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Mostafavi NDepartment of pediatric infectious disease

Isfahan university of medical sciences

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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.

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What diagnosis?Diagnosis

Uncertain non-severe AOM in 6-24 mo old

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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

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