on bacterial cell wall (organisms without cell wall won’t be inhibited eg Mycoplasma pneumoniae).
Sulphonamides prevent bacteria synthesising folic acid whereas humans can use preformed folate.
Generally drugs that act on cell membranes or protein synthesis are more toxic to humans.

9. Antibiotics acting on cell wall of bacteria
Beta lactams:
Penicillins, cephalosporins, carbapenems, monobactam
Glycopeptides:
Vancomycin, teicoplanin

10. Indications of benzyl penicillin
Strep pyogenes sepsis (from sore throat to fasciitis)
Pneumococcal pneumonia, meningitis
Meningococcal meningitis, sepsis
Infective endocarditis (strep)
Strep group B sepsis
Diphtheria
Syphilis, leptospirosis

11. Broader spectrum penicillin
Penicillinase (b-lactamase)-sensitive penicillins
Benzylpenicillin (penicillin G, parenteral)
Penicillin V (phenoxymethyl penicillin, oral)
Penicillinase-resistant penicillins
Flucloxacillin
Broad-spectrum penicillins
Ampicillin
Amoxicillin
Co-amoxiclav (amoxicillin plus clavulanic acid; Augmentinآ
Antipseudomonal penicillins
Piperacillin (with tazobactam; Tazocin
Ticarcillin (plus clavulanic acid)

12. Penicillin (cont) Allergy to penicillin is common (1-10% of patients).
Those with a history of true allergy to penicillin should not be given any b-lactam antibiotic, including cephalosporins, the carbapenems, and co-amoxiclav

13. Drugs that used in penicillin allergy
Macrolides: erythromycin, clarithromycin
(mainly gram positive cover)
Quinolones: ciprofloxacin, levofloxacin (mainly gram positive cover)
Glycopeptides (serious infections)
Fusidic acid, rifampicin, clindamycin (mainly gram positive)

14. Cephalosporin Cefuroxime: surgical prophylaxis
Cefotaxime/ceftriaxone: meningitis nosocomial infections excluding Pseudomonal,
Ceftazidime: nosocomial infections including Pseudomonal

15. Aminoglycosides Gentamicin, amikacin (tobramycin, streptomycin)
Mainly active against gram negative bacteria
Mainly used to treat nosocomial infections: pneumonia in UTI, septicaemia
Limiting factors are nephrotoxicity (and ototoxicity) and resistance
Also used in combination

16. Carbapenems
Imipenem, meropenem: have a very broad spectrum activity against gram-negative bacteria, anaerobes, streps
Now used to treat gram negative infections eg, E coli, Klebsiella
Ertapenem is a new member of the group but its not active against Pseudomonas

17. Other types of antibiotics
Co-trimoxazole ( UTI)
Chloramphenicol (typhoid fever, meningitis)
Colistin (resistant Pseudomonas) topical
Neomycin: gut decontamination, topical

18. Antibiotics resistance
Some bacteria are naturally resistant to particular antibiotics (Pseudomonas has permeability barrier to many antibiotics)
Antimicrobial resistance occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process
Other species acquire resistance via plasmids (infectious resistance) eg Neisseria gonorrhoeae, many gram negatives

19. Methicillin-Resistant Staphylococcus aureus (MRSA)
These organisms commonly cause hospital-acquired infection and are increasingly common in the community as well.
They are resistant to all b-lactams, including flucloxacillin.
Consider MRSA as a causative organism if a patient becomes unwell in hospital or does not respond to conventional treatment.

20. combination antibiotics therapy
When treating serious infection empirically
(severe pneumonia:cefotaxime+erythromycin)
To prevent the emergence of drug resistance: tuberculosis regimens
For synergy: Penicillin + gentamycin
For mixed infections eg, abdominal sepsis (tazocin+metronidazole)

21. Case scenario
An 8-year-old boy is seen in because of fever, headache, sore throat, and malaise. He’s had no rhinorrhea, cough, or hoarseness. Physical examination reveals a temperature of 39C, exudative pharyngitis, and tender cervical adenopathy
How will you treat him?

22. Larger doses of penicillin once daily result in more relapses*
AAP recommends oral penicillin V 2-3 times daily for 10 days, a single dose of benzathine penicillin, or amoxicillin 250 mg/kg tid for 10 days
Larger doses of penicillin once daily result in more relapses*
*Breese, 1965, Gerber, 1989

23. Massages to take home
Irrational Overuse of antibiotics is the direct cause for resistance.
Start antibiotic only if indicated
Always use first line drugs
Use Microbiology Lab more often
Develop culture of culture
Spend more time with parents (counseling)
Select proper empirical antibiotics
Do not use antibiotics in nonbacterial conditions

24. references Oxford Handbook of Practical Drug Therapy, 1st Edition
Some lectures about antibiotics therapy